Integrating Data Across The Healthcare Continuum


Middleware integration software gains popularity as an interoperability slingshot

The lack of EHR interoperability continues to pose a serious threat to healthcare initiatives, according to a recent report published by the American Hospital Association (AHA) that discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability.1

The report notes that the exchange of health information is critical for the coordination of care.  When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.

HSM_062016_Final_p017Last year, ECRI Institute released a survey outlining the top 10 safety concerns for healthcare organizations in 2015.2  The second highest concern was incorrect or missing data in EHRs and other health IT systems caused by interoperability. For the second year in a row, EHR data is identified as a concern. 

The Partnership for Health IT Patient Safety, a branch of ECRI Institute, has released safe practice recommendations for using the copy and paste function in EHRs that can adversely affect patient safety, such as the use of copy and paste that can overpopulate data and make relevant information difficult to locate, according to the partnership’s announcement.3

Meanwhile, a survey of 68 accountable care organizations (ACOs) conducted by Premier, Inc. and the eHealth Initiative found that despite steep investments in health information technology (HIT), they still face interoperability challenges that make it difficult to integrate data across the healthcare continuum. The survey found that integrating data from out-of-network providers was the top HIT challenge for ACOs, cited by almost 80% of respondents. Nearly 70% reported high levels of difficulty integrating data from specialists, particularly those that are out-of-network.4

User Frustration

The Office of the National Coordinator for Health Information Technology (ONC) is asking the healthcare community for its thoughts on establishing metrics to determine if or to the extent to which electronic health records are interoperable. The push to achieve interoperability is in response to last year’s mandate by Congress, contained in the Medicare Access and CHIP Reauthorization Act (MACRA). Among provisions of that law is a requirement to achieve “widespread” interoperability of health information by the end of 2018. 

When it comes to how health information exchanges (HIEs) handle the challenges associated with interoperability, a recent Government Accountability Office report cites barriers such as insufficient health data standards, variations in state privacy rules, difficulty matching records, resources necessary to achieve interoperability goals, and the need for governance and trust among entities to facilitate sharing health information.5

In its annual interoperability survey of hospital and health system executives, physician administrators and payer organization IT leaders released in April 2016, Black Book Research found  growing HIE user frustration over the lack of standardization and readiness of unprepared providers and payers.6

Of hospitals and hospital systems, 63% report they are in the active stages of replacing their current HIE system while nearly 94% of payers surveyed intend to totally abandon their involvement with public HIEs.  Focused, private HIEs also mitigate the absence of a reliable Master Patient Index (MPI) and the continued lack of trust in the accuracy of current records exchange.6

Public HIEs and EHR-dependent HIEs were viewed by 79% of providers as disenfranchising payers from data exchange efforts and did not see payers as partners because of their own distinct data needs and revenue models. Progressive payers are moving rapidly into the pay-for-value new world order and require extensive data analytics capabilities and interoperability to launch accountable care initiatives.6 Those looking at touted standards such as Fast Healthcare Interoperability Resources (FIHR) point out that it is only capable of connecting one medical facility to another and requiring specific end point interfaces to even do that.  For every additional facility, a customized interface must be built.  At the end of the day, FIHR is really a point-to-point customized interface requiring extra steps and ties developers to specific hospitals or EHRs and without universal access.6

“Progressive FHIR standards can allow EHRs to talk to other EHRs should standard definitions develop on enough actionable data points as we enter a hectic period of HIE replacements, centering on the capabilities of open network  alliances, mobile EHR, middleware and population health analytics as possible answers to standard HIE,” says Doug Brown, managing partner, Black Book. “However, middleware is gaining popularity fast by hospitals using EHR-dependent HIE systems with extremely expensive custom development for data sharing outside the network.” 

IT Leaders act

To alleviate concerns of HIEs with poor connectivity outside their IDNs and hospital systems, interoperability middleware is also a fast-growing consideration, according to 16% of hospital systems IT leaders with EHR-dependent HIE grievances.6 Middleware software sits within the data pipeline and translates data from disparate EHRs, showing promise for private HIEs, particularly payer-centric enterprise models. It creates a business intelligence layer that provides information to all stakeholders in real time.

The global healthcare analytics market is projected to grow to $18.4 billion by 2020 and the need for that complex data will propel the interoperability needs of providers and payers.6 “The only way to accomplish that is robust bidirectional interoperability and that’s what will ultimately force comprehensive interoperability into reality, not government-scripted vendor pledges,” says Brown.

According to Black Book’s survey, 57% of providers also confirm their beliefs that the whole interoperability industry will evolve by leaps by 2018 if some basic issues are addressed, with or without a vendor pledge, Brown finds.6

Frost & Sullivan predict a lack of interoperability in healthcare IT and devices, along with a push from the Office of the National Coordinator for Health Information Technology, will lead to middleware, connectivity and application program interface platform vendors seeing a jump in their revenue.8


  1. Why Interoperability Matters.” American Hospital Association. Available at:
  2. ECRI Institute Announces Top 10 Health Technology Hazards for 2015.” ECRI Institute. Available at:
  3. Health IT Safety Collaborative Releases First Set of Safe Practices.” HIMSS 2016. Available at:
  4. The Evolving Nature of Accountable Care.” Premier, Inc. Available at:
  5. Electronic Health Records: Nonfederal Efforts to Help Achieve Health Information Interoperability.” GAO U.S. Government Accountability Office. Available at:
  6. 2016 Interoperability Survey. Black Book Market Research. Available at:
  7. Interoperability Pledge. The Office of the National Coordinator for Health Information Technology (ONC). Available at:
  8. 2016 Global Outlook for the Healthcare Industry. Frost & Sullivan. Available at:

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About Author

Donald Voltz, MD

Voltz is medical director of the main operating room, Department of Anesthesiology, Aultman Hospital, and assistant professor of anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.

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