Interoperability Gets Personal

Let me start with my personal firsthand experience of health information interoperability.

While playing football for his college last fall, my son sustained a pelvic fracture. He was initially seen and evaluated at the local community hospital, an excellent institution. He was transferred to an outstanding quaternary institution about 35 miles away. At the community hospital he had the appropriate imaging studies performed a CT scan and MRI.

Unfortunately, there was no way to electronically transmit my son’s clinical record and imaging studies between these two cutting-edge institutions. More unfortunately, someone, while including my son’s MRI in the manila package of patient information I carried by hand to the University Hospital, forgot his CT scan. This required, after having been up for almost 24 hours, a return trip to the community hospital for the CT scan disk. Both hospitals are digital meccas, using both PACS and EHRs. Other than faxes, neither hospital can exchange electronic data with one another.

Assessing the results of HITECH
Having this experience added to my enjoyment of the March 4, 2015, Health Affairs Blog Where Is High Tech’s $35 Billion Investment Going by Senators John Thune, Lamar Alexander, Pat Roberts, Richard Burr and Mike Enzi. Noting that we are six years and $28 billion into the 2009 HITECH Act, an act intended to promote the adoption and meaningful use of technology in the provision of healthcare, the senators opined that our spending to date “(has) not resulted in significant improvements to clinical care coordination or quality.”

The blog focuses on areas of concern: program sustainability, privacy and security, oversight, increasing costs, and everyone’s universal concern, interoperability. Privacy and security concerns are ubiquitous to all Internet undertakings; healthcare information technology is not immune. Whether you are Sony or Anthem, cyber security is a priority.

More specific to health information technology, the senators highlighted concerns of cost, both in aggregate to society and to the individual hands-on providers of care. The report notes clinical practices spending of $100,000 to $200,000 for initial EHR implementation. These numbers do not reflect ongoing operating expenses for the practices. The blog additionally reports the Annals of Internal Medicine December 2014 study observation that only one-quarter of the studied HIE’s consider themselves financially stable. (Although not reported by the blog, it is worth noting very few HIE’s, according to a 2013 report, are capable of sharing imaging information at this time.)

The senators also express dismay that “significant progress towards interoperability has been elusive.” The blog observed that Stage I incentivized adoption of EHR systems without assuring interoperability, and that “ONC’s certified products fail to deliver the value of easily exchangeable health information to better coordinate care.” The senators further the lack of “real and actionable next steps” toward interoperability in the ONC roadmap.

In 2013 the same senators along with the now retired Senator Tom Coburn authored a white paper titled REBOOT: Re-Examining The Strategies Needed To Successfully Adopt Health IT. Their Health Affairs blog reviews the predictions of the white paper, and concludes that little has changed: Interoperability remains nebulous and unrealized, costs are rising, oversight is absent, concerns for privacy and security remain, and financial sustainability is worrisome.

Read together, the blog and white paper are an invite by the senators for the ONC to take the lead at a granular, operational level in achieving interoperability. And an essential component in this will be a Meaningful Use initiative where the objectives are clear and hard linked to interoperability.

Costs vs. benefits
Although not highlighted, a significant yet subtle observation of the white paper is echoed in the blog. In scoring the HITECH Act, the CBO estimated $12.5 billion in savings would be achieved at a net cost of $20.8 billion. Could it be that the increased use of technology in delivering healthcare will not pay for itself? That may be the case when one considers the profound challenges, read expenses, for true meaningful use and interoperability.

Should this be true, it would not be the first time clinical medicine embraced a very expensive technical improvement in healthcare.

I came of age in medicine at a time when CT scans were not available. To image lesions, subdural hematomas, tumors, etc., inside the skull, we subjected the patient to cerebral arteriograms and pneumoencepalograms. The procedures were risky, difficult and painful. The information acquired was scant and indistinct.

Today, through CT scans and MRIs, we acquire massive amounts of high resolution information with minimal risk and patient discomfort. What we spend on imaging has soared. Yet any patient who ever had a cerebral arteriogram or pneumoencephalogram will testify the value added of CT’s and MRIs overwhelms the cost.

Driving between hospitals with my son’s CT disk, not having slept for almost 24 hours, made me sure the value added of interoperability will also overwhelm the costs.