Interoperability is a four-letter word: Inching toward true exchange
“While healthcare transactions generate an enormous volume of data, too much of it is disjointed and inefficiently used.”
The above quote was written by Edmund F. Haislmaier, senior research fellow, health policy studies at the Center for Health Policy Studies at The Heritage Foundation. In light of HHS’ HIMSS announcement that various healthcare stakeholders pledged to work together to ease EHR use, this seems like a rather timely quote. However, it was written 10 years ago as the beginning sentence of a June 2006 article.
The truth is true interoperability is still a ways off.
Incentives beget adoption
CMS recently released data that showed the agency has paid a total $34.69 billion so far to eligible hospitals and professionals as Meaningful Use incentive payments, a program under 2009's HITECH Act that sought to help modernize the healthcare industry by providing federal incentives for adopting health IT such as EHRs.
Holding opinions of what an EHR should and should not do in terms of care management workflow, the Meaningful Use program did largely achieve its goal of widespread EHR adoption. Last month, ONC reported that 96% of all non-federal acute care hospitals in 2015 possessed a certified EHR.
Despite these efforts, the trope "the systems need to talk to each other" is still bandied about at conferences as attendees knowingly nod as if to say, "Oh interoperability, you are a fickle beast! You've done it again!"
Cracks in the armor
As HIMSS' spirit of togetherness gave way to the early summer and the MACRA implementation rule was released, various stakeholders every so often pointed fingers when addressing interoperability.
For example, at the American Medical Association (AMA) Annual Meeting last month, CMS acting Administrator Andy Slavitt said, "It’s...time to ask a lot more of the technology and technology vendors. This is particularly true in the area of what many call interoperability."
"Today’s data silos are more a function of business practices than technology capability and we cannot tolerate it any longer," Slavitt continued.
Earlier that month, the AMA and 36 other medical associations sent a letter to CMS and ONC asking them to rethink how interoperability of EHRs is measured. “The lack of interoperability is one of the major reasons why the promise of EHRs has not been fulfilled,” Steven Stack, MD, AMA's immediate past president, said in a prepared statement. “Vendors have been incentivized to meet the flawed benchmarks under the Meaningful Use program. We need to replace those benchmarks with ones that focus on better coordinated care.”
"The biggest problem with interoperability is, like many aspects of healthcare, the demand curve does not mitigate towards integration," Jonathan Bush, CEO of athenahealth, told Healthcare Dive, adding "In fact, the way healthcare payment and delivery is structured, the demand curve pulls people toward isolation."
One idea behind such a pull involves the sensitive topic of a patient's health data as a commodity. In this view, once a patient enters a hospital the provider has little incentive to send or refer the patient to a second location as that could equate to revenue exiting the building. "Your highest margin stuff as a hospital are easily performed in lower cost settings," Bush says. "The last thing you want to do is make it so you can get an X-ray done at Joe's Imaging down the street for half the price. IT companies have the same dilemma."
As Sen. Sheldon Whitehouse (D-RI) recently told Healthcare Dive, the driving force behind Meaningful Use was to incentivize doctors and set technology standards to prime a bank shot into the tech community to come up with the tools for doctors. "In principle, that's not a bad idea," Whitehouse said. However, "there simply wasn't the information transfer infrastructure to do that," he said.
He added, "The idea that Epic and other big data services providers were going to build out data exchanges and share data without looking to get a competitive advantage against each other was optimistic in the extreme." Because of this, Whitehouse believes the U.S. is behind where it should be on health IT considering the $34 billion price tag.
"The primary barrier to interoperability is not the technology but operationally as there is a lack of universally adopted policy for exchange," Eric Helsher, vice president of client success at Epic told Healthcare Dive. "You don't compete over patient's information, you compete over better products and support." He adds that the current state of EHR tech can be interoperable and perform meaningful exchange but that the industry needs to adopt a policy framework, such as Carequality, to allow for such an exchange.
Helsher adds there likely is no finish line with data standardization as medical breakthroughs and market influences dictate more data fields continually be added to an EHR. One hot topic currently includes the prospect of adding wellness or wearable data to a patient's chart. "Innovation precedes standardization," Helsher said.
Both athenahealth and Epic signed HHS' interoperability pledge.
Where the wild data exchanges are
EHR development should be applauded as widespread as adoption is alongside the slow crawl to true health data exchange. Still, "we think that we are in the Tesla stage of EMR use but it's more likely we're in the Ford Fairlane stages of development and we have years to go before we're going to get to the kind of interoperability we expect," Daniel Barchi, CIO at New York-Presbyterian in New York City, told Healthcare Dive.
Workarounds and homegrown tools seem to be the name of the interoperability game for providers. For example, "HIEs have really filled a gap for many years in terms of sharing data," Barchi said. At NYP, a shared data set, named iNYP, was created to take input from all EMRs across the health system to allow physicians to receive read-only data about their patients.
However, HIEs can involve limited data sets and might not necessarily flow discretely into EHR data fields. They may provide a good snapshot of a patient but may not align with the digital tools at a physician's fingertips, such as a smartphone or tablet.
"To heck with interoperability," Michael Restuccia, vice president, CIO at Penn Medicine told Healthcare Dive, adding, "We are going with integration." Penn Medicine has implemented a core integrated patient electronic record that is one of multiple systems that feeds its homegrown data warehouse, branded Penn Data Store. It's been a solution that took many years to develop for the 2,000 physicians using the core patient electronic record in conjunction with Penn Data Store. It supports Penn Medicine’s ability to transmit homogenized scrubbed data throughout the enterprise and the regional HIE to support transitions of care. Restuccia noted the warehouse has begun accepting data from wearables such as blood pressure cuffs. To date, the data are directly interfaced which has minimized interface challenges, he notes.
Restuccia adds most providers in the Philadelphia region are aligning on the Epic platform which also assists in sharing data with other healthcare facilities in the region. The fact that the region largely aligns on Epic's platform isn't surprising as it is a dominant player in the EHR market. A July Health Affairs article found out of 2,974 hospitals studied, Epic was used in 16.6% (485 hospitals) and accounted for 23.5% of all beds. Authors Jordan Everson and Julia Adler-Milstein, both from the University of Michigan, set out to research HIE and vendor dominance, including whether hospitals using tools from dominant vendors perform HIE more than hospitals that don't.
"We found that, overall, hospitals that used the dominant vendor in their market engaged in more HIE than hospitals that used a different vendor," the authors wrote. "This was counterbalanced by our finding that greater vendor dominance was associated with greater hospital engagement in HIE for hospitals that did not use the dominant vendor. However, that positive spillover effect held for only a subset of vendors, and not the largest vendor (Epic)."
The authors state the results could give credence to concerns over EHR dominance causing stakeholders to hesitate over HIE and "that dominant vendors in competitive markets may be least likely to facilitate HIE with other vendors."
Barchi believes vendors are innovating the technology space. However, he also believes it's up to providers as customers of EHRs to demand data exchange from the vendors.
Declare victory over adoption and create the use case
There is little debate whether or not the MU program heavily influenced the widespread adoption of EHR technology. The argument over the technology now has shifted to who and how health data exchange should be regulated. "As we think about interoperability, a lot of the discussion has gone to the promise," Dr. Vindell Washington, principal deputy national coordinator at ONC, told Healthcare Dive.
"As more and more healthcare providers have adopted the technology, we're really getting to the point of true exchange," Washington said. "We talk a lot more about what can be achieved from information flow once we've seen the effect of a more digital footprint in healthcare." Washington believes there wasn't really a time the benefits of interoperability could be discussed until certain points of adoption within the digital space were reached. "You can't get true value until there's a high amount of information to share that's digital," he said.
Stack acknowledges the industry was able to digitize heath information at a blistering pace thanks to the MU program. However, he believes the program did supplant the free market in determining what the appropriate and valuable use cases were with well-intended, centralized policymaking.
Bush noted that generally "the primary role of government is to protect the borders and regulate society," adding, "If the government starts to assume the role of a player in society as well as the regulator...it's going to be hard to call the ball just right. When they get into setting up regional health information [organizations], telling people how to manage medical records, they now have a dog in the hunt."
Stack shared there are innumerable ways digital information is being shared and should be shared that would be valuable to patients for which physicians and hospitals should get credit in federal programs. He gave Healthcare Dive examples including: Automated appointment reminders, online scheduling, and sharing disease specific information between visits that may be relevant to patients.
He said it's time for the federal government to declare victory over EHR adoption and step back to allow the market participants to determine the use cases that most fulfill their needs in providing higher quality and more affordable healthcare. "Part of that now means we have to back off and have less of a heavy hand in regulation of what must be done and a bit more 'light touch, right touch' approach," he said. This, he said, will let the industry innovate at a pace that will be far faster and probably much more finely tailored to the needs of both patients and clinicians.
"The gravitational pull of the market is a cleansing, forcing function in most aspects of society and it must somehow find its way into healthcare," Bush said.
Potential new market: The patient experience
HealthTap's CEO Ron Gutman recently told Healthcare Dive that, in truth, EMR technology is built around billing codes. He wants health IT future technology to create end-to-end experiences with the patient centrally in mind. "The industry needs to create more forums to increase collaborations," he said. He added the government could create incentives to stimulate activity but the burden is on the vendor community to create the engagement of data and promote the idea that patients' data belongs to patients.
If this idea sounds familiar, it's because the idea was also recently written about by David Blumenthal, former National Coordinator for Health IT and president of the Commonwealth Fund, in The Wall Street Journal. He wrote the move toward consumer-dictated HIE is possible. To achieve it, HIPAA's information-sharing provisions need to be strictly enforced, data stewards will be needed to help patients navigate their heath data, and "we will need to perfect the technical ability of these new data stewards to access the electronic-data repositories of healthcare providers."
Such initiatives could be lucrative to market players that focus on the patient experience. "A robust new business sector could provide these data services to interested patients," Blumenthal wrote.
What is the finish line?
Earlier this month, ONC released released two metrics for evaluating "widespread interoperability" as required by MACRA. "MACRA specifically calls on HHS to establish metrics for the exchange and use of clinical information to facilitate coordinated care and improve patient outcomes between participants in the Medicare and Medicaid EHR Incentive Programs and others nationwide," wrote Seth Pazinski and Talisha Searcy, both at the Office of Planning, Evaluation and Analysis at ONC, in a Health IT Buzz blog post.
ONC concluded these two measures are the most appropriate for fulfilling the MACRA's requirements as well as incorporating feedback from the 83 comments the agency received:
- Proportion of healthcare providers who are electronically engaging in the following core domains of interoperable exchange of health information: Sending; receiving; finding (querying); and integrating information received from outside sources; and
- Proportion of healthcare providers who report using the information that they electronically receive from outside providers and sources for clinical decision-making.
So how will we know when we have achieved interoperability? Expanding data fields, especially genomic data, are likely to build out the digital EHR wish list and need for greater interoperability. "We're not there until physicians can look at a patient and know they can access that patient's data, everything they need to know about their patient without logging into different systems and when patients feel confident that the data are available to them or their doctor is the same no matter where it's seen," Barchi said.
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