Interoperability: The Cornerstone to Improved Healthcare Delivery, Costs, and Outcomes
Interoperability and its effect on patient safety has become an important topic in recent years. Interoperability occurs when health information technology systems work with or use parts of other technology systems. Interoperability can seamlessly exchange data across the patient care continuum and has the potential to lower costs, improve health outcomes, reduce medical errors, enable further innovation, and positively affect population health. When systems are interoperable, patients and their families can access patient information. This interoperability, in turn, facilitates patient engagement and education.
Over the past six years, there has been a substantial increase in the use of health information technology by providers, but the lack of proper interoperability is the biggest barrier to using this technology effectively. The failure of technologies in care settings to communicate with each other often results in wasted time, alarm fatigue, and, worst of all, patient harm.
Nurses in the United States spend one third of their day transcribing or imputing data.[ref]Missed Connections: A Nurses Survey on Interoperability and Improved Patient Care, (2015). Westhealth.org.[/ref] This is time spent away from patients. Connected technology for patient monitoring and medicines can reduce the time needed to record data, and also improve the accuracy of the data.
Errors in prescribing medications is one of the most common medical errors. Medication errors cause adverse drug events that have the potential to cause patient harm. The Institute of Medicine estimates that every year in the US, one and a half million preventable adverse drug events and more than seven thousand patient deaths occur as a result of prescription errors and poor handwriting.[ref]Proterfield, A., Englebert, K, Coustasse, A. (2014). Electronic prescribing: Improving the efficiency and accuracy of prescribing in the ambulatory care setting. Perspectives in Health Information Management:v.11 (Spring)[/ref][ref]Amirfar, S. Anane, S., Buck, M., Cohen, R., Di Lonardo, S, Maa, P., McCullough, C. Plagianos, M. Pulgarin, C. Taverna, J., Sinter, J. (2011). Informatics in Primary Care, 19(2):91-97.[/ref] When medication information or a prescription is entered via technology, this information becomes linked to a patient’s electronic health record. The electronic health record houses a register of all of the medications a patient is taking. Linking this information enables alerts to any potentially harmful drug interactions. The Medicare Prescription Drug Improvement and Modernization Act of 2003 prompted the use of ePrescribing. The program has continued to develop over the years and the use of ePrescribing has continued to rise.
Easy access to a patient’s electronic health record allows physicians to see the whole health picture across a patient’s care continuum. Hospitals and private care providers have been steadily adopting electronic health records. This is good progress, but these records need to be connected seamlessly to the entire care team, including pharmacies, laboratories, specialists, insurers, patients, the primary care provider, and hospitals.
Care coordination makes for better diagnostics and treatments. An analysis of eleven thousand primary care doctors from ten high income countries found that care coordination and communication between social service and healthcare providers is a global challenge.[ref]The Commonwealth Fund (2015). Primary care physicians in ten countries report challenges caring for patients with complex health needs.[/ref] One example of the need for interoperability is that only one third of primary care doctors in the US are notified when their patients are discharged from the hospital.[ref]Ibid.[/ref] With connected technologies, a hospital admission or discharge would automatically alert the patient’s care team and be logged into the patient’s electronic health record. Technology that is interoperable can coordinate and share real time information.
A dangerous outcome of interoperability is alarm fatigue. Alarm fatigue occurs when many unconnected alarms go off regularly. If these alarms were connected and processed information together, there would be only one alarm per patient, instead of many. Caregivers and providers often ignore or turn down alarms because of their constant ringing. Alarm fatigue causes caregiver burnout, medical errors, and even death.
The Martin Luther King Jr./Drew Medical Center, a Los Angeles based public hospital, illustrates this point all too clearly. The cardiac department experienced two deaths due to alarms being ignored. One patient was not discovered until forty five minutes after her heart had stopped. During the two year period following those deaths, five more patients died because monitor alarms were turned down or ignored.[ref]Weber, T., Ornstein, C., & Allen, M., (2012). Why can’t medicine seem to fix simple mistakes? ProPublica.org, Accessed June 5, 2015.[/ref] Because of these errors and other care quality issues, the Centers for Medicare and Medicaid revoked funding and the hospital closed. Another disappointing outcome of this closure is that the hospital left an underserved, low income area of Los Angeles without an emergency department or medical facility.[ref]Bihm, J, (2007). King/Harbor tragedy leaves many open wounds, Los Angeles Sentinel.[/ref]
Lenore Alexander started Leah’s Legacy after she lost her healthy eleven year old daughter because of a post operative monitoring error. Leah’s pain medication was administered by a patient controlled pump monitor. Leah’s pump monitor was not connected to her vitals monitor. Leah was essentially euthanized while Ms. Alexander slept in a chair by her bedside. Had Leah’s pump been in communication with her vitals monitor, it would have sent an alarm to her mother and to the nurses. The vitals monitor would have communicated to the pump to lower the amount of pain medication that Leah was receiving. While speaking as panelist for the West Health Interoperability Webinar, Ms. Alexander said: “If Verizon and ATT can talk to each other, why can’t hospital devices talk to each other?” Ms. Alexander now dedicates her time to educating adults and high school youth about the importance of patient knowledge and engagement.
Interoperability has the potential to lower health costs in the US by thirty billion dollars annually.[ref]West Health Institute, (2013). The value of medical device interoperability: improving patient care with more than $30 billion in annual healthcare savings.[/ref] Analysis by the West Health Institute estimates that there is thirty six billion dollars in addressable waste within the US healthcare system.[ref]Ibid.[/ref] Ninety seven percent of that waste is attributed to the lack of interoperability.
According to the Journal of Patient Safety, an estimated 210 to four hundred patients in America die annually because of medical errors, making medical errors the third leading cause of death in the US.[ref]John, J.T., (2013). A new, evidence based estimate of patient harms associate with hospital care. Journal of Patient Safety, (9) 3, P122-8.[/ref] Creating a technology ecosystem that uses seamless interoperability has the potential to lower the rates of medical errors and deaths.
The US has made strides to promote interoperability, but there remains room for improvement. In a study published by Health Affairs,[ref]Furukawa, M., Patel, V., Charles, D., Swain, M. & Mostashari, F. (2013). Hospital electronic health information exchange grew substantially. Health Affairs, doi: 10.1377/hlthaff.2013.0010.[/ref] hospitals in the US showed a forty one percent increase in the practice of exchanging information with other providers and organizations. In a different study,[ref]Furukawa, M., King, J., Patel, V., Hsiao, C-J, Adler-Milstein, J. & Jha, A. (2014). Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Affairs, doi: 10.1377/hlthaff.2014.0445.[/ref] researchers collected data from office based physicians, from 2009-2013. The researchers found that seventy eight percent had an electronic health record system, yet only fourteen percent shared the information with other providers or organizations.
Public and private agencies are making efforts to encourage the adoption of electronic health records. In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law. The law provides for financial incentives or penalties based on the demonstration of “meaningful use” of electronic medical records. Unfortunately, this was a missed opportunity because interoperability was not a requirement. The government quickly recognized the problem, and programs introduced after this law require interoperability and information.
The Centers for Medicare and Medicaid Services introduced the Electronic Health Record Incentive Program. The program makes payments to eligible professionals, hospitals, critical access hospitals and Medicare Advantage Organizations that use health information technology for the purposes of quality improvement at the point of care and for information exchange. In 2011, the program paid the first round of incentive payments. As of May of 2015, the program had 468,000 providers participating. To date, nearly forty million US dollars have been paid to participating providers. Over seventy percent of eligible clinicians and physicians and over ninety five percent of eligible hospitals have demonstrated successful electronic health record use and have been given incentive payments from the federal government. A national survey[ref]Jamoom, E., Patel, V., King, J. & Furukawa, M. (2012). National perceptions of her adoption: Barriers, impacts, and federal policies. National conference on health statistics.[/ref] of physicians who use electronic health records found that ninety four percent of providers reported that having an electronic health record made a patient’s records easily available at the point of care. Eighty eight percent reported having clinical benefits to their practice due to their adoption of electronic health records. Seventy five percent reported that electronic health records enabled them to provide better care.
The Office of the National Coordinator for Health Information Technology works to advance the interoperability of information technology in health. In a 2015 vision paper, Connecting Health and Care for the Nation: A 10 Year Vision to Achieve An Interoperable Health IT Infrastructure, the Office of the National Coordinator provided a framework and vision to achieve interoperability as “a core foundational element” of better health outcomes at a lower cost. The Office of the National Coordinator has granted over 547 million dollars for states to improve their health systems through the exchange of health information.
Despite these investments from the government, the interoperability of health technology still lags behind other technological innovations that we take for granted, like cellular phones and personal computers. The most difficult challenge in achieving interoperability is the fact that device manufacturing companies do not have sufficient incentives to share their inventions and designs with other companies in order to facilitate interoperability. The best way to incentivize the device manufacturers is through policy, combined with a collective demand by patients, doctors, nurses, and hospitals. As the conversation around interoperability and patient safety continues to gain steam, I am hopeful that we will see meaningful efforts on the parts of policymakers, healthcare providers, and patients to push for greater interoperability and, ultimately, safer healthcare for all patients.