An interoperability update: Do we need more carrots and sticks?

Earlier this year, the ONC released the Trusted Exchange Framework and Common Agreement (TEFCA), which responds to a mandate included in 2016’s 21st Century Cures Act and lays out principles, terms and conditions on which to base an interoperability framework that healthcare organizations can embrace.

 “This means patients who have received care from multiple doctors and hospitals should have their medical history electronically accessible on demand by any other treating provider in a network that signed the Common Agreement,” said National Coordinator for Health IT Donald Rucker in a recent blog post.

To achieve that goal, TEFCA is divided into parts A, the principles, and B, the terms and conditions, which is also where the rubber meets the road for many who live in the healthcare IT world.

“Part A good, Part B not so much,” John Halamka, MD, CIO of Beth Israel Deaconess Hospital in Boston, said in recent comments.

The departure between A and B, per Halamka and others, is that TEFCA has the temerity to spell out both the how (A) and the what (B). Describing the what as “old, very cumbersome standards,’ Massachusetts E-Health Collaborative CEO Micky Tripathi said, “Developers won’t touch those things with a 10-foot pole.”

I have no quarrel with Halamka and Tripathi on their evaluation of standards, but ONC and Congress are right to feel that this whole healthcare IT ubiquity thing is taking too long.  

Sure, the proposal and the responses illustrate well that the ongoing project to make healthcare IT systems communicate is long and arduous. But the real issue is that it’s also fraught with complexity, as Tripathi points out, and that insufficient incentives, misplaced priorities and narrow perspectives leave some tasks without any identifiable advocate.

The short list of remaining interoperability obstacles is significant.

Incomplete EHR Adoption: For starters, while incentives to adopt electronic health records have worked well, they’ve really only been applied to hospitals and clinics. Left out of the deal were skilled nursing facilities, behavioral health facilities, long-term and post-acute facilities and other providers. It will be difficult to have comprehensive records to share if only certain segments of the overall healthcare complex have the necessary tools.

Uneven Network Availability: To this point, rural hospitals and clinics, ironically the most essential of all facilities, have fared the worst in adopting EHRs. Funds are in short supply and trained personnel are often scarce outside urban areas, so it doesn’t help that internet service providers have often not built secure, reliable networks in these areas either. How will these facilities exchange patient records if there is no method of exchange?

Lack of an Accepted Exchange Standard: Part B in TEFCA designates HL-7’s FHIR standard moving forward, and while FHIR certainly has the early lead and a lot of support, the specific naming of it as a standard makes Halamka and others uncomfortable.

“Maybe a better way to say it is that FHIR enables many new possibilities, rendering a number of historical approaches obsolete,” he said.

No National Directory: There is currently no comprehensive way for providers to find each other should they need to. What’s needed is a “national phone book” that connects providers electronically when they need to exchange patient data.

So, where is the push to close these remaining holes going to come from? Let’s think about who has sufficient incentive to make them happen. Ideally, each of these concerns can be addressed by creative business ideas. Realistically, the free market probably can’t get us across the finish line by itself.

The solution, then, has to be some kind of collaboration between ONC, healthcare and IT vendors that offers proper incentives for facilitating patient data sharing and overcomes industry concerns, which remain. Healthcare IT vendors fear they’ll undermine their own market share by making it easier to share patient data. Hospitals fear losing patients who can easily switch providers without having to provide a complete medical history.

The federal government, however, is the only semi—objective advocate for healthcare IT systems that focus on patients. It’s also the only entity with the funds and heft to get some things on the wish list done. Far from arguing for big government, I am instead promoting dialogue that takes advantage of a healthy tension that empowers each entity to pursue the best possible outcome. If this gets done in a timely fashion, both carrots and sticks are necessary. What other entity has both?

“If interoperability were a ‘stay-in-business’ issue for either vendors or their customers, we would already have it, but overall, the opposite is true,” wrote Julia Adler-Milstein in a NEJM Catalyst article on interoperability. “… the weak regulatory incentives pushing interoperability … even in combination with additional federal and state policy efforts supporting HIE progress, could not offset market incentives slowing it.”

I agree with Halamka and Tripathi that mandating technological solutions is a bad approach in that it shackles ingenuity and picks winners and losers. But there is still a role for government in terms of providing strong incentives, setting realistic deadlines that advance the overall mission more rapidly and perhaps funding certain projects where no business solution is truly viable.

A year since Adler-Milstein’s article was published, we seem to be in the same place, despite the effort TEFCA represents. While foot-dragging may be an effective business tactic, it often forestalls broader public goods. To improve America’s fragmented healthcare system, it’s past time to make that the highest priority.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Category: Interoperability

Interoperability standards are essential, and someone has to create them.

It’s not exactly a sweater or tie that gets worn once and then relegated to the top of the closet, but it turns out that patient data may have something in common with unloved holiday gifts. Both, it appears, are shared and then seldom used.

At least that’s one takeaway from a recent Health Affairs study on interoperability and how far forward we’ve actually moved the ball. The authors used the most recent available data (2015) and the four interoperability standards established by the Office of the National Coordinator (ONC)—finding, sending, receiving, integrating—to conclude that progress on this measure is lagging, at best.

“… progress toward interoperability has been slow, with fewer than 30 percent of hospitals engaging in all four domains of interoperability in 2015 and with an increase of only 5 percentage points from 2014,” the authors write.

The low percentage of hospitals using all four standards is particularly significant in that simply sending or receiving data does not guarantee its use. Of those hospitals that said they sometimes, rarely or never use outside patient data in care (55.8 percent), or didn’t know (11.2 percent) how often they used it, the most oft cited explanation was that “clinicians could not view the information in the EHR as part of their workflow.”

“Issues with integrating information into existing EHR systems and clinical workflows were the most commonly cited barriers for hospitals that were not routinely using external information for patient care, which further underscores the need to shift the policy focus from transmitting information to information usability.”

Ah, yes, usability … yet another technological imperative that ends in ‘ability.’ Health Affairs suggests that data usability has a lot to do with EHR sophistication.

But is it having an advanced EHR that improves data usability? Or is it perhaps having the same EHR as the facility you share data with? As Health Affairs points out, those hospitals that most frequently share patient data via HIE are those working with an EHR and HIE from the same source.

“Without strong incentives that would have created market demand for robust interoperability from the start, we now must retrofit interoperability, rather than having it be a core attribute of our health IT ecosystem,” writes Julia Adler-Milstein, also an author of the Health Affairs study, in a recent NEJM Catalyst article. “And, if there had been stronger incentives from the start, we would not now need to address information blocking: the knowing and intentional interference with interoperability by vendors or providers.”

Adler-Milstein argues that policymakers dropped the ball more than any stakeholder group. The EHR vendors and providers, she says, are just working within the boundaries to retain or improve their respective positions.

“Of the stakeholders, only policymakers have a clear, strong interest in promoting interoperability,” she says. “Therefore, it is up to them to ensure that robust, cross-vendor interoperability is a stay-in-business issue for EHR vendors and providers.”

To suggest, however, that the onus is on policymakers to alter the incentives for adopting shared standards is to concede that healthcare is merely a business. In America, this is pretty much true. And where else might the incentives to adopt common standards come from, anyway?

“This is the basis for a system,” said Larry Weed, MD, in 1971, as he held aloft a think folder of patient data. “The record has to be. You can write a check in Atlanta on a New York bank, why? Because there’s a system, and it’s known throughout. But you get a coronary in Atlanta and your records are in Chicago, just try to find things out in the first 24 hours.”

“The historic lack of structured data and standardization in the healthcare industry today causes problems when sharing EHR content between providers,” wrote Tom Murray and Laura Berberian in a Computerworld op-ed. That was 2011.

To paraphrase one commenter on Adler-Milstein’s Catalyst article, Weed—or Murray or Berberian—could give the keynote at HIMSS 2018.

“Once the business case for interoperability unambiguously outweighs the business case against it, both vendors and providers can pursue it without undermining their best interests,” says Adler-Milstein to wrap up her Catalyst article.

A business case created by which group of stakeholders? Vendors have made and continue to make their case on interoperability by effectively controlling how rapidly it happens, or whether it happens at all. But what of providers? Is there a coordinated message from that group of stakeholders that might shift the interoperability landscape?

If so, it’s time to hear it. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Interoperability

Hurricanes highlight healthcare IT improvement, expose gaps

Yes, Katrina was already losing appeal as a girl’s name by 2005, when it had fallen to 247th most popular in the United States. But the so-named hurricane that swamped New Orleans in August of that year pushed it off a ledge. By May of 2007 Katrina had fallen more than 100 spots to number 382, its lowest level since the 1950s.

Less trivial is the impact of Katrina on hospitals and healthcare, which has regularly measured itself against the ghost of a seemingly manageable Category 3 storm that morphed into a disaster of historic proportions and nearly destroyed one of America’s more storied cities.

Since Katrina there’s been Rita and Wilma, also in 2005, and Superstorm Sandy on the eastern seaboard in 2012, but nothing else. The recent arrivals of Harvey in Texas and Irma in Florida are healthcare IT’s first real opportunities to test existing infrastructure against mother nature.

So, what are the early reports on the shift to electronic records, remote / cloud hosting and disaster recovery sites after the hurricanes? Things are better, but it’s still a work in progress. After all, many hospitals in New Orleans had EHRs, but it didn’t matter when the water kept rising.

“When Hurricane Katrina smashed into New Orleans in 2005 … tens of thousands of patients lost their entire medical histories—boxes of paper files disintegrated or washed out to sea by the rising waters,” writes Megan Molteni in Wired magazine. “Widespread data loss won’t be as much of a problem for Houston. Today, about 75 percent of providers keep records electronically. But patients still may have trouble accessing their records when it matters most: in the middle of crisis and recovery.”

That’s right. Interoperability remains the hill healthcare IT still has not taken, despite the proliferation of EHRs.

The fear of a Katrina redux inspired many hospitals to improve their physical infrastructure by installing “submarine doors, flood gates, and above-ground backup generators,” which kept 90 of 110 Houston-area hospitals from having to evacuate patients. Darrell Pile, CEO of an organization that coordinated patient evacuation and relocation related to Harvey, said he knew of no hospitals in Houston that lost access to patient records.

And yet, everything was still not totally copacetic in Texas.

“For lots of these patients, these are not their normal clinics,” explained Dan Jensen, manager of 11 clinics in the VillageMD Houston network. “We can try to pull data on some of them, but it’s very limited what we can get. A lot of times we have to start from scratch.”

But Jensen also illustrated the ways in which healthcare IT enables flexibility and rapid response during emergencies. Able to reach only 10,000 of 160,000 patients before the storm, VillageMD Houston’s IT provider was able to engineer a patient portal fix overnight that extended portal communication to all patients, even those who had not signed up.

While Houston was drying out, Irma’s visit to Florida ended up being less destructive but more directly impactful because it shut down most of the state. In total, 36 Florida hospitals closed either in anticipation of the storm or because of its impact. Statewide, 54 hospitals were forced to use backup generators and some reported modest flooding but remained open.

And the Florida Hospital Association received no reports of EHR failure.

Arriving so close together, Harvey and Irma almost entered the national consciousness as one storm. Taken together, early returns suggest healthcare IT has progressed significantly since Katrina.

“Policymakers and health care providers can celebrate one quiet success in the wake of the Houston storm: the computers are still running,” writes Darius Tahir in Politico. “The preservation of patient health records represents a partial vindication for the HITECH Act … that was conceived, in part, as a way to ameliorate natural disasters like Hurricane Katrina by replacing waterlogged paper with modern technology.”

But it wasn’t just Katrina that spurred lawmakers to pass the HITECH Act. It was also the VA’s response to the hurricane.

“The VA — with its pioneering VistA EHR — was able to retain records and access them much more rapidly than its private-sector peers during Katrina,” says Tahir, “… the organization restored access to records from 40,000 New Orleans-area veterans within days; it would take years for the private sector to reassemble its records.”

Indeed, where former Surgeon General Regina Benjamin thought she couldn’t afford an EHR before Katrina, she knew she couldn’t run a hospital without one after.

And yet, despite the generally positive results and clear benefits of healthcare IT proliferation, obvious gaps remain. Patients often scatter to the four winds in a disaster and reattaching them to their records is both challenging and not yet reality.

Plans are, however, in the works to fill this gap. The PULSE project, initiated by the Department of Health and Human Services in 2014, is working to create a data-sharing network that’s switched on in emergencies and makes patient records available to first responders and clinicians when they enter patient name, birthdate and gender.

Initial PULSE tests in disaster-familiar California have gone so well that the California Emergency Medical Services Authority plans to keep the system in place and may switch it on during one of the Golden State’s regular events.

All the testing in the world can only provide so much real-world preparation. With climatologists suggesting that the relatively hurricane-free period between Katrina and Harvey is probably over, it’s encouraging to see the progress represented by both PULSE and the performance of Texas and Florida hospitals. Any optimism at this point, however, should be buffered by an urgency to get it even more right the next time the winds start to swirl in the Atlantic, regardless of what name we give them. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Michigan study: Information blocking as a sales strategy

Looking to boost the entertainment value of this blog, a couple of years ago we compared information blocking to the mythical jackalope—a creature no one has seen in nature but many have encountered hanging over bars in various western towns.

Continuing with that metaphor, it now appears someone has actually seen an antelope-horned jackrabbit bounding through sage brush and pinion. I’m talking about a recent University of Michigan survey that 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, who 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).

The ‘Why?’ in all this is what one might expect from companies working to ensure profitability. Survey respondents mostly said they think 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 time 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?”

Why? Because that’s the business model that most benefits EHR companies and many of their large hospital and health system surrogates. Even while the technology to readily enable interoperability is not there yet, interfaces can still be built, all HIEs can be supported, and there simply is no legitimate healthcare-oriented reason for gag clauses.

“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 health care.”

The solution, according to the Michigan study, is a change of incentives. While the federal incentives for EHR adoption are obviously reimbursement, the incentives enabling 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 Twenty-First 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.

Richard Sullivan is chief government and revenue officer for Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Interoperability
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