The Challenges of Electronic Health Record Interoperability

In the last ten years there have been significant efforts made toward building a healthcare information technology (IT) infrastructure in the United States that allows for secure and reliable exchange of patient information between healthcare providers, medical professionals, individual patients, and their families. The success of these systems has tremendous implications for the overall health and well-being of the entire population—allowing providers and patients to have a more complete understanding of their particular needs. While individual patients are the centerpiece of these efforts, it is important to also acknowledge the impact that effective electronic health record (EHR) interoperability would have on healthcare policy by providing population-level data for national decision making. Despite the seemingly obvious benefits associated with health IT interoperability, numerous barriers still stand in the way of its successful implementation. The complexity of standardization, cultural challenges, physician burdens and burnout, privacy and security concerns, and high costs associated with EHR and HIE adoption are all challenges that remain to be addressed.

In 2009, President Obama signed the American Recovery and Reinvestment Act, which sought to improve the national health care delivery system by digitizing all patient records. The Health Information Technology for Economic and Clinical Health (HITECH) Act was a part of this initiative that invested $35 billion in an effort to incentivize the adoption of EHRs by hospitals and providers, and to achieve interoperability through all levels of the health system. HITECH evaluates “Meaningful Use” of EHR information based on: 1. Data Capture and Sharing, 2. Advance Clinical Processes, and 3. Improved Outcomes. Though HITECH has succeeded in its mission to increase utilization of EHRs, with 96% of hospitals and 80% of office-based physicians in the US having adopted a certified EHR program, the overall effectiveness of these systems is less conclusive. Only 12% of physicians were able to meet stage 2 of the Meaningful Use criteria and only 6% were able to share patient data with other EHR systems in 2015.¹ In a survey of 5,000 anesthesiologists, 49% reported unanticipated need for ongoing IT support and 61% reported difficult integration of Anesthesia Information Management Systems (AIMS)

with an existing EMR as major problems associated with adopting such a system.²

Experts examining the Health IT ecosystem identify challenges that include lack of cooperation among stakeholders, bureaucratic red tape and regulations, along with a misplaced focus on incentivizing EHR adoption without considering health information exchange (HIE) between EHR systems that would allow EHR platforms to interface. In fact, the Office of the National Coordinator for Health and Information Technology (ONC) found evidence of information blocking between EHR and HIE leaders, which led to the passing of bipartisan legislation instituting penalties of up to $1 million to tech developers, networks, and providers who participate in information blocking.^1,3

Increased adoption of EHRs also place additional strain on physicians in their daily practices along with financial burdens for small-practice physicians. Researchers found that physicians spent two hours on clerical or EHR-related duties for every hour of clinical work they performed.^1,4 Certification demands by the federal government as well as documentation requirements for demonstrating “meaningful use” of EHR systems can unintentionally penalize physicians for technology failures. Eligible practices that failed to implement EHR or demonstrate its meaningful use could be penalized between 1-5% of Medicare Part B reimbursements each year. In 2017, over 170,000 providers have faced meaningful use penalties.^1,5 Additional financial strains that place disproportionate burden on smaller practices include the high yearly EHR implementation costs that are estimated to range from $15,000-$70,000 per provider. Many have opted out of the meaningful use program, choosing to lose Medicare reimbursements rather than comply with requirements that divert time and resources away from patient care.^1,6 Despite these caveats, some argue that EHR systems could save smaller anesthesiology practices by keeping them relevant as anesthesia procedures require more data-driven justification by insurance companies for MACRA and MIPS reporting.⁷

Since the passing of HITECH, the ONC has outlined a 10-year vision for achieving an interoperable health IT infrastructure by 2024. Among their list of guiding principles are customization, ease of use and access, value of care, and security of patient information.⁸ They plan to establish core technical standards and functions for terminology, vocabulary, content and format, transport, and security while utilizing the ONC Health IT Certification Program to test health IT products and services. “Building Block #5” in their plan also addresses their responsibility to help establish a governance mechanism for a national health information network. Additionally, the document describes continued monitoring of digital health information exchange systems to identify and address weaknesses and gaps in security.

As a health care professional in your own practice, you may already have encountered the challenges and benefits associated with EHR adoption and compliance. Moving forward, it will be important for you to continue to weigh the short and long term costs and benefits associated with investing in EHR interoperability, considering what is necessary and meaningful for your practice’s bottom-line while also considering the bigger picture in terms of contributing to a national vision for improved patient care through improved information access and exchange. As a health care provider and leader in your field, it is important to advocate for and empower your patients to utilize the EHR information that is available to them.

References:

1. Reisman M. (2017). EHRs: The Challenge of Making Electronic Data Usable and Interoperable.P & T : a peer-reviewed journal for formulary management,42(9), 572–575.
2. Trentman, T.L., Mueller, J.T., Ruskin, K.J. et al. J Clin Monit Comput (2011) 25: 129. https://doi.org/10.1007/s10877-011-9289-x
3. Upton F. H.R.6—21st Century Cures Act. 114th Congress (2015–2016); July 13, 2015; [Accessed June 4, 2017]. Available at:www.congress.gov/bill/114th-congress/house-bill/6?r=9.
4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in four specialties.Ann Intern Med.2016;165(11):753–760.
5. Centers for Medicare and Medicaid Services.Medicare electronic health record (EHR) incentive program payment adjustment fact sheet for eligible professionals.[Accessed June 25, 2017]. p. 2017. Available at:www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_EPTipsheet.pdf.
6. Creswell J. Doctors find barriers to sharing digital medical records.The New York Times.Sep 30, 2014. [Accessed June 30, 2017]. Available at:www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but-sharing-remains-challenging.html.
7. Health IT News. (2017). Anesthesiologists find EHRs free up face-time for patients. Retrieved from https://www.healthcareitnews.com/news/anesthesiologists-find-ehrs-free-face-time-patients.
8. The Office of the National Coordinator for Health Information Technology (ONC). (April 30, 2018). Interoperability. Retrieved from https://www.healthit.gov/topic/interoperability