Call to Interoperability Action: What Would Amazon Do?

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In reviewing a schematic diagram of the integration points of the imaging information systems of Kaiser Northern California (Oakland), Richard (Skip) Kennedy, MS, bewails the current state of point-to-point integration in health care. Not only is this approach inefficient, time intensive, and wildly expensive, it’s not working very well.

On March 22, 2012, Kennedy presented “The Blind Men and the Elephant: A Parable of Imaging IT Interoperability” at a Long Beach, California, regional meeting of the Society for Imaging Informatics in Medicine. In the presentation, Kennedy (who is technical director of imaging informatics, Northern California, Kaiser Permanente) explains not only why health-care IT should evolve, but why it must.

Richard (Skip) Kennedy, MS“We worked in an interfacing environment that’s dedicated to building very professional, very custom-crafted Rolls Royce Phantoms, and we’re living in a world now, in health care, that can only afford an Accord. We’re not going to be able to spend $300,000 for interfacing anymore.”

—Richard (Skip) Kennedy, MS

 

In preparation for his presentation, Kennedy tried to figure out how many man-hours went into the nearly 50 interfaces linking his information systems (see figure).He gave up; he did, however, report that each HL7 interface took an average of six to nine months to complete.

“We spend an enormous amount of time building these interfaces, and the sad thing is, frankly, about 90% of the content between these interfaces is all replicated: This is the same information we are sending from system to system, and that’s how we always have done it,” he says. “I am going to make an argument that this is a bad way of doing it, and that we have better ways to do it.”

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Figure In this representation of most of the imaging and imaging-support systems at Kaiser Northern California, each line represents a system-integration point for which an interface had to be built. [Click on image to see full size]

Over the Wall

The reason Kaiser (along with nearly every other health-care enterprise in the United States) has found itself in this predicament is that many systems originated as stand-alone systems serving individual purposes. “We bought a RIS; maybe we have a billing interface. In some cases, in the past, we even wrote out a billing file, and then we tossed it over the wall; that was the model,” he explains.

While Kaiser has a single integration engine (or interface broker) that attains most integrations, each one is implemented, from system to system, as a unique, point-to-point HL7 2.2 or 2.3 interface. In general, these interfaces are unidirectional and can’t inform the system on the other side if there is a problem. “As a result, those of us who work in IT spend an enormous amount of time clearing up queues, error logs, exception files, and the like of things that went over the wall and didn’t stick,” he explains.

“These are all legacies, essentially, of building something that’s not changed its fundamental structure in well over two decades. We haven’t had a fundamental difference in this mechanism for a long time,” Kennedy says.

The Compromise

The problem with this approach is that it entails compromises that limit information access in a complex environment with multiple information systems.Beyond three or four systems, hundreds of interfaces could be necessary to share specified information from one system with multiple other systems. The problem becomes multiplicative, in effect.

Kennedy offers the example of making available up-to-date and consistent creatinine values in the RIS, which many organizations do not do because they would have to build a creatinine interface. For this reason, “The radiologists don’t have all of the information they need to do their work,” he notes.

Another problem is the inability to leverage structured content—for example, in obstetric interpretations, Kennedy says. “There is nothing sillier than watching a radiologist dictate head circumference on an obstetric study,” he suggests. “It’s there in the data. We should have solved this problem five years ago, but in most cases, we haven’t—because we haven’t built the structured-content system. We need point-to-point interface systems to support it.”

Reporting Dose

Kennedy’s final example pertains to the conference theme: complying with California’s new dose-reporting requirements under the Medical Radiation Safety Act of 2010 (originally SB 1237). Beginning July 1, 2012, all of the state’s health-care