Wednesday, June 3, 2015

So What is Interoperability Anyway?

One of my most memorable experiences as an IT leader was working with with a dissatisfied customer.   I asked what requirements were unmet, what features were priorities, and what future state was desired.   The answer was “I’m not sure, but I know I’m not getting what I need”.

The use of the term interoperability is being tossed around in ways that makes it seem like the test for obscenity used by Supreme Court Justice Potter Stewart in 1964 when he wrote “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"], and perhaps I could never succeed in intelligibly doing so. But I know it when I see it…”

Congress is angry about the lack of interoperability.   What does that mean?

House and Senate stakeholders believe that vendors enjoyed a government funded windfall yet are building proprietary networks.   They have heard that vendors are blocking information sharing by charging significant interface fees and that HITECH distributed $30 billion with minimal requirements for information sharing. Many in the House feel after all this investment, the country is not prepared for new payment models.

Some in the House have stated that Americans can communicate because "we speak English" so interoperability is about picking a common language.

Senate HELP Committee Chairman Lamar Alexander plans to take up this issue, working closely with Ranking Member Senator Patty Murray through a bipartisan effort over the coming months. 

So what is the real issue causing providers anxiety and resulting in Congress wanting to take action?

Providers are fed up with interface fees and at how hard it is to accomplish the workflow required by Accountable Care business models including care management and population health. They are unsatisfied with the kind of summaries we’re exchanging today which are often lengthy, missing clinical narrative and hard to incorporate/reconcile with existing records.

All these things are true.

So what is our next step to help providers do their job and improve satisfaction to the point that Congress no longer wants to legislate the solution to the problem?

I think we all have to step back, carefully define the requirements for care coordination and care management in an ACO world and admit that the Meaningful Use regulations did not address those requirements.   We should allow the private sector initiatives already in progress (Argonaut, Commonwell, eHealthExchange) to address these market needs in collaboration with vendors, entrepreneurs, and innovators.   The economic incentives of the Affordable Care Act and the Sustainable Growth Rate fix will result in hospitals and professionals demanding different kinds of technology than was prescribed in regulation.

The role for Congress should be to hold us accountable for the outcomes we want to achieve.

At a recent AMIA presentation in Boston, Zak Kohane, Ken Mandl and I were asked to be provocative - to go rogue.

I suggested that the Meaningful Use program should be eliminated.    Yes, there should be Merit-based incentives for achieving stretch goals, but those can be created in another CMS program. Meaningful Use is no longer necessary.

ONC should focus on the 5 enablers I’ve written about

1.  Facilitating the creation of a national provider directory for message routing

2.   Encouraging the adoption of a voluntary national identifier for healthcare

3.  Providing guidance to streamline the heterogeneous patchwork of state privacy laws that are impeding information exchange

4.  Serve as the coordinating body for aligning federal government health IT priorities.

5.  Supporting private sector initiatives such as Argonaut that are simplifying the tools for health information exchange.

It's not a problem of "language".  We have the terminologies we need, already included in certified EHRs. We have standards for content and transport, again written into certification requirements. So what's the gap? We need to make the standards better, and build interoperability into EHR workflow. That doesn't require top down regulation, it takes the kind of  goal-oriented interaction between providers, developers, and standards bodies that characterizes efforts like the Argonaut Project.

No more regulation, no more legislation.   Those will only crush innovation.

Instead of saying we need interoperability, the conversation needs to include a crisp set of requirements for care management and care coordination with defined metrics of success, supported by government enablers, and accelerated with the economic incentives provided by new reimbursement models.

To paraphrase Justice Potter, if patients and providers are happier, I’ll know it when I see it.

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