Is monopoly the solution for interoperability?
It's been a year since President Biden signed an executive order aiming to address market concentration and competition within a host of industries. Healthcare featured prominently in the list, with the president decrying the effects of hospital mergers and the continued high cost of prescription drugs. Very valid concerns, in my opinion, and issues that should be tackled not only by the executive branch but also the legislative one.
The premise of the executive order is that excessive market concentration, monopoly, and limited choice are bad. With this I wholeheartedly agree. But the question in my mind is: is this a concern within healthcare interoperability? In a way, we seem to have the opposite problem. As I argued in our last edition of Nonstop Interop, healthcare IT suffers from ailments such as fragmentation that make it difficult to exchange data. Could we see benefits to our pursuit of frictionless data exchange if the market were more condensed? Let's ponder.
Ground rules
First, let's be clear about the scope of this analysis. I'm examining this topic through the lens of interoperability in healthcare technology only; in no way does it apply to healthcare delivery, price transparency, pharmaceuticals, or the myriad other topics where reduced competition are real and relevant concerns.
In the subsequent paragraphs, I'm making an assumption that the market has solidified around one offering per type of software. So, imagine a monopoly for EHRs, for radiology and cardiology PACS, for lab information systems, etc., on top of which developers can build narrowly tailored apps. How we got to this point—whether through mergers and acquisitions, government action, or something else—isn't pertinent. It just matters that we are at the end state of one dominant player with no imminent threat of competition.
With the ground rules in place, let's re-examine the factors from our last post with an eye towards how greater market concentration could change the interoperability landscape.
Availability
Here I'm doubtful that greater consolidation will make interoperability easier. If anything, I would argue that having a single market participant would disincentivize offering greater integration options.
A software provider is first and foremost protective of its own usefulness and viability, so its goal is to elevate its product as a must-use tool rather than to debase it as a repository. Why go out on a limb and offer more integration choices when your customers have nowhere else to turn? Absent an external force, such as rules by a regulatory body, the dominant entity would have little reason to invest in greater interoperability.
Complexity
Even if there were high availability of integration options in a monopolized environment, there's no guarantee the complexity of integrations would be alleviated. On the one hand, having a single system and data model to align to would provide a level of consistency that is lacking today. For example, if you knew that all healthcare providers used the same version of athenahealth as their EHR, your integration decisions would become simpler.
The complexity of interoperability, however, is ultimately rooted in the complexities of culture and medicine. No buffet of software choices, or lack thereof, can eliminate this reality. In our imaginary ecosystem of monopolies, the data model of the EHR likely won't be perfectly complementary to the data model of the LIS, which in turn won't be perfectly complementary to the data model of inventory management system. Thus, interoperability will still face a mountain of complexity to climb.
Fragmentation
When I began writing this post, I had high hopes that monopolies could at least solve the fragmentation problem. A single source system for all to tap into—how much better can it get for interoperability? Much better, actually.
The sticky and unavoidable problem in healthcare is that patients don't carry their data with them. The healthcare provider owns the software and the data within it, and they typically only know what happens within their four walls. In IT speak, this is the dreaded problem of every provider having its own software instance. Even with a single ubiquitous system, nothing prevents a patient from having a different health record across multiple instances, and an app developer has to be aware of and connected to each of those instances in order to gain a complete picture of the patient's health.
A road not yet traveled
This post's title is admittedly a bit gimmicky. It's obvious in my mind that monopoly would be terrible for practically anything, healthcare interoperability included. Monopoly of software would not solve the major challenges of interoperability, and there are factors such as cost, choice, and innovation that make monopolies detrimental to our economy and our lives. But while market concentration may not be beneficial, could data concentration perhaps be a win for interoperability? I'll leave that question for exploration in a future post.
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