Niam Yarhagi’s THCB piece, Congress Can’t Solve the EHR Interoperability Problem (March 21, 2015) raises excellent points with which I mainly agree. So why write a responding blog? Because I don’t agree with his solution.
To review: Dr. Yarhagi discusses a draft congressional bill that calls for the creation of a “Charter Organization” that “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.”
Four agreements: I agree with Dr. Yarhagi’s conclusion that the proposed charter organization will not succeed; I agree with his prediction that it won’t be able to develop useful interoperability measures (hint: these are the same vendors that have refused to cooperate for the past 30 years); I agree that the ONC or CMS will not decertify an EHR vendor that has over 50% of all American patients and providers; and I agree that there are some medical providers who intentionally refuse to share patient information (because they think it gives them a competitive advantage over their local rivals).
One disagreement: But I disagree strongly with Dr. Yarhagi’s faith in the market to ensure that healthcare information technology (HIT) vendors will be obliged to “develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.” That is, he asserts that if there were a real market without federal subsidies and requirements that all healthcare providers buy the HIT, then providers and the HIT vendors would agree on reasonable fees for exchanging patient records.
But why would the vendors do this? Hospitals and doctors are generally locked into their HIT systems for years. A very big hospital EHR can cost $400 million plus 4 times that for implementation (e.g., training, software upgrades, etc.) over several years. Installing an EHR in a small clinic or doctor’s office is of course far less money, but nevertheless costs a few hundred thousand dollars. The healthcare providers have no bargaining power. Why would the vendors even bother to negotiate over fees for sharing patient data?
The more salient question is: why should any HIT vendor be permitted to charge a penny to help share data that is needed to make medical care safer, more efficient, more informed, better? A key feature of HIT is that it allows exchanging information on patients. The government is giving $30 billion to subsidize purchase and use of these technologies; hospitals and other providers are spending trillions of dollars buying and installing them. It is unconscionable that a vendor would even think about charging clinicians to share data on patients’ health—data that clinicians themselves entered in the first place! The government need not threaten vendors who don’t allow sharing of data. There should be no choice. Data exchange must be required through regulation. We don’t negotiate with car drivers about stopping at red lights, and we don’t compromise on truck weight limits on certain bridges. Some rules are simply necessary for public safety.
Vendors are allowed to keep patients’ data, but they should not be allowed to hold those data hostage until the creators and users of those data pay up. Anyway, officially, the data are owned by the patients. The last thing patients want is to be treated by doctors who are blind to their medical needs.
Ross Koppel and Stephen Soumerai
Ross Koppel, PhD, FACMI, is at the at the University of Pennsylvania, where he teaches sociology and where he is a Senior Fellow at the LDI (Wharton School) .
Stephen B Soumerai, ScD, is Professor of Population Medicine at Harvard Medical School