The Big Barriers to EHR Interoperability

In the June 17, 2013 issue of “InformationWeek,” reporter Chris Murphy asks Judith Faulkner CEO of EPIC, Jamie Ferguson of Kaiser Permanente and Frank Byrne of Wisconsin’s St. Mary’s Hospital: “what are today’s big barriers to EHR interoperability.”

Not surprisingly, they cited a laundry list of largely technical issues such as the need for data-definition standards, APIs and specialist systems, financial incentives and the lack of provider training.

These, of course, are issues but I submit that they are not the big barriers preventing providers from accessing a patient’s medical record at the point of care.  The two big barriers are myopia and government mandates.

Most legacy vendors, industry insiders, academics and government officials have a limited, myopic objective: “to make all patient records accessible to providers over the Internet.” They have an equally myopic approach to meeting this objective: “every provider must have an EHR/EMR system connected to a health information exchange (HIE).”

They persist down this myopic path even though we all know it doesn’t work.  We’ve spent nine years and more than $15 billion, yet neither civilian nor military providers can exchange patient records electronically or access a patient’s complete medical record at the point of care.

When Senators and members of Congress recently demanded to know why patient records still can’t be exchanged, advocates of this myopic approach urged patience—asserting that everything will work beautifully by 2016.  Given the lack of success to date and the technical, security, privacy and identification problems that remain to be solved, that’s highly doubtful.

Compounding the problem, the sweeping government mandates designed to achieve this myopic objective are, in fact, blocking innovation.  While ONC claims to want innovation, its programs make it almost impossible for new solutions to see the light of day!

The requirements providers must meet to satisfy the government’s massive mandates—that they adopt EMRs, meet MU requirements, connect with HIEs, form ACOs, adopt ICD-10, and so forth, leave providers overwhelmed with no time to consider or evaluate other innovative solutions.  In some cases supervisors have looked at other solutions, know they work but refuse to implement them for fear that doing so will interfere with the government-mandated programs.

So we keep doing the same thing over and over—expecting to eventually get a different result.  Isn’t that one definition of insanity?

Isn’t it time we take off the blinders and look for a different solution—one that works today and will work tomorrow?  We can’t afford not to.  The annual costs of continued delay are staggering.

Each year while vendors are focused on trying to match data fields and providers on trying to comply with massive government mandates, hundreds of thousands of patients are made sicker rather than better and a hundred thousand or so die from medical mistakes.  The human costs are incalculable.  Depending on whose estimate you believe, the financial costs fall somewhere between $100 billion and $330 billion annually!

Since today’s government-mandated solution doesn’t work and many doubt it ever will, what if we adopt a similar-but-different objective: “to make all patient records electronically accessible to providers and patients?” Period.  The differences? This revised objective removes the current requirement that provider records must be exchangeable over the Internet, and it brings the patient into the healthcare equation.

Suddenly, we’re liberated.  We’re free to turn today’s approach upside down! Now, instead of trying to standardize how providers keep records, we can standardize how we manage the disparate records providers keep.

Now we’re free to use technologies other than the Internet to aggregate and manage patient records.  Now we’re free to organize a patient’s records around the patient and give the patient control of them—so they can move with the patient rather than merely follow them.

Now we can be sure a patient’s record is complete, including electronically manageable paper records.  Now this complete record—including such documents as complete progress notes and operative reports, not merely CCDs, other summaries or insurance records—can be accessed in one place.

Now we can satisfy patient security and privacy concerns, avoid patient identification problems, and involve patients in managing their care.

We can do all of these, and more!  This isn’t a pipe dream.  Innovation in healthcare IT is alive albeit on life support.  When we overcome today’s myopia and government mandates preventing new ideas and approaches from surfacing, it will take off!

The fact is we can make a patient’s complete medical record from all their providers electronically available today so providers anytime, anywhere can coordinate their patient’s care, avoid mistakes and unnecessary tests, and practice better medicine.  And we can update it for the patient after they see a provider so it is always current.  Our MedKaz® personal health record system does this and more.

Best of all, we can do these things today, easily and inexpensively.  And soon we’ll be able to automatically send a patient’s record to anyone the patient authorizes, such as other providers, family members, care givers, and others.  Just imagine what this flexibility will mean!

How do we make this happen?  First, we must acknowledge that new solutions can work—perhaps even better than the one we have been pursuing.  Second, we must recognize that the needs of providers and patients drive our healthcare system, and that they hold the keys to success, not vendors, consultants or government.  Third, we must foster innovation and the testing of innovative ideas.

To do this, HHS should institute programs that support innovation, and establish a small department to promote innovation and manage new programs. Several suggested programs follow.

•    First, they should give grants to providers to test innovative solutions, as ONC did with Beacon Communities and the Robert Wood Johnson Foundation did with OpenNotes.
•    Second, they should stop the clock on MU deadlines and other mandates when a provider tries an innovative approach.
•    Third, they should require all vendors to provide interfaces so innovators and others can integrate with their established systems.
•    Fourth, they should aggressively publicize and promote innovative solutions—taking a similar-but-stronger approach than they are doing with Blue Button.
•    Fifth, they should encourage the DoD and VA to collaborate with HHS; their exchange problems are similar.
•    Finally, when an innovative approach has been tested and proven by providers to work, they should publicize it and push for its quick adoption.

If we take these steps, our self-imposed barriers will fall.  New ideas will get heard and tested.  Providers will be able to access a patient’s complete record when and where they need it to coordinate care, avoid mistakes and unnecessary tests.  Care quality will go up; costs will come down.  Patients will be able to participate in their care decisions.  Insurers, employers and government will enjoy lower healthcare costs.

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