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Readers Write: Information Blocking: Don’t Blame the EHR
Information Blocking: Don’t Blame the EHR
By Michael Burger
Healthcare IT seems to be getting some attention in Washington these days, and not necessarily in a positive way. As a case in point, a statement which affects healthcare IT was included in an explanatory statement by the chairman of the House Committee on Appropriations regarding the house amendment to the recently passed government spending bill.
Information Blocking. The Office of the National Coordinator for Health Information Technology (ONC) to use its authority to certify only those that … do not block health information exchange. The agreement requests a detailed report from ONC … regarding the extent of the information blocking problem, including an estimate of the number of vendors or eligible hospitals or providers who block information.
This is clear evidence that Congress is frustrated by the relative lack of data exchange despite an investment of $30 billion for healthcare IT. As the explanatory statement states, “ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use.”
No question, information blocking is a significant factor in the lack of data exchange. It is appropriate for Congress to expect a return on taxpayers’ investment. What concerns me is the prevailing but erroneous perception that EHR vendors have conspired to block information.
In the nascent HIT business of 20 years ago, there was a notion of a “closed system,” where data was only accessible by those using that system. In those days, the closed system was certainly used to sell additional software by controlling the flow of data. That business model was ideal for a marketplace many years ago with few competitors and no real demand for interoperability.
However, such a strategy no longer exists in today’s HIT marketplace, if for no other reason than to meet the certification requirements for Meaningful Use (MU), EHRs must be capable of interoperability with other EHRs. A claim that a company’s EHR “doesn’t work well when you mix and match vendors” would not be a smart selling tactic, since it openly defies the very premise of MU and because there are many, many competitors.
There are fees from EHR vendors for interoperability, data extraction, and conversion from one system to another. These cover the vendor’s cost to do the work plus a profit margin. (Let us not forget that these are, in fact, for-profit businesses.) While the marginal cost of extracting the data may be small, it is not a provider’s inalienable right to have their vendor provide services for free.
One form of information blocking is called a “walled garden.” In Joel White’s recent blog post regarding Information Blocking, he says, “Information blocking [in a walled garden] occurs not because different technologies or standards prevent data transfer between EHRs, but because EHR vendors or health care providers engage in this activity as a business practice. This is not a technology problem, but a competition one.”
I disagree that EHR vendors in recent times conspire to strategically erect walled gardens, but I do see that healthcare providers routinely engage in this activity as a business practice. The following example illustrates my point.
Let’s say that there are two integrated delivery networks (IDNs) in a given market. Each IDN has acquired ambulatory practices and positioned itself to be able to offer a full spectrum of care, from pediatrics through geriatrics. Each advertises to their potential customers (patients) that they offer the highest quality, most convenient care in town. There is a competitive and profit incentive to keep patients within the network.
Now let’s say a patient is treated at IDN A and then receives treatment at IDN B. From a public health perspective, the patient’s records should flow from one to the other. But from a business perspective, there is no incentive in making it easier for a patient to go out of network and seek treatment at the other IDN. All IDNs use EHRs that are capable of exchanging clinical data in some capacity, but they do so grudgingly because of competitive concerns.
It’s appropriate for Congress to expect a return on our $30 billion healthcare IT investment. It’s refreshing to see that the authors of the spending bill understand the existence of information blocking. Let’s hope, however, that our new Congress doesn’t take the easy way out and blame EHR vendors for this phenomenon when it is really a result of competition of healthcare providers in the free market.
Michael Burger is a senior consultant with Point-of-Care Partners of Coral Springs, FL.
The future of interoperability needs to be a single repository of patient data for every person – the Virtual Care Plan. All EMRs will interoperate by updating relevant data, via standard protocols, into the Virtual Care Plan. EHRs will not interoperate with each other, they will all update the patient’s Care Plan. This is the only model that makes sense. We need to modernize the idea of interoperability from being record-to-record to becoming relevant data-to-patient care plan.
Someone should investigate AthenaHealth for Information Blocking. They are slow playing standards based connections while they try to get the OAG to allow for paying the originating doc for creating the chart.
Thanks, Michael, for this insightful piece. There is another issue which I believe is more obstructive – the lack of excellent standards for interoperability, the TECHNICAL problem. DIRECT is the lowest-common-denominitor, but often sends a record which can be read within the target EHR, but not really incorporated into it. And data standards seem to be less important. For example, using the very-strict type of data standard such as the CCR/CCD/consolidated CDA (cCDA – these are similar to one another), where any application that can read and incorporate the fields can read and incorporate anyone’s such output, allow most of the history data to be transferred. This could be expanded by a few more sections to include everything but the HPI narrative which could be sent as a text block, and both the transferred record would include both universal data elements that could be incorporated into the receiving record, but also retain the richness of natural language for the HPI – a great start in my opinion. Sure, this doesn’t address deliberate blocking of interoperability, but it would allow easier sharing when that is desired.
BTW, the issue os the DIRECT standard will be overcome by the new RESTful transfer standards such as FHIR (not going to be able to go into those here, even if I understood them well enough).
Chief Medical Office, DrFirst
Member, Transport and Security Standards Workgroup, HITSC