Interoperability Needs More Than Fired-Up Buyers

Health information technology buyers have been demanding interoperability for some time, yet too many IT vendors have too often kept the door to interoperability locked tight, denying the industry $30 billion in potential savings.

On his first comedy album, Bill Cosby did a timeless bit called The Pep Talk where a football coach gets his team all fired up in the locker room before game time and then sends them forth… only to be stopped by a locked door.

This bit came to mind as I read a new report from the Gary and Mary West Health Institute, which along with the Office of the National Coordinator for Health Information Technology, held a one-day conference on healthcare IT interoperability last month.

In the report, the authors urge all buyers of healthcare IT, that's healthcare systems, hospitals, practices and patients, to insist that technology vendors make their products work well with each other, share data, and support open standards.

But when I talked to the report's author, Joseph Smith MD, chief science and medical officer at the West Health Institute, I was somewhat taken aback when he told me that healthcare IT buyers have yet to make it clear they want interoperability.

"Part of the mission we have in front of us is to make the buyers aware that there's something you can ask for, and that the vendors can innovate and provide it," Smith told me. "I don't think there's been an adequate focus from the buying side of the equation to understand that if they do specify that [products] talk using open standards, the vendors, because they're trying to sell their wares… will follow that requirement."

I would argue that buyers have been like that pumped-up football team in Cosby's comedy bit. They've been fired up and loudly demanding interoperability for some time, yet too many IT vendors have too often kept the door to interoperability locked tight, denying the industry $30 billion in potential savings, according to West Health's estimate.

During the February event, organizers asked the audience what was preventing functional interoperability in medical devices and information systems. "Their dominant answer was, [it was] purposeful strategies to maintain market share and increase switching costs," Smith said.

"The assembled audience was dominantly of the opinion that this was kind of a market failure, as opposed to not having the technology available, not having sufficient standards. They were saying that this was kind of a vendor-driven reality."

Guidance is Only a Start
My continuing concern is that just asking for interoperability without specifically naming the products that should interoperate, or the standards with which to do it, continues to give vendors a big excuse to continue their ways. Otherwise, vendors may simply say the calls for interoperability are too vague for realistic implementation.

FDA officials will have draft guidance this year on medical device interoperability. But draft guidance is not the same thing as interoperability – far from it. True interoperability is often a mixture of shared demand, technical sophistication, dogged testing and a dollop of diktat. The weaker the combined power of the stakeholders involved, the less likely they will even be at the table when the big decisions get taken about what will work with what, and how.

Another thing about healthcare that sets it apart from some other IT interoperability challenges is that it is never sufficient to simply get data from one place to another. It is also necessary to integrate that data into the workflow of those who receive the data, in such a way that the imported data practically feels like data entered by someone in the next exam room or next cubicle.

That workflow integration is itself another compromise that IT systems and stakeholders have to make, because when you get right down to it, much modern software is differentiated by the experience it affords its users – an experience expressed in the workflow of the software.

None of which is to say we should despair of striving for healthcare IT interoperability. I am pleased that West Health Institute and the Gary and Mary West Foundation have formed the Center for Medical Interoperability to drive this cause.

"We've got real people hired into these jobs, many with very deep technical chops to try to push us, because we do see this as a bit of a campaign. It's not going to be over at one meeting or with one paper," Smith said. The list of participating health systems has yet to be released, and time will tell how successful this new center will be.

ONC's Role
One thing, however, is pretty ironic about the ONC's participation in this new interoperability push. Not only did ONC deliberately pull away from issuing specific guidance of its own on health IT interoperability in 2013, it also could be argued that the meaningful use program which so far has funded $22 billion of HIT technology in the U.S. is partly responsible for our current tower of IT babel.

By only requiring a minimum of interoperability in Stage 1 of meaningful use, and marginally more in Stage 2, and meanwhile not addressing the workflow issues I've described, ONC is probably singlehandedly responsible for institutionalizing a certain level of incompatibility between systems, if not on the device side, then certainly in the EHR space.

Perhaps it couldn't be helped, but critics continue to lambast meaningful use as too much of a stimulus program, and not enough of a true systems-based approach to sharing healthcare information in this country.

I realize it's easy to sit and take potshots at meaningful use these days. The recent announcement that extensive hardship exemptions will be considered for achieving Stage 2 compliance in 2014 is a concession by CMS that the program is struggling.

But that will not stop critics, especially on Capitol Hill, from continuing to pound the table, perhaps overly simplistically, demanding the interoperability that they thought their billions were buying.