Who’s to Blame for Healthcare’s Interoperability Struggles? An Expert Weighs in—and Urges Stakeholders to Move Forward

When something goes wrong, it is human instinct to want to blame someone. We see this quick-triggered reaction in all aspects of life, and there might be no clearer example of it in healthcare IT than the sector’s problems with the interoperability of electronic health record (EHR) systems. Indeed, may are wondering: now that certified EHRs are in just about every U.S. hospital, why can’t the technology seamlessly exchange information from one system to another? Someone—the vendors, the providers, the federal policymakers, whoever—has to be the guilty party, right? These are the questions and conversations currently that take place health IT circles.

Sure, fingers can be pointed in any of these directions, but maybe it would be better if this “blame game” stopped, and a path forward to greater interoperability were created and agreed to. This was essentially the narrative in the latest piece in NEJM Catalyst from Julia Adler-Milstein, Ph.D. The Feb. 22 commentary from Dr. Adler-Milstein, titled “Moving Past the EHR Interoperability Blame Game,” is a great read for anyone who is looking for a fresher take on healthcare’s interoperability struggles. Adler-Milstein is an associate professor at the University of Michigan’s School of Information with a joint appointment in the School of Public Health (Health Management and Policy), and is considered a national expert on policy and management issues related to the use of IT in healthcare delivery. Here are some excerpts from her article that I have pegged as most noteworthy:

• On the part of policymakers, Adler-Milstein noted that the overall design of HITECH [the Health Information Technology for Economic and Clinical Health Act], “pushed interoperability in a fairly limited way, rather than creating market demand for robust interoperability.” Maybe health information exchange (HIE) capabilities should have been considered early on in the EHR design process, and in the Meaningful Use program, she said. She added that if it was a matter of “staying in business” or not for vendors and their customers, interoperability would be present today. But as it stands, both providers and vendors are not incentivized to let the data free.

• She said that policymakers “should have selected or certified only a small number of certain EHR systems, because narrowing the field of certified systems would have at least limited the scope of interoperability problems.”

• On the part of vendors, Adler-Milstein said that “by avoiding or simply not prioritizing interoperability, [vendors] are acting exactly in line with their incentives and maximizing profit. Normally, the United States glorifies companies that behave this way.” In other words, with the demand for interoperability not present, vendors should not be blamed for doing what’s best for their business in a legal manner.

• Nevertheless, she said that EHR vendor leaders should not claim to have robust interoperability solutions when they clearly do not.

• Similarly, Adler-Milstein noted that providers also have business reasons to avoid prioritizing interoperability, despite it being in the best interest of their patients. She added that providers lean towards not going on the path of pursuing complex interoperability solutions, and that “It’s hard to justify investing in a complicated, expensive capability that also poses a strategic risk—a double whammy.”

• As she has stated before, Adler-Milstein said, “The emergence and rapid growth of Epic’s Care Everywhere platform (which connects providers using Epic) suggests that even in highly competitive markets, providers may easily tip the other way when the cost and complexity of interoperability are reduced. Therefore, any efforts that successfully reduce cost and complexity are highly valuable, though not a substitute for stronger incentives for providers (and vendors) to engage in interoperability.”

While it might seem that Adler-Milstein is assigning levels of responsibility for why interoperability has not been achieved yet in healthcare, what she is really implying is that because of the way business incentives have been laid out, vendors and providers have valid reasons for not prioritizing this more. Indeed, Adler-Milstein’s piece concludes by noting, “The point of the blame game is not to punish the players. It is to understand the dynamics at play and plot a path forward. Of the stakeholders, only policymakers have a clear, strong interest in promoting interoperability. Therefore, it is up to them to ensure that robust, cross-vendor interoperability is a stay-in-business issue for EHR vendors and providers. Once the business case for interoperability unambiguously outweighs the business case against it, both vendors and providers can pursue it without undermining their best interests.”

Again, the core point by Adler-Milstein is that playing the blame game is counterproductive to pushing interoperability forward. Rather, what are the lessons learned from the mistakes that have been made, and how can decisions be made differently in the future? She argued, “Though billions in monetary incentives fueled EHR adoption itself, they only weakly targeted interoperability. I have come to believe that we would be substantially farther along if several key stakeholders had publicly acknowledged this reality and had made a few critical decisions differently.”

Adler-Milstein’s piece also generated comments from health IT senior experts. David McCallie Jr., M.D., senior vice president of medical informatics at Cerner, wondered why there was no mention of CommonWell or Carequality, “vendor-heavy associations that have created national-scale interoperability for query of remote patient records,” he wrote, adding that the two associations recently agreed to interoperate their networks. To that point, Walter Sujansky, M.D., Ph.D., president, Sujansky & Associates, LLC, responded that “only a handful of those EHR vendors [in the two associations], per my information, have implemented the interoperability stack in released products, such that their customers can benefit from it.”

Now the critical question becomes, what can be done to change business practice incentives so that interoperability can be enhanced?  Adler-Milstein puts this particular responsibility on federal policymakers, and perhaps we are starting to see the impact of the report that the Office of the National Coordinator for Health IT (ONC) issued to Congress in 2015 about healthcare data blocking. Indeed, at HIMSS17, Allscripts CEO Paul Black told me that those data-blocking hearings on Capitol Hill "created a fair amount of activity" and led to some people "changing their business practices as a result,” adding for some organizations this happened “literally overnight.”

The hope here, and what Adler-Milstein lays out, is that a better understanding of incentives will help drive decisions in the future. No healthcare stakeholder—provider or vendor—wants patient care to suffer because of a lack of information available. In the end, it will be collaboration, transparency and trust that determine how quickly interoperability can be achieved, so those are the things industry leaders should be focused on—not playing the blame game.