- Whatever its shortfalls, there is no denying that the EHR Incentive Programs have created an enormous market for healthcare information technology that would likely be lacking if the HITECH Act was never passed. EHR adoption has reached nearly every eligible hospital in the nation, and continues to spread among physicians at a slow but steady pace, making data-driven infrastructure an absolute must-have for patient care, not to mention participation in value-based purchasing and population health management.
But the technology hasn’t delivered on all of its promises, and providers continually complain that they have been left in the lurch. Poor usability, plummeting productivity, and frustrating data siloes have left many providers feeling like the victims of a mugging – but emerging market forces that prize interoperability and EHR data standards are shifting the balance of power back towards customers who now know a thing or two about what works and what doesn’t.
Yet providers and vendors only warily work together in an atmosphere that seems rife with suspicion and mistrust, punctuated by revelations about hefty fees and worst-case scenarios where providers lose access to the patient data they need to do their jobs. When healthcare providers are mandated to purchase and implement EHR technology that meets certain stringent specifications, it’s easy to believe that the vendors of that technology are using their position to put the squeeze on helpless customers forced to buy whatever is on offer, even if those products do not foster interoperability and meaningful health information exchange through standardized protocols.
But Micky Tripathi, CEO of the Massachusetts eHealth Collaborative and Chair of the eHI Interoperability Workgroup, doesn’t believe in conspiracy theories when it comes to EHR data standards and the vendors charged with supplying them. Instead, he said to HealthITAnalytics.com, vendors are being as responsive to shifting market forces as they can be, despite challenges facing the healthcare industry that are making interoperability a difficult proposition.
“I guess it’s just hard for me to accept the sense that there’s some kind of cabal of EHR vendors holding power over providers,” Tripathi said. “For Stage 1 meaningful use, there were something like 1,000 vendors certified. For Stage 2, there are around 300. Now, where in the history of the world have we ever seen 300 independent companies forming a cabal to walk in lockstep, keeping their prices in line, and being able to enforce that?”
“Someone is always willing to say, ‘If there are really people who want this stuff, I’m willing to undercut the next guy and offer that service. I can do it at lower price.’”
The healthcare industry isn’t anywhere near as unified as it would have to be to produce such a scenario, he argues. In fact, it’s surprisingly fragmented – so much so that getting any two vendors to agree on any communal EHR data standards whatsoever has been one of the biggest ongoing headaches for regulators, providers, and everyone in between.
“You have lots of small providers as well as large providers; lots of small vendors and lots of large vendors,” Tripathi said. “And you have them trying to deal with some very complex things in terms of medical terminology, privacy issues, and connectivity. Not surprisingly, when you have that kind of fragmentation both on the supply side and the demand side, it’s hard to solve what political scientists call the ‘collective action problem.’ How do we get enough people together to say that we need to solve this problem and it’s time for all of us to get in a room to do it?”
The EHR Incentive Programs were designed to jumpstart the process of bringing healthcare organizations together on a seamless infrastructure that allows the fluid exchange of health information for clinical decision making, predictive analytics, and preventative population health management. But healthcare organizations have struggled to expand their budgets sufficiently to cover EHR technology that often makes their lives more difficult rather than helping to improve patient care. Staggering through Stage 1 has been difficult enough, and Stage 2 attestations have been less robust than CMS and the ONC might wish to see.
“It’s harder for healthcare than in other industries,” Tripathi points out, due to the decentralized structure of the healthcare system and the stark differences between the needs of various provider types. Other major sectors, most of which are based on 20th century technology and a modern perspective of profit-driven efficiency and customer care, have had the benefit of being relatively consolidated from their start. Healthcare, in contrast, has no experience with this degree of regulation, and has never developed the nimble response time of other technology-dependent sectors.
The demands for data-driven modernization are coming thick and fast, and it’s difficult for providers to meet them while still providing the best possible patient care. “It isn’t that people aren’t working hard enough,” says Tripathi. “It’s just that we have some expectations in healthcare that are unrealistic right now.”
“In the airline industry, you could get four airlines together to say they need a common scheduling system,” he explained. “All right, fine, they’ll use the system that American Airlines has already done. With the ATM business, there were like six or seven ATM networks that were able to get in a room and say, ‘We need to connect our ATM networks because this isn’t working anymore.’ In the 1940s, there were 55 auto companies in the US. Now how many of them are there?”
“I guess we could argue about whether consolidation is a good thing or a bad thing, but one of the things it does do is produce lower costs, because people start to build to scale and you get standardization. And that’s what we’re starting to see in the health IT industry,” he continued. “Finally, you’re starting to see a shakeout where people are starting to consolidate on a smaller number of vendors.”
That consolidation is bringing the healthcare technology market in line with other service-oriented sectors, but vendors are still in the process of defining what EHR data standards should be adopted and how to bring that standardization into poorly interoperable products that are already being used by providers.
“You’re starting to see vendors create things like the CommonWell Alliance, and you’re getting other sets of vendors who are getting together and delivering real solutions,” Tripathi said. “Now, they’re not perfect, and it’s going to take a while, but at least we now have people understanding what the real need is. Now that there’s real demand out there, and people are willing to pay for it, they’re going to get together and do some joint things.”
“CommonWell is one example of vendors getting together, and the Argonaut Project is another. Argonaut is a group of eleven completely private sector – not government involvement whatsoever, with no government incentives at all,” he went on to say. “It’s eleven providers and vendors who got together and said, ‘We’re going to put our own money toward advancing a set of standards that are going to move the industry forward. All nonproprietary information will be made available to the market; anyone is welcome to join, but we’re going to fund it and we’re not going to ask anyone else for money, because we want the private sector to start taking this stuff over.’”
“You could probably bring together ten organizations who account for a majority of the health information exchange in the country. And if you just work with those ten organization to define what constitutes interoperability for the nation, I would lay down the gauntlet with those organizations and say, ‘We need you guys and gals to figure out among yourselves how you’re going to do this, otherwise the government is going to have to intervene.’”
It may be a little too late to leave the process up to the commercial sector entirely, especially as providers pour over the recently released Stage 3 meaningful use proposals that will close out the EHR Incentive Programs and bring significant changes to EHR development.
CMS is certainly instrumental in pushing the expansion of accountable care and value-based payments into the industry through its developing quality-based payment programs, but private payers have also taken the initiative to urge providers to embrace bundled payments, reimbursements based on episodes of care, and outcomes-driven financial arrangements that cut costs across the healthcare continuum.
This greater focus on preventing chronic diseases, lowering hospital readmissions, and shifting care to cheaper settings has forced providers to rely more heavily on their EHRs and other infrastructure, further driving the financial argument for more EHR data standards, greater communication between providers, and more robust reporting and analytics capabilities. And vendors are responding to the call, Tripathi says.
“I think we’re finally at that point in healthcare where there is enough demand for that type of interoperability because of value-based purchasing,” he stated. “I’m just amazed at how value-based purchasing and accountable care organizations have created this huge demand for interoperability that wasn’t there before.”
But the EHR market has built up a great deal of inertia over the past few years, and it will take time and dedication to change the direction of technical development to truly embrace the idea of EHR data standards, interoperability, and less restrictive health information exchange. Providers have experienced more than their fair share of growing pains through the first few stages of meaningful use, but there are more to come, Tripathi predicts.
“If we expect that we’re going to have some software engineers in Wisconsin or in Boston perfectly architect something before we release it, that’s just not the way anything has ever worked in the history of technology,” he said.
“People architect something, and they put it out there, and it gets beaten every way to Sunday. It doesn’t matter if you’re talking about cars or blenders or EHRs. The first generation of something is always bad. Once you get a big enough user base, that’s when you start refining it. And I think that’s where we are in healthcare. We finally have a big enough user base so that we can start to see some of these refinements that we need.”