Information Blocking is Routine and Fairly Widespread, Survey of HIEs Finds

March 22, 2017
In a survey, 50 percent of HIE leaders said electronic health record (EHR) vendors "routinely" engage in information blocking, and 25 percent reported that hospitals and health systems routinely engage in business practices that interfere with electronic health information exchange.

Information blocking has been a widely debated policy issue, and a recently published survey of health information exchange (HIE) leaders provide some data on the extent of information blocking and also examines policy strategies to address it.

According to the survey of health information exchange (HIE) leaders, information blocking appears to be “real and fairly widespread,” according to Julia Adler-Milstein, Ph.D., 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), who led the research, which was recently published in Milbank Quarterly. Eric Pfeifer, University of Michigan Schools of Information and Public Health, also was an author of the research.

As background on why the survey was necessary, Adler-Milstein wrote in the published article, “Congress has raised concerns about providers and electronic health record (EHR) vendors knowingly engaging in business practices that interfere with electronic health information exchange (HIE). Such “information blocking” is presumed to occur because providers and vendors reap financial benefits, but these practices harm public good and substantially limit the value to be gained from EHR adoption. Crafting a policy response has been difficult because, beyond anecdotes, there is no data that captures the extent of information blocking.”

However, before concerted action is taken in response to information blocking, Adler-Milstein notes, it is critical to assess the extent to which information blocking occurs and the specific forms that it takes, as well as to better understand the effectiveness of policy responses.

Between October 2015 and January 2016, Adler-Milstein spearheaded a national survey of leaders of HIE efforts who work to enable HIE across provider organizations, and the survey findings are based on 60 HIE leaders’ responses.

Of the survey respondents, half of respondents (50 percent) reported that EHR vendors routinely engage in information blocking, with an additional 33 percent reporting that EHR vendors engage in information blocking occasionally. “The remaining 17 percent of respondents indicated that EHR vendors rarely engage in information blocking,” Adler-Milstein wrote.

Frequency of information blocking by hospitals and health systems was lower, according to the survey findings. “Twenty-five percent of respondents indicated that these providers routinely engage in information blocking, with an additional 34 percent reporting that they do so occasionally and 41 percent saying that information blocking was rare,” Adler-Milstein wrote.

Among the eight specific forms of information blocking in which EHR vendors may engage, the most common form was deploying products with limited interoperability (49 percent of survey respondents), according to the survey findings. Additionally, 47 percent of respondents reported that vendors routinely or often charge high fees for HIE unrelated to cost, followed by 42 percent that reported that vendors routinely or often make third-party access to standardized data difficult.

“Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology,” Adler-Milstein wrote. In addition, 22 percent of respondents reported that hospitals/health systems routinely or often control patient flow by selectively sharing patient information, according to the research article.

“Information blocking appears to be real and fairly widespread,” Adler-Milstein wrote. “Policymakers have some existing levers that can be used to curb information blocking and help information flow to where it is needed to improve patient care. However, because information blocking is largely legal today, a strong response will involve new legislation and associated enforcement actions.”

The survey respondents perceived information blocking to be motivated by opportunities for revenue gain, according to the study. For EHR vendors, 69 percent of respondents cited maximizing short-term revenue as either a “routine” or an “occasional” motivation for information blocking.

Among hospitals and health systems, the most frequent perceived motivation was also related to improving revenue, namely to strengthen their competitive position in the market (47 percent cited that as a routine motivation and 30 percent as an occasional motivation), followed by accommodating more important internal priorities than HIE.

The survey respondents also cited a number of policy recommendations to curb information blocking by EHR vendors, such as prohibiting gag clauses and encouraging public reporting and comparisons of vendors and products; stronger demonstrations of product interoperability “in the field”; and establishing stronger state and/or national infrastructures, policies, and standards for core aspects of information exchange.

“Focusing exclusively on the proportion of respondents who reported that a policy strategy would be ‘very effective,’ making information blocking illegal was the most frequent choice” to curb information blocking among both EHR vendors and providers, Alder-Milstein wrote.

For hospitals and health systems, survey respondents identified two policy remedies—stronger Centers for Medicare & Medicaid Services (CMS) incentives for care coordination and/or risk-based contracts and public reporting or other efforts to increase transparency of provider business practices.

Alder-Milstein noted that the survey findings have direct policy implications. “First, they suggest that policymaker concerns about information blocking are founded and that efforts to pursue policy actions to curb information blocking are warranted,” she wrote.

“Enforcement is a near-term strategy that could be used in a narrow way to target egregious offenders and help overcome inertia that is impeding the uptake of policies aimed at realigning economic incentives. In the long run, transparency and value-based payment should create market dynamics that foster broad-based information sharing,” she wrote.

She also noted in the article that many of the strategies identified are not included the current healthcare regulatory framework. “Because there is no federal law that directly prohibits information blocking, federal enforcement agencies can only take action against information blocking in very limited circumstances,” she wrote, citing how the Office for Civil Rights can impose penalties on entities if the information blocking violates HIPAA, or how the Office of the Inspector General (OIG) can investigate information blocking if it involves kickbacks or fraud.

In the absence of a federal prohibition against information blocking, the tools that are within the authority of the ONC and CMS are fairly weak, she noted.

In conclusion, Adler-Milstein wrote, “Current ONC efforts and bills in Congress pursue enforcement by authorizing the OIG to investigate and establish deterrents to information blocking. If successful, reducing information blocking will help ensure that data follow patients across provider organizations, which is essential to improving the quality and efficiency of care.”

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