Healthcare IT’s Big Challenge

David W Bates

David W Bates

Chief Division of General Internal Medicine, Brigham and Women’s Hospital, USA.


Any time you start with data exchange, you identify issues which need to be worked out. Many of the key standards are not fully mature—for example, just because a message is represented as HL7 version 3 doesn’t mean that it will be possible to read it on the other side.


What is your take on the issue of interoperability in healthcare IT?

The inability to move clinical data from place to place—that is to say, the lack of interoperability—clearly hinders delivery of good care around the world. It also imposes barriers to move between healthcare systems. Work done by our group at the Center for Information Technology Leadership has estimated that the US could save US$ 77.8 billion annually if interoperability were in place. Another key finding that emerged from this analysis was the importance of standards for addressing this issue—if standards are not in place, and data are exchanged for example in PDF format, most of the savings would not be realised. We did a further evaluation for Australia, and found that Australia could save approximately $ 4 billion (AU) annually, if interoperability can be implemented there.

What is currently being done to overcome this issue?

Relatively little is being done with respect to regulation in the US to promote clinical data exchange. Most of the emphasis has been placed on what we call regional health information organisations, or RHIOs. In early 2007 we surveyed 145 regional health information organisations (RHIOs), and published the results in Health Affairs in 2008. The key findings were that nearly one in four was defunct, and only twenty were of at least modest size and exchanging clinical data. With respect to what was being exchanged, most successes related to exchange of test results, and few prescriptions or referrals or notes were exchanged. The RHIOs are expected to support themselves, but struggled to do so: thirteen RHIOs received regular fees from participating organisations, but eight were heavily dependent on grants. These data suggest that the business model for clinical data exchange may be problematic, and federal support may be needed.

Other countries are using a much more centralised approach. For example, Australia has implemented data exchange in several regions. The UK has a national approach, and “the spine” will eventually allow exchange of a core of clinical data for all citizens in England.

Clearly standards play a key role in facilitating this. In the US, the federal government and quasi-governmental entities have established standards for most of the key types of clinical data, but the problem has been that there are costs to convert, and few users have demanded conversion, so that even though they exist they aren’t yet widely implemented. Other countries like the UK are much further along in this regard. Much more work needs to be done internationally so that standards become accepted.

In the far east, Singapore has been a leader in this area, as has Australia and Hong Kong for example has established data exchange within the Health Authority.

Issues with privacy and security also represent an important concern, and a small but vocal minority in many countries has substantial concerns. One way of dealing with this is to use an ‘opt-in’ as opposed to an ‘opt-out’ or mandatory approach toward having one’s data included in the clinical data exchange.

What, according to you, could be the panacea for interoperability?

I think that panacea is too strong a word, but one key will be to represent data in standard format and then actually to implement data exchange. Any time you start with data exchange, you identify issues which need to be worked out. Many of the key standards are not fully mature—for example, just because a message is represented as HL7 version 3 doesn’t mean that it will be possible to read it on the other side.

Another key issue is the architecture of the data exchange. All the exchanges that have worked well to date have used some sort of central repository structure. The alternative approach has been to use a federated approach, and only to extract data on a ‘need-to-know’ basis. One of the biggest issues with the latter approach has been speed, which is central in clinical care.

How are vendors responding towards this trend?

Vendors are clearly interested and paying close attention, but they are also waiting to be pushed by their clients to be asked to use key standards and to set up the portals to facilitate data exchange. This makes good business sense, as being a ‘first mover’ in this area carries significant risk, but on the other hand will be very problematic for vendors to be laggards in this area.

How is interoperability affecting patient care?

Many predictions have been made about how interoperability will affect patient care, but relatively few empiric data are available regarding this.

But it can be expected that patient safety will improve, that it will be possible to decrease redundancy for example with respect to tests, and that the quality of care will improve. We are evaluating the impact of clinical data exchange that has been established in three communities in Massachusetts, and will be looking at these and other issues.

In our own network, we have achieved interoperability, and it has been very helpful clinically in my own practice to be able to look at lab results from anywhere in the network. Before this, it would often take a long time to get results from some other site by lab or fax, and this often represented a big enough barrier that it was easier to just repeat the test. Furthermore, another effect has been that the pool of specialists I am comfortable working with is much larger, as I can now see data from several thousand specialists.

What could be the role of Internet in overcoming interoperability?

Clearly, the Internet provides a platform that makes it easy to exchange information at low cost. There are issues at the same time with security, but these should be manageable with techniques like the use of virtual private networks.

Any other comments?

Overall, clinical data exchange has the potential to dramatically improve care, and reduce costs. That being said, there are many practical hurdles to be overcome. Some of the biggest are better defining the business case, actually using key standards so that they become more mature and the kinks get worked out, and then dealing with the inevitable privacy and security concerns that will arise.

David Bates is an internationally renowned expert in using information technology to improve clinical decision-making, patient safety, quality-of-care, cost-effectiveness, and outcomes assessment in medical practice. He has published on medication errors and injuries due to drugs, and the use of information systems to improve medication safety and the use of ancillary tests, as well as on predictors of bacteremia and evaluation of patients with suspected sepsis. He has published over 400 peer-reviewed papers. He is a graduate of Stanford University, and the Johns Hopkins School of Medicine.