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Modularity, a Key Component of Healthcare Interoperability?

Modularity - Key Component of Healthcare Interoperability

Time to Set the Ground Rules for a Nationwide Healthcare Interoperability Roadmap

Recently the Office of the National Coordinator for Health IT (ONC) published an Interoperability Vision Paper called “Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure”.

The ONC will be at the forefront in the development of what they see as a shared, nationwide interoperability roadmap. The roadmap is planned as the platform that will ensure stakeholders can connect care, improve health, and develop the IT ecosystem apart of the larger “learning health system” envisioned

Under Guiding Principles, ONC talks about utilizing a modular approach:

“Complex systems are more resilient to change when they are divided into independent components that can be connected together. Because medicine and technology will change over time, we must preserve systems’ abilities to evolve and take advantage of the best of technology and health care delivery. Modularity creates flexibility that allows innovation and adoption of new, more efficient approaches over time without overhauling entire systems.”

However, let’s get realistic about implementation of this guiding principle of modularity.

This modular approach is a far cry from the model used by the entrenched EHR titans with the bulk of market share. Hospital CIO reported, “At the end of 2013, 10 EHR vendors accounted for about 90 percent of the hospital EHR market, based on meaningful use attestation data from CMS: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare.“ In fact, three of the ten significantly expanded their market share in 2013 per a Klas report — Epic, Cerner and MEDITECH, together now accounting for more than half of the acute-care EHR market!

What riles me is that as of May of 2014, CMS has paid out a total of $14.6 billion in incentive payments to hospitals and health systems for the adoption and use of EHRs and these three vendors are notorious for having closed systems that are anything but modular and flexible. Given the ONC’s position, it makes no sense to “reward” vendors that offer the direct opposite of what ONC proposes and envisions in its roadmap. In addition to roadmap mandates, utilization of ONC specific recommendations by EHR vendors needs to be not only a condition of receiving Federal dollars but enforced. Lip service isn’t enough.

Let’s take a deeper look at the ONC’s view on modularity: “Complex systems are more resilient to change when they are divided into independent components that can be connected together.” This relates to what we, as an integration engine provider, refer to as “loosely coupling systems.” Instead of hard wiring systems, loosely coupling them adds flexibility, reduces maintenance, and offers the ability to easily change and modify.

Through years of experience as a software company providing middleware we’ve evolved a tested strategy to deal with the inherent issues presented by the ONC:

  • The architecture should provide for the loose coupling of business applications.
  • Interfaces should not be part of the business applications, but instead implemented within a common integration “hub” or “middleware.”
  • The middleware should be responsible for the connectivity to the business applications that are going to share data and for the transformation of that data. It is this middleware that will allow the connectivity of the various and diverse components.

Point-to-point interfaces are anything but flexible. Allowing any vendor system to connect to any EHR via loosely coupling allows leveraging of the latest and best technology. Based on our experience, adherence to this approach and mandating it as a requirement should be part of the ONC’s 10 year plan.

Feel free to contact me about how middleware can solve your healthcare interoperability challenges.

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Monika Vainius

Written by: Monika Vainius

Executive Vice President of Applied PilotFish Healthcare Integration. Monika has extensive experience with systems interoperability. She combines this experience with her professional passion for healthcare and healthcare technology to comment on current healthcare and IT news. Website

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