Healthcare Interoperability Series Outline

Interoperability is one of the major priorities of ONC. Plus, I hear many doctors complaining that their EHR doesn’t live up to its potential because the EHR is not interoperable. I personally believe that healthcare would benefit immeasurably from interoperable healthcare records. The problem is that healthcare interoperability is a really hard nut to crack

With that in mind, I’ve decided to do a series of blog posts highlighting some of the many challenges and issues with healthcare interoperability. Hopefully this will provide a deeper dive into what’s really happening with healthcare interoperability, what’s holding us back from interoperability and some ideas for how we can finally achieve interoperable healthcare records.

As I started thinking through the subject of Healthcare Interoperability, here are some of the topics, challenges, issues, discussions, that are worth including in the series:

  • Interoperability Benefits
  • Interoperability Risks
  • Unique Identifier (Patient Identification)
  • Data Standards
  • Government vs Vendor vs Healthcare Organization Efforts and Motivations
  • When Should You Share The Data and When Not?
  • Major Complexities (Minors, Mental Health, etc)
  • Business Model

I think this is a good start, but I’m pretty sure this list is not comprehensive. I’d love to hear from readers about other issues, topics, questions, discussion points, barriers, etc to healthcare interoperability that I should include in this discussion. If you have some insights into any of these topics, I’d love to hear it as well. Hopefully we can contribute to a real understanding of healthcare interoperability.

About the author

John Lynn

John Lynn

John Lynn is the Founder of HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

11 Comments

  • John,

    Interoperability is not an elusive goal that requires a scientific breakthrough. It’s easily accomplished and in fact is achievable today! All we have to do is take a different approach!

    The “conventional” approach ONC and HHS are pursuing creates the very problems that make it impossible to achieve interoperability today and probably in 2024 as well.

    What are these problems?
    * our inability to standardize data field names
    * Our inability to ensure accurate patient identification
    * the legal issues surrounding patient consents and the transmission of PHI across state lines
    * our inability to ensure the security and privacy of PHI
    * the financial instability of HIEs that depend upon government funding

    Resolving each of these problems is a monumental undertaking; trying to solve them all is a nightmare. Isn’t there a better easier way to accomplish interoperability? The answer is a resounding YES! All we have to do is take an approach that doesn’t create these problems.

    When a road has been washed out, you can sit in your car and wait days or weeks for it to be repaired or you can detour around it. It’s the same with interoperability.

    That’s precisely what we do with our unique patient-focused MedKaz® personal health record system, and it works! We avoid the problems. With MedKaz, we have complete interoperability, including all types of records, today, and everyone can benefit!

    Instead of trying to specify how providers keep records and then link them electronically,
    we aggregate a patient’s complete medical record from all his or her providers in whatever format they keep them along with the application to manage them, on a device that the patient owns and gives to any provider at the point of care, anytime, anywhere. With two or three clicks, any provider or the patient can search for and open specific records. They are displayed as pdf documents in a browser.

    MedKaz succeeds where our current government-sponsored approach fails because it:

    • avoids the problem of matching data fields—we display complete, searchable documents in a browser
    • avoids the patient identification problem—we display the patient’s picture on his or her MedKaz
    • avoids the legal consent issue—the patient implicitly “consents” when he gives his MedKaz to his providers and enters his password
    • avoids the interstate transmission issue—the patient is free to carry his records anywhere he or she wants
    • avoids the security and privacy problems—we erase patient records from our server after they have been downloaded; we provide two levels of password control to access records on a patient’s MedKaz
    • avoids the financing problems—our unique business model is self-sustaining, doesn’t require government funding or grants, and provides a material new revenue source for providers

    You can learn more about MedKaz at our website, medkaz.com.

  • Merle,
    I like how you laid out many of the challenges. I’ve probably seen a dozen companies at least that are a variation of what you’re talking about with MedKaz. The biggest challenge that each of them has is getting patients to actually care enough to collect and manage their health record. How many patients do you have using it actively? How are you working to solve the problem of patient ambivalence?

  • John,

    Three aspects of our MedKaz@ system differentiate it from all other systems.

    One is that all patient records on it, including paper, are complete records (as compared to insurance records or CCD summaries) and electronically sortable and searchable. With only two or three clicks a provider or the patient can find and read specific record(s). Not even today’s most powerful EMR systems can electronically manage and search paper records!

    A second is that with MedKaz the patient doesn’t have to “collect and manage their health record.” Their providers or we do it for them. As described in the How It Works and FAQs for Providers sections on our website, we either pay providers to upload their patients’ records to our Server, or we do it. After our server has processed a record (i.e., made it searchable), we send the patient an e-mail telling them a record is waiting to be downloaded. The patient merely clicks on a button and down come her records! She can then read them and if she finds a mistake or wants to expand upon a point, she merely creates and addendum to the note.

    Third, our unique subscription business model drives the system. The patient subscribes to our MedKaz Update and Support services. These subscriptions constitute our primary revenue stream and it is from this revenue that we pay providers to update their patents’ MedKaz devices. A typical PCP can earn as much as $50K more per year by supporting MedKaz; large practices, hospitals and ACOs can add $$millions to their bottom lines!

    As happens with almost every product or service, some people don’t care how useful and functional MedKaz is and will not use it — i.e, until they become critically ill! So we don’t expect to get 100% adoption. However, consumers/patients are becoming increasingly interested in controlling their records so they can ensure their doctors have them available when they need care and they can participate in their care decisions, so we expect more and more to get involved so long as they don’t have to do the data entry!

  • @Merle
    So, in the bigger picture this sounds like what Google, Microsoft and other have tried.

    They all failed, because, as it turns out, not enough people really care that much about their medical records.

    Why will this method succeed where these others (with very deep pockets) have failed?

  • Hi John,

    With all due respect, your basic assumption is wrong. Google Health failed and Microsoft Health Vault is failing (but won’t acknowledge it) NOT because “not enough people care that much about their medical records.”

    Sure, a small number don’t care about having their records but most do. From what I’ve seen and learned Google and Microsoft failed for a myriad of other reasons: their products were/are too difficult to use, they require(d) the patient to enter the data, they relied on insurance info rather than real medical records, providers couldn’t trust them and wouldn’t use them, they provided no financial benefits to anyone, etc., etc., etc.

    The enormous forces driving change in healthcare all require one thing, namely, the ability of providers to access a patient’s complete medical record at the point of care. But to succeed, a system must meet the needs of the many groups concerned with health care — patients, providers, insurers, employers and government, and their sub-groups which also are not homogeneous.

    Our MedKaz system is the only system I’ve seen or heard about that meets the needs of today’s highly diverse market segments. Moreover, it is just a starting point. Future versions will permit patients to move their records and information in ways we cannot begin to imagine today.

  • As a EP that is also a database programmer (I’m weird), I can tell you that interop in the current form or proposed form will fail.
    1. It is very difficult to make a database fail safe without a unique ID, to pass data back and forth without a unique ID is fraught with danger and problems.
    2. If data is blasted out from one EMR thru and HIE to all other connected systems, and the data is WRONG, you are in a heap of trouble. How do you get it back? How do you correct? How does the patient fix the incorrect information.
    3. There are HUGE security issues with all this data movement. And ripe for hackers to make a mess, like giving everyone the bird flu or something. Current CCDA, is a waste of bytes and a terrible mess, FHIR won’t be much better.
    4. Matching database fields is sometimes impossible or unclear. Here is one. At our hospital we use allergies for sensitivities and allergies. If someone is sensitive to codeine and not allergic, we still mark it as an allergy, even though we know its only a sensitivity. If we pass that to a system the separates sensitivities from allergies, how do you fix that?
    5. You cannot FORCE the public to use EHRs. You get one national full scale breach and everyone will run for the hills. Add in the NSA snooping and our lack of trust for the government spying on us already, no one will want to participate. It will definitely become an OPT IN at that point.
    6. I do not know about MedKaz, but I can tell you that is the way it SHOULD work. Its on the patient/patient family to coordinate their care, and ANY EHR can upload to it, not just certified ones. I feel that if I take an xray, make a office note or report, that I should be able to send that information to any patient that asks me to send it to them. Even if its later on. To send everything to a HIE and then it gets blasted out, just scares me from a safety and security standpoint.
    7. EHRs right now are barely useable, certainly not safe nor secure. To pile on interop even before we have achieved usability, safety and security, is a bad idea. Its best left to the companies like MedKaz and others that can be there for the proactive patient. If MU 2 has made it clear to anyone with eyes and ears, it just does not work to overburden EPs with terrible EHRs, overly complex overlapping programs like PQRS, VBM, etc.

  • @meltoot – I’d be hard pressed to state an EHR that I think does things great…or even well, but to call them “…not safe nor secure” is a stretch.

    If the fact that data is densely populated and can then be accidentally set out in the wild, well, sure, but for the most part, EHRs are secure.

    It is the user that is greatly un-secure…of course, this is the case for all software.
    There are certain security aspects that should be set by default like inactive logout, but that varies wildly from office to office, even among the same EHR. Still, this is a bad choice of settings, not an insecure system.
    From what I see, paper is still a big risk to a medical practice.

    @Merle
    Ok, I’ll clarify: not enough people care enough about their medical records to put much effort into storing them.
    Of course there will be those that are: early adopters, think it’s cool, have a high-attention issue (diabetes, elderly, etc), but docs can’t get people to take their meds properly, exercise, eat right, floss…well, are these the people who are going to care about their medical records?
    Why didn’t people carry their paper records around before?
    Heck, I did it in the military. For most people it would be but about a ream of paper. Not too much to carry, no real hassle.
    Nobody did it because they didn’t care.
    If people were now carrying around a briefcase full of medical records to each visit, I’d say this is a winner…I just don’t see the interest.
    I’ve been wrong before, just ask my kids.

  • John,

    There are many reasons people don’t carry their paper medical records. One, indeed, is indifference. But others that I think are more important include the fact that they don’t have copies of all their records (in many cases their doctors decline to give them copies), piles of paper records are unmanageable and their doctors don’t have time to look at them, and carrying a pile of paper simply is grossly inconvenient – would you carry a pile of paper with you everyday so you’d have your records available in the event you get hit by a car or have a health emergency?

    The fact is that we live in a very different world today than 30, 20, 10 or even 5 years ago. Today, we must deal with at least four major differences. One is the explosion of information and technology that is changing healthcare delivery and extending life expectancies. A second is that specialists dominate our care system like never before. A third is the escalation of costs which must be stopped or we’ll bankrupt the country and most of us in it. A fourth is that younger people, from baby boomers to millenials, no longer accept their doctors as all-knowing – they want a say in their care.

    The net effect of these differences is that the need for care coordination, the exchange of medical records, and the inclusion of the patient in their care decisions have never been greater. Having said that, it still must be convenient and not place a burden on either the patient or their providers.

    Unfortunately, the “big“ solutions to interoperability offered to date by the “big,” deep-pocketed companies haven’t met that simple test. MedKaz® does. Our challenge is to get our message out to patients, providers and employers/insurers!

  • Merle,
    It seems that really your core difference between the other solutions I’ve seen is that you’re charging the patient to collect their medical records. I agree that I haven’t seen that model before and is an interesting way to approach the issue that we’re all too lazy (or don’t care or whatever other reason we haven’t done this ourselves) to get our record.

    However, this still begs the question of how many consumers will pay for you to collect your record for them. Patients still have to care enough about having their patient record aggregated to fork over the money. Whether it’s paying someone or doing it yourself, you still have to care enough to do one or the other. Aggregating medical records is a painful task right now, so maybe some will pay for you to do it.

    I do wonder how you figure out who all my doctors are and where you need to go to get all my health information. I assume the patient has to provide it. If that’s the case, then you’ve just charged me and I still have to provide you all my doctors names. One more barrier to usage. You might say that most people only have a few doctors that they’ve seen recently (or they likely can name). If that’s the case, do those people who almost never go to the doctor care about having their care record aggregated?

    Finally, there’s still the major issue of once you aggregate my care record on MedKaz, how does the next doctor I see get that record? I know people who have literally faxed in their full health record to a doctor before their visit and when they get to the doctor, no workflow changes. The patient still has to fill out all the forms and the doctor barely noted that the patients full paper record was available. It’s a nice “if needed” situation, but not something compelling like if MedKaz was accepted by doctors as a replacement to the lengthy intake paperwork.

    This seems to go back to my previous theory that this type of approach works well with chronic patients, but I have a much harder time seeing the average “healthy” patient using it.

    Love to hear your thoughts and thanks for the discussion.

  • John, you still don’t seem to understand our approach or who does what with our MedKaz System. It is designed specifically to blend into the care process and not place a burden on anyone.

    The “How It Works” and “FAQs for Patients” pages on our website, medkaz.com, answer most of your questions. But let me address them here as well.

    We do NOT charge a patient for collecting their records for them. He subscribes to our Update and Support Service. And believe me, this is an important difference.

    At the outset, when activating his MedKaz, the patient enters his care provider info using our automated procedures, and automatically generates two pre-populated documents for each provider from whom he wants to request records: a Record Request that tells his doctors what records he wants and to send them to us, and a HIPAA Release. The patient signs these documents and mails or delivers them to his providers. When we receive these batches of records, we process them on our server to make them searchable, send the patient an e-mail that we have records for him, he downloads them with two clicks, and we erase them from our server. Couldn’t be simpler or easier.

    On an ongoing basis, the patient schedules an appointment and, prior to the visit, in the quiet of his home he completes a Pre-Visit Questionnaire (it lists the meds he is actually taking and his complaints and asks the same questions the doctor or his PA normally ask when the patient arrives to see the doctor; it summarizes the information in a Complaint Report which is waiting when the doctor logs onto the patient’s MedKaz). Instead of having to ask the questions, the doctor simply reads the report and other information waiting for him about his patient’s conditions and issues and now is free to spend more time talking with his patient. I should add that it also contains his patient’s insurance and other information that the doctor’s assistant or receptionist typically asks to see.

    The doctor examines his patient and when he has questions about the patient’s prior or ongoing care from other providers, with merely two or three clicks he searches for and opens the other doctors’ records on his patient’s MedKaz. If he wants a copy for his records, the patent enters his password and the doctor downloads the other doctor’s records to his computer — either as a pdf document or structured data (if his EMR vendor has created an interface with MedKaz).

    At the end of the visit, the patient tells the doctor to send a copy of his notes for the visit to us to process; the doctor uploads them to our server, for which we pay him, or faxes or mails them to us (for which we do not pay him). We process them, e-mail him to download the notes to his MedKaz, and erase them from our server when he has done so. (in the future when his EMR vendor has implemented an interface with MedKaz, the notes will automatically be sent to our server when the doctor signs his notes and sends them to his own server).

    This whole process is seamless, couldn’t be easier for all parties, and benefits all parties. The patient has his records and knows they’ll always be available anytime, anywhere he needs care. The provider can practice better medicine, coordinate care, avoid mistakes, reduce the cost of care — and increase his income!

    Notwithstanding how simple MedKaz is to use, if a consumer/patient doesn’t want to embrace it, they won’t. But as I wrote before, as more and more people want to participate in their care decisions — and their numbers are increasing, more and more of them will adopt MedKaz. Similarly, when they find that it can save them money by reducing their out-of-pocket co-pays and deductibles, more and more will embrace it.

    When we asked a panel of doctors how many of their patients might adopt MedKaz, they said, to my astonishment, ca 70%! While I think that is way overshooting the mark today, the percentage will be much higher than you think, and it will only grow.

    Hope this answers your questions.

  • Merle,
    It’s an interesting model you’ve created by paying doctors to participate. I just think you really underestimate how clinics will react when a patient shows up with MedKaz. You have a long, hard battle to have them accept this new workflow. I don’t see patients convincing the doctors on this like you describe in the FAQ. Same for relatively healthy patients who don’t have much of a record.

    I’m still of the opinion that a solution like you describe is most appealing to chronic patients. I can’t see it having mass adoption. Obviously you have a different opinion. That’s the beauty of entrepreneurship. Looking forward to seeing how it goes for you.

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