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Healthcare & Interoperability: What Ever Happened to Best of Breed?

By: Carl Witonsky – Managing Director

I can remember, years ago, speaking with an IT Director of a very large multi hospital system about what was his biggest headache on the job, and, without taking the slightest moment to reflect, he said it was the inability to bring software vendors together to cooperate on detailed interface specifications, and worse yet, once the interface was operational, the inability to resolve issues when problems arose. Whether it was physician office to hospital, outpatient clinic to inpatient, Emergency department to inpatient, or ICU to EMR,  clinical data was being rejected, lost, incorrectly formatted, double entered, or, worse yet, unsynchronized between systems.  It often resulted with vendors pointing fingers at each other and IT Directors attempting to referee.

Think of it; there were different vendors for every clinical departmental system including Laboratory, Pharmacy, Radiology, Physician Order Entry, Intensive Care, Emergency, Surgery, Labor and Delivery, etc., and, each vendor had significant software releases every year; it was not unusual to have a smooth running interface operation go haywire after a release was installed, with the finger pointing starting all over again.  On the positive side, from a departmental user standpoint, many of these systems were best of breed that included the nuance and the medical specialty functionality that truly addressed clinician needs, and did so with fast response times and well-designed workflows. However, doctors making inpatient rounds would have to sign in (with a different ID and password) to every application on every nurse station they visited, a time consuming and irritating task. There were two developments in the 1990’s that were designed to alleviate the problem, CCOW (Clinical Context Object Workshop) and SSO (Single Sign On).  CCOW is a vendor independent standard developed by the HL7 organization to allow companies to share information at the point of care. This meant that when a clinician signed onto one application within a CCOW environment and selected a patient, that same sign on was simultaneously executed on all other applications and the same patient was selected, and now the doctor could look at orders, lab results, radiology reports and nursing notes without any additional system interactions.  For the clinician, it was like accessing a virtual Electronic Medical Record.

So, why isn’t this the end of the story? It turns out that each vendor had to modify their applications to be CCOW compliant and the big vendors did not see any value for themselves; worse yet, it would make it easier for competitive vendors to gain business at their “expense”. So, the large vendors dragged their feet, signed contracts that set no date for CCOW availability, and promised to develop a suite of clinical applications that would make interoperability issues disappear.

So, what did hospital IT directors and senior management do?  Rather than focus on improving interoperability solutions, or adopting interoperability standards, or leaning on vendors to implement CCOW, or even increasing their own IT staffs to manage interoperability issues, none of these  easily accomplished, they looked to the largest vendors to provide an integrated solution that would offer one stop shopping.  The IT Directors knew that the end to end vendors were not able to match the existing best of breed in domain knowledge, functionality, nuance, workflow or speed but senior executive management bought in and the clinical users were told that they had to take a few steps backwards in order to move the institution forwards.  Incomprehensively, the doctors went along with the decision.  Most likely, many of the doctors were unaware of what was happening, didn’t really comprehend the full impact of the decision or just threw up their hands.

This was a monumental decision, requiring hospitals across the country to spend billions upon billions of dollars in replacing highly functional best of breed solutions with new applications that were functionally inferior, lacked clinical specificity, turned doctors into super data entry clerks who, with the introduction of Meaningful Use, were now seeing fewer patients and working longer hours.  However, the IT interoperability issues were greatly reduced.  I often wondered how a hospital with 500 doctors and 2,000 nurses caved to the needs of an IT department with a 100 member staff.

So, where are we today?  After a decade of development, four major vendors dominate the industry and offer an end to end clinical solution that significantly reduces interoperability issues but is still a far cry from delivering the best of breed functionality, workflow, and efficiency of use that clinicians critically need. Hence, a next generation of clinical application development is upon us, mostly from early stage companies focused on mobile devices and cloud computing which are revolutionizing clinical applications with best of breed solutions rich in domain expertise for each clinical specialty. The comprehensiveness of function, the exactness of workflow, the sub second speed of movement and the complete domain knowledge is truly a game changing solution.

Physicians recognize the true value of the new technology immediately. No longer will they spend patient visits focused on a PC screen.  No longer will they spend hours entering documentation notes after they have seen the last patient of the day.  Finally, they will use a system that was designed exclusively for their specialty that will improve outcomes, increase efficiency, lower costs and make them more effective. But, in order for the data to flow from the new clinical front end to the EHR they will need a seamless interoperability solution with the major end to end vendors that control access to the hospital, a group who historically disdains anyone getting a toe hold in their customer base. Just this month vice president Biden was so frustrated, he threatened to lock EHR vendors in a room until they agreed on interoperability!

There are now interoperability software firms that are proclaiming connect ability between end physician clinical specialty systems and the EHR, but it is too early to confirm success.

The Falcon team has seen how the dominant large HIT vendors have reacted in the past and may be able to assist next generation clinical software firms on how to formulate approaches to win this battle.

Contact Carl Witonsky, Mark Gaeto or Ted Stack to discuss interoperability and how Falcon Capital Partners might be able to help.

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