Wednesday, May 27, 2015

Interoperability and the Trough of Disillusionment

Every technology has an adoption journey.     The classic Gartner hype curve travels from a Technology Trigger  to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.

Have you noticed that Congress and the popular press have entered the Trough of Disillusionment for EHRs and interoperability over the past month?

Congressional staffers writing the 21st Century Cures bill (which is not yet law) seem to have concluded

1) we don¹t have interoperability (although no one is sure what exactly we have and do not have)
2) therefore we need more standards and that will solve all the business, political, and policy barriers to health information exchange
3) The Health IT Standards Committee must not be doing a good job because there are not enough standards
4) Therefore we should disband it and create a new politically appointed body
5) That new body will invent all the standards we need and then force vendors to stop their information blocking behavior (whatever that is), enabling precision medicine

USA Today, in one of the most one sided articles I’ve read, confuses ACA and HITECH, ignores the data about EHR adoption/health information exchange and concludes that EHRs “don’t talk to each other”, whatever that means.

It’s time to take a step back, define our requirements, examine our current state, and then focus on closing any gaps we find.

I oversee 5,000 patient data exchanges at BIDMC every day.   50,000 patients view/download/transmit their data every month.   We’re in beta testing with apps using Apple HealthKit, connecting home devices, iPhones and our EHR.     We have numerous affiliates with bidirectional data exchange.    There are few technology limitations.  The real challenges are political and policy barriers.

The Direct protocol, although more complex than the RESTful methods used by Facebook, Amazon and Google that we should embrace, has provided a foundation for health information exchange across the country.    Below is a snapshot of the current Massachusetts State HIE (the Mass HiWay) connections to Health Information Services Providers (HISPs), creating thousands of connections among hospitals and eligible professionals nationwide.   Every week, some new practice or hospital comes knocking at the BIDMC door and within hours we can create a connection.

Interoperability is real.  Interoperability has a very positive trajectory.   Saying otherwise is oversimplifying the reality of ongoing good work in progress.

When confronted by naysayers, we have only three choices

1.  Give up and declare defeat
2.  Get angry, frustrated, and flustered by the negativity
3.  Move forward with gusto, identifying gap after gap, then solving them.   We eat the elephant of interoperability one bite at a time.

Over the past week, I’ve found myself setting aside my emotions.   I’ve redoubled my commitment to doing the right thing, hiring great people and broadly communicating the change processes needed to ensure more data is exchanged with more people for more reasons, while still respecting patient privacy preferences.

I’ve thought long and hard about the day to day criticism we hear from government, special interests, and various press resources.  We have to avoid being distracted by the politics of any given moment.  In  a year and half the federal government will change completely .  Every major political leader in healthcare IT has changed since 2013.

If we stay above the fray, work on interoperability one practice and one institution at a time, and toil diligently to enable new infrastructure such as record locator services/provider directories/quality registries, we will create a learning healthcare system that is better with each passing year.

So next time you encounter the Trough of Disillusionment about interoperability, do your best to educate stakeholders about the trajectory we’re on and the challenges we can overcome by focusing and working together.

Maybe we can all stand on a hilltop and sing "I'd Like to Teach the World to Interoperate (In Perfect Harmony)" celebrating our progress to date and highlighting the work yet to be done?


Anonymous said...

Interoperability is real. It's not happening everywhere and with everybody, but it is happening.

I would love to see ONC post a blog on their website asking folks where they see interoperability occurring.

Medical Quack said...

We have so much "fake" news out there today it's hard to see what's real. A CBS journalist made a really good video about "Astro Turfing" in the news and she's right. Granted there's a little push in there for CBS, but not bad as she sticks to the content. News rigging has arrived:) We can't tell what's real and what's fake out there and as you pointed out with Information Blocking comments, it's a made up story. There's more of it out there as we enter into the financial areas.

News feed bots drive stock trading bots as we know, now add on journobots that react to the stock bots and bingo within a few minutes or seconds, we have all kinds of news created to potentially manipulate stock too by creating an alternative view, commentary or whatever.

The circle repeats itself as that story now feeds stock bots and the cycle starts all over, and so it goes. It's pretty scary and we have the same type of hype and fake grass roots and Astro Turfing in Healthcare, as many of the products in Health IT of course are traded on the market too, and of course that might make a case for all the fake grass roots we see in that area. I saw the USA today story and just kind of shook my head. They just don't get it. As Mark Twain said, "It's easier to keep fooling people than convince them they've been fooled"

Here's the TED video and it specifically addresses big pharma fake campaigns as well.

Tariq Abu-Jaber said...

The NY Times published this interesting (and somewhat depressing, but not at all news, really) article on the barriers to data exchange:
It is nice, though, to see this critical, although somewhat "deeply geeky" issue make it to the nation's newspaper of record.

Unknown said...


Your comments are excellent. There is no question we are in the trough of disillusionment regarding EHR interoperability. What we need to keep in mind is not the implementation of standards, the building of more data respoitories, new congressional committees or policies. Although all of these are important, they are at the system-level and attempting to find a single solution to everyone's needs. In the trenches, during an office visit or in the ICU, we are still juggling paper, verbal and multiple applications to be navigated as we search for and attempt to piece together patient data in order to care for our patients. We are dependent on the technology to redesign processes that work locally while meeting global requirements. There is no question HIE's and pilot connection projects have been demonstrated with many EHR's, but the real question is do we have a framework of health IT development where solutions and workflows developed for one system can be used in another? Technology adoption in fields outside of medicine have cycled through a similar adoption/frustration curve, however, they have reduced costs and brought efficiencies because of this ability. In the trenches, we are using proverbial ductape and for lack of a better word, hacks, to connect information and being forced to adopt process and workflow to meet the constraints of technology, instead of the more efficient and effective inverse. 

Although I agree with the overall premise of this post, we all experience frustration with change and the adoption of new technology, I think we need to take a step back and look at how we can extract the benefits of technology we have implemented. I envision a health IT ecosystem where developers are easily able to develop on top of a framework and not limited by the technical designs and data models of an individual system. We must be careful as we highlight hacks to getting things done if they are not easily translated to the the clinical realm where physicians and patients are struggling with inefficiencies to accessing and more importantly using the data being gathered. Although the frustrations are not being heard as loudly, there are a great deal of issues we still need to address in order to develop clinically relevant solutions to improve care delivery. I recently heard a CEO state 'why are my printing and toner costs continually increasing now that we have system-wide EHR adoption?' Solving problems with technology is hard. Without a framework where standardized development can occur and be shared between institutions and EHR's, we are unlikely to realize financial, quality and efficiency gains from these systems. 

Looking at health IT from the perspective of other industry, there is ample support for implementation of a interface level such as middleware to address the issues we are dealing with. This perspective does not negate EHR's but instead brings the ability to enhance them in a uniform way where solutions can be shared between providers, institutions and allow customization that is now not possible. The future for a connected and distributed health system is great if we think beyond the current limitations and imagine how to solve these grand challenges in a scalable and cost-effective manner. Technology costs in medicine will decrease as we shift our focus from enterprise software architecture to service oriented design, a validated, effective, more cost effective and rapid developmental model. 

Donald M. Voltz, MD

Anonymous said...

True interoperability would first start with a national patient identification number. Please see the NHS and most other developed countries for details

David said...

Good post, John. I empathize and can relate to the difficulties dealing with criticism that is partly misinformed. Of course, there have been plenty of legitimate problems to criticize re interoperability, but the problems are seldom solved as quickly or simply as people would like, such as by passing new laws or forming new committees. I hope you will continue to be a public voice for progress, reason, and fairness, ever when your term on HITSC ends.

Unknown said...

Many healthcare IT leaders lack a comprehensive understanding of what exactly they implemented with their Direct-enabled Meaningful Use Stage 2 certified system, even if they have successfully completed their attestation (and even more so if they are behind, which is the case for many independent practices). Sadly their is no requirement that you make a meaningful exchange of health information, only that you exchange it. I live in a geographic region without an HIE, and what I see most often is organizations purchasing an isolated pseudo-HIE for their own physicians (dbMotion), setting up accounts for their physicians that they may/may not ever use, then sending a CCDA to the physician inbox to meet the MU2 requirement. A physician could log in to look at the data, but generally these physicians already have remote access to the EHR directly so typically it's an exchange to nowhere--a huge missed opportunity that has nothing to do with a lack of interoperability standards.

Vendors share some of the blame here as well. Our EHR vendor has been so focused on getting everyone upgraded onto the certified EHR system that no effort whatsoever went into guiding the optimization process so we could benefit from new tools, like the ability to import structured data from a CCDA (available in all certified systems and rarely used). Of course if we really get into why upgrades take up half the year then I think we'd start truly seeing the main EHR platforms are not sustainable if the goal is to optimize interoperability and other key can you effectively optimize if 4 - 6 months of every calendar year is dedicated to routine system upgrades?