Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

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Can Middleware Succeed in Achieving EHR Interoperability?

- A growing emphasis on value requires healthcare providers to coordinate care effectively and efficiently. However, a lack of EHR interoperability can easily disrupt the communication and exchange of patient data between clinicians and require these end-users to use more of their time piecing together disparate bits of relevant information.

Although EHR technology has the potential to capture pertinent clinical data, Donald M. Voltz, MD, argues that it falls short of giving meaning and context to patient health information. The member of the Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital in Canton, Ohio, is always board certified in Informatics and is an Assistant Professor of Anesthesiology at Case Western Reserve University and Northeast Ohio Medical University. 

In this one-on-one interview with HealthITInteroperability.com, Voltz explains how previous attempts at achieving EHR interoperability have failed and why middleware has the potential to improve both the use of EHR technology and the clinical workflows of providers.

HealthITInteroperability.com: How does a lack of EHR interoperability impact patient care?

Donald Voltz: The easiest way to look at this is with a complex patient such as someone in the intensive care unit. We have had flow sheets, single sheets that I can use to see all the different trends of my patients and I can intervene on those trends all in a single sort of platform. Now what happens is that I have to search around for all these various pieces of information.

The biggest frustration is not knowing if somebody else has accessed a piece of information for a patient who happens to be a provider in the whole care and has found and addressed an issue. I have to go back an piece together this every time I open up a patient's medical record. There are dashboard-type views for the medical record, but again they are not giving us the information in a contextual manner and also not allowing us to bring our meaning or communicate that information to other providers on the team. We have to search through tables of information.

HITI.com: How is non-interoperable EHR technology impact your clinical workflows?

DV: At a hospital I currently work at, I literally will have to interact with as few as three different EHR systems depending on how my patient would transfer through the system. There is a different system available in the emergency department than there is in the operating, than there is, for instance, in a pediatrics. There are three separate EHR systems which currently are not communicating or connected between one another. And I have access multiple platforms for radiology or cardiology.

That has gotten a little bit better in that our EHR system has finally implemented a solution to connect those systems together, but really what they have done is interconnected systems — they really haven't interoperated systems. As a clinician, I need a view of into my patient. I don't need to know the nuances or backends of where that data resides or is coming from. With the current technology, that is exactly what I’m interfacing with. There is no well-designed system to connect the data and display that to individual physicians or providers who need certain parts or pieces of that data.

HITI.com: What do you perceive as the cause of limited EHR interoperability?

DV: If we look at medical documentation and medical systems across history, the purpose of the medical record used to be to bring context to our interventions with a patient. And it used to be that a single physician pretty much orchestrated the care for the entire hospitalization or even across hospitalizations along the entire care continuum. It always has been a medical, legal, and billing platform, but it was mainly a communication platform and a bringing together of information and interpretation, which brings the meaning or knowledge to the data as the patient goes through the health system. Now what has happened is that the EHR platform has collected data but I don't have the ability to bring my meaning to that data. All I have is that I use to extract data back to. So now we get into this whole interoperability problem.

HITI.com: Are health information exchanges or interfaces the solution?

DV: The way most people are describing interoperability if you look at health information exchanges or interface engines, all those are doing is trying to connect data together — whether it is allowing you to access data from different databases — and it is not any better ability to deliver high-quality care and get the information I need on a moment-to-moment basis. Instead, it's our care, our process, and my interaction with the data being defined by these EHRs. Even if we connect them all together, it is still defined by the databases that they really are.

Any EHR system is a front face to a database behind it. Unfortunately, the way that health information exchanges are being developed and are moving forward, they are becoming nothing more than large EHR systems where everything is being dumped into. It is not empowering or engaging the clinicians and the patients to use the data.

HITI.com: Why will middleware succeed where other technologies have failed?

DV: The benefit of middleware is to be able to develop specific applications that go far beyond the data. Right now I am completely tied to an EHR system and I am dependent on their evolution and innovation cycle as they try to meet their requirements (government requirements, hospital demands, etc.). When it gets down to the users in the field  — providers, nurses, or physicians — they can address the big issues, hot-ticket items, but they can't allow us to innovate or expand the EHR platform which is what's there.

There is clearly a lot of competition in the space, but no matter who survives it's always going to be a playing field where you have multiple technologies at various stages of development that need to be utilized as tools. But they need to have a platform that I can interface with. My biggest excitement about middleware is that as technologist and clinician in the field I have the ability to develop on top of all of this data to make better use of it, deliver better care, and even work with my patients to get better engagement on their end.

No one is going to develop for 75 different EHR platforms when they come out with some sort of idea. But instead if we can develop into a system that then has its fingers or tentacles into all the different EHRs, then now as a clinician I don't care what I'm accessing — I just know that I’m accessing the patient data that I need. Middleware could actually allow communication to everybody on the care team even if people join the team later on and there is a piece of information out there that hasn't been addressed.

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