Should Healthcare Institutes Perform “Rip-and-Replace” to Achieve Interoperability? Less Disruption, Please!

The following is a guest blog post by Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.
Dr Voltz
A KLAS Research Report on the EMR buying trends of 277 hospitals with at least 200 beds has identified that almost half will be making a new EMR purchase by 2016.  Of the providers considering a change, 34 percent have already selected a vendor and another 44 percent are strongly leaning toward a specific vendor. Driving factors include concerns over outdated technology and health system consolidation.

But is the technology really outdated and health system consolidation necessary, or is the real issue lack of interoperability?  And if you are a hospital looking for a new EMR, let’s not forget the history of technology before we jump to conclusions that the greatest market share means the best of breed.

When we look at EMR adoption over the past number of years, we need to be careful with the data we use. Implementations, and now rip and replace switching to other venders, has been the only choice offices, clinics, hospitals and health systems had to address the issues with interoperability.

Most of current deployed EMRs are designed as a one-size-fits-all, leading to the situation where today out-of-the-box functionalities fit none of the care providers’ requirements. Besides that, EMR vendors have been designed with proprietary data where patient medical sharing (or exchange) becomes the biggest roadblock for patient care continuum. The reason for the rip-and-replace approach by some hospitals is to reach interoperability between inpatient and outpatient data with a single integrated and consolidated database approach.

A 50 percent turnover of EMRs is an incredibly high numbers of hospitals and clinics who have either replaced or are looking to replace their current EHR’s. Being that the majority of the initial implementations were supported by the HITECH act, one would think the government would raise issue with vendors to address this high turnover of EHR’s. There seems to be a general misperception that if our current systems do not meet the demands and needs of providers, administrators, and financial arms of a healthcare delivery system, ripping out the system and implementing a new one will solve the issues.

What is the True Total Cost of Ownership of an EMR?

Healthcare management must look beyond the actual cost paid to an EHR vendor as the only cost but they must look into the total cost, much beyond the normal Total Cost of Ownership (TCO). TCO only includes the initial license cost, maintenance cost, IT support cost, but in healthcare, there is another cost – it is the disruption of the care providers’ workflow. That disruption is directly correlated to healthcare system revenue and patient care outcomes.

Stop this disruption and let’s look for another solution where we integrate disparate systems since many of them are built upon databases that can address the needs of health. The cost to providers in time to learn a new system, the migration and loss of patient data that has been collected in the current systems, the capital expense of system software, the hardware, trainers, IT personnel, etc. all add to the burden, something that is currently being looked at as a necessary expense.

Interoperability Saves Resources

This need not be the case when platforms exist to connect systems and improve access for providers. Having a consistent display of data allows for more efficient and effective management of patients and when coupled with a robust collaborative platform, we close many of the open loopholes that exist in medicine today, even with EHR’s.

2.0 EMR connectors like Zoeticx and others have taken the medical information bus, middleware platform, to solve the challenges that current EHR’s have not.  This connection of systems and uniform display of information that physicians depend on for the management of patients is crucial if hospitals want their new EMRs to succeed. In addition, a middleware platform allows for patients to access their medical information between EMR’s in a single institution or across institutions, a major issue for Meaningful Use.

Fragmentation Prevents Some EMRs From Connecting With Their Own Software

Large EMR vendors’ lack of healthcare interoperability only reflects on how they compete against each other. Patient medical data and its proprietary structure is the tool for such competition where the outcome would not be necessarily beneficial for the hospital, medical professionals or patients. There are plenty of examples where healthcare facilities with EHRs even from the same vendor fail to interoperate with each other.

Such symptoms have little to do with the EMRs that have the same data structure, but about the fragmentation being put in place over the years of customization. We believe that the reason for this is to address fragmentation of the software product. Fragmentation is a case where deployments from the same software products have gone through significant amounts of customization, leading to its divergence from the product baseline.

To believe that ripping the whole infrastructure – inpatient and outpatient–as the method to reach interoperability would only cause a lot of disruption, yet the outcome would be very questionable down the road. Appreciating the backlash of calling the implementation of EMR’s a beta-release, we have much data to use in looking for the next solution to HIT.

As with much of medicine, we are constantly looking for the best way to take care of our patients. Like it or not, EMR’s have become a medical device and we need to start to evaluate them as we would any device used to manage health and disease. As we move forward, there will be an expansion in the openness of patient data, and in my prediction, a migration away from a single EHR solution to all of the requirements of healthcare, and into a system of interconnected applications and databases.

Once again, we have learned that massively engineered systems do not evolve into complex adaptive systems to respond to changing environmental pressures. Simple, interrelated and interdependent applications are more fluid and readily adaptable to the constantly changing healthcare environment. Currently, the only buffer for the stresses and changes to the healthcare system are the patients and the providers who depend on these systems to manage healthcare.

About Dr. Donald Voltz
By Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.  A board-certified anesthesiologist, researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.

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  • Nice article.
    I think CMS and ONC really have no idea how databases work. True interoperability will never happen.

    1. To be sure that the right information goes to the correct person, everyone needs a unique medical ID. Without that, databases will make mistakes putting the wrong information in the wrong chart. To run routines of name, birthday, etc to try to match will always have problems when doing interoperability, always, and that leads to very dangerous medical care. And how to undo a change is even crazier, if the information gets propagated to every interconnected EHR.
    2. Having middleware to constantly keep up with EHR database changes, updates, etc. is a nightmare scenario at best. It would be all too easy to get the wrong information placed in the wrong database fields, and SUPER expensive and highly technical and truly out of reach of the regular provider.
    3. The only real way interop will work is that every patient that “opts in” have a designated “address” that all the information comes to. So if the EHR updates, changes, etc. it doesnt matter. Similar to email or DNS, your patients address is or ….everyone sends information to you at that address. There would be no need for any middleware or big changes if Epic changes their database which hammers the link to Cerner, etc. You could have HIEs keep the encryption keys from both ends. The EP or EH sends the info encrypted to the HIE who decrypts and re-encrypts with the patients key and makes sure it goes to the patient’s address. The HIE holds the keys. If things fail, the HIE has the keys. If a patient wants to give access to a provider, they can give it to a provider, who can choose to view it. If you make a note, run a lab, do an xray, you are responsible for sending the info to the patient. No worries about the other provider’s broken EHR/middleware, etc.

    With all the security needed and updates needed for EHR, there is no way any interop will ever happen. I will eat this computer the day that Cerner will populate a Epic EHR correctly every time, without any fuss or muss, or huge expense or a team of IT people keeping watch, it will Never. Ever. Happen.

  • @Meltoots. Your correct, current thinking about interoperability is wrong. Cannot happen as you say. I’ve worked in EDI for 30 years, and with real money on the table, it still hasn’t provided true interoperability.

    There is a solution I believe. Our model of a patient “data custodian”, an entity contracted by the patient, responsible for the management of data storage, privacy, and retrieval of PHI, provides the platform which can serve as the “authoritative” patient database. Ideally, all EHRs would be built to use this database. Absent that, they could be “enhanced” to interface to it. This custodian would be capable of storing ALL patient data; clinical (visits,tests,diagnoses,care plans, etc.), personal (social, device/smartphone apps, etc.), and more. A platform from which to build healthcare supporting apps.

    Putting the data in one place, curating the data, and providing privacy and security, will result in the most effective interoperability.

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