To make such a system, you are hit with important design decisions. Right away! Just off the top of my…
Readers Write: The Illusion of EHR Interoperability
The Illusion of EHR Interoperability
By Pawan Jindal, MBBS
Pawan Jindal, MBBS, MHI is CEO of Darena Solutions of Chesterfield, MO.
Isn’t EHR interoperability great?
It would be, but there is a huge gap between the published standards and the reality. Sharing data among healthcare providers, health plans, and patients was supposed to be much easier now that EHR interoperability through FHIR-enabled apps is the universal standard. Developers should have been able to integrate their SMART on FHIR apps with virtually any EHR and have the resulting integrations work seamlessly across multiple platforms. Sadly, it is not working as intended.
In Q1 2023, the Office of the National Coordinator for Health Information Technology (ONC) reported that 95% of certified health IT developers met the December 31, 2022 compliance deadline to enable access to information through application programming interfaces (APIs) “without special effort.” However, our experience with FHIR app developers, providers, and EHRs shows that true EHR integration remains elusive, despite ONC’s claims.
Out of the nearly 300 EHRs certified by ONC to be interoperable with FHIR-enabled apps, only a few allow developers to integrate apps with their EHRs. By enforcing the Cures Update requirement only on EHR vendors, ONC is not penalizing providers, the ones who seem to be refraining from information sharing. Out of the total 763 claims of information blocking filed so far with the ONC, 85% of the claims (646) are against providers. This problem is further exacerbated by the fact that provider education on the benefits of information sharing from ONC is severely lacking.
The Information Blocking provisions of the Cures Act currently only mandate making data available to patients upon request. The EHRs have geared up to allow providers to honor these requests. However, if you ask providers, they say, “No one is asking for it, or I send them to the patient portal, or I ask them to fill out a request form to obtain a hard copy of their records.”
Most providers aren’t aware of the requirement to provide data to patients in an app of their choice. If healthcare is ever to achieve a reality that includes easily integrated apps facilitating the seamless sharing of patient data between organizations, it must actively engage providers in information sharing.
Healthcare has been working toward interoperability for a while through the creation of rules and standards. It’s been three years since the Centers for Medicare and Medicaid Services (CMS) adopted the interoperability rule, removing many barriers that prevented patients from accessing their health data. The rule also issued version 1 of the US Core Data for Interoperability (USCDI v1) standard that EHR vendors must meet for ONC certification.
An information blocking provision went into effect in 2021 requiring EHR vendors, providers and others to share the data specified in USCDI v1. That rule was expanded in 2022 to include even more types of data. Last year, ONC also published the Trusted Exchange Framework and Common Agreement (TEFCA), which sets a nationwide standard for interoperability and establishes the process for health information networks to become Qualified Health Information Networks (QHINs), a sort of “super network” for sharing data.
FHIR (Fast Healthcare Interoperability Resource) is the standard developed to enable this data exchange. It can be used on its own and with existing standards, like the USCDI and billing-related data elements used in EHRs. FHIR-based apps are designed to be used with any FHIR-capable EHR. It is important to note that the TEFCA agreement is meant to establish a minimum standard for performance across the healthcare continuum. Based on that, FHIR is on the map for future phases and is not required out of the box.
So why does widespread EHR interoperability remain an illusion despite ONC claims?
Glitches are to be expected any time there is development and adoption of a new technology standard, particularly one that must integrate with older EHR platforms. Companies, sometimes unwittingly, fail to disclose all the ins and outs of their products and capabilities. Take for example, NextGen Healthcare’s agreement this summer to pay a $31 million fine to settle claims that the company misrepresented its software’s capabilities and paid users kickbacks for their endorsements. Similar cases have resulted in settlements with other EHR vendors, including EClinicalWorks, Practice Fusion, Greenway Health, and Modernizing Medicine.
Even when considering glitches and a few bad actors, it’s become obvious that ONC certification alone doesn’t necessarily guarantee successful app integration in the field because developers, EHR vendors, and healthcare systems continue to struggle to achieve interoperability.
For its Health IT Certification Program, the ONC includes a Real World Testing annual requirement. According to the website, “The purpose of this Condition and Maintenance of Certification requirement is for Certified Health IT Developers to demonstrate interoperability and functionality of their certified health IT in real world settings and scenarios, rather than in a controlled test environment with an ONC-Authorized Testing Lab.”
Anyone with experience in IT development (or any complicated technology, for that matter) knows that what works well in the lab can fail in the field. That’s because real-world conditions and demands can be more challenging than what designers anticipated. This highlights the need for more realistic real-world testing from the ONC in addition to tests conducted by independent entities. Currently, each EHR tests its own application in the field. Unsurprisingly, they all seem to replicate the certification testing. We need a Consumers Reports-style impartial review for health IT.
In the meantime, app developers and other stakeholders can work with third-party experts who can guarantee EHR integration.
This article brought back memories!
I wrote a few articles for HIStalk 8 years ago on similar themes (albeit in a very different style):
https://histalk2.com/2015/01/12/startup-ceos-and-investors-brian-weiss/
https://histalk2.com/2015/01/19/startup-ceos-and-investors-brian-weiss-2/
https://histalk2.com/2015/06/26/startup-ceos-and-investors-brian-weiss-5/
Carebox has long since shifted our focus (“pivoted” is the cooler Startup term) to solutions that aren’t predicated on ubiquitous consumer access to EHR data via digital apps. It was fun tilting at windmills, but at a some point I realized that this was probably best left to characters in 17th century novels and not to a 21st century company that I founded and very much wanted to see do some practical good in the world (not to mention provide a financial future for me, my employees, and my stakeholders).
I do still dream of closing the loop one day and incorporating FHIR-based access to EHR records in the Carebox Connect platform for connecting patients and doctors to clinical trials.
For now, though, my advice to Mr. H is to just to republish these articles on an approximately 10-year cycle…
First, thank you for calling this out as an issue
You make several really valid points here, but I am confused as to which of the several problems you mention would be solved by a Consumer Reports style ranking. What specifically would be ranked? Their alignment to the standards, their accessibility, or data usability?
Yes, real world data is not aligned with the standards, for any number of reasons. Causalities range from the EHR, to the practice, to the clinician, to the external influencers such as ONC themselves, or payer organizations. But even if they were, those same factors cause the data to be very difficult to use meaningfully.
The scary part in my mind is that we have set the standard, defined “real world data” along with “real world testing” and decided that means we are all unicorns and rainbows in the land of interoperability. When in reality I know for a fact that semantic exchange of clinical data does not work. Just as frequently between like systems as unlike systems.
Now, because we have “solved the problem” there are pushes by the FDA to use this data as part of the off label drug reclassification. Or, to use this data for research. Or, to train AI models. There is great promise in this data but we must also contend with the messiness of this data and disinformation in order to use it. On the AI model front, if you train the model with clinical data that is trying to align with payer needs, are you developing payer based AI model? Great for the payers, bad for the medicine.
I believe that regionalized efforts, concentrated efforts, that address each participant in that region are really the only way to get significant improvements in the quality of the data. And, you have to address the idea that it costs money to make something like that happen. Someone has to watch the data, someone has to define the failure taxonomies, someone has to work with the clinic, vendor, or agency to get the data entered correctly in the first place.