Reflections on the history of interoperability in hospitals.

OBJECTIVE: To discuss the origins of HL7 and its subsequent impact on interoperability in hospitals. PROCESS: Reconstruction of historical events from review of personal notes, interviews with key participants and review of relevant publications. CONCLUSIONS: The first versions of HL7 were based on the StatLAN protocol developed at the University of California, San Francisco and later commercialized by Simborg Systems Corporation. With the emergence of specialty clinical and departmental systems in the 1990s, a debate ensued between proponents of "open architecture" vs. "single vendor" systems. Although HL7 became the most widely used data-interchange protocol worldwide in healthcare, open architecture did not prevail in healthcare as it did in other industries. This is due to the unique market characteristics of the healthcare provider industry. The result today is the dominance of the healthcare IT marketplace by a small number of large vendors with relatively few options for in-depth specialty clinical systems.

The wave has finally broken: now what?

In 2005, the authors published a paper, 'Will the wave finally break? A brief view of the adoption of electronic medical records in the United States', which predicted that rapid adoption of electronic health records (EHR) would occur in the next 5 years given appropriate incentives. The wave has finally broken with the stimulus of the health information technology for economic and clinical health legislation in 2009, and there have been both positive and negative developments in the ensuing years. The positive developments, among others described, are increased adoption of EHR, the emergence of a national network infrastructure and the recognition of clinical informatics as a medical specialty. Problems that still exist include, among others described, continued user interface problems, distrust of EHR-generated notes and an increased potential for fraud and abuse. It is anticipated that in the next 5 years there will be near universal EHR adoption, greater emphasis on standards and interoperability, greater involvement of Congress in health information technology (IT), breakthroughs in user interfaces, compelling online medical and IT education, both increased use of data analytics for personalized healthcare and a realization of the difficulties of this approach, a blurring of the distinction between EHR and telemedicine, a resurgence of computer-assisted diagnosis and the emergence of a 'continuously learning' healthcare system.

There is no neutral position on fraud!

In 2005, Dr David Brailer, our first National Coordinator for Health Information Technology, had a vision of widespread adoption of electronic health records connected through networks run by regional health-information organizations. An advisory panel recommended at that time that proactive fraud management functions be embedded in this emerging information infrastructure. This has not occurred. Currently, the agencies responsible for fraud need the assistance of the Office of the National Coordinator for Health Information Technology in order to most effectively manage the growing problem of fraud related to the adoption of electronic health records and health-information exchanges.

Consumer empowerment versus consumer populism in healthcare IT.

Institutions, providers, and informaticians now encourage healthcare consumers to take greater control of their own healthcare needs through improved health and wellness activities, internet-based education and support groups, and personal health records. The author believes that "untethering" all of these activities from provider-based record systems has introduced a form of unhealthy consumer populism. Conversely, integrating these activities in a coordinated manner can sustain both consumer empowerment and consumer well-being.

Crime and punishment. Can the NHIN reduce the cost of healthcare fraud?

In his 2004 State of the Union Address, President Bush called for the adoption of the electronic health record (EHR) to increase efficiency and improve the quality of healthcare. This system could reduce healthcare costs by 20 percent or more per year. Some of those savings would be attributed to a dramatic reduction in losses due to fraud. Though IT by itself cannot solve the problem of healthcare fraud, developing an interoperable National Health Information Network (NHIN) can provide a platform to implement real-time anti-fraud controls. In this paper we inventory the costs and benefits of fraud detection from the NHIN and conclude that such an infrastructure investment has the potential to produce significant national savings.