Thursday, August 27, 2015

Mutual self-interest leads to antitrust concerns

We have a bright new Attorney General here in Massachusetts who has already earned her bona fides with regard to putting the brakes on economically unsupported market power expansion by the local dominant provider network.  That corporation, Partners Healthcare System (PHS), has now indicated that its primary expansion activities will be outside of the United States, but that statement hides a bit of misdirection.  Indeed, PHS remains focused on maintaining its hold on physician organizations and its overall market share here in the state.

It is on this front that the provider group is engaged in a relationship with one of the country's largest electronic health record companies, Epic.  And it is here that the Attorney General should rejoin the antitrust battle--not only in Massachusetts on her own--but in cooperation with Attorneys General in other states.  The target, though, should not be the provider groups per se, but rather the EHR corporation.

What we are seeing here is a remarkable reinforcement of mutual self-interest in the behavioral patterns of the two entities. Here's how it works.  Partners enters into a contract with Epic for the construction of an EHR for its facilities.  The two organizations go to the Partners-affiliated, but independent, medical practice groups and tell them that they have to install the Epic EHR--even if the EHR they have had for years is perfectly adequate for their purposes.  If a doctors' practice asks why they can't keep their old system, Epic makes clear that interoperability between its system and the practice's legacy system is not feasible.  Meanwhile, to clinch the conversion, Partners also informs the local practices that failure to install the Epic system will foreclose those practices from participating in the favorable insurance contracting relationships it enjoys.

It is in this manner that the Epic-Partners actions box out the competition in this market, acting on the pair's mutual self-interest.  They are complicit with each other in helping to ensure that PHS keeps its network strong by holding on to physician groups and that Epic expands its market power by expelling established competitors.  This may not be your usual type of anti-trust activity, but it is anti-trust activity nonetheless.  And you can bet it is happening in other states as well.

In the past, Attorneys General have joined forces on matters of interest to many states--public health, environmental protection, and the like.  Here, we have a pattern of behavior that seeks to limit competition in an arena of great importance to the public well-being. I hope that our new AG puts this case on her list of priorities for her term of office and seeks allies from other states to join her.

41 comments:

Anonymous said...

Hi Paul,

Remember reading an article by Dr. Halamka of BID, as you know one of the visionaries in medical information technology systems and their interaction. He said he had a "magic button" that converted data back and forth from Atrius EPIC system to BID's homegrown system, which is now being developed by Athenahealth also.

So why can Dr Halamka make interaction with EPIC work, but no one else can?

I don't know the answer, but seems like an interesting question?

Paul Levy said...

I don't recall that it was back and forth. As I recall, it was from BIDMC to Atrius, i.e., an Atrius doctor using Epic could push the magic button and get full access to the BIDMC patient record. I don't know if the reciprocal capacity was ever installed, i.e., allowing BIDMC doctors to peer into the Epic system to see the patients' records there.

Here's his article from 2010: http://geekdoctor.blogspot.com/2010/01/atrius-integration-is-live.html

I don't recall a follow-up. I recall frustration with Epic's slowness is following through. My memory is that when I left BIDMC a year later, the reciprocal capacity had not been installed.

Barry Carol said...

If BIDMC’s technology to make the Epic EHR system interoperable with other systems works, it sounds like a good potential business opportunity to sell or license it to other hospital systems and provider groups. Perhaps payers, for their part, could create an incentive to make these systems interoperable by offering to pay a bit more if they are or a bit less if they aren’t.

The mindset to resist interoperability is intended to keep as much care (and revenue) within a hospital’s system as possible but it works against the interest of patients who may need the timely transfer of records between hospitals, especially in an emergency, so doctors treating the patient can have all the information they need to provide appropriate care without adverse interactions. This looks like selfish behavior to me that probably would not stand in other industries.

Paul Levy said...

Barry,

Note above that BIDMC desire was to provide interoperablity to the Atrius doctors. Brigham and Women's Hospital, part of Partners Healthcare System, had had a referral relationship with Atrius for the previous 20 years. They had often promised to give Atrius that capability but stubbornly refused to provide it. There was nothing about what Halamka set up in roughly 60 days that BWH could not have at some point during the two decades.

But providing interoperablity was counter to the PHS strategic plan. This point was actually made by PHS at a financial briefing to bond investors in NYC--where they used the fact that interoperability was NOT available as a feature securing their finances--by making movement of patients out of their network more difficult. Folks on Wall Street found that an attractive strategy, too.

Paul Levy said...

Finally, as late as a few months ago, Epic was charging a high fee to export data from one of its systems to other EHRS. Under pressure from Congresspeople, this fee was eliminated.

Story here: http://www.healthcaredive.com/news/himss15-epic-to-remove-data-sharing-fee/387480/ The quote:

"Epic Systems has revealed that it will no longer charge a fee for data transfers between Epic customers and non-Epic customers through its Care Elsewhere module. "We're not going to charge for Care Everywhere for at least until 2020," CEO Judy Faulkner said.
Up until now, clinical messages sent to an information exchange were priced at 20 cents apiece and incoming messages from a non-Epic system cost $2.35 for that patient for a year for unlimited messages, according to Faulkner."

Now, that might not look like a large fee, but consider that you need to multiply it by thousands of patients per year. It adds up. Plus, that's not the whole cost. There's programming and such that you need to carry out to make it happen.

It is also not interoperability of the sort that allows you to "look into" the other EHR, a la Halamka's magic button, which truly facilitates the clinician's job. It is a porting of data from one system to another.

Anonymous said...

Thanks Mr. Levy! I am sending your blog links and questions to every legislator and senator in my state, including Atty General, etc. as to WHY they are not taking action like this to protect taxpayers, everyones' Grandma, and basically everyone seeking health care, on these issues. Stuff like this affects us all.

I've been hitting them up with emails, multiple ones, sometimes in a week. I'm very vocal. Thank you for bringing stuff like this up so we can hit these guys up on the lack of what they do for people.

Govt is to be by the people, for the people, of the people, not rich folks, your friends, and businesses.

Dr. R @ cptips.com said...

As a practicing physician and prior medical director, your comments are right on. The EMRs (as currently structured) not only decrease the value of an in person visit as the physician is "forced" to do needless housekeeping tasks, without providing the prompts and backup safety checks promised, but they subtly change the character of referral patterns. It is difficult for those not involved in actual care and referral to understand how this works, and I know that the key interoperability requirement (what is most important to the practicing physician - summaries and lab/imaging data) should be easy to accomplish, IF EPIC and the medical organizations wanted it to. Basically as easy as sending a secure email - or making a comment on this blog.

Anonymous said...

I get the impression that Halamka's "magic button" is for two way viewing. Each side has one for the other, but correct me if I am wrong. The articles mention the topic are below.

Though he did say he thought it was cumbersome the more separate EHR systems were involved.

http://geekdoctor.blogspot.com/search?q=magic+button

There are also other major efforts on interoperability....

Halamka was also working on another issue, the "Argonaut project" which is design to enhance interoperability among EHR's and inludes: EPIC, Cerner, Meditech, AthenaHealth, BIDMC, Partners, Boston Children's and the Advisory Board Company. Here are some articles on it.

Was wondering how this project was coming along.

http://geekdoctor.blogspot.com/2014/12/the-argonaut-project-charter.html
http://www.ca-hie.org/blog/jason-task-force-and-the-argonaut-project

There is also the "commonwell health alliance" which includes: cerner, athenahealth, allscripts, McKesson, Greenway and others...Meditech is also a contributor. They are also pursuing EHR interoperability.

http://www.commonwellalliance.org/members/


The Massachusetts State, HIE effort appears to be successful. It appears all participating systems - in masshiway - could talk to each other. EPIC doesn't appear to be a participant

http://www.masshiway.net/HPP/Resources/ParticipantList/index.htm

http://mehi.masstech.org/ehealth/health-information-exchange


Not sure how there efforts are going.

I know interoperability is important. All major vendors and providers should be forced to participate in my view.

N.M.


Anonymous said...

Thank you for this post. Unfortunately, there is a lot of fear in discussing this issue.

This isn't just happening in Boston, here is an article from the Portland Business Journal by the CIO of Tuality Healthcare .

Full text below:

Recent Congressional hearings that focused on electronic health record systems are drawing national and local attention to the barriers to making important health information available at the right time to every provider who cares for us as patients.

Providers are discovering grave limitations of EHR systems that thwart sharing data with clinicians using other vendor systems.

Five years into the federal EHR Incentive Program, with billions of dollars invested, patient data is still not moving as it must to support high quality, coordinated care.

Frustratingly, many of these barriers come from business practices, not technical limitations. In key markets, the presence of a dominant EHR vendor allows large health systems to “box out” clinicians using different EHR systems. The victim in this market strategy is always going to be the patient.
In Oregon, the state has teamed with the federal government to expand Medicaid and retool payments for providers serving Medicaid patients, with the goals of better health, better care and lower costs for these patients.

Oregon contracts with 16 regional organizations tasked with improving quality, sharing financial risk, and coordinating their patients’ physical, mental and oral healthcare. This model depends on coordination among providers sharing information across a community, for instance between primary care and mental health providers, between specialists caring for patients with complex medical conditions, or when hospitals discharge patients to long term care facilities.

Unfortunately, that coordination is severely limited by business practices that create walls around a patient’s data, and block its movement to other EHRs.

More specifically, a majority of hospitals in Oregon use the Epic EHR. The techniques used by Epic to “box-out” competitors and gain market share include charging their own customers transaction fees for exchanging data with non-Epic systems and requiring expensive proprietary interfaces designed for long-term profit.

These strategies generate substantial rewards for some EHR vendors, and make it easier for large health systems to convince some smaller organizations to use a shared EHR platform. While this may seem like positive outcome, it actually perpetuates the problem of critical information locked out of — or locked within — the largest vendor’s system.

Many practices are feeling forced to scuttle EHR systems they like — more affordable, interoperable systems, better suited to their practices — in order to exchange basic information with users of the dominant regional vendor. This is playing out around the country, just as it is in the Portland metropolitan region.

Every time we need care, we face risks if our providers are missing our health information. We all have a stake in pushing EHR vendors toward less self-serving mindsets.

We need to stop enabling market dominance, and work for a system structured to support better, safer patient care through real EHR interoperability.

Sonney Sapra is the Chief Information Officer of Tuality Health.

Paul Levy said...

Dear NM (anonymous),

I'm sure John Halamka can update folks on those efforts, but the simple fact--that any and all of us know from our own experiences in the medical system--is that for the most part interoperability does not exist. When was the last time you went to a doctor in one health care system who could seamlessly (in real time) get access to your medical record, a test result, or an image from another health care provider system?

The point of today's column is that this situation is not an accident. It is a direct result mutually supportive strategic business interests of both certain provider groups and certain EHR suppliers. I make the case here that actions in pursuit of those mutual interests also act in violation of our anti-trust laws.

Anonymous said...

Paul,

I agree with the premise that obstruction of EHR interoperability, when it enhances the business interest of firms like EPIC shouldn't be allowed. And should be opposed with legal action if necessary.

I also wholeheartedly agree that interoperability has worked poorly to this point in time, from everything I have read and heard.

But I also would like to know if the "Argonaut Project" (which EPIC is participating in) is working to improve interoperability. Are positive efforts being made? [The same is true of other interoperability efforts like "commonwell health alliance", which Epic is not participating.

Are there efforts making real progress to improve interoperability or are they "false flag" operations designed to delay and confuse, those who want to take action, like you? [and me]

I also think the Mass State HIE Project could force EHR vendors who want to sell or lease their software in Massachusetts to interoperate.

Just like Europe can force software vendors to meet certain standards to operate there [latest example is protecting privacy] , the same can be done in Massachusetts. Or possibly rather than just Massachusetts, we could band together with other like minded states to achieve a common standard of interoperability that every vendor who wanted access to the Massachusetts [consortium of states] health market must achieve.

N.M.

Paul Levy said...

I'm not optimistic. See this article by Darius Tahir from Politico: https://www.politicopro.com/go/?wbid=59482

'After several weeks of discussions and testimony, members of an ONC task force agreed today that interoperability is advancing without the need to confront a lot of bad actors.

“The market is moving in the right direction, but not fast enough,” said Paul Tang, chair of the Clinical, Technical, Organizational and Financial Barriers to Interoperability Task Force.

“We didn’t hear a lot of blocking with malice,” said Micky Tripathi, founder of the Massachusetts eHealth Collaborative.

Consensus emerged in the eight-member group that many of the interoperability solutions in the market — such as Direct and the various networks — are quite young and that sorting out the foundational work will produce the desired effects. That means building infrastructure and creating metrics to define what interoperability is and where it’s lacking, said Tang and others.'

My comment: Oh, please! The folks who have created the problem say that the solution is coming fast enough? And the new "standard," from the New England guy, is that "we don't hear about a lot of blocking with malice"?? How about a standard that says, "This should work, now, for any doctor or patient who needs it."

Anonymous said...

Paul,'

Again I go back to Halamka's "magic button"[see above]. If something like that can be done in the short term until longer term infrastructure issues are resolved (assuming goodwill)....maybe there is a short term way to help doctors now, until the longer term infrastructure is resolved.

But the magic button would have to be for all major vendors including epic and maybe managed by someone like Masshiway or Mass ehealth Collaborative.

Barry Carol said...

Health systems like PHS have been telling anyone who would listen for a long time that they have great hospitals, wonderful doctors and they provide terrific healthcare. Patients often travel great distances to seek care at PHS facilities, especially its flagship hospitals. If all that is true, why are they so afraid of EHR interoperability?

I think I know the answer. It’s because they use their market power to extract well above market prices from payers and EHR interoperability would make it easier for referring doctors to send patients to less expensive providers who can deliver equally good care at a significantly lower cost.

The original merger between MGH and B&W had more to do with enhancing market power with payers than anything else. I think regulators or legislators should change the rules to allow payers to contract with either MGH or B&W without having to accept both hospitals into their network or neither.

In the meantime, taxpayers shouldn’t be subsidizing the installation of electronic record systems, especially in hospitals, unless they’re interoperable in a way that’s meaningful and user friendly for clinicians.

Anonymous said...



http://www.healthcareitnews.com/news/mass-hiway-moves-next-exchange-phase

Isn't Mass Hiway doing some (much) of this now?

Extract from article above:

"The Mass HIway went live for use by the Massachusetts healthcare community on Oct. 16, 2012. At the launch, Patrick's physician sent the governor's medical record across the state securely over the Mass HIway in real time. In its first year, 55 institutions have connected and are using the Mass HIway to support care coordination, case management, quality reporting and public health.

At the Jan. 8 [2014] event, emergency department clinicians at BIDMC simulated an encounter where a patient was unresponsive. Using the Mass HIway, doctors discovered the patient had medical records at Atrius Health, Holyoke Medical Center and Tufts Medical Center. Doctors used the Mass HIway to request and retrieve the records. With a comprehensive medical history on the patient, the care team avoided drug-to-drug and allergic reactions, duplicative testing and delayed diagnosis, and was able to treat the patient with greater speed and safety."

See the link above for more details...

NM

Paul Levy said...

1 - Look at the list of Health Information Services Provider (HISPs) and see which vendor is missing. http://www.masshiway.net/HPP/Resources/ParticipantList/index.htm

2 - Look at John's quote: "I can imagine a day in the next few years, when all patients in the Commonwealth, with their consent, benefit from secure, coordinated care." As noted, this remains in the future.

In the meantime, though, you've gotten a bit off topic from the thrust of my post.

Paul Levy said...

Also, I wonder, and here's where experts can tell us more, whether Mass Hiway is the kind of interoperability that results in real transparency. From the description, it seems to rely on a query, a response, and then an additional query and response. That's good, but quite different from being able to directly look into the patient's record, a la the Magic Button we set up for Atrius to look into our BIDMC EHR. That approach required no additional query or password--just a seamless view into the BIDMC EHR by the Atrius MDs who needed the information in real time.

BP BP said...

My comment still awaits "moderation" I see.
Pity.
Bharani Padmanabhan MD PhD

Paul Levy said...

Your comment accused a person of being a criminal. I don't post personal attacks like that. Please feel free to resubmit it with that sentence omitted.

Anonymous said...

Partners has a similar Magic button integration with atrius too. Both in prior EHR and Epic. Not sure if any differences between that and bidmc version. Are you aware of any relevant differences?

Paul Levy said...

Does it go in both directions, i.e., can you look into the Atrius EMR from a Partners hospital or doctor's office?

Robert Rowley MD said...

The kind of scenario you describe is a good illustration of the current dynamics of healthcare organizations. It is not a unique or isolated event. Large healthcare delivery organizations want to find a way to put all their clinical information on a platform where data is shared by everyone delivering care – and collaboration across settings of care is increasingly important in a value-driven model. It is natural to expect that such an institution will search, consider, and settle upon an enterprise EHR vendor with whom to partner and deliver this vision.

Not uncommonly, the institution will try to lean on community physicians to rely on them, capturing and consolidating local market presence, and they do so by pushing their EHR technology out into the community, even if local practices are using something else (perhaps something better suited for their own particular workflows, rather than the “generalist” EHR pushed out by the institution). We see this in communities across the country.

There is the assertion that data integration and migration “cannot be done” and that interoperability with what a community physician has in her practice won’t work. This is not exactly true, but it is sentiment used in coercing physicians to adopt the institutional EHR.

So long as health data remains institutional-centric, and remains siloed that way, I don’t think this dynamic will change. In my view, the only long-term solution comes from de-coupling health data from within the EHRs, and aggregating it into a longitudinal patient-centric record that follows the individual wherever they go, through institutions, practitioners and health plans. I’ve blogged on this more here.

As an interesting side-effect of having a universal data store be able to capture and normalize data (such as CCDA data, or any of a number of other data feeds), is the ability to use it as a data-migration bridge from one EHR system to another. I recently moved from one EHR (and obtained CCDAs for all my patients from the old system) to another one. I have been able to move those CCDAs into the universal data store, and then output that data into the new EHR (via APIs that the EHR makes available).

This experience leads me to really question that “interoperability is not feasible.” That has not been my own experience.

I believe that the next generation of EHRs will be ones that do not have to manage all their clinical data internally, but instead interact with universal shared data. They will be therefore lightweight, and many in number, focused on specific use-cases that will actually help those workflows function better. Data migration is no longer an issue. An EHR can easily be swapped out for one that works better in a particular setting, much like we swap out cellphones or computers – so long as the real content (the clinical data) is in the cloud, then the particular device or app is merely a matter of individual preference. Such a vision is a major challenge to the current state of large institutions and the enterprise EHRs they install.

Anonymous said...

Thanks for writing this Paul Levy. This scenario is happening in other states, and it's too bad that fear of retaliation prevents people like me from being as courageous as you in speaking out publically. But, I am going to send a copy of your blog to the Attorney General in my state.

Anonymous said...

Hi Paul:

Great post. It's worth looking at SB 811, now Public Act 15-146 in Connecticut, which passed in June. The bill was authored by the bipartisan Senate leadership and aggressively takes on the use of EHRs as a tool of market dominance. Among many other things, Public Act 15-146:

-Requires the state to establish a health information exchange
-requires all EHR systems in the state to be interoperable with the state exchange.
-enshrines the patient's right to control release of the records
-Creates a new unlawful act: "health information blocking," which is the unreasonable refusal to share patient data with another provider. It's purpose is to stop what you describe as Partners' behavior in bullying small providers into adopting EPIC and ultimately selling themselves to the hospital or health system.
-Makes health information blocking a violation of the state Unfair Trade Practices Act, which allows aggrieved parties to sue and recover attorneys' fees, punitive damages and treble damages.

This is not to say that Attorneys General shouldn't exercise their anti-trust power in this area, but these are additional new tools. If the state succeeds technically, it will create market openings for less expensive products and take this particular whip out of the hands of the big systems.

Leonard Kish said...

Robert Rowley is spot on, data shouldn't be an asset or tool used to drive lock-in of technology or business model. Common data stores could help prevent anti-competitive practices.

We need to see some real evidence. From what I've heard, it's a pervasive, widespread practice, and VERY serious. This is a patient safety issue and a civil rights issue. It's no accident that HHS has an office of Civil Rights. Access to the best care available is a civil right. Denying access to patient data is effectively denying that right to physician and patient alike, and, we could expect, worse outcomes.

Perhaps an investigation is what's needed to surface these practices.

Anonymous said...

What do you suggest the AG tell Epic? (Since your focus is more Epic-focused as opposed to Partners) It is a pretty simple "sell" to say that interoperability is better when all parties are on the same system/vendor.

Epic won the Partners business fair and square. Cerner, or any other vendor for that matter, would tell the independent docs the same thing. What vendor wouldn't? (And in most cases its probably true that interoperability is better when all parties are on the same system/vendor.)

This just looks like capitalism at its finest. Not sure what the AG should do? Tell Epic that they cant tell prospects about how they think they can improve interoperability between Partners and their practice? Tell Epic they need to change their product?

Anonymous said...

Paul,

Interesting that you did not mentioned that a number of Epic sites are part of the eHealth Exchange and sharing with non-Epic sites
(both ways). Also Epic has been part of CareQuality which is working with a number of other vendors in sharing
information (both ways). I do not use Epic but use the data that they supply to my organization through the eHealth Exchange.
This type of information has been going on for at least four years.

Regards,
Dean

Paul Levy said...

The last two comments don't go to the heart of my post--what I see as the mutually beneficial coercion between the medical provider and the EHR provider that acts to force a medical group to abandon an incumbent service.

Dean, thanks for mentioning the points you raise, as it's hard for those of us observing from the outside to know all the ins and outs of the field. As noted, it's not my purpose here to delve into those issues. But there are apparently some differences of opinion as to the relative merits of CareQuality versus Commonwell. Readers can find an interesting story here: http://healthitanalytics.com/news/epic-carequality-challenge-commonwell-on-ehr-interoperability

Based on what I hear from clinicians around here and elsewhere, it is not clear to me that eHealth Exchange solves the day-to-day interoperability issues, i.e., allowing an MD to look into the medical records of another system in real time while seeing a patient. Maybe you know more, but I have yet to find MDs who feel able to do that as needed (indeed, sometimes even from one Epic site to another.) Maybe it will happen some day. Meantime, I'd love MDs out there to tell us all if they find the current level of interoperability satisfying to them in their practices. And if they do, to give us the setting and how it works for them.

I think Dr. Rowley's comment above is particularly insightful on all these issues. I'd like to see people commenting on his points.

In discussing some of the dangers of market consolidation, I raised some similar points to Dr. Rowley's way back in 2010, here: http://runningahospital.blogspot.co.uk/2010/11/transparency-and-dial-tone-to-fight.html A quote:

"The second idea is a simple as dial tone: Complete interoperability of medical records among providers. As long as proprietary electronic medical record systems exist, a given provider network can control the degree to which patients can choose lower priced or higher quality doctors and hospitals outside of that network."

Anonymous said...

Dr. Rowley,

I am assuming that you are saying that we have a single universal cloud based repository of clinical information. We already have a number of cloud based clinical data repositories that act in data silos. A number of the ambulatory vendors support this model. From my crystal ball, it looks like Epic and Cerner are headed this way to with their rather large capital investments in IT infrastructure on there respective campuses.

If you are talking about a single repository that all vendors use, I want to understand who controls that and for what use. Sounds like the Learning Health System, which is to consume all data and use it for population, personalized and precision health. So eventually once they have copies of most of the data, than it starts to be easier to switch to a centralized model. Sounds exactly what ONC is laying the groundwork for. Keep an eye on Lucca Savage (ONC Chief Privacy Officer) as she works on the policies for this to happen. I am personally concerned about the who stores and provides access to all my data. Hope they have not only policies in place, but security to prevent breaches. Whoever has this type of information is going to get attacked. The Federal Government cannot protect its own as seen by the OPM breach in which federal employees, retirees and contractors most sensitive data was accessed.

Dean

Dr. R @ cptips.com said...

As a practicing physician who has worked with dictation and paper for most of my professional life, I have to say the current system is cumbersome as a stand alone, and with the clunkiness of whatever interoperability is provided limits the effectiveness of this data in the general office visit.

The idea of common cloud data (not formatted with plenty of extra verbiage that is vendor specific) , well protected, and equally accessible by all systems (transparent), is the ideal to be strived for. Then each vendor can sell thier formatting and ease of use only.

Anonymous said...

Hi Paul -

Thx for response. Understood what you said, "mutually beneficial coercion between the medical provider and the EHR provider that acts to force a medical group to abandon an incumbent service.

However, you called on the AG to act. "And it is here that the Attorney General should rejoin the antitrust battle--not only in Massachusetts on her own--but in cooperation with Attorneys General in other states. The target, though, should not be the provider groups per se, but rather the EHR corporation."

My question was: what action do you suggest the AG take on Epic.

If you dont feel this is getting at the heart of your point, disregard.

I enjoy your blog by the way! Thanks for running it!

InformaticsMD said...

The government will push for interoperability as far as its industry masters will allow.

Blog writing, pleading with politicians, and similar measures will accomplish nothing because Big Money is the issue here.

I know this from almost two decades at this type of activity.

Dan W. said...

Dr. R. Succinctly summarizes the fundamental EHR requirements for which which clinicians, primarily, should be the ultimate acceptance decision makers/ and dissonance arbiters. To the extent that a specific vendor, whether EPIC, CERNER, SIEMENS, etcetera has the capability to achieve sufficient clinical (not, CIO, CFO, OR COO) acceptance majority, I have no problem. That said, we should, wherever possible and meaningful, avoid custom interfaces which tend to introduce greater complexity and access risks.

Dalai said...

Interoperability is certainly a tremendous concern, but as a physician, my primary concern is with operability, or lack thereof. I've blogged for years about the deficiencies in PACS software, and those are found in RIS and EMR systems as well.

My theory has always been that those who use the software are not those who buy the software. You add yet another layer of possible explanation as to why this horrifically-expensive software is as bad as it is.

Robert Wagner said...

While I am not a big advocate of government mandates, after having witnessed 40 years of industry efforts to achieve interoperability of both financial and clinical information, one of the few successful endeavors has for the most part been the government mandate for EDI of claims, payment and eligibility data. With respect to digitized health records there are numerous impediments. Most are either self preserving business tactics or too many very intelligent folks developing and trying to promote their own solutions. In the mean time I would guess that hundreds of millions or even billions of private and public funds have been expended to date with no resolution in site. I have to conclude that the Federal Government should add to current legislation or draft new regulations that mandate an industry standard with prescribed milestones for development and implementation. It has to be funded as well in a bipartisan and collaborative effort between the private and public sector. Unfortunately, this important issue does not get nearly as much attention as the seemingly endless number data breaches that currently plague all industries.

Anonymous said...

This all seems overly biased against Epic.
Why not illuminate us on what Cerner does, and how well it interoperates. Seems like a gripe session, with little substance. By the way, Epic is actively involved in HL7 FHIR... which is all about "interoperability"... These things are very complex, can be very political, and take a considerable amount of time and effort. If you are not part of the solution, you are part of the problem...
Just saying...

Archive said...

Well I guess this explains why leading EHR companies are not proactively developing technology that would utilize CCDA Direct protocol to truly move health information from one EHR to another. I do not work with Epic but I have worked with trying to exchange to Cerner and to Allscripts; the support to meet the Meaningful Use mandate is there to simply check the box but if you are actually trying to utilize this technology support is very thin.

With Direct, you can specify what data elements are needed from system A. These data elements are coded with a uniform coding standard (SNOMED, LOINC, ICD-10, RxNorm, etc.). All Meaningful Use-certified technologies can generate a visit summary CCDA that contains the information desired for exchange. While Meaningful Use specifies certain data to exchange such as problem list and labs, you can expand upon this if necessary.

All Meaningful Use compliant systems are also required to receive AND reconcile, but there is no requirement that hospitals or facilities actually perform any reconciliation. As a result there is little motivation to develop systems that reconcile CCDA in a streamlined an efficient manner. The EHR company has the least incentive to support and promote adoption of this technology because as you point out here there is an advantage to continue to support uniform EHR adoption, even though the core technology exists to avoid this.

Archive said...

After reading some of the other comments I would like to add my own opinion that action via AG, new regulation, or new mandates to require true interoperability. The problem is motivation: hospital systems and EHR vendors alike have no motivation to achieve EHR-agnostic interoperability in the current healthcare world where decreasing competition improves financial outcomes. One way to compromise the competition is to withhold data that could improve quality of care. Now those who are "in" your data sharing network can achieve outcomes greater than those who are "out." It is gross and shameful to see patient safety deprioritized this way, but not very surprising: when quality care is defined as being above average in outcomes there is no incentive to improve quality of care for patients not currently being served by your organization; keeping the average down improves the relative "quality" of your own organization.

What is truly needed is innovation that concurrently disrupts the EHR oligopoly and the health system oligopolies. Technology has advanced far beyond what Cerner, Allscripts, and Epic provide, and the lack of true patient-centered systems cannot continue. NLP charting, wearable technology, Bluetooth-enabled equipment, genetics data management: the need for integration extends far beyond institution-to-institution, we need EHR systems that truly support technology advances. I am a fan of Direct and think it is poorly utilized due to lack of motivation and not technology deficiencies, but I agree what would be optimal is the ability to share view-only EHR access to any verified provider for true interoperability.

HIT today provides so little added value to a hospital/system it is embarrassing. Truly. I believe an Elon Musk approach is needed: someone needs to get in the business of delivering healthcare with a focus on developing scalable, cloud-based, disruptive technology that will replace BOTH today's generation of clunky EHR's and the inefficient organizations that rely on them.

THE BULL said...

It's Epic not EPIC. After I read EPIC I go, blah blah blab blah..........

Anonymous said...

Does not hospitals also control non-salaried physicians by paying a huge portion of the costs for Epic instillation or replacement? When the parent hospital pays 75% or more for a private medical group's EHR, does that not limit the rewarded individual's or group's practice affiliations.

PACSFerret said...

In my mind it is symptomatic of the increasing commoditisation of IT/Informatics skills, reminiscent of early-mid- nineties, when 'downsizing' was a big thing. The notion was, downsizing + SLAs meant smaller, leaner IT departments. Trouble was, by downsizing, the skills to monitor/challenge vendors and SLAs also left the building. 'Downsizing' morphed into 'rightsizing', saving a little face while turning 180.

In this instance, somebody in an informatics context should be asking the question: If connecting these systems is not feasible - why? Interface engines have been around for 15 years or more and can do great things. Explain why, or sling your hook. But too few Informatics departments maintain the skills to critically challenge vendors, and end up having to accept the vendor's spin.

There are reasons behind commoditisation, though. Maintaining those skills has a cost, and they may not be used very often. It is possible to bake those skills into day-to-day life, but that reduces efficiency. Finding the right balance is key, but IMO the drive to Ford-like automation is far too dominant.

Martin