Relax Chicken Little, The Interoperability Sky is NOT Falling!

Written by: Brian Mack

There is arguably no topic in health information technology that generates more industry media coverage and online chatter than Interoperability.

There is no doubt that a nationally connected system for securely and seamlessly sharing electronic health data is an inevitable necessity. Making progress toward this goal has proven to be… challenging. But is the urgency and attention really warranted? Or has the hype blown practical consideration of the topic completely out of proportion? How do average providers and their patients feel about the access they have to information necessary to support their health? What role does (or should) provider/patient perception play in how we rank priorities and their urgency?

Particular subjects have a way of capturing our collective consciousness. That can certainly be said for those who spend a lot of time and effort wrestling with interoperability and all its challenges. What may begin as another development project, can easily be blown out of proportion. Then, before you know it, savvy HIT consultants and developers have identified the opportunity and emphasize the urgency to their clients and prospects in hopes of landing some new business. Next the various industry media pick up the narrative and develop several competing story lines, each trying to scoop the other. Finally, the cycle comes full circle, social media reinforces the narrative, until it has taken hold across the industry.

Chicken Little

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When you’re sitting in the eye of this storm, It’s easy to lose perspective on how much impact an issue may (or may not) have on the rest of the world. It’s like the story of Chicken Little. A falling acorn lands on our collective head, and before we know it, the sky is falling! This is in my view what has occurred with the “problem” of Interoperability.

The most often cited reasoning for a national interoperability standard is to assure that an individual’s health information “follows them”, and is electronically accessible anywhere in the country. This logic assumes that there is significant demand for this level of access. But is there? Let’s look at the state of interoperability in Michigan:

Great Lakes Health Connect (GLHC) is the state’s largest health information exchange, connecting 85% of acute care beds, over 4,000 provider offices, and 6.5 million unique patient records. Utilization data from one of the state’s largest health plans suggests that less than 5% of annual claims come from outside the state. If 95% of healthcare claims in Michigan are generated in state, and the vast majority of hospitals and physician offices are connected to an HIE, then it would seem logical to conclude that interoperability, the ability for providers to bilaterally share patient data across the continuum of care, has been achieved!

This is of course a major over-simplification of a very complex issue, and there’s still plenty of work yet to do in Michigan. But from the patient’s and provider’s perspective, we are well on our way to achieving interoperability; and Michigan is just one example among many states making significant strides in advancing the goals of health information exchange for their own residents.

Elephant in the Living Room

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The elephant in the living room, as was detailed in the recently released ONC Final Report: Evaluation of the State HIE Cooperative Agreement Program, is that it’s very difficult to make apples to apples comparisons of HIEs across states. The report suggested that after investing $564 million in grants from 2010-2014, issued to create tailored state-level solutions, “Health information exchange adoption and use is experiencing ‘considerable growth’, but only in a few states”. In developing the program, multiple approaches were accepted to give grantees flexibility, depending on the state/territory and its relevant ecosystem. As a result, there are now literally dozens of unique variables that distinguish HIEs from state to state, including economics, political will, organizational structure, competitive self-interest, regulatory climate, and more.

A shortcoming of the ONC report is that it focuses only on those efforts included in the Cooperative Agreement Program. In many cases, private regional HIEs are the models underpinning much of the success and progress in HIE Interoperability today.

Rather than an endorsement of a rush to a national HIE standard, the varied range of progress in HIE development from state to state highlights the need to focus concerted energy on bringing all states up to a minimum level of connectivity. Without it, establishing a national standard becomes that much more challenging.

National interoperability efforts like the CommonWell Alliance and The Sequoia Project, are important and well intentioned, but at this point may be generating more smoke than heat. To date, they are primarily focused on the utilitarian effort of getting participants connected to their networks. This technical approach does not take into account whether a state level exchange is far beyond this basic operational level, or is still in the process of getting their basic infrastructure up and operational. The net effect is that despite the good intentions of some very smart people, buy-in from some MAJOR players in the space, and huge financial investments, there remain WAY more questions than answers as to how and when they will actually be able to deliver on their promises.

Six Million Dollar Man

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All of the effort being exerted to achieve a national HIE infrastructure still misses the larger truth of REAL interoperability – the largest barrier standing in the way is not fundamentally a technical problem. To paraphrase the great health-tech and Bionics pioneer, Oscar Goldman, “We CAN build it. We HAVE the technology!”

What years of experience in the HIE trenches has reinforced is that ALL healthcare is personal. No technical solution, no matter how robust, can address the unique needs of individual providers, practices, and patients. Attempting to replace the human factor in the healthcare equation with a technical solution is a recipe for failure. Real interoperability is about building relationships between providers and there patients one interaction at a time. It’s about boots on the ground solving REAL problems, seamlessly and securely delivering critical information that enhances the physician’s insight, elevates the patient’s experience, improves the outcomes of care, reduces costs across the continuum, and ultimately contributes to a better quality of life for all involved. So by all means, let’s continue to work toward a national health information exchange infrastructure. But let’s also recognize that the sky is not falling. And as long as we maintain focus on making a difference in the lives of patients, it won’t.


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