“Only connect,” E.M. Forster famously wrote in his Edwardian novel “Howards End.” Although Forster was referring to joining prose and passion, these two simple words seem to sum much of our information needs, frustrations, and desires in the digital age of healthcare.
When proprietary or disparate IT systems or devices need help connecting to other programs or networks, their administrators often turn to middleware—software and hardware solutions that provide a sort of magic interoperability link between systems and operations that speak different digital languages and feature incompatible data formats. The aim is to bridge information technology gaps and deliver usable data seamlessly to end users on demand while facilitating increasing needs for big data that can be easily procured and restructured, analyzed, and wrung for answers and efficiencies by health systems, care givers, and patients alike. Reducing risks and building in value along the way are part of the process.
HMT asked its expert panel of healthcare middleware solutions providers about key trends in getting systems to talk to each other and share information, what the challenges are that healthcare systems and users face today, and how their latest products and services can address interoperability challenges.
We’re at an “EMR 2.0” moment, in which many hospitals are asking themselves, “Now what?” After years of effort to implement EMR systems and document meaningful use, hospitals are looking for more ways to extract value from the data they are collecting. We’re finding that tactical integrations focused around RTLS and intelligent tracking technologies are of increasing interest because they offer care facilities quick and measurable results for improved efficiency.
Learn about STANLEY Healthcare’s latest middleware/interoperability product solution here
Todd Winey, Senior Advisor, Strategic Markets, InterSystems
Middleware has evolved from a simple enabler of data communication between analyzers and laboratory information systems to a provider of business intelligence capabilities that generate metrics and key performance indicators for managing the business. The market has expanded to include workflow, analytics, and text analysis.
Key to this shift is the capability to pull together test requests, results, and complete patient information on demand and then analyze and act on all of the data in near real time. For example, with access to complete patient information, lab applications can flag requests for duplicate or expensive tests for review to ensure that the tests are necessary and that time and money aren’t wasted. The trend is definitely moving beyond “just connecting” systems to actually working with data in-flight to drive workflow, analyze patient data in real time, and expand who is interacting with patient data as it changes.
Value-based care requires more coordination of information and care teams who rely on it more than ever before. Interoperability is moving from point-to-point to broadcast mode, sharing data with all approved members of the care team instantly and in real time.
Beyond traditional interoperability, middleware must also do more to actually bring new clinical data to various clinician types. Most clinicians only see the patient data pertinent to their task at hand. In a value-based world, each clinician requires more clinical context, which comes from other systems, and middleware is the vehicle to facilitate aggregating and sharing that expanded set of patient information.
The biggest obstacle to this change, as always, is not the technology, but coordinating the processes and expanded teams across different organizations that often are not under one roof.
Learn about InterSystems’ latest middleware/interoperability product solution here
Thanks to regulatory initiatives and other national movements focused on interoperability, the good news is that the industry is achieving better information flow between systems. There is greater recognition of the critical role interoperability plays within risk-bearing payment models. For instance, uptake and use of consolidated clinical document architecture (C-CDA) continues to increase based on Meaningful Use incentives. Also, Fast Healthcare Interoperability Resources (FHIR) is beginning to take hold in pilot projects and is likely to expand with strong support from industry leaders.
While these are important steps forward, the industry at large still struggles with meaningful communication between health IT systems. HL7 V2 messages, with all their variations in data representations, are still prevalent. Laboratory data outside of C-CDA messages generally remains unencoded in LOINC. And even when appropriate standards are used, there can be great variability in how they are used. Medications may be encoded in RxNorm, but use the wrong kind of RxNorm code (e.g., dispensible drug) for the context (e.g., allergy). And even with FHIR, different profiles can specify different representations for the same clinical data. So, while the availability of data (data liquidity) is greatly improving, the data normalization challenges we’re helping clients solve today aren’t going away any time soon.
Learn about Health Language’s latest middleware/interoperability product solution here
Thanh Tran, CEO, Zoeticx
Unfortunately, the trend in the middleware/interoperability space has been more of the same across the healthcare continuum of providers, CIOs, payers, and others. Large EHR vendors claim to be offering interoperability systems, but don’t.
Middleware solutions have been available for a few years already, but hospitals are slow to adopt and EHR vendors continue to throw FUD at the concept. Despite the fact that middleware is available now, offers a great economy of scale, saves hospital systems countless resources, can work with existing EHR systems, enables patients to obtain their medical records, and more, there is little movement toward adoption.
The obstacles continue to remain the same as they have in the past. Change will come when there is real interoperability of patient medical records that are locked into EHR systems. HIEs, designed to address the lack of EHR interoperability, have also failed to support care operational needs. The HIE’s data duplication architecture is more applicable to data analytics than accessibility to patient medical data for healthcare applications. This would also have to change to move forward.
Learn about Zoeticx’s latest middleware/interoperability product solution here
We see five key trends in the healthcare digital middleware/interoperability space:
- Convergence: Clinical and financial transactions will continue to converge to support the industry’s transformation to value-based care payment models.
- New protocols: New, emerging and more prevalent protocols of FHI + Web Services are being used to help supplement and support the traditional formats of HL7 and ANSI X12.
- New computing models: As cloud computing matures and becomes a logical extension of on premise systems, we see the rise of new computing models and a “smart-hybrid” approach.
- Focus on outcomes: Interoperability is not an end onto itself, rather it is becoming more widely recognized as a means to an end and a critical component of achieving the Quadruple Aim—better cost, higher quality, population health, and provider satisfaction. This holistic approach to care must be accomplished with interoperability, workflows, and analytics to drive specific improvements for targeted outcomes.
- Innovation collaboration: No group of providers, vendors, or payers can get this done alone. We live in a complex ecosystem where industry stakeholders must come together to share, collaborate, and innovate to drive better outcomes.
The biggest obstacles to innovating in the healthcare digital middleware/interoperability space are trust, transformation, and sustainability. Stakeholders must learn to trust one another as they collectively focus on shared goals. The transformation will not be a big bang where fee-for-service disappears one day and value-based care arrives the next. We need to be nimble and adapt to the transformation, making smart and relevant choices in line with changing business models. And each choice must be sustainable—able to pay for itself and serve as a building block to achieving transformation.
Learn about GE Healthcare’s latest middleware/interoperability product solution here
Richard Garcia, Vice President of Marketing, NextGate
Among other things, interoperability relies on sharing information about the same entity, whether it’s a patient or a provider. The challenge is that application systems often use their own local identifiers for that patient or provider, creating the opportunity for exchange errors.
Key trends
- Advancements in patient identity management, including facial recognition and biometrics technology that provides a two-factor authentication and identification method.
- Provider identity management and database reconciliation are becoming priorities as organizations merge, acquire, and grow nationally.
- Attribute or relationship mapping capabilities that can automatically link related information and data elements together, external to the source systems, which are often silos of data. The trend is to identify relationships and build connectivity maps that show how data is related, such as patients to their provider care network. This capability prompts data sharing of patient information with the right providers during care transitions and includes pertinent visit events (for example, discharge, radiology results, and office visits) in the patient’s medical history.
Main obstacles
- Data management limitations within EHRs. EHR data matching capabilities aren’t sophisticated enough to resolve duplicate patient records that come from a diverse enterprise at a rate and quality level needed to perform accurate analytics and timely management of patient care decisions.
- Interoperability and data sharing amongst care teams, payers, ACOs, HIEs, and other broadened partnerships. These are fragmented and cause duplicative efforts amongst teams. Difficulty remains in data standardization and process automation.
Learn about NextGate’s latest middleware/interoperability product solution here
Kristin Russel, Vice President of Product Strategy, Transcend Insights
We’re currently seeing a need for an EHR-agnostic approach to interoperability to allow data to flow freely across disparate health systems. Poor data sharing is still a main barrier toward achieving well-coordinated and contextual care that is specific to each individual patient.
Another issue we’re seeing is that access to claims and clinical data remains a major challenge. Data is often siloed and difficult to access in addition to lacking standard normalization. To address this concern, we work closely with our customers to develop systematic processes that help standardize the data that sits within our HealthLogix platform.
Lastly, another trend we’re monitoring closely is the accelerating development of healthcare apps using the SMART on Fast Healthcare Interoperability Resources (FHIR) standard. With this in mind, we are building a solution called HealthLogix Market, which is built on FHIR and will open our platform to third-party developers to create new healthcare applications and solutions for our customers.
Beyond just the data, we realize that once the data is connected and normalized, a host of other systems will benefit from access to this information. Standard FHIR Application Programming Interfaces (APIs) provide both our native as well as our partner’s non-native applications with the ability to access rich clinical, claims, and wellness data. This includes offering near-real-time access to health plan data to monitor the actual utilization of resources and outcomes.
Learn about Transcend Insights’ latest middleware/interoperability product solution here
Dustin Lake, RVP, Sales, Aventura
There is no one-size-fits-all solution when it comes to how clinicians access patient information at the point of care. Today’s clinical workflow reality involves a myriad of computers, logins, and applications, not to mention the mind-numbing process of searching for the right information during each patient encounter. A routine pattern of technology over promising and under delivering for clinicians has turned into more time with keyboards and less time with patients. The constant spotlight on healthcare data breach headlines drives the implementation of security controls, which compete with the panacea of ease of access to clinical information. Furthermore, once clinicians have endured the burden of becoming proficient with working in their EMR, a sprawling suite of supporting applications appears that clutters their desktop and workload.
There has been a convergence of a high focus on increased security, and at the same time a flood of innovative clinical applications all competing for desktop real estate and a clinician’s attention.
The concept of interoperability is the magnet that can bring all of these systems together, but interoperability is a broad term and means many different things given different contexts. The primary challenge with exchanging and utilizing information between clinical applications is coming up with the protocol to do so. Some applications expose API sets, others do not. Some support HL7 and CCOW, while others are pushing SMART on FHIR. Regardless of the protocol that is used, the EMR is typically the source of truth on the clinical desktop. As such, delivering an integrated workflow experience is largely tied to the EMR’s capability to exchange, or at an incremental level expose, the needed information.
Vendors who develop applications complementary to the EMR routinely site the capability to integrate with the clinician’s primary EMR as a critical factor for their success. Any application that adds a cognitive computing burden outside of the EMR will likely experience a dismal adoption rate among clinicians. EMRs have put a notable effort into evolving their APIs and application eco systems, and while I have witnessed success with vendors utilizing those APIs, clinicians are still dealing with a very disjointed workflow experience.
On the obstacles end, each time a clinician touches a computer there are multiple logins, long lists to search, and endless clicks; each add a toll to the mindless computing that must be endured. Multiply this by a handful of applications and dozens of encounters a day, and the net result of the security and information overload is usually frustration, followed by circumvention of the security controls that ends in abandonment. Filtering out the noise and delivering the right information, when and where clinicians need it, is one of the largest obstacles toward shifting the focus off the keyboard and back to the patient.
Learn about Aventura’s latest middleware/interoperability product solution here
John Kelly, Principal Business Advisor, and Vik Sachdev, Vice President, Smart Trading and Community Product Lines, Edifecs
The biggest trend is a move from fee-for-service to VBC. VBC requires, not just administrative and finance data, but clinical data to be exchanged and made available at point of care. From an HIT standpoint, the challenge is dealing with clinical data—which has been in silos and not standardized—and not in a structured and in a machine-consumable format.
The biggest obstacle our customers face is connecting to provider’s EMR/EHR systems in a scalable manner. Payers and pay-viders need to establish clinically integrated networks which can scale and work with a multitude of EMR and EHR systems. They need to be able add new channels for new processes for consuming and providing applicable clinical data. They are also still figuring out how to deal with the variety of clinical data and how to normalize that data for use in VBC programs such as shared savings, narrow networks, and ACOs. Of great importance, is the fact that interoperability is not just about data movement, but the incorporation of that data directly into automated care delivery processes. That transformation in delivery hasn’t really taken place yet. The innovations currently being demonstrated are really just science projects, and the key hurdle facing us, as a true tsunami of data comes online in the next 12-24 months, is about stakeholders not possessing the infrastructure to scale in an industrial strength manner. Edifecs is working aggressively to bring the power of the scale we offer in the HIPAA and supply chain world to the task of supporting highly complex, digital information exchange relationships in a world that includes hundreds of millions of consumers and millions of care delivery sites and people.
Learn about Edifecs’ latest middleware/interoperability product solution here
