NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Academy of Medicine; The Learning Health System Series; Wang YC, Zenooz A, Sriram RD, et al., editors. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington (DC): National Academies Press (US); 2018.
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Show detailsSpurred by several policy initiatives, most notably the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, health care in the United States has experienced a steeply upward adoption curve of electronic health records (EHR) technology. As of 2016, 96 percent of hospitals and 78 percent of physicians' offices were using certified technology for health care records (Office of the National Coordinator for Health Information Technology, 2018). No longer in paper form, the digitized information opens opportunities for patients and clinicians to have a fuller and more timely picture of an individual's health and health care experience. Widespread availability of health data via EHRs has enabled more data-driven, team-based approaches to care coordination and patient-centric case management. However, to optimize our investment in health IT, information from multiple sources, devices, and organizations across the care continuum must be able to flow at the right time, to the right party, for the right patient.
Unfortunately, most EHRs, medical devices, and other IT systems are not interoperable—that is, they do not have the functional ability to “work with other systems or products without special effort on the part of the customer” (IEEE, 2016). In an elaborative variation of this definition, the 21st Century Cures Act of 2016 specificially defines an interoperable health IT system as one that “(a) enables the secure exchange of electronic health information with, and use of electronic health information from, other health information technology without special effort on the part of the user; (b) allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law; and (c) does not constitute information blocking” (114th Congress, 2015).
Recent data indicate that fewer than one in three hospitals is able to electronically find, send, receive, and integrate patient information from another provider (Figure 1) (Holmgren, Patel et al., 2017). When patients experience a care transition such as discharges or referrals, most providers still rely on paper or fax to some extent when sending a care summary, potentially creating fragmentation in care coordination (Figure 2) (Lin, Everson et al., 2017). Of note, HITECH Act's stage 2 Meaningful Use program, which began in 2014, required hospitals to send the care record summaries electronically to the subsequent provider for a minimum of 10 percent of care transitions (Office of the National Coordinator for Health Information Technology, 2014). Although hospitals and health systems have increased sharing inside and outside of their organizations, many encounter barriers to data sharing and to using the shared data effectively (Figure 3) (American Hospital Association, 2018). Some of these barriers are technical in nature, such as the format of the information transmitted, yet, equally if not more challenging barriers are socio-technical and relate to the integration of information into EHRs and clinician workflow to support decision making.
In addition to weak incentives, poor coordination, and other market barriers, suboptimal acquisition processes in the current marketplace also contribute to data silos and (unintended) blockage. Hospitals and other health care providers purchase systems and equipment from a variety of different manufacturers, and frequently, each comes with its own proprietary interface technology. As a result, most health care provider organizations spend time and money setting up each technology in a different way, instead of being able to rely on a consistent means of connectivity. Organizations often invest in separate proprietary “middleware” systems in efforts to connect disparate pieces of technology to feed data from bedside devices to EHRs, clinical registries, and other applications. Many bedside devices are unable to transmit data to other clinical IT systems and require manual transcription from one device or system to another. Nationwide, health systems must devote countless resources and personnel simply to dealing with the consequences of “non-interoperability” (West Health Institute 2013).
This environment has produced an entire market segment dedicated to health care integration technology. Vendors compete on solution effectiveness, driven by profitability and optimization for their customers, not necessarily aligned with patient interests or the industry as a whole. In the absence of standardized, shared solutions, proprietary software and hardware solutions remain common across the ecosystem. The resulting procurement “vendor lock” and reliance on makeshift workflow solutions perpetuates a culture that resists a transition to interoperability.
The lack of interoperability imposes an exhausting litany of clerical tasks for the clinical staff, contributing to staff burnout and waste (Cantwell and McDermott 2016). In addition to staff time spent on manually entering readings from a device (e.g., vital signs) onto paper or electronic charts (Hendrich, Chow et al., 2008), another common source of inefficiency is time spent manually programming devices (e.g., infusion pumps), a process that is often cumbersome and prone to error. These time burdens are also felt intensively by clinicians who have become responsible for a mix of documentation and reporting requirements that can add hours of extra work every day. Unlike in other industries where computerization has made work easier, deployment of EHRs in their current state—coupled with growing requirements for high-quality reporting and regulatory compliance—create additional work and exacerbate clinician burnout (Strongwater and Lee 2016). In addition, although EHRs have been widely adopted, essential areas for improvement remain, such as the inclusions of high-granularity measurements, waveforms, alarms, device alarm threshold or filter settings, and incomplete/erroneous data in EHRs partially attributable to manual entry (Weininger et al. 2016). Enhancing seamless exchanges of data as a means to improve data quality and minimize the need to rely on manual staff processes is recognized by the Office of the National Coordinator for Health Information Technology (ONC) as a core goal for reducing provider burden.
A report published by the West Health Institute in 2013 estimated that widespread medical device interoperability could eliminate at least $36 billion of waste in inpatient settings alone (West Health Institute, 2013). It was estimated that functional interoperability leads to increased efficiency, lower costs, and better quality of care through four primary drivers: reducing adverse events because of safety interlocks ($1.9 billion); reducing redundant testing ($1.5 billion); reducing clinician time spent manually entering information ($12 billion); and shortening length of stay through more timely transmission of critical information such as lab results ($18 billion).
Waste, inefficiency, and clinician burnout contribute to patient safety risk. Despite recent improvements in health care quality, preventable patient deaths and other adverse events still occur at an alarming rate. Medical errors result in as many as 3 million preventable adverse events each year, leading to as much as $17 billion in excess annual medical costs and nearly 100,000 deaths per year (Institute of Medicine, 2000; Jha et al. 2009). Although the proportion of patient harm that is directly attributable to the lack of interoperability is unknown, several common causes of medical errors, including drug errors, diagnostic errors, and failure to prevent injury, can partially be addressed by better data exchange among patients, medical devices, EHRs, consumer applications, and other health technology (Jha et al. 2009).
SUBOPTIMAL NATURE OF HEALTH CARE TECHNOLOGY PURCHASING
Although there are many technical, cultural, and political barriers that limit the progress toward system-wide interoperability, three main challenges stand out. First, despite the existence of certain health data standards, a common view of interoperability is lacking across health care systems. Second, in the absence of a harmonizing or coordinating body across health care systems, implementation of these standards is subject to interpretation, with minimal consistency across technology suppliers and health care organizations. Third, even if technical interoperability could be achieved, the practice of data blocking and data hoarding limits the flow of information.
Currently, procurement requirements and requests for proposals (RFPs) are generally based on narrow technical specifications of clinical use and regulatory guidance, reflecting the views of a small number of specialized end users or technical experts. Many health systems lack the technical and human resources required to create detailed specifications and to incorporate them into contracts on their own. Rather than purchasing an integrated suite of technologies, many health care organizations still acquire numerous individual “best-of-breed” IT modules to support specific workflow needs in areas such as operating rooms, intensive care units, and clinics.
Many organizations also face the conundrum of whether to upgrade a technology or device incrementally, or to acquire new systems with advanced functions to support emerging needs. Given financial constraints and past investment in existing technologies, especially the EHR, organizations tend to prioritize actions that contain costs and minimize workflow disruptions above everything else. To optimize long-term value in the procurement of medical technologies, purchasers need to consider multiple dimensions—life cycle costs, device functions, use cases, interoperability, safety, usability, effect on productivity, and more. It will become increasingly important not only to define purchasing requirements but also to develop a measurement framework for assessing progress and effectiveness. According to the National Quality Forum, “interoperability-sensitive” quality measures, such as patient and caregiver burden and care coordination, reflect the areas that must be addressed to provide a comprehensive understanding of interoperability and its effect on health processes and outcomes (National Quality Forum 2017).
In other large and complex industries, such as aviation, telecommunications, and banking, a high degree of interoperability is not only advantageous and desirable, but also essential. Many of these industries did not rely solely on standard-setting bodies but, in addition, drove the introduction of more interoperable systems by exerting their market power. In some circumstances, vendors identified and pursued interoperable solutions as a market opportunity, (e.g., Internet communication protocols, Bluetooth headsets, and digital camera memory cards). In other cases, purchasers and consumers worked together to require detailed data-exchange capabilities through contracts and purchasing agreements. This is, in part, why we can use our ATM card at virtually any bank in the world, plug a charger into any socket on the wall, and book or obtain the up-to-date departure and arrival status of any flight on any airline.
The lack of integration common throughout health care would be unacceptable on safety grounds alone in any other high-risk field. Imagine if commercial airplanes were designed like many hospitals today. If a plane's safety system was unable to obtain real-time input from the landing gear sensor to sound an alarm while trying to land without its wheels down, it would be considered a defect and a safety risk. In this case, the aircraft's builder would either require data sharing to remediate the error or get a new landing gear vendor; in health care, health systems accept vendor constraints and purchase the technology, accepting safety risks and higher costs. The aviation systems engineering approach reconciles interoperability by design and provides valuable lessons for health care and its critical mission to ensure safety.
The ability to collaborate and share information is essential for delivering higher-quality care and better outcomes at a lower cost. Health care organizations are uniquely positioned to accelerate interoperability through the use of a more disciplined process by which to procure technologies. Moreover, beyond the potential tragedy of lives lost, the longer health care systems delay in taking necessary steps to adopt and implement interoperable systems, the higher their exposure to legal and economic risk resulting from avoidable errors and adverse events.
Progress toward interoperability at the point of care delivery is especially needed. In contrast to the “plug-and-play” world of consumer electronics, where consumer demand has driven a convergence on a few standardized interfaces and platforms, health care providers have not collectively demanded a consistent means of interoperability (West Health Institute, 2013). As a result, many vendors use distinct proprietary and closed communication methods even among their own devices. Additionally, some standards are loosely specified, with a number of options for configuration, meaning that even devices that use similar standards are unable to communicate with each other without further customization. Another barrier is that many medical device interoperability standards and profiles are published without a reference implementation to ensure implementability and adoption. The cost of medical device integration, for example, integrating ventilators and physiologic monitors to the EHR, was estimated at as much as $6,500 to $10,000 per bed in one-time costs, plus as much as 15 percent in annual maintenance fees (Moorman, 2010). These investments represent a substantial undertaking for hospital systems already contending with operating margins of less than 3 percent on revenue of approximately $700,000 per bed, based on average length and cost of inpatient stays (Becker's Hospital CFO Report, 2011). Solving this lack of interoperability in health care requires solutions beyond common data standards. As demonstrated in other industries, enabling data liquidity across the health care continuum will require the creation of a vendor-neutral interoperability platform architecture that is modular, scalable, services based, and secure. In health care, this approach should be driven by health systems, the purchasers of technology, in partnership with the vendors.
IMPROVING OUTCOMES AND VALUE THROUGH INTEROPERABILITY-FOCUSED PROCUREMENT
Making interoperability a priority core and affordable requirement within the acquisition strategy speaks directly to the value and return on investment in health technology spending. Regardless of size and for-profit status, most health system leaders who acquire and upgrade IT solutions, devices, and data systems aim to achieve the following basic goals:
- Reduce medical errors and protect patient safety
- Ready and full access to records on patient health, health care, and progress
- Identify and better manage patients' risks to achieve the best outcome possible
- Ensure that patients and families are part of the care team
- Facilitate compliance with relevant rules, regulations, and contractual mandates
- Link to new data exchange partners, (e.g., technology, analytics, and social services)
- Automate data entry and reduce administrative burden
- Improve staff productivity and caregiver/clinician satisfaction
- Reduce cost, variation, and duplicated care
- Streamline relevant administrative workflow, including billing and quality reporting
- Ensure continuous quality improvement and learning
Health care organizations are therefore not just seeking the ability to transmit records electronically from point A to point B; they are looking for clinically meaningful interoperability that improves patient safety and workflow, enhances value, and enables person-centered care. Being able to construct a longitudinal patient record enables providers to care for the whole patient rather than a single diagnosis or episode. True person-centered interoperability has the potential to empower individuals to become partners in their health care, and allows for their ability to directly contribute to and receive data from the EHR. To ensure that health care dollars are spent in pursuit of a safer, more productive and more cost-effective system, interoperability must be a prime purchasing priority.
In this special publication, we explore an acquisition approach to health care technology integration whereby purchasers drive interoperability in the course of procuring new technologies or updating technologies already in use. The accompanying Technical Supplement provides further guidance, including an implementation framework for procuring interoperable systems (Appendix A, Section 1); an engineering tool to facilitate the interoperability identification process called N-squared diagram, which helps systematically document interactions among hardware, software, and people (Appendix A, Section 2); example interoperability specification language (Appendix A, Section 3); and lessons learned from the defense industry (Appendix A, Section 4). By focusing on an acquisition-based approach to promoting interoperability, we see an opportunity to help transform how the industry procures health IT that includes beneficial clinical interoperability capabilities that can lead to system-wide interoperability.
- WHY INTEROPERABILITY IS ESSENTIAL IN HEALTH CARE - Procuring InteroperabilityWHY INTEROPERABILITY IS ESSENTIAL IN HEALTH CARE - Procuring Interoperability
Your browsing activity is empty.
Activity recording is turned off.
See more...