With all of the advancements in healthcare IT, there’s still a huge divide between the wide array of EHRs systems that prevent patient data from flowing seamlessly and securely from provider to provider. Compounding the problem, the other key systems that make healthcare work for providers and patients alike – from practice management to billing to appointment setting and reminders – can’t always interoperate with EHR/EMR solutions.

Kevin Montgomery, Chief Technology Officer of Relatient, gave us his view on the current state of digital integration, what might be changing for the better, and why, in 2019, we’re still faxing patient records.

HITD: What’s the biggest obstacle to getting the most out of these digital tools?

KM: A lot of the challenges we see as “workflow alignment training” — how the EHR fits into the provider’s routine and how it affects operational flows in the office should be an area that is properly vetted out. Let’s face it, health care is extremely busy. The path of least resistance is often followed, but the path may be chosen because of the level of understanding of the EHR by the users; it may not be the most efficient use of the system.

The big question is, “Am I able to access the data that I need to make decisions in a fast and effective manner?” I’ll give you a good example. I recently read an article about a health system that my family visits that had added some clinical tools to make searching through the patient record easier. We walked into an exam room and I noticed that there was a sign on the workstation that indicated that it was enabled for this new tool. During the course of the visit, the provider was trying to find a lab value for our prior year.

They were having difficulty finding it, to the point where they were getting noticeably frustrated. The answer on how to find this was right there in front of them. Either they just didn’t know how to use it or got caught up in past workflows of sorting through pages of clinical notes to find it. This really sheds light on the challenges they are facing trying to integrate technology into their day.

The other challenge we see is integration between systems. Interoperability has been talked about for years. It’s like we’re searching for the Holy Grail. We keep looking for ways to streamline integration between systems. HL7 API, now FHIR, are all out at the forefront of the conversation. We’re still at the mercy of the EHR vendors’ interpretation and implementation of these methodologies to get the data that we need.

A good example of this is billing data. Our MDpay platform is used to send messages to patients, post-insurance adjudication, to let them know that they have a balance due and give them a link to pay online. Our largest challenge today is pulling and the Accounts Receivable balance for all open charges. As bad as that sounds, PM systems are not really designed to be accounting systems.

In the normal workflow of a practice, you’re dealing with patients on a one-on-one, so it’s easy to go into Kevin Montgomery’s file and see how much he owes. But it’s often challenging to get a report of all patients with balances. You can easily find a report to some degree that provides this data. This is a point-in-time value, not a transactional value that can flow across HL7 between systems.

Most vendors haven’t provided a way to efficiently pull this through an API call. They tend to have this information available for single patient lookups, not querying a wide variety of data. FHIR should accommodate this, but few vendors have fully adopted it and they may or may not have implemented that portion of the FHIR API.

Even though we’re moving forward with technology integration, we still may be making the same mistakes of the past of not having all the data available. You need to seek out vendors that understand these challenges and have demonstrated experience in integration.

HITD: As you said, each of these vendors seems to be doing their own interpretation of the standards. But what if you want to add a capability or if there’s changes in patient demands or in regulations? Are these closed ecosystems that can’t be easily adapted?

KM: Each vendor is different in their thinking on “open-versus-closed ecosystem.” EHR vendors are focused on their core business, that’s a given. They’re fighting for revenue in a saturated market. Some of them embrace the idea of a vendor marketplace. They’re monetizing on their API integrations by giving vendors API access to the data. This allows their customers to select advanced tools going forward that accomplishes operational clinical goals.

Some vendors are not offering this today. They may want to, but it’s competing for space on the roadmap with other core features. The important thing to remember here is that, though there are many tools out there to meet patient demands, you really need do long-term strategic planning. Committing to a single tool today may not work well or integrate with another tool in the future.

We’re really hearing from the market that practices want more vendor consolidation. Early on, there are fewer vendors with depth across multiple products and it was a challenge to put in multiple tools and to get them to work cohesively. Now, you have vendors, such as Relatient, that have a larger product offering that can help facilitate more tools with a single vendor. It’s the “one throat to choke” philosophy.

For us, this came about from our customers asking us for more tools because they liked working with us, knew we could integrate, and really just didn’t want to get through another vendor selection process. We see ourselves as a partner not just a vendor. I’ve often had discussions with customers on how to accomplish goals and how to make it work seamlessly for their practice.

HITD: This walled garden approach is something we’ve seen in other areas of technology. What are the pluses and minuses of a closed ecosystem?

KM: Well, you’ve got to understand that some of these vendors are doing this for a reason — they’re the vendor of record, they’ve got a clinical record here and they have to adhere to regulatory standards. They have to make sure that whatever is going into that record has come in from a secure source that is properly documented, is properly logged in case there’s ever any compliance issues that come up. So, to an extent, they’ve closed their systems off for certain features. They did that years ago — it seemed like everybody was just dropping a hammer and saying, “We’re locking our systems, you’re not communicating with us.”.

Their customers got kind of frustrated because some of the tools that they had built weren’t as robust as some of the companies like ours that our core business was building these add-on tools. And so, we had more features and they wanted those features and they went back to the vendors and said, “Hey, you’ve got to give these guys a way to integrate.”

So, the vendors came back with, “Okay, we’re going to allow you to integrate, we’re going do it in this manner, whether it’s sending flat files, do an API, do an HL7, so that we can manage and maintain it.”

And, like I previously mentioned, they had to have a way to monetize on this, because they couldn’t add a whole lot more work if they weren’t gaining a lot more market share. There just wasn’t money to invest in building these. So, they decide to monetize it, to help them out with accommodating for supporting these tools.

So, what we’re starting to see is vendors are starting to open back up. You look at all the stuff that’s been coming out with Epic lately with the AppOrchard. It’s been in existence for quite some time, but they’ve really started talking heavily about it. You’ve got Cerner talking about their FHIR installation. You’ve got all these vendors that are now coming around saying, “Hey, we’ve got a handle on integration and we’re going to start opening our systems back up.”.

But, I think a lot of it has to come from a control perspective. They were concerned about the regulatory requirements, making sure that they weren’t getting in trouble for letting a vendor like us just go starting injecting information into their system without some kind of oversight. So, we’re starting to see that open back up. There are still vendors out there that have closed ecosystems. We run into those. We get leads in all the time for systems we haven’t heard, that are you know maybe a small regional system or it’s a specialized EHR system. And we reach out to them and it’s like, “Well, we’ve got everything, or we feel like our customers need and we’re not going to give you access to our data.” And, it’s really a preference on them accomplishing their goals and what their management feels is their path going forward.

I can tell you all the large EHR vendors are embracing this. They’re opening up their systems, they’re starting to build APIs, more of them are starting to gravitate to FHIR. It’s really starting to be hopeful that we’re going to, at some point, get to better integration across the board.

HITD: As patients go from provider to provider, whether they’re inside or outside of the same healthcare system, they need their records to follow them, and those records have to be up to the minute accurate. Otherwise, there’s a risk of unintended outcomes. What’s the key to making technology work for both providers and patients?

That’s always a challenge if you’re going to providers that are not connected, it’s always going to  be a challenge get your records. You can ask for the records and they can give you files, they can give you a CD. But, that doesn’t mean that the next provider you go to can ingest that CD.

I thought I was being clever one time — my wife was switching providers, and I got on the portal of the provider she was leaving and downloaded her CDA documents, which is an entire electronic record of her health care at that provider, and took it to next one and handed it to them and said, “Hey, you can just upload it in your system,” and they looked at me and said, “What are we supposed to do with this?” I knew what system they were on, so (I said),”You just go to her chart, hit “File/Import,” hit “CDA Import,” and pull it in. And they just kind of shook their head and said, “We don’t do that.” So, they had to call and get her other provider to fax all the records.

You know there’s a challenge out there. What we are seeing that’s a lot more interesting is before — years ago — there just wasn’t a whole lot of communication between them. They’d send faxes… We’re starting to see more health care organizations that are creating these relationships with private practices to try to integrate the data around them.

I’m in Cookeville, Tennessee and our hospital up here works really closely with Vanderbilt. If we had a scan in Cookeville that went to Vanderbilt, Vanderbilt would want to re scan with their equipment, because the format that was coming from Cookeville just wasn’t compatible. Now, I can go to Vanderbilt and Cookeville can pull up their images. If I go to Cookeville and want to get something done to go to Vanderbilt, they can access their images. So, we’re starting to see more of this across the board and this is all becoming because the vendors are a little bit more open about their integration methodologies now. And they understand that the patients need this. They understand that the providers need to get that data more quickly to give them better health care.

HITD: So, what can practices and providers do to turn the situation around?

KM: It’s really a clear definition of goals is always key. I talked about that in the last podcast, I’m going to continue talking about that going forward. Instead of just looking at one facet of your business and saying, “I need to accomplish this,” you need to look at an overall goal: “What am I trying to accomplish in the short term and long term?” I want to do X now and do Y in six months and Z in next year. How does that affect my clinical staff, my administrative staff, how does it affect the patients? Who am I going to align myself with to make sure this happens efficiently? It’s all about connecting with the right partner that can have these conversations with you. We do this all the time, from small practices to large health systems. You just have to really think through where you want to be. What do you want to offer out to your patients as far as engagement or tools for them to communicate with you in a meaningful way and then align yourself with a vendor, or really more of a partner, to get to get this done?

HITD: Any final thoughts for us?

KM: I think the big challenge today is, since we’re moving into a more dynamic ecosystem of data sharing, is starting to not worry about the data as much but worry about what the outcome needs to be, and then start looking at how do we backfill into that. We have these conversations with EHR vendors all the time, too. We’ve got some that are coming to us and wanting us to be betas for some of their APIs, and we’re having these discussions of ‘what features were you wanting to add.’ And so, we talk about those features and say, “Here’s what we’re seeing out of our customer base. They’re wanting these things. We want to be able to interact with the patient in this method.” And then we start going back and say, “Okay. how do we get the data to do that?”.

So, the conversation has really changed from ‘here’s what you got, make it work,’ to ‘what do you need to make your tools work better. And the EHR vendors are getting so much better about having those conversations today. So, I’m extremely hopeful about the future and how we’re going to be able to share data and accommodate all these different new tools and workflows and needs out of the medical community.