January 21, 2016
Achieving it is a predominant theme in healthcare today, and a priority agenda item ever since Meaningful Use / MIPS (MU) incentives took over the industry in 2009. To clarify (from HIMSS), the definition of interoperability is “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.”
Interoperability sure sounds like the next step in Meaningful Use / MIPS, achieving the ability to broadly aggregate and analyze health data and manage our population’s health, right? Yet, the industry seems to be at an impasse. What is holding it up?
Anyone who has observed the evolution of healthcare IT knows that our implementation cycle of major changes is long. Look at electronic transactions. HIPAA was passed in 1996, but it was 2003 before the standards were put in place, and well into the current decade before key payers could handle all the transactions. And, while claim and remittance advices gained universal acceptance fairly quickly, claim status transactions took much longer. Even today, 20 years after HIPAA was passed, hospitals must struggle with different payers that have implemented the standards in different ways.
The industry’s road to interoperability is paved with strikingly similar bumps and ruts. Some EHR technologies are decades old, but implementation of EHRs only became mainstream when the federal government incentivized their use through the Meaningful Use / MIPS program. Interoperability was a behind-the-scenes goal then, but with certified EHRs now in place throughout the country, it’s a front and center concern. This is because interoperability is only practical if EHR usage has reached enough critical mass to make the possibilities realistic, including providing the basis for common standards for data sharing.
According to an ONC report to Congress on December 2015, there are still at least five powerful barriers that are preventing interoperability in healthcare management:
This post will focus on perhaps the most problematical issues: the lack of universal standards across EHRs and their adoption, and weak or misaligned incentives.
All healthcare providers have not been equal under the Meaningful Use / MIPS initiative. Many providers weren’t fortunate enough to be eligible for MU incentives, including long term care / post acute care facilities (LTPAC) and behavioral health providers. There are thousands of them, large and small. Both fields are making quantum leaps in growth, yet most continue to operate without even the most basic of EHRs (let alone ONC-certified systems).
But a strong relationship exists between behavioral health, LTCPA, and physical health, welfare, disease, and, ultimately, treatment. With the onset of the baby boomer “coming-of-age” era, this relationship is being strained as never before. A simple example: according to Mental Health America, more than two million of the 34 million Americans age 65 and older already suffer from some form of depression. Symptoms of clinical depression are often triggered by chronic physical illnesses common in later life, such as Alzheimer’s, Parkinson’s, heart disease, cancer and arthritis. Yet for all the investment put into MU-certified EHRs, hospital emergency rooms still have no access to the mental health records of a patient who arrives after taking a suicidal overdose of barbiturates.
The lack of information exchange capabilities between the MU incentives “haves” and “have-nots” has resulted in dysfunctional, even contradictory care programs for shared patients. For example, cardiac specialists prescribe beta-blockers for hypertension; psychiatrists recommend against them, knowing that notorious side effects of beta-blockers include depression and fatigue. The specialists have no access to others’ information. This problem is not different than in pre-MU years, but is much greater in magnitude, and creating increasing frustration across the provider community. A resurgence of interest by Congress in these issues is afoot…but no decisive action seems imminent. In the meantime, this fragmentation of EHR users poses a significant barrier to nationwide interoperability.
The technical side of interoperability has been compromised by Meaningful Use / MIPS’s profitability for vendors. Certainly, ONC has tightened the standards used by EHR systems, and has noted that one benefit is that “reporting to public health has expanded enormously across the country since it was included as a requirement in the EHR Incentive Programs.” But this remark is a tip-off on a major reason why EHR-to-EHR interoperability across providers has progressed slowly. It was never a requirement of Meaningful Use / MIPS.
The highly competitive EHR vendor industry has not been motivated to collaborate on technical standards for interoperability. Just the opposite. The EHR Incentive Program has been a bonanza for individual EHR vendors. Why would they compromise their profits by amping up technologies to share clients’ data with competitors? In February, 2015, all five former and current ONC leaders came together to acknowledge and analyze this obstuctive factor in achieving interoperability. In an ONC Meeting, they decried the discontinuity between interoperability objectives and the stance of the vendor industry. Per Farzad Mostashari: “This [problem] is not because of the data standards, it’s because of the business practices…. Vendors haven’t been incentivized to make progress on interoperability and data sharing…. this is a market failure.” Should we be surprised?
In addition to the commerical barriers to adopting standards for exchanging clinical information, the current Meaningful Use / MIPS technical standard, the Consolidated-Clinical Document Architecture (CDA) standard, isn’t sufficiently robust to handle the kinds of data needed in an interoperable environment. The proposed Fast Healthcare Interoperability Resources (FHIR) standard would go a long way to making interoperability real. If you are inclined to find your way through these technical weeds, I recommend doing so.
Meaningful Use / MIPS Stage 2 has not been a rousing success. A November 2015 Health Affairs report notes that while there has been a marked increase in hospitals’ ability to meet core Stage 2 MU criteria (40.5 percent of hospitals, up from 5.8 percent in 2013), this progress is “undoubtedly still much lower than the Centers for Medicare & Medicaid Services would’ve liked to see.” According to the report, “Hospitals most often reported up-front and ongoing costs, physician cooperation and complexity of meeting Meaningful Use / MIPS criteria as challenges.”
The number of physician practices that have attested to Stage 2 is much lower. They have not kept up. Penalties started becoming part of their accounting considerations in 2014-2015 and have continued. The Medical Group Management Association is concerned. “Those EPs [eligible professionals] who invested considerable resources in their Stage 1 certified EHR, many of them in small or rural clinical settings, are now in danger of falling behind.” While the details of these penalties are beyond the scope of this article, you can read more about them here.
This decreased momentum in following through on meeting Stage 2 EHR usage standards offers another signal that providers as a whole are not ready for interoperability and won’t be any time soon.
For the thousands in the healthcare industry that understand that the thrust of HIPAA was long term preparation for industry-wide interoperability of health data systems and resulting data aggregation and population health research and management, ONC’s Meaningful Use / MIPS program has achieved significant progress. It has not been a holy grail, but couldn’t have been considering inevitable roadblocks such as those discussed above. Overall, ONC should be praised…MU has been a giant step in contributing to world wide healthcare advances.
Without substantial course corrections now to fast-forward interoperability, the industry risks setbacks in reaching long term goals that both the federal government and many healthcare providers have embraced. The latest announcements from ONC regarding an overhaul (or replacement) of the Meaningful Use / MIPS program should be welcomed.