The lack of interoperability is causing animated discussion among healthcare stakeholders and medical software developers. Everyone seems to know there is a problem, but somehow the community isn’t even close to fixing it. Why is that so? In this post, we’ll attempt to put together some of the most profound commentaries born from this debate to help you form a more balanced view of the problem.

Where Is the Problem?

While IT spending in healthcare is steadily growing, adopted technologies fail to support better care, namely to increase productivity and reduce errors. The reason is, hospitals simply can’t take advantage of all that data generated by devices and systems. In an HBR article, Peter Pronovost, Sezin Palmer and Alan Ravitz of John Hopkins University frame this problem at the stakeholder level:

  • Vendors: most hardware and software systems can’t seamlessly share data with one another
  • Policymakers: there is a lack of interoperability standards to be embraced by vendors
  • Providers: focusing on price instead of requiring that vendors ensure openness and interoperability

Many observers put most of the blame on vendors. But Julia Adler-Milstein, a PhD who studies electronic health records (EHRs), argues that their share in this problem is overstated. She says we cannot blame them for “acting in their economic best interest in wholly legal ways.” However, she points out, vendors could have been more open to explaining why their bottom line is at odds with the regulations.

The problem is, Adler-Milstein believes, in the overall design of the Health Information Technology for Economic and Clinical Health (HITECH). The legislation has specified interoperability as a must but pushed it in a limited way, rather than creating market demand:

If interoperability were a “stay-in-business” issue for either vendors or their customers, we would already have it, but overall, the opposite is true. Vendors can keep clients they might otherwise lose if they make it difficult to move data to another vendor’s system.

A commenter to the above-mentioned HBR article, who is a product manager for a medical device company, also begs to not oversimplify vendors’ unwillingness to satisfy the market demand:

We are very aware of this need and actively work to integrate more data/devices. What is not discussed… is the barriers we face due to ever-changing operating systems and constraints/validation requirements from the FDA before we make software updates to our systems… Regulatory requirements must adapt to keep the healthcare market at pace with commercial products.

Nevertheless, another commenter, John Weiss, argues the reality is different. Manufacturers don’t want standardization because it will disrupt their market status quo:

When they say, “We’d really like to [stick to standards], but we can’t because of government regulations,” what they are really saying is, “Thank God healthcare is a mess.”

Just like vendors, providers are driven by conflicting motivations: prioritizing interoperability may benefit their patients but harm their competitive advantage. Many providers decide not to pursue interoperability (including not demanding it from vendors) because existing solutions are too complex and costly. “It is hard to justify investing in a complicated, expensive capability that also poses a strategic risk — a double whammy,” says Julia Adler-Milstein.

Moving Past the Blame Game

According to Julia Adler-Milstein, of all the stakeholders, only policymakers have the power, and strong interest, to push interoperability forward:

It is up to them to ensure that robust, cross-vendor interoperability is a stay-in-business issue for EHR vendors and providers. Once the business case for interoperability unambiguously outweighs the business case against it, both vendors and providers can pursue it without undermining their best interests.

Pronovost, Palmer and Ravitz believe that part of the solution must involve providers. As purchasers, they should treat equipment and IT procurement in a new, un-siloed way, only buying devices and systems that support interoperability.

John Weiss is sure that the only way for providers to propel changes they require is an initiative coming from the largest national healthcare systems like HCA and Ascension Health. Only they have the power to go into the marketplace and declare that vendors do business under specific standards. In this way, there are not too many vendors that will be able to resist.

But what is this new, un-siloed way of treating technology? John Hopkins scholars suggest that providers look at a hospital — or a room, to begin with — as a single, integrated unit, just like airlines do when they buy planes from Boeing or Airbus. The latter don’t buy wings, engines and other parts and then put them all together; they buy the whole plane, ready to safely carry passengers from point A to point B. That’s where systems engineering can be of great help, integrating technology, people and processes in pursuit of a common goal.

Wayne Sadin, a commenter to another article on the lack of interoperability in healthcare, also sees the opportunity for the healthcare community to draw on the experience of other, more digitized industries. Take, for instance, the transitions financial services made 25 years ago:

There was a time when your paycheck had to be brought to your bank; a time when ATM networks didn’t connect; and a time when a stock trade took 30 days to settle as the paper was moved across the US… anyone remember the 1980’s?

Avoiding the Trap of Thinking Short-Term

As Julia Adler-Milstein rightly points out, interoperability in healthcare is hard. If it were easy, we would already have it. There is too much money and too many competing interests at stake to get all the parties to sit down and talk openly.

Pursuing interoperability might incur a competitive disadvantage at first, but in the long run it might also bring tremendous opportunities, including increased employee productivity, lower costs, and, most importantly, more saved lives. But someone has to be first.