Looking for Interoperability in All the Wrong Places

To achieve interoperability, simply reduce the cost of interfaces. The economic value will follow.

Vendors, hospitals, patients and the states are all the wrong places to look for interoperability. Vendors prefer to lock-in their customers, differentiate their product and derive revenue from interfaces. Hospitals prefer to lock in their patients, differentiate their service and derive revenue from pricing power in the marketplace that results from consolidation. Patients confused by the technical nature of interoperability are easily misled into erecting privacy barriers that obscure quality and cost transparency. Finally, the states spend federal money designed to seed interoperability following established bureaucratic and political paths dominated by unchallenged input from vendors, hospitals and misinformed patients.

The cost of interfaces is the sum of Identity, Consent, Transport, Software and Opportunity. Reducing the cost of all five to near zero is possible and relatively easy. The Web and DICOM interfaces to radiology systems demonstrate many of the details at a large scale and for over a decade.

Identity can be free and easy if it’s voluntary to the person or system being identified. On the Web, identity is an email address. Email is free and available to all, even if they have to go to the library to use it. Email IDs are voluntary, you can use one or another as you choose without prejudice or permission. For a system example, DICOM interface IDs are IP (Internet Protocol) Addresses. They too are free and voluntary. The Direct Project is healthcare’s version of a free and voluntary ID for people and for systems. For both patient and clinicians, Direct Project identity is based on email addresses. Patients can already get a free Direct email ID from Microsoft HealthVault. Doctors can get one from Surescripts/AAFP for $15/month and free options are sure to follow. Free, voluntary identity eliminates one of the major costs of health information exchange: the Master Patient Index (MPI). MPI is one of those technologies that costs more the larger it gets. It’s time we abandon MPI as a path to interoperability.

Consent can be free and easy when the patient makes the connection directly. On the Web, consent is typically handled by the OAuth protocol. It allows you as a subscriber to the New York Times to grant The Times limited access to your list of friends on Facebook. In healthcare, DICOM interface consent is handled by an administrator entering the same application name into two or more systems. Neither OAuth nor the DICOM consent systems involve the software vendor and there is no interface charge. OAuth has already been recognized by both the Markle Foundation and the ONC HIT Standards Committee Power Team. It eliminates the paper and much of the cost of managing consent in a proven and scalable way.

Transport is an obvious requirement for interoperability. Internet transport is the foundation for the Web, DICOM, the Direct Project and the Markle Blue Button Download Capability. Internet transport is basically free because it’s hard to put up pay walls. By comparison, transport that requires Health Information Exchanges is costly and probably unsustainable. HIEs can have a role in interoperability but assuming them as a transport layer raises the cost of Identity, Consent, Software and Opportunity. As HIEs struggle to find a sustainable business model, transport paywalls are a shaky foundation to build upon.

Software can (and some say should) be Free. This is particularly important for interfaces. Free software is at the core of both Web and DICOM. Free email and Direct Project software is readily available and in clinical use. Unfortunately, additional software for healthcare interoperability is hamstrung by a tradition of standards such as HL7 that pose a barrier to small open source software developers. Interoperability will require free and open standards compatible with free and open source software. In healthcare, open source software could also be a matter of ethics.

The fifth major factor driving interoperability is the Opportunity cost of interfaces. This is the cost of increased competition seen by hospitals and lost revenue streams seen by vendors. This cost seems large in the short term. In the long run, increased competition and interoperability are essential to our health and to the health of our economy.

The right place to look for interoperability is on the Web with patients and individual doctors in control using open source interfaces. Let’s all urge the current cast of stakeholders, the vendors, hospitals and public servants, to look beyond the paywall and move on for the health of us all.

Adrian Gropper, MD is a founder of MedCommons and consulting on health services strategy at He is driven by the vision of doctors and patients collaborating around shared health records on the Web.

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Rafael RichardsprashantRupert Fawdry, FRCS, FRCOGArno Recent comment authors
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Rupert Fawdry, FRCS, FRCOG

More 30 years after we started to use Microcomputers in medicine there is still only one large group of people in Britain who have a fully inter-operative medical record! ( JRSM Oct 2011 for a full review) However every person in the whole of the K.K. in this group has a totally inter operative medical record whereby any health care worker anywhere worldwide can access all the medical history and all the laboratory and imaging results and all the information about any recent hospital admission. This magical breakthrough in IT technology started in the 80s here in Milton Keynes and… Read more »


This is an interesting post, in particular I find the part on HL7 true and others have already started attempts to simplify this problem see The part I disagree, as a developer, is that using Open Source will reduce your cost as there is no licensing. If it were true projects like OSCAR would be dominating our industry — but the reality is these projects have a lot of configuration and you still bring in the experts for support and training (the only advantage it gives you a little amount of flexibility on choosing who you are going to… Read more »

Rafael Richards
Rafael Richards

Agreed completely. We must move forward and away from both antiquated and proprietary systems and standards, and into both open source and web-centric technology for our healthcare information infrastructure. Open, modern web standards: HL7 is one of the biggest barriers to moving forward with healthcare interoperability. HL7 is over 35 years old, which predates the internet and any of our networking, transport (TCP/IP, etc.) or security protocols (SSL) It lacks any intrinsic capability to provide semantic interoperability. HL7 is simply a one-way instant message protocol that blindly broadcasts data over a port. It is like a radio station that you… Read more »