Much has been discussed in recent years about the “platformization” of healthcare, although it usually does not include a description of the technology involved. A platform approach facilitates collection of data that multiple individuals and entities can access based on agreements and permissions. The health information technology (HIT) designed to replace paper medical records is not flexible enough to anticipate multi-organizational collaboration or easy integration of data from other sources including data generated by patients into most electronic health records (EHRs) being used in the U.S. today. The anticipated use and benefits of AI will require high quality data, and a platform model can facilitate more complete, reliable and usable data compared to the data warehouse models that are currently used for data aggregation by the government, health care clearinghouses, and payers.
Better has documented its success over the last year in its yearly Mission report, Postmodern EHR: Transforming care at Europe’s leading healthcare institutions. Some in the U.S. wonder why there haven’t been more provider and even payer organizations that have taken advantage of this kind of technology. Comparing the European countries’ health organizations and financing schemes to those in the U.S. gives some insights into the potential success of these types of projects in this country.
In the U.S., there are several barriers to implementing a platform approach that make it impractical and unaffordable to take advantage of its benefits as compared to European providers. European governments in various countries and regions manage data platforms for multiple provider organizations, making it easier to use the same data at multiple providers and for various purposes. In the U.S., private organizations would have to do that, and even if they could agree on how to share data, it may mean multiple implementations with additional data sharing mechanisms.
In addition, providers in the U.S. are paid through enhanced reimbursements when they use certified electronic health records technology (“CEHRT”) that adds cost and complexity to developing/offering products. Vendors are busy designing technology to meet certification specifications rather than developing innovative products to meet clinicians’ specifications. If a platform system were to be used in the U.S., what components would need to be certified – the platform or each module component? How would that be managed across various provider, payer and government organizations?
The “covered entity” / “business associate” paradigm is also problematic. If you have a vendor-neutral platform, the most practical solution would require each app or module to have agreements for data use and disclosures as well as mechanisms for individual patient permissions and consents. If we want patients to contribute data, and if we want clinicians to access and use that data more easily, each vendor product would have to utilize a common data model enforced by the platform that would provide usable data to multiple administrative, clinician and patient users that, with organization and patient permission, may use the data for care, administrative purposes and research.
Some Better implementation examples from their publication
| Example | Issues in the U.S. |
| Karolinska University Hospital, a large health system in Sweden. Multiple EHRs are currently implemented.Tietoevry Care, an EHR and HIT vendor, is the contractor implementing the platform utilizing Better software.Utilizing openEHR standard is an important factor.Allowing organizations to create their own apps by the development processes can be controlled to reduce cost and project risks.Goal is to make data available for clinical care and research. | No example in the U.S. of having a vendor agnostic platform.The openEHR standard not utilized in this country.Would current regulatory rules support this kind of distributed data/care in this country? |
| University Hospital Basel, a large health system in Switzerland.A consortium led by OWT using Swisscom, x-tention and Better, with Swisscom implementing the platform.A commitment to using the openEHR standard.The past data warehouse (data collected from various systems) found not to deliver reliable data for clinical decision support, so using the platform approach to rectify that problem. | A large research-oriented system in this country may be able to implement this kind of approach.Would have to figure out some sort of agreement with its current EHR vendor(s) to map data from one system (or more) to the common data model.Would need to find a partner to configure, implement and manage an openEHR standards-based platform, including security. |
| OneLondon, platform for distributing a Universal Care Plan to be accessible to all health and care professionals across London.Also available in urgent care centers outside London via National Record Locator (NRL).Can be continuously co-created by any user in London.Displays via the London Care Record and primary care providers.A new specific use case has been developed to address sickle cell disease to allow access to a specific care plan when in a crisis. | This would require a state or region to implement this kind of program, and it may also require a new government or quasi-government entity to be formed.New regulations, or at least an exemption from some and agreement with one or more state governments to utilize different data sharing agreements, may be required. |
| Slovenian Ministry of Health manages the national demographic and operational data repository for Slovenia.Uses FHIR for demographic and status data, including:Patient, related person, practitioner, etc.Organization, location, etc.Care team, episode of care, coverage, consent.A dedicated FHIR profile developed for each resource.Reference data synchronization platform (RDSP), a FHIR based repository with data from population registries, healthcare insurance companies, national registry of healthcare organizations and workers, ministry of education and mapping authority.Uses openEHR for clinical data.Supports the Institute of Oncology Ljubljana.Clinical Data Repository (CDR) and Operational Data Repository (ODR).A unified patient record contains embedded clinical modules. | This kind of implementation would require a government deployment. |
Are there U.S. implementations that could be successful?
There are a few instances where the stars could align to allow this new approach to HIT to help implement better, less expensive clinical care and research. Here are a few possibilities and the considerations that would have to be involved:
- A specialty medical organization dedicated to research that aggregates data from multiple provider organizations.
- Design a data platform that will require a contracting organization to select the technology, set up technology and ensure regulatory compliance in the relevant jurisdictions.
- Determine data sharing relationships with applications that gather patient data.
- Write agreements and consents with patients and other provider and/or payer organizations involved.
- A large specialty medical practice that also engages in research or a large specialty practice that crosses state boundaries.
- Set up a data platform that will require a contracting organization to select the technology, set up technology and ensure regulatory compliance in the relevant jurisdictions.
- Determine data sharing relationships with applications that gather patient data.
- Write agreements and consents with patients and other organizations involved.
- Start with a specific use case and add more use cases, possibly with the goal of eventually replacing its stand-alone EHR.
- A large hospital or health system separating from an even larger organization.
- Figure out any possibility of utilizing the “parent” EHR temporarily, for months or over a year’s time.
- Set up a data platform that will require a contracting organization to select the technology, set up the technology and ensure regulatory compliance.
- Develop minimal viable product to carry out critical operations.
- Determine the needed data to carry on operations and figure out a mapping strategy to migrate to the data platform.
- A large public health organization. The data requirements may mean a less complicated path to getting a viable system in place. It will require technological resources and expertise in security and significant funding, but a pilot project may be able to attract that funding.
- A state or regional health authority. The platform would be implemented and managed by a separate organization, possibly a public-private partnership, under the jurisdiction of a government agency. It could be used by organizations and individuals based on rules developed by the organization.
In any case, it will be a challenge to get the first project operational in the United States.
Sandra Raup, R.D., J.D., M.P.H.
Sandra was a co-founder of CareFacts, Inc., an early EHR for home care, and Datuit, LLC, a health IT company that developed modern technology for healthcare. Datuit contributed to standards development with HL7, including early contributions to the FHIR standard. She began her healthcare career as a dietitian in nutrition support, where she accumulated extensive experience in care of patients with critical and chronic conditions. After more than 20 years in healthcare, she obtained degrees in law and public health. Throughout her career she has been involved in research and publications in journals and textbooks.
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