Hospitals can have hundreds of IT systems. Vendors have built proprietary databases. Not everyone follows the same standards. Health systems fear sharing data with competitors. Policymakers have not focused on health information exchange or EHR usability.
These are just a few of the reasons why true interoperability of health information remains so elusive, according to a panel of informatics luminaries.
"Technology is only one obstacle to interoperability," said Gilad Kuperman, MD, director of interoperability informatics at New York-Presbyterian Hospital, who moderated the panel at the just-concluded American Medical Informatics Association (AMIA) Annual Symposium about why interoperability is "taking so darn long.
"Charles Jaffe, MD, CEO of standards development organization Health Level Seven International (HL7) described a "circle of blame" involving government agencies and regulators, hospitals and healthcare systems, technology vendors, clinicians, academicians like those at AMIA and, yes, standards development organizations (SDOs), such as HL7. "The policy always preempts the technology," said Jaffe.
"And just like [in the 1983 Cold War movie] WarGames, in this finger-pointing, no one wins." He noted that not-for-profit HL7 in September made most of its standards and other intellectual property available free as a means of building trust for HL7 communications messaging. "Without trust, none of this is possible," Jaffe said.
Harry Solomon, interoperability architect at GE Healthcare, and a lecturer at Oregon Health and Science University, explained the road to interoperability with four numbers: 2, 4, 3 and 5.
There are two overarching concepts that need to be defined, namely interoperability and standards, and Solomon said "good enough" definitions exist from Institute of Electrical and Electronics Engineers (IEEE) and the International Organization for Standardization, known as ISO. Therefore, healthcare should not have to do any more in this arena. "We can't afford to have custom integrations for every data transfer that we have," Solomon advised.
The number 4 stands for the levels of interoperability specification: workflow, messaging, format, vocabulary.
The other two numbers represent three phases – standards development (generally handled by an SDO), product development (vendors), and system deployment (users) – and five process steps for each phase.
These steps include: the decision to proceed on each phase; allocation of resources; development; validation; and deployment.
Healthcare IT has been burdened by too many standards, offered University of Pennsylvania sociologist Ross Koppel, a former chair of AMIA's evaluation working group, and a frequent critic of large, established EHR vendors. For example, he said, there are 40 different ways to record blood pressure in EHRs, and perhaps three of them are "proper" from an informatics standpoint.
Koppel argued that meaningful use stems from a plan hatched by vendors 30 years ago to sell more software with the help of government subsidies and did not always have interoperability in mind. Koppel said that a 2009 New England Journal of Medicine article by then-national health IT coordinator David Blumenthal, MD, Ashish Jha, MD, and other Harvard researchers that heavily informed Stage 1 meaningful use regulations did not ask a single question about usability, patient safety, interoperability, data standards or what Koppel called "clunky interfaces."
One attendee, David McCallie Jr., MD, the vice president of medical informatics at Cerner, challenged Koppel's assertion, saying that vendors got together with ONC and created the open-source Direct Project that anyone can use right now to exchange health information securely. The complexity comes from incorporating it into EHR code and into workflows.
McCallie further noted the speed in which the industry developed the continuity of care document. "It happened in two years, which in standards terms is lightning fast," he said.
Koppel was more praiseworthy of the new Stage 2 rules. "I really appreciate what has been done in MU2. It's a marked step forward," he said. He also acknowledged that health IT has so many components, complexities and "moving parts," making interoperability particularly difficult.
Solomon said that interoperability often falls off the priority list when vendors update products, and urged AMIA members to demand it.
"Interoperability is not an unachievable goal," Solomon said. He cited the DICOM standard in radiology that is essentially universal today.