Why Is EHR Interoperability So Difficult?

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Do you feel the slightest breeze, carrying the faintest whisper, “If you build it, they will come”? Listen again. Unmistakably, the whisper carries a different message, “You built it. There they go.”

Christine Sinsky, MD is Vice President of Professional Satisfaction at the American Medical Association. The Internet is replete with her papers and interviews. According to Sinsky, the more EHR functions that are turned on in a physician’s electronic system, the higher the rate of burnout and intent of physicians to leave practice. Sinsky speculates, “I think, though, that we can create an environment where there’s an incentive for vendors to create delightful products.” “Delightful” products? Sinsky really said that! You just can’t make this stuff up. Of course, anyone in a position of power and influence will have both critics and supporters.

Dr. Sinsky is a Director of the American Board of Internal Medicine and Vice Chair of the Board of Trustees of the ABIM Foundation. She is a fellow of the American College of Physicians (ACP) and is the recipient of the Iowa ACP 2013 Laureate Award, which honors a physician for outstanding contributions to their field(s).  A board-certified internist, Sinsky also practices at Medical Associates Clinic and Health Plans in Dubuque, Iowa. She is one of those female doctors who makes a lot of female doctors (me, too) feel inadequate.

Sinsky continues, “If we develop that kind of product, if we can measure and report on the usability of different EHR products, we will probably start to change that environment [that generates burnout].”

Sinsky suggests hiring a “documentation specialist” or “scribe” – someone who follows the doctor around, writing notes, or keying information into an EHR. That, I think, would be a good thing, but can your overhead costs bear it? In just the last few months, I’ve been seeing the job listed on job-posting sites.

Sinsky makes no mention of, or suggestions about, conquering the lack of interoperability between and among different electronic record systems. A scribe will not improve interoperability. The 2018 Directory of EHR Vendors lists more than 60 venders: Practice Fusion; Sage, Cerner, Mckesson, Epic, Eeny,  Meeny, Miny, Moe …….

Julia Adler-Milstein, PhD, is a researcher who studies electronic health records (EHRs). She is an associate professor at the School of Information, School of Public Health, University of Michigan. Adler-Milstein says that the question she is asked most often is, “Why don’t we have interoperability?” Part of the reason, she says, is that interoperability of health information is hard. If it were easy, we would have it, or at least have more of it, by now. Though it’s a technological issue, it’s not just a technological issue. Interoperability requires all parties to adopt certain governance and trust principles, and to create business agreements and highly detailed guides for implementing standards. The unique confidentiality issues surrounding health data also require the involvement of lawmakers and regulators. Tackling these issues requires multi-stakeholder coordinated action, and that action will only occur if strong incentives promote it.

EHR Vendors. Most observers assign EHR vendors the majority of blame for the lack of interoperability. Adler-Milstein believes that this share is overstated. As noted above, by avoiding or simply not prioritizing interoperability, they are acting exactly in line with their incentives and maximizing profit.

When neither policymakers nor providers were demanding interoperability, vendors risked harming their bottom lines by prioritizing it, and they were just acting in their economic best interest. EHR vendors should, however, have been more willing to come forward and explain why their economic best interest was at odds with existing regulations. Instead, they claim to have interoperability solutions when they do not, and claim that they treat interoperability as a top priority, although they don’t treat it that way. There’s a problematic gap between rhetoric and reality.

Providers. As noted above, providers may not have a strong business case to prioritize interoperability. However, providers have professional norms and mission statements that should motivate them to pursue interoperability to benefit their patients.

The emergence and rapid growth of Epic’s Care Everywhere platform (which connects providers using Epic) suggests that in competitive markets, providers may find that EHRs are advantageous when the cost and complexity of interoperability are reduced. Any efforts that successfully reduce the cost and complexity of EHR use are highly valuable.

Providers can’t be faulted for acting in ways that are aligned with incentives, but their vow to deliver excellent patient care, requires, at least, more disclosure about the rationales affecting their interoperability decisions.

The point of the blame game isn’t to persecute the players, but to understand the dynamics of interoperability issues, in order to create solutions. Of the stakeholders, only policymakers have a clear, strong interest in promoting interoperability. They should ensure that cross-vendor interoperability isn’t prohibitively costly for EHR vendors and providers. Once the business case for interoperability outweighs the business case against it, both vendors and providers can pursue it without great harm to their bottom lines.

References

1. Sinsky CA, Shanafelt T. Reducing the burnout effect of EHRs. From the NEJM Catalyst event Leadership: Translating Challenge to Success at Mayo Clinic, June 2, 2016. https://catalyst.nejm.org/videos/reducing-the-burnout-effect-of-electronic-health-records/ Accessed May 21, 2018
2. Adler-Milstein J. Moving past the interoperability blame game. NEJM Catalyst July 18. 2017 https://catalyst.nejm.org/ehr-interoperability-blame-game/ Accessed May 21, 2018