The Impact of Revenue Streams and Consumer Behavior on Interoperability
During the 2004 State of the Union Address, President George W. Bush stated that by 2014, most Americans would have an electronic health record that would help “avoid dangerous medical mistakes, reduce costs, and improve care.” The policy’s goal was to “ensure that complete health care information is available for most Americans at the time and place of care, no matter where it originates.”1
After completing the Medicare Part D go-live in 2006, the US government began to codify Bush’s proclamation by establishing interoperability, or the ability of systems to communicate, exchange, and use information, as a core tenet of improving health care. The HITECH Act in 2009, the Affordable Care Act in 2010, and the Federal Health IT Strategic Plan and Nationwide Interoperability Roadmap in 2015 all drove the nation closer to interoperability.
To a large extent, adoption of healthcare technology in the form of electronic health records has occurred, with 75% of eligible providers and 90% of eligible hospitals having received payments for meaningfully using certified Health IT.2 However, the second part of Bush’s vision, to ensure complete data is available for most Americans at the point of care, hasn’t come fully to fruition.
To-date, instead of unconstrained exchange of data between systems, the current landscape is compartmentalized, caused by the lack of common interfaces between established systems, limited success in the creation of sustainable Health Information Exchanges (HIEs), and by the purposeful prevention of sharing from many players in the healthcare space. Senator Lamar Alexander (R-Tenn) recently speculated information blocking may be occurring for several reasons, including legitimate privacy concerns by physicians or hospitals, as well as targeted business strategies. There are those within the healthcare industry who view information blocking as “rational competitive practice” by for-profit businesses in a competitive industry, Alexander said. It would be against their business interests to make it easy for patients to go out of network.6
Recently, however, the tide may have begun to swing towards increased interoperability. On July 29, 2015, the Department of Defense announced that a team consisting of Cerner, Leidos, and Accenture would receive a multiyear, multibillion dollar Defense Healthcare Management System Modernization contract. The project is intended to overhaul the military health system’s electronic records, and while it hasn’t been directly stated, there has been talk that Cerner’s successful bid was partially due to their openness to interoperability. Dan Haley, vice president of government affairs at athenahealth, recently commented that “Cerner has demonstrated with us, both via CommonWell and more generally, [that] they are philosophically dedicated to evolving to an open platform. We think that’s the good thing.”4
While the size and magnitude of the DoD’s contract decision is a significant push in the direction of interoperability, there is more work to be done. Earlier this year, in response to reports of providers and technology companies purposefully blocking the sharing of information, the Office of the National Coordinator (ONC) sent a report to Congress addressing interoperability challenges. The report provided several recommendations to help address blocking, including increased in-field surveillance, governance, education and standards, and the promotion of greater competition and innovation in Health IT and Healthcare. While these recommendations are noble, ONC noted that “current economic and market conditions create business incentives for some persons and entities to exercise control…in ways that unreasonably limit its availability and use.”2
If economic and market conditions are at the core of the problem, then the most efficient and effective way to address the problem is to adjust those conditions so that the industry, instead of the government, drives interoperability. So, how do we do that? The best option is likely a combination of creating new revenue streams while also threatening existing revenue streams, and putting the consumer at the center of driving change.
Adding new revenue streams to the Healthcare system may not seem intuitive, but we must realize that the cost of sharing information today is not zero. In today’s environment, information sharing costs include time spent printing, mailing/faxing, and re-inputting patient records into various systems, and the cost of postage to send those assets between offices. Additionally, there are significant costs based on the re-execution of tests because of incorrect or missing information in the patient record and, in some circumstances, additional treatment, hospitalization, or even death that can occur as a result of treatment errors made because HCPs don’t have a complete set of patient information. A 2009 report from Thomson Reuters suggested that a lack of care coordination between healthcare providers resulted in $25-50 billion in wasted spend.5 That number has surely grown in the past five years with the emergence of new care modalities like pharmacy based clinics, urgent care centers, and mHealth. Certainly refocusing these billions of dollars towards exchanging digitized information would be enough to motivate parties to enable interoperability between systems.
The good news is that this type of data exchange is not new. In a May 2015 post on Becker’s Health IT & CIO review, Daniel O’Neill from Practice Fusion calls out that a transmission network already occurs in the Healthcare space: electronic prescribing. Daniel notes that “some 600 different EHR applications have connected to the largest prescribing network using a single standard, [and] half a million physicians write prescriptions electronically.”3 Best yet, the network was created more than 15 years ago because “pharmacies and health plans believed they would benefit commercially by digitizing the data flow, through processing efficiencies and healthier patients, and so began paying for the service.”3
While creating new revenue streams for technology companies may reduce their desire to actively block data sharing, it doesn’t affect blocking by providers. To combat this, consumer (patient) preference must drive the behavior change for providers through these consumers seeking services from entities (physicians/hospitals) that openly share information, at the cost of those that do not.
Luckily, healthcare is in the midst of a major consumer movement. Patients are becoming more empowered and informed on health care services, focusing on convenience, value, and out-of-pocket costs. To further enable this focus, patients need to understand how their data is critical to decision-making and, ultimately, health outcomes. As a result, they must also demand its availability when they need care, regardless of the provider or medium through which they receive that care. Seventy-five percent of respondents to a recent survey conducted by the Society of Participatory Medicine said it is very important that their health records be easily shared between physicians, hospitals and other health care providers.8 We, as a health care system, need to take this a step further to drive action that reinforces this consumer view.
One avenue by which we can achieve increased consumer engagement is through delivering educational programs via a patient’s trusted source (e.g., family physician, care taker, family member, community resources, etc.). To make these programs truly effective, we must realize that the level of engagement can vary from consumer to consumer, and increasing engagement is not a one-size-fits-all approach. We must understand the socioeconomic factors that impact consumer decisions and design the educational programs to address these factors in clear, simple language.
In addition to educating consumers on the value of data sharing, we must look at incentives to drive behavior. Becoming increasingly more common as a result of health care reform is innovative health insurance benefit design. Consumers today are encouraged to use physicians and hospitals identified by their health plan as providing care of both high-quality and high-efficiency (read: low cost). These providers are known as “high performers.” What if we expanded the definition of “high performer” to include providers who are openly sharing health information with other providers? This could be an additional avenue for incentivizing both consumers and providers who recognize the benefits of interoperability.
The challenge of driving interoperability is neither new nor one that can be solved by a single sector of the healthcare industry. Instead, as an industry, we must find ways to create a multi-faceted approach to drive more engagement and participation from technology vendors and providers in creating a free flow of information between systems. Using a combination of revenue and consumer demands to drive changes in behavior is far more likely to be successful than regulation by ONC or any other government agency.
Note: On July 23rd, 2015, Senator Alexander highlighted in a press conference that the Senate health committee will ask CMS to delay the third and final stage of meaningful use to allow the panel time to submit recommendations on the incentive program.7
- White House Archives. “Promoting Innovation and Competitiveness – President Bush’s Technology Agenda.” January 2004. Downloaded August 6, 2015 View in Article
- The Office of the National Coordinator for Health Information Technology (ONC). “Report to Congress – Report on Health Information Blocking.” April 2015. Downloaded July 20, 2015 View in Article
- O’Neill, Daniel P. Vice President, PracticeFusion. “Durable interoperability? Maybe a market isn’t such a bad idea.” Becker’s Hospital Review. May 13, 2015. Downloaded July 20, 2015. View in Article
- Jayanthi, Akanksha. “Where the DOD contract falls short: Thoughts from athenahealth.” Becker’s Hospital Review. July 31, 2015. Downloaded July 31, 2015. View in Article
- Wicklund, Eric. “Report: Americans waste up to $850 billion a year in healthcare.” Oct 26, 2009. Downloaded Aug 6, 2015. View in Article
- John. “Congress Tackles EHR Woes, Information Blocking, Interoperability.” Aug 6, 2015. Downloaded Aug 6, 2015. View in Article
- Dickson, Virgil. “Senate panel will push HHS to delay Stage 3 MU rules”, Jul 23, 2015. Downloaded Aug 6, 2015. View in Article
- Greene, Marc. “Americans Believe Personal Medical Data Should Be Openly Shared with Their Health Care Providers.” Mar 19, 2015. Downloaded August 16, 2013 View in Article