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EHR interoperability’s uncertain future


Exchanging information is vital for quality patient care in an era of technology-based medicine, but progress is lagging.

For urgent care physician John Kulin, DO, interoperability of electronic health records (EHRs) has long been a dream-one that remains unfulfilled.

In his Manahawkin, New Jersey, practice, he and his staff of 17 physicians have access to complete medical records for fewer than 5% of all patients despite significant investments in interoperability software. With 60,000 patient visits annually, he gets the patient information he needs electronically from only 3,000. For the rest, the practice relies on paper records. 


Related: With hacking on the rise, physician records at risk


“Interoperability is a huge problem,” he says. “Yet, it’s one of the holy grails of actually engaging patients more and using our EHRs to make patient care better so that we’re not operating in different silos. But so far, it’s not happening well at all.”

The federal Office of the National Coordinator for health information technology (HIT) defines interoperability as the ability of information systems to exchange patients’ electronic health information and use information from other EHR systems without any special effort from the user.

For many patients, Kulin has a semblance of interoperability because he benefits from data on prescription medications and lab test results sent directly to his EHR . 

“When we get lab results back through our lab interface, it all comes right into the chart, so now we can compare and graph that data against prior lab work,” Kulin says. “That’s one of the few systems where we have prior data from other providers. That gives us a much better understanding of what’s going on with patients and enhances care.”

Kulin shares patient records via Direct secure messaging (Direct), a protocol for exchanging clinical messages and attachments such as patient records. In the second quarter of this year, physicians and other providers sent 24 million Direct exchange transactions via this secure email system, which complies with federal privacy standards under the Health Insurance Portability and Accountability Act (HIPAA). 

But when it comes to getting patient information from area hospitals and other physicians or imaging test results, Kulin is mostly operating blind. “From an urgent care perspective, I want access to every one of our patients’ medical records, particularly from primary care physicians,” he says.

When he does get medical records from hospitals or physicians, they come mostly via fax. “That’s problematic because it’s a hard copy that we need to read and put into a PDF that goes into the chart,” he explains. 

Interoperability still out of reach

Certainly paper is inconvenient, but for Kulin it’s also a sign that true interoperability is still years away, a factor that drives up costs needlessly. Without access to records, for example, he can’t compare a current EKG with an earlier one, making it impossible to know what’s normal for a patient, he adds.

Next: The double-sided coin of sharing data


Not knowing what’s normal means Kulin or someone on his staff may need to send a patient to the nearest emergency department. “Without that information, we’re just operating in a vacuum, and that’s something we never want to do,” he says.

Earlier this year, physicians were optimistic when the Senate Health Education Labor and Pensions (HELP) Committee unanimously passed S. 2511, the Improving Health Information Technology Act, to reform the rules governing federal standards for health information technology and EHR systems. Finally, Congress seemed to be addressing the problems that resulted after it passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

But despite the unanimous committee vote and support from members of both houses and both parties, the bill has not come up for a vote. Action on S. 2511 may have slowed because physicians and the Centers for Medicare & Medicaid Services (CMS) are preparing to implement new payment systems next year under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Physicians and HIT vendors have expressed concerns to Congress that the U.S. Department of Health and Human Services (HHS) may be changing too many of the requirements they impose on how  physicians practice all at once. 

So how long will it be before we achieve true interoperability? HIT experts tell Medical Economics that HHS will need to provide more incentives to HIT vendors to make their systems truly interoperable and that HHS has the power to do so now.


Further reading: Will your system be ready for EHRs and Medicare reform?


In its October, 2015 report, “Connecting Health and Care for the Nation. A Shared Nationwide Interoperability Roadmap,” ONC predicted it would be 2021 to 2024 before the nation’s health system achieves interoperability, which it defines as one that would “enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.”

Our experts agree, predicting that true interoperability will be in place by the ONC’s target date. “We definitely want a system where information moves around seamlessly,” says Robert M. Wachter, MD, author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age”and a practicing hospitalist.

It would be best, he adds, if EHR vendors would allow physicians to move patient data easily from one system to another. But that seems unlikely given the restraints physicians face under HIPAA, the fear of system breaches that can-and do expose patients’ records to hackers, and the fact that vendors have little incentive to promote interoperability.

“There’s not a great market advantage for vendors to share. In fact, you could say there’s a market disadvantage to sharing information,” explains Wachter, a professor and interim chair of the Department of Medicine at the University of California, San Francisco. Some EHR vendors for hospitals and health systems don’t share patient information with physicians who are out of network, for example.

To address this problem, the federal government should use its clout as the nation’s largest purchaser of healthcare to get HIT vendors to enable patient data to flow more freely among systems, Wachter says. If necessary, he adds, the government should threaten that “interoperability will be forced on you if you don’t do it yourself.”

A combination of actions such as those called for in S. 2511 and government steps  to require HIT vendors to achieve interoperability will force those organizations standing in the way of interoperability to begin to do so, he explains. 


The double-sided coin of sharing data

But for now, even though all HIT vendors are not working toward true interoperability, Wachter says, “I don’t see any villains here.” He cites the problem of information blocking, which occurs when one EHR system does not allow providers working with another system or working for a different healthcare organization to access patient data. Information blocking is generally not malicious, says Wachter. 

Next: What’s the solution?


Instead, most IT vendors working for physician groups, hospitals, and health systems serve the needs of their customers-healthcare providers--rather than the needs of the larger healthcare system. In these situations, committing scarce IT resources to sharing with other systems falls to a lower place on the priority list, Wachter says. Moreover, sharing patient data across multiple systems increases the risk that patients’ records could be hacked or stolen, he adds.

What’s more, if patient information leaks out due to a breach, leading to a $1 million fine, then a provider organization might be conflicted about data sharing, he says. “On the one hand, the provider might say, ‘Yes, we want to share information,’ but, on the other, they’re really saying, ‘No, we can’t do this because we don’t feel completely safe with that kind of risk,” he explains. 

The way Farzad Mostashari, MD, former National Coordinator for Health IT, sees it, physicians and other providers bear some of the responsibility for allowing hospitals and health systems to block information and should demand more, he says. 


Related: The challenges of switching EHRs


Not only should physicians demand more from hospitals and health systems, they need to ask more from their EHR vendors, says Mostashari, the founder of Aledade, a company that helps primary care physicians form and operate accountable care organizations. Those vendors are required to meet specific certification requirements, and, previously, these systems were tested against the ONC’s certification standards and showed they could meet those requirements, he adds. But when Aledade evaluated 33 EHR systems to determine if they could meet those certification requirements, most of them failed, he says.

“Only 38% of those EHRs could actually give us an electronic download of the patient’s summary records in standard form,” he says. But when most don’t perform in the field, then neither legislation nor new regulations will solve the problem. “What we need is enforcement of the laws and the regulations we already have on the books,” he says. 

To ensure that their physician clients get the data they need from hospitals, Aledade pays EHR developers and interface vendors to improve the flow of patient information. “That’s a tax on physicians that we pay in order to ensure the success of population health,” he says. 

“Patient data shouldn’t be held hostage,” he adds. “If a physician has a certified EHR and that EHR can’t get the data physicians need, then physicians should complain to the certification body and to the ONC.” 


What’s the solution?

Still, it would be unfair to level all of the blame on providers and IT vendors, because regulators also bear some responsibility for the failure of HIT systems to achieve what physicians want, Wachter adds. “To a large degree we have not created a regulatory environment that promoted the development of an infrastructure for sharing,” he says. 

Congress anticipated that interoperability would reduce redundant services and lower costs, but that hasn’t happened. Realizing the benefits of interoperability will require Congress and regulators at HHS to urge vendors and health systems to allow a more unrestricted flow of patient data. “But exhortation is only the first step,” Wachter says, adding that HHS needs to flex its market power as a buyer and threaten to require interoperability.  

For John D. Halamka, MD, chief information officer of the Beth Israel Deaconess Medical Center in Boston, Massachusetts, interoperability requires technology standards and policies and a business case for sharing data, he says. 

Next: The problem with new interoperability standards


S. 2511 would address some of these issues, such as commissioning the Government Accountability Office to investigate the possibility of a national healthcare identifier, critical for exchanging data, explains Halamka, the former chair of the US Healthcare Information Technology Standards Panel. Also, interoperability requires governance and data use agreements, he adds. “We need to understand who we can trust, the electronic address for sending them data, and how they’ll use the data,” he says.

The problem with new interoperability standards, he adds, is that they can impede progress. S. 2511 addresses the need for better standards by calling for the creation of a federal policy and standards committee, he says. In the past, members of Congress drafted policies and then staff members wrote the standards needed to implement those policies. But the act requires one group to produce policy and technology standards in parallel, he says. 


Further reading: How to balance telemedicine advances with ethics


Halamka agrees with Wachter that HIT vendors have an important role to play in solving the problems physicians face. Vendors already are taking steps to enhance interoperability, he adds, citing two examples that will ease the data-collection burden physicians face and the lack of true interoperability. 

First is the Argonaut Project, which aims to advance industry adoption of interoperability standards to foster the sharing of patient data in EHRs and HIT systems, he says. The project is a joint venture of EHR vendors such as athenahealth, Cerner, and Epic; health systems such as the Beth Israel Deaconess and the Mayo Clinic; and consultants such as Accenture. 

Second is a system to measure interoperability that KLAS is developing. An HIT research organization, KLAS rates EHR systems in such areas as usability and plans to report publicly on physicians’ experience using the interoperability functions of every EHR vendor, Halamka says.

Wachter cites another promising development: IT companies that were not previously involved with healthcare, such as Apple and Google, have seen the potential that follows when the federal government makes a $30 billion investment in HIT and Meaningful Use. “That amount of money woke up Silicon Valley,” he says. 

Consumer IT companies see a significant opportunity given that the United States spends $3 trillion on healthcare annually. While those companies are not solving physicians’ problems with interoperability or Meaningful Use, it is nonetheless significant that they are involved, even if it’s only to develop wearable technologies designed to get patients more involved in managing their health, he says. Apple and other companies making and selling gadgets to collect health data will start by serving consumers and then branch out to serve healthcare providers, he adds.



As consumers take on a larger role in managing their own health, Halamka says, they will demand improvements in HIT systems. “Every provider should have an EHR system and every patient should have access to that record,” he adds. And once EHRs can exchange data, if a consumer finds that his or her provider has one that cannot do so, that consumer should change providers, he says. 

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