Integration, Interoperability, and the Future of Healthcare

If there’s ever been a time for ensuring providers have access to the most accurate, connected data, it’s now.

Yes, healthcare organizations have successfully moved from paper filing systems to electronic health records (EHRs). But now, more than ever, we need a complete view of the patient to safely deliver care and promote the health of the population. How do we get there? The industry seems to have come to a consensus on the answer: through interoperable systems.

It wasn’t long ago we were shifting from paper to digital. Our ambitions grew as healthcare reached for a complete view of the patient, no matter where the data resided. Despite many incentives, data sharing advanced slowly. So, the U.S. Congress got on it, with the 21st Century Cures Act and its open APIs “without special effort.” The White House and CMS created the Promoting Interoperability incentive program and the MyHealthEData Initiative. And standards organizations and collaborations continued to promote standards adoption and advocate their use.

Salesforce and MuleSoft are a critical part of this effort, working diligently to provide the systems that can help organizations create a 360-degree view of the patient and foster a healthcare system that can attend to patient needs in real time — especially during a crisis like the COVID-19 pandemic or emerging situations such as the monkeypox virus. Interoperability is the brass ring in achieving these goals.

Competitive, cost, and security pressures are pushing us harder than ever toward an interoperability model. We see this come to life in the spate of recent megadeals, including Intermountain Healthcare and SCL Health's merger to create a larger Intermountain Healthcare, Advocate Aurora and Atrium Health's 67 hospital merger to form Advocate health, and Amazon buying One Medical. When healthcare organizations come together, so do their systems, creating an opportunity to gain insight from rapid aggregation. This all can lead more quickly to new strategies, products, and services. It also can lead to an invaluable source of truth for patient data — all of which will improve trust between providers and patients, and, ultimately, healthcare outcomes.

The initial phase of going digital helped create the EHR system. Now we aim to go beyond EHR, toward API-enabled, interoperable systems. Technology has advanced so much in the past decade, and with that, our Salesforce toolkit is so much more robust, with blockchain, advanced analytics, and, of course, CRM. They are not, however, all neatly packaged in the EHR.

At Salesforce, we see so many factors speeding us toward interoperability: the rise of value-based care and regulatory disruption, the accelerated creation of industry data and services, the need for virtual care, as well as the need to access modern digital capabilities. It’s all exciting but it will take time before interoperability becomes routine and patients can reasonably expect a consumer experience that is as convenient as ordering dinner online.

In this guide, we explore the need for interoperability in our healthcare system, the roadblocks preventing it from thriving, the interim steps we need to take, and the role of integration to provide that consumer experience that ultimately helps patients be more informed on their own healthcare journeys and lead a healthier life. Then we introduce you to industry pioneers who are paving the way for truly connected healthcare.

The U.S. healthcare system is a vast web of systems, applications, and data. The majority of hospitals and private practices have implemented an EHR of some kind, which is helpful, but most of these systems are completely separate, often from different EHR vendors that cannot talk to each other. This last of interoperability isn't just across separate healthcare organizations but can happen within the same health system as well with disparate systems that are locked in data silos. All this hampers care coordination and stands in the way of improving health. These shortcomings result from three challenges:

1.  Siloed patient data across clinical and nonclinical systems. This creates fragmented experiences and missed opportunities for preventative and total health. Yet, many IT decision makers are still at a loss on how to connect the data, despite recognizing the need to adopt interoperability in order to improve data quality and patient experiences. With this in mind, fewer than 40% of providers in the U.S. reported that they've managed to embrace interoperability to the point where they can perform it well enough to be able to share health data with other organizations.
2.  Legacy health IT proving incompatible with modern engagement technology. This delays efforts for digital transformation. In fact, 64% of IT leaders cite legacy infrastructure, processes, and tools as a top barrier to transformation.
3.  System connections that are driven by point needs for data. This results in a growing inventory of point-to-point integrations that are costly to maintain and don’t scale well enterprise wide. And with 75% of U.S. hospitals managing more than 10 EHRs, maintaining these connections becomes exponentially cumbersome. 

To truly achieve a complete view of the patient, healthcare organizations must be able to seamlessly connect with and act on data collected by the patients’ overall care team across multiple providers and do it in a secure way. And they must be able to preserve all the context that comes with the data. This is where interoperability shines.

Interoperability takes systems integration to the next level. As it matures, interoperability can use integrated connections to drive meaning across systems by giving context to the data. It does this by enabling information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated way within and across organizational, regional, and national boundaries.

Integration connects disparate systems but may not carry the context of the information it brings together. It performs a vital function, orchestrating multiple interfaces that support process automation. It also brings together component subsystems into one system, ensuring that they function together as a unit. Integration is the foundation for interoperability.

While many systems integrate, the data they share frequently lacks context. By contrast, interoperable systems can talk to each other in the same language — preserving meaning, without the added complexity or delay. Interoperability allows computer systems to transmit data with increasing sophistication.

Interoperability is the ultimate goal. But healthcare won’t reach it until the entire healthcare IT ecosystem can seamlessly connect and transmit all clinical and nonclinical information necessary to drive the most well-informed, best possible outcome for each patient. Until then integration will continue to evolve to a higher level as it aims for meaningful interoperability.

Discover how you can set up open, collaborative exchanges.

At Salesforce, we know an open, collaborative exchange of data is achievable. Our suite of solutions was designed to not only integrate, but to meet your increasing demands for interoperability. In applying these capabilities using the Salesforce family of products, we have a methodology that works to get the right data in the hands of the right people at the right time. With this, finding the right integration solution that puts you on the patient to interoperability can be broken down into four discovery steps:

1. What’s the use case?
   Understand the business context and assess your data, systems, direction, and timing.
2. What type of integration is needed? 
   Identify the integration layers across security, data, process, and application.
3. What’s the integration pathway?
   Select your integration approach. Will it be API-led? Where will you host your integrations? What kind of monitoring and run-time capabilities are necessary?
4. Should you do it alone or engage a partner?
   Assess your resources and make a decision between build and buy.

No matter what answers are best for your organization, Salesforce enables you with integration capabilities to help you establish a pathway that leads to frictionless connected experiences. This includes multi-layer integration capabilities, data models, open APIs, integration orchestration, and, of course, intra-Salesforce integrations — all on top of a secure, compliant platform.

For anyone in healthcare, Health Cloud provides the most complete view of the patient, member, or customer because it has been built with an eye to interoperability. As a result, it enables users to access critical clinical and nonclinical patient information across legacy systems. 

Using the capabilities identified above, interoperability between Health Cloud and external systems can be achieved at the back-end database level and user interface (UI) level. At the back-end level it would mean that data from an external system would be copied into Health Cloud. At the UI-only level the data would be presented in Health Cloud UI by pulling it in real time from the external system, also known as data virtualization. But it would never be stored in the back end.

For many, the most pressing need is to unlock real-time EHR data. The MuleSoft Anypoint Platform offers an elegant integration solution for Health Cloud, connecting any data, device, or application across both clinical and nonclinical IT systems. Combined with our new out-of-the-box Accelerator for Healthcare, developers have access to customer-validated, prebuilt APIs and integration templates to quickly and easily complete critical digital health IT. This includes integrating real-time Patient 360 data into Health Cloud, building FHIR APIs required by the new CMS and ONC interoperability rules, and more.

At the same time, we recognize that simply providing an API, template, or connector isn’t sufficient to advancing your integration — or interoperability — aspirations. Our drive toward end-to-end integrations starts with defining and understanding the use case, then using it to inform how we prioritize development through a multistep process:

1. Define the use case;
2. As needed, extend data models with fields necessary to accommodate the use case;
3. Where feasible, ensure fields’ definition align to the standard;
4. Create orchestrations from the destination system data model to the source system;
5. Design and build the end-to-end integrations.

End-to-end integrations will come over time. As business needs evolve, look for opportunities to enhance existing integration — that is, by streamlining orchestration or by building composite APIs — in order to ease the integration burden. 

By fitting together APIs, templates, and connectors, we can better forge your integration pathway. Comprehensive integration solutions like those offered by MuleSoft enable integration through a variety of exchange types. While each integration is unique, there are common patterns that can help solve for your integration needs. Below, each pattern describes the design and approach for a particular scenario rather than a specific implementation.

Core to reusing and scaling integrations is the application network; this integration approach is a new way of connecting applications, data, and devices through APIs that expose some or all their assets and data on the network. As a result, the network allows other consumers from other parts of the business to discover and reuse those assets. Modern APIs are fundamental to this approach as reusable building blocks that enable end-to-end connectivity. With built-in security and governance at every node, these pluggable, reusable building blocks support the fastest deployment, lowering your costs and helping you achieve true digital transformation.

Open APIs, orchestration services, and standards-based exchanges are the key to a unified platform for patient care.

As we continue on the path toward interoperability, we see three main areas of continued focus and investment: open APIs, orchestration services, and standards adoption.

Open APIs

At Salesforce, we launched our first API nearly 20 years ago and haven’t looked back since. We support API-enabled fields that can be used for synchronous or asynchronous flows and promote the foundational use of standards-based APIs like REST, SOAP, Bulk, OData, and streaming. As more organizations seek true interoperability, the need has grown for enterprise-scale API management capabilities in order to properly secure their endpoints.

Orchestration Services

We recognize the need to move away from point-to-point integrations toward enterprise reusability through modern orchestration that connects data, devices, and applications quickly through APIs. We also recognize the reality that integration can be messy and our AnyPoint Platform thrives on orchestrating data in a heterogeneous environment — from real-time APIs to processing batch files or event-driven messages. What we have learned, though, is that when unified data is used for purpose-built applications that are owned and managed by the business, you can stream more value and keep control closer to the end user.

Standards Adoption

For us to achieve our vision and to become the leading patient experience platform for synchronized care in all segments, we have invested in developing what healthcare providers need in order to convert legacy healthcare standards such as HL7 v2, C-CDA, and X12 into FHIR, including our MuleSoft FHIR RAML auto-generator. When organizations adopt standards these standards, only then can they deliver on the promise of connected, personalized, and holistic care.

As such, we will continue our adoption of FHIR R4 and United States Core Data for Interoperability (USCDI) to inform and guide our data models and define our FHIR APIs. We are also continuing to evaluate SMART on FHIR apps as another pathway to the EHR — and to better support life sciences companies.

Brands Making Strides in Interoperability

The COVID-19 pandemic disrupted some healthcare providers more than others. One thing became clear: anyone who had a connected, digital experience in place was better able to weather the pandemic. Patients needed questions answered. They clamored for virtual visits and Salesforce customers were able to stand up solutions in days. Employees needed to be able to work from home — and get a 360-degree view of patients. Salesforce users could do this, thanks to data integrations already available that provided the right information at the right time. Here are two stories of how Salesforce put users on the path to interoperability and helped patients achieve better outcomes.

MIMIT Health
MIMIT Health, a Chicago-based independent physician group specializing in minimally invasive and targeted treatments, is a leader in digital innovation. A Health Cloud customer, MIMIT integrates with a number of systems to continue adding value to the patient experience, while also advancing the overall interoperability solution. Before implementing Health Cloud, the company began with Service Cloud, where it realized the tremendous value of having EHR data integrated for increased patient engagement, scheduling, and care plans. MIMIT now integrates its EHR, Medstreaming LLC, with Salesforce using HL7:

• CCDA for clinical documentation around encounters

• ADT messaging for patient registry

• SIU messaging for appointments

Nebraska Medicine

Nebraska Medicine operates two hospitals and 39 specialty and primary care clinics throughout the state of Nebraska, with partial ownership in two rural hospitals outside their central hospital location, and a specialty hospital as well.

With these various locations with differing needs, this leading healthcare organization looked to Salesforce and MuleSoft for their interoperability work, both for their clinical and non-clinical systems. Currently, they use two core systems to manage patient care – Salesforce Health Cloud and EPIC, they took these systems, and working across Salesforce added MuleSoft to create a new API-led integration approach which enabled patient data to flow between both systems in real-time and keep their records accurate and up-to-date for patient data that was at staff fingertips when they needed it. More than 110 staff and contact center agents now use Health Cloud to update and create patient records, creating a 360-degree view of the patient across all systems and enhancing the quality of care.

With this, they utilized bi-directional sync between Epic and Health Cloud for real-time data feeds across: patient demographics, appointments, vaccinations, medications, guarantor and insurance information, admissions/discharge/transfer messages, and more.

Using Salesforce, teamed with the MuleSoft Accelerator for Healthcare, Nebraska Medicine has achieved a 150% increase in API consumption.

In this same regard, they have seen increased productivity and savings across their call center operations. In their first year working with Salesforce and MuleSoft for integration across Epic, Nebraska Med saw enhanced agent productivity that resulted in over $104K in realized savings, plus over $376K in realized savings from one call resolutions.

Now, they are taking this work across internal and external business solutions as they move forward with Salesforce.

The Future of Healthcare Is Interoperability

Interoperability is key to the healthcare community, and API-led connectivity and application network approaches are the paving stones to get there. As healthcare becomes more consumer-driven, the demand for connected experiences increases, creating more use cases for sophisticated, context-driven integration — true interoperability. MuleSoft and Health Cloud were designed to extend the value of your source systems, not only unlocking EHR clinical data across applications, but furthering collaboration to extend patient care for improved health outcomes. As we develop our capabilities with these goals in mind, we will continue to turn to the latest health data standards to further align with the industry and ensure a fully connected healthcare ecosystem. And, as always, we will continue to invest in our platform to make it even more open, trusted, and collaborative.