Interoperability Isn’t a One-Dimensional Problem or an Intellectual Exercise

With all due respect to the thousands of earnest folks spending untold hours meeting and writing papers and blogs about how best to make patient records interoperable, they’ve got it wrong

Interoperability isn’t a one-dimensional problem.  Neither is it an intellectual exercise. The well-being and even lives of hundreds of thousands annually depend upon our care providers being able to access our complete medical record at the point of care.  It’s simply not good enough to hope we’ll finally achieve this by 2017, 2020 or 2024.  We need to do so today.

Before I proceed, let me say that I define interoperability in terms of the end result, not in technical terms.  To me, we have interoperability when a care provider or his patient can routinely and instantly access, sort and search the patient’s complete medical record from all her providers — anytime, anywhere, in or out of her network, at home or away, even without Internet or server access. Anything less is like being half pregnant.  Either we have complete, total interoperability, or we don’t.  Period.

Applying this simple definition, how close are we?  Sadly, we’ve spent ten years and more than $26 billion but interoperability remains years away.  Our doctors can’t begin to access all our records at the point of care.  Why?  Because we approached it as a one-dimensional problem.  We assumed that getting doctors and hospitals to adopt electronic records would solve the problem, and that linking them via an electronic network would be a no-brainer.

As we all know, this was dead wrong.   So here we are today with most providers having invested small fortunes and using electronic records but still unable to access a patient’s complete record or even share or exchange a patient’s electronic records beyond very narrow networks, if then!

What went wrong?  Simply put, we addressed an important structural issue but ignored six other critical problems.  They include: how data are managed, how easy a system is to use, how patients are identified, and how to solve critical legal, security/privacy, and financial issues.  Until we solve all of these problems in a single, easily functioning system, we’ll not have interoperability.

Compounding the problem, dare I say the confusion, a new flavor-of-the-month solution recently emerged from a 2013 JASON study.  It’s called Fast Healthcare Interoperability Resources, or FHIR, and our healthcare IT cognoscenti have embraced it as the panacea, the solution to interoperability.

I am deeply concerned, as all of us should be, that we’ve not learned our lesson and are about to repeat our past mistake.  FHIR once again is a one-dimensional approach that by itself can’t and won’t achieve interoperability.

For example, assuming everyone adopts a public API as called for with FHIR, doctors still won’t be able to access a patient’s complete record at the point of care. Patient identification will still be a problem. They’ll still not know if they have all of their patient’s records and only her records. The legal issues surrounding consents and sending records across state lines will still not be resolved.  Patients will still not be certain their records are secure.  And the system will not be financially sustainable.  In short, we’ll still not achieve interoperability.  In the interim, we’ll have killed off hundreds of thousands more people, harmed millions more and wasted hundreds of $$billion more.  What a grim prospect!

How do we avoid this fate?  Happily, it’s not rocket science!  All we have to do is ask ourselves if there are other ways to solve all six of the problems blocking interoperability today, and if we can combine them in a single system. (Hint, hint: the answer to both is YES.)

First, is there a proven technology available today that can easily and instantly exchange all types of records, documents, images, etc?  The answer is yes and it is used billions of times each day.  It is Portable Document Format, or “PDF,” technology.  While looked down upon by healthcare IT techies for some unknown reason, it accomplishes precisely what we want.  As described on one website (thank you, Google), “It was introduced to ease the sharing of documents between computers and across operating system platforms when you need to save files that cannot be modified but still need to be easily shared and printed.  Today almost everyone has a version of Adobe Reader or other program on their computer that can read a PDF file.”

Second, is there a technology available today that makes it easy to instantly search masses of PDF documents so we can find specific ones?  The answer again is yes and, it too, is used billions of times a day.  It’s called optical character/mark recognition, or OCR/OMR.  It makes PDFs instantly searchable.

Third, is there a simple way to solve the patient identification problem?  Again, yes.  We can give the patient a PDF copy of all her records (which she also can read and amend to correct mistakes), and store them on a device that includes her picture.  She can carry it with her and give it to any care provider she sees.  When he logs on, he can compare the photo with the patient’s face.  If they match, he can assume the records are hers.

Fourth, is there a way to ensure that her records are secure and that whomever accesses them has her consent to do so?  Again, yes and yes.  We can encrypt and store her records on her device not on Cloud or web servers so they cannot be breached or stolen, and require her password to access them.  When she enters it, she implicitly gives her consent, and her records open up.

The other legal question is how can we overcome state laws that restrict care providers from sending patient records across state lines.  This, too, is simple to solve.  The patient is free to carry her records anywhere she likes including across state lines.  So by mounting her records on a device she owns and moves “with” her, we solve this legal problem.

Fifth, are there easy ways to manage a patient’s records so neither she nor her providers must manually enter masses of data or click through multiple windows to access specific information? Again, yes.  Care providers can upload copies of their actual notes as PDF documents, whether paper or electronic, to a third-party server that, using OCR/OMR, makes the records searchable.  It can then e-mail her to download them.  Also when authorized by her, it can send copies to other parties such as family members, doctors and care givers.  In addition, PDF documents can be downloaded from the patient’s device to her providers’ various systems, or as structured data if her providers’ EMR vendors use a common API.

Sixth, can we create a business model that is financially self-sustaining and aligns the financial interests of all parties?  Again, the answer is yes. Neither government nor care providers need to fund interoperability.

A subscription business model can do just that.  The patient, or her employer, insurer or government, all of whom will save money when interoperability enables doctors to provide better, coordinated, lower-cost care, can be charged an annual subscription fee for Updating and Support services.  And care providers who incur modest costs to upload a patient’s records, can be paid a fee from this subscription revenue every time they upload a patient’s records.

In addition, an independent third party can create the applications that manage the patient’s records, the server and OCR/OMR systems, and the subscription system that pays providers.

Thus, by solving all six problems, we can, in fact, achieve interoperability—and everyone benefits.  The nice part is this solution is not merely an intellectual exercise.  Our company, Health Record Corporation, has built a system that does just that.  It is called MedKaz®.

MedKaz aggregates searchable PDF copies of a patient’s records in all formats from all her providers and the application to manage them, on a distinctive MedKaz Green Drive® which she carries on a keychain, in a wallet or wears, and gives to any provider at the point of care.

As he examines and treats her, with only two or three clicks he can sort, search for and access specific records and, thereby, provide better, coordinated, lower-cost care.  If he wants to download another provider’s record(s) to his system, she enters her password and he can download them as PDFs (or as structured data when his EMR vendor adopts HRC’s API).

Following each visit, he uploads his records as PDFs to HRC’s server, for which HRC pays him.  The server makes each PDF document searchable and e-mails her that records are waiting to be downloaded.  She logs on to her MedKaz and downloads her records to it. Cycle complete; mission accomplished—and everyone benefits!

It couldn’t be easier.  It solves all six problems blocking interoperability and it meets everyone’s needs. So why are we still chasing partial, one-dimensional solutions?

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9 Responses to Interoperability Isn’t a One-Dimensional Problem or an Intellectual Exercise

  1. I could not agree more, but what you are missing, at least at the State and Federal Government level, they don’t want IT that way. Why? Power, Control and political advantage. We have a highly interoperable Medicaid and Payer Eligibility Determination solution….can’t win a State deal over the traditional vendors. Why, way, way too much money in that party….

    When our system is reviewed and scored, comments like “we don’t know who you are”, Your COTS installation was too “Hard to Score”, our IT team really liked the approach but our administrative and policy wonk personnel selected another vendor…..

    Translation….”we have chosen our vendor and the commissioners and the governor’s office really like them. Yes, the very vendors developed the very systems that ONC and HHS are trying to replace…..Really….yes, Really.

    My 2 cents!


  2. Mary Cessna says:

    You are so right in what you are saying. A patient or their physician where ever they may be should be able to access their record at the point of care.

  3. John Kraft says:

    You’re missing the forest for the trees. FHIR is the first time a spec has been created to allow for widely published, directly consumable APIs to be put on top of the CEHRT data silos that can be leveraged by a completely new ecosystem of creative solution providers to solve specific needs and workflow issues of the various entities involved in patient centered care.

    Well documented, widely published, and easily consumable direct APIs are not just another partial, one-dimensional solution, they are a game changer.

    It’s a methodology that would allow enterprising third party developers to create the PDF driven Use Cases your article describes, regardless of what back-end certified EHRs are involved.

    It’s an enabling technology, not an end solution.

  4. Jason Lee says:

    The author and the product omit perhaps the most critical component that will make interoperability possible: a common language, which is to say standards.

  5. Scott Mace says:

    What if the patient is in the ER, unconscious, and cannot give consent or provide a password?

  6. Merle Bushkin says:

    Scott, basic medical and administrative information is accessible to emergency providers which enable them to stabilize the patient and contact the patient’s providers and emergency contacts.

  7. Merle Bushkin says:

    Jason, MedKaz displays documents as PDFs in a browser. While you may not think of them as such, they are universally accepted “standards” for exchanging information and data in disparate formats.

  8. Merle Bushkin says:

    John, whether FHIR is better than HIEs or Direct is irrelevant. The patient identification, legal, security, ease of use and financial problems remain. MedKaz solves them today and makes complete interoperability available today!

  9. Merle Bushkin says:

    Thomas, if enough patients, providers and hospitals embrace a system like MedKaz that results in better, coordinated, lower-cost care, I suspect all levels of government will follow suit. They’re slow or reluctant to embrace it today because they’re afraid to deviate from “convention,” even when they know convention is wrong! It’s the IBM syndrome of the past. No one got fired for adopting IBM even if it didn’t do the job!