Healthcare industry market analysts, technology gurus and IT reporters sometimes like to envision a powerfully capable future in which software architectures are open, small application developers are thriving and healthcare IT solutions from numerous sources create a confluence of patient data that will advance healthcare quality.
A survey organized by the California Health Care Foundation and Health 2.0 suggests we may be far from that ideal.
In a nutshell, the survey of more than 100 small healthcare IT companies tells us this:
- Information blocking is a real thing, although it’s not always the fault of big EHR vendors and there is broad variation in the degree of blocking by individual companies.
- Only two EHR companies have an actual program for integrating with smaller applications, all impose interfacing costs of some kind, and most small companies feel the customer has to apply pressure before they are permitted EHR access.
- For the most part, EHR vendors are not enthusiastic or helpful when it comes to integrating with small patient data applications. Small development companies were split 50-50 when asked if the larger entities helped or hindered integration.
- The small vendors say most APIs designed by the large EHR companies are of poor quality.
Then there’s the fact that small application developers are not the only ones accusing bigger players of being uncooperative. The American Board of Family Medicine, the American Academy of Ophthalmology and the American College of Cardiology all accuse EHR companies of blocking access to clinical data registries.
As reported by Politico, “ ’The vendors often delay requests to connect, quote prohibitive prices for integration or flatly refuse to transmit the data and instead offer to sell physicians their own software,’ says Marta Van Beek, co-chair of the American Academy of Dermatology’s registry committee.”
The importance of data in improving individual and population health, a benefit to the public as a whole, is what leads to relatively normal business practices being labeled as information blocking. In other industries, this might be considered simply protecting your market position.
But healthcare is not a typical industry because health is not breakfast cereal. More information available to providers at the point of care makes for more positive clinical outcomes, which has to be a goal for all in the industry.
Of course, the Centers for Medicare and Medicaid Services (CMS) is all for full interoperability. But at the onset of the Meaningful Use era, CMS seemed to naively expect that providers attesting with certified EHRs would achieve this goal through trickle-down pressure on the EHR vendors. It didn’t happen. As various leaders from the Office of the National Coordinator for Health IT (ONC) have lamented, EHR vendors as a group were not incentivized enough by sales potential to make genuine interoperability part of their deliverables.
Now, CMS is engaged in catch-up strategies to offset this Meaningful Use miscalculation.
For example, CMS undertook a major PR effort at HIMSS 2016 to get vendors to sign the toothless Interoperability Pledge. Most recently, the 2,000-plus pages of the final MACRA rule include requirements that providers attest to not blocking information. Commenters on earlier draft versions complained that, “EHR vendors are unwilling to share data in certain circumstances or charge fees that make such sharing cost prohibitive for most physicians.”
In recent remarks to the American Osteopathic Association, CMS’s Acting Administrator Andy Slavitt put the onus for EHR interoperability squarely on the shoulders of EHR vendors, not end users.
“The burden needs to be on the technology, not the user,” he said. “EHR vendors and hospitals that use them will now be required to open their APIs—so data can move in and out of an application safely and securely—and technology can become plug and play … Today’s data silos are more a function of business practices than technology capability and we cannot tolerate it any longer.”
Real interoperability and the free flow of patient data depend on providers and EHR vendors implementing and embracing core prerequisites:
- A single standard: Perhaps the data exchange standard will be FHIR or maybe it will be something else, but one standard for the industry is necessary.
- Granular data: The FHIR standard enables the exchange of pieces of patient data instead of whole documents, giving power to application developers, who traffic in data pieces and chunks.
- Application programming interfaces: A public API is a unified approach to data exchange. Ideally, it enables a plug-and-play scenario similar to the relationship between your phone and the thousands of apps in the App Store and Google Play.
- Fines for blocking: To convince EHR companies that cooperation is in their best interest, penalties of some sort, e.g., fines, and a monitoring agency will have to be identified. Absent that, corporations will respond to their own DNA and continue working toward domination.
There are those in healthcare who consider information blocking by EHR vendors unethical, but ethics are beside the point in this conversation. There is more at stake than protecting competitive advantages because this is not a scenario to be viewed through the lens of traditional business.
Again, we are not talking about producing breakfast cereal. Viewed broadly, permitting information blocking to harm healthcare consumers might be akin to allowing corporate mergers to harm technology or entertainment consumers, except that good health is far more important than low costs for hundreds of TV channels.
The job of CMS and Congress is to consider the American people collectively. When discussing interoperability, the financial goals and revenue projections of healthcare IT companies are no more relevant to CMS and Congress than is the profitability of pizza companies to the FDA. The goal must be to establish a network of incentives and penalties that yields a system in which patient care improves and costs decline. Anything that detracts from those goals should be set aside.
The good news—or perhaps the bad, if you represent a recalcitrant EHR vendor—is that in a final rule released last month, the ONC will have more oversight of EHRs and other technologies that store, share and analyze patient data. The rule also gives ONC the authority to ask developers to pull noncompliant products from the market.
With this final rule, the ONC has the power to decertify health IT products that don't comply with regulations or are found to pose “serious risks to public health or safety.” If ONC decertifies a product, the developer must notify affected customers and providers, and the ONC can also issue a cease-and-desist notice to prevent the future sale or marketing of the product.
It feels like this essential focus on technological cooperation is long overdue. So, can we finally say, “Interoperability, here we come?”
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