Making Interoperability A Reality: A Vendor & CIO Share Their Thoughts

One of the hottest buzzwords in the healthcare IT industry is interoperability. But while for many it is just talk, two organizations are walking the walk: Beth Israel Deaconess Medical Center and athenahealth. Last year, athenahealth purchased BIDMC’s home-built clinical applications and EHR platform, and Beth Israel agreed to roll out athenahealth’s EHR, revenue cycle management, and patient engagement services to its physician network. The collaboration certainly made waves, but how is it working out so far, and what can other organizations learn from it? We spoke with John Halamka, MD, CIO at BIDMC, and Jonathan Bush, CEO of athenahealth, who will be co-presenting a session at HIMSS, about these issues, and got their thoughts on where the industry stands with interoperability — and what still needs to happen.

A year ago, athenahealth and Beth Israel Deaconess Medical Center announced they were collaborating on a cloud-based EHR platform. Can you talk about what has happened since that time? What are some of the early success and challenges you’ve experienced?

Jonathan Bush: athenahealth’s R&D team has been shadowing BIDMC’s Needham location providers; learning their workflows, and learning everything about how they’re providing care so we can accelerate our athenaOne in-patient offering for hospitals and health systems. We’ve made great progress, and in fact, have further grown the team that is tackling our in-patient focused work. In addition to BIDMC, we’ve recently partnered with the University of Toledo Medical Center. We’re studying their workflows to ensure that when we do extend our cloud-based network and network-enabled services to these types of systems, we become true experts in the people, workflows and the jobs to be done.

Do you think this collaboration can serve as a model for other organizations, particularly those that don’t have an integrated EHR across the system?

John Halamka: The collaboration between the two organizations provides athenahealth the chance to take BIDMC’s experience to a much larger audience, hopefully making a difference to providers, patients, and payers across the country. athenahealth will also accelerate its ability to develop expanded functionality more rapidly than doing it alone. I’m not sure if this can serve as a model, but it can serve as an example to the industry — the future of health care belongs to social, mobile, analytics and the cloud. Although most industries have embraced these technologies, the health care IT industry has been slow to adopt them. The country has taken good first steps to digitize the paper-based medical industry, but now it is time to build on what we’ve done, enhancing usability, better engaging patients/families, and preparing for the future of reimbursement, which is based on value, not more health care.

Bush: This collaboration demonstrates the need for integrated systems and free flow of information. The health care industry will never move forward if we constantly try to take the one-size-fits all approach. athenahealth recognized WebOMR had important capabilities we could use and learn from, and BIDMC in turn, recognized the value of our system. This kind of collaboration should be happening more in health care — as we’ve said, “More Disruption Please!” We actually have started a program called just that, where we invite entrepreneurs with health IT solutions we may not have, to plug into our system and sell directly to providers. These kinds of open platforms will not only enable the same user experience and access to a single patient record, but also can act as a channel for easy-on innovation.

The word “interoperability” is used so often — how do you define it?

Halamka: You’ll know it when you see it — it’s the seamless transfer of information from one place to another.

Bush: Interoperability is the ability for different systems to exchange information and then use that information in a way that is helpful to the users. It’s not simply just the movement of data, it’s the useful movement of it to achieve some sort of goal that the end user can use and understand and digest.

What are the stages of interoperability, and where do you believe most organizations are at this point.

Bush: There are basically three stages to interoperability. The first, intra-operability, or the ability to share information within the walls of one organization, already exists. This is what the old legacy software that was first implemented — and is in many major health systems today — enabled. The second, inter-operability, or the ability to share information with outside entities, is what we’re currently trying to implement, and where most vendors fall short. It’s not that the technical standards don’t exist; it’s that there hasn’t been real incentive to support open systems that enable this kind of information sharing. That’s starting to change. We’re seeing lots of vendors and hospital systems that had been unwilling to connect with the athenahealth network and our clients change their tune; now they are actively asking to connect. The third and final stage centers on open platforms, which will enable information to be accessed in an elegant, inherent way — information will be presented within single interfaces and can be queried from the network. Also with platforms, we’ll see direct lightweight web service-based interoperability that actually allows you to directly graft new functionality onto the underlying platform. It’s at this stage that new innovation will flood into health care.

What are the most significant barriers to interoperability?

Halamka: There’s been a lot of talk in regulating the standards and “language.” 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.

You’re both big proponents of infrastructures being nimble — why is this so critical?

Halamka: I have long believed that the key to the future of health care involves maintaining wellness across the continuum of care; not optimizing the treatment of episodic sickness in siloed organizations.  Academic medical centers are important for research and education, but the majority of care can be delivered safely in community hospitals and practices near the home, at lower cost. The HIT software of the future needs to leverage the experience of internet centric companies, offering cloud-hosted services with a zero client footprint, easily deployable in all sites of care. There should be no special browser, desktop, or infrastructure requirements. The services should be delivered via a subscription model that can be easily turned on and off as needed. Products should include practice management, billing, a patient/clinician inpatient/outpatient shared medical record, care management, population health, and an app store of third-party developed mobile products.

Bush: Almost nothing is static. Certainly not health care. In fact, I believe the industry will see its greatest change in the coming years. Keeping up with moving information, new innovations, and new reimbursement models will require highly adaptable infrastructures — those that thrive and get smarter on change, not resist the very thought of it.

Jonathan, you’ve made it a point to be present at a lot of discussions about interoperability (particularly the KLAS Summit) and have a voice. Why is this so important, and what do you want to say to vendors who refrain from these discussions?

Bush: As we’ve seen in other industries, internal information sharing isn’t novel. Think of United and Delta, both of which invested heavily redoing their websites in the 90s, thinking consumers would skip the travel agent and book directly through them. But along came Kayak, which disrupted that idea; now a vast number of travelers book tickets directly through Kayak without visiting those new United or Delta websites. Consumers want a marketplace, a choice. Instead of returning to the one place or one brand with which they are familiar, consumers want to shop around, find the best prices for the best deals or buy the deluxe version. The same applies to health care. Those care organizations who realize sharing information is not only the right thing to do, but has the potential to win them a new kind of market share — well beyond their current geographical footprint — will lead the charge for more informed and competitive health care.

What do you expect will be the most talked about issues at HIMSS?

Halamka: I think the biggest will be the evolution of meaningful use and transition to fee-for-value.

Bush: I’d say interoperability will still be a hot topic, in addition to population health. Also, the ability to track diseases in real-time, most notably with the recent outbreak of the Zika virus.

If you could give one brief message to hospital CIOs about interoperability, what would it be?

Bush: It’s necessary to survival in the future. The business of health care is changing very quickly; technology has to enable and keep up with the business as opposed to drive it. The strategic battlefront of health care is moving out of the hospital and toward retail clinics, community doctors and urgent care chains. As the landscape changes, interoperability, the need to be able to track a patient from affiliated and non-affiliated care sites, is very important. It’s critical to build information bridges now. I believe the best way to do that is to walk away from software and join an information network.

Halamka: Interoperability is use case driven. I was recently speaking with folks in Congress and they told me that interoperability is the free, effortless exchange of every data element in the EHR with every stakeholder for every purpose. If you define interoperability with those terms, you will fail. Pick a business case that has a champion, identify the workflow needed to achieve an outcome, and build the interoperability necessary. In 10 years, we’ll look back on this era and reflect that creating interoperability was like building the interstate highway system — one on ramp and off ramp at a time.