Despite the prospect of coming home with an updated gadget or smooth new ride, most consumers get sweaty palms when it’s time to think about making a big purchasing decision like renewing a cell phone contract or buying a car.
Endless paperwork, complex mathematics, dense paragraphs of fine print, and the ever-present threat of looking a bit foolish as a practiced salesperson glosses over some important detail make the process of haggling over contract terms an anxiety-inducting experience for the average shopper.
Buyers come in with their hackles up, intending to fight for every penny, and leave again feeling deflated, regretful, and a little bit cheated, certain that they must have missed some critical flaw that their adversary used to his advantage.
Purchasing an electronic health record or other health IT solution has often left providers feeling the very same way.
With billions of dollars in incentive payments up for grabs at the start of meaningful use, many healthcare organizations seized the chance to have the government pay for their EHR infrastructure, certain that they could handle the attestation requirements that would keep much-needed funding rolling in.
After all, with a relatively wide range of technology vendors in a market full of rapid innovation and limitless promise, organizations couldn’t possibly fail to find a product suite that would complement their existing efforts and set them up for continued growth during a time of turbulent transition.
Unfortunately, it doesn’t take too many conversations with providers to get the sense that many providers feel very strongly shortchanged by the EHR vendor community and its supposedly slippery ways.
Productivity losses, usability concerns, alarm fatigue, data blocking accusations, security concerns, and limited functionality have become depressingly commonplace complaints for a staggering number of providers – and that doesn’t even begin to address the vitriol reserved for CMS and the EHR Incentive Programs themselves.
At the root of all these grievances is a lack of health data interoperability.
Previously of little concern to fee-for-service organizations who had no reason to care about what was happening outside of their own health systems, interoperability has become a primary goal for providers who are anticipating the inescapable importance of actionable insights that will support the transition to value-based reimbursement and population health management.
Interoperability, or the capability to send data across health IT systems and receive it in a readable, usable manner, is the cornerstone of the industry’s efforts to ensure that patient information follows the individual across all of his or her interactions with the care continuum.
But the paths along which this data needs to travel are growing increasingly complex, and providers are notoriously short on resources to stretch any further than they are stretched already.
With so much to manage just to keep the doors open and the lights on, healthcare organizations have started to lean hard on the only part of the industry that still has more to give. Their vendors.
Slammed by Congress for what appears to be rampant information blocking, endlessly criticized by an industry in distress, and sneered at by clinicians who roll their eyes at the very notion that EHRs may actually be able to help them deliver higher quality care, the vendor community is very used to feeling as if it is chronically on the wrong side of that antagonistic negotiation table.
Jaded, weary, and frustrated providers may not be very interested in hearing the other side of the story, but EHR vendors are eager for the industry to hear them out.
There is too much misinformation floating around about juicy, incendiary topics like data blocking, argues Judy Faulkner, CEO of Epic Systems.
Cerner Corporation wants providers to know that interoperability is happening, and it’s happening now.
Allscripts has had its eye on APIs since before the Affordable Care Act, and athenahealth is working to make the cloud a secure foundation for seamless analytics and coordinated care.
Even Dr. David Kibbe, President and CEO of DirectTrust, who has skewered vendors in the past, thinks the notion of data blocking is much ado about very little.
Most importantly, there’s nothing adversarial about the way EHR vendors deal with their customers – or with each other, claims each and every executive.
Whether or not that is just a fairy tale for prospective clients is up to the individual to decide, but one thing seems very clear about the health IT development world: interoperability is no longer a nice-to-have showpiece. It has become a central tenet of every calculated move vendors are going to take from now on.
One big, happy, data-driven family
The annual HIMSS Conference and Exhibition is one of the healthcare industry’s biggest parties. In 2016, more than 40,000 attendees from every imaginable type of organization descended on Las Vegas.
For providers, it was an occasion to celebrate recent achievements, learn from their peers, get a glimpse into the future of the regulatory landscape, and browse the vast exhibit hall in an attempt to make more informed decisions about any big-ticket acquisitions on the horizon.
For vendors, it was a valuable opportunity to chat with new potential customers in an informal way, connecting a friendly face and a handshake to their latest and greatest product offerings.
And for journalists, it was a chance to sit down in person with some of the brightest minds in the business and try to get to the root of why there is so much tension, upset, and frustration in the provider-vendor relationship.
Across the board, the answers were nearly identical. We’re making health data interoperability happen, insisted every vendor. We know how important it is. We are not blocking data. We’re collaborating with our customers and with each other. We’re making progress.
“At Cerner, we think interoperability is not just the right thing to do. We are bold enough to say that we think it’s immoral not to,” stated the company’s Executive Strategist, Brian Carter.
“Our value doesn’t come from how much data we have, or even how we capture it. The market just wants to see how smart your insights are. So it doesn’t make any sense not to move data back and forth. And that’s exactly what we’re doing.”
Cerner, along with supposed arch-rival Epic Systems, joined a number of other prominent stakeholders to sign an HHS-led pledge to improve data interoperability.
The agreement, which Secretary Sylvia Burwell and National Coordinator for Health IT Karen DeSalvo touted as the biggest news to come out of the conference, binds its signees to adhere to three core principles of open, standards-based data exchange.
But the meat of the pledge is old news, said Epic CEO Judy Faulkner.
“It’s not a new thing at all,” she shrugged. “They got a bunch of the CEOs together in a meeting, and we pretty much all knew that we had already committed to these things already."
"It’s nice to have officially unveiled it, but it’s what everyone is already planning to do, which is the right thing to do: sending the data wherever the patient goes.”
Carter was similarly blasé about the commonly-held notion that EHR vendors are doing everything they can to maintain an unbreakable death grip on their clients’ data.
As for the vaunted rivalry between Cerner and Epic, two market leaders using every trick in the book to battle each other for high-dollar customers? Not even close to the truth, he asserted.
“If you went out to Cerner’s booth at HIMSS, we would be able to show you Cerner’s patient portal pulling Epic data,” he said. “You can go to the Epic booth and see Epic’s portal pulling Cerner data. It’s not just a pledge. You can see real software doing it right now.”
Drew Schiller, Chief Technology Officer at digital health company Validic, added his own anecdotal evidence to the notion that cooperation is the name of the game for anyone who’s anyone in the vendor space, including Epic and Cerner.
“I was at the White House for the Precision Medicine Initiative conference last month, and everyone was in the same room,” Schiller recalled. “Cerner was there; Epic was there – they were sitting right next to each other in the break-out sessions by choice.”
“I think this is an example of a new set of initiatives that is transcending the barriers of business. That’s what’s unique about healthcare. There’s a greater purpose for why we do what we do: our patients. So it’s really nice to see companies that are traditionally competitors in the marketplace working together for the common good.”
“If you sing loud enough, they’ll think the band is wrong”
Epic Systems is particularly sensitive about its reputation for snubbing the competition and keeping its secrets behind locked doors.
Faulkner avoids undue media attention in order to maintain her personal privacy, and historically, her company has not seen the need to behave much differently. With a thick portfolio of high-profile clients and a customer base that seems to grow primarily via the recommendations of peers, Epic enjoys undisputed dominance in the hospital market.
But such a giant can’t avoid the spotlight forever, especially when Congress is involved. The company has not come away unscathed from the Senate HELP Committee’s insistent questioning, during which Epic executives were grilled about data exchange fees and faced some Twitter taunting from competitors who lampooned the company's reluctance to pay its way into the CommonWell Health Alliance.
After Cerner defeated Epic for the multi-billion Department of Defense modernization contract, industry observers wondered aloud if Epic’s less-than-perfect interoperability reputation gave the Leidos Partnership for Defense Health an edge over the competition.
But rumors of Epic’s uncooperativeness are greatly exaggerated, Faulkner says.
“There’s a quote I like that says, ‘if you sing loud enough, they’ll think the band is wrong.’ And that goes to many of the stories you hear about Epic,” she said.
There’s no lack of hearsay surrounding the company. Attention-grabbing headlines about catastrophic financial failures due to implementations gone awry make the news on a fairly regular basis, but they do not often accurately portray the vendor’s role in installations that don’t go perfectly.
“We have never had a failure in our software,” she insisted. “We’ve never had a lawsuit. We have never had anyone just leave us because they were unhappy with the software. That’s after 37 years of being in business. Every once in a while, someone has a rocky start. But then they pull through.”
Source: Google Maps
Many implementation missteps have nothing to do with the vendor and everything to do with poor planning, inadequate project management, or divisions within the organizations itself, she added, but it’s easy just to point to vendors as the problem.
“Misinformation is hurtful to us as a vendor, and it’s hurtful to the customer who says it’s not accurate. And that’s not good for people who want to make a decision with full knowledge rather than skewed knowledge bent by people singing a song that is too loud and not accurate. It does hurt everybody when true facts are not available.”
The nuisance of information blocking
The infamous notion of information blocking, or purposely preventing data from moving freely across the care continuum, may be another unfortunately case of scapegoating, several other vendors said.
“The data blocking thing has always been very annoying,” said Erik Kins, Vice President of Innovation at Allscripts.
“We have always said that the data is not the competitive advantage. It’s not our data to begin with. We are stewards of the patient record, so we should do everything we can to make it available to the people who need it.”
Dr. Kibbe, President and CEO of DirectTrust, agrees that the uproar over information blocking may not match the reality of the situation.
“I think the issue is overblown,” he said.
“There are, without question, consumers of these products and services who feel like information is being blocked, and perception is really important. So it’s a good thing to recognize that there’s a problem, but we really need to define it and how to handle it.”
“I know that in the case of Direct exchange, sometimes consumers can’t do everything they want to do, so they perceive that someone is blocking them from doing it. But it’s not as conscious of an effort as some people might think it is.”
“There are technical difficulties. There are technical misunderstandings,” he acknowledged.
“But generally speaking, the vendors and other organizations who are participating in Direct exchange are trying really hard to make it work.”
Stanley Crane, Chief Information Officer at Allscripts, went one step further. He believes that the vendor community should no longer be using technical difficulties as an excuse not to exchange data on a broad scale.
“The target has moved. It’s no longer about if you have the technical capability to be interoperable. It’s about how many times you’ve done it.”
Allscripts is an old hand at the interoperability game, he added. “On December 24th, 2015, we hit one billion exchanges. Between 2013 and December of last year, we shared data through our API with our partners a billion times. We’ve crossed the 170 million mark already this year, and we’re on track to do another billion in 2016 alone.”
“It’s not about if we built it. It’s about how many people came. It doesn’t matter what type of wire you’re using or what color it is. Is it a FHIR-colored wire or is it some other color? It doesn’t matter. The only thing anyone cares about is how many times you do it.”
Allscripts may have made data exchange happen a billion times, but that achievement is dwarfed by the number of times interoperability should happen across the industry.
No matter how quickly vendors are working to increase their interoperability capabilities, patients still face health information exchange barriers each and every day, and their providers are still feeling cheated and hamstrung by vendor shortcomings.
"Is it a FHIR-colored wire or is it some other color? It doesn’t matter. The only thing anyone cares about is how many times you do it.”
“Vendors are getting punished by their customers, because the expectations around the ability to move data from one place to another are so strong now that vendors are having to respond to it,” Kibbe said.
“Even just a few years ago, their customers really didn’t want interoperability. But everything has changed, and the market is moving in response to it.”
Lawmakers are also trying to respond in a way that will light a major fire underneath developers. The threat of penalties is a strong motivator for the health IT industry, and recent legislation moved to the Senate floor includes the possibility of fines or other punishments if a vendor is convicted of information blocking practices.
The problem is that no one, including Congress, actually knows what “information blocking” means, argues Leslie Krigstein, Vice President of Congressional Affairs for CHIME.
“Congress likes to talk about data blocking, but there’s a lot of misunderstanding,” she said. “There is just so much gray area that it’s going to take a lot more than just a stand-alone bill and strengthening certification.”
“We’re going to have to think very carefully about exactly what data blocking is. What’s technical? What’s political? What’s business? What is malicious? What if your patients want one type of interface, but you don’t want to build it that way? Is that information blocking?"
"There are so many layers of the onion to peel back. I don’t think any of us know what data blocking is at this point.”
The HIMSS EHR Association (EHRA) made the same argument in October of 2015 in response to the April ONC information blocking report that kicked off the whole conversation. The report mentioned no names and gave no concrete examples of documented malicious business practices, yet vendors were still subject to widespread condemnation for something they may not actually be doing.
Like Dr. Kibbe, the EHRA acknowledged that the public is convinced that information blocking is a problem, and something must be done to address the issue. But they believe that unfortunate circumstances, rather than spite or greed, are to blame for any challenges that may crop up.
“In many cases, there is no intent to interfere, but rather a series of events that result in less data exchange than desired by some parties (e.g., conflicting provider business models, misalignment of objectives/priorities, lack of funding, limited infrastructure, etc.),” the Association said in a letter to the ONC.
“Any assessment of potential information blocking must be fact-based, given a specific situation, and include the perspectives of all stakeholders before declaring that information blocking has, in fact, occurred.”
That data doesn’t exist, the EHRA contested, because no one has defined what information blocking really means.
“We find, based on review of the report and subsequent policy discussions, that the concept of ‘information blocking’ is still very heterogeneous, mixing perception, descriptive, and normative issues in ways that are not easily untangled,” the letter concludes.
“As a result, this concept and ‘label’ does not provide a good basis yet for policy actions or enforcement, as it could encompass a broad range of actions, few of which are likely to warrant civil or other penalties.”
Kibbe agrees that talk of punishment for such a nebulous and hard-to-prove concept is premature and probably unnecessary.
“I don’t think there’s a need for federal legislation or regulation that pushes penalties,” he said. “It’s always reasonable to have consumer protection and oversight, but I think it can be done with a light hand.”
Shifting the focus back to the basics of EHR usability
Vendors may be eager enough to gloss over the data blocking argument, but they can’t ignore an even more fundamental problem with some of their EHR products: their usability – or lack thereof.
Usability concerns are perhaps even more pressing than insufficient interoperability. If providers can’t even get their EHRs to work the way they want to when inputting basic patient data, there seems little point in even thinking about what may or may not happen when external information is added to the pot.
Providers have been griping about usability since the beginning of the EHR Incentive Programs. Stage 1 of meaningful use was CMS’ way of cramming as much technology as possible into as many healthcare providers as they could reasonably reach, and many organizations have pointed to this mad dash philosophy as the root of their pain.
The rush to adopt EHRs left little time for deliberate, considered choices, they say, and the dangling lure of incentive payments made it impossible to do anything but grab at whatever sub-par technologies they could get their hands on.
And when CMS started to ratchet up the requirements in Stage 2 of meaningful use – and revamped the Certified EHR Technology (CEHRT) thresholds – the disappointments were compounded.
Many organizations scrambled to obtain new versions of software that would allow them to continue with the program. Tight deadlines and a laborious certification process made the beginning of Stage 2 a cringe-inducing time for the industry.
During the first attestation period, just four hospitals and fifty eligible professionals successfully met the challenging criteria. Seventy-two hospitals and six hundred EPs applied for hardship exceptions.
Since then, the EHR Incentive Programs have seen a number of slowdowns, extensions, exemption opportunities, and reductions in rigor just to ensure that the majority of good-faith participants have a shot of avoiding payment reductions.
Underlying EHR usability deficiencies aren’t the only reason why stakeholders started throwing confetti the moment Acting CMS Administrator Andy Slavitt hinted at the end of meaningful use as we know it, but the prospect of no longer being held to stringent – and some say pointless – reporting rules that make their daily tasks that much harder was too exciting not to celebrate.
The enthusiasm was a little premature. CMS was quick to clarify that meaningful use isn’t going anywhere.
It will look a little different in the future, as it merges into the Merit-Based Incentive Payment System (MIPS), but providers will still need to address their foundational usability concerns if they are to succeed with whatever quality measurement and reporting structures will develop under MACRA rules.
The vendor community wants to be there to help craft this next step towards the development of a seamless health IT ecosystem that supports providers and patients, but as frustrations mount to a fever pitch and data emerges showing that not all companies engage in optimal usability testing processes, they have had to carefully walk the line between offering mea culpas and urging providers to take responsibility for their own actions.
When asked if vendors get blamed too often for usability difficulties and implementation disasters, Faulkner set the stage with a discussion of the psychological theory of self-actualization.
“Maslow’s hierarchy of needs basically says you need to have food, warmth, and shelter before you can write poetry,” she explained. “It’s the same with an EHR implementation process.”
“If you don’t have that bottom layer of good software, then you’ll never have the rest. The next layer up is good implementation. But if you have good software and bad implementation, that won’t work, either. You’ve got to have both layers. There’s no other way around it.”
“If you have good software and a poor implementation, you can always redo the implementation. You can correct your problems and retrain people and redo some of your designs. You can’t redo the foundation as easily – you have to get rid of the EHR and bring in a new one – so it’s really important to get the software right the first time,” she acknowledged.
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Faulkner wasn’t the only one at HIMSS with Maslow on her mind. Todd Rothenhaus, MD, Chief Medical Officer at athenahealth, used exactly the same example to talk about the role of the EHR and its vendor in the modern healthcare organization.
“When the charts are all over the place or providers aren’t even doing the basic recommended minimum of care, you can’t build anything on top of that,” he said.
“What we try to do is help our clients with their lower-level Maslow needs so they can drive financial performance, clinical performance, and patient engagement.”
“Then they can learn from the data about what makes patients decide they want to sign up for the portal or adhere to their medications, and then start improving on their ability to encourage those positive behaviors.”
The vendor responsibility to make it work
Vendors don’t want their customers to view them as a one-and-done product provider. Instead, they are starting to take on more of a consulting role, recognizing that many healthcare organizations simply don’t have the depth of experience required to extract maximum value from an EHR right away.
"There is this problem of people learning best what they learn first."
In order to avoid taking the blame for a provider’s Maslow pyramid crumbling before it can get off the ground, vendors need to take a hands-on approach to helping organizations cultivate success, Faulkner says.
“I think the vendors have a responsibility to try to get providers back on track when they’re off track. To try to get them up to the latest and greatest; to look at the new designs we have coming out and help them replace their old designs. But it’s really hard.”
“Here’s an example. A number of years ago, I was helping a woman use the system, and she had a screen that she wanted to save without making any changes,” she recounted. “So instead of hitting the ‘next page’ button, she just hit the return key eleven times. I said, ‘Let me teach you a trick.’ And she just kind of froze, and she said, ‘Well thanks, but I’m used to this, but I’ll keep doing it this way.’”
“So there is this problem of people learning best what they learn first. And then they don’t move to the better things, which is painful for us. Because we know that once they get over the re-learning hurdle, they’ll be better off.”
“It’s the provider’s job to encourage their staff to do that, and then it’s our job, as the vendor, to keep it in each of our customers’ brain that we do keep coming out with better tools for usability, and to try to get that implemented,” Faulkner said.
It isn’t always easy to keep that process smooth and intuitive, especially as the provider landscape is shifting rapidly towards larger groups with more employed physicians, Rothenhaus added.
“Providers are moving into employment, and bigger organizations are rapidly acquiring these physicians,” he said. “But it’s almost like they’ve bought 1000 delis and are trying to make a Whole Foods out of it. It doesn’t work.”
“They don’t always have a very strong ability to create clean systems of care from these aggregated practices. The value proposition from an EHR vendor’s perspective is that we can help them streamline their processes and reengineer their systems.”
That type of help may be where the money is in the future, for both healthcare organizations and service-oriented consulting providers.
Outsourcing groups and consultancies are seeing a great deal of interest from providers who are so overwhelmed with the basics that they can’t extend themselves into more advanced areas of big data analytics, population health management, or revenue cycle management.
“The new philosophy is about leveling up what your EHR does,” said Tamara StClaire, Chief Innovation Officer of Commercial Healthcare for Xerox.
“With some of the new initiatives coming into play, like value-based care and patient engagement, we’re going to have to move to the next level.”
“But people don’t really know how they can tackle this. In a recent survey, we asked them where they need help. Is it with technology? Analytics? Services? Across the board, they just said ‘yes.’”
A little extra support can go a long way towards developing the competencies required to dive into risk-based reimbursements, another initiative that has sparked trepidation among providers.
CMS has set a high bar for the transition to accountable care, stating that 50 percent of current fee-for-service payments will become value-based by 2018, and private payers have embraced the same spirit.
Healthcare organizations are a little less eager to try to swap out their financial foundations while maintaining strong growth, especially since EHRs and complementary big data analytics technology products are not always as robust as they need to be.
“You need to be able to use your data to monitor these programs so that you can understand how to tweak them and achieve better results,” StClaire said. “That will give you the visibility you need to understand how to meet your financial and contractual obligations.”
The cleansing effect of FHIR
Despite the promises of value-based reimbursement to slash costs, improve outcomes, and overhaul care coordination, more data may just mean more problems – especially when the healthcare system is still struggling to define the data standards that will form the basis for streamlined interoperability.
The internet-based protocol masterminded by HL7 International is still a draft specification, but it has become the poster child for interoperability in a way no other standard has before.
"Eventually, we’re going to stop building the Swiss Army knife."
This is because it’s an idea that has already worked, says Stanley Crane of Allscripts. “The internet exploded when we all agreed on a protocol, and healthcare interoperability isn’t that different from the internet."
“In the old days, if you wanted to send email to someone who had an AOL account, you had to have an AOL account. You couldn’t send email from an AOL account to a CompuServe account, because they weren’t connected.”
“We agreed on a standard to use for sending email to AOL or Microsoft or CompuServe or any other provider, and that changed everything. FHIR is the same thing for healthcare. This is absolutely a huge step for us as an industry. It will at least start us down the path of agreeing on what the specifications will be. It’s a great first step.”
Along with rapidly growing interest in application programming interfaces (APIs), the burgeoning FHIR ecosystem could have a significant effect on the way EHRs are designed, and that could render most of the current objections about EHR usability and interoperability moot, Crane believes.
“The future of the EHR is going to look a lot like your phone,” he predicted. “How much time do you actually spend sitting in front of the Apple or Android interface as opposed to any number of apps written by third parties? How many people use an email client that isn’t written by Apple, or the Facebook app, or Twitter? Those weren’t written by Apple. Apple just provides the platform.”
“And I think that’s what EHRs are going to look like. Eventually, we’re going to stop building the Swiss Army knife, and we’re just going to have a basic platform with lots of little applets sitting on top of it."
"If you’re an anesthesiology nurse, you can have an anesthesiology set of tools you use, as opposed to configuring the Swiss Army knife in an increasingly complex fashion just to do what an anesthesiology nurse needs to do.”
Many of the major vendors, including Allscripts, are already promoting this type of application-based mentality. athenahealth launched its online marketplace back in 2013 to bring third-party development ideas to the table, and in November of 2015, Epic Systems teased the industry with a similar project by trademarking the phrase “App Orchard” for its eventual use.
And the Allscripts Developer Program has three thousand participants, Crane said, who develop apps that connect to the company’s products, expanding the potential toolkit for providers – and pushing Allscripts itself to constantly embrace innovation.
“Creativity is not going to always come from the halls of Allscripts. It's got to come from outside,” he stated.
“It shouldn't always be internal,” added his colleague Erik Kins. “It's incredibly arrogant for someone to think that they're always going to come up with the best solution to everything.”
StClaire also believes in the promise of APIs, and the possibilities inherent in the idea of bringing in fresh minds with new perspectives on chronic pain points for the industry, such as patient engagement.
“One of the things that is likely to happen with the new API model is that vendors will find innovative ways to come in and curate, aggregate, and generate insights for patients about what their data means,” she said.
“We may not even call the interfaces ‘patient portals’ any longer. They may become a more sophisticated way to serve up information, access unique insights, and take actions based on those tailored recommendations.”
“If we have this API infrastructure so that the data can actually flow, we should be able to have elements of personalization, flexibility, transparency, and real-time access that will completely change the dialogue between patients and stakeholders,” she said.
The potential is there, but FHIR has a long way to go before it is fully mature enough to support a completely new type of electronic health record, Dr. Kibbe points out.
“If FHIR is really tacked down, then it’s going to work,” he said. “But we don’t know that for sure. There are a lot of promises, and a lot of hope, and some very, very good people working on it. But realistically, we’re still several years away.”
It may take time, but APIs and applets could help resolve the basic conflict that makes providers so uncomfortable when it comes to renewing their contracts or signing a new deal with EHR vendors.
If they start investing in smaller, cheaper, more interoperable and more modular products that simply snap onto an interchangeable operating system, they can avoid that sense of buyer’s remorse that so often follows an unsuccessful commitment to a vendor that can’t deliver on expectations.
FHIR may be just the spark that the healthcare industry needs to turn providers and vendors into true partners for patient care, and it may help to reduce the amount of head-butting that characterizes so many current vendor-provider relationships.
As vendors embrace new technologies and a new outlook on their role in the EHR marketplace, and providers start taking advantage of new opportunities to retool their technology suites, interoperability may become less of an agonizing argument and more of a lesson in how to collaborate, innovate, and succeed in a deeply challenging environment.
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