Why healthcare information still doesn’t flow freely

A recent study from the University of Michigan suggests that incentives still don’t line up to support wider interoperability.

A recent University of Michigan survey asked health information exchange (HIE) professionals about their experience with information blocking. Respondents clearly indicated that information blocking is real and is practiced by both health systems and EHR vendors.

“Half of respondents reported that EHR vendors routinely engage in information blocking, and 25 percent of respondents reported that hospitals and health systems routinely do so,” write professors Adler-Milstein and Pfeifer in their report. “Among EHR vendors, the most common form of information blocking was deploying products with limited interoperability. Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology.”

The survey results are especially incriminating for EHR vendors—researchers contend that they either “routinely” or “occasionally” engage in information blocking, according to 88 percent of respondents. Hospitals and health systems fared better, but 59 percent of survey participants still used “routinely” and “occasionally” to describe information blocking behavior.

The survey gets more interesting as it delves into specific tactics. Respondents said information blocking among EHR vendors usually takes these eight forms and occurs with a corresponding frequency shown in parentheses.
  • Products have limited interoperability (49 percent)
  • High HIE fees unrelated to cost (47 percent)
  • Third-party access to data is difficult (42 percent)
  • Refuse to support particular HIEs (31 percent)
  • Data export is difficult (28 percent)
  • HIE contract terms change after implementation (19 percent)
  • Unfavorable HIE contract terms (17 percent)
  • Gag clauses on speaking about info blocking (12 percent)

Hospitals and health systems, the survey showed, try to block information by pressuring providers to adopt specific technology (28 percent), controlling patient flow through selective data sharing (22 percent) and using HIPAA as an excuse to not share patient data (15 percent).

When survey respondents were asked why they thought these impediments to interoperability still exist, they mostly said they believe that EHR vendor goals are to maximize short-term profit and increase the likelihood their products will be selected.

Of course, as has been pointed out many times and in various forums, healthcare is not just like any other marketplace. In truth, EHR vendors are caretakers of information that nurtures a public good. The measures of success in this arena are both patient health and sales totals.

The Michigan study survey results are supported by the anecdotal experience of individual physicians like Peter Masucci. “I went digital 11 years ago and embraced an electronic health record,” writes Masucci in a recent article on STAT. “While things aren’t perfect, they’re very good. Yet now I’m being told by the managers of my affiliated group that I and all of the other physicians in the affiliated group must adopt and use the same new electronic health record platform.

“That doesn’t make sense to me. I have an iPhone and my neighbor has an Android, but we can still communicate. My bank account is with TD Bank and I regularly get my money from Citizens Bank ATMs; communication seems to be working there. Why in 2017 must all doctors be on the same system to communicate and share information?”

Even though the technology to readily enable interoperability is not there yet, interfaces can still be built and all HIEs can be supported—there is simply is no legitimate healthcare-oriented reason for such EHR limitations on practitioners.

“What has been substantially underappreciated, however, is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not [participating in HIEs],” writes Julia Adler-Milstein in Health Affairs. “And as a result, these actors may behave in ways that interfere with the free flow of patient information that is needed to improve health and healthcare.”

The solution, according to the Michigan study, is a change of incentives. While the federal incentives for EHR adoption are obviously reimbursement, the incentives that enable the free flow of patient information between systems and doctors remains elusive.

How might those incentives change? One obvious approach is government regulation, which is mentioned in last year’s 21st Century Cures Act, but more oversight is not what most in healthcare want to see. Since five EHR vendors control roughly 70 percent of the EHR market, a better approach might be to willingly embrace HIE and the policies/technologies necessary to make it happen.

Is that asking too much of for-profit businesses? It might be. But as with most issues in healthcare, what is not effectively managed to benefit patients eventually becomes something potentially regulated by Congress. The question now might be who will blink first—the information blockers or Congress?

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