5 things to know about middleware in healthcare

Interoperability is on the minds and lips of most people in healthcare IT these days.

One of the cornerstones of the debate is how to make existing systems interoperable. What is called the "rip and replace" cost — the expense of taking out an existing EHR system to replace it with one that would be interoperable with other systems — is inhibitive to many hospitals actively looking for one.

However, other industry professionals have suggested adding an insulating layer to hospital IT systems, called middleware. It already exists in other industries, such as banking and retail, and exists in some sectors of healthcare: Surescripts, a national e-prescription software, is a type of middleware. Essentially, it is a padding layer between EHR systems that provides interoperability.

Donald Voltz, MD, a clinical anesthesiologist and medical director of the main operating room at Aultman Hospital in Canton, Ohio, advocates using middleware to alleviate the frustrations of many physicians as well as to encourage patient engagement. He works with San Jose-based middleware company Zoeticx, writing and speaking about interoperability issues.

"If we wait for an EHR platform to develop all of these capabilities, it's going to be a monstrosity of a software product," Dr. Voltz said. "I'm not trying to bash vendors, but for them to keep pushing on everything a physician or provider requests is not reasonable. Instead, we need another platform, and that platform [should be] able to expand as new technologies come."

Here are 5 things to know about middleware in healthcare.

1. Middleware acts as a go-between to provide interoperability. Essentially, when major EHR systems do not network, adding another application that draws records from that EHR and communicates through a middleman to facilitate the exchange of health information provides interoperability. Additionally, it saves physicians the step of having to convert the information into an interface, as most middleware platforms pull the data into a format that is easily transmissible. "The frustration and the problems that arise from the clinical side is that I still have to extract that [data] into a meaningful interface," Dr. Voltz said.

2. Middleware allows for more flexibility between departments. Specific departments in hospitals are interested in particular sets of patient information, says Thanh Tran, CEO and cofounder of Zoeticx. Instead of having to sort through the entirety of a patient's records stored on an overarching EHR system, middleware platforms allow different departments to draw from the EHR and organize the information quickly into a format that serves their needs best.

3. Middleware allows for connection with mobile devices. Middleware platforms are able to be transmitted to smartphones and other mobile devices, allowing for physicians to receive alerts with patient information. Dr. Voltz explains that providing mobile access can enhance efficiency in hospitals, eliminating the step where physicians must find a terminal, log in and review patient information before making a decision.

4. Middleware allows hospitals to adapt more gradually to new EHR functionality. To expect EHR vendors to provide all the functionality required to fully meet the ONC's interoperability standards by 2017 is unreasonable, Dr. Voltz says. The growth of middleware and software-as-a-service markets can help provide some of that functionality without the cost burden on providers and demands on EHRs. This is not new; a 2005 study published in Perspectives in Health Information Management suggested that middleware could help fill some of the gaps in the creation of a smooth digital system in healthcare.

5. Middleware can boost patient engagement. Approximately one-third of patients in the U.S. had access to a patient portal as of August 2014, according to a survey from Austin, Texas-based market research firm Software Advice. According to Mr. Tran, this is because patient portals frequently provide patients health information without any indication of what it means or what to do about it. A software that could draw information from a patient's medical record and process it into a readable, usable format could help engage patients to be more involved in their care, Mr. Tran said.



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