Avoiding healthcare interoperability ‘train wrecks’
Why everyone in healthcare delivery has a vested role in achieving standards-based bidirectional data exchange – to avoid needless deaths, reduce wasteful spending, share better experiences, and achieve better outcomes.
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On the frigid morning of Dec. 18, 1867, the last train from Cleveland began its 190-mile trek toward Buffalo, N.Y. The eastbound train included a locomotive, mail and baggage cars, a passenger car designed for immigrants and three first-class cars. As the train approached a truss bridge 160 feet over New York’s Big Sister Creek, it ran over a railway switch – a common mechanism that enabled train wheels to cross from one track to another. One of the front wheels of the trailing first-class car jumped the track and derailed the car. It swayed violently as the train dragged the car over the ties. Then uncoupling from the train, the rear car plunged 40 feet down the icy slopes toward the creek.
Because the rear car landed with one end inclined sharply downward, the passengers tumbled onto the pot-bellied stove at the bottom end of the car. The stove from the elevated end of the car also came crashing down on them while releasing hot coals. Flames quickly engulfed the carriage fueled by kerosene lamps.
One of the observers of the tragedy said, “I could not see them. I could hear them.” And a local newspaper reported: “The shrieks died into moans and moans into silence” over five minutes. Some 49 people perished in what is known as the “Angola Horror.”
The New York Central Railroad used a standard gauge, meaning that the load-bearing rails were 4-feet, 8 ½-inches apart. The Lake Shore Railroad used a wider 4-foot 10-inch gauge in Ohio. The train in our story was a “compromise car,” meaning it was built to run on both the standard and Ohio gauges. The lateral movement on the wider Ohio gauge made the train unstable. The non-standard rail gauge combined with the high speeds and an almost imperceptible bend in the front axle of the rear car caused the train to derail just outside of Angola, N.Y.
Public outcry from this event led to several railroad reforms. These included replacing loosely secured stoves with safer forms of heating, improving brake systems and standardizing track gauges across the country. We will never know how many lives were saved by these changes.
The state of interoperability
The lack of interoperability standards in population health is creating a modern-day version of the Angola Horror. It’s estimated that more than 100,000 people die from “wrong patient errors” in the U.S. each year.
That is just one type of healthcare interoperability issue. Here are a few ways that lack of standardization and interoperability infrastructure hurt patients:
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These issues are exacerbated as the number of data types grows and data volume explodes.
Injuries caused by data exchange snafus are avoidable. After all, interoperability problems are manageable and have already been addressed in other industries.
To be successful in value-based care, providers, payers and vendors need the ability to implement bidirectional data exchange across a wide variety of data domains.
Compared with other western countries, the United States has a particular need for interoperability because healthcare is not administered through a single monolithic entity. Thousands of providers, payers and vendors each manage a tiny fraction of the U.S. healthcare services, so they need to coordinate with different information technology systems to have any hope of providing integrated care. That coordination is not happening enough, and where it is happening, it’s not as efficient and cost-effective as it needs to be.
Many health systems and payers have home-grown processes and data structures for exchanging population health data. Others pay vendors enormous sums to help standardize the data and then store it in a data-siloed warehouse or in dashboards. And other organizations engage in value-based contracts with payers or government programs knowing that they do not have the infrastructure to be successful.
Interoperability standards are in place for HL7 and EDI transactions, enabling the exchange of clinical and billing data for individual patients. But the industry is sorely lacking administrative data to support patient populations and contracts between payers and providers responsible for those populations.
To be successful in value-based care, providers, payers and vendors need the ability to implement bidirectional data exchange across a wide variety of data domains. Without some level of standardization, providers and payers develop their own pet data formats and badger their partners into adopting them. The outcome is a kind of interoperability standoff – with each trying to convince the other to use its homegrown standard.
The call for flexible standards
Some may fear that rigid interoperability standards would stifle healthcare innovation and fail to meet the rapidly evolving needs of the industry. Without a certain level of interoperability, however, innovation in value-based care slows to crawl.
Entrepreneurial technology companies cannot get off the ground because the costs of data acquisition and normalization are too high, and data is often stuck in difficult-to-access databases. Although the data siloes are larger than they were in a world of paper charts, optimal patient care requires that health systems, payers, technology vendors and patients access data wherever a patient receives care.
Just like the railroads, which for decades have used a standard gauge with a wide variety of engines, passenger cars and storage cars, the healthcare industry can align around HL7, FHIR and future data standards.
It is true that inflexible data exchange standards would create some barriers to innovation, but new FHIR (Fast Healthcare Interoperability Resources) standards appear to be sufficiently flexible to meet the value-based care needs of the near future.
Value-based care, population health and accountable care organizations have been around since at least 2006, and managed care has been a reality since the late 19th century. The time for closed systems in healthcare has passed. Value-based care has been around long enough for us to agree on flexible and evolving standards for data exchange.
Just like the railroads, which for decades have used a standard gauge with a wide variety of engines, passenger cars and storage cars, the healthcare industry can align around HL7, FHIR and future data standards.
On a common foundation, we can exchange multiple types of data and support the expansion of value-based care. In so doing, we can prevent future interoperability train wrecks and usher in an age of rapid healthcare innovation.
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Michael Westover is Vice President - Population Health Informatics at Providence St. Joseph Health where he leads the technical teams managing performance on over 120 risk arrangements with payers and government programs covering over 1.5 million members across five states. Westover also manages the Population Health Division’s data factory and operational analytics.
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