Interoperability in Healthcare and Zero-Sum Thinking



There has been a lot of ink spilled in the last few years about the problem of interoperability in healthcare. Put simply, we struggle to connect various healthcare IT systems to each other in effective and user-friendly ways. This struggle with healthcare interoperability has become particularly apparent (and painful) when it comes to electronic medical records (EMRs). For the most part, EMR software does not play well with others. The resulting “EMR Lock” affects everyone:

  • Providers can’t find the information they need or wrestle with painful workflows
  • IT shops spend inordinate amounts of time designing, building and maintaining arcane interfaces
  • Healthcare IT professionals' patience wears thin as they wait for their project to make it through the “HL7 Project Queue”
  • Patients wonder why we still can’t keep track of all their vital information

More than that, innovation is stifled: it’s overly difficulty for 3rd parties to develop useful applications that will integrate easily with EMR’s while providing elegant workflows. As a result, healthcare IT systems are dependent on EMR vendors to innovate. And they do innovate, but at their own pace and in areas that are of benefit and interest to them – which may or may not be the same as what their customers need. Contrast that with app development outside of healthcare. Think about rich diversity of the apps available for your iPhone or Android device and then consider how well these various apps collaborate with each other. Each does what it does well and, where appropriate, allows others to harness those capabilities and data. Why can’t healthcare information systems function this way?

We are told that the barriers to interoperability in healthcare are technical, legal and financial. And of course there is some truth to this – but I think less than is claimed. In the end, I would argue this is more about leadership and business vision than any specific barriers. Let’s examine each of these areas briefly:

Technical Barriers:

From a technical standpoint, it’s quite clear that strong EMR interoperability solutions already exist. As is often the case, if we look outside of healthcare there are solid models to follow. Modern RESTful APIs are the way much of the rest of the world is communicating and collaborating. Built using robust tools, methods, and technology that is widely recognized outside of healthcare, modern organizations have adopted approaches that make it easy to “show up and plug in." Emissary, Sansoro’s middleware product, is an example of the power of this approach when applied to healthcare. Using Emissary, healthcare IT systems communicate using universal APIs and normalized data structures. The complexity of the underlying EMR software is hidden, while the rich power of the data is exposed in ways that are easily accessed in real time. Installation takes hours or days instead of the weeks-to-months timeframe of traditional EMR implementation.

Legal Barriers:

The legal barriers to EMR interoperability are often discussed in terms of HIPAA compliance or other regulatory frameworks. Again, these challenges are real but typically overblown. Mechanisms exist today to facilitate the appropriate free exchange of data for purposes of patient care and to carry out basic business functions. Put simply, organizations that want to share data with each other and with patients have the ability to do so. And, while Meaningful Use Stage 3 may be on the way out, CMS has made it clear that open APIs are not. Clearly this approach is catching on in Washington, D.C. as well.

Financial Barriers:

So if technical and legal issues are not insurmountable, then what is the problem? I would argue it comes down to leadership and the zero-sum mindset that dominates much of the thinking in healthcare IT. Essentially, this view holds that data and control of the “clinical desktop” are valuable assets to be hoarded and controlled for financial gain: if I give it up to you then I have lost something; if I can get it from you then I have gained something.

This same thinking extends to innovation and design within healthcare IT. Too many organizations take a top-down, command-and-control view of the world. They believe they must control the evolution of products tightly, jealously guard their “IP.” and actively block competition. Competitors are seen only for their potential to “take customers away”. EMR vendors appear to fall on a spectrum with some embracing openness while others seem to be dragging their feet. For the most part, they have a very conventional 20th century approach to business and it has strangled innovation in healthcare technology. No one company can do it all nor meet the diverse needs of the healthcare market. This approach, by definition, devalues customers and overestimates the ability of individual companies to deliver progress.

But there is an alternative to this “zero sum” view of the world as a pie of fixed size with competitors fighting for their slice. The alternative approach is to seek to grow the pie larger and for the benefit of multiple stakeholders. It places great emphasis on meaningful collaboration with customers and competitors. It is about “co-opetition” – a mash up of competing on some things and collaborating on others. And it works. Studies like the work done for the book Firms of Endearment show that “opportunities increase by an order of magnitude when the mind breaks free of zero sum thinking"*.

EMR Interoperability is Coming!

So where does that leave us? It’s clear we have the means to dramatically improve interoperability in healthcare and that the first step is to reduce “EMR Lock” by making it much easier to integrate with EMR’s. The success of our company demonstrates that it is possible to connect, share, and collaborate across multiple EMR platforms by offering more powerful solutions that are easier to setup and maintain. Third party vendors love Emissary’s “build one, roll many” solution that gives them access to a wide array of data in real time. And there are signs that more of the big EMR companies are awakening to the possibility that true interoperability is not a threat to their future, but rather the key to the growth of EMR technology and healthcare IT as a whole.

Dave Levin, MD is the Chief Medical Officer for Sansoro Health where he focuses on bringing true interoperability to healthcare. Dave is a nationally recognized speaker, author and the former CMIO for the Cleveland Clinic.

*Firms of Endearment: How World-Class Companies Profit from Passion and Purpose. By Rajendra S. Sisodia, Jagdish N. Sheth, David B. Wolfe, Chapter 11