Middleware has vocal champions as a solution for interoperability between electronic health record systems, but despite its potential, its future may depend less on its merits and more on whether implementation is driven by business incentives.
The question comes to the forefront as some providers back away from HIEs for sharing patient data due to issues of unpredictability and concerns regarding costs and business models.
"Systems-level glue"
Proponents of middleware tout it as an easy alternative that has proven itself in other industries such as retail, banking and transportation. The technology is often referred to as the "glue" that allows connections between databases or applications.
Tiffany Casper, CEO of EMR Consultants, Inc., which implements EHR systems for medical facilities, suggests middleware should be at the heart of an EHR's operating system. "It will enable medical institutions to seamlessly connect multiple EMRs, resulting in a convenient, consistent and universal view of patient records from a single platform, regardless of where they reside," she says.
At the same time, a 2014 study in the Journal of Internet Services and Applications provides a list of open challenges that middleware needs to meet to move beyond providing "systems-level glue" to "actively driving new functional possibilities." The paper details challenges arising from both technology-driven and population-driven developments in healthcare.
Betting on the future
So will middleware grow to play a larger role in the future of healthcare?
"That's very much how we see things," says Morris Panner, CEO of DICOM Grid, which specializes in interoperability for diagnostic imaging.
Panner tells Healthcare Dive, "The question, I think, is how do you open systems up so you can interchange data in a way that is common in many other sectors in the economy, and what shape is that going to take?"
Some of the challenges that middleware is solving today, Panner says, include "demographic normalization"—harmonizing patient information between different institutions so the right information can flow to the right patient regardless of the different naming systems and the different institutions. On top of that, it can assist in securely moving information in that software solution.
In DICOM Grid's case, the company created a patented solution that separates patients' information from their imaging data to more securely move the data. "So we take care of demographic normalization in the middleware solution, we take care of secure transfer in the middleware solution, and then we have a workflow setting in the software solution that lets you appropriately audit and control who's seeing what, when," he says.
As for comparing middleware to HIEs as a solution for interoperability, Panner notes that HIEs use a lot of this software too.
"I often take the view that technology is an enabler and that business needs and requirements tend to rule the day," he says. "And what we have right now are a set of very powerful tools that enable a lot more capability than has ever before existed, and we need the right care and business models to drive the adoption of those technical tools."