- The ongoing task of digitizing the healthcare industry has never been anything short of frustrating for every stakeholder involved. Regulators have struggled with convincing providers that investments in EHRs and health information exchange are worthwhile; providers have pled empty pockets, packed calendars, and suspicious staff as reasons why progress has been slow; innovators have bemoaned the shaky foundations of health data interoperability that make data integration and big data analytics such a challenge to implement.
There has been no lack of grumbling, snide remarks, and finger-pointing as the industry continues to grind through the requirements of the EHR Incentive Programs, which hope to place information sharing and its subsequent benefits at the core of its ongoing work. In April, the accusatory atmosphere reached fever pitch after the Office of the National Coordinator released a report on purposeful information blocking across the care continuum.
Difficult to prove but even more difficult to overcome, data blocking may be one of the key reasons why the industry has made only sporadic progress towards true health data interoperability thus far.
The other issue is one of responsibility, says David C. Kibbe, MD MBA, President and CEO of DirectTrust and Senior Advisor for the American Academy of Family Physicians (AAFP) during testimony in front of the Senate Committee on Health, Education, Labor, and Pensions this week.
Whose job is it to ensure that health IT systems are capable of conducting the sophisticated level of health information exchange necessary to support population health management and coordinated care? How can the industry overcome its tendencies to use information blocking for financial gain? Can interoperability become a reality if stakeholders continue to operate in an environment of mistrust?
The healthcare industry’s mandate-driven leap into EHR adoption and health IT development has had both its pros and its cons. While the vast majority of providers have managed to implement certified EHR technology in a relatively short period of time, the hurried financial pressure to do so has left some organizations with systems that don’t meet their needs, don’t communicate well with business partners, don’t promote productivity, and don’t particularly improve patient care.
Organizational policies, implementation process flaws, inaccessible customer support, privacy concerns, and exorbitant data exchange fees all compound these problems, Kibbe said, leaving providers feeling like they have been set up to fail.
It’s easy to blame the regulators for the mistakes they may have made in the early days of meaningful use, or the vendors for pumping out poorly designed products, but that doesn’t take healthcare providers off the hook.
“In my opinion, the responsibility for assuring secure interoperable exchange resides primarily with the healthcare provider organizations, not the EHR vendors, and not the government,” Kibbe says.
“Health care provider organizations must come to realize that acting in the best interest of patients is to assure that health information follows the patient and consumer to whatever setting will provide treatment, even if that means in a competitor’s hospital or medical practice. And they must demand collaborative and interoperable health IT tools from their EHR vendors to make this routine and ubiquitous as a practice in every community in the United States.”
Providers may protest that in 2009, they couldn’t just demand better tools from vendors who didn’t yet know how to make them. The healthcare community has complained about being held captive by the strict deadlines and looming penalties of the EHR Incentive Programs. The ONC was slow to certify EHR products for Stage 2, leaving providers to choose from only a limited number of products by the time their reporting periods started.
Left with a choice between choosing a good-enough-for-now system and missing out on tens of thousands of incentive dollars, some providers implemented EHRs that later proved to be mistakes. More providers simply didn’t know what they were getting into when switching from paper to electronic workflows, and did not anticipate having to spend thousands of dollars to implement an initial EHR system that would allow them to attest for meaningful use – only to rip it out and replace it a few years later with an infrastructure that better supports health data interoperability. The cost isn’t fair, they have said, and the return on investment is hard to find.
Healthcare providers may have more choice of health IT products in 2015, but for many organizations, damage has already been done. It’s difficult to make a clean start with technology systems, and perhaps even more difficult to change the attitudes of staff members feeling disgruntled by past failures, lost hours, annoying alerts, and convoluted interfaces.
As Kibbe points out, however, a shift in perspective is a fundamental requirement for health data interoperability to flourish, no matter what the technical challenges. Healthcare providers are increasingly responsible for how a patient accesses and receives care across the healthcare ecosystem, which means that organizations must collaborate with their colleagues to ensure that services are coordinated, chronic diseases are managed, socioeconomic barriers are overcome, and patients aren’t receiving conflicting advice.
“Attempts to redress the root causes of information blocking must address the unwillingness of some providers and their EHR partners to share and exchange data, and not just the specific problems that may be encountered in making exchanges run smoothly and reliably,” Kibbe said.
A large part of the problem is that providers still have a financial incentive to play coy with the care continuum. Most healthcare providers receive the lion’s share of their reimbursement under fee-for-service contracts, which gives them little reason to collaborate with competitors who will simply be stealing revenue out from under them.
Shifting into a collaborative stance isn’t always an easy adjustment to make for organizations that have always fought rabidly for market share and patient loyalty. Even hospitals that are participating in data sharing and interoperability arrangements, including those who have agreed not to use their quality and performance data against their competitors, are reluctant to put all their cards on the table.
“In my opinion, that unwillingness originates in the current business models of some health care provider organizations, and the health care industry in general, wherein fee-for-service payment creates disincentives for sharing of health information and rewards information hoarding, or at least the delay of timely information exchanges,” Kibbe says.
Will the ongoing interest in value-based reimbursement and accountable care drive a sea change in the way providers view their competition?
“Changes to these payment incentives could do much to reward business models where collaboration and interoperability are highly valued, and where the technological capabilities, standards, and infrastructure for interoperable health information exchange now in place would be put to much better use,” he argues, and many other healthcare leaders agree.
Accountable care organizations have already proven themselves effective at bringing providers together around financial risk while raising the quality of patient care and population health management. Indeed, value-based reimbursement has been such a success that CMS is staking the future of Medicare on pay-for-performance arrangements, and private payers seem to announce new value-based collaborations and initiatives on a weekly basis.
Making health data interoperability a primarily economic concern shifts the burden of responsibility back to regulators and lawmakers who draw up payment schemes and fee schedules. Providers cannot do much on their own to change those, except to express their willingness to participate in them, and regulation is often slow to work its way through the process of development, proposal, public comment, and publication.
And where do vendors come in? Without products that allow for simple and intuitive health data interoperability, such as those based on modern data standards and health information exchange frameworks, neither providers nor regulators have much hope of enacting meaningful change.
Vendors must offer providers the tools they need to meet the continuing influx of mandates. More importantly, they must create and implement the infrastructure providers require to enact measurable improvements in workflow, communication, patient care, and financial outcomes while harnessing the potential of big data analytics.
Without all three parts of the equation working together – and taking full responsibility for the interconnected roles they must play in the continuing evolution of the healthcare ecosystem – health data interoperability will remain little more than a pipe dream. The healthcare industry has been building momentum towards solving many of its interoperability problems, but stakeholders must drop their defensiveness, break down the barriers of information blocking, and square their shoulders to meet the many challenges of patient care and health IT development that will surely always lie ahead.