Imagine you’re on a commercial jet headed from Beijing to Paris and you’re descending over the Netherlands through heavy cloud cover with limited visibility. Your pilot contacts air traffic control in Amsterdam for instructions, speaking Mandarin Chinese. After a momentary pause a voice responds, speaking Dutch. Unknown to you, another plane, 55 minutes after taking off from Charles De Gaulle airport, is climbing over Belgium headed in your direction. Its pilot contacts air traffic control in Brussels, speaking Danish. The response crackles back over the radio in French. Meanwhile, the blips on the respective radar screens keep getting closer together.
When I began my career in 1979, medical records consisted of manila file folders, with brightly colored numeric tabs. Rooms were filled with floor-to-ceiling shelves that were filled with those manila folders. Inside those folders were stapled papers and handwritten notes about the patient. When a patient had an appointment, a medical records librarian pulled their file folder and put it into a metal basket on wobbly wheels, much like a shopping cart, to be walked to the location of the patient encounter. It wasn’t uncommon for the patient to arrive before their chart or for the chart to arrive after the visit was completed.
With digital technology came the opportunity to replace old-fashioned medical records with electronic health records or EHRs. Patient records would be able to move from place to place at the speed of light, improving communication, eliminating gaps in information, increasing quality and lowering costs. Since 2009, the federal government has invested $36 billion to subsidize the adoption of EHRs by health care providers. Annual spending on EHRs exceeded $14 billion in 2019 alone and is forecast to approach $20 billion in 2024. About half of that total will be spent by hospitals.
Unfortunately, most of the benefits anticipated to arise from EHRs have been largely unrealized. The issue revolves around the term interoperability, or the capacity for various EHR systems to share information with each other. If EHRs cannot “talk to each other”, the clinical benefits of care coordination and the economic benefits of eliminating avoidable duplication of services are lost.
Not only does one vendor’s EHR not interact with another vendor’s, but different providers using the same EHR vendor commonly struggle to create an efficient interface. While interoperability was an expressed desire, it was never an outright condition for accessing federal funds. As a result, in a 2019 article published in Fortune magazine the state of the EHR situation in the United States was characterized as an “unholy mess.” We have been left with the medical record equivalent of a pilot speaking Mandarin Chinese to an air traffic controller who is fluent in French.
A friend of mine recently described an extremely trying experience involving their elderly parent with dementia and several comorbid chronic conditions who was admitted to a community hospital twice in five months. Three days after the first admission, they took their parent to a major teaching hospital for an evaluation and to develop a care plan. The workup at the community hospital had included an MRI scan of the brain, a CT of the head, carotid ultrasound and more than a dozen lab panels. Despite exhaustive efforts by the patient’s daughter, the results from the tests done in the community hospital could not be made electronically available to the specialists at the tertiary medical center. Not even the diagnosis was available.
A second hospitalization occurred in the community hospital. Following an MRI scan of the brain, CT of the head, ultrasound of lower extremities and lab tests, it was concluded that the episode was psychogenic syncope. A follow up visit with the tertiary medical center neurologist again occurred with no records from the hospitalization. The neurologist was unsure whether the case involved syncope or visual loss and noted that the patient could not provide a detailed history that the doctor could understand. Following each discharge, the patient went on to have extensive diagnostic imaging and other testing by the specialist physicians at the tertiary medical center.
What went wrong? With more than 10 years to solve the interoperability problem and roughly $100 billion already spent, it’s difficult to make the case that we had too little time or money. How did we fail to deliver on one of the bedrock value propositions associated with EHRs—the efficient exchange of clinical information among medical providers? To an outside observer, the answer seems tantalizingly simple: customization and market share.
If there was a technical roadblock to interoperability that simply could not be overcome, the answer would have been to select one EHR and require everyone to adopt it. No one has suggested that interoperability is impossible. Among health care providers, the issue is customization…among EHR vendors, the culprit may be market share.
Health systems are by their nature inwardly focused. Processes and systems tend to be designed around the providers, not always the patients. EHRs have been customized to fit the preferences and practices of each health system, and customization works against standardization and interoperability. While an EHR is being customized to move information around within a health system, attention is unlikely to shift to how that EHR interacts with those of outside providers, and in particular with competitors. The first half of the last decade of EHR implementation has been an exercise in getting the internal functionality working properly. More recently, interoperability has become a more pressing issue for providers.
Twenty-five years ago, if one of my flights was cancelled and that airline had no options for me, I took my ticket to a competing airline and they applied its value to a seat on one of their flights. A close cousin of “interoperability”, reciprocity between airlines was not required by law; it arose from something called Rule 240 of an old contract between airlines. When the airline industry was deregulated, Rule 240 quietly faded away. Today, reciprocity between competing airlines is uncommon.
With billions of dollars at stake for EHR vendors, it’s no surprise that they lack enthusiasm for technical capabilities that make it easier for health care providers to select a competing product. Their natural tendency is to gain and protect market share, which should be expected to have a chilling effect on an all-out push for interoperability. That realization alone should have triggered external pressure; purchasers should have made payment contingent upon the achievement of functional interoperability.
In 1951, the International Civil Aviation Organization mandated that all commercial pilots flying international routes must be proficient in English pronunciation, structure, vocabulary, fluency, comprehension and interaction. At the time, the United States and the United Kingdom manufactured and operated the majority of the world’s aircraft. Since then, international pilots and air traffic controllers speak English to avoid confusion which, at 550 miles per hour, can have disastrous consequences.
It’s easy to imagine a future in which electronic health records exchange crucial clinical information with one another effectively and effortlessly. It’s easy to imagine…but after investing nearly $100 billion we shouldn’t have to.
About the author: As executive director of the Vizient Research Institute, Tom Robertson and his team have conducted strategic research on clinical enterprise challenges for more than 25 years. The groundbreaking work at the Vizient Research Institute drives exceptional member value using a systematic, integrated approach. The investigations quickly uncover practical, tested results that lead to measurable improvement in clinical and economic performance.