Thoughts on Senate bill calling for EHR interoperability report

A bill drafted by the Senate Appropriations Committee would require the Office of the National Coordinator for Health IT’s (ONC) Health IT Policy Committee to issue a report on the operational, technical and financial challenges of EHR interoperability as well as the role of EHR certification in advancing or hindering interoperability.

The bill follows up on an April report that concluded that a lack of interoperability among data resources for EHRs is preventing seamless information exchange and establish a robust health data infrastructure.

The report senators seek from the HIT Policy Committee should address the “extent of the information blocking problem, including an estimate on the number of vendors or eligible hospitals or providers who block information,” according to the draft bill. “This detailed report should also include a comprehensive strategy on how to address the information blocking issue.”

“Many people are frustrated by what they perceive as too slow a pace of change, and this now includes the Senate. It appears that the Senate believes that the lack of interoperability is preventing a return on investment from the HITECH Act--and that moving more quickly towards immediate interoperability will make our healthcare system better, safer and maybe even more affordable,” says Peter Basch, MD, medical director of ambulatory EHR and health IT policy MedStar Health based in Columbia, Md., speaking to Clinical Innovation + Technology.

 “I appreciate the frustration of the Senate and of healthcare providers who are still struggling to bring data into their EHR systems, and certainly we need to keep working to make it easier for systems to talk to each other. However, I am concerned that this bill’s narrow focus on interoperability as a solution misses a key point. Making an interoperable system valuable to patients and their families is more than data exchange," he says. ONC is charged with promoting  health IT and information sharing to improve healthcare, “which is far more complicated than just liberating data.”

“Meaningful Use should have had more of this baked in from the start and in a very rigid way to ensure true interoperability which would imply they would define data model standards as well,” says Lyle Berkowitz, MD, associate chief medical officer of innovation at Northwestern Medicine in Chicago. “Unfortunately, we are now stuck with diverse data models and various ‘shades’ of interoperability so that even if one EMR sends data to another, it's usability is rarely ideal, and sometimes so slow and awkward that it is just not realistically going to happen.”

However, Berkowitz says “perhaps we just needed this time to get to enough saturation to have this discussion. “It is most definitely time to dig in and see if they can smooth out the rough bumps and promote interoperability in a way that is both about the data and the usability of that data in normal workflows.”

Basch says he also appreciates the pace ONC has taken regarding interoperability. “I like a more reasoned course, what I would term ‘just enough interoperability.’ I believe, frustrations aside, many clinicians are as concerned about too much information as too little, particularly when that information comes without filters or context. And an approach that forces interoperability and thus data mobility out of sync with our ability to thoughtfully use it is likely to feel more like quenching one’s thirst by drinking from a firehose .

A key challenge is to keep focused on using our emerging health IT infrastructure on making care better, which includes data collection and sharing, but also limiting excessive structuring of data and retaining thoughtful narrative. When we can do that better, we have a more limited click burden on doctors and more meaningful documentation. 

If the Senate subcommittee is thinking that vendors are intentionally preventing data sharing, Basch says that fits the historical business plan of “vendor lock” but probably isn’t possible today. “To succeed in the U.S. and be compliant with 2014 and later certification requirements requires an iterative progression toward more interoperability, not less.”

Vendors have to work with home monitoring devices, hospital lab systems and other external apps. Some EHR systems are built with open source code, and others use proprietary code but “that doesn’t necessarily mean the vendor, in my opinion, is trying not to interoperate with the rest of the American healthcare ecosystem. To me, it doesn’t make a lot of sense.”

Basch also says it’s not fair to “blame vendors for initially building systems with limited interoperability. Aside from only recently having a limited set of standards on which to code their software, there really was not a market for widespread interoperability. It wasn’t that long ago that hospitals were considered the primary culprits of information blocking. Responding to a market where data silos made sense--volume-based, fee-for-service is different than intentional engineering of information locks. Until the U.S. healthcare system includes a sustainable business case for health information management and quality outcomes, I find it hard to fault vendors for not innovating faster than the health system changes--and thus innovate themselves away from what their customers are asking for.”

Circling back to the report the Senate subcommittee’s bill calls for, Basch says he hopes it won’t be too much of a distraction from other key work that could make health IT work better now and without risking information overload. “There are other ways we could direct the Policy Committee and ONC’s attention and resources that would be a better use of their time than crafting another report on interoperability.”