COMMENTARY

What's the Health IT Buzzword of 2015?

Hint: It Can Make Your Professional Life a Lot Simpler

Aaron Neinstein, MD

Disclosures

May 22, 2015

While walking my dog one recent evening, I listened to a podcast in which two Internet pioneers suggested that there are only two ways to make money: via "bundling" or "unbundling."[1] They described everyday examples, such as the music industry, which started out by bundling individual songs into record albums. The music industry then turned to unbundling, when iTunes® sold individual songs for 99 cents, then bounced back to a bundling phase with such services as Spotify® or Rhapsody® that bundle entire music libraries to sell for a monthly fee.

A similar ebb and flow occurred with television. Cable TV channels have long bundled individual channels to be sold as a package. However, we are now seeing unbundling, with such services as HBO GO® selling individual channels to consumers.

Remember browsing the never-ending connections of the Internet on the World Wide Web using your desktop browser? The Web has also been unbundled. We all now have dozens of smartphone apps that offer unique, distinct, and generally siloed functionalities.

Bundling and Unbundling Digital Healthcare

Healthcare has experienced similar trends. Before the era of electronic health records (EHRs), the typical physician's office had its own paper chart for each patient. Every chart was its own silo, unseen and inaccessible to other physicians' offices. I can still remember working in my primary care clinic and having to ask my patients what their specialist had said in consultation, because I had no access to their consult note. Lab information systems, pathology systems, radiology systems, and billing systems were all separate.

Today, at medium-sized to large healthcare organizations, the enterprise EHR has facilitated the integration of these systems. Hundreds or thousands of physicians across an organization share a single chart for a patient, which includes the patient's lab results, radiology results, pathology results, and billing functionality, providing a unified and accessible medical record for each patient at each healthcare institution.

At the same time, these institution-wide EHRs include potentially unwanted or unneeded functionalities, much like that bloated cable TV bundle at home. In some cases, EHRs contain some inferior modules that must be used simply because they came with the package, and they lack other capabilities that the organization really needs.

Entrepreneurs have seized this opportunity, filling these functionality gaps and creating thousands of digital health apps. Each app attempts to offer a slice of functionality to consumers or to the healthcare system that is either unique or of higher quality.

We are not yet able to allow healthcare organizations to create mix CDs

The trouble is that most apps create siloed data and siloed functionalities. Although the EHR is the centerpiece of clinical workflows, most apps do not easily interact with the EHR. Most apps do not exchange data with the EHR. Nor do most apps even interact with each other, allowing free flow of data between them.

This is "unbundled" digital health. It is the iTunes era. We are not yet able to allow healthcare organizations to create mix CDs, where there is an intentional order and flow from track to track. Instead, we remain in the era of "come and buy your favorite songs à la carte for 99 cents, stick them all on your iPod Shuffle, and hit 'play.'"

Riding the Interoperability Wave Forward

As a result of all this, "interoperability" is the health IT buzzword of 2015.

Many clinicians have bemoaned the notion that the digitalization of healthcare has thus far failed to deliver its full promise, and I share the belief with many others that interoperability is a key missing ingredient. We are all waiting for the creation of an interconnected web of data, apps, and functionalities—the "learning health system" described in the 2012 Institute of Medicine's report Best Care at Lower Cost.[2]

Although a growing number of the necessary pieces have already been built, we remain mired in a chaotic mix of disconnected EHRs, apps, paper documents, insurance systems, and other information systems. Logical and efficient workflows connecting these together are mostly absent from our daily lives.

But on the horizon, effective digital health bundling is beginning to appear. The 2014 JASON report,[3]the Office of the National Coordinator for Health Information Technology (ONC) Interoperability Roadmap,[4] and the ONC's proposed meaningful use stage 3 guidelines[5] have all called for increased interoperability, with use of application programming interfaces (APIs) in healthcare. An API is a tool that allows different pieces of software to easily communicate with each other, "speaking the same language."

 
It would be like having the freedom to use Google Maps on your iPhone
 

What would interoperable healthcare APIs mean for us as physicians? It potentially means having plug-and-play apps that we can mix and match to create our desired workflows. These apps could pass information back and forth without friction. As Ashish Jah[6] points out in his Health Affairs blog, it would be like having the freedom to use Google Maps on your iPhone, rather than being forced to use Apple Maps.

Such efforts as the Argonaut Project[7] are trying to bring us closer to implementing these bundles of interoperable healthcare apps. In April, IBM announced that it was purchasing several companies to bundle into its big data Watson software.[8] Startup companies such as Redox are jumping into the fray to try to facilitate app integration with EHRs.

Thus, we are moving toward an age where consumers and healthcare organizations can pick and choose what apps they want to use, while still expecting information to flow from place to place with integrated rather than choppy workflows. This seems like it will be the best of both worlds—allowing us to choose the best apps without having to sacrifice the integrated workflows that have come with EHRs.

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