Curbside Consult with Dr. Jayne 7/3/23

In advance of the holiday, the HHS Office of Inspector General dropped this sweet hundred-plus page final rule on information blocking. It includes the details of the civil monetary penalties that health IT developers will be subject to if they’re caught and OIG determines that information blocking did indeed occur. The document won’t be fully official until it is published in the Federal Register, and the majority of it will go into effect 30 days after that publication date.

I like the OIG’s clear description of the problem that it is trying to address: “Information blocking poses a threat to patient safety and undermines efforts by providers, payers, and others to make the health system more efficient and effective. Information blocking may also constitute an element of a fraud scheme, such as by forcing unnecessary tests or conditioning information exchange on referrals.” The fact that the mention of patient safety is the first thing on the list is important. Often, in the technology space, I see organizations that forget that none of the things that we’re trying to do mean anything if there’s not a patient at the center. Personally, I know I can give better care when I have full access to all of the patient’s information, but I often don’t have it.

This final rule specifically addresses civil monetary penalties for practices that are “likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI) if the practice is conducted by an entity that is: a developer of certified health information technology (IT); offering certified health IT; a health information exchange (HIE); or a health information network (HIN) and the entity knows or should know that the practice is likely to interfere with, prevent, or materially discourage the access, exchange, or use of EHI. Most of the information blocking that I see as a physician isn’t being done by healthcare IT developers. I’ve been behind the scenes with the development teams of multiple EHRs over the last two decades and I’ve seen a tremendous amount of effort around data sharing. One of those vendors helped me stand up the first HIE in my state “way back when” and was as shocked as I was when we couldn’t get healthcare delivery organizations to play nicely with us.

On the flip side, the HIE in a neighboring state was charging what I thought was an exorbitant fee for providers to connect. In digging deeper, their entire pricing model was built around the idea of connecting large health systems to the HIE, with little consideration for independent providers. I was working as a locum tenens physician at the time, providing coverage across a number of organizations in the state and was trying to get my own credentials to access the system so that I could have the most data at my fingertips regardless of where I was seeing patients. They had no way of accommodating anything like that at the time and said they could only do a direct EHR connection. Even if a smaller practice (most of the ones I was working with had five physicians or less) wanted to connect, the price tag was daunting. They definitely wouldn’t be going to the expense and time commitment of a project like that just because I asked for it, so I was never able to get connectivity to better serve my patients.

In reality though, the majority of information-blocking activities that I see in real life are directly related to behaviors by health systems and care delivery organizations. The hoops that patients go through to try to make sure that consulting physicians receive the records needed to render service are unreal. And sometimes, the physicians themselves don’t even understand what needs to happen or how to help make the system effective even when organizations are freely sharing data. I’m a member of a number of online physician forums, and questions about this come up frequently. Just this past week, there was a complaint from a primary care physician that a consulting physician sent back a “snarky” letter about a patient’s condition, suggesting that the primary care physician hadn’t taken appropriate steps to address the patient’s condition before sending a referral.

In digging deeper, the relatively inexperienced primary care physician assumed that since they and the consultant were on the same enterprise EHR, that the consultant would have full access to the chart. It didn’t occur to them that the consultant might not want to (or have the time to) wade through the dozens of encounters that were present trying to figure out what was going on, especially if those encounters contained a lot of confusing cut-and-paste documentation. Since the EHR’s referral module was largely about handling insurance referrals and ensuring payment for the consultant versus conveying useful clinical information, there wasn’t clear communication about the nature of the consultation request. Several more senior physicians chimed in with stories of “back in my day” before we could easily share records, where we’d draft a one-page letter to the consultant, summarizing what had already been done, our thoughts, and what questions we had for them. It sounds like the primary care physician didn’t do anything like this, and ultimately the patient’s time was wasted (not only at the appointment but the multi-month wait leading up to it) as well as the consultant’s time.

Unfortunately, this is all too often the kind of care we see now that everyone is operating under great pressure – whether it’s time pressures created by administrative teams, or whether it’s due to the scarcity of certain kinds of consultants, or whether it’s due to physician burnout, patient care ultimately suffers. Information-blocking rules aren’t going to fix that. The current information-blocking rules also aren’t going to fix the problem of health systems dragging their feet releasing records or images to competing health systems, although many of us are hopeful that a proposed rule for provider penalties will help with that particular problem. As a patient who watched organizations argue with each other about some pathology slides a couple of years ago, I’m supportive of most anything that will make things easier for the patients.

Over the weekend, we slipped from June into July. For many of us who are physicians, July 1 has a special place in our memories because it’s traditionally the date that newly minted physicians become interns at training hospitals. For other residents, it’s the day you move up in the hierarchy, becoming a supervisor of the brand-new interns who just started. For those just using their medical degrees for the first time, it can be terrifying, especially when you’re called in the middle of the night to look at a STAT x-ray or to give orders in response to lab results for patients you’ve never met. I was fortunate to be part of an amazing intern class that you could always count on to have your back. Even decades later, we know we can call each other for things big or small. Honestly, I would hop on a plane with a moment’s notice if one of them needed me, because those are the kinds of relationships that are forged when you go through those kinds of circumstances with a team like that. A toast to my class, and a salute to all the new interns who are on Day 3 of the rest of their lives.

If you’re a physician, what’s your best or worse memory of internship? Leave a comment or email me.

Email Dr. Jayne.