An interoperability update: Do we need more carrots and sticks?

Irv LichtenwaldEarlier this year, the ONC released the Trusted Exchange Framework and Common Agreement (TEFCA), which responds to a mandate included in 2016’s 21st Century Cures Act and lays out principles, terms and conditions on which to base an interoperability framework that healthcare organizations can embrace.

“This means patients who have received care from multiple doctors and hospitals should have their medical history electronically accessible on demand by any other treating provider in a network that signed the Common Agreement,” said National Coordinator for Health IT Donald Rucker in a recent blog post.

To achieve that goal, TEFCA is divided into parts A, the principles, and B, the terms and conditions, which is also where the rubber meets the road for many who live in the healthcare IT world.

“Part A good, Part B not so much,” John Halamka, MD, CIO of Beth Israel Deaconess Hospital in Boston, said in recent comments.

The departure between A and B, per Halamka and others, is that TEFCA has the temerity to spell out both the how (A) and the what (B). Describing the what as “old, very cumbersome standards,’ Massachusetts E-Health Collaborative CEO Micky Tripathi said, “Developers won’t touch those things with a 10-foot pole.”

I have no quarrel with Halamka and Tripathi on their evaluation of standards, but ONC and Congress are right to feel that this whole healthcare IT ubiquity thing is taking too long.

Sure, the proposal and the responses illustrate well that the ongoing project to make healthcare IT systems communicate is long and arduous. But the real issue is that it’s also fraught with complexity, as Tripathi points out, and that insufficient incentives, misplaced priorities and narrow perspectives leave some tasks without any identifiable advocate.

The short list of remaining interoperability obstacles is significant.

Incomplete EHR Adoption: For starters, while incentives to adopt electronic health records have worked well, they’ve really only been applied to hospitals and clinics. Left out of the deal were skilled nursing facilities, behavioral health facilities, long-term and post-acute facilities and other providers. It will be difficult to have comprehensive records to share if only certain segments of the overall healthcare complex have the necessary tools.

Uneven Network Availability: To this point, rural hospitals and clinics, ironically the most essential of all facilities, have fared the worst in adopting EHRs. Funds are in short supply and trained personnel are often scarce outside urban areas, so it doesn’t help that internet service providers have often not built secure, reliable networks in these areas either. How will these facilities exchange patient records if there is no method of exchange?

Lack of an Accepted Exchange Standard: Part B in TEFCA designates HL-7’s FHIR standard moving forward, and while FHIR certainly has the early lead and a lot of support, the specific naming of it as a standard makes Halamka and others uncomfortable.

“Maybe a better way to say it is that FHIR enables many new possibilities, rendering a number of historical approaches obsolete,” he said.

No National Directory: There is currently no comprehensive way for providers to find each other should they need to. What’s needed is a “national phone book” that connects providers electronically when they need to exchange patient data.

So, where is the push to close these remaining holes going to come from? Let’s think about who has sufficient incentive to make them happen. Ideally, each of these concerns can be addressed by creative business ideas. Realistically, the free market probably can’t get us across the finish line by itself.

The solution, then, has to be some kind of collaboration between ONC, healthcare and IT vendors that offers proper incentives for facilitating patient data sharing and overcomes industry concerns, which remain. Healthcare IT vendors fear they’ll undermine their own market share by making it easier to share patient data. Hospitals fear losing patients who can easily switch providers without having to provide a complete medical history.

The federal government, however, is the only semi—objective advocate for healthcare IT systems that focus on patients. It’s also the only entity with the funds and heft to get some things on the wish list done. Far from arguing for big government, I am instead promoting dialogue that takes advantage of a healthy tension that empowers each entity to pursue the best possible outcome. If this gets done in a timely fashion, both carrots and sticks are necessary. What other entity has both?

“If interoperability were a ‘stay-in-business’ issue for either vendors or their customers, we would already have it, but overall, the opposite is true,” wrote Julia Adler-Milstein in a NEJM Catalyst article on interoperability. “… the weak regulatory incentives pushing interoperability … even in combination with additional federal and state policy efforts supporting HIE progress, could not offset market incentives slowing it.”

I agree with Halamka and Tripathi that mandating technological solutions is a bad approach in that it shackles ingenuity and picks winners and losers. But there is still a role for government in terms of providing strong incentives, setting realistic deadlines that advance the overall mission more rapidly and perhaps funding certain projects where no business solution is truly viable.

A year since Adler-Milstein’s article was published, we seem to be in the same place, despite the effort TEFCA represents. While foot-dragging may be an effective business tactic, it often forestalls broader public goods. To improve America’s fragmented healthcare system, it’s past time to make that the highest priority.