Predictions in a field as rife with change as healthcare can be risky, but I’m going to venture out on a limb and say that 2020 will be our industry’s most pivotal year in at least a generation. A year from now I predict we’ll look back at 2020 as the year of interoperability.
More than a decade after the HITECH Act spurred the widespread adoption of EHRs, we have yet to achieve the kind of interoperability it envisioned. Even though 95% of eligible hospital-based providers use federally certified EHRs, along with roughly 90% of office-based physicians, data sharing between these systems remains isolated and piecemeal. Success to date has been mainly at the patient level. To achieve the ambitious goals of safer, more efficient, and less costly care management at the population level, we need to master the sharing of thousands of patients’ records at a time.
That’s why I think we’re on the precipice of great change. We have all the necessary ingredients to make comprehensive interoperability happen: widespread EHR use, the HL7Ⓡ FHIRⓇ standard, and the 21st Century Cures Act—which includes important provisions about interoperability, information blocking and patient access to EHR data. But the most important ingredient is the new FHIR Bulk Data API (FBDA).
Establishing a standard for the sharing of data on thousands, potentially millions, of patients at a time is a big deal. It’s essential for public health research and surveillance, for the development of machine learning models, for reporting on quality and costs, for multi-EHR data warehouses, and much more. And it’s absolutely critical for achieving the Triple Aim—simultaneously improving the patient experience, the health of populations, and the per capita cost of care.
Simply put, getting the sharing of bulk data right will make or break population health.
Effectively managing the care and costs of populations requires robust and timely data on large groups of patients—data from the many providers that patients have seen, across multiple organizations, operating a disparate mix of information systems. Incomplete data can lead to imprecise risk scoring, which in turn leads to the misallocation of resources. The results are less effective outcomes and higher costs.
The challenges of sharing bulk data are still with us. The lack of a common patient identifier remains our industry’s Achilles’ heel. It is one thing to resolve individual patient matching issues, but the problem is exponentially bigger when you’re trying to process thousands or millions of patient records at a time. The Cures Act and the Trusted Exchange Framework and Common Agreement (TEFCA) help us address several of our other challenges—such as information blocking and other anti-competitive behavior—but another hurdle has emerged with the potential mix of opt-in versus opt-out patient consent laws at the state level. If large groups of patients are not included in the data-sharing ecosystem by default, it’s going to be very difficult to get them to enter later, and that produces big gaps in data. As any first-year psychology student knows, systems designed to depend on people taking action are far less effective than those that rely on inaction.
Even so, I’m confident we’ll clear all of these hurdles. One reason for my optimism is that patients are becoming more enlightened consumers—not just of healthcare but of health data as well. In just a few years, consumer health apps have exploded in popularity. Between 2015 and 2017, the number of health apps doubled to over 300,000, according to a IQVIA report. Patients are growing more comfortable sharing their health data with others and they’re recognizing the value of health data aggregation—getting all of their data together in one place.
One company changing not only technology, but also consumer behavior, is AppleⓇ, and they’re subtly educating patients on the power of healthcare interoperability by aggregating patient health records from multiple institutions—precisely what we’ve been trying to do—and making it available to consumers alongside their own patient-generated data. And the company’s using the SMART on FHIR API and the Argonaut implementation guides to do it.
This is a truly catalyzing development. All at once it’s validating our standards, educating patients about the power of health data, and coaxing healthcare organizations further into the world of apps. It’s a great example of the power of the consumer-facing economy for driving innovation.
This economy isn’t just driving innovation in patient-facing apps, but in provider-facing apps too. Some are being developed by EHR market suppliersthemselves, but many are being produced by third-party vendors with limited experience in healthcare. That’s the power of open standards. Since FHIR is an open, free and standards-based API, developers can use languages and structures they already understand, such as XML, JSON, HTTP, and OAuth. Moreover, SMART on FHIR creates an open platform where developers can create apps that run securely across the healthcare system, instead of waiting for EHR vendors to create apps for them.
The vast potential for apps to open up the EHR and its trove of data is exciting, if a bit daunting to many organizations—both to market suppliers and the healthcare organizations using their software. As a colleague, Kenneth Mandl, MD, MPH, recently told me, the idea of patients being able to connect the app of their choice has created tension within our historically paternalistic and centralized healthcare system. But it’s just this kind of tension that’s necessary to produce change.
For interoperability to have its intended impact on both patient-level and population-level health, I can’t stress enough that it has to be delivered where and when it’s needed. For providers, that means directly within existing workflows at the point of care. That’s the goal of the Blue Button FHIR API pilot, Data at the Point of Care, which seeks to deliver Medicare beneficiary claims data from the Centers for Medicare & Medicaid Servicesdirectly into physician workflows. This API will give physicians a more complete picture of care by incorporating data received from other healthcare providers—including previous diagnoses, past procedures and medication lists—without the need to log into another application.
We must also offer the same capability for healthcare executives and administrators by delivering population-level data to them when and where they need it. For EHR vendors, that means consuming large volumes of data from external systems and platforms, and presenting it in ways that are intuitive and meaningful within the context of our own software and the conventions our users understand.
The grand promise of the EHR revolution was the ability to seamlessly and securely share patient data between healthcare organizations regardless of the software they were using. The road we traveled to get here was rocky at times, but we’ve achieved broad acceptance that healthcare digitization was a necessary step for improving safety, efficiency and care quality. Very few providers—even those dissatisfied with their EHRs—want to go back. Now we need to take the next step and connect the patients, providers, payers, and others who use our systems so they can safely access and share data for making better decisions at the personal, individual, and population levels.
Thanks to FHIR, SMART, FBDA, and a host of highly innovative organizations and developers, I predict 2020 will be the year it happens.
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