Tech

Congress Can’t Solve the EHR Interoperability Problem

Niam YaraghiRep. Mike Burgess (R-Texas) has released a draft bill entitled “ensuring interoperability of qualified electronic health records” in which interoperable (Electronic Health Records) EHRs are defined as those that do not block sending and receiving data to and from other EHRs and provide users with complete access to the captured medical data. The draft bill proposes that detailed methods to assess interoperability be defined by a “Charter Organization.” According to the draft bill, this Charter Organization shall consist of one member from each of the standard development organizations accredited by the American National Standards Institute and representatives that include healthcare providers, EHR vendors, and health insurers. To keep its certification after January 2018, an EHR vendor should comply with the definitions of the Charter Organization, publish API’s to enable data exchange with other EHRs and attest and demonstrate that it has not willfully interrupted data exchange with other EHRs. The draft bill suggests that the Inspector General of HHS shall have the authority to investigate both EHR vendors and medical providers with regards to claims that they have interrupted interoperability.

The proposed Charter Organization will not be successful.

The language in the draft bill abandons the traditional approach of focusing on standards and instead is pushing for establishing methods and measures for assessing the level of interoperability in EHRs. However, it is not clear if the proposed charter organization would be able to come-up with such measures. As I have discussed before, some EHR vendors, along with many other medical providers are reluctant to become interoperable and exchange medical information.

It is unclear how vendors and medical providers with diverse interests can work together and come-up with actionable measures of interoperability.

Decertification is not good policy

It is exciting that Congress has finally acknowledged that some medical providers do not want to share their patients records even if there are no technical barriers to interoperability. According to the draft bill, if it is determined that a medical provider has willingly refused to exchange health information with other medical providers, it should be subject to penalties under provisions of sections 11281128A, and 1128B of the Social Security Act. While these penalties will probably prohibit the medical providers to intentionally withhold data, they may not apply to the EHR vendors. The threat of decertification is a bluff. ONC cannot decertify an EHR vendor that has more than 50 percent of the market share. In the best case scenario, after Congressional pressure, such vendors may enable data exchange, but will demand very high fees to overcome a plethora of technical barriers, especially if the EHR vendor has a monopoly in the market.

This is a complicated situation which I believe cannot be resolved through regulation. A better solution is to stop funding HITECH’s meaningful use incentives and avoid negotiating with the EHR vendors over the exchange fees. Without HITECH incentives, the market will force health IT vendors to develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.

Niam Yarhagi is a research fellow at the Brookings Institute’s Center for Technology Innovation.

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Ashank HarlalkaDavid Do, MDBethany V. Recent comment authors
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ParthDalal

Hello all. I’m a 4th year medical student wanting to help solve the interoperability problem. Although it’s not a perfect fix, I’ve developed a software called FreeMyEHR that helps bridge the gap between different EHR brands. Please check out my website for more info. FreeMyEHR.com

Merle Bushkin
Guest

David, What if your patient arrived with all his/her records , and the application to manage them, on a flash drive which enabled you with two or three clicks to electronically search for and access specific records including complete progress notes, lab reports, etc.? And what if it also enabled you, with your patient’s permission, to download specific records from your patient’s other providers to your EMR system? Finally, what if it paid you to upload copies of your notes, etc., so your patient’s device was always up to date? Sounds to me like this would save you all kinds… Read more »

David Do, MD
Guest

I presume most people engaged in this discussion talk about interoperability in the context of sharing data between institutions to better coordinate care and avoid repeating tests. This is primarily a non-technical problem. If I request medical records for a patient, this costs me two phone calls, two faxes, and probably two hours. This makes it impractical given the patient volume, and it’s much easier to order a repeat test. The paper records I get in the end of the arduous process are a nuisance but are sufficient to take care of the patient. Having all the outside lab values… Read more »

Ashank Harlalka
Member

Greetings, We have created a platform which solves your problem. The records of the patient gets automatically uploaded by the partnered Health Care Service Providers under one log in ID. So, you don’t have to make phone calls or you don’t have to ask for faxes from the patients. You can view those documents if the patient wants you to view the documents since all the records will be by default locked and can only be visible if the patent unlocks it. The charges for this is also very reasonable which is approximately $2 p.a. As an introductory offer, we… Read more »

Bethany V.
Guest

Without interoperability, we can’t achieve the entire purpose of going digital with health care data. It’s not just between EHR vendors, either. Physicians, practices, and hospitals are using a multitude of available technology to not only help care for the patient, but to try to increase their productivity/organization/efficiency for the administrative side. The programs used to submit claims need to be able to link to EHRs without causing headache, mobile charge capture applications should be able to link, and there’s talk of whether or not wearables prescribed by physicians should upload latest data so the patient doesn’t keep having to… Read more »

Guest

Bethany – you can lead a horse to water….you cannot regulate behavior. Until the price of being a data island exceeds the cost of connecting, barriers will remain.

@BobbyGvegas
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Paul Slobodian
Guest

Attribution:

I am simply saying in a somewhat different way what Adrian Gropper MD said:

Merle Bushkin
Guest

Paul, Bravo! Your diagnosis of what ails Interoperability is spot on. Our primary, most important priority should be to give doctors access to their patients’ complete records at the point of care so they can deliver better, lower-cost care. Period. We can accomplish this today if we want to. All it will take is for ONC and HHS to abandon their Meaningful Use requirements which, though well intentioned, have made it impossible to achieve interoperability. This simple act would permit us to look for and adopt simpler solutions to achieving interoperability and would free hospital CIOs and execs to try… Read more »

Guest

Yes, the healthcare market has some dysfunctional characteristics to it that will hinder its ability to be truly market driven. But then again, do we really want healthcare to be a market-driven sector? That will raise a whole host of other issues, some not too pleasant to think about. My main point is: Prescriptive guidelines won’t work. What has proven to work are market-based incentives – this is what truly drives innovation. If we can move to a PHM model of care with associated incentives, there will be a need for interop, deeper clinician and patient engagement, etc. Healthcare orgs… Read more »

Paul Slobodian
Guest

The proper customers of a medical product like electronic health records should be doctors and patients! In the current system, Epic and its competitors serve two customer-masters: 1. The technocrats and social engineers who devised Hitech and ACA provisions. Their objective is a utopian system that allows monitoring and control of doctors and patients for population management and cost control. Many see this as a threatening dystopian world of surveillance and coercion (some combination of Orwell’s Big Brother and Kurbrick’s HAL). 2. Hospital system administrators who are fearful of falling out of compliance with federal regulations and want to take… Read more »

Guest

It always strikes me as a bit odd that everyone throws stones at the vendors, but few providers look closely at their own practices of sharing data with fellow providers. Both are to blame. Providers want to retain their customers/patients and the data therein as there is competitive value in it. Vendors have a vested interest in locking-in customers and nothing does a better job than that in software than locking up data. And I disagree with Yarhagi. stopping HITECH payments is like trying to saddle a horse after it left its stall an he ago. The train has already… Read more »

civisisus
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civisisus

The problem, John, is you are staring straight at market dysfunction, and deciding that “natural” market forces are the best solution for it.

Economics is not physics. The “natural” forces that drive it are forces we (“marketplace actors” – ugh, the terminology) bring to bear, not merely with dollar votes but with insistence on what behavioral standards will “well order” the market under consideration.

@BobbyGvegas
Guest

“Economics is not physics. The “natural” forces that drive it are forces we (“marketplace actors” – ugh, the terminology) bring to bear, not merely with dollar votes but with insistence on what behavioral standards will “well order” the market under consideration.”
__

Thank you.

Guest

Agree John – we’ve hit that point where “natural market forces” may be the last resort. Continuing to throw money at a problem the market participants do not uniformly want to solve is a zero sum game. Data sharing will occur when the “business” is at risk because it is disconnected or a data island. This will occur not as consumers embrace “interoperability”, or support providers that use interoperable software but as the management of their health becomes “convenient”. This will take the form of mobile apps, alternate points of care, financial incentives – simple easy to engage apps and… Read more »

Merle Bushkin
Guest

The way to achieve interoperability is to a avoid the problem and ignore EMR vendors. Give the patient control of her records and the ability to deliver them to any provider she sees anytime, anywhere. Couldn’t be simpler!

@Bill_McCann
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@Bill_McCann

There are always going to be unintended consequences. If you eliminate the HITECH incentives, you’ll likely trigger a wave of consolidation among EHR vendors which could impose not the best solution, but the most-profitable. While we may agree that less government interference can be a good thing, history has shown–from telecommunications to energy to even beverage manufacturers–that unregulated industries go through a Consolidation Curve that results in lower competition. I want to share a terrific article in the Harvard Business Review about this phenomenon (https://hbr.org/2002/12/the-consolidation-curve). So, while many industries benefit from consolidation, we have to wonder whether this makes sense… Read more »

Philip Lederer
Guest

Have other industries created a standard file format, and if so, how can healthcare learn from them?

@BobbyGvegas
Guest
William Palmer MD
Guest
William Palmer MD

Excellent argument, Adrian. I have a fear, however, that the privacy/security needs are going to outweigh the interoperability dictum and that hackers would tell us that universal EHR formats and software standards are going to make it easier for them to breech our PHI data. In other words, maybe it IS better to have a lot of software that doesn’t mix very well. Also, open software sounds nice, but take a look at distrowatch.com a website discussing all the linux versions. I have tried many of these and, although free, they are not often compatible. There are hundreds of programmers… Read more »

Adrian Gropper, MD
Guest

William, I’m not talking about security. Almost 100% of security software is already open source. That ship sailed years ago.

I’m talking about the clinical functions of EHRs: decision support, quality measures, summarization. Those things are Medicine and I can’t think of any part of Medicine that used to be secret before EHRs came on the scene.

steve
Guest
steve

Let me help you. If a patient had an echo or a cath (anything really) at our competitor network, I don’t have access to those records. Well, I do if I can wait for quite a while. In an emergency setting, even an urgent setting, I effectively have zero access.

Steve

Paul Slobodian
Guest

I think the vast majority of patients don’t care about interoperability and don’t care about electronic access to their records. The EHR incentives and penalties have little to do with most patients’ concerns…..and in aggregate to date have detracted from medical care quality….not enhanced it.

Adrian Gropper, MD
Guest

I agree, Paul. But, as Joe says above, physicians should be able to advertise that they do care about interoperability and that they don’t use secret software. I think patients will understand that.

Joe Flower
Guest

Everybody in healthcare claims that they are all about the patient. Interoperability is one of those fault lines that puts the lie to that claim. You are either truly building for real patient data transparency across all platforms, or you are not, building systems that only communicate with each other, and even that in a limited way, and in even more limited ways with other platforms — and then blaming the other vendors for the lack of real transparency. It’s one or the other. One of the two positions is clearly better for the patients and the actual clinicians working… Read more »

http://carebridgesolutions.com
Guest

Can EHR and transparency go hand in hand? Doesn’t one preclude the other?

Joe Flower
Guest

I am not sure what you mean, unless you are defining “transparency” in some other way than I am.

Your bank account, for instance, is private. When you do a bank transaction (say, an interbank transfer of funds), though, the information shows up at the other bank. Imagine what our banking system would be like if the banking software vendors had convinced each bank that it would be best if their software couldn’t talk to the software of other banks?