Maybe you haven't heard but interoperability is all the rage these days. At the recent HIMSS16, HHS Secretary Sylvia Mathews Burwell announced a major push forward in the effort to achieve interoperability of EHR. Companies that provide 90% of EHRs used by U.S. hospitals, including Epic and athenahealth, have agreed to increase patient access, no information blocking, and adoption of federally recognized interoperability standards.
But those goals are easier said than done. And will they really improve EHR workflow and patient care?
A lack of standard dialogue
Current estimates are that less than a quarter of the data being aggregated in EHRs are actually useful in addressing health outcomes and improving value in the healthcare system, said Douglass Given, founder and CEO of Health2047, a San Francisco-based healthcare innovation firm. “This is a result of diagnostic codes not talking to procedural codes, not talking to functional outcomes codes, not talking to patient attribute data represented largely in free text."
“In order for the data we collect to become actionable, we need truly connected, networked, and mobile EHR solutions, with the physician-patient relationship centrally positioned,” Given said.
Doctors and health systems must also keep up with a mounting influx of data that will need to be systematically captured and characterized — including massive amounts of patient-generated health data such as steps walked or how someone feels as they check there blood glucose, said Dr. Jennifer Schneider, CMO at Livongo Health, which offers a product that captures real-time data and provides recommendations to people with diabetes. The data is also integrated into EHRs to improve provider access to the information.
“As these new data points have emerged, we have not developed a standard ontology with agreed upon definitions to map this data throughout the system.”
Quality can be frustrating
The sheer effort to keep up with the government’s EHR, Meaningful Use and HIE requirements are taking a toll on patient care and providers, experts say.
A report in the March issue of Health Affairs found physician practices spend an average of 785 hours per doctor and $15.4 billion annually reporting quality measures to Medicare, Medicaid and private insurers.
“While much is to be gained from quality measurement, the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report,” the researchers wrote. Among the obstacles physicians cited were lack of interoperability across EHRs and lack of EHR functionalities to aid in retrieving data for quality measures.
The effect this is having on quality of care and costs is obvious, said lead author Lawrence Casalino, with Weill Cornell Medical College. “Perhaps less obvious is the dissatisfaction and cynicism about measuring quality that the problems described in the article provoke in physicians.”
Indeed, one family practice responding to the survey complained of being “so focused on making sure you are clicking all the right fields in the EMR that you lose touch/connection with the patients.” Another, an orthopedic practice, described the effort to meet minimum use and PQRS quality measures as a “complete waste of time” because the measures are geared toward primary care and cardiology.
A race to the middle?
While EHR workflow and interoperability continue to be a major challenge for physicians and hospitals, there are a growing number of companies that are offering solutions.
One that shows particular promise is middleware, software that helps to connect the various pieces of information across a care continuum and make different EHRs interoperable. The technology is already used successfully to link disparate data in the banking and manufacturing industries.
Think of middleware as tubing through which information flows. The middleware software sits within the data pipeline and translates data from disparate EHRs, creating a business intelligence layer that provides information in real time.
It can also be used to construct workflows or to customize applications for specific physicians or hospital units. Middleware can “address patient issues, physician and clinician issues and also not break the IT budget, because right now custom developments are very expensive,” said Donald Voltz, head of anesthesiology at Aultman Hospital in Canton, OH.
With middleware, “we can develop applications that are agnostic to the platform where the data are stored,” he added.
Middleware offers “the basic layer in the data switch” so users can connect to any source, any EHR vendor, and the application works in the same way, said Thanh Tran, founder and CEO of Zoeticx.
The technology also has implications for population health. The San Jose, CA-based startup recently teamed up with WellTrackOne to bring interoperability to hospitals and clinics offering CMS annual wellness visits. The partnership uses Zoeticx’s middleware platform to integrate WellTrackOne patient reports and related health data with EHRs, HIEs, and other databases.
Arcadia Healthcare Solutions, headquartered in Burlington, MA, also offers a middleware solution. Its EHR data aggregation and analytics platform integrates data from 30+ EHRs, along with claims and operational data, to enhance care quality, provider efficiency and financial results.
To build trust among its various stakeholders, Arcadia does a number of things, including extracting directly from core data to capture information that may be missed in HL7 and CCD feeds, said Jonathan Cook, Arcadia's CTO. The implementation process also includes a detailed data quality assessment, and there are ongoing data quality checks against source and destination systems.
Big EHRs have been slow to endorse the middleware concept, however. Epic spokesman Eric Helsher said the firm’s sites share patient information with other organizations ‘without the need for a central technology.” He added that widespread data exchange requires a central trust framework, such as that developed by the public-private Carequality partnership, “so that health systems don’t have to make individual exchange agreements with each trading partner.”
The great interoperability conundrum
Health2047, the San Francisco startup, is also working to solve the interoperability quandry. The firm, whose founding partner is the American Medical Association, plans to take on some of healthcare's most challenging issues, including connected health solutions.
“Health2047’s work on EHRs will focus on user experience and quality because we believe that enhanced usability and desirable features will be what drive adoption,” said Given. “Curating all valuable data streams, supporting patient situational awareness, security, user experience, and symantec data interoperability are the precedents for this next-generation healthcare cockpit information system.”
Elsewhere, Commonwell Health Alliance, a group comprised of some of the top U.S. EHR vendors, is working to improve patient identification in disparate databases and provide the capability to share that information.
Patient identification is key to enabling true interoperability, said Mark Hollis, CEO of MacPractice, a medical management software firm. Currently, there’s duplication of medical record and account numbers across the healthcare system and there’s no way of easily determining which Jane Doe is the right one in a medical emergency. “Identifying every system and database that a patient is in … that number is unique in that database,” he said.
As for interoperability, “most of us [vendors] think it’s never going to happen," said Hollis. Why, he asked, would the government require EHRs before creating a national identifier system for patients?
Voltz is doubtful, too. “If you look at each vendor themselves and their development, they may come together to standardize some of the models where they store data or at least provide another layer where they can transfer data back and forth,” he said. “But the real problem is will the systems be open enough to allow for development of more sophisticated data—whether they’re data products or clinical products—that can be displayed on top of any platform.”
That’s where middleware’s promise lies, he said.