Interoperability Beyond Barriers: Information blocking?
November 14, 2017
Third blog in a series
As we continue to look at the state and progress of interoperability pushing beyond the current barriers, it is important to delve into the topic of information blocking. This is a topic that has been explored before by the Office of the National Coordinator for Healthcare IT (ONC) in a 2015 report to Congress. In that report, information blocking is defined as occurring “when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information.” There were further details in the report delivered to Congress, which then provided a more inclusive definition in the 21st Century Cures Act, which states that information blocking includes the following criteria:
- Interference—a practice that is likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information
- Knowledge of a developer—conduct that the developer knows or should know interferes with, prevents, or discourages access, exchange, or use of electronic health data
- Knowledge of a provider—conduct that the provider knows is unreasonable and would interfere with, prevent, or discourage access, exchange, or use of electronic health data
The act goes on further to describe some practices that may be considered as information blocking, including:
- Practices that restrict lawful and authorized access, exchange, or use
- Implementation technology in nonstandard ways that substantially increases the cost and complexity of access, exchange, and use
- Implementing technology in ways likely to restrict access, exchange and use data with respect to exporting complete information sets or transitioning between systems
- Implementing technology in ways likely to lead to fraud, waste, or abuse or impede innovations and advancements in health IT access, exchange, and use
This latest definition casts quite a large net and the Department of Health and Human Services (HHS) has quite a bit of work to do to further refine these definitions in regulation. The ONC is working with the HHS Office of the Inspector General (OIG) to further investigate practices that fall under this definition.
I feel that I have a unique perspective on the topic as I have a diverse background in healthcare IT interoperability. While I now work for a company focused on bringing interoperability to all healthcare IT systems, I previously worked for an EHR vendor for over a decade. As an active member of the HIMSS Electronic Health Record Association (EHRA) in the Interoperability Workgroup, I saw the good work that was being done and the collaboration that was taking place. In fact, for a time the EHR companies were getting along better than some of the standards development organizations.
There are several conditions that can cause actual or perceived information blocking. Some of it purposeful and not focused on improving patient care, such as competing hospital systems using data access as a means of patient retention. I am not going to get into those, instead I want to explore what has been defined as information blocking from the side of the vendors of Healthcare IT.
Historically, a real issue has been around business incentive and value. Interoperability has been focused around areas where a business case could be made. The early days of interoperability started with payment and financial based transactions. There was obvious value in these use cases. Existing use cases were soon followed by use cases where interoperability was a requirement to get information in a timely and efficient manner. These specifically focused around lab results, radiology orders, scheduling and others. However, the focus was mostly regarding internal clinical and operational concerns. While cross-enterprise interoperability helps improve care, the business case has been harder to make. The issue has historically been complicated by loose standards that have been left up to interpretation and require cross-enterprise coordination for systems to interoperate.
These challenges are reflected in healthsystemCIO.com survey done in October 2017 of 53 CIOs, IT Directors, and other health system technology leaders. When asked if they have “ever experienced any information blocking by a vendor and if so what sort of issues are or were causing the blocking?”, most said they had, but not necessarily purposefully. You can see a couple of the reasons given below.
However, times are changing. With movement toward value based care, there is a real business case, not just for care collaboration, but to find new and innovative ways to cut costs and improve efficiency. Major vendors are seeing this and are starting to move toward support for APIs that can greatly improve the state of interoperability. These vendors are in large part starting with Meaningful Use API access requirements. Some EHRs have even gone further than this by developing their own FHIR based and proprietary APIs that extend beyond Meaningful Use. With wide adoption of the FHIR standard, the issues cited regarding information blocking above should largely disappear.
One of the challenges I am seeing, however, is that the current approach is often focused on supporting app integration. While this is a great approach to help extend EHR functionality in innovative ways by enabling tight integration, an app integration approach does not seem sufficient to address cross-enterprise or even intersystem interoperability needs, such as public health, inter-enterprise care coordination, linking with other business critical systems (such as an ERP system), and many more.
As an industry, we should continue to challenge ourselves to find new business models, in addition to the app model, that further open up data and put the patients and providers in control of their own information. Truly open APIs could do a lot to transform not only the healthcare IT industry, but the entire healthcare industry by unlocking data and making it available to use in new and innovative ways.
This is the focus of the Cloverleaf Integration Suite and associated products like Clinical Bridge, the recently released Cloverleaf Consolidator, and the upcoming FHIR Bridge. These systems help unlock the data and enable communication between systems no matter what standard or mechanism, such as an API, the connected systems support. Our goal is to provide the means and the tools for providers to unlock, connect, and manage their data so that they can provide the best care with the systems they want to use and enable the patient to have access and use of their own data.
-Corey Spears, Director of Interoperability Standards
- North America
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