Is Interoperability a Pipe Dream?

Webinar

Featuring

UCSF

Description

Interoperability is often framed as a technology problem, but what about its impact on patient lives? These impacts can include unnecessary tests, repeat procedures, and even death.


It's been a tough challenge to tackle because systems refuse to communicate. Because they refuse, we need action and guidance as part of our overall healthcare policy.


Dr. Julia Adler-Milstein influences these federal polices and researches how interoperability impacts patient experiences and lives.


Let's learn from her work and discuss where we may be moving with interoperability:

  • What's in it for our patients and consumers
  • The state of interoperability today
  • Federal policy efforts to advance it
Julia Adler-Milstein

Julia Adler-Milstein

Professor
University of California, San Francisco

Chris Hemphill

VP, Applied AI & Growth
Actium Health

1

Transcript

Chris Hemphill (00:01):
All right. Hello Healthcare, welcome everybody to the latest in our series, Hello Healthcare Unplugged, where we have conversations with people that are leading research in the industry. So this is an extremely exciting topic, and we're really happy about the enthusiasm that everybody has been showing around coming together and discussing interoperability. To have this conversation, it's a major concern that we see around how systems communicate with each other, what kinds of experiences we can create as other market entrants, and as people's experience are defined by other industries, what kind of experience we can create for our patients. So we brought in Dr. Julia Adler-Milstein, her current role is Director of UCSF's Center for Clinical Informatics Improvement and Improvement Research, and that has her focusing on EMR usage on how systems connect with each other and how clinicians respond to that. So, Julia, just want to get a quick hello from you.

Julia Adler-Milstein (01:18):
Hello.

Chris Hemphill (01:20):
And with all the work that you've been doing, Julia, I thought that it would be a good idea to, in our conversation ahead of this call, we were talking about why the focus on interoperability, what this research is aimed on. I think that a lot of us get caught thinking ourselves as technologists, where our jobs are to move bit from point a to point B, but there's something deeper that I've seen in your research around connecting to some patient outcomes. So really, I wanted to hear from you, why you're interested and how you got started down this path researching interoperability?

Julia Adler-Milstein (02:00):
Yeah, absolutely. Well, thanks for that question. So I am really, really passionate about this topic and I think it's because it's such a pervasive issue. When I often give talks, I'll ask how many people in the room have experienced a gap in their information or missing information when they interact with the healthcare system, and almost always, everyone raises their hand. I mean, that's really striking right? That this to something that we all just see and experience all around us and our own interactions, and when you're at a really scary moment where something's wrong with you, or you have a loved one that's in the hospital, or making a transition to a skilled nursing home, and you know that, that information, that clinician might need to take best care of you or your loved one isn't there, I just think there's nothing more scary.

Julia Adler-Milstein (02:46):
So I really am motivated to help address this problem by thinking about the direct, tangible impact it will have on care. And frankly, it's something that I think the healthcare system should be doing much better than it is today, and I think we all need to help work towards making that happen.

Chris Hemphill (03:06):
Well Julie, I think that in that sentence alone, you just answered the question, that's the title of this webinar, which is, is interoperability a pipe dream? I think the answer's no. It sounds like you've devoted a lot of time and research into what might need to be done at the health system level, and at the federal level, and we're going to be digging deeper into what that framework looks like. So thank you for sharing that story and that background, and thank you for the folks that have logged in, you might have seen, even in the past presentations we've had in the past, where we discussed the difficulty that patients have navigating their care experiences, understanding what to do next, and it's clear that interoperability is a huge component down then.

Chris Hemphill (03:48):
While we dig deeper into the subject folks, you see me popping messages on the screen, hey, David, keep the messages coming, keep the comments and the concepts flowing. Julia, she agreed to come with us because she wants to be able to have a conversation with you all, who are directly affecting change or influencing within your own organizations.

Chris Hemphill (04:10):
If there are questions that you have, or stories that you want to share, that's why she's here, so we appreciate that and we appreciate your interactivity. So Julia, could you start us off by talking about your journey down this path of studying interoperability?

Julia Adler-Milstein (04:27):
Yeah, absolutely. I, in some ways, got lucky to fall into this topic early. I was frankly, just a couple years out of college, and I went to work for a research group within Partners HealthCare system in Boston, and this was a group that, this is before high tech, before really the modern day health IT era, and this relatively small group was trying to help the country see the value of widespread investment in digitization in the healthcare industry. And we wrote basically large reports on cost benefit analyses of, if the whole healthcare system moved to CPOE, Computerized Provider Order Entry, what would be the cost and what would be the value? And the first report I worked on there was, what would be the value of nationwide interoperability? And so, I got exposed to something I frankly knew nothing about.

Julia Adler-Milstein (05:19):
And as I read and learned more about out the potential value of, really, moving information across our healthcare system in a more efficient way, it almost became like, "I can't believe we're not doing this." I mean, the costs were substantial, but the benefits were just dramatically bigger. And so, it really motivated me to say, "Okay, well, now we've said, in theory, what the value would be, how do we actually start to work towards making that happen?" And so, I don't think at the time I realized that it would be so foundational to the rest of my career, but it's still the majority of what I think about and work on.

Chris Hemphill (05:56):
So you've had the opportunity to study interoperability long before it even became a buzzword?

Julia Adler-Milstein (06:03):
Definitely. Yep.

Chris Hemphill (06:04):
So, I want to hear it from you because the challenge that happens with buzzwords, is that definitions start becoming murky, that people start having different thoughts, and if we use that word over and over again, it might mean a different thing to a lot of the people on this call. So how would you define, at a very basic level? How should we be looking at what interoperability actually is? I just wanted to put that out before we get deeper into the conversation.

Julia Adler-Milstein (06:33):
Yeah. I'm so glad that you asked this question because frankly, I do think that people, when they use the term, they often mean very different things or they just mean a general notion and they don't actually think about, what does that mean in practice? And so, I think one of the things that oftentimes hampers progress is just that we haven't agreed on the definition or what it means. So, I think at the very highest level, the definition I like is, a notion of systems talking to systems. Moving information between two computer systems that doesn't require a human to be in the middle to make sense of what's being moved around, and I think what I like about that definition is it becomes clear that it just can happen, and it's so much more of an efficient, streamlined way.

Julia Adler-Milstein (07:19):
If you can send a summary of care record from one EHR to another, and you don't need a human in the middle to try to make sense of what information is there and what to do with it, that really is, I think, the core of interoperability. But the longer version of that is, it really has to do with, what data are we talking about moving, who is that data coming from, what is the format in which it is being transmitted, what are the data standards that are being used and how seamless is that integration? So some people will say, "oh, well, I can log into a hospital's portal and see the information that's in their EHR. Is that interoperability?" I think most people would say no, but some people would say, "well, you're still getting access to the information, so you're still doing a better job of allowing data to be at least viewed by a human eyeball."

Julia Adler-Milstein (08:18):
So again, that's why there's so many different ways in which it's happening today, in which information is being moved, shared, or viewed. Whether we lump all that in under the heading of interoperability or whether we really hold this notion of interoperability to a higher standard of computers doing all the work. That's why I think oftentimes our conversations can get muddled because we're not always clear about which definition or which bar of sophistication of information-sharing we're using.

Chris Hemphill (08:47):
That is a helpful way to think about it, is to break it up into bars of sophistication. Moving, and sharing and things like that, and viewing, so that opens up the door to more clear understanding so that maybe if, somebody brings up interoperability in a meeting or a conversation, it doesn't sound like somebody trying to boil the ocean entirely, there's different levels to be able to strive for.

Julia Adler-Milstein (09:10):
Yeah, absolutely. And again, I think part of it is just being clear and any given initiative of, what are we trying to get to here? I mean, in some cases, it can just be really powerful to say, "we want to be able to electronically receive a scan document." Again, I don't think most people would be like, "that's the ideal," but if you weren't getting those documents before, still better to get them than not to get them. So a lot of this is just incremental, just doing better than the current state.

Chris Hemphill (09:37):
So earlier in the conversation, we were talking about doing better than the current state, we're talking about what interoperability is. You framed it up at the beginning, about how it's extremely important to healthcare, and I think that we have the opportunity to go a little bit deeper in that, based on some research that you've done. It's great that you're up here to be able to talk about, not only what interoperability is, but what's at stake, because when you talked about identifying how patient outcomes might improve or how things might change. I'm wondering if you could go a little bit deeper into that, why, of interoperability and what you're seeing in terms of how that relates to patient outcomes.

Julia Adler-Milstein (10:22):
Yep, absolutely. So this is often where we'll talk about different use cases for interoperability and I think it's always useful just to start with the basic care coordination and clinical decision making one. So, a patient that's seen in two different health systems, if the provider at the second health system can't see the records or information from what was done at the first health system, it means they have an incomplete picture of that patient's medical history, they may not have critical test results or understand what medications that patient is taking. And so, that creates all sorts of risks for duplicative or redundant care, a medication error. So, I think a lot of the, at least, early work on interoperability was motivated by just trying to solve those types of problems and then the benefits, as you would expect, would be lower repeat lab testing, lower repeat imaging, and if you look to the data, that largely bores out.

Julia Adler-Milstein (11:26):
So when you see, which outcomes most often look better when places are interoperable, we do see that. We see lower levels of repeat testing, so that's I think, good news, but also what we would expect. It gets a little harder when we talk about some outcomes that are influenced by a lot of different factors so, is a patient less likely to be readmitted to a hospital, or is a patient more likely to have a shorter length of stay? So many things go into that, having access to the prior records is certainly a piece of it, but it's probably not the main driver. So that's where, some studies will show that things look better there when there's more interoperability, others don't, and a lot of it probably has to do with context, really understanding, what is the interoperability solution that's being studied, what kind of patient population is it being applied to? So that's where it's really hard to clearly draw a line between interoperability existing and outcomes getting better.

Chris Hemphill (12:32):
Yeah, and I could see that being a really difficult part of the research, is sussing out huge amounts of confounders, different things that could be impacting. Just curious about, I don't know if you can name names or anything like that, but what are some of your approaches to teasing out interoperability as that causal metric for improved outcomes?

Julia Adler-Milstein (13:00):
Yeah, no, it's a great question. So I think, partly, we would only expect interoperability to have an impact on outcomes if we know that the clinicians are actually using it, and it sounds silly, but we actually have quite a few studies that show that, even when those outside records are available electronically, oftentimes clinicians aren't looking at them. And there's all sorts of reasonable reasons for that like, they're busy and they already are trying to look at a lot of information. And so, to take the time to then also go find some outside record, maybe they don't have the time to do that or they might not even be aware like, within their EHR, they can find that outside data. Oftentimes, it's stored somewhere else because it's not that home institution's own data, so they'll configure it so that data exists separately, so they may not know that they could even go and get that.

Julia Adler-Milstein (13:53):
So what I usually start is, can we measure if this information is even being used, And then if it's being used, we can then move on to say, "okay, and then do we see that outcomes are getting better in the scenario, in which we actually know that the clinician looked at that outside data?" So some of the studies that we've done, have compared those scenarios of like, this is a patient, for which we know that a clinician reviewed an outside record, that was available in their EHR, versus, this is a scenario in which they didn't, or we know that they had to get a fax return of information. So that's how, frankly, we try to disentangle some of this, and it also just shows that we have a lot of work to do on that workflow integration piece. How do we make sure that, even when that information's available, it actually gets in front of a clinician to look at it, because if that doesn't happen, the rest of the benefits we know, won't be realized.

Chris Hemphill (14:49):
That's a really good point. Again, I said it earlier, we often make the mistake of thinking ourselves solely as technologists, but it's not just a patient experience that we should be focused on delivering, but also an experience where all these systems and all these great things that are in place for clinicians to help them improve outcomes, that has to be usable by them too. It has to be something that, yeah.

Julia Adler-Milstein (15:11):
And I just want to say that, I think that whole area of, what does good usability for interoperability look like, is very nascent, there's very little research that I think's trying to tackle that question, but yet it's critical. So I really hope if we have this conversation, five years from now, that we'll be able to point to a lot of research that says, "oh yes, we actually studied different approaches to user interface design that help bring together lots of different sources of records and put it in front of the clinician in a way that makes it easy for them to understand." Again, very, very little out there right now that tells us how to do that well.

Chris Hemphill (15:51):
We'd love to have that conversation five years from now, and a question just came in from Edward Lindahl, hey Edward, with regards to who's doing this well overall? We've been talking about it at a high level, but really, are there some organizations or groups that you can think of and point to, that are really knocking it out of the park, that other organizations might be able to research and study?

Julia Adler-Milstein (16:19):
Yeah, it's a great question, and I don't think that there is, what I would think of as, the organization that's really figured out how to do all of interoperability, but I think there's certainly organizations that have excelled at a certain component of it. So for example, and a lot of times I just want to say that this will sit with the networks, the approach to connectivity, that's allowing the interoperability to happen because a health system at the end of the day, usually, is going to use a network to connect to outside organizations and pull that data in. And so, a lot of what they're able to do depends on what that network supports. So we've seen, for example, some really sophisticated interoperability strategies around COVID and COVID reporting, and there are some states that have health information exchanges that have really invested in that.

Julia Adler-Milstein (17:15):
So, HSX in Pennsylvania, for example, have just been doing some research with them on some dashboards they've been building, where they're pulling together data from a bunch of different hospitals and physician practices for COVID, and then putting that into a really nice dashboard for their public health department. So I'd be like, "well, that's an example of that one solution that's being done well." I think that, as a vendor, I know there's been some controversy about some of their approaches to interoperability, but their Care Everywhere network is pretty vast and does a good job, in particular, of pulling together the information in a way that makes it easy for clinicians to see and review. They're doing more and more to improve that functionality.

Julia Adler-Milstein (18:05):
And so, for places that are on epic and where many of the other places they need to connect with are on epic, that's a pretty good and mature solution, and then there are other, again, different networks in different regions. So in Colorado, for example, the CORHIO, the Colorado Regional Health Information Organization, is probably the most advanced on sharing information between hospitals and skilled nursing facilities. So, I would point you there if that was where you really wanted to see an example of good information sharing, around that particular care transition. So again, I hope at some point, we'll find the place that could be the model that the rest of us work towards, but I think right now, different places have prioritized advancing interoperability in a given domain, and then worked to achieve that. So anyway, hopefully those three examples just give you a sense of different types of success around different use cases.

Chris Hemphill (19:05):
And those examples are good primers into some of the things we'll be talking about a little bit later, such as pragmatic approaches at the health system level, versus some of the things that you're seeing and influencing at the federal level. Speaking of the federal level, I like Jade Chase's comment down there around, we've seen this multi-billion dollar push for interoperability, but we still haven't seen it adopted widely, kind of the way you were describing.

Julia Adler-Milstein (19:35):
Yep. So I think it's a very fair criticism of the HITECH Act, and at the point in time that HITECH was passed, there was a sense of, first you put in the systems and then you connect them all together. And frankly, I think even the people who were in the administration at that point in time would say, "we really didn't appreciate how much harder you make that second piece of tying everything together if you don't think about it at the start." So I think where we are now, this notion of USCI, the core data for interoperability, what information needs to be shared using what standards and requiring the EHR systems can share that data. If that had been in place at the start of HITECH, and we had said on day one, "EHRs need to be capable of doing this."

Julia Adler-Milstein (20:27):
We would probably be a lot further along than we are today. So I think there was just an under-appreciation of how hard this problem was, and especially how hard it is, once everyone has systems in place and are already using their own standards for capturing and sharing that data. So I think you really do need the standardization there at the start, and we've learned that lesson the hard way, but I don't think it's a closed door, it just means that we're now having to spend a lot more time and effort than we expected to get that interoperability there. And the federal government's still really actively [inaudible 00:20:58] on this, they're not like, "oh well, we got it wrong. Sorry." The bulk of their efforts today, and as we've seen in subsequent legislation, they're really trying to get interoperability right. So, I think it's too bad that we didn't know that at the start, but at least we're still making progress.

Chris Hemphill (21:16):
So at the very beginning we had this issue of, "Hey, tell me what you want me to do." And overall, we got the big picture right, but then, tell me how to do it, that varied across the different stakeholders involved.

Julia Adler-Milstein (21:30):
Yeah, and I think the vendors were perhaps rightly. The whole timeline for HITECH was really, really accelerated because it was part of the stimulus bill, the goal was to get dollars out into the economy as quickly as possible. And so, there was the sense of, we need people to adopt the systems that we have today, we can't spend five years getting the systems to a level of plug-and-playness and then have everyone adopt them. So, I think it's just important to realize what the policy objectives were at that point in time, which was to stimulate the economy, and so that's, I think, what drove that accelerated timeline and, let's just adopt the systems we have and then work towards them being interoperable later. So again, we can always argue about whether that was right or wrong, but we often forget that HITECH was part of the Recovery and Reinvestment Act, not health reform.

Chris Hemphill (22:25):
So that feeds into another question. We were contemplating the impediments at a policy level, but are there any other, maybe organizational impediments that prevent interoperability from happening at a lot of these places?

Julia Adler-Milstein (22:42):
Yeah, that's a great question, and I have to say that, I do think a lot of it comes down to incentives. So, you can pick my health system or frankly, any other health system and say, "if interoperability is not at the top of your priority list, do you think you're really going to suffer? Is the bottom line of your organization going to suffer?" And the answer, frankly, is no. Maybe you'll leave some meaningful use dollars on the table if you don't adhere to meaningful use criteria, but I think there's just not a really strong business case for many organizations to put interoperability at the top of their priority list. As we shift to accountable care organizations and different approaches to value-based care, it certainly ups the incentive and interest to have a better picture of where the patients you're accountable for, are getting care and what kind of care they're getting.

Julia Adler-Milstein (23:37):
So that probably has nudged it up the priority list, but Fee-for-service is still dominant and frankly, what we talked about before, that interoperability helps you reduce redundant utilization, in a Fee-for-service model, that's just lost revenue for an organization. So we have to be really real about the financial incentives that are out there and for an average healthcare organization, we need them to feel like this is critical to their success as an organization, and it can't just be a nice to have. Again, I think that point often gets lost in many of these conversations, and when we get frustrated with the pace of change, it's like if we don't have really strong incentives, whether those are financial or if you think about the hospital readmissions reduction program, where basically Medicare is like, "we're not going to pay for readmissions that we think could have been avoided. We're not going to pay for hospital acquired infections."

Julia Adler-Milstein (24:32):
That really rocketed those issues to the top of a hospital or health system's priority list, because they knew if they didn't get that right, they are just going to lose a huge amount of money. And it was the right thing to do for patients too, which is important, but again, we have to be real, if your CFO is not on board with your investment, it's probably not going to happen. And I think interoperability has always been, frankly, a hard sell from a financial and business case perspective.

Chris Hemphill (25:04):
Well, earlier this year, you and a few other doctors put an article in Health Affairs, regarding pragmatic approaches to interoperability. And that got me really thinking, because if we look at it pragmatically, we break things into pieces. You were talking about the bars of sophistication a little bit earlier. So maybe interoperability becomes a boiled the ocean issue if it's presented to a CFO, but I'm wondering if, for some of the people on this call that might want to realize some of these improved outcomes that you were discussing earlier, what are some ways that we can overcome those organizational hurdles? Would you say that there's some pragmatic approaches that start getting pieces and parts of the issue at the very least, on the CFO radar?

Julia Adler-Milstein (25:55):
Yeah, no, absolutely. I think it's a great way to think about this because at the end of the day, even the notion of if you're like, "okay, we want to be interoperable by this time next year." What does that even mean? I think you have to pick what you want to do, do you want, for example, in an emergency department, to make sure that those clinicians have better access to records from the other health systems in your market or region? That will help you figure out who you need to connect to and what networks there are, will help you design your ed workflows around making sure that that information is presented to those ed clinicians in a way that they can actually have time to review.

Julia Adler-Milstein (26:41):
So maybe you're going to take certain key fields and make sure that those are the ones that are readily available and integrated. So I think, getting down to that nitty gritty of, what information do we want to put in front of who, when, will really focus the question and say, "okay, this is the interoperability use case that we want to tackle." I've gotten increasingly passionate about the hospital skilled nursing facility care transition, because the people who are going to skilled nursing facilities are often, the most sick and fragile and frail, and they have incredibly complicated care and care needs, that need to be conveyed to the skilled nursing facilities. And I think hospitals haven't done a great job, by and large, of really thinking about how to get that information to the sniff in a timely way, that facilitates that care transition.

Julia Adler-Milstein (27:31):
And so, if I could wave my wand and say, "hospitals, what should you spend your time working on?" I would spend time really thinking about how to do good interoperability with skilled nursing facilities and get them that information to support that care transition, and a lot of those patients end up bouncing back to the hospital's ed. And I think that you could work on that issue too, so that, how do you make sure that people who go to sniffs don't bounce back to the ed? That is my number one current top use case that I think is tackleable. If you, as you say, narrow down to some practical solutions that you could work with.

Chris Hemphill (28:10):
Interesting, and we could have a full conversation on that alone, that would be a very interesting subject to bring up. While we were going through that, thinking through some impediments and ways to cross over them, Laurel Skurko, actually reached out. Laurel, thank you for your comment, she's been a long term friend of the show, and of course, made the introduction between me and you. But it's a powerful question because when we talk about incentives, we also think about the competitive, the business dynamics among the Epics and Cerners of the world and things like that. How do you see that factoring in as a hurdle to interoperability?

Julia Adler-Milstein (28:55):
Yeah. So it's a great question again, and there was a really devoted policy initiative under 21st Century Cures, with moving towards application programming interfaces. That is essentially, forcing the vendors to open up their systems more and to do a better job of making data available, to support these interoperability use cases. And so, yes, I think prior to that, there were not strong incentives for vendors to be interoperable with each other, and I think that that set of regulations has really attempted to tackle that. Frankly, they're still getting phased in and adopted, and so whether they're going to succeed is an open question. But given that policy is a blunt instrument, I think they did a good job at trying to tackle some of these competitive business practices that were really impeding interoperability.

Julia Adler-Milstein (29:58):
And again, the best case scenario is that we create incentives for vendors to do a good job sharing information, so not just saying like, "we're now going to force you to open up your systems and having to pull them along and do the bare minimum." But to actually say, "you, vendor, will do better in the market, the more interoperable you are." So, how do we flip to those positive market dynamics where it's not just, I'm doing this to comply with the regs, but, I actually do better. I'll get new customers or my customers will be willing to pay more if I really have strong interoperability offerings and solutions. So that's, I think, the market dynamics that we really want to get to, where we still need to figure out what is the model that gets vendors to really say, "we want to invest in improving our products in this area."

Chris Hemphill (30:58):
Great. Yeah, that's another thing that I want to talk to you about in five years. This is really an experiment that's happening at this level, and it would answer so many different questions. If we can get this right for this particular interoperability use case, then it would kind of answer a lot of questions about how you can turn competition into collaboration.

Julia Adler-Milstein (31:22):
Exactly. Let's compete on the basis of good interoperability, let's not compete on the basis of hoarding and making data inaccessible.

Chris Hemphill (31:30):
Exciting. So that leads to another area that we touched on lightly. We talked about policy a little bit earlier, but I know that you've had some influence and some research at the policy level. Could you talk about some of the things that you're seeing at the federal level and what we might be expecting to see in the next one year to three years?

Julia Adler-Milstein (31:55):
Yeah, absolutely. I mean, I think COVID shown another spotlight on how important interoperability is in frankly, not just doctors and hospitals, but labs and public health agencies. So, it's really, I think in a helpful way, expanded the aperture on, when we talk about interoperability, who we need to be thinking about. And so, I think we're going to see a lot more progress in, what we might call the public health interoperability area, partly due to COVID and the fact that we were having trouble understanding how COVID was differentially impacting different types of populations, made us realize that we don't always capture and share in a great way, data on different patient demographics and other types of information that have important implications for equity and other types of issues about underserved populations.

Julia Adler-Milstein (32:54):
So I think we're going to see a big push around interoperability that expands data to include those types of demographic and other information, and I'm really excited about the potential that will unleash, for not just improving interoperability in general, but for allowing us to actually make interoperability and its potential benefits like, disproportionately help populations that have more fragmented care, or that otherwise might not be well served by our healthcare system. So I think those are two of the newer priorities, but overall, I think we have a really good regulatory process in place now, now that we have the API regulations kicking into effect, and now that we have this notion of US core data for interoperability that will continue to be expanded and updated over time, capturing a broader and broader set of the information that's in the EHR that has to be able to be accessed through an API.

Julia Adler-Milstein (33:49):
So in general, I feel like we're in a really good place, and I just hope the momentum continues. But in some ways, I hope that some of the activity shifts from the policy domain to the private sector and to companies and vendors and healthcare systems, and I think policy has done a lot to try to create the conditions for success and now it's time for the market, I hope, to pick it up and to work with these and to turn them into valuable solutions that impact everyday patients in everyday care.

Chris Hemphill (34:26):
Great. And Julia, I have to say that by clearly defining these various tiers of interoperability, by making these things, discussing how to approach it and think about it in a pragmatic and accessible way, that helps give hope to the pocket of people that you're talking to today. And it's hopeful hearing that you're going to be continuing these conversations in other venues and hopefully with us, again, maybe even sooner than five years, right?

Julia Adler-Milstein (34:56):
I hope so. It would be great if we're talking about it in a year, but it's actually quite hard because if you think about opening up the spigots and saying, "okay, now you clinicians can have access to every piece of data about this patient you're about to see." Most clinicians would be like, "that sounds terrifying." No way I can look at it and make sense of and understand that, so we have to be really thoughtful as we expand it, how we really make sure that it's the key information that still needs to get reviewed by a human, in a way that allows them to make a good decision. So going from too little information to too much information, isn't necessarily really getting us to a better place. We often say, the right information to the right person at the right time, and that's what we need to make progress towards.

Chris Hemphill (35:38):
Yeah. That's something that we focus on heavily, even looking at interoperability within the health system itself. Within a single institution, if there's too much information going to, anybody who's having interaction with a patient, then they're not going to be able to act on any of it. So with that, I ask the last question. Why we should be discussing this, what you'd want people to come away with first? Usually what I have as the last question, I ask it first, but even coming to the end of this and coming to a lot of the materials and things that you referenced here, are there any sources like, somebody gets a couple of hours this weekend, is there any article they should pick up or video they should watch, anything that you recommend?

Julia Adler-Milstein (36:25):
Ooh, it's a good question. This is such a complicated topic that, in some ways, there is no good primer on, where do you start? It's like, you can go so deep on the regulations and understanding what they're trying to do, and there's a lot of research out there. And so, even if you go to, for example, the journal of the American Medical Informatics Association, which is sort of our premiere journal in the informatics world, and search on interoperability. I mean, in the last year, you'd probably find 10 to 20 articles and they're all important, they all help us understand a different part of the problem, so I don't know. Maybe I'll end with a self-serving comment, which is that, I wrote a piece for NEJM Catalyst that was called, Moving Beyond the Interoperability Blame Game.

Julia Adler-Milstein (37:19):
And it was sort of my point of, how can we figure out how to just move together productively, and I asked different stakeholders to take different types of actions, so. Kind of feels weird to end with, you should go read something that I wrote, but when people say, "if I can only read one thing of yours, what'd you recommend?" But that's usually the one I point to, so I hope it's okay to end with that.

Chris Hemphill (37:44):
Definitely okay. We dropped a link to the Health Affairs article that I referenced earlier, and honestly, one of the big reasons I was excited about this conversation was seeing the papers that you have published in the past and what you're working on now. So, absolutely, if you didn't do it, then I would've. So yeah, extremely excited and thank you Terry, Melayna, [inaudible 00:38:10], Laurel, everybody, Shantae, David. It was so good hearing from you and hearing these perspectives and getting your questions on interoperability. For folks that want to keep in touch and hear Hello Healthcare, maybe on your phone or on YouTube or et cetera, you can watch all of our past videos on LinkedIn, or you can find Actium Health on YouTube and find it there.

Chris Hemphill (38:35):
Plus we do a biweekly podcast, our latest episode is Physician Relations: A Love Letter, I really recommend you go and listen to that episode this weekend. Next, we'll actually be coming out with an episode on Healthcare IT and its role in the patient relationship. So, Julia, this was a very good conversation, and for folks that want to continue to ask questions, is there a good way that they can reach out, get in touch?

Julia Adler-Milstein (39:03):
Yeah, absolutely. I mean, feel free. There's so many options today, but I'm on Twitter, LinkedIn, good old fashioned email also works, I guess. I just say, don't send me a fax.

Chris Hemphill (39:15):
All right, don't send me a fax, that's a great way to end the conversation on interoperability. Again, thank everybody for spending a little time with us, and again, you're able to access this conversation and share it on YouTube or across all channels, and our podcast. Melayna just dropped the hellohealthcare.com link, you can also access it on Apple, Spotify, or wherever you do your podcast.

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