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A Circular Chat On Healthcare Interoperability

Posted on September 6, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

About a week ago, a press release on health data interoperability came into my inbox. I read it over and shook my head. Then I pinged a health tech buddy for some help. This guy has seen it all, and I felt pretty confident that he would know whether there was any real news there.

And this is how our chat went.


“So you got another interoperability pitch from one of those groups. Is this the one that Cerner kicked off to spite Epic?” he asked me.

“No, this is the one that Epic and its buddies kicked off to spite Cerner,” I told him. “You know, health data exchange that can work for anyone that gets involved.”

“Do you mean a set of technical specs? Maybe that one that everyone seems to think is the next big hope for application-based data sharing? The one ONC seems to like.” he observed. “Or at least it did during the DeSalvo administration.”

“No, I mean the group working on a common technical approach to sharing health data securely,” I said. “You know, the one that lets doctors send data straight to another provider without digging into an EMR.”

“You mean that technology that supports underground currency trading? That one seems a little bit too raw to support health data trading,” he said.

“Maybe so. But I was talking about data-sharing standards adopted by an industry group trying to get everyone together under one roof,” I said. “It’s led by vendors but it claims to be serving the entire health IT world. Like a charity, though not very much.”

“Oh, I get it. You must be talking about the industry group that throws that humungous trade show each year.” he told me. “A friend wore through two pairs of wingtips on the trade show floor last year. And he hardly left his booth!”

“Actually, I was talking about a different industry group. You know, one that a few top vendors have created to promote their approach to interoperability.” I said. “Big footprint. Big hopes. Big claims about the future.”

“Oh yeah. You’re talking about that group Epic created to steal a move from Cerner.” he said.

“Um, sure. That must have been it,” I told him. “I’m sure that’s what I meant.”


OK, I made most of this up. You’ve got me. But it is a pretty accurate representation of how most conversations go when I try to figure out who has a chance of actually making interoperability happen. (Of course, I added some snark for laughs, but not much, believe it or not.)

Does this exchange sound familiar to anyone else?

And if it does, is it any wonder we don’t have interoperability in healthcare?

Smartphone Strategy May Cause Health Data Interoperability Problems

Posted on July 13, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Tonight I was out at my local electronics store looking over the latest in Samsung gear. While chatting with the salesman behind the Samsung counter, I picked up a wireless charging pad and asked what it cost. “Don’t bother,” he said. “That won’t work with your phone,” which happens to be a none-too-old Galaxy Note Edge.

New batteries? Same problem. I strongly suspect that the lovely VR gear, headset and smart watch on display suffer from the same limitations. And heaven knows that these devices wouldn’t work with products produced by other Android-compatible manufacturers.

Now, I am no communications industry expert. So I won’t hold forth on whether Samsung’s decision to create a network of proprietary devices is a smart strategy or not. Intuitively, my guess is that the giant manufacturer is making a mistake in trying to lock in customers this way, but I don’t have data upon which to base that claim.

But when it comes to health IT, it’s clearer to me how things might play out. And I’d argue that Samsung’s emerging strategy should generate concern among providers.

Interconnecting proprietary tech is far from new. In fact, Apple long ago won the battle to force its users onto its proprietary platform, and AFAIK, the computing and media giant has never back down from the stance, including where its telecommunications gear was concerned. But at least until recently, we’ve had interoperable Android phones and tablets to work with, which ran on a freely-available operating system that played nicely with other devices running the system.

But with the device maker moving away from “works on Android” to “works on Samsung Android devices,” the chain of interoperability is broken. This could lead to shifts in the telecommunications industry which don’t bode well for healthcare users.

On the surface, we are only looking at relatively petty IT concerns for HIT leaders, such as seeing to it that the Samsung user gets a Samsung charging pad. Like enterprises in other industries, health leaders will adapt to this inconvenience. But the problems don’t stop there.

If telecommunications manufacturers follow Samsung’s lead, and decide to add proprietary quirks to their devices, providers may pay the price. Depending on how these newly-proprietary devices are configured, and how they must be supported, it could become much harder to dig data out of them on an ongoing basis. That’s the last thing we need right now.

Not only that, what happens if proprietary differences between Android phones and tablets make it harder for them to communicate with medical devices, a tantalizing possibility which is just beginning to present itself? While we don’t yet know how devices such as infusion pumps to interoperate with mobile devices, nor the latter two with desktops, wearables and servers, we don’t want to close off options.

Bottom line, I may be crying wolf too soon, but these developments alarm me. I’d hate to see additional walls go up between various data sources, particularly before we even know what we can do with them.

No, The Market Can’t Solve Health Data Interoperability Problems

Posted on July 6, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

I seldom disagree with John Halamka, whose commentary on HIT generally strikes me as measured, sensible and well-grounded. But this time, Dr. Halamka, I’m afraid we’ll have to agree to disagree.

Dr. Halamka, chief information officer of Beth Israel Deaconess Medical Center and co-chair of the ONC’s Health IT Standards Committee, recently told Healthcare IT News that it’s time for ONC and other federal regulators to stop trying to regulate health data interoperability into existence.

“It’s time to return the agenda to the private sector in the clinician’s guide vendors reduce the products and services they want,” Halamka said. “We’re on the cusp of real breakthroughs in EHR usability and interoperability based on the new incentives for outcomes suggested by MACRA and MIPS. {T}he worst thing we could do it this time is to co-opt the private sector agenda more prescriptive regulations but EHR functionality, usability and quality measurement.”

Government regs could backfire

Don’t get me wrong — I certainly appreciate the sentiment. Government regulation of a dynamic goal like interoperability could certainly backfire spectacularly, if for no other reason than that technology evolves far more quickly than policy. Regulations could easily set approaches to interoperability in stone that become outmoded far too quickly.

Not only that, I sympathize with Halamka’s desire to let independent clinical organizations come together to figure out what their priorities are for health data sharing. Even if regulators hire the best, most insightful clinicians on the planet, they still won’t have quite the same perspective as those still working on the front lines every day. Hospitals and medical professionals are in a much better position to identify what data should be shared, how it should be shared and most importantly what they can accomplish with this data.

Nonetheless, it’s worth asking what the “private sector agenda” that Halamka cites is, actually. Is he referring to the goals of health IT vendors? Hospitals? Medical practices? Health plans? The dozens of standards and interoperability organization that exist, ranging from HL7 and FHIR to the CommonWell Health Alliance? CHIME? HIMSS? HIEs? To me, it looks like the private sector agenda is to avoid having one. At best, we might achieve the United Nations version of unity as an industry, but like that body it would be interesting but toothless.

Patients ready to snap

After many years of thought, I have come to believe that healthcare interoperability is far too important to leave to the undisciplined forces of the market. As things stand, patients like me are deeply affected by the inefficiencies and mistakes bred by the healthcare industry’ lack of interoperability — and we’re getting pretty tired of it. And readers, I guarantee that anyone who taps the healthcare system as frequently as I do feels the same way. We are on the verge of rebellion. Every time someone tells me they can’t get my records from a sister facility, we’re ready to snap.

So do I believe that government regulation is a wonderful thing? Certainly not. But after watching the HIT industry for about 20 years on health data sharing, I think it’s time for some central body to impose order on this chaos. And in such a fractured market as ours, no voluntary organization is going to have the clout to do so.

Sure, I’d love to think that providers could pressure vendors into coming up with solutions to this problem, but if they haven’t been able to do so yet, after spending a small nation’s GNP on EMRs, I doubt it’s going to happen. Rather than fighting it, let’s work together with the government and regulatory agencies to create a minimal data interoperability set everyone can live with. Any other way leads to madness.

When Providing a Health Service, the Infrastructure Behind the API is Equally Important

Posted on May 2, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

In my ongoing review of application programming interfaces (APIs) as a technical solution for offering rich and flexible services in health care, I recently ran into two companies who showed as much enthusiasm for their internal technologies behind the APIs as for the APIs themselves. APIs are no longer a novelty in health services, as they were just five years ago. As the field gets crowded, maintenance and performance take on more critical roles in offering a successful business–so let’s see how Orion Health and Mana Health back up their very different offerings.

Orion Health

This is a large analytics firm that has staked a a major claim in the White House’s Precision Medicine Initiative. Orion Health’s data platform, Amadeus, addresses population health management as well as “considering how they can better tailor care for each chronically ill individual,” as put by Dave Bennett, executive vice president for Product & Strategy. “We like to say that population health is the who and precision medicine is the how.” Thus, Amadeus can harmonize a huge variety of inputs, such as how many steps a patient takes each day at home, to prevent readmissions.

Orion Health has a cloud service, a capacity for handling huge data sets such as genomes, and a selection of tools for handling such varied sources as clinical, claims, pharmacy, genetic, and consumer device or other patient-generated data. Environmental and social data are currently being added. It has more than 90 million patient records in its systems worldwide.

Patient matching links up data sets from different providers. All this data is ingested, normalized, and made accessible through APIs to authorized parties. Customers can write their own applications, visualizations, and SQL queries. Amadeus is used by the Centers for Disease Control, and many hospitals join the chorus to submit data to the CDC.

So far, Orion Health resembles some other big initiatives that major companies in the health care space are offering. I covered services from Philips in a recent article, and another site talks about GE. Bennett says that Orion Health really distinguishes itself through the computing infrastructure that drives the analytics and data access.

Many companies use conventional relational database as their canonical data store. Relational databases are 1980s-era technology, unmatched in their robustness and sophistication in querying (through the SQL language), but becoming a bottleneck for the data sizes that health analytics deals with.

Over the past decade, every industry that needs to handle enormous, streaming sets of data has turned to a variety of data stores known collectively as NoSQL. Ironically, these are often conceptually simpler than SQL databases and have roots going much farther back in computing history (such as key/value stores). But these data stores let organizations run a critical subset of queries in real time over huge data sets. In addition, analytics are carried out by newer MapReduce algorithms and in-memory services such as Spark. As an added impetus for development, these new technologies are usually free and open source software.

Amadeus itself stores data in Cassandra, one of the most mature NoSQL data stores, and uses Spark for processing. According to Bennett, “Spark enables Amadeus to future proof healthcare organizations for long term innovation. Bringing data and analytics together in the cloud allows our customers to generate deeper insights efficiently and with increased relevancy, due to the rapidity of the analytics engine and the streaming of current data in Amadeus. All this can be done at a lower cost than traditional healthcare analytics that move the data from various data warehouses that are still siloed.” Elastic Search is also used. In short, the third-party tools used within Orion Health are ordinary and commonly found. It is simply modern in the same way as computing facilities in other industries–così fan tutte.

Mana Health

This company integrates device data into EHRs and other data stores. It achieved fame when it was chosen for the New York State patient portal. According to Raj Amin, co-founder and Executive Chairman, the company won over the judges with the convenient and slick tile concept in their user interface. Each tile could be clicked to reveal a deeper level of detail in the data. The company tries to serve clinicians, patients, and data analysts alike. Clients include HIEs, health systems, medical device manufacturers, insurers, and app developers.

Like Orion Health, Mana Health is very conscious of staying on the leading edge of technology. They are mobile-friendly and architect their solutions using microservices, a popular form of modular development that attempts to maximize flexibility in coding and deploying new services. On a lark, they developed a VR engine compatible with the Oculus Rift to showcase what can creatively be built on their API. Although this Rift project has no current uses, the development effort helps them stay flexible so that they can adapt to whatever new technologies come down the pike.

Because Mana Health developed their API some eighteen months ago, they pre-dated some newer approaches and standards. They plan to offer compatibility with emerging standards such as FHIR that see industry adoption. The company recently was announced as a partner in the Commonwell Alliance, a project formed by a wide selection of major EHR vendors to pursue interoperability.

To support machine learning, Mana Health stores data in an open source database called Neo4j. This is a very unusual technology called a graph database, whose history and purposes I described two years ago.

Graphs are familiar to anyone who has seen airline maps showing the flights between cities. Graphs are also common for showing social connections, such as your friends-of-friends on Facebook. In health care, as well, graphs are very useful tools. They show relationships, but in a very different way from relational databases. Graphs are better than relational databases at tracing connections between people or other entities. For instance, a team led by health IT expert Fred Trotter used Neo4J to store and query the data in DocGraph, linking primary care physicians to the specialists to which they refer patients.

In their unique ways, Mana Health and Orion Health follow trends in the computing industry and judiciously choose tools that offer new forms of access to data, while being proven in the field. Although commenters in health IT emphasize the importance of good user interfaces, infrastructure matters too.

Big EMR Vendors Agree To Interoperability Scheme

Posted on March 6, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

John’s Comment: See my coverage of the CommonWell announcement on EMR and HIPAA.

Could it be that real interoperability between vendors is on the way? Five big EMR vendors — including three hospital-oriented giants and two doctor-focused players — have come together during HIMSS to announce plans to create common standards for health data sharing, reports Forbes.

Cerner, McKesson, Allscripts, athenahealth and Greenway Medical Technologies have joined to create a new non-profit called the CommonWell Health Alliance. (As most wags have noted, Epic is conspicuously absent from the mix.)

The partners haven’t disclosed a lot of detail as to how they plan to achieve interoperability amongst themselves, but the scheme seems to rely on creating a unique national ID. “Without a national ID and the ability to create true data that can be safely and securely sent between individuals, we are going to introduce new systemic risk back into the system,” Neal Patterson, founder, chairman and chief executive of Cerner told Forbes.

Patterson, public citizen that he is, said that the CommonWell Alliance isn’t a commercial effort but “an obligation.”  That certainly sounds lovely, but with five hyper-competitive public companies forming up this effort, I’m skeptical to say the least. Besides, if it’s an obligation, why isn’t Epic so obligated?

John Halamka, Chief Information Officer of Beth Israel Deaconness Medical Center in Boston, has probably sniffed out more of partners’ true motivation. “They’re thinking of it as an enabler for new technologies,” Halamka suggests to Forbes, a move which can “raise the tide for all boats.”

Whether it raises any boats or not, creating interoperability links between these vendors certainly can’t hurt. After all, the more data sharing the better, particularly by major players with significant market share.

That being said, there’s still the matter of Epic being out of the picture, not to mention other major EMR players. How much of a practical difference the CommonWell Health Alliance can make is very much in question.