I recently had a great conversation with Dr. Farzad Mostashari, M.D., one of the leading voices in health IT. A former National Coordinator for Health IT, Mostashari subsequently founded Aledade in 2014—a Bethesda. Md.-based company focused on physician-led accountable care organizations (ACOs).
During our interview, which can be read in full here, we touched on a multitude of industry-wide issues, but there was one thing that Mostashari said that definitely deserved a deeper dive. We were talking about IT challenges that ACOs in the trenches were having, and then I asked him about other physician pain points when it comes to IT. Here is what he said:
"First, there is the real world data blocking that we’re seeing. The first example is EHR [electronic health record] vendors—in order to fully develop that picture and really know your patient, and to know who needs your help, you need to do predictive modeling with the clinical data. It’s about getting clinical data out of EHRs that the practices have paid for and spent tens of thousands of hours putting data into them. Wanting to get your own data out is way too hard, expensive and slow. It’s neither cheap, easy nor fast; you get zero out of those three, and honestly I would settle for getting two out of those three. So that needs to be fixed."
"The part that galls me the most is that the vendors can’t or won’t do what they pledged to do as part of the certification program for EHRs. These EHRs got tested in a lab to be able to produce batch downloads of patient care summaries, but in the field they either can’t or won’t do it. Some vendors actually implemented their technical solution in order to past the certification lab test, so it’s as if they 'hardcoded' it to their lab test. It’s like knowing what the questions would be, they hardcoded their answers to that. But you can’t have a conversation with them in the field. They played a compliance game to pass the test, but they knew they didn’t actually have to have it working in production. That needs to have consequences. There needs to be a robust surveillance program response from ONC. If vendors don’t comply with the certification requirements they should be at risk of having their certification revoked. Or the vendors will charge you, say $40,000 for an interface engine that they didn’t originally say was needed as part of the certification program’s transparency requirements. They said it was a complete EHR."
To me, this was as damning a statement we have heard in quite some time regarding data blocking, a major point of contention ever since the Office of the National Coordinator for Health Information Technology (ONC) produced a report last year, per the request of Congress, that detailed several examples of EHR developers and health systems blocking health information sharing between each other. If data blocking does take place on either the vendor or provider system side, the likely cause is that they are avoiding competition by favoring the services they control. Of course, as healthcare looks to become more interoperable, this blocking of information would have a direct effect on that goal.
Naturally, organizations such as the HIMSS EHR Association (EHRA), which is comprised of some 40 health IT vendors including the very biggest industry players, called the ONC report into question, saying that “the concept of ‘information blocking’ is still very heterogeneous, mixing perception, descriptive, and normative issues in ways that are not easily untangled. The EHRA later said that charging for interface software and services should not be considered information blocking.
It should also be noted that the ONC, which also called for Congressional action to put a stop to the data blocking in the report, based much of its findings on and anecdotal evidence and accounts of potential information blocking found in various public records and testimony, industry analyses, trade and public news media, and other sources.
It’s not hard to see why the government is trying to figure out if data blocking is a true problem in healthcare, after it has spent $30 billion in healthcare technology investments via the Health Information Technology for Economic and Clinical Health (HITECH) Act alone. But depending on who you ask, it may or may not exist. And if it does, there are plenty of complications about what exactly defines data blocking.
That’s why Mostashari’s comments stuck with me. He is directly claiming that vendors are “working” the system to their advantage, meaning doing just enough to pass the certification test, but not enough to fulfill the requirements of the spirit of the regulation, in terms of functionality in the field when it matters. This is not just a simple “loophole” without consequences either; the lack of information sharing can unequivocally have significant healthcare implications.
On the provider side, Mostashari also said that he is seeing data blocking form hospitals. He said in our interview, “It’s a way to keep patients in their own network, to encourage doctors to join their ACO, rather than an external ACO, out of concern there might actually be fewer admissions, maybe? I don’t know what it is, but we are seeing very conscious and active information blocking on the part of hospitals.”
But once again, this accusation has been refuted in healthcare circles. The Medicare Access and CHIP Reauthorization Act (MACRA) proposed rule from this past April called for physicians to attest they are not engaging in information blocking, and stated that there would be surveillance to ensure that health systems’ EHRs were enabled for information exchange. However, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center in Boston, in response to that proposal, said on his blog that the surveillance is simply unnecessary. “I’ve never seen a location in Boston where a clinician, in a volitional way, disabled functionality in an EHR to block information flow.” Halamka said.
Meanwhile, last September, Daniel Barchi, senior vice president and CIO of Yale New Haven Health System & the Yale School of Medicine, was so focused on this issue that he penned a piece for Healthcare Informatics titled, “Eclipsing the Perception of Data Blocking.” Barchi wrote:
"There is little evidence that hospitals or physicians are hoarding patient data for their own gain. Quite the opposite is true—after years of building and implementing EMRs, health providers have turned their focus to better data sharing with patients and other providers.”
He gave examples of patient access to data and information sharing at his own health system, also noting that “Other hospitals and physician practices are also using technology and interface standards to share data locally."
Why is there such disconnect about what people think about information blocking? Mostashari said it’s because those who deny it either have strategic reasons to disagree or simply aren’t “walking in the shoes of the people who are in the field trying to get data across networks.”
To me, the answer may lie somewhere in the middle. And as healthcare stakeholders continue to struggle to move data in a free flowing manner, this debate likely won’t go away. Issues such as lack of progress in technology system upgrades and lack of agreed upon standards only muddy the waters more. Is it really data blocking when vendors are charging money for interface software? And when hospitals point to the many frictions that make data exchange less of a priority for them, does that count as information blocking?
In the end, opinions will vary and there will be misconceptions. At this year’s HIMSS conference in Las Vegas, companies that provide 90 percent of EHRs used by hospitals nationwide as well as the top five largest private healthcare systems in the country agreed to sign a pledge that among other things, not block electronic health information (defined as knowingly and unreasonably interfering with information sharing).
But perhaps the core issue is in that definition itself. Only those in the trenches know the real truth, and here’s hoping that the future brings with it greater clarity.