In the wake of medical home certification, meaningful use, the Cures Act, and the pandemic, it’s clear that virtually all health care is now built on a digital foundation. EHRs are pervasive in the delivery system and are increasingly connected to practice management software, virtual visit, mobile capabilities, health information exchanges, and population health platforms. As we consider the criticality of interoperability throughout this evolving digital ecosystem, I’m moved to reflect on the issue of interoperability in another time, the 1960s.
A firsthand view of clinical practice
As a child, I had the opportunity to observe my father in solo pediatric practice. Sub-specialization was relatively new. General practitioners would come to him as a pediatric “specialist” to consult on their complex patients. There were no neonatologists, intensivists, hospitalists, or emergency physicians. He took care of his patients throughout their health care journey. If they needed surgery, he would follow them pre- and post-operatively along with the surgeon. In the office, he and his nurse developed seamless workflows to manage patient care throughout the day. With house calls a routine component of the care model, he easily identified and assessed financial, social, and cultural issues that might impact his patients and integrated those assessments into his care plan.
Minimal regulation and a simpler business model
Even as this clinical picture harkens back to simpler times, so were the business models and regulatory requirements. Ambulatory care was largely a cash business. Many still had insurance that only covered hospitalizations. Even for those with coverage of ambulatory care, the patient typically paid the doctor and filed a claim to get reimbursed by the insurance company. Medicare and Medicaid weren’t even signed into law until 1965, and then took most of the rest of the decade to get implemented. HMOs were rare and geographically isolated, there was no such thing as prior authorization, and HIPAA was three decades away.
Technology matched the need.
In these simpler times, simpler technologies were sufficient to support interoperability needs. With so few hand-offs, face-to-face discussions and telephone calls for “sign-outs” worked just fine. Typewriters, carbon copies, and snail-mail sufficed for formal sharing of assessment and plan in the referral process. Urgent or abnormal test results were delivered via a phone call to the ordering physician. In the absence of pagers and cell phones, every doctor had an answering service that was kept informed of who was on call and how they could be reached, e.g., at home, church, or restaurant. There was continuity of care stemming from less specialization, fewer sources of information, fewer providers in need of information, and a much simpler business model. Getting the right information to the right people at the right time was a fairly straightforward issue.
Lessons for today
In contrast, today’s health care is characterized by increasing complexity in every realm—clinical care, business models, regulations, and technology. Providers have historically depended on their own diligence to ensure they had all relevant information at the point of care. Given the vast and growing number of sources of information, continuing segmentation of care across time and specialties, and the rapidly advancing diagnostic and treatment modalities, it is no wonder providers experience enormous stress related to information sharing. While great strides have been made to present meaningful information from other care settings to providers when and where it is needed, the sheer volume of data flowing across systems requires leaders and data engineers to be diligent about what information flows directly to the care team.
Today, providers must focus on harnessing the capabilities of integrated EHR, health information exchange, population health management platforms, and mobile and virtual technology. They can then leverage solutions to collect, sort, and present this growing volume of clinical data to effectively and efficiently support their clinical decision-making.
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