Interoperability and Toppling the Tower of Babel

Interoperability is a great concept. Unfortunately, when EHRs were first introduced, and stimulus dollars provided for their adoption, the healthcare industry failed to recognize the importance of interoperability! So today we have all these systems that can’t talk to one another. Essentially, we’ve created the healthcare IT version of the Tower of Babel.

The story of the Tower of Babel offers an explanation for how the world moved from one common language to a multiplicity of languages. Just like in ancient biblical days, the existence of multiple languages creates communication challenges. In the EHR world, interoperability tools are meant to facilitate communication so that regardless of the system, patient records can be easily shared – which in turn minimizes expensive duplicate testing, enhances patient safety, improves care coordination, and ensures more efficient and effective care. What a novel concept!

The government is now aware of the benefits of EHR interoperability and has stepped in to try to fix the problem they helped create. As the nation’s largest payer, the US government should be greatly concerned about eliminating waste and improving patient outcomes. That’s why Congress is attempting to mandate changes and the Office of the National Coordinator (ONC) created a roadmap for achieving nationwide interoperability over the next few years.

Despite everyone’s best intentions, achieving nationwide interoperability won’t be an easy task. Here are a few reasons why:

Too much variation – Because we failed to establish interoperability standards a few decades ago, data is currently collected, stored, and shared in a wide variety of ways. Take for example, state and community immunization registries that collect and store inoculation data. While you might think that standards for inoculation information would be fairly rigid, in reality most registries have their own format and criteria – making record sharing between these entities a difficult task.

Self-interest – Most EHR vendors will assure users that their platforms are interoperable with other systems. But in reality, how many EHRs really speak to one another? One popular theory is that vendors resist interoperability because they fear the loss of market share to competing products. Another reality is that while interoperability benefits the healthcare ecosystem as a whole, it also creates a direct expense with no direct compensation for providers and vendors Similarly, in order to preserve revenues, a health system may dissuade the referral of patients to outside lab and testing facilities and only offer its providers electronic record sharing capabilities within the organization’s own facilities.

Too much flexibility in standards – So far the government interoperability “standards” have been pretty flexible. Too flexible, in fact. The requirements are so variable that vendors have plenty of wiggle room in their interpretation. Interoperability suffers when standards are too loosely defined.

CommonWell Health Alliance, of which Aprima is a member, has approached interoperability a bit differently than the government and so far has set the table very nicely for achieving its goals. Unlike the government’s flexible standards, CommonWell vendors adhere to very, very detailed specifications when sharing data with other members. There is no room for flexibility, nor for protecting the vendor’s proprietary data structure. If you are going to be part of CommonWell, you must adhere to very specific formats when providing and accepting information. This approach has allowed the CommonWell initiative to grow quickly in a short amount of time and deliver actual interoperability between vendors.

Compare that to the government’s approach, which has been to create pages and pages of requirements to achieve interoperability with the entire universe. The regulations themselves are long and verbose and slow to be approved - which sometimes means that by the time they are released, they are often outdated and miss the mark in terms of advancing interoperability. The ONC also just announced it is looking for public input on how to measure the country’s progress towards achieving interoperability so that we’ll be able to recognize when health information exchange goals have been achieved. In other words, the government is still trying to figure out how best to define, measure, and achieve interoperability.

Meanwhile, we have both healthcare vendors and providers stuck in turf wars. Unfortunately, the turf wars aren’t the Beta vs. VHS kind, but involve the life and death of patients. None of us wants to waste time giving one provider after another the exact same information, nor be subjected to the exact same test multiple times. We especially don’t want to find ourselves in an ER that can’t access any of our medical history – especially if our situation is critical and the lack of records threatens the timeliness of diagnosis and treatment.

For many years Aprima has taken the approach that while we may be able to automate your practice within your four walls, we cannot control the world around you. As such, we have consistently delivered our customers huge value by making them interoperable with devices and other systems in whatever format and delivery methodology was needed. Our participation in CommonWell is expanding that mentality with a better, more structured approach, where vendors come together in the private sector to solve an issue that is larger than any single patient, provider, or vendor alone.

As an industry we have to get past making decisions based on the profitability of a particular line item and on protecting our pieces of real estate. Instead we must adopt ways that create a better universe for delivering healthcare, for avoiding unnecessary procedures that waste billions of dollars, and for producing better patient outcomes.

If the government really wants to reduce healthcare costs, it needs to start at the ground floor, define its expected outcomes, simplify and rigidize the details in its regulations to achieve those outcomes, and focus on setting the stage for how everyone speaks to one another. Perhaps rather than attempting to hit a lead-off home run, we should start with smaller wins and establish a subset of requirements and build on those requirements each subsequent year.  

After all, isn’t it about time we toppled healthcare’s Tower of Babel and achieve true EHR interoperability?

Michael Nissenbaum, Aprima President and CEO


As a long time partner of Aprima, we share your sentiments regarding the state of interoperability in healthcare. When you have so many standards, you have no standard. This creates a very difficult and expensive operating environment for healthcare providers just looking to deliver quality care. To that end and in partnership with Aprima, we are excited to roll out the Kno2 solution to the user base and help the Aprima providers tackle this exact challenge. Aprima and Kno2 are taking an innovative approach to let any Aprima provider get electronically connected to any other provider across the care continuum and start moving to true interoperability and care coordination.

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