As Criticism Mounts, Health Records Firms Chart Path to Data Sharing
The Great Recession devastated many industries, but health information technology was not one of them.
The stimulus package Congress and President Obama approved in 2009 included $29 billion in incentives for U.S. hospitals and clinics to adopt electronic health records (EHR) systems. The legislation ignited a period of explosive growth for companies that develop software for managing those records.
A 2010 White House report on using technology to improve healthcare envisioned an ideal setup in which all systems are “interoperable and intercommunicating, so that a single authorized query can locate a patient’s records.” The list of leaders whom the report credits for their input includes executives from two leading EHR vendors: Watertown, MA-based Athenahealth (NASDAQ: ATHN) and Epic Systems, based in the Madison, WI, area.
Five years later, the industry still seems nowhere close to achieving the functionality described in the White House report. Epic is among the companies chastised by critics who consider it a “closed platform.”
“It can be challenging and costly for hospitals [that use Epic] to interface their EHR with the clinical or billing software of other companies,” according to a 2014 report from the Rand Corporation.
Given that unfavorable assessment, it may come as a surprise that Epic was rated as an industry leader in overall interoperability, according to a report published earlier this year by Klas, a market research firm.
Observers are naturally starting to ask whether the $29 billion was money well spent. Anecdotes abound from people inside and outside the healthcare industry on the headaches that result from incompatible systems.
A key question is whether vendors are deliberately walling off their systems in an attempt to add customers. In June, Connecticut became the first state to pass a law banning the use of EHRs to block the flow of data. Politico reported that independent practices are accusing large hospital groups—including Yale New Haven Health System, an Epic client—of using their records systems to coerce the smaller groups, who might be on different systems or still using paper records, into joining their networks. Epic could not be reached for comment regarding the law.
By contrast, the Klas report found that information blocking, which it defines as intentionally refusing to share data, is rare.
Still, sectors like telecommunications and banking are light-years ahead of healthcare when it comes to data sharing, something industry-leading companies are now acknowledging by launching cross-vendor networks known as health information exchanges (HIEs). In 2013, Kansas City, MO-based Cerner (NASDAQ: CERN), Athenahealth, and five of their peers formed CommonWell Health Alliance. According to the association’s website, its goal is “to drive forward ubiquitous interoperability.”
Noticeably absent from CommonWell is Epic, which belongs to Carequality, another vendor collective. On Monday, Carequality announced it has published an interoperability framework, which it said is an alternative to “one-off legal agreements” that have heretofore been necessary any time organizations wished to share information.
Last month, during a panel discussion at a healthcare technology conference in Madison, Bob Robke, vice president of interoperability at Cerner, invited Epic to join CommonWell.
“We have a lot invested in CommonWell, and we’d love for Epic to be part of that,” Robke said. “That would guarantee [its] success.”
Peter DeVault, Epic’s interoperability director, did not say whether it would join. Instead, he explained that Epic will proceed based on the wishes and needs of its customers, and that scrapping its interoperability work in favor of CommonWell would be “going backwards.”
“The way we operate is our customers say who they want to connect to,” DeVault said. “If they want to connect to CommonWell, we can make it happen. We have nothing against CommonWell.”
He went on to say that there will always be a need for multiple systems.
“This is the world we will always be living in,” DeVault said. “There’s no magical future down the road in which there’s one HIE called CommonWell.”
The focus of vendors should be to “make sure that Carequality, CommonWell, and all the HIEs can communicate with one another,” he added.
Experts say one thing that would help the industry get to that point faster is a more modern standard for data exchange, which has been in development for years and health systems are just now starting to use. Another idea is a nationwide patient identifier, which could help reduce costs and documentation errors. Let’s examine both concepts.
Fast Healthcare Interoperability Resources (FHIR) is a much-anticipated standard for exchanging health data electronically. It’s the latest in a line of standards developed by Health Level Seven International (HL7), a nonprofit based in Ann Arbor, MI. According to its website, HL7 is used at more than 1,600 healthcare organizations that span more than 50 countries.
Grahame Grieve, an interoperability consultant who is co-leading the FHIR project, says one reason it has many leaders in healthtech excited is that FHIR would bring health data exchange into the latest era of computing. Whereas previous HL7 standards were developed using a document-centric approach, he says, FHIR is built around “resources,” meaning individual sets of information like lab results or medication lists. Clinicians can pinpoint the data they need faster with this change, part of a broader shift to a modern, Web-based framework that uses application programming interfaces (APIs) to send and receive data.
There is buzz surrounding FHIR not only because new technologies are being used, but because they’re being incorporated in an intuitive manner that leverages the prior work done on HL7 standards, Grieve says.
“The content is deeply aligned with what [users have] done in the past,” he says. “That makes it an easier transition. A big part of why people like FHIR is it takes the knowledge of having done this stuff for 40 years and adds it to the [latest] technology. That combination is proving very attractive to implementers.”
Indeed, Grieve says EHR vendors have partnered with some of their most prestigious customers—Cleveland Clinic, Duke University Hospital, and Mayo Clinic among them—to set up FHIR-based connections. Some of them are already live, he says.
But many health systems will have to continue waiting. Arien Malec, vice president of data platform and acquisition tools at RelayHealth, a subsidiary of McKesson (NYSE: MCK), said in an interview that he expects U.S. hospitals and clinics to upgrade their technology to support FHIR-based APIs in the next two to three years. Grieve says next year, his group will release a “working” standard that’s not fully fleshed out but will have “some well-recognized, solid parts.”
“That’s what the big EHRs and the government will be targeting,” he says.
But the new data-sharing tools won’t fix all the problems.
When a new HL7 standard becomes available, health systems don’t often go back and upgrade previously installed connections, says Dan Wilson, founder and CEO at Moxe Health, a Madison-based startup focused on EHR integration.
“FHIR isn’t going to replace the need to continue leveraging [existing] HL7 interfaces,” Wilson says. “Vendors aren’t going to go back and retrofit a bunch of interfaces that already exist, and health systems aren’t going to rip out and replace interfaces that are already in place.”
Plus, said Robke, the Cerner executive, getting all the technical pieces into place is only one step in the effort to improve the ability to share patient records. Parties must agree on terms—like whether patients must opt-in for their records to be shared, and who will pay to set up the connections—and ensure they don’t violate patient privacy rules or any other law.
“The emergence of FHIR will hopefully make things simpler,” Robke said at last month’s panel. “But [it’s] just a standard. You still need contracts and governance.”
Still, healthcare providers and EHR vendors believe FHIR holds more promise for improving interoperability than any of the cross-vendor networks that have been formed to date, according to a Klas survey.
“I think Klas is right in that CommonWell and Carequality are inherently limited in their scope by the commercial arrangements around them,” Grieve says.
Lack of Identifier an Obstacle
Medical records software companies are often the ones blamed for making records less portable, but some industry observers contend the federal government could do more to enable record sharing.
In fact, that was part of the original intent of the landmark 1996 law, the Health Insurance Portability and Accountability Act (HIPAA). According to a 2009 book by researchers at the Institute of Medicine that analyzes parts of the law, it included a directive for the secretary of the U.S. Department of Health & Human Services to come up with “standards for unique health identifiers for patients, employers, health plans, and providers” across the nation.
But within a couple years, that changed. When deciding on appropriations for fiscal year 1999, legislators added language to the bill saying federal funds couldn’t be used to support the creation of a nationwide patient identifier. The same language, which was born out of patient privacy concerns, has appeared in appropriations bills every year since.
“The single biggest information block is the federal government’s block on having a single patient identifier,” argues Grieve, the FHIR co-leader. “Matching patients is hard and expensive. [In] Germany, everyone gets a healthcare identifier at birth, and it saves them lots of money for exchanging data and building clinical interoperability systems on top of the data.”
Between 8 and 14 percent of medical records contain inaccurate information, owing to a mistaken patient identity, according to industry estimates. “The result is increased costs estimated at hundreds of millions of dollars per year to correct information,” along with potential hazards to patient safety, according to a 2012 Healthcare Information and Management Systems Society report.
The auto industry faced a similar problem until 1981, according to a report on the website Healthcare IT News. Even though the National Highway Traffic Safety Administration introduced the vehicle identification number in 1954, for decades, manufacturers used different formats for the identifier. When the federal agency standardized the format, it became easier to track thefts, recalls, and collisions.
Time will tell if the government takes similar action in healthcare.