Just about every summer when I was growing up my parents piled us in the station wagon to drive from our home in northwest Florida to my paternal grandparent’s row house in Philadelphia. During one summer drive when I was about 10 years old we stopped for a day to visit Grandfather Mountain near Linville, North Carolina. I vividly remember stepping out onto the famous Grandfather Mountain Mile High Swinging Bridge, drawn by the awesome view and the challenge of walking the wobbly way across the wood-and-rope suspension footbridge. Halfway across the bridge is a fine place to find commitment; the view is spectacular, but the 80-foot chasm seems sure to swallow you up with any misstep. Despite the fear at the halfway point, there’s not a lick of sense in considering a retreat back to where you started, so it’s a good time to set your sights for the end of the bridge on the far side and finish your brave 228-foot journey one careful step at a time.
The chasm in EHR functionality
This year we are halfway across the Grandfather Mountain Mile High Swinging Bridge with Electronic Health Records (EHRs). The digitalization of medical records is complex and while big gains have been made, EHR functionality is not ideal. Many physicians have adopted EHRs because of incentives and the hope that patient care will improve with data sharing. However, data sharing and health information exchange (HIE) have been a big disappointment so far.
While HIE has not met expectations, EHR adoption has been good. In December 2014 the Office of the National Coordinator for Health IT (ONCHIT) reported that 70% of U.S. physicians have adopted an EHR. Most of the physicians who are not using an EHR today are from small or solo practices, but adoptions by larger practices has been impressive:
- 92% of physicians in practices of 11+ physicians
- 81% of physicians in practices of 4-10 physicians
The main motivation for physician adoption of EHR technology has been the lure of incentives and, more recently, the desire to avoid penalties. Another major adoption driver is the physician desire for HIE, since most physicians believe this will improve the care of patients and reduce health care costs.
After $30 billion in incentive payments over the past 4 years, EHRs are still not a delight to many physicians. In particular it is disappointing that despite Meaningful Use standards and EHR certification, patient health information exchange does not happen routinely. There is absolutely no way to return to where we started, which means that physicians need to have a vision that costly and wobbly steps forward will lead us to significant benefit on the other side.
Combatting information blocking
If there’s no turning back, then what is the achievable goal that will energize forward progress? In 2015 all focus is on sharing health information to support better patient outcomes. While this may have seemed like a given with the digitization of health records, it has not happened and “information blocking” by EHR vendors has been identified as a key HIE barrier. Some “information blocking” examples include EHR vendors charging big dollars to pull data out of an EHR for data sharing or EHR vendors suggesting that it is only possible to share information within their proprietary system. Both “information blocking” behaviors have been noticed by congress and ONCHIT.
How is congress dealing with this “information blocking” barrier to health information exchange? If you want the details, check out the 701 pages of the Cromnibus spending bill (Cromnibus = continuing resolution + omnibus). Several good articles provide details on the Office of the National Coordinator for Health IT (ONCHIT) funding contingencies from the Cromnibus legislation, but here are the highlights regarding HIE:
- The Cromnibus bill provides $60 million in funding for ONCHIT, which is tied to some polite requests on dealing with information blocking.
- Congress “urges” ONCHIT to not certify or to de-certify any EHR that is not actively supporting data exchange.
- Within 90 days of the Cromnibus enactment ONCHIT must also provide a report to congress on any vendors, eligible hospitals, or eligible providers who are blocking information exchange.
- ONCHIT has a 1-year deadline to identify and address technical, operational, and financial issues that inhibit interoperability.
As a result of ONCHIT oversight and legislative mandate your EHR vendor should not:
- Have proprietary data formats that lock you into their product
- Send information that is intentionally unusable or incompatible to another health care entity
- Charge exorbitant fees to send or share information with another health care entity
- Require expensive middleware to exchange data
- Suggest that you can’t mix and match data vendors
In the January 12 Acumen blog post Terry mentioned the physician discontent with Meaningful Use. In this case ONCHIT may use some of the MU process and EHR certification requirements to take significant steps toward HIE. This action may make some of the EHR shortcomings easier to live with.
The Mile High Swinging Bridge at Grandfather Mountain cost $15,000 to construct in 1952. In 1999 it underwent a $300,000 rebuild that included replacing the wooden boards I walked across in the 1960s with a metal frame. Those amounts are tiddly winks in the shadow of the $30 billion committed to full use and implementation of EHRs. If we can ever get fully across the health record digitization and HIE chasm on our swinging bridge I think the 360-degree panoramic view will be worth it….totally!
Dugan Maddux, MD, FACP, is the Vice President for CKD Initiatives for FMC-NA. Before her foray into the business side of medicine, Dr. Maddux spent 18 years practicing nephrology in Danville, Virginia. During this time, she and her husband, Dr. Frank Maddux, developed a nephrology-focused Electronic Health Record. She and Frank also developed Voice Expeditions, which features the Nephrology Oral History project, a collection of interviews of the early dialysis pioneers.