Toppling the Tower of Babel

May 25, 2016
Michael Nissenbaum, President and CEO,
Aprima Medical Software

Interoperability is a great concept. Unfortunately, when EHRs were first introduced, and stimulus dollars provided for their adoption, the healthcare industry and government failed to recognize the importance of interoperability! So today we have all these systems that can’t talk to one another. Essentially, we’ve created the healthcare IT version of the Tower of Babel.

The story of the Tower of Babel offers an explanation for how the world moved from one common language to a multiplicity of languages. Just like in ancient biblical days, the existence of multiple languages creates communication challenges. In the EHR world, interoperability tools are meant to facilitate communication. Ideally, regardless of the EHR system in place, patient records can be easily shared – which in turn minimizes expensive duplicate testing, enhances patient safety, improves care coordination, and ensures more efficient and effective care. What a novel concept!

The government is now aware of the benefits of EHR interoperability and has stepped in to try to fix the problem that they helped create. As the nation’s largest payer, the U.S. government should be greatly concerned about eliminating waste and improving patient outcomes. That’s why Congress is attempting to mandate changes and why the Office of the National Coordinator (ONC) created a roadmap for achieving nationwide interoperability over the next few years.1

Despite everyone’s best intentions, achieving nationwide interoperability won’t be an easy task. Here are a few reasons why:

Too much variation – Because we failed to establish interoperability standards a few decades ago, data is currently collected, stored, and shared in a wide variety of ways. Take, for example, state and community immunization registries that collect and store inoculation data. While you might think that standards for inoculation information would be fairly rigid, in reality most registries have their own format and criteria – making record sharing a difficult task.

Self-interest – Most EHR vendors will assure users that their platforms are interoperable with other systems. But in reality, how many EHRs really speak to one another? One popular theory is that vendors resist interoperability because they fear the loss of market share to competing products. Another reality is that while interoperability benefits the healthcare ecosystem as a whole, it also creates a direct expense with no direct compensation for providers and vendors. Similarly, in order to preserve revenues, a health system may dissuade the referral of patients to outside lab and testing facilities, and only offer its providers electronic record-sharing capabilities within the organization’s own facilities.

Too much flexibility in standards – So far the government interoperability “standards” have been pretty flexible. Too flexible, in fact. The requirements are so variable that vendors have plenty of wiggle room in their interpretation. Interoperability suffers when standards are too loosely defined.

CommonWell Health Alliance, of which my company is a member, has approached interoperability a bit differently than the government and so far has set the table very nicely for achieving its goals. Unlike the government’s flexible standards, CommonWell vendors adhere to very, very detailed specifications when sharing data with other members. There is no room for flexibility, nor for protecting the vendor’s proprietary data structure.

Compare that to the government’s approach, which has been to create pages and pages of requirements to achieve interoperability with the entire universe. The regulations themselves are long and verbose – and slow to be approved. Sometimes means that by the time they are released, they are outdated and miss the mark in terms of advancing interoperability. The ONC announced it is looking for public input on how to measure the country’s progress toward achieving interoperability, so that we’ll be able to recognize when health information exchange goals have been achieved.2 In other words, the government is still trying to figure out how best to define, measure, and achieve interoperability.

Meanwhile, healthcare vendors and providers are stuck in turf wars. Unfortunately, the turf wars aren’t the Betamax vs. VHS kind, but involve the life and death of patients.

As an industry, we have to get past making decisions based on the profitability of a particular line item and on protecting our pieces of real estate. Instead, we must adopt ways that create a better universe for delivering healthcare, for avoiding unnecessary procedures that waste billions of dollars, and for producing better patient outcomes.

If the government really wants to reduce healthcare costs, it needs to start at the ground floor, define its expected outcomes, simplify and rigidize the details of its regulations to achieve those outcomes, and focus on setting the stage for how everyone speaks to one another. Perhaps, rather than attempting to hit a lead-off home run, we should start with smaller wins and establish a subset of requirements and build on those each subsequent year.

After all, isn’t it about time we toppled healthcare’s Tower of Babel and achieved true EHR interoperability?