Wednesday, November 8, 2017

End of an Era For Academic Informatics: Demise of the Home-Grown EHR

Pick your cliche to describe a major event this past week: Another domino is falling. The dawn of a new era. The news that Vanderbilt University Medical Center, home to one of the most esteemed academic informatics programs in the country, is replacing its collection of home-grown and commercial electronic health record (EHR) systems with Epic shows that the era of the home-grown academic EHR is coming to a close.

Whatever cliche we wish to use, the change is real for academic informatics. One by one, many of the major academic informatics programs have sunset their home-grown EHRs in favor of commercial systems, including Partners Healthcare, Mayo Clinic, Intermountain Healthcare, and the Veteran’s Administration.

The enterprise EHR has become too complex for a single academic program to maintain. Academic informatics programs are great at fostering innovation in areas such as clinical decision support and re-use of clinical data. But they are less adept at managing the more mundane yet increasingly complex operations of hospitals and healthcare systems, such as the transmission of orders from the hospital ward to departmental (e.g., radiology or pathology) systems, the delivery of results back to clinicians, and the generation of bills for services. When compliance and security issues are added on top, it becomes untenable for academic programs to maintain.

Some in academic informatics lament this closing of an era. But ever the glass-half-full optimist, I do not necessarily view it as a bad thing. Now that EHR systems are mission-critical to healthcare delivery organizations and must be integrated with their myriad of other information systems, it is probably inappropriate for academic groups to develop and maintain them.

Fortunately, there are emerging tools for innovation on top of the mundane “plumbing” of the EHR. Probably the leading candidate to serve as such a platform is SMART on FHIR. A growing number of academic programs are using SMART on FHIR to innovate on top of commercial EHRs. Granted, some of the commercial EHR systems (e.g., Epic) currently support the Fast Health Interoperability Resources (FHIR) standard incompletely, but we can remember another cliche, which is the famous Wayne Gretzky quote of skating not to where the puck is, but where it will be going. As SMART on FHIR matures, I can envision it as a great platform for apps that read and write data from the EHR.

In some ways I liken the situation to the relationship between computer operating systems and academic computer science departments. Very few academic computer scientists do research on operating systems these days. Most academic computer scientists, just like the rest of us, use Windows, MacOS, Linux, iOS, and/or Android. Today’s modern operation systems are complex and require large companies to maintain. Most academic computer science research now occurs on top of those operating systems. There, academics can carry out their innovation knowing that the operating systems (to the best of their capabilities) can manage the data in files, connect to networks, and keep information secure.

This new environment should lead to new types of innovations in informatics, which take place on top of commercial EHRs, which may now be better viewed as the “operating system” that provides the foundational functionality upon which academic informatics innovators can build. This could be a boon to places like my institution, which never even had a home-grown EHR. We are certainly pursuing SMART on FHIR development with rigor going forward.

1 comment:

  1. Bill, great post

    I am one of those who laments the closing of the era. My career in informatics was inspired by the work of these academic pioneers, and I have never stopped learning from academic informatics. But whilst I agree that good informatics work can continue on top of commercial systems, I also do not believe EHRs have reached the "mundane plumbing" stage. The demise of at the home-grown EHR in the US was not because there is nothing left to discover, it was for financial and organisational reasons. There are still fundamental issues to solve and now these issues are largely in the hands of commercial vendors...

    ...Largely, but not entirely. Although some of the most famous and revered examples of homegrown EMHR have indeed retired, there are still those of us such as here at the Hong Kong Hospital Authority, where a different set of circumstances means that we continue to pursue the development of tightly integrated EHRs on an enterprise or national scale. Perhaps in the future the experience of these "independent" developers will be reflected in the products that the commercial vendors provide, even as the academic informaticians continue to inspire us with their work on SMART on FHIR and elsewhere.

    NT Cheung
    Hong Kong Hospital Authority