By Heather Seftel-Kirk, FedHealthIT Magazine Contributing Author; with Photos by Chris Spielmann

With the inauguration of Donald Trump scheduled to take place as this publication goes to press, many businesses and industries are abuzz with speculation about what the new administration will mean, what changes might be expected under the new leadership, and what promises, or challenges, 2017 will hold. The business of healthcare and those providing services to healthcare are among those waiting and watching, to see what, if any, shifts are to come.

I recently had the opportunity to speak with George Hou to get his insights. Hou is the Managing Director and National Account Manager for the Department of Veterans Affairs with InterSystems, a global leader in software for connected care and health data interoperability. Well over half of the hospitals and health systems in the U.S., as well as the Department of Veterans Affairs (VA), Defense Health, and Indian Health Service, manage their health data through InterSystems technology.

Hou hopes to see federal acquisition reform. Currently, federal IT acquisitions are geared towards a “build rather than buy” approach. This approach, according to Hou, often falls short of delivering what end-user communities actually need and can cost the government more time and money in the end. A new administration may signal changes to existing policies, Hou suggests.

“Under current acquisition policies, the way offers are scored, a product company may rate negatively – deficient or non-compliant – because they have a capability that is not exactly what the agency asks for. However, the product can be easily modified or configured to respond to the need without starting from scratch, reducing time to desired capability, risk of program failure, and development costs to the tax payers. An integrator who says they will build something scores neutral at worst, not deficient or non-compliant – even though they are starting with nothing.”

The result of this policy, he says, is that government often ends up investing valuable resources such as time, money, and people in research and development, starting from scratch to develop capabilities, and creating solutions that may or may not be adaptable or supported by organizations other than the company that developed the solution. In that scenario where government funds the R&D, the taxpayers bear the full brunt for the development and maintenance of those solutions. Instead, agencies and acquisition strategies should be focused on solutions that are modular, leverageable, and built on past successes, wherever they may be.

“Leveraging expertise from others is a universally proven approach. In the auto industry, for example, current offerings are the culmination of what each automaker does best, while relying on partner companies to provide the various components that make their offerings better. They don’t spend time developing and perfecting each small part of the vehicle, but instead take a modular approach where possible, pulling together the best capabilities or subcomponents from a variety of sources.”

He says the Digital Health Platform similarly has various components brought together through middleware, and having different components doesn’t mean the back-end systems won’t fit together.

“Integrators and agencies reduce their risk for delivering capabilities when they start with something that is partially or even mostly in line with what they are looking for and then contract out for specific unfulfilled needs – a subset of the whole – to achieve the full end result they seek.”

This approach takes collaboration, from within the agencies and with external companies or partners, and must include the end users as peer members of the overall team. In information technology, relying on commercial off-the-shelf (COTS) solutions that are proven in similar environments, ideally at scale, means that no one organization bears the brunt of the overall research and development costs, while mitigating risk from building an unsustainable “one off” solution. R&D costs in this model are amortized across all who license or acquire products from commercial industry. Conversely, if an agency contracts for services to develop a system, that one agency carries the burden of paying for all of the R&D for that solution. The benefit of not having one agency or company bear the burden of R&D costs is worth opening those doors.

Hou says building on what exists lets federal agencies start fast and grow fast, the best position to be in. But, he cautions, it calls for a different way of thinking, including a willingness to look to solutions that already exist and leveraging open architecture, which is a superset of open source options.

“COTS options are also a huge opportunity to reduce R&D costs, lower the risk of failure, and speed time to capability for those willing to keep an open mind.”

The Clinger Cohen Act, in conjunction with Office of Management & Budget (OMB) Raines rules governing federal agencies’ strategic investments in information technology, call for a buy-first approach. Only when solutions cannot be leveraged by other agencies or cost-effectively acquired should agencies be looking to fund development from scratch.

Another necessary component to ensure the future-proofing of new acquisitions is relying on industry standards and application program interfaces (APIs). These APIs, Hou says, provide governance at the technology level. When commercial providers adhere to the same standards and API sets as those who develop from scratch, whether they develop in open source or use proprietary technology with an open architecture, the result is a variety of alternatives that can satisfy the needs of agencies and commercial entities alike, making IT infrastructures interoperable because they are based on the same industry-accepted APIs and metadata standards.

“This strategy, although endorsed by law and governed by OMB, requires not only a change in acquisition approaches, but may also challenge the relationship between integrators who want to build applications and software publishers who have partial, if not complete, solutions. Often when integrators design and develop software and systems, documentation including the API sets and metadata standards are an afterthought. Open architecture uses guiding principles of following accepted industry standards and documenting the use of those standards at the points of demarcation, at the APIs, such that anyone has the ability to design, innovate, and deliver additional or enhanced capabilities. If what they have implemented needs to be augmented, upgraded, or replaced over time, a truly modular and extensible architecture eliminates the need to start from scratch, reducing risk of failure, time to capability, and cost.”

The advantages of adhering to API sets means specific offerings can be unplugged and plugged in as needed, creating a modular environment that supports starting and growing fast while keeping an eye on the end result. It isn’t technology for technology’s sake, but enabling users to improve the delivery of care, improve outcomes, and create overall business efficiencies.

“We use this strategy a lot at InterSystems. By looking at best practices, and taking components from products developed specifically for other clients – health data interoperability compliant with ONC guidelines, for instance – we can apply the effort that satisfies the need, and provide that solution to others without any one organization bearing the brunt of the R&D investment. Again, R&D is amortized across all users and not just one.”

Engineering principles are engineering principles. Whether applied to systems supporting the finance industry, manufacturing, or health information technology, understanding the function of subsystems or subroutines and governing at the edges – the APIs – is critical to successful delivery of systems while also providing the ability to evolve. In healthcare, IT happens to be more complex; health data has more than 60,000 data elements, each with its own data descriptors or metadata tags.

“InterSystems is focused on reducing the complexity of health IT for its clients,” Hou says.

Hou sees some agencies beginning to recognize the advantages of not starting from scratch. VA, he says, has moved toward a policy of establishing quick wins, or reduced time to capability, by leveraging a buy-first approach, largely thanks to guidance provided by LaVerne Council, the agency’s Assistant Secretary for Information and Technology and Chief Information Officer; Paul Tibbits, MD, Deputy CIO for Architecture Strategy & Design; and John Short, Director responsible for VistA Evolution.

“It’s been a slow start, but there has been a lot of talk about not starting from scratch, and we’re seeing several projects now coming forward with an interest in leveraging existing capabilities and past successes from industry where the needs are the same.”

The change is slow in coming, due in part to the challenges in changing basic premises and ways of thinking. He says 20 years ago, VA made sound decisions around technology selection and strategies for future-proofing. However, some of those policies had the unintended side effect of restricting innovation and advancements. Companies such as InterSystems have continued to evolve their software to meet the needs of commercial clients. Those needs are similar if not the same as VA’s needs now.

For example, under the Affordable Care Act (ACA) for commercial care delivery organizations, making patient data interoperable is a requirement under Meaningful Use 2. InterSystems provided the document exchange capability required under ACA, knowing that document exchange was not good enough. InterSystems focused on data exchange at the elemental level, with the appropriate metadata tags endorsed by industry and ONC, which provides the interoperability really needed in health IT.

“We are seeing further progress with the emergence and demand for the Fast Healthcare Interoperability Resources (FHIR) standard. Some of our own clients went on to build solutions based on the draft standard. When the recent Draft Standard for Trial Use 2 (DSTU2) for FHIR was signed, InterSystems released product within three weeks leveraging the standard. When clients heard of this, they asked how InterSystems could have accomplished FHIR DSTU2 compliance so quickly when evolving their home-grown solutions from the draft standard to DSTU2 was literally going to take them millions of dollars and more than a year of development? InterSystems was able to do so because it has always focused on data at the elemental level. It started with a strategic interoperability platform in mind, a platform that could literally be the core of VA’s Digital Health Platform.”

According to Hou, adhering to a document exchange convention is easy when all of the elements are already parsed out and tagged.

“Through the InterSystems approach, we reached the required capability for FHIR DSTU2 in weeks instead of months, and we anticipate the same when Standard for Trial Use 3 is approved.”

There have already been demonstrations of the opportunity and the potential available for modular approaches and collaboration in the global health information exchange arena. With the interchange of health data well beyond its infancy and now being adopted at all levels, the opportunities to really share and to plug in specific capabilities, as needed, has huge implications for citizens.

As an example, he cites the work of the New York eHealth Collaborative (NYeC) and the New York State Department of Health. Partnering with regional health information organizations and three health information exchange vendors to create the Statewide Health Information Network of New York (SHIN-NY), the effort connected providers at all levels for the purposes of improved emergency and ongoing care for more than 19 million citizens. If a patient presents in an emergency room in New York and does not remember all of the medications she is taking, providers in New York are able to pull all the active medications for the patient through the exchange. When the patient is discharged, her primary care physician can be alerted and can provide appropriate followup. The alerting mechanism alone has been shown to reduce emergency room readmissions within 24 hours by about 20%.

“This effort demonstrates that it isn’t just the exchange of information that is important, which is impressive enough, but the end state of improved care and better health outcomes for our citizens is the real value.”

This same potential – the ability to see the bigger picture, to utilize and analyze data at individual levels or on a population-based perspective – is available to government agencies like VA, as well as organizations in a variety of sectors.

“More and more agencies are seeing that data without context is meaningless. The holistic analysis which only comes with interoperable data, including context, needs to be there. Information must be shared across multitudes of systems and platforms, for all sectors. Think about the way intelligence agencies aggregate streams of data to understand its implications. True insight comes from many sources. Understanding the data’s context by understanding APIs and utilizing metadata is critical resulting in true information.”

He says there are a lot of positive changes happening within agencies such as VA, and “even more can be done.”

While the future of the government and the agencies under its direction yet remains unclear, Hou is confident about the future.

“I do hope the new administration will take a pragmatic approach and enforce buy-over-build thinking to reduce time to capability, reduce risk of program or project failure, and reduce cost to the tax payers.”


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