Federal meaningful use mandates and developers of large electronic health records advocate the use of fully-integrated systems for improving workflow and ensuring seamless data sharing. But some question whether the one-size-fits-all approach will lead to the types of changes the health care industry is looking for.
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Alternatives to integrated EHRs
Isaac Kohane, a researcher at Harvard School of Medicine and Boston Children's Hospital, said the meaningful use program, which incentivizes physicians to adopt complete EHR systems, places a premium on monolithically integrated systems.
However, he and his colleague Kenneth Mandl, M.D., have advocated for an alternative approach based on a standardized application program interface. Any application developer, not just EHR vendors, would be able to create new programs to run on platforms that use universal programming languages. This could speed up the pace of app development, according to Kohane. But the current pursuit of meaningful use incentives makes this approach unlikely.
"The funding model makes it easy to buy shovel-ready software, as opposed to saying 'let's buy a platform and develop apps.' A full ecosystem of apps takes time to develop," Kohane said.
There's no way that these huge companies, with hundreds of developers, can compete with the creativity of potentially tens of thousands of developers who would be all too happy to have their apps being used for health care.
researcher, Harvard School of Medicine at Boston Children's Hospital
Moving away from the current focus on all-in-one systems could be a key to incorporating an app-based approach, he said.
Another potential alternative to system-wide EHR integration is virtualization. John Robles, an Epic Corp. implementation specialist, said many of the large vendors who have traditionally offered locally-hosted systems, including Epic, are beginning to virtualize many of their components. This could make it easier for organizations to customize components to their specific needs.
Providers may also find it simpler to use multiple vendors for different purposes when turning on a specific component does not require setting up new servers.
Interoperable standards could slow pursuit of EHR integration
Vendors have long resisted standardization. Stakeholders looking at the updated 2014 certification and standards say this is because their business models rely on locking customers into complete systems. Making it easy for providers to purchase systems from other vendors could decrease sales.
But federal mandates and demand from customers is increasingly pushing vendors toward standardization. Forbes recently reported that Epic and Cerner Corp. are working with Greenway Medical Technologies to enable the exchange of patient records between the two systems. And eClinical Works announced this month a plan to facilitate the development of cross-platform interoperable communication standards.
Luis Kun, member of the IEEE Computer Science Society Board of Governors and founder of the organization's USA Electronic Health Record and High-Performance Computers Working Group, said this could have a number of benefits. The current lack of interoperability makes it difficult for hospitals to get out of one-vendor packages if they decide they need to make a change. Standardized technology will also enable providers to pick the products that suit their needs, regardless of which vendor supplies it.
Kohane added that standards will foster innovation. For example, he said Children's Hospital Boston was finding that its EHR made it difficult to track the blood pressure of pediatric diabetes patients because the system did not account for natural age-related blood pressure changes. Because the hospital uses HL7 standards in all its IT systems, it was a simple job for a developer to create a new blood pressure management system that reflected the hospital's needs and incorporate it into the IT infrastructure.
"There's no way that these huge companies, with hundreds of developers, can compete with the creativity of potentially tens of thousands of developers who would be all too happy to have their apps being used for health care," he said.
The meaningful use program does include provisions that require interoperability. One rule specifies that providers must exchange data with physicians who use systems that are different from their own. But the current rush toward integrated systems may make it difficult to satisfy this requirement, according to Melanie Vance, Epic director at Everett Clinic. This is because most of the other hospitals and clinics in the area that Everett works with use Epic as well, which is recognized as one of the leading vendors for integrated products.
The anecdote depicts how providers have prioritized EHR integration. However, it also highlights the tension that exists between this approach and the direction some commentators and government regulators would like to see the health IT industry head.