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Wandering the exhibition floor this year, any outsider to the health IT industry would have assumed interoperability was a problem already solved. Exhibitors across the hall boasted ever-growing portfolios of clinical, diagnostic and operational software, all of which seemingly could be implemented and interconnected simply and efficiently. Yet dig under the surface of this glossy marketing and all is not what it appears.
Most solutions at the show don’t interface well with existing and legacy health provider networks or other third-party software. Worse still, software modules from within a vendor’s own portfolio commonly don’t interface well together. Many require individual customised implementations, at significant cost to the provider. Others have developed or partnered with third parties to establish application programming interfaces (APIs) to make more common combinations of software easier to integrate.
Essentially, there is a huge gulf between the “vision” being displayed in the exhibition hall and the reality for healthcare providers when they come to implement software. Admittedly, healthcare has come a long way, most notably with common use of HL7 V3 standards and solid progression of the emerging Fast Healthcare Interoperability Resources (FHIR) standards. Yet, much of this work has still only enabled relatively basic exchange and “messaging” of administrative and basic clinical data, typically centred around EHRs – though even here data protectionism remains rife. But this is only part of the problem. Outside of core EHR and administration, healthcare providers also have an array of smaller clinical and diagnostic modules, catering for everything from diagnostic imaging to departmental operational workflow to clinical care coordination. Few of these systems, especially older legacy systems, can exchange information within the health provider’s network, let alone externally with other providers. So, what can be done?
Unsurprisingly, there is no simple fix for such a complex problem, especially given the big issues interoperability can stir-up: data ownership, patient access, cybersecurity, inter-provider competition. Healthcare is an enormous business, meaning significant change will require a commercial driver as well as clinical and ethical pushes. The high-profile announcement from the US government at the show, aiming big fines at interoperability “blockers” was clearly intended to signal a “big stick” approach to data protectionism, by targeting health providers’ balance sheets. The expectation is that vendors will also be impacted due to the trickle-down effect in the long run. However, any fines will likely be tied to an overhaul of the Meaningful Use and MACRA policies overhaul, suggesting a drawn-out and lengthy process. It will also mostly address core EHR and administration, with some expansion on Population Health Management (PHM) and patient data access.
A Little Less Vision, a Little More Action Please
Yet this does little to change how vendors develop or market their products, especially outside of the core EHR and administrative space. It also only impacts the US healthcare market, doing little to change the agenda in international markets. So, what can clinical and diagnostic IT vendors do to get ahead of the curve on interoperability? Here’s our thoughts:
1) “Value-based” Will Increasingly Create Market Value
As IT and digital technology is seeping into healthcare delivery, there has been a marked improvement in healthcare providers analysing operational data, to try and run their systems more efficiently, as well as longer-term patient outcome measurement. Both are already dramatically altering the way in which procurement of IT is conducted, as well as fundamentally shifting how healthcare funding is provided.
Yet today, health IT vendors have been slow to jump on the “value-based” bandwagon. After three days at the HIMSS show visiting imaging IT, clinical IT and EHR vendors and seeing various demonstrations, I could count on one hand the case study examples demonstrating the actual value of their products in real terms over time (operational spend or clinical outcome). Admittedly, healthcare providers are still getting to grips with analytics and value-based care management. But given the growing push by vendors for selling consulting and professional services to support use of their software, vendors serious about winning in the increasingly value-based market need to increase both the volume and prominence of customer success stories based on value-based care.
2) Transparency Counts – as painful as it may be
There is also an argument that vendors also need to be taking a more transparent approach to their ability to integrate, both within their own portfolio and with other third-party solutions. Moreover, many vendors present their “vision” for their product portfolio as if all their solutions are “off the shelf” ready, when most are far from well-integrated and may require years of further development to be developed as a fully integrated product set.
Enterprise imaging IT is a great example; too often we hear reports of failed or delayed implementations due to certain software modules or components being incompatible from the same portfolio. Add in unique challenges associated with legacy applications and software at the commissioning provider and the validity of vendor marketing claims is seriously called into question.
Therefore, vendors need to be more transparent and up-front in the capability and maturity of their solutions today. Many have traded too heavily on over-promising and under-delivering, creating a culture that expects costly delays and customisation. While being more transparent may be viewed by some in the hyper-competitive market as a sign of weakness, greater clarity on product capability and interoperability maturity of a portfolio will go a long way to winning the trust of current and potential new customers.
This should also be the case for third party integration. The industry and providers have done a poor job thus far of establishing a defined scale for what can be counted as “integration”. There were certainly various degrees of integration observed at the show, from seamless integration (essentially embedded within the same user interface) to web-enabled hyperlinking and results integration (the “app store” model being commonly touted for diagnostic AI solutions). Yet in most cases there is little understanding for customers on the maturity of each vendor partnership. At best, most will show a list of logos for partnerships, but give little away on the interoperability and the workflow supporting use of applications in each partnership.
3) “Clustering” is Coming – focus on integration for the most common partners
Why is this so important? Because the structure of the clinical IT market is also undergoing a significant change. The scale and complexity of health IT has rapidly grown, resulting in no single vendor being able to provide an all-encompassing offering.
Instead, vendors are now needing to partner far more to service the needs of expanding healthcare provider networks. While some may argue the acute EHR market consolidation suggests clinical and diagnostic IT will follow suit, especially given the push from healthcare providers for fewer vendors in their supply chain, this is a more nuanced and specialist market. Experience and best of breed capability really counts when it comes to the surgical scheduling, cardiology catheter lab management or diagnostic imaging workflow.
Therefore, we see a definitive shift in market direction to “clustering” of vendor solutions. Collaboration in tenders and procurement deals has long been a characteristic of the clinical IT market, but most vendors have entered into these arrangements on a case-by-case basis. Moving forward, this will proliferate into more established common clusters of partnered vendors, to offer a more mature, integrated and quicker to implement solution across a wider breadth of clinical capability. These clusters may associate more closely around a specific EHR partner in some markets, or others may emerge from leading health tech firms positioning themselves as a central clinical IT platform and central contractor – or as we define, agnostic clinical enterprise (ACE) platforms.
However, the success of these alliances will be heavily dependent on their ability to integrate seamlessly. Thus, vendors must look to improve the maturity of their integration with selected partners – an embedded hyperlink to launch a new application and different interface is rarely well received by users. How vendors position partners must also improve, especially requiring more clarity on both the level of capability and interoperability. Even better, be able to showcase working case studies that can demonstrate the operational and clinical value of the combined capability of the product cluster.
A.I. Caramba! We Need Interoperability
On reflection, HIMSS18 offered a glimpse of a bright future overshadowed by the legacy issues of the past. Many of the challenges surrounding interoperability in healthcare stem from past decisions – most notably the sluggish adoption of standards, protectionism from vendors and healthcare providers, all set against the ongoing tussle between commercial gain and patient care.
From three days of meetings and viewing product demonstrations, it was evident that the market legacy continues to doggedly slow movement towards a more interoperable future. There was certainly more discussion on interoperability than in past years, somewhat buoyed by the emerging hype surrounding blockchain technology and the growing presence of FHIR (boosted by its use in the recent launch from Apple for integration with select healthcare providers’ EHRs). However, both are a long way from widespread adoption across all aspects of healthcare IT and much more work is required.
But why the big fuss over interoperability? We’ve made it this far without it after all. Apart from the fact that many health systems still rely on fax machines, improving interoperability for health data is essential to better manage the cost and adherence to care in the 21st century. Healthcare needs to catch up with industries such as finance, travel and retail in ease of access, transfer of data and adoption of IT. Healthcare is also becoming hugely expensive for society, hence the growing momentum for more value-based care.
Perhaps above all, access and exchange of data will be fundamental to the long-term improvement in care provision and management. It was nigh on impossible to avoid artificial intelligence (AI) at HIMSS, such has been the rapid emergence and potential uses. More efficient and cheaper care, better diagnosis and precision medicine, smarter care management and improved care outcomes were all touted as a potential output from the new era of AI. Yet for AI to have any real impact or success in healthcare, it relies on a significant improvement in the way in which health data is managed and shared, for which interoperability will be an essential component. No AI system can be developed if data remains marooned in siloed proprietary archives produced from software applications that won’t interface with each other.
While interoperability might not today have the most glamorous image, it is perhaps one of the most fundamental challenges facing the healthcare IT sector today. Here’s hoping for HIMSS19 it gets some serious attention.
About Signify Research
Signify Research is an independent supplier of market intelligence and consultancy to the global healthcare technology industry. Our major coverage areas are Healthcare IT, Medical Imaging and Digital Health. Our clients include technology vendors, healthcare providers and payers, management consultants and investors. Signify Research is headquartered in Cranfield, UK.
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