Uncovering the fact that they do get along
In the realm of healthcare information technology, interoperability isn’t just a hot topic. It’s on fire. Sparked by billions in federal incentives, healthcare organizations have largely moved away from paper based-systems over to electronic medical records (EMRs).
The enormous flow of money being spent by healthcare providers, subsidized by the federal government, has led to increased levels of federal scrutiny as interoperability and data exchange issues between competing vendors continues to linger. A RAND Corporation report identified Epic as a roadblock to interoperability. The report fueled the flames for articles from multiple media outlets, including Forbes, Politico, Mother Jones and others. Epic representatives state that these stories sometimes seem sensationalistic, lack fact checking, and contain some misleading statements about Epic’s approach to data exchange. WTN News, invited senior executives of both Epic and Cerner to speak publicly together at the Disruptive Healthcare Conference and the comments were very candid on this issue.
The Quest for Standards
Cerner has joined other Epic competitors to form CommonWell Health Alliance, dedicated to creating industry standards for interoperability. Epic has declined to join. Epic’s lack of participation has fueled the media’s hype and speculation of a bitter fight between the EMR vendors, portraying them as feuding arch enemies with little to no cooperation between them. The leadership of Cerner and Athena publicly call out Epic and its founder Judy Faulkner with satire and headline grabbing quotes. Epic’s critics publicly state that Epic is blocking data and not advancing the availability of health data records exchange.
Uncovering the Facts: “We Do Get Along”
The Disruptive Healthcare Conference, held Tuesday in Madison, sought to tackle this debate with executive leadership from Cerner and Epic demystifying the issue. Both companies agreed that this public meeting and discussion would set the record straight that the companies are working well together at dual client locations, and on interoperability issues.
Heading into the event it may have been easy to assume that an Epic executive sitting next to a Cerner executive is either a rarity or an impossibility. “It is actually highly usual for us to be sitting next to each other,” said Peter DeVault, vice president and director of interoperability at Epic. “There’s been much too much made about the rift between Epic and CommonWell. There’s a whole lot of water under the bridge.”
During the session entitled “Obstacles to Interoperability: Can’t We All Get Along?” some of the complexities surrounding this whole notion of interoperability were unpacked as the vendor representatives were joined by panelists with the Medical College of Wisconsin and UW Health. Although the EMR vendors tend to receive much of the blame for the problems of exchanging patient data, it may be a larger, more nuanced issue that extends beyond the service providers.
One of the things about interoperability that makes it such a difficult subject, noted DeVault, is that it means so many different things to so many different stakeholders. “We focus on particular standards,” he said, “but we don’t focus a lot on the entire ecosystem that’s required in order to solve real, concrete problems.”
The Missing Ecosystem
There is an entire ecosystem of policy and national infrastructure that has not been developed yet. “Those are the really difficult things,” said Robke, “and that’s what takes the entire industry to solve – not how can we get the bits and bytes from one system to another, because frankly, that is very easy.”
Epic and Cerner have mutual clients and their teams work together and that hasn’t been an issue, noted Bob Robke, VP of interoperability at Cerner. “We have several implementations to prove that out,” he said. “Scaling those solutions, however, gets tricky.”
“It’s a much bigger problem than just standards,” he added. These complexities extend beyond the technical realm to include legal issues such as rights and liabilities of those who use and share data. That’s what takes the existing challenges and problems to a whole other level.
“It is frustrating to us that policy and politics get in the way of the patient experience,” Robke added, noting that what’s good for business and what’s good for the patient don’t necessarily have to be in conflict. “There are lots of challenges, but lots of opportunities to make this ecosystem of healthcare better, and that’s what we’re trying to do.”
While Robke publicly invited Epic to join CommonWell during the session, DeVault urged audience members to brace themselves for a world in which there are a variety of competing vendors who are all working to provide effective services to the healthcare industry.
“How can we make sure that CommonWell, which is one network among many, and Care Everywhere, which is one network among many, and all the different HIEs (health information exchanges) can communicate with each other?” DeVault asked. “Because that is the world we will always be living in. There is not a magical future down the road in which there is one health information exchange network called CommonWell or anything else.”
DeVault commented further in an interview with WTN News, “CommonWell is one among many networks in the country, and so far, it’s not an especially large one. We don’t typically join networks, although we help our customers connect to whomever they choose. In fact, our customers have connected directly to Cerner, Allscripts, and Meditech customers without going through CommonWell. We believe there will always be many networks, and that we therefore need the technology and governance to connect those networks together. That’s why we back Carequality underneath the Sequoia Project.” Both Epic and Cerner are members of Carequality, a health data interoperability framework intended to connect disparate health information exchange networks.
Neil Patterson, CEO of Cerner, who was quoted in an article in HealthITAnalytics, published in April 2015 said, “I predict that CommonWell will become a major interoperability-enhancing utility and network in the years ahead, but like most networks, it will take time to get a large enough mass of users signed up and content flowing to make a real difference.”
The article also reported that, “CommonWell aspires to be a nationwide network with a record locator service that will tell you where every part of a patient’s record is,” Epic Systems’ Director of Interoperability Peter DeVault told Congress last month in a hearing on the sluggish progress of EHR interoperability across the industry. “They are not there today. According to their latest report that I have seen, they have four different sites live on their network, fewer than a 1000 physicians compared to a 100,000 in Care Everywhere and almost 10 million records exchanged a month now.”
According to Epic, Care Everywhere’s interoperability patient data exchange platform is the largest EHR exchange network in the United States. Organizations on the Care Everywhere network range from the Cleveland Clinic, and Kaiser Permanente to Wisconsin-based Aspirus Health System. Epic has stated that Care Everywhere will be used by over 275,000 providers at more than 26,500 clinics, 800 retail clinics and 1,050 hospitals, representing over 54% of the U.S. population.
A Chief Medical Information Officer’s View
In an interview prior to the conference,” Shannon Dean, MD, CMIO with UW Health views the issue from multiple viewpoints. As a participant in the session, Dean shared her experiences dealing with EMRs. “In my CMIO role, I really oversee the implementation of health information technology for our providers, as well as their use of these tools and their satisfaction or lack thereof,” she explained.
As a practicing pediatric physician, Dr. Dean deals with interoperability in a different way. While there has been success at her facility in terms of exchanging information between existing Epic customers, she explained that interaction with patients who come from other systems utilizing different platforms relies on faxing forms or having the patient come to the hospital or clinic with a printed record in hand.
Her hope, looking ahead to the future of EMRs, is that vendors will find ways to allow interoperability between systems, ensuring usability by clinicians in their daily workflows. “It’s not just about having the information available,” said Dean, “It’s making sure that that information is seamlessly incorporated into the patient’s record, so that it can be acted upon as the provider is making clinical decisions about that patient.”
Specific Problem Issues
Dr. Dean clearly sees the challenges and roadblocks that have and may continue to prevent interoperability from becoming a reality in the near future. “Number one, we still have a long way to go as healthcare organizations and the provider community develop usage standards for the existing functionality within the various EHRs,” she says. An example would be uniformity surrounding something as seemingly straightforward as the definitions for allergies or how medication is documented.
“Some of those things really lie outside of the vendor, and it’s going to be incumbent upon providers to develop standards surrounding the way that we communicate those things and the way that we use those tools within each of the EHRs,” she adds, “so that as information exchange becomes more of a reality we’re really comparing apples to apples.”
Another important aspect is making the right information accessible and not just doing another bunch of incomprehensible data dumps that physicians cannot easily digest. “Physicians these days are pretty overwhelmed with the availability of data” Dr. Dean explains, “that the data needs to be presented in a way that can be comprehended by physicians to make medical decisions at the point of care.”
From the vendor perspective we do all understand that some of this is about market share, she adds. If every system has to function in a similar way in order for data exchange to be easy, it does make it challenging for the vendors, and there’s not a whole lot of incentive on their side to make the exchange of information across vendor systems easy.
Though she doesn’t pretend to have all the answers, Dr. Dean says interoperability is an issue that may need further oversight in the form of industry or government regulations so that the best interests of patients – and not the business models of the various vendors – is made top priority moving forward.
Dr. Seth Foldy, MD, Medical College of Wisconsin, another panel participant, helped develop the Wisconsin Health Information Exchange in the mid 2000s. When he asked how many people in the audience thought they could define “interoperability,” few raised their hands. He suggested one functional type of interoperability is “data liquidity,” that critical health data could follow a patient between different providers and vendors.
“By that yardstick, we are still far from interoperability,” he said in a post-session interview. “Until common standards are used, expensive interface requirements block liquidity.” He agreed with the vendor representatives that agreements about data use, security and confidentiality (often called the “trust fabric”) is important as well. “Negotiating multi-lateral agreements on standards and the trust fabric has been a major feature of successful regional health information exchanges, and need now to be accelerated on a national level.” He is concerned that vendors could not describe how competing interoperability collaboratives (CommonWell and HealthWay/Sequoia) will converge with time.