Connecting the Railroads: Reflecting on Healthcare and the Future of Interoperability
By Gail Kalbfleisch, Director, Federal Health Architecture, U.S. Department of Health and Human Services (HHS)
Every American connects with the healthcare industry at multiple points in their lives, interacting with medical care providers like primary care physicians, dentists, pharmacists, surgeons, nurses, psychiatrists, optometrists, and OBGYNs. In these interactions, we expect and depend on innovation and new advancements in medical technology and computing. However, the healthcare community is often criticized for its lack of, or very slow advancement in, leveraging computing technology in the area of information exchange. In many areas, much of our health information still exists in paper and PDF formats, siloed within the confines of an individual doctor’s practice. This makes it difficult for information to move with the patient where and when it might be needed. That is why, over the course of my career I have been asking: What does an interoperable future in healthcare look like, and how do we get there?
"Proper implementation of standards for data storage and exchange provides a path toward innovation which enables efficiency and ultimately better care for American citizens"
In many ways, healthcare is no different than any other industry that needs to be interoperable. Consider the similar transition once faced by the American railway system. American railroads began as individual organizations with their own individual standards. Eventually, the American public realized it was in the country’s best interest to build a national railway system—where cargo and passengers did not have to disembark from one train and move to another, all because their train was not compatible with the tracks in the next area. With interoperability, however, came necessary change. Tracks were replaced in some areas, cars replaced in others, companies had to invest in standardized equipment (some actually had to find new areas of business) and some companies ceased to exist. But in the end, it had an overall positive effect for the individuals and companies who relied on the system.
Striving for interoperability in health IT means that as a nation we should be moving toward electronic storage and exchange of health information at the process, data, and context levels. Automated computing requires repeatable processes and data. One obvious industry which successfully integrated electronic record keeping and data management into its processes is the banking and finance industry. The recording and movement of financial sums, calculation of interest, distribution of withdraws and transfers—are everyday activities for which the industry has had repeatable processes for decades (or centuries). Conversely, the difficulty with electronic records and data processing in healthcare is that, until recently, defining and agreeing on common, repeatable processes have not been a priority.
The nature of health data and the methods of collection make for an overabundance of variables and unpredictable results. For example, when a nurse takes a patient’s blood pressure, the number she records would seem to be an easy data point to add to the patient’s electronic health record (EHR). But the context of the patient’s blood pressure is equally important. Was the patient sitting or lying down? Was this measurement taken at the beginning or end of the exam? Could their results have been affected by the walk into the doctor’s office or the weather outside? The processes understood in one office may be different in another. Understanding context is as critical as understanding the data, exponentially increasing the complexity of sharing healthcare information.
As computers grew in capability, physicians recognized the value of putting their information into electronic form. Eventually, EHRs began to appear in medical settings, supported with federal incentives under the American Recovery and Revitalization Act. Each office or medical facility functioned within its own unique environment and had their own technical processes for which systems were specifically designed. Without awareness of how their processes differed from those in other healthcare practices, many systems were not designed to easily communicate with systems in other practices.
Adding to the complexity, much of the content in a patient’s file is confidential. The industry must overlay complex processes to ensure security and to conform to federal, state, and local privacy laws. It is worth noting that medical professionals who understand the liabilities that come with protecting patient confidentiality will likely want to fully understand where the data and information goes, how it’s used, and who is responsible for its security before committing to implementing an EHR or sharing data.
So how do we move toward a future of interoperability within health IT? One of the many challenges the community must overcome is reaching agreement on standards for even the simplest data elements. Until there are agreed upon and implemented standards for how to record and exchange data, the health IT community will struggle to take advantage of the value of computing. Those of us in the medical and IT communities must ultimately agree to compromise for the good of the whole; we must adopt standardized fields and processes so together we can help better the lives of patients, families, and the medical community.
To move forward across the health IT community, a commitment must be made to implement business processes and standards that allow information to flow across boundaries. Identifying how information is technically stored and recorded should no longer be viewed as something that stifles innovation. Instead, we must embrace that proper implementation of standards for data storage and exchange provides a path toward innovation which enables efficiency and ultimately better care for American citizens. Health professionals, IT professionals, federal/state/local government, health IT developers, patients, and family members, must all be willing to collaborate and more importantly compromise, even if compromise means being willing to potentially re-tool or find new areas/ ways to do business. Like the early American railroads, it will undoubtedly be a difficult transition, but it provides a proven track to interoperability.