I volunteer at an amazing organization here in Madison, Wisconsin, that serves disconnected youth by training practical trade and business skills in construction and conservation while helping them obtain a high school diploma. Part of my work is tutoring young adults in math.
Last week we were working on fractions; not only fractions, but fractions for construction. For example, convert 2’ 3/8” to a decimal. I don’t use that part of my brain very frequently, but as soon as it started coming back to me, I remembered my mom’s mathematical advice when I was eight years old—learn the metric system. According to her, a switch was imminent. After all, as a nurse living on a 24-hour clock, administering IV’s in milliliters, having gone through elementary school in the 70’s, she believed everything was in place for the transition to occur. Yet, here we are, in 2017, and we’re still not on the metric system.
I sometimes feel like healthcare interoperability is akin to the metric system:
- Some oppose it because it’s bad for their bottom line.
- Some are misinformed about what it really means and how complex solving “it” is (as if a single word can sum up decades of a FUBAR system).
- Others are out there trying to figure out how to roll out a standard at the highest levels with a 10-year plan towards adoption.
The Metric System in America
Thomas Jefferson tried to move the nation towards the metric system in 1789, but without the support of scientists, the idea flopped. According to a PopSci article, in 1906, “Alexander Graham Bell told Congress that ‘few people have any adequate conception of the amount of unnecessary labor involved in the use of our present weights and measures.' [...]
"Things looked promising in 1968 when Congress authorized a three-year study that eventually recommended converting to metric and laid out a 10-year plan to get there. But they did not make the switch mandatory. Instead, business owners and people who opposed big government and globalization—and who saw conversion as ceding control—won the battle for hearts and minds. A Gallup poll at the time showed that 45 percent of Americans opposed the switch.”
There have been several failed attempts at converting to the metric-scale in the US (all government-led) while Great Britain ditched most of its Imperial System back in the 70’s. Their reason? It was the only way to expand into other European markets.
Sound familiar? It should, because it's a lot like interoperability—incompatible systems are leading to a lot of headaches and trouble for people who need them to power their products. There have been new "standards" introduced that only lead to more fragmentation, and there still has not been a governement-led solution for this industry-wide problem.
So, where does that leave us?
The Clusters Solving the Cluster
Inteperability is a problem of clusters. One cluster uses one system; another cluster uses different system with their own unique set of standards, and so on. In response, individualized solutions have been developed to help these clusters communicate. In one way, this is bad because each solution only improves one cluster and doesn't do much to solve interoperability as a whole. But, it's also good because it means we have options—from vendor-led interoperability to HIEs, different groups have different motivations for wanting to solve interoperability. Let’s take a quick look at each of these options.
EHR Vendor’s incentive is to stay in business. In the best case scenario, you get something that looks like this, and a worst case scenario probably looks something like this. Interoperability in a wholly useable form is not a “stay-in-business” issue for EHR vendors, it is a “tick a few boxes to meet regulations” issue, and, at a minimum, that is how vendors approach it.
Lots of people write about this, and I’ve shared my opinions before. In a nutshell, I believe we need policymaker support, but I am not ready to sit around and wait for the government to be the silver bullet. It’s too volatile, too slow, and interests are all over the place (some policymakers have their hands in vendor’s pockets while others represent their constituents, i.e., the patients).
While they have some characteristics of the above, HIEs haven’t done well since their inception. Sure, there are strong HIEs, but more generally, the value isn’t always clear. To whom the value is being provided to is a toss-up, and organizations have a hard time buying into something (literally) that their competitor isn’t paying for but is benefitting from. In addition, supported data is typically minimal with just a few key concepts being exchanged seamlessly and the rest of the data looking like a jumbled pile of Latin.
These include “rules of the road” groups like The Sequoia Project Care Equality or CommonWell who are trying to achieve a network by offering a shared framework (technology and process) for understanding interoperability. The idea is strong and use case driven, but the technology lift is not insignificant. Beyond that, there's still using a pay-to-play model, and the cost combined with the technical lift (and timelines) means that the network grows at a slow pace.
With all these parties racing to contribute to the interoperability problem, there's only one thing that is certain—we can’t forego what we've already done and start over. Whatever the solution, we don’t just get to stop providing care.
The Metrics of Healthcare
We can’t just hit “pause” and solve interoperability—patient care continues, technology projects continue, and as a nation we’re unwell. When I stop and consider the current state of affairs, it makes me question what patient-led interoperability would look like. What about provider-led?
What would it look like if the people who are the most directly impacted on a daily basis were the drivers behind interoperability? It could mean we implement interoperability on a case-by-case basis as we go. But this alone doesn’t get us anywhere, since we'd end up with a tangled mess of point-to-point, expensive, and time-consuming connections.
Like switching to the metric system, the cost of switching to a single standard is massive, and while the benefits in healthcare could be great, getting everyone onboard with drastically different “what’s in it for me” sentiments seems impossible.
But the Metric System doesn’t exist in the US today... or does it?
We run 5k’s (well, I don’t—I routinely couldn’t finish the mile-run in high school, much to my HS PE teacher Mr. Griffin’s dismay). I could, however, manage to throw a bowling ball backward (but I don’t think that inspired much confidence in Mr. Griffin either). We drink wine out of 750 mL bottles, buy soda by the liter, and measure medication in milligrams, while our packaged goods contain both metric and customary units of measurement. Heck, we’ve been using the decimal system for our currency since the 1790s!
All this and we're still not on the metric system.
Just like how measuring soda bottles in liters isn't enough, solving for the single word problem of "interoperability" is not realistic if only a few of the clusters are pushing it forward. It needs to be many (or better yet, all) since technology vendors don’t ‘need’ it to stay in business, clinicians have gotten by without it, and policymakers alone can’t solve it.
While policymakers argue about standards and EHR vendors try to figure out what their second wave looks like, clinicians, providers, and healthcare organizations are going to keep moving forward. Aetna may provide Apple Watches to its members to set the stage for the pop health space, ACOs will continue to try and piece together technology to better care for their patients, and digital health apps will continue to innovate and bring SaaS to healthcare. What if each of these vendors, serving a personalized value proposition, took on interoperability on a use case by use case basis? Standardization could happen. The standard could be a use case driven connection each time, and if all those point-to-point connections are reusable and on the same network? Now we’re talking.
I’m going to continue valuing incremental improvements over overarching mandatory standards. After all, in the words of FDR, “to reach a port we must set sail.”
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