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There needs to be accountability for the lack of interoperability


Interoperability is important and probably the main driver of cost savings. So where are the IT vendors on interoperability? The answer is probably close to nowhere.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Keith Aldinger, MD, an internist who practices in Houston Texas. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


It has been 12 years since Rand Corporation published a study in Health Affairs extolling the values of a wide adoption of Electronic Health Records (EHR).[1] However, 12 years after the fact, the IT industry has seemingly missed the main point.


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 In the opening section, it addresses the potential savings, costs and safety benefits. In the sentence that follows, they define what is meant by the word potential,  “assuming interconnected and interoperable EMR systems are adopted widely and used effectively.” In the concluding section, it states, “also, even if EMR systems were widely adopted, the market might fail to develop interoperability and robust information exchange networks.”

Obviously, in the study, interoperability was an important and probably the main driver of cost savings. So where are the IT vendors on interoperability? The answer is probably close to nowhere.

In a recent study that appeared in March of 2017, investigators at the University of Michigan conducted a survey of Health Information Exchanges (HIE) nationwide that addressed their experience with information blocking.[2] Fifty percent of respondents reported that EHR vendors routinely engaged in information blocking and 33% reported that EHR vendors occasionally engaged in information blocking.

For hospitals and healthcare systems, 25% were reported to routinely engage in information blocking and 34% were reported to occasionally engage in information blocking. When the survey asked about the form of information blocking used by EHR vendors, 49% reported products with limited interoperability and 47% reported that vendors routinely or often charged high fees for health information exchange unrelated to cost.


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Obviously, the EHR vendors appear to be the main source of information blocking and limited interoperability is the most cited method. I would draw your attention to the statement by the Certification Commission for Health Information Technology (CCHIT) which listed the criteria that would take effect on July 1, 2009, for Certification of Ambulatory EHRs.[3] It lists three areas, functionality, interoperability, and security. Under interoperability it states:  “the ability to receive and send electronic data between an EHR and outside sources of information such as labs, pharmacies and other EHRs in physicians’ offices and hospitals.” This appeared sometime prior to July 1, 2009. The University of Michigan study above appeared in March 2017. That would be at least 7 years, 8 months after the CCHIT requirements for interoperability were set to take effect.

Next: 'How is it that certified EHRs are still not interoperable?'


How is it that certified EHRs are still not interoperable? Not to mention that 12 years ago interoperability was emphasized in the Rand Corporation study, which was financed by several of the leading IT vendors.

To put this in proper perspective, it is essential to look at how independent physicians have been held accountable.[4] To qualify for the maximum reimbursement for the adoption and implementation of a certified EHR under the requirements of the HITECH Act, physicians needed to demonstrate meaningful use by July 1, 2012. Each year thereafter, the maximum reimbursement decreases, and as of January 15, 2015, for those not accepting Medicaid assignment, the reimbursement totally disappeared. Also, as of January 1, 2015, penalties were applied to Medicare payments for physicians who did not demonstrate meaningful use of a “certified” EHR.


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Let me emphasize that reimbursements and avoidance of payment penalties was based on a complicated process of reporting meaningful use to the Centers for Medicare & Medicaid Services (CMS). This was most burdensome for small medical practices that lack ancillary staff. Remember, this was based on demonstrating meaningful use of a tool that the majority of physicians found not clinically useful. Now let us review these time frames.

The HITECH Act was enacted Feb. 17, 2009. In essence, physicians’ reimbursement, based on failure to demonstrate meaningful use of a “certified” EHR, started to decline July 1, 2012, about three and a half years after enactment.

As of Jan. 1, 2015, with failure to demonstrate meaningful use, any and all reimbursements were lost and penalties began. This represents almost six years after enactment of the HITECH Act. Wow! The IT industry, to date, has had almost an eight- to 12-year grace period to achieve interoperability while physicians began feeling the wrath of meaningful use within three and a half years of enactment, and penalties at six years after enactment. Then again, maybe grace just naturally flows to the Digital Deity?


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The Office of the National Coordinator of Health Information (ONC) has presented a report to Congress on health information blocking.[5] In the report, it presents findings similar to those in the study cited above. However, in this 38-page report, it seems to take a feckless, ambivalent position on enforcement. For example, on page 11, in defining interference with the exchange or use of electronic health information it mentions “…organizational practice that make doing so more costly or difficult.” Subsequently, on page 13, it again addresses this, “Charging prices or fees (such as for data exchange, portability, and interfaces) that make exchanging and using electronic health information cost prohibitive.”

Next:  'The responsibility or lack thereof needs to fall directly in the lap of the IT industry'


However, in a section entitled “Where Knowledge of Information Blocking is Limited and How to Resolve,” it states: “ONC also lacks access to the kind of detailed price and cost data, contractual language, technical documentation and other evidence necessary to objectively determine whether conduct meets the definition and criteria for information blocking established in section II of this report.” Really! If EHRs from day one were to be interoperable, why should one cent above acquisition, implementation and maintenance costs be allowed for transferring information (interoperability)?


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It would appear that the ONC needs to put more teeth into its recommendations. Since 2005, there have been 10 directors of the ONC (3 interim and 7 permanent). Most of these have been physicians. Maybe to get more bite into their enforcement the next one should be an orthodontist.

In conclusion, why have physicians been assessed financial penalties for not attesting to meaningful use and yet the IT industry gets a pass? Interoperability is not an example of MEANINGFUL USE. It is, in every sense of the word, MEANINGFUL PROGRAMMING.

Yes, the responsibility or lack thereof needs to fall directly in the lap of the IT industry. They should not be allowed to charge one cent for transferring information and any attempt to do so should elicit a financial penalty. Perhaps these EHR vendors could simply tweak the mother board, because with the EHR, they have certainly hit the mother lode.



[1] Hillestad R, Bigelow J, Bower A,Girosi F, Meili R, Scoville R and Taylor R. Can Electronic Medical Records Systems Transform Health Care? Potential Health Benefit Savings and Costs. Health Aff. September 2005 Vol. 24 No. 5 1103-1117

[2] Adler-Milstein J, Pfeifer E. Information Blocking:  Is It Occurring and What Policy Strategies Can Address It? The Milbank Quarterly. Vol. 95, Issue 1, March 2017, p 117-135

[3] CCHIT Certification – What Does It Require. Mycourses.med.harvard.edu/ec_res/nt/930820C0-27CB-4080-92CA-C5C152738BD9/cchit.pdf

[4] Gadkak, S. Avoiding the 2015 Medicare HER Incentive Program Penalty. bulletin.facs.org/2014/06/avoiding-the-2015-medicare-ehr-incentive-program-penalty/

[5] Office of the National Coordinator for Health Information Technology. Report to Congress: Report on Health Information Blocking. Washington, DC: Department of Health and Human Services; April 2015 https://www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf

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