Medical Economics: Solving EHR interoperability

EHR systems are now used by almost every physician and healthcare organization in the United States.

Now the challenge is: How do we get EHRs to talk with each other?

Achieving interoperability is now a concerted effort by the federal government, EHR vendors and many other players to make it easier for physicians and health systems to share patient records.

Calling this a challenge is an understatement. Physicians need this functionality to achieve the central tenets of value-based care, which requires coordinating care between providers, hospitals, labs and myriad other players. The sad reality is that many doctors still rely on fax machines for many of these functions.

So how can the healthcare system achieve true and functional interoperability?

Today, we are back with Dr. Andrew Pecora, to talk through the challenges-and opportunities-of EHR interoperability.

Medical Economics: Our cover story focused on efforts to use apps to make EHRs more usable and interoperable. What do you think of these plans?

Pecora: Well, interoperability has several meanings. To a doctor, it means one thing. I need information when I need it, and I shouldn't have anything getting in the way of me getting it, so I can best treat my patients. And the problem is, that that doesn't exist today. So as an example, if I see a brand new patient, and I'm on EHR system 1, and EHR system one doesn't talk to EHR system 2, I can't even get their prior medical records without calling having them printed fax to me, while the patients sitting in the waiting room waiting for me to see them. That's just nuts. And so that's a very basic level.

Medical Economics: Why is EHR interoperability such a challenging issue?

Pecora: Well, interoperability is several issues. One is technical, right? And I'm not a technology expert. But my understanding is, up until a few years ago, the actual ability to get content from one system to another was not necessarily there. The other is the idea of ownership: Who owns the data? Does the EHR own the data? Does the patient own the data? Who owns the data? And while most people believe it's my data as a patient, my doctor should have access to everything. That's not quite how it works yet. And then the third thing is the practical; not every hospital system, not every physician, has the wherewithal of a major corporation. Information Technology is complicated. So if I'm a doctor in a private office, and I even if I have an EHR in my office, the ability of that EHR to connect to my hospital’s EHR is not necessarily readily available. So I think we're still a couple years away, and this is going to take legislation. I know Congress and our political leaders understand this as a problem. CMS understands this as a problem. It'll eventually be dealt with. But I think this is a multi-level problem that needs to be adjudicated by each constituency, and it's going to take some time to resolve.

Medical Economics: How has a lack of interoperability held back value-based care?

Pecora: Well, it's hard to know value if you don't have the information. Now what is value-based care? The best possible outcome for the individual patient, and the lowest total cost of care for the population you're serving. So if you're a doctor, it's your patients that come to your practice. If your CMS, it's half the United States, or something like that.

So how do you enable the right outcome for the individual patient each and every time, but yet lower total cost of care.?There are companies that are now in the marketplace that have been built to do this. But these are early days, and how this is all going to come together is going to be a matter of time to see. But ultimately, I believe that no different than when you put in your GPS, you want to go from where you are to someplace you've never been before. It will show you all the possible routes and then the best route for that moment. I think we're going to see the equivalent of that in healthcare within the next year or two or three.

Medical Economics: What role should the federal government take in achieving interoperability? Should they lead the charge? Or should they let the market dictate how interoperability is achieved?

Pecora: I think this one is going to have to be both, because right now the real question is, it's a matter of property. If content is in my system, it could be my laboratory system, it could be my EHR, who does that content belong to? Who has rights to it? What are those rights? And layered on top of that is the complexity of privacy with HIPAA, and those sorts of things. So this is a meaty complex issue, but fundamentally needs to be resolved that a doctor at the point of care with a patient in front of them and that patients can send there should be no obstacles to that physician getting the information they need to make the best possible decision for their patient at that point in time, in real time. I don't think anybody argues with that. It's just a question of how do you get there and respect property rights, intellectual property, and all the other things-and ensure privacy. That's why I do think the government needs to be involved in this one.

Medical Economics: Some experts believe that interoperability would be achieved if patients had more control over their own health records. What do you think of this idea? What are the pros and cons of this approach?

Pecora: Data is not the same thing as information. So the caution I think people have is data without information. Information can be dangerous, meaning that-you're a patient, you look something up, you misinterpret the test. You're a patient, and you get a complex genetic profile without an explanation to the benefit of the pros and cons of the information. People are worried about that. Also, the doctor-patient relationship is still a sacred thing. Of course, patients have the right to access their information, but it has to be in the context of a caring relationship with a healthcare provider who can interpret the complexity. And I think that's a concern that if people have access to everything, and it's not filtered, it might lead to harm. And so that is a bit paternalistic, and some people may feel it's that way. But as a practicing doctor, I don't think it is, because the biggest thing I worry about is my patients being afraid. And of course, they have to get the right care, but I don't want them afraid. I don't want them to have unfiltered data without the context of what it means and the benefit of providing a caring environment to explain it. And I think most doctors would feel that way.

Medical Economics: What do you think should be done to make it easier for physicians to switch EHR?

Pecora: That's a big question, because that involves interoperability, intellectual property, privacy, so I think it goes back to the question before. If you have one system and you want to go to a next system, all the information should flow readily. But who pays for that? Who incurs the cost of that? These are things that will have to be worked out. And I believe the marketplace will work them out. And ultimately, the consumer of healthcare, the patient, I think will drive this indirectly and directly. But this is not here today. It's still a conversation.

Medical Economics: One of the trends in the EHR market has been consolidation of vendors. Do you think consolidation will actually help improve interoperability?

Pecora: It could improve interoperability as market contracts or it could create on you know, huge corporations that are going to protect their IP and their IP is the content in their EHR, not the EHR, and so it could be as big a problem as it is a benefit.

Medical Economics: How can we get physicians more usable data to improve treatment decisions and patient outcomes?

Pecora: Well, I think that's a huge market opportunity. As you know, I'm the founder of a company COTA (Cancer Outcomes Tracking Analysis). It's dedicated itself to providing actionable information at the point of care, real-world evidence and analytics to allow for patients to have better outcomes, enable their doctors to make better choices, and to reduce total cost of care. And COTA is not alone in this. There are others that are doing this as well. So I think you're going to see a whole new group of companies come into existence whose sole purpose is to enable this massive data set that exists and evolves and put a lens on it, and a filter and a lens and provided at the point of care so doctors can make the best decision in guiding their patients.