How Closed EHR Records Cause Paralysis

Take a step back from the challenges that surround health information technology (HIT) interoperability and you will recognize that market forces and a desperately fragmented health care system make hospitals and vendors act the way we do.

It calls to mind the fable of the scorpion and the frog, which is worth revisiting.

Wanting to cross a river, a scorpion spies a frog in the water and asks for a ride to the other side. Naturally afraid of being stung and killed, the frog hesitates, but is finally convinced by the scorpion’s argument that stinging the frog would be the end of them both in the dark flowing water. Midway across the river, the scorpion does indeed sting the frog, dooming them both. When the frog asks why as they sink beneath the surface of the water, the scorpion says, “Because I’m a scorpion.”

Compare what the fable has to say about innate characteristics with the current state of interoperability. The predominant proprietary HIT vendors know about the interoperability gap yet engage in prolonged foot-dragging on even basic data interfacing. Yes, healthcare IT is their business. No, interoperability is not in their nature.

A recent report by health research firm KLAS underscores this less-than-ideal reality: The federal government (they use our tax dollars, I must remind) has spent more than $25 billion on EHR adoption incentives and less than half of acute and ambulatory providers say their EHR is interoperable with other systems. Indeed, only 20 percent of providers are "optimistic" about vendor collaboration initiatives like the Cerner-led Commonwell Health Alliance.

The problem (apologies for beating a dead horse) is with the business model. The prevailing proprietary HIT business model is based on making the vendor the sole source of technology. Complexity of data sharing helps create a vendor lock scenario in which opening up the records is bad for business.

This situation has not gone unnoticed in Congress. As widely reported this past summer, U.S. Rep. Phil Gingrey (R-Ga.), a physician and member of the House Energy and Commerce Committee, singled out Epic for criticism, quoting a RAND report that asserts Epic provides “closed records.”

With incentives focused on driving interoperability, Gingrey asked the obvious question:

“Is the government getting its money's worth? It may be time for the committee to take a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer.”

Of course Epic founder and CEO Judy Faulkner counters that her system is actually open and interoperable. In a September interview with the New York Times, Faulkner explained that Epic’s Care Everywhere solution connects hospitals nationwide. What she did not say is that the company created this bridge to compensate for the complexity of Epic implementations, which are so unique that two distinct Epic systems cannot plug and play. Uniqueness drives complexity and dependence.

Hospital-based health systems, the primary clients of proprietary vendors, are not embracing true interoperability even when it’s mandated. Once again, our fragmented health care market drives hospitals to hold onto patients and keep them in the system. Beyond the financial carrot of Meaningful Use, what is their incentive to truly interoperate on patient care and sharing patient information? The squeeze on hospitals is only increasing; the compulsion to retain patients and provide all possible services, thereby driving up revenue, persists, ACA be damned.

I experienced these forces recently while talking with a large health system that wanted to integrate more tightly with affiliated hospitals. The health system uses a proprietary EHR that the affiliate hospitals cannot afford. When lawyers for the health system became involved in the search for a “less expensive alternative” to use at the affiliate hospitals, talks abruptly ended. Restrictive contracts? Anti-disparagement clauses? The exact cause remains a mystery.

The JASON task force, an independent scientific group that advises the federal government, provided a glimmer of interoperability hope last April in a report commissioned by the Agency for Healthcare Research and Quality. The report called for HIT to open its platforms through as many application programming interfaces (APIs) as possible, enabling EHRs to truly interoperate.

JASON Co-chair Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, believes government should require “public APIs” and the market will drive outcomes oriented around true interoperability. "Federal government doesn't have to be regulatory in this model," he said, explaining that Washington could simply align its own programs around an API strategy and use its massive purchasing power to move the market.

Like the frog in the fable, the US health care system, patients and taxpayers are all paralyzed, as is Congress (still and again). Like the scorpion, large health systems and proprietary HIT vendors are doing what comes naturally. Unless something dramatic happens in the way we pay for care, the paralysis in the American health care system will endure.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.