Self-Congratulation on HIE Advancement Would Be Premature at This Point

June 25, 2018
Even as many healthcare IT leaders are helping to facilitate major advances in health information exchange, a recent phone call with a good friend confirms that very major gaps in HIE remain, at the most basic levels

Even as many healthcare IT leaders are justifiably congratulating themselves on the recent advances they’ve made in the arena of health information exchange (HIE), both in its formal sense and more broadly, reports from the trenches speak to the vast gaps in efficient, effective clinical communication that remain.

Take for example the current medical odyssey that a married couple who are good friends of mine are experiencing. I’ll call my friends “A” and “B.” A is the husband, and B is the wife. They live in one of the nation’s largest cities, one known for the excellence of its patient care—which plays into this story. In any case, A is 47 years old and B is 45. They are generally both robustly healthy. But a few months ago, A began experiencing serious symptoms, including fainting, very poor sleep, and chest pain. And, a couple of months ago, after he had fainted and gone unconscious at home, he was rushed to the emergency department at the suburban hospital near to where A and B live. So far, after many diagnostic tests and other diagnostic work, he has received a preliminary diagnosis of sinoatrial node dysfunction, though many questions remain to be answered. Most patients with cases like A’s will need to have a pacemaker implanted, but his physicians are taking him through a battery of tests to help them obtain diagnostic certainty, given the seriousness of pacemaker implantation, especially at his age.

Now, here’s where the health IT and interoperability and health information exchange issues come in. A and B have been having a terrible experience with those issues at the suburban community hospital to which A was rushed a couple of months ago via ambulance. Let’s call it Happy Suburban Hospital. B isn’t certain exactly what kinds of health IT capabilities Happy Suburban Hospital has, but they clearly are substandard. They handed her several CDs, containing A’s CT and MR scans and echocardiograms, and she had to snail-mail them to the tertiary/quaternary care hospital down the road, which I’ll call Big University Hospital. Shockingly, with regard to associated paperwork and documentation, B ended up having to go to her own work office to fax piles of printouts she had received from Happy Suburban, to Big University.

What’s more, B told me in a recent phone call, she had had to make four separate trips to the medical records office at Happy Suburban, where she received poor service and experienced lackadaisical attitudes on the part of the medical records office staff.

So A and B are having two experiences here. The first is with the core clinical situation, which involves great uncertainty for A and for them as a couple and, with their children, as a family. There have even been numerous complications there, in terms of handoffs, in terms of communications between and among primary care physicians, hospitals, specialists, and subspecialists, that are too complex to explain clearly. But in any case, that is one situation.

The other, though, has to do with this incredibly frustrating experience of dealing with a lack of interoperability and data flow between and among the various clinical parties. Patients and their family members are still having to fax basic documentation, and to snail-mail CDs with diagnostic images on them, now, in the middle of the year 2018?

What’s particularly frustrating here is that the technology absolutely is available, through HIE arrangements, the DIRECT program, and other means, to move this key data and information appropriately from one patient care organization to another, and from one clinician to another. So part of the core problem is process and human and organizational, not technological. As Robert Wachter, M.D., states in his 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, “[T]he speed with which health IT achieves its full promise depends far less on the technology than on whether the key stakeholders—government officials, technology vendors and innovators, healthcare administrators, physicians and other clinicians, training leaders, and patients—work together and make wise choices.”

Indeed, in his chapter, “A Vision for Health Information Technology,” Dr. Wachter, in the middle of a several-pages-long description of his vision of the electronic health record (EHR) future, writes, “All patient data will reside in the medical cloud, which will provide the essential infrastructure to ensure complete interoperability. Successful EHRs will be open, not by legislative fiat but because closed systems will be unable to compete in market that demands that useful apps developed by third parties be accepted. Ditto usability: the government will not dictate usability, the market will, and it will do so effectively.”

What’s more, when Dr. Wachter delivered a keynote address at our Health IT Summit in Beverly Hills on Nov. 3, 2015, he spoke of some of the process and organizational changes that will need to take place before technology that either is already available or is beginning now to emerge, can successfully be used for optimal benefit. With regard to all the disruptive changes now buffeting providers, Wachter said, “In my book research, I did not find that there were bad people at Epic or Cerner or in the government or in hospitals, or anywhere. Everybody’s trying to do their best. But part of the problem is that we treated computerization in healthcare as technical change, meaning that you turn it on and follow a series of steps; and we thought healthcare IT would be like that, like turning on an app. But in fact, technology has posed adaptive problems: it’s been about people having to change because of technology implementation.”

So on the one hand, Wachter said, “It’s natural to think that you just put it in and it will work. But we all kind of whiffed on it. And now we’ve learned. And Erik Brynjolfsson in 1993 coined the concept of the ‘productivity paradox’ of information technology, across all industries. The idea was that there will be an inevitable delay in the productivity gains expected from computerization. And then somewhere between years five and 15, you see major gains in productivity. Brynjolfsson says there are two keys. First is that you see improvements in the technology. The second key is that people begin reimagining the work itself.” And that, Wachter said, is exactly what is beginning to happen in healthcare, as automation begins to afford possibilities for true process transformation in healthcare delivery.

Things will continue to be rocky and complicated for a while, Wachter concluded in his November 2015 address to our Health IT Summit, but he said that healthcare leaders need to be prepared for the profound changes in re-visioning what healthcare delivery will be like, that will come soon enough. And with regard to technology, he said, “It’s a standard response to change: people don’t know what they want or need from a new system until they’re using it. Henry Ford said, if I’d asked people what they wanted” before he had invented the automobile assembly line process, “they would have said, faster horses.”

Sadly, my friends A and B have come away from their ongoing medical odyssey with the sense that, in terms of health data exchanges, we in the healthcare delivery system are still using horses. Now, to be fair, advances are being made in many places, advances that in the future could help A and B and A’s caregivers in future episodes of care. For example, as Senior Contributing Editor David Raths learned when interviewing Laura Young, interim executive director at healtheConnect Alaska earlier this month, that state’s statewide HIE, that organization is working developing on a radiology image exchange with a company called Ambra. Imagine the potential of that system for diagnostic image exchange, in a state as large as the entire Upper Midwest (Minnesota, North and South Dakota, Iowa, Missouri, Iowa, Wisconsin, Illinois, Michigan, Indiana, and Ohio) states combined. It is well-known that distances are immense within Alaska; the electronic sharing of diagnostic imaging studies could be an important breakthrough there.

Meanwhile, my friends A and B would be thrilled in Happy Suburban Hospital could get its act together to get images and data on A’s tests and conditions just three or four miles to Big University Hospital. So before anyone gets overly self-congratulatory about the successes to date of HIE in the U.S., let’s keep in mind that there are countless stories like that of my friends A and B out there.

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