Value-based Interoperability: Less is more

flying cadeuciiInteroperability in health care is all the rage now. After publishing a ten year interoperability plan, which according to the Federal Trade Commission (FTC) is well positioned to protect us from wanton market competition and heretic innovations, the Office of the National Coordinator for Health Information Technology (ONC) published the obligatory J’accuse report on information blocking, chockfull of vague anecdotal innuendos and not much else. Nowadays, every health care conversation with every expert, every representative, every lobbyist and every stakeholder, is bound to turn to the lamentable lack of interoperability, which is single handedly responsible for killing people, escalating costs of care, physician burnout, poverty, inequality, disparities, and whatever else seems inadequate in our Babylonian health care system.

When you ask the people genuinely upset at this utter lack of interoperability, what exactly they feel is lacking, the answer is invariably that EHRs should be able to talk to each other, and there is no excuse in this 21st iCentury for such massive failure in communications. The whole thing needs to be rebooted, it seems. After pouring tens of billions of dollars into building the infrastructure for interoperability, we are discovering to our dismay that those pesky EHRs are basically antisocial and are totally incapable or unwilling to engage in interoperability. The suggested solutions range from beating the EHRs into submission to just throwing the whole lackluster lot out and starting fresh to the tune of hundreds of billions of dollars more. When it comes to sacred interoperability, money is not an object. It’s about saving lives.

Every EHR vendor flush with cash from the Meaningful Use bonanza is preparing to take its unusable product to the next level, machine interoperability is shaping up to be the belle of the ball. A simple minded person may be tempted to wonder why people who, for decades, manufactured and sold EHRs that don’t talk to each other, are all of a sudden possessed by interoperability fever. The answer is deceptively simple. After exhausting the artificially created market for EHRs, these powerful captains of industry figured out that extracting rents for machine interoperability is the next big thing.

The initial pocket change comes from selling machine interoperability to their current bewildered (or stupefied) clients, and to less fortunate EHR vendors. But the eventual windfall will not come from the health care delivery system or the hapless patients caught in its web. How much do you think access to a national and hopefully global network of just-in-time medical and personal data is worth to, say, a pharmaceutical company giant? How about life insurance, auto insurance, mortgage, agribusiness, cosmetics, homeland security, retail, transportation? Google built an empire by piecing together disjointed bits of personal data flowing through its electronic spider webs. What do you think can be built by combining everything Google knows with everything your doctor knows and everything you know about yourself?

Machine interoperability is not about patient care in the here and now. Interoperability is not about ensuring that all clinicians have the information they need to treat their patients, or that patients have all the information they need to properly care for themselves. Interoperability is about enriching a set of interoperability infrastructure and service providers and about electronic surveillance of both doctors and their patients. Machine interoperability is about control, power and boatloads of hard cash.

For example, if you are hospitalized, it makes sense that your primary care doctor should know that you are (not in the past tense), and when you are discharged, he or she should be appraised of what transpired during your hospital stay. In the old days, before the advent of hospitalists, this could be assumed. Today, thanks to more efficient division of labor, not so much. If the government was genuinely concerned about smooth transitions of care, it would mandate that upon discharge, hospitals must provide all pertinent information to the primary care doctor, and the patient, by any means necessary. If this meant that a piece of paper is stapled to the patient’s robe, and that the hospital employs an army of delivery drones for the purpose, so be it. Eventually, hospitals, which are big businesses, would come up with the most cost effective and efficient way to be compliant with the law.

That’s not how things currently work or how they are envisioned to work. Discharge summaries have a mandated format of structured data elements, complete with metadata, based on government approved standards that change with frightening regularity. Furthermore, to satisfy regulations, the summaries must be generated and transmitted electronically from one “certified” EHR to another, allowing for a host of intermediaries to access and collect said data or at the very least its metadata. Consulting with the PCP by phone for an hour doesn’t count. Sending the information from a non-certified software package doesn’t count. Printing and sending over information by special courier doesn’t even begin to count. Attempting to build a device that streams the information as it happens directly into the PCP medical record will get you excommunicated or burned at the stake.

If you refer a patient to cardiology service, and in a misguided senior moment decide to pick up the phone and talk to the cardiologist at length about this patient, it doesn’t count. If the cardiologist pens a concise and beautiful letter to you after she sees your patient, thanking you for the referral and summarizing her impressions and plan of care in proper English, it doesn’t count. The only thing that counts is a lengthy clinical summary containing all the sanctioned data elements sent from you to the cardiologist, copied in its entirety and returned from the cardiologist to you, hopefully with some indication about what happened during the consult. Having your EHRs talk to each other this way is considered interoperability. Whether you actually read the interoperated information is irrelevant. As long as the contents are captured by the network for other uses, it’s all good.

But wait, there is more. If you practice, say, in St. Louis, Missouri and work for a huge health system or somehow managed to string together a machine interoperable network with the twenty or so specialists you use on a regular basis and the four hospitals where you have admitting privileges, that’s not good enough. Nothing is good enough unless any research lab in Hopewell, New Jersey or Bangalore, India can discover you on the (inter)national interoperability network and request data about a patient you may have treated five years ago, and nothing will be good enough unless any app store developer in Cupertino, California can discover your patient and subsequently obtain her medical data once she downloads a free diet app from iTunes.

Are you “just” a patient eager to be “engaged” in your own care? Picking a doctor who will spend two hours with you listening carefully and explaining things you don’t understand, and who will give you his cellphone number in case you have more questions, doesn’t count. Getting a team of physicians together on a conference call to brainstorm about your mom’s options, doesn’t count. Building a long term relationship with your pediatrician and having her come see your sick kid at home because your car is in the shop and your toddler can’t keep any food down, and now the baby won’t stop crying, doesn’t even register on the interoperability radar. Nothing counts unless you log into a website or an app, accept the cookies, the tracking beacons, the small print, and then click on some buttons to verify that you are a “Never smoker”, or to peruse machine generated visit notes that even your doctors don’t read anymore.

Perhaps machine interoperability on a national scale is a wonderful thing, but so is having arugula in every fridge. There is absolutely no evidence that either one will improve health and/or reduce the price of care. Every dollar spent on national machine interoperability is a dollar that was previously used, or could be used, to provide medical care. Where did we find the moral fortitude to demand that people experience adverse outcomes at least three times before letting them have a slightly more expensive pill, while spending billions of dollars to incentivize the purchase of unproven and often failing technologies? If we are supposed to be parsimonious in our use of health care resources, if we are supposed to choose wisely in all other areas, where is the comparative effectiveness research showing that expensive machine interoperability on a grandiose global scale provides more value than cheaper and simpler localized or human mediated communications?

  • Add one doctor visit for every Medicare beneficiary for the next 8 years
  • Give primary care a 20% raise for the next 4 years
  • Double the number of residencies for the next 3 years
  • Educate 60,000 new primary care doctors from scratch
  • Buy an iPhone glucose monitor for every diabetic patient and an iPhone BP monitor for every hypertensive patient (no, I’m not a “technophobe”)
  • Put a brand new playground, a gym teacher and a home economics teacher in every elementary school in the U.S.
  • End homelessness in America

These are some of the things we could do with the billions of dollars spent on machine interoperability. Which has more value for our collective health? How did health care become a fully owned subsidiary of the computer industry? Who authorized this unholy acquisition and how much were those brokers paid? Have we forfeited our right to choose, or even know, how endless fortunes are steadily interoperating out of our treasury and into the hands of global technology firms? Publishing fuzzy ten year plans on obscure websites, so the Technorati can tweak them, doesn’t count. Publishing thousands of pages of regulations in the federal register, so interest groups can preview the fruits of their labor, doesn’t count either. Raiding public coffers to please friends and family and to curry political favors is hardly a disruptive innovation, so let’s just call it what it is.

<em>Margalit Gur-Arie is an author, entrepreneur and a partner at BizMed</em>

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36 replies »

  1. Wow, what a fantastic piece! And what a great discussion, save for the HIT guy who seems to think that because it’s hard that proves we should do it.
    I personally think that some combination of name plus a thumbprint scanner would do the trick relatively cheaply. They cost about 100 bucks on Amazon. My meaningful use stage 1 check could have bought about 180 of them, and would have been money better spent.

  2. Superb. Unfortunately, I fear the Medicare “doc fix” will allow the EMR masters to keep up their momentum, as doctors’ pay will be very subject to measures as reported by EMR.

  3. Hold on. You can’t go after people when they build closed systems and then turn around and go after the movement to open them up ..

  4. Medical care is getting worse, not better, directly proportional the the $$$ spent on HIT.

    Agree. Spend it on medications, homeless, infant mortality, ghettos, nurses, nutrition.

    The government has treated the HIT vendors to $$$$. Instead of HITECH, they should have called it the “Great EHR Vendor Welfare Bill of 2008”.

    Would you not rather spend that money on the indigent and downtrodden, or hand it over the the millionaire EHR vendor CEOs?

  5. Now now, broccoli in every fridge, as long as it is ingested, will improve health!

    Hitech has been a collossal failure. MU does not improve outcomes. Interoperability will waste even more time of health care professionals.

    One EHR for all in the land is the only solution.

  6. Makes a person want to go back to Telnet. What fun that was. This was before even TCP/IP. It was a hacker’s seive and was replaced by SSH. There is an Open SSH also. This allows one to use passwords and encryption and take over a target OS and computer. I think the weakness today would be with images.

  7. “Perhaps machine interoperability on a national scale is a wonderful thing, but so is having arugula in every fridge. There is absolutely no evidence that either one will improve health and/or reduce the price of care. ”

    Well said! Somehow we need find a way to pull the plug on the ehr mandates/incentives and penalties if the digitization of health records is ever going to evolve in a way that adds value to doctors and patients.

  8. Clinical Support Systems are generally accepted as having the power to improve the quality of healthcare. This article raises valid questions of cost benefit analysis although it does so with a lot of whining and complaining. People are treated by multiple providers in multiple locations. Doctors need clinical data from many sources pulled together to make accurate diagnoses.

    Let me now toss out some problems that an interoperability healthcare IT data architect works with on a daily basis and see how well you do at solving them. Let’s start with patient identity. A patient arrives at an emergency room in an unconscious state. His name is John Smith and he lives in New York City. Sometimes the date of birth is not enough to identify someone but it is commonly used. You are the ER doctor. Does he have drug allergies? You can’t ask him. What is his blood type? You don’t know. Has he been in this hospital before? Which John Smith is he? You look up the addresses for all your John Smiths none of which match the one on an item in his wallet. Is he an existing patient? Did he move? Is he an organ donor? He has no drivers license. All you have is questions. How can you be sure of who he is? If there was a state or a national Health Information Exchange, chances are you could find this name and this address. But he may never may have been at this hospital. Is there a cost benefit here? Yes! I could go on and on. The vast majority of people have no understanding of the difficulties of Healthcare IT.

    Patient data exists in various vendor silos which are not compatible with each other. This is because the medical data has been coded differently (blood type A+ = “A+” in one but blood type A+ = 10289 in another) . If one exchanged the patient data, it would be meaningless to the other system. So standard international sets of codes are used when exporting data outside an EHR system. Everyone translates to the international code set and a meaningful exchange of data is possible. What is the problem? Well it takes years and many subject matter experts to do these translations and create these international healthcare data standards. It is an on going effort.

  9. These are very good questions being asked here. To understand the real issues here, one needs to delve deep into the workings of Healthcare IT data architecture. Please see healthcareITINteroperability dot com for explanations of these issues. This site was written to explain the complexities of medical terminology, data exchange betwen EHRs, and interoperability.

  10. We’ll “solve” interoperability by defining it down into operational meaninglessness (i.e., we’ll simply give in to more complex workflows).


    Gasoline powered automobiles are “interoperable” is two senses.

    [1] They all run on gas available from ANY gas station (“standard data”), and,

    [2] The “user interfaces” are functionally “standard” as well — both the info “dashboards” and the physical manipulation “interface” tools.

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