If interoperable user-friendly EHRs are the key to value-based care and population health, why don’t we have them?
By Thomas Campanella
An Electronic Health Record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs are a vital part of health IT and can:
- Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
- Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
- Automate and streamline provider workflow
Interoperability in healthcare is the ability for devices, software, and information systems to connect within or outside the boundaries of physician practices and health systems to exchange and access patient data for the purposes of addressing health issues with individual patients and the general population.
EHRs can improve patient-centered care by sharing results among clinicians. Diagnostic decisions can be made more accurately and safely and be patient specific if EHRs show results among all the applicable clinicians that are seen by the patient.
The value of interoperability includes the following:
Reduced Medical Errors:
1. Interoperability offers organizations ways of preventing medical error deaths by making it possible to share data across systems and applications. This allows care providers to have a better understanding of how and why these errors occur and empowers them to act.
2. Simply standardizing data within a single healthcare system is not enough. To fully enable physicians to reduce errors, interoperability must happen externally across healthcare organizations – not just within departments in a single organization.
Increased Efficiency:
1. Presenting data to care providers in real time and in a consistent manner can boost efficiency across an entire organization. Real-time data and other healthcare analytics advancements would enable providers to quickly identify the root of a patient’s problem and empower them to make more informed and faster decisions. For example, an emergency room patient might need blood tests performed, costing the healthcare system time and money. With interoperable data, a care provider might access the patient’s health record and find they already had blood tests conducted earlier in the week with some other healthcare provider.
2. Seamless exchange of health data will not only cut down on the repetitive tasks physicians often perform but also on the administrative ones, such as patient data entry, greatly impacting the quality of care being delivered and leading to more cost savings and efficient workflows.
Tools that are connected to the existing patient record and EHR will be essential in identifying patients most at risk and assure resources can be allocated rationally which will have a positive impact on patients’ health, health costs and overall population health.
If EHRs are not interoperable, primary care physicians, for example, would not have a complete picture of their patient’s health status which could result in adverse consequences.
Patients’ health suffers and healthcare costs and population health are negatively impacted if there is lack of interoperability of Electronic Health Records.
Empowering the primary care physician
While it is important that EHRs are interoperable, it is also very important that the data provided to the busy clinician is both user-friendly and actionable, especially for the primary care physician.
Researchers in a VA-funded study stated the following: Electronic health records are overloading outpatient docs with info in “disparate files and folders rather than presenting comprehensive, actionable data in a context that gives meaning.”
The study, “Electronic Health Records’ Support for Primary Care Physicians’ Situation Awareness,” contends that EHRs “are not rising to the challenges faced by primary care physicians because EHRs have not been designed or tailored to their specific needs. As researchers see it, many EHRs as currently configured, make it too difficult for primary care docs to do their job in a streamlined and efficacious manner – requiring navigation through multiple screens and tabs to find basic information, increasing redundancy and decreasing efficiency.
Current EHRs are overloading primary care physicians with information in disparate files and folders rather than presenting comprehensive, actionable data in a context that gives meaning. EHRs should be redesigned to improve situational awareness for busy primary care physicians and support their tasks including reviewing patient information, care coordination, and shared decision-making.”
As noted above, EHRs should be redesigned to provide user-friendly actionable data for the primary care physician. As we find ways to provide primary care physicians with actionable data within the EHRs, the primary care physician will be required to take ownership of that data. As the role of the primary care physician expands as part of our risk/value-based world, it now becomes important that they operate in a team-centered approach to address their patients’ healthcare needs.
The primary care team may need to consist of nurse practitioners, physician assistants, social workers, disease specific educators (depending upon the risk factors of their patients), and staff that understand data analytics. Some or all of these positions could be employed, outsourced to third parties, or addressed through collaborated relationship within their community.
Because primary care physicians are the key to providing value-based care and population health, all of this will require changes as to how we pay the primary care physicians for the services they and their team provide. Some form of capitation or global payment needs to be implemented by payers to reward primary care practices for the multifaceted work and value they provide their patients and our overall health system.
Finally, as we find ways to provide primary care physicians and their team with actionable data within the EHRs, primary care physicians will be required to act on this data as part of their overall patient care.
The role of EHRs in addressing public health
A critical success factor in addressing a public health crisis is seamless communication and collaboration among all the key stakeholders. That communication and collaboration become even more challenging when multiple entities at the state, local and national level have different degrees of responsibility for public health as well as diverse regulations and policies. Compounding this challenge is inadequate funding for public health at all levels.
The only way such a multiple level and layered system can effectively operate would be to provide seamless linkages among all the key stakeholders with a common agenda. Information and surveillance systems and communication tools are necessary to bring together the critical data and related actions to adequately address our public health needs especially during times of crisis such as the COVID-19 pandemic.
Sadly, the lack of a seamless information and surveillance system and appropriate communication tools contributed to the breakdown of our public health system during the COVID-19 pandemic and contributed to the increased number of hospitalizations and deaths in our inner cities.
Specifically, the inability to adequately connect providers of care and non-profit and government social service and public health agencies as well as the lack of information relating to social determinants of health have a negative impact on the health status of our most vulnerable population.
Responsibility of disease surveillance is shared among federal, state, and local public health agencies, but to be effective those responsibilities require a seamless inter-connected information system.
Complete and interoperable EHRs allow access and data sharing across the public health system, facilitating better monitoring, and reporting of suspected and confirmed cases, treatment regimens and abnormal conditions.
As noted by an article in the National Library of Medicine: “In addition to research-related use of data, there is also a need for the collection and integration of data from EHR systems and its communication to public health information systems in order to inform critical policy making and intervention planning. Developing interconnected health data nodes that include, but are not limited to, EHRs, public health surveillance and reporting systems, disease registries, and patient-reported data is critical to a COVID-19 response and multiple other health conditions. An IT infrastructure to support public health that leverages EHRs and associated health data is needed.”
The long journey
As noted in a thoughtful article in JAMA in March of 2021, “The patchwork of the United States’ health care delivery is accentuated by fragmentation of information systems that silo populations and care settings and deepen disparities. Interoperability – i.e., computer systems’ ability to exchange information and put it to use – has been on the minds of policy makers, technology leaders, electronic health record (EHR) vendors, and health systems for decades; however, significant challenges have hampered the nation’s progress toward true interoperability.
The following are some of the key moments in how we got to this point with EHRs:
- In 1996, the Health Insurance Portability and Accountability Act (HIPAA) elevated security and privacy of patient data, standardizing what patient information was to be protected and how this had to be achieved.
- It took until 2004 for coordinated efforts, such as the national health information technology (IT) network to be created by the Office of the National Coordinator for Health Information Technology (ONC).
- This was advanced in 2009 through the Health Information Technology for Economic and Clinical Health (HITECH) Act which incentivized EHR adoption. The HITECH Act also created health IT policies and standards and promoted electronic exchange of useful health information between patients and clinicians via, what it termed, meaningful use.
- The 21st Century Cures Act, passed in 2016, further encouraged collaboration across federal agencies and between public and private organizations to improve the quantity and quality of information exchange.
- August 4, 2020 – ONC Cures Act that addresses interoperability and patient access to their EHRs was passed.
- On September 15, 2021, CMS published three FAQs which explain that CMS will not take enforcement action against certain payers for the payer-to-payer data exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized. CMS’ decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking occurs does not affect any other existing regulatory requirements and implementation timelines outlined in the final rule. Please review the relevant FAQs for details.
- On December 8, 2021, CMS announced the publication of a Federal Register Notice (FRN CMS-9115-N2) to formalize its decision to exercise enforcement discretion not to take action against certain payer-to-payer data exchange provisions of the May 2020 Interoperability and Patient Access final rule (see FAQs associated with this decision). The Administrator also released a blog on this notice, which included additional information about the administration’s commitment to increasing health data exchange and investing in interoperability.
- February 21, 2022, more promises that we are close to finish line, but still not there yet.
Barriers
If we, as a society, recognize the value of interoperable EHRs that share data across all relevant stakeholders, why has it taken over 20 years to implement?
A combination of technology challenges and incumbent self-interest from major EHR vendors and large health systems attempting to protect their market shares from disruptors are the key reasons why we still do not have true interoperability.
According to an article in the National Library of Medicine, hundreds of government-certified EHR products are in use across the country, each with different clinical terminologies, technical specifications, and functional capabilities. These differences make it difficult to create one standard interoperability format for sharing data. In fact, not even those EHR systems built on the same platform are necessarily interoperable because they are often highly customized to an organization’s unique workflow and preferences.
Interoperability itself is complex. The term refers to more than just the ability to exchange information. For two EHR systems to be truly interoperable, they must be able to exchange and then use the data. For this to occur, the message transmitted must contain standardized coded data so that the receiving system can interpret it. However, lack of standardized data is an issue that has plagued the U.S. health care system for decades and now certainly limits the ability to share data electronically for patient care.
Perhaps the biggest obstacle facing EHR interoperability is not technological but cultural. As in other industries, interoperability in health care requires the close coordination and collaboration of various stakeholders, including patients, providers, software vendors, legislators, and health information technology (IT) professionals. Yet the U.S. health care delivery system continues to have a culture defined by silos, fragmented processes, and disparate stakeholders, and where data have become more of a commodity and competitive advantage than a basis for coordinated care.
There has been plenty of finger-pointing over interoperability issues. Both providers and vendors have been accused of “information blocking” or intentionally interfering with the flow of information between different EHR systems.
In a survey of HIE leaders, 25% of respondents said that health systems routinely coerce providers to adopt and use certain EHR technology rather than simply making it possible to collaborate across these technologies. In addition, they reported that hospitals and health systems selectively share patient health information or do not always share complete information. The perceived motivation was that by controlling patient referrals and having exclusive access to patient data, they could potentially improve their revenue and enhance their market dominance.
Also, as noted in an article in JAMA, “Challenges remain given that patient data have been treated as a commodity owned by EHR vendors, potentially leading to reluctance to share data due to a desire to maintain vendor market share as well as increasing barriers for smaller companies to enter the interoperability space.”
The Humana President and CEO Bruce Broussard in a November 18, 2020 opinion article in Stat wrote: “Making interoperability a widespread reality requires contending with the fact that vendors profit from building closed systems that are only marginally interoperable. To effectively drive change, American health care leaders will need to communicate the importance of interoperability by leveraging their purchasing power and strengthening the regulatory environment.”
No more excuses
While I am not an expert in this field, I do know that after 20-plus years of promises, I am still skeptical and tired of the excuses as to why we do not have true interoperable EHRs. It is more than just interoperability that is needed; we also need to have user-friendly actionable data (including applicable social determinants) being provided in a timely manner to have a positive impact on patients’ health, as well as on our population health, especially during times of crisis such as COVID-19.
I believe that interoperable EHRs will spur innovation between vendors and entrepreneurs that will positively impact our society. I also believe that interoperability along with price and quality transparency requirements will also spur competition and innovation in the provider space that will benefit our communities and society overall.
Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry — particularly the health insurance, physician and hospital sectors — he’s focused on strategic advising and community outreach. Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry and to read archived publications (www.linkedin.com/in/thomascampanella). If you want to receive his monthly recap, e-mail him at tcamp@bw.edu.