- Without knowing it, the Centers for Medicare & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) may have actually saved the health information technology (HIT) industry from becoming a closed network incapable of sharing information, even within a single system. Prior to the launch of the CMS Electronic Health Records (EHR) Incentive Programs, the healthcare industry, namely hospitals, were using one of a handful of proprietary systems to implement the use of electronic records (medical, health, personal) in their treatment of patients. And before the advent of incentivize programs on a national scale, the creators of these propriety systems had no reason to accommodate new players and novel approaches to streamline the business of digital healthcare.
The boom of EHR vendors in recent years is proof positive that the industry is thriving. Now, all these companies cannot survive; however, their work is integral to opening closed systems and enabling health information exchange (HIE). Unlike their forerunners, these new developers are employing industry-wide conventions (e.g., the internet) and languages (e.g., XML) to improve care through the use of interoperable systems.
Opening doors to interoperability
One of the fast-growing developers of ambulatory EHR systems is Practice Fusion. The company offers free web-based EHR systems that leverage the power of the web browser to communicate seamlessly with outpatient services as well as inpatient settings, labs, and pharmacies. The service is free because it is subsidized through highly-targeted ads and marketing your providers can pay to remove (though many indeed choose to keep them).
Given the success of Practice Fusion to increase its user base quadruple fold in the past few years, you might never have thought the company faced serious roadblocks finding inroads into the industry. VP of Engineering Matt Douglass points to strong resistance from vested interests that attempted to snuff out competition before it even had the chance to catch on.
Part of the reason for that is the vested interests that have been in the industry for 20–30 years keeping other players out. They want to add as many barriers to entry as possible. And frankly, if we had known that when we were starting Practice Fusion, we might not have tried to do what we’re trying to do.
The recent evolution of electronic medicine owes much of its development to incentives that forced large vendors to adjust to the market because their “innovations” in American medicine were not moving forward at a respectable clip. According to Douglass, what the EHR Incentive Programs represent is a condemnation of previous ways of doing business in HIT: “The only reason those health information exchanges are being first of all mandated by the federal government, funded by tax payer dollars, and spun up within individual states is because the industry completely failed.”
Whether the incentives will lead to true advancement remains to be seen, but they do single out these dominant forces as culprits in forestalling change. However, the rumblings of change haven’t prevented the landed gentry from disparaging the new kids on the block. “I think generally they’re doing all of the health IT industry a disservice by continuing to prop up of these old technologies that will die eventually. The dinosaurs will die,” claims Douglass.
A taste of their own medicine?
One of the challenges of making systems more interoperable is that the term interoperability means different things to different people. As Douglass mentions, some hospitals consider interoperability as “connections within the hospital,” rather than networking with providers off hospital grounds.
The term tends to get overloaded. Interoperability for a hospital means that one or two pharmacies connect internallyand maybe if you’re lucky communication between different physicians operating out of that facility.
Another challenge is the number of vendors currently in the HIT market. Oversaturation would be a blessing were it not the case that many of these systems speak only to themselves. “We have maybe 400–450 different electronic medical record providers, and maybe three of them can talk to each other in a meaningful way, maybe” observes Douglass.
The answer to these challenges lies in industry standards already successful at exchanging information on a massive scale, the internet. Because vendors themselves have contributed greatly to limited connectivity, it’s necessary to adopt open ways of exchanging data that are non-proprietary and open. The internet is capable of clearing obstacles in the way of interoperability because it uses standards and requires individuals and organizations to speak its shared language.
With having those individual single points of failure, a network will never survive. So something more like the internet approach is the only way that we’re going to be able to exchange medical information between physicians about a specific patient and then connect to all the different players even outside of the doctor’s office.
Because hospitals are unlikely uninstall their long-used software solutions, Practice Fusion and others have made more significant progress in ambulatory settings, which is the Douglass’s focus. Ambulatory services are not only unencumbered by traditional vendor’s closed systems; likewise, they are the first and greatest number of sites where medical care takes place for most of the nation. “Once we leave the hospital space and you get into more ambulatory care like what we offer, the possibilities become green field. With users come leverage, with leverage comes the ability to force some of these entrenched players into more modern technologies,” says Douglass.
And it would seem that in the battle between David and Goliath, the tables are beginning to turn. With its user base increased 400% in the past several years, Practice Fusion is finding itself in the driver’s seat when it comes to deciding how information should be exchanged, not because they want to complicate matters but because hospital systems need to be able to integrate the former’s standards in order to access patient data from ambulatory providers. “It’s not really us dictating so much as we’re providing them the way that they integrate with us and that way is standard internet technologies,” Douglass continues, “The approach you take is you go with XML because everybody can speak it.”
What’s old is new again
If this gamble by Practice Fusion and others pays off, this new breed of healthcare software developers (which is ironically using industry standards that have existed for decades in IT) will change the look and feel of EHR and EMR systems for years to come. At present, the challenge remains ensuring that patient information can move securely and efficiently between organizations and providers.
We will integrate with those hospitals. We will be providing Practice Fusion patient information to those hospitals in an interoperable way. It will probably be via HIE — unless we get to the point where we’re a third of the country and we can say, “Well, if you want access to patient information on Practice Fusion, you integrate with us.”
Fortunately for the old guard, these newcomers are very willing to play fair — for now. Because the future of meaningful use hinges on HIE, one side will have to budge. Given the recent call from providers for systems with improved ease of use and connectivity, it’s looking good for the upstarts.
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