Falling Between the Cracks in the Software

Commentary by Julia Adler-Milstein, PhD

The Case

A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prior to surgery, he saw his orthopedic surgeon in clinic because of increased pain. The surgeon prescribed oxycodone. The new prescription was reflected in the outpatient medical record, which was on a different information technology platform than the hospital system and did not communicate with it. At the time of hospital admission, the patient did not remember to mention the oxycodone as a new medication when asked for his list of outpatient medications.

Unaware that the patient had started taking oxycodone, the anesthesiologist, hoping to achieve adequate postoperative pain control, placed an epidural catheter through which morphine was administered. While in the postanesthesia care unit, the patient became somnolent from receiving morphine on top of the oxycodone he had already taken earlier that day. Despite the administration of naloxone, the patient required intubation and a brief intensive care unit stay. He was quickly extubated and experienced no long lasting adverse effects from the medications.

If the inpatient medical record had been automatically updated to include the patient's oxycodone, the anesthesiologist would have taken this into account when administering morphine. The lack of interoperability between the office-based medical record platform and the inpatient system contributed to the error.

The Commentary

by Julia Adler-Milstein, PhD

Interoperability is defined as the ability of a system or product to work with other systems or products without special effort on the part of the user.(1) In the case described, the lack of interoperability between two distinct electronic health record (EHR) systems is evident from the fact that the inpatient medical record did not automatically update to include the patient's outpatient oxycodone prescription. Interoperability of EHRs is a top policy priority in the United States because it offers clinicians the ability to easily access health information about their patients from multiple sources. This access is essential when providing medical care to patients who receive care from multiple delivery systems, each with their own EHR.

Although traditional methods of information sharing (e.g., phone, fax, mail) across distinct health systems are available for transmitting patients' medical information, such methods are error-prone, not secure, and inefficient. Estimates suggest that achieving EHR interoperability on a national level could save tens of billions of dollars by improving efficiency, quality, and patient safety.(2,3) While little empirical evidence specifically speaks to how many errors could be avoided with interoperability, inadequate availability of patient information is a widely recognized contributor to errors, and one study determined it was the root cause of 18% of inpatient adverse drug events.(4)

Despite widespread agreement on potential value from interoperability, it has proven challenging to achieve. Technical barriers are one obstacle. For electronic systems to share information with each other "without special effort on the part of the customer" (1), the systems need to encode information in a standard manner and transport it to where it is needed. While some information coding standards are widely adopted and work well (e.g., standards that enable e-prescribing), it has been challenging to get all stakeholders to agree on a single standard for a given type of information, as well as to implement that standard consistently across the diverse electronic systems in our health care system.

If development and implementation of universal standards were the only barriers, we'd likely see substantially more interoperability. Unfortunately, current patient consent policies, financial incentives, and existing norms of medical practice present additional challenges. For example, state policies governing patient consent requirements for health information sharing vary from state to state and based on the type of information being shared.(5) Provider organizations and health care systems concerned about maintaining market share might further slow progress toward interoperability. Hospitals view clinical data as "a key strategic asset, tying physicians and patients to their organization."(6) More recently, concerns have been raised about EHR vendors intentionally making interoperability more difficult and costly in order to improve their competitive advantage.(7) In addition, clinicians have developed workflows adapted to incomplete patient information and have yet to use their political capital to demand interoperability. Furthermore, clinicians may be apprehensive about the notion that they would be responsible for, as well as potentially liable for, reviewing patient data from many sources.

What's notable about the case described is that it takes place within one health care delivery system, which should make interoperability easier. For example, issues related to patient consent and competition should not be relevant in the case of a single organization needing to share data between ambulatory and inpatient settings. Clearly the inpatient anesthesiologist would have preferred to receive an up-to-date medication list from the ambulatory EHR.

Why might the health system described still lack interoperability between its inpatient and outpatient EHRs? Across the US, it is common for health systems to select ambulatory and inpatient EHR products from different vendors to implement EHRs that are more customized to each setting. When the systems are initially selected, vendors often claim that cross-vendor interoperability can be accomplished easily. Furthermore, administrators may not prioritize interoperability of systems from the outset. Down the road, the expenses associated with interoperability often prove higher than expected and must be weighed against other competing priorities.

While this reasoning may explain why a lack of interoperability resulted in this particular adverse drug event, it does not explain, from a public policy perspective, why the federal government has not stepped in to require EHRs to be interoperable.(8) EHR adoption has been subsidized with taxpayer dollars in the form of Meaningful Use incentives.(9) Given this fact, policymakers are in a strong position to facilitate interoperability, perhaps more so than provider organizations or EHR vendors. In fact, the original HITECH legislation that authorized the financial incentives for EHR adoption stated, "such certified EHR technology is connected in a manner that provides […] for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination."(10) However, federal policymakers responsible for implementing HITECH chose a staged approach in the form of increasingly robust Meaningful Use criteria, and interoperability was deferred to later stages.

In light of the barriers to interoperability, one can understand the decision to defer it. Yet this case illustrates the problems with the EHR adoption first–interoperability later strategy. Today, our electronic system is fragmented, with thousands of different EHRs being used by providers and health systems across the country. The cost and complexity involved in making them interoperable is substantial. The good news is that there continues to be widespread agreement that interoperability is essential to ensure safe, high-quality care for patients. Policymakers, providers, and vendors realize that each has a vital role to play in making interoperability a reality, and it seems likely that meaningful gains in interoperability will be accomplished in the US within the next several years.

Take-Home Points

Interoperability is defined as the ability of a system or product to work with other systems or products without special effort on the part of the user.
In the context of EHRs, interoperability means that it should not require special effort on the part of clinicians or their organizations to access health information about their patients that exists in other EHRs.
Inadequate availability of patient information is a widely recognized problem that results in patient safety failures and could be solved by interoperability.
We lack interoperability across EHRs today because of myriad technical, policy, and cultural barriers, misaligned incentives, and due to the fact that EHR adoption was prioritized over interoperability.

Julia Adler-Milstein, PhD
Assistant Professor of Information, School of Information
Assistant Professor of Health Management and Policy, School of Public Health
University of Michigan
Ann Arbor, MI

References

1. IEEE. Interoperability. Standards Glossary. [Available at]

2. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff. 2005:W5-10-W5-18. [go to PubMed]

3. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. 2005;24:1103-1117. [go to PubMed]

4. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43. [go to PubMed]

5. Adjerid I, Acquisti A, Telang R, Padman R, Adler-Milstein J. The impact of privacy regulation on technology adoption incentives: the case of health information exchanges. Manage Sci. 2015:62;1042-1063. [Available at]

6. Grossman JM, Kushner KL, November EA. Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome? Res Brief. 2008;(2):1-12. [go to PubMed]

7. The Office of the National Coordinator for Health Information Technology (ONC). Report to Congress: Report on Health Information Blocking. Published April 2015. [Available at]

8. Blumenthal D. Health Information Technology: What Is the Federal Government's Role? Washington, DC; The Commonwealth Fund; March 2006. [Available at]

9. Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010;363:501-504. [go to PubMed]

10. Stimulus: American Recovery and Reinvestment Act of 2009, Pub L No. 111–5, HR 1–356.