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Are we there yet?

Experts discuss the status of EHR interoperability initiatives

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Are we there yet?

Experts discuss the status of EHR interoperability initiatives

abstract illustration of car on road

By Ruth Carol, contributing writer

In an ideal world, physicians could access their patients’ health information from other physicians with the click of a button in real-time. Patients could access their medical records from all of their physicians, even those in different states, with a swipe in moments. Is medicine there yet? No. However, things are moving in that direction, albeit, at a slower pace than most in the health care industry would like.

What’s the hold-up? “The bottom line is there are multiple stakeholders with competing interests and contradictory priorities,” said William Brady, the Academy’s associate director of health care policy. “That’s always been the problem.” Health information and interoperability policy has evolved over the past 15 years in on-again, off-again phases, surviving several administrations’ vision, direction, goals, and priorities, he noted.

All of that could change when the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) issue final rules for interoperability. Currently, both agencies are reviewing comments about their proposed rules which were released earlier this year.

What’s taking so long?

There are many confounding circumstances that stand in the way of interoperability becoming a reality. Among them are a lack of standards for health information data (i.e., electronic health records (EHRs) don’t speak the same language) and a large price tag for making that happen, noted Cheryl Lee Eberting, MD, chair of the Academy’s Health Information Technology Committee.

“The major holdup on interoperability is the issue of proprietary technology,” stated Michelle Mathy, the Academy’s associate director of political and congressional affairs. Dermatologists cannot easily connect to consulting practices or hospitals because they have different EHR systems that can’t communicate with each other. Neither EHR vendor wants to build an application programming interface (API), to bridge the two systems, claiming that the other company would steal proprietary technology, she explained.

As part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, EHR vendors were given funding to bring EHRs into the 21st century. However, that didn’t happen due to the lack of incentives for EHR vendors to become interoperable. “We’ve been waiting for market pressure to be the incentive,” Mathy said, “but that hasn’t happened yet.” Because the U.S. Department of Health and Human Services (HHS) has limited jurisdiction over EHR vendors, but a lot of jurisdiction over physicians and hospitals, the physicians are being held accountable regarding their use of EHRs.

The fundamental problem with data sharing versus data blocking is that EHR vendors have realized over the past few years that they can commoditize their clients’ EHR data, Brady stated. Selling data to a third party for population health data research is a new revenue stream for them, he said. The licensing agreement typically allows the vendor to decide if the physician can share their patient health data with external parties. Additionally, EHR vendors can make 15-25% above and beyond their licensing agreement as a fee for allowing physicians to plug into other technologies, Dr. Eberting said.

IMPACT ON DAILY PRACTICE

The lack of interoperability affects dermatologists and their patients on a daily basis. Dermatologists can’t easily send patient information to, or receive it from, other physicians and/or hospitals if they have different EHR systems, Dr. Eberting said. This scenario can play out even if the dermatologist is employed at the same health system as the consulting physician or if the practice is owned by the hospital or multispecialty group, Mathy noted. Even if the EHRs are connected, the dermatologist may still have to go through a lot of extra steps to send/receive patient information and/or pay a fee to the vendor for relaying the information, she added. As a result, dermatologists are denied the ability to coordinate care seamlessly, Brady added.

Also, many payers have proprietary portals that dermatologists must access to obtain prior authorizations for certain medications and procedures. The payers, however, don’t connect their portals to the dermatologists’ EHR system because of proprietary technology, Mathy said. As a result, the dermatologist is forced to toggle between the EHR system and payer portal to fill out the prior authorization forms. “Dermatologists are frustrated that they spent all this money on an EHR system, and it doesn’t streamline or simplify their life,” she said.

Patients are equally frustrated when they have to repeatedly answer the same questions or provide the same information that is in the EHR that the dermatologist can’t access because it’s at their primary care physician’s or rheumatologist’s office.

DataDerm™ recognizes EHR vendors for platform integration

Reliable and complete data from EHRs ensure that the information driving DataDerm™ is robust, meaningful, and comprehensive. The AAD recognizes EHR vendors for their level of integration with the platform, noted Academy Secretary-Treasurer Marta Van Beek, MD, MPH, co-chair of the AAD Ad Hoc Task Force on Data Collection Platform and Registries. Not all EHRs integrate with DataDerm equally. Some EHRs do not yet allow their physicians to share their data with a separate quality improvement registry such as DataDerm.

For vendors that do allow integration, the Academy offers recognition at the gold, silver, and bronze level to platforms meeting key criteria:

Gold: The EHR offers full integration with DataDerm data requirements and all its measures, she explained. The EHR vendor agrees to use DataDerm’s specific templates, offers streamlined integration for most users, and participates in DataDerm pilot programs.

Silver: The EHR offers partial integration by mapping the majority of data requirements and measures, but it doesn’t have templates available yet nor does the EHR vendor participate in DataDerm pilot programs.

Bronze: The EHR offers initial integration, in that it maps less than half of DataDerm’s data requirements and measures, and it doesn’t participate in DataDerm pilot programs.

An increasing number of EHR vendors are expressing an interest in integrating with the DataDerm platform, Dr. Van Beek said. But it’s very important that they do not put all the onus on the physician to integrate. “We are trying to make it easier for dermatologists to comply with federal regulatory reporting requirements and eliminate the need to do double data entry,” she said. DataDerm is a registry built by dermatologists for the betterment of the specialty. Data collected are de-identified and used to help develop specialty-specific quality measures to demonstrate the true value of dermatology within the house of medicine. Ultimately, the goal is to develop more meaningful quality measures that are more easily integrated into the dermatologist’s workflow. The measures can be used to demonstrate the value dermatologists add to the entire health care team, which hopefully can be used for negotiations with private and other payers, Dr. Van Beek added.

SNAPSHOT OF TODAY

As part of the 21st Century Cures Act, the CMS 2018 proposed rule would require insurers participating in Medicare, Medicaid, and the federal Affordable Care Act exchanges to grant EHR access to patients at no cost. The CMS proposed rule was really focused on facilitating more patient engagement and empowerment over their own data so that they could share their data with providers without any restrictions, noted Jeff Coughlin, senior director of federal affairs for the Healthcare Information and Management Systems Society (HIMSS).

The ONC proposed rule would:

  • Provide standardized criteria for API development.

  • Call for the adoption of these standardized APIs within two years after the rules are completed.

  • Require hospitals to send admission, discharge, and transfer notifications as a condition of participation for Medicare and Medicaid.

The ONC proposed rules focused on API access to information and providing patients more control over their data, Coughlin said. To address data blocking, the ONC added seven exceptions for blocking patient information from being shared, such as preventing patient harm or harm to others. The agency also added monetary penalties for data blocking if it does not fall under one of these exceptions, Coughlin said.

The current landscape is the result of a combination of unsuccessful regulatory efforts and government action on interoperability that dates back to the early 2000s. Since the Bush Administration established the ONC, there have been numerous road maps and grandiose strategic plans to make interoperability a reality, Brady said. Back then, the technology wasn’t mature, it was expensive, and it lacked standard specifications for data sharing. The latter two barriers still exist. Since then, the market is evolving so fast that the laws can’t keep up. At the same time, physicians fear releasing data to any external party because of potential HIPAA issues — despite that fact that EHRs and data registries are permitted to exchange information on behalf of physicians under HIPAA. Although local or regional health information exchange (HIE) networks have been built, there is no robust HIE system, which fuels a lack of confidence and trust among physicians, he said.

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Additionally, while the vision and objectives of the CMS proposed rule are commendable, the Academy expressed concern about some of the assumptions made in the rule and potential unintended consequences. For example, the proposed rule assumes that patients will know how to use the additional health data they will be able to access and what it means. “If a patient isn’t well versed in how to read the data, having more data only creates more confusion,” Brady said. There is also concern that some provisions pose an undue and onerous administrative burden on physicians to achieve compliance with the regulations.

The proposed rule also had an extremely aggressive timetable. The Academy recommended that these regulatory requirements be tested and validated before they are made final, said Brady, adding, “All stakeholders should be involved so we can iron out the bugs before it goes live.” The Academy’s position is that whatever the final rules are, there needs to be a grace period between the time when the EHR vendors deliver their standards and when physicians are required to implement them, Mathy stated. Adopting and implementing the rule in a phased-in, incremental manner, beyond the 24-month timeline will help ease adoption of new requirements and increase compliance success, the Academy maintains. “We’re waiting to see how the two final rules will address more of our concerns,” Brady noted.

Two months after CMS and ONC released their proposed rules, HHS provided additional guidance on its efforts to develop a Trusted Exchange Framework and Common Agreement (TEFCA). The idea behind TEFCA is that different vendors and health information technology (HIT) developers would adopt the framework and abide by certain conditions that would facilitate data exchange regardless of the developer or HIE, or where a patient’s records are located, Coughlin explained. Currently, a hospital may have agreements with the state HIE and a few vendors. TEFCA would provide one “on-ramp” to electronic health information so that hospitals would no longer have to have separate agreements with different entities. “It would serve as an entrée into broader sharing of health information across the nation,” he said. The ONC released the first version of TEFCA in January 2018. After receiving a fair amount of criticism, the ONC revised it and released version two in April 2019.

Similarly, in August 2019, CMS launched a new pilot program, Data at the Point of Care, that would give physicians access to Medicare claims data through an application programming interface. The pilot program is part of CMS’s MyHealthEData interoperability initiative.

MOVING IN THE RIGHT DIRECTION

“After the proposed rules were released, EHR vendors said that they want to move toward interoperability,” Mathy said. “At least publicly all the players have agreed they need to do this.” A few years ago, there was a lot of frustration regarding interoperability, but neither Congress nor the Administration were paying attention. Congress is taking notice now because they see that Americans have invested millions of dollars in EHRs and HIT, and all of this investment hasn’t improved the patient care experience, she said. “So the federal government is now taking steps to move toward interoperability instead of leaving it to the market to figure this out.” What those steps are is yet to be determined, Mathy said, but at least the proposed rules are a step in the right direction.

What would really move interoperability along is if the CMS and ONC final rules offer incentives to share data and impose penalties for blocking data sharing, Brady said. The proposed rules don’t offer incentives, per se, but they are requesting that payers, such as the Medicare Advantage plans, start developing apps, which would serve as “a workaround” to unlocking the data in the EHR.

The proposed rules have moved the process forward and made clear where the federal government stands in terms of facilitating more opportunities for the seamless exchange of patient-level data, Coughlin said. It’s clear that CMS and ONC support more data exchange across facilities using different types of technology, which HIMSS also supports. “We don’t want certain technology to be the driver of information exchange. It should be those technologies that provide cross-cutting access,” he added.

The final rules could be years away — as Brady points out, the proposed rules took almost three years to be formulated. “When released, they could signal a turning point, or they keep us on this merry-go-round of inertia.”