Right now, interoperability is a topic of much discussion among hospitals, health systems, systems providers and the government. As the industry heads into the first stage of meaningful use, key role players are scrambling to get a grasp around what the requirements for interoperability should be, what interoperability will require and what healthcare providers can do to prepare for it. Although the government has not yet released official rules and regulations on interoperability, hospitals and health systems can still achieve it. Here, Charles Jaffe, CEO of HL7, an authority on standards for interoperability of health information technology with members in over 55 countries, explains the state of interoperability and how hospitals can become interoperable.Q: What do hospitals need to do in order to become interoperable?
Dr. Jaffe: Hospitals have to make decisions based on good business practices. Whatever drives the fiscal requirements of the hospital or healthcare system must be the keystone for technical implementation. Many of the health information exchanges, which are predicated on interoperability, have floundered because they don't have a good business model to sustain the organization. It's clear that their motives are appropriate or their technology is up-to-date, but it costs money to run such an organization and driving that business model is difficult to achieve. So while interoperability is critical in order to be successful, the reasons for doing it and the ability to be successful aren't always aligned.
Q: In regards to interoperability, what is one of the most common challenges facing hospitals right now?
Dr. Jaffe: One of the incentives for achieving interoperability is the reimbursement process. Hospitals and caregiver organizations receive significant incentive payments if they meet meaningful use criteria. Other incentives are less clear. For example, in Chicago, Rush and Northwestern compete for patients. It's a tough reach as to why they should share information with each other, other than it's best for the patient. On the other hand, it's clear why a rural hospital may send a patient to Chicago because a newborn baby or a burn victim can receive better care at a tertiary center where specialists are often more experienced. What is the business case for a Chicago hospital to send information back to another Chicago hospital or another the primary care provider? That's less clear. If we are focused entirely on what's best for the patient, then interoperability and seamless data sharing are inevitable, but sometimes we have to better define our incentives.
For example, at the research level, the National Cancer Institute developed a model by which researchers were obligated to share research data in near real time. The business case was simple. NIH is not going to give researchers the grant unless they comply with that interoperability requirement. But the big payor in the U.S., CMS, hasn't chosen to enforce that yet among hospitals and health systems. But when they do, I think you'll see compliance with interoperability go up dramatically.
Q: Are there any other common challenges facing hospitals?
Dr. Jaffe: Early in its life, HL7 became very widely adopted because it was easier to use and because it was easily customizable. If you want to make your healthcare information system entirely suited to your local and often parochial needs, the technology allowed you to do so. Unfortunately, that doesn't always mean that the hospital across the street will customize their system same way. Additionally, the rate of change for these technologies can be formidable, and different hospitals evolve in different ways, often following technologies and adopting localization that other organizations chose not to follow. So now 25 years later, even though everyone may be using HL7, the systems that were developed — either as a local solution or developed by a big vendor — are not quite identical. For example, in regards to gender, one hospital may use "male/female", and another hospital may use "M/F." While you may think that's trivial, multiply that by the hundreds of other ways specific types and classes of information may be identified. Mapping technologies can become complex and expensive. Interfaces that enable the same data sharing are equally complex.
Q: What are your thoughts on meaningful use as we make our way into Stage 1?
Dr. Jaffe: The future electronic health record will provide robust decision support. This support will not only combine evidence-based medicine but also clinical guidelines. Achieving that objective will also improve quality of care and reduce costs. So we will need to have very intelligent algorithms to tell providers, for example, one intervention is the best treatment for a given condition, although a specific medication may not be recommended. That will require a significant philosophical change for caregivers because they are trained to commit everything to memory. It's as if train conductors in Chicago were required to memorize schedules and fare codes for all the trains coming in and out of the city and were expected to make use of that information immediately. You just can't do it. However, new sciences make new opportunities for caring for patients.
There are technical solutions that are evolving all the time. When I trained [in medical school], genetics was easy. That's why we gave every patient the same dose, male or female and regardless of race or ethnicity. We just totally disregarded the genetics and the unique characteristics of these individuals. But every day we define new concepts in genetics. So, while it was once a chore to imagine how we were going incorporate EKG findings into an EMR, very soon, we will be obligated to incorporate genomic data because it's critical to how we make decisions. So as Stage 2 and 3 of meaningful use approach, systems absolutely must be sufficiently flexible to do the type of things caregivers must have, including effective decision support. It is going to just be a dramatic explosion.
At my graduation, a professor said if you read an article every night and absorb the information into practice, in 10 years, you'll only be 10 years behind. So that's the challenge that information systems really have to face.
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