“Interoperability” of Electronic Health Data Is a Unicorn

A version of this Health Alert appeared at Forbes.

Having spent $26 billion of taxpayers’ money since 2009 inducing hospitals and physicians to install electronic health records (EHRs), many champions of the effort are dismayed that the EHRs are not interoperable. That is, they cannot talk to each other — which was the whole point of subsidizing the effort.

All this money has achieved a process goal: There has been a significant uptake in EHR adoption. According to a recent review, the proportion of physicians who have at least a basic EHR has increased from under 22 percent to 48 percent. Doctors were motivated by the bounty offered, plus the threat of having reimbursements clawed back in 2015 if they did not adopt EHRs. The proportion of hospitals with EHRs has similarly increased from 12 percent to 44 percent.

But what do these EHRs do? What they do not do is talk to each other. According to the same review, “only 10 percent of ambulatory practices and 30 percent of hospitals were found to be participating in operational health information exchange efforts.”

All those billions of taxpayer dollars are paid out to providers who attest to “meaningful use” of EHRs. However, there are three stages of meaningful use.  Stage 1 was easy: Plug it in and turn it on. Stage 2 was originally supposed to be achieved by 2013, but that has been pushed back until 2016. The hang up is that Stage 2 has a high hurdle for interoperability.

According to the final rule published in September 2012, requirements include “the expectation that providers will electronically transmit patient care summaries with each other and with the patient to support transitions in care. Increasingly robust expectations for health information exchange in Stage 2 and Stage 3 would support the goal that information follows the patient.”

Despite the delay, providers are still complaining that the requirements are too demanding. According to Russell Branzell, president and CEO of the College of Healthcare Information Management Executives: “Now the very future of Meaningful Use is in question.”

So it should be: Evidence from Congressional investigations suggests that meaningful-use bounties have encouraged the adoption of EHRs that are deliberately closed to exchange with other parties. The problem is that exchanging data with competitors is fundamentally against the self-interest of the party which created the data. Nobody would expect the U.S. Department of Transportation to set up a fund to incentivize car makers to exchange data with each other, or the U.S. Department of Agriculture to set up a fund to incentivize grocery stores to exchange data with each other.

That is not to say that there would be no value to such data exchange. If Safeway were out of my favorite brand of breakfast cereal, I’d love for the clerk to tell me that Giant had plenty in stock just down the road, instead of selling me something similar. However, the amount of government funding required to overwhelm competitors’ resistance to doing this would surely not be worth it.

The same goes for health information exchange: $26 billion has not done the trick. It is unlikely that the remaining $4 billion in the pot will get the job done. The Office of the National Coordinator of Health IT has been promoting a ten-year plan for more funding — even a trust fund like the Federal Highway Trust Fund!

Congress should be very skeptical of appropriating yet more funding to hunt this unicorn.

Comments (23)

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  1. Perry says:

    Once again, the government in its infinite wisdom has set forth a path that will be nearly impossible to follow.
    First, while interoperability for all EHRs is an excellent idea and could greatly improve health care delivery, the way they have gone about it does not encourage this.
    Secondly, what with all the stealing of information from Target and other entities, I have serious reservations about the ability of EHRs to protect my information adequately.
    Probably the most effective way of tranmitting medical data is through the patients themselves. I would be very wary of the Feds being in charge of this, though.

  2. Brian Williams. says:

    Great post, John. This sounds like standard government procedure. My neighbor who flies airplanes for the Navy once told me that his radio couldn’t contact Air Force pilots flying in the same airspace.

    • John R. Graham says:

      And the VA does not even have an EHR that works with the Defense Department. But the government thinks it can get all the private providers to get it done!

  3. Kenneth A. Fisher says:

    Not mentioned is the interference in the patient-doctor relationship, less face time with patients, poor histories, lack of physical exam skills. Copy and pasting reams of irrelevant information, internet security and via certification inhibiting newer, better and cheaper programs. Today’s programs are primarily for billing and not patient care.

  4. Big Truck Joe says:

    I agree with Perry – these EHRs are HIPAA breaches just wIting to happen.

    • Perry says:

      Social Security # and date of birth is all they need for major ID theft.
      And this from a government that can’t even get an online health insurance site right.

  5. Charlie Bond says:

    Good morning,
    I have travelled the country since 1992 talking about electronic medical records. In every talk on the subject my message is very succinct:
    When it comes to electronic medical records, the state of the art isn’t.
    Recently I have added:
    Meaningful use has no useful meaning.
    In the end, the only speciality that has benefitted by going digital is proctology–and the EHR mandates have had about the same effect . . .
    Charlie Bond

  6. Tom says:

    What you fail to mention in this article is the overwhelming expenses to physicians in clinical practice. Yes, the govt has provided financial incentives to this EHR monster but it doesn’t come close to covering the expenses associated with this Federally mandated nightmare.

    MU1 was not just simple plug it in and turn it on. Once you culled the info from the program at the end of the year, filled out the myriad forms, submitted it electronically and then had to resubmit your report by mail because HHS was not equipped to handle the influx of data you had dedicated a lot of man-hours just to be compliant. Now throw in the costs of the hardware, installation and IT tech support and this govt boondoggle is a financial nightmare.

    We did the math and have decided that we will not participate in MU2. The cost to meet all of HHS’ requirements and mandates vs the financial incentives we will receive for “cooperating” is a pittance of our overall costs.Yes, in 2016 I will take a hit of 1% reduction in Medicare/Medicaid reimbursement and each year going forward for a maximum cut of 7% but the overall loss is less than the cost of participating.

    If HHS goes through with implementing this ridiculous and irrelevant program I will cut my losses by seeing fewer Medicare/ Medicaid patients and thereby open more appointment slots for private payment plans. The only ones who will suffer from this program will be the patients. Perhaps that is what it will take to awaken the American public to this travesty and the heavy handed approach by the Feds to get what they want

    • John R. Graham says:

      Quite right. That sentence was a little flippant. There are many stories out there about how awful the hoop-jumping is.

  7. Greg Scandlen says:

    It’s okay. Don’t worry, be happy. Every penny of the $26 billion ended up in somebody’s pocket. These somebodies are highly motivated to contribute a portion to the politicians who gave them the money and promise to keep the gravy train flowing.

    The HITECH act totally achieved its goal of enriching some people at the expense of everybody else. Mission accomplished!

  8. Big Truck Joe says:

    I so heard the VA has been building an EHR for years and it doesn’t communicate with other armed forces hospitals so they are going to have to scrap it or use an uncooperative EHR.

  9. Tom says:

    Interestingly, the VAH/DOD EHR compatibility problem was granted an extension for them to come into compliance. No such extension has been offered to the private medical community; only threats of penalties, audits and large fines.

    • John R. Graham says:

      Thank you. Meaningful-use state 2 was pushed back, and standards lowered, as we’ve discussed at this blog.

  10. Narayanachar S. Murali, MD, FACP, FACG says:

    I have found the greatest benefit from digital records when patients carry their records in a rapidly accessible manner. So in my practice ( I DO NOT use any EMR because they are NOT usable). ALL my Patients have secure digital files or rapid access to it when /if they need it. I send (push securely) updated records after any significant evaluation or procedure. They can get these secure files on a thumb drive or we e.mail it to them securely. They are also asked to have a copy of consultation forwarded to me so that I maintain their chronological digital file. This costs me a lot in time and manpower costs but saves a lot of hassle for aptients, reduces mistakes and added costs at point of service, especially avoids CT scans in Emergency department when patients go with vague pains etc. Never underestimate the harm from good intentions. ( MR_EHR aside, a good common example is an unnecessary contrast enhanced CT scan land a patient in ICU with kidney failure or worse surgery for an incidentaloma). The satisfaction of outcomes among my patients is uniformly high.

    The CCHIT enterprise EMR data sharing is an albatross. The CCD document is a joke, totally useless and poor in needed content.
    I am very computer literate, I have yet to be able to access on first try, chronological patient history from from tertiary centers and regional teaching hospitals where I refer patients. They have invested heavily in the big name enterprise EMRs, which are just crappy to use, contain useless repetitive data entries of no value to patient care. These just don’t match the efficiency and usability of my office process which I have developed with lot of thought and research. If only we can access labs and X-ray results, that would be helpful. The process should be as easy as patient allowing very rapid biometric login, unfettered chart access when they are in the office. I can view/ print what I need. , close browser, EMR documents access on its audit trail.

    I see lot of non-physician, computer programmers here. If it interests you, PM me and I can give you a demo of desired workflow and how to get it right.
    Let us all think beyond mandates and 1-5% incentives or punishments from CMS. I have never found CMS incentives useful to me, my practice, my employees or my patients. SO I generally do the opposite of what they tell us to do and skip the incentives.

  11. Tom says:

    Dr Murali, Your system sounds like a great plus for patients however, as you admitted it is time and manpower intensive. In a practice like mine where 75% of patients are Medicare/Medicaid with constant cutbacks in reimbursement I can’t imagine tying up more overhead than I already have in EHR.

    It won’t be long before I start paying the govt to see their patients rather than the other way around.

  12. Don Freeman, PhD says:

    The answer is simple. Whereas institutional EMR has value for its constituents, the patients records, as noted above, need to be PATIENT CENTRIC. This can be done in a safe, incrypted manner, fully HIPPA compliant, at a cost of about $5/month usually.

  13. Tom says:

    $5/month per pt? if so, that is $60/year/pt With a practice of 5000+ active patient records that would constitute an annual cost of $300,000. I’m hoping that is not what you meant in your post. Additionally, how is the govt getting access to these records for their penalty creating audits?

    • Narayanachar Murali, MD, FACP, FACG says:

      Why do you think that is a huge amount. The CMS is willing to pay $100/visit EXTRA ( in addition to physician fee) to hospitals just for taking over physician practices!
      $5/chart/year is a reasonable fee for record maintenance. Alternatively charge the patient $5/record sent to them electronically. If the patient desires they ought to have the option of not paying it, but getting digital records once and updating / filing it on their own with no HIPAA headache for physician office. When people pay for something they value it. If you waste their time and cause “digital stack overflow”, they will regard docs as spammers and tune them out. If the government wants info, just ask for submission of record with bill, send that record for NLP-Electronic processing, digital filing and create silos that everyone with the need to know can access with verified credentials. ( Just don’t put lady Lerner type in charge of this project..!) . Let this be a government IT project. They are the ones who need info. I refuse to be their data entry clerk with or without incentive.

      • John R. Graham says:

        Especially as most patients only see the doctor once or twice a year, $5 pppm seems extraordinarily expensive.

  14. Tom says:

    Except that Dr Freeman quoted $5.00 / month, not /year.

    Additionally, I practice in rural NC. Ownership or even interest by the senior population for computers is small. Which means you have two systems or you stick with what will work for the largest segment of your pt base i.e.. EHR, unfortunately.

    Finally, there is no way the Feds are going to pony up that cash for records. By law HHS can request records and you are not allowed to bill for it when you submit them.

    • John R. Graham says:

      Thank you. Of all patient populations interested in electronic health records, the Medicare population may be the least interested.

  15. Narayanachar Murali, MD, FACP, FACG says:

    Agree, absence of uniformity of access among patients is a major hurdle of IT implementation. For busy physicians, requirign them to maintain multiple modalities of information sharing is a royal headache and expense that is not reimbursed by anyone.
    I am not so worried about the Angie’s list posting “worried well” who like to see their colonoscopy photos as much as the sick guy with cancer who needs urgent multispecialty input by doctors who have no time to log on to portals of different hospitals. If that sick patient is not able to carry digital file, there is a huge problem. It is even worse if the operating surgeon works in a tertiary medical center where the IT people will delete e.mail attachments of secured patient file. ( so the doctor’ nurse calls my office to get a fax! Photos do not show up well in BW fax and can lead to errors of judgement! This happens to me all the time. So I now send them a secure link to the file on cloud.
    They have a health information exchange in SC( SCHIEX), but they are quite backward. They cannot accept input from sources other than a few EMRs and that is just limited to the CCD document which is pretty useless to physicians. I cannot run my practice with an EMR because I cannot do my work! For such patients who really need to carry info and have no e.mail access or are unwilling to buy a thumb drive, I burn a disk and give them the access password. So back to making the patient the custodian of the record. It works!

  16. Narayanachar Murali, MD, FACP, FACG says:

    Even CMS auditors cannot receive a digital file. They request faxes! When will all this idiocy end?