Making sense of our digital medicine Babel

Abstract

Interoperability is a common-sense idea that has proven uncommonly hard to put into practice in the world of medicine, a fact highlighted in a new report released on Oct 12 by the National Academy of Medicine, Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. The idea is a simple one: ensure that electronic health records (EHR) technology—all the modern tools of medicine, such as monitors, blood pressure devices, dialysis machines, record keeping systems—can communicate so that a patient's vital statistics can be gathered, transmitted, and used. In an interoperable system, this would allow clinicians to share information about a patient's status, to provide a record to other clinicans working with the same patient, and to ensure that the most up-to-date information about a patient is available when it is needed. This seemingly simple idea has proven frustratingly difficult to implement. Medical devices manufactured by different corporations (an industry valued at US$147·7 billion, with EHR accounting for $20·5 billion in 2016 in the USA) use different software platforms, output data in different ways, and might not play nicely with other devices. 96% of hospitals and nearly 80% of doctors' offices use EHR systems. The lack of interoperability is a drag on the health-care industry, by one estimate costing $36 billion in time wasted with manually re-entering data, redundant testing, and non-electronic transmission of laboratory tests and other information. Health-care systems tend to approach their needs for new devices and systems in a narrow way, focusing on technical abilities of particular systems rather than broader interoperability. This means that those systems may be well suited for their task, but might fail completely when it comes to sharing data with other departments, at a cost of additional time and effort. EHR system manufacturers use proprietary, non-standardised protocols. When a health-care provider signs a contract with one company, it locks itself into a proprietary system that makes interoperability with other systems difficult. This has the consequence of increased inefficiencies, but it also has given rise to tertiary markets designed to bridge the gap between these mutually exclusive systems—all at an additional cost. Interoperability also raises profound questions about the security of patient data, some of the most sensitive data in a person's life. Digital data are easy to transmit and perhaps easy to accidentally disclose, or even steal. Many EHR-system providers handle storage and security of patient data, but health-care systems need to put patient data security that complies with the Health Insurance Portability and Accountability Act at the forefront of their concerns. Procurement of EHR systems can take years and millions of dollars, and no matter how powerful or useful a medical device system is, if it does not fit into a clinician's workflow, it is not going to be used. This disconnect between medical devices and EHR systems is part of the reason why the touted benefits of digital medicine have largely failed to appear. The need to get it right is enormous, and so far health-care providers have been approaching procurement in entirely the wrong way. The report provides in-depth descriptions of how to structure requirements so that the resulting systems put the needs of clinicians and patients first. The necessity of interoperability becomes apparent when considering other industries. Airlines purchase planes from any number of manufactures and send them all over the world, but they do not worry whether their plane will work with air control systems or equipment at the next airport. Health-care systems have the same need, but where electronics consumers and airlines have made their desire for interoperability clear, health-care systems have not. The 21st Century Cures Act, enacted in late 2016, calls for the implementation of standardised access protocols that would further interoperability between systems. But health-care providers need to act to make interoperability and patient security first-level considerations when formulating procurement requests for new equipment and EHR systems. EHR manufacturers have a financial motivation to lock as many providers into their proprietary systems as possible, and interoperability cuts against that interest. The report lays out a detailed roadmap for health-care organisations to use their purchasing power to force marketplace innovation and demand systems that can safeguard patient data, work across platforms, and allow the integration of equipment from the doctor's office to the imaging suite, and to the hospital bed, to improve patient-focused care. Interoperability standards can help reduce the waste of time, money, and lives that the status quo extracts, and help make the promise of a truly interoperable digital health-care system a reality.