View from the Bridge

Interoperability – Make it so.

When Jean Luc Picard, Captain of the Starship Enterprise of Star Trek fame, had gathered his facts and made a decision, he uttered the phrase, “Make it so.” After a career spent working intermittently but consistently on interoperability, I’m thrilled that a confluence of factors make nationwide interoperability a reality. The benefits are obvious…the facts are clear. The time has come for our nation to “Make interoperability so.”

We work, play, and live in a digitally enabled world where interoperability is common practice. Healthcare providers in the acute care and ambulatory settings have made great strides in adopting information technology, but healthcare lags other sectors in interoperability.

We have all the pieces of the puzzle. To achieve interoperability, we simply, though not easily, must choose the appropriate pieces based on the nation’s and its citizens’ best interests, arrange them strategically and tactically, and make an organizational and individual commitment to embrace those choices.

Before identifying the pieces, it is important to have a definition. There are significant variations, but for this post, I’d suggest interoperability is the ability to:

  • Share information easily and securely,
  • Achieve common understanding of meaning based on agreed upon and widely available standards, and
  • Use that information to facilitate the pursuit of activities associated with work, play, and living.

Fortunately, the pieces of the puzzle for interoperability are available, some more mature than others. Briefly, the required elements (pieces) for interoperability are:

  • Agreed-upon standards sufficiently constrained to ensure adherence,
  • Shared trust framework,
  • Shared, multi-stakeholder governance with incentives to ensure compliance,
  • Nationwide network (or more likely a network of networks),
  • Effective privacy and security,
  • National health safety identifier for every recipient of products and services in the healthcare ecosystem, and an
  • Approach that builds on existing systems, with the commitment of the custodians of the existing systems to evolve.

Because of HHS’ Meaningful Use program, most providers have both internal and external interoperability working. None of them, however, claim to be satisfied with where they are because of the cost and effort required to connect systems and the lack of participation by all providers. Currently, many healthcare organizations are operating in multiple networks (Health Information Exchanges, internal networks, external networks, and others) simultaneously. Few, if any, of these networks currently share data efficiently and effectively. How do we attain true interoperability to support high quality care, engage patients, and support new models of care, and do so in a cost-effective manner?

Though I’m grateful for the public sector’s role in achieving wide-scale adoption of electronic health records in the acute care and ambulatory settings, it’s time for the private sector to step forward and provide the needed leadership. The private sector must address the gaps that were missed or ignored by regulators and expand the scope of efforts to all of health information technology, not just EHRs. And most importantly, the consumers and their families must be able to participate as partners.

The best candidate from the private sector to lead this effort has an existing track record, significant support from providers and implementers, deep technology expertise, and policy proficiency. This combination of attributes should allow them to craft a practical and pragmatic solution.

Currently, the single biggest barrier in the private sector is economic. Interoperability is disruptive, expensive, requires special talents, and can only work when competitors put national and consumer interests above their parochial interests. To reduce the costs and eliminate ambiguity, a system, not component, approach must be chosen. That means constraining standards to eliminate unnecessary variation, identifying less complex use cases, and making it possible for the recipient to use the transmitted information upon receipt, assuming some quality control process is in place to ensure data integrity.

The cost of the software to make one component interoperate with another must be absorbed by the vendors. That will inevitably lead to cost shifting, but we’ve survived that already in other areas of our lives. Printers and cell phone apps are examples where interoperability works well at no obvious additional cost. The costs for interoperability are already included in the existing business models. Would anyone reading this post buy a printer and then pay extra for the software to make it communicate with their personal computing device or mobile phone? Would anyone acquire an app and then pay extra for an interface to make sure that it works with their smart phone?

Healthcare interoperability is special, very personal, and often life-altering. We must act now, we must act decisively. Incentives to use it and liability protections to ensure adoption are essential. Success is a matter of effective, radically aggressive private-public collaboration. In our existing health information technology ecosystem, we have the pieces. Let’s agree to identify and use the trusted participants, the proven solutions, and commit both organizationally and personally to make interoperability so. We all need IT.


  1. Well stated blog on interoperability. I would agree constraints are economic but perhaps more challenging are the continued political constraints in many communities. We see it over and over again, and these issues have impacted many emerging HIE success stories. Here’s hoping the industry is feeling the push and the value to address the economic and political constraints for “making it so”! Our consumers expect it and it’s time to get it done.

    Love the look and feel of your logo and branding. Very nice!

    1. Great to see your name. Agree wholeheartedly with your comment. Your observation is right on point, and might be based on our shared experience. Thanks for responding and for your compliment. Best to you, David

  2. David,
    The most successful implementation of standards based EDI have all been because the industry stakeholders came together to figure it out. I’ve spend considerable time researching these over my career. Healthcare remains an enigma where in the supplier of the data bears almost all of the cost and is expected to share it freely. In contrast, almost every other EDI exchange you can think of, the receiver of the data pays for it.

    That cost/profit per transaction balance is a large reason that we have yet to answer the “what’s in it for me for doing all this investment and work”?

    Even the patient who wants a copy of their medical record pays. Medicare and some insurance plans pay. I content that the days of “free data exchange” are coming to a close simply because of the burden on the providers to provide this service.

    Docs and hospitals were very quick to adopt financial claims systems because of the turn around to their accounts receivable. The rate of claims errors dropped because of scrubbing and payment was made in days rather than months. When I can get my payment that fast, 10 cents a transaction is meaningless.

    I think incentive alignment will fix the business case of EDI of health data as well. We fix this and we’ll have come a long way to make health data exchange sustainable and robust.

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