What’s impeding interoperability and hurting small healthcare orgs? And how can they overcome these challenges?
When patients have their healthcare data, they receive better care.
The simplest data exchange can look like this: After a trip to the emergency room, a patient sees a specialist. For the visit to be most useful, it’s important for the provider to have access to the results of any tests performed in the hospital. The first thing a specialist would likely do is order more tests — but often, due to incomplete data exchange, these tests end up duplicating procedures that have already occurred.
That is one way how the lack of data exchange drives up healthcare costs and creates unnecessary delays in care delivery. Interoperability — the state in which data can be transmitted electronically and understood by different users, from providers to patients — could help change that, but many obstacles stand in the way. (The 2018 comment period for interoperability is open, and physicians and health system leaders should share their experience with how technical burden affects their practice.)
Despite clear benefits for patients, patient data are not readily accessible to providers who didn’t order the original tests or those who are working outside a large health system. Many challenges exist, and when added up, it certainly seems like small practices are most at risk.
A lack of consistent coding is the first obstacle of interoperability. Many criticize electronic health record (EHR) companies for holding on to data (EHR orgs have a reputation for blocking health data exchange), or vendors for decreasing security through data breaches. Sometimes, the problem even affects different departments within the same health system.
One difficulty in incentivizing interoperability is that healthcare data have become a commodity. In July, 23andMe entered into an agreement to share genetic data with GlaxoSmithKline for a $300 million stake. When health data are seen as a competitive advantage, interoperability efforts are discouraged.
Another financial disincentive for data sharing is fee-for-service reimbursement. If a health system or provider is paid based on each test they order, then they financially benefit from testing. Regulations wherein financial incentives don’t align increase the divide between the haves and have-nots in terms of healthcare market consolidation.
A challenge facing interoperability regulations is that many see them as the death of the small physician’s practice. Regulations encouraging better data exchange are also driving up costs for small practices. Healthcare systems with money to develop better technology are buying up smaller practices and hospital systems, and interoperability standards can increase this divide. According to a Deloitte report, only 50 percent of today’s healthcare systems will exist in 10 years. The rest will be purchased and integrated into these larger systems. The cost of compliance is onerous, and many smaller practices (with already-overburdened physicians and staff) simply do not have the the bandwidth to add technology and new workflows.
I asked Corinne Proctor Boudreau, senior marketing solutions manager at MEDITECH, what an EHR company would say about technical complexity and how it impacted small practices. She pointed to the increase in regulations and the burnout physicians are facing.
“EHRs and interoperability are major contributors to the shift away from small private practices towards healthcare organization employment. Inefficiencies in workflow in both areas increase time spent and burnout rates for physicians, but there is the technical knowledge and staff needed to support EHRs,” Boudreau explained.
She cited other factors, as well: “Twenty to thirty years ago, the core competency of small practices was practicing medicine with little administrative overhead or requirements. Today, medicine and patient care are more complex. In addition, administrative requirements of payers have skyrocketed, not just the actual work, but also being knowledgeable about all of the different demands, undergoing audits and understanding all the analytics and staffing models as the industry moves from fee-for-service to value-based care.”
Administrative complexity, including communicating with insurance companies, means the data exchange can be too much for a small physician’s practice, which might not have the technical talent or time to train its staff in the latest procedures for interoperability in data exchange and health record capabilities.
Seema Verma, M.P.H., administrator of the Centers for Medicare and Medicaid Services, has called for an end to faxes, but she has given little guidance on better workflow solutions for practices that rely on fax. Is there a convenient way to transfer data and coordinate with other practices? If sending a fax wasn’t the easiest solution, it wouldn’t be used.
Without a clear solution that creates easy data exchange within physicians’ existing workflow, this is not a useful call to action. One of the most important things that will influence the efficiency of care and the ability of providers to communicate will be the elimination of a system wherein doctors receive hundreds of pages of faxes each day. Despite criticism of faxes as a means of transmitting data between providers, no better solution appears on the horizon — at least not without significant added technological complexity and cost.
This high cost is especially burdensome for small practices. Each provider pays a fee every year to belong to a health information service provider (HISP), and if the exchange doesn’t contain existing patient data, or not all providers have uploaded information into an exchange, members end up paying for the potential to have data exchange with no real value.
I spoke to Spencer Kubo, M.D., about his experience setting up data exchange for his smaller practice. He currently works for CareCognitics, a healthcare company created by casino technology experts to improve care coordination and loyalty. He said, “the incremental costs associated with developing and maintaining electronic health records could be the death of the small practice.”
“It’s astounding that you can do a banking transaction in Singapore or Zurich or Minneapolis or New York and everything is fine. You can purchase on four different continents with your credit card, and everyone understands what has happened. A hospital can be four blocks from a clinic, but because it is on a different [EHR] or a different health system, you cannot exchange information freely.” — Spencer Kubo, M.D.
In working with some EHRs in a practice setting, Kubo found that a small practice doesn’t always get responses from their EHR vendor about interoperability. After three years of effort to get approved, Kubo’s practice still faced the barrier of building and maintaining information systems. This technology cost can be untenable for smaller practices, which can go on to harm data-sharing networks
In a marketplace like Las Vegas, where smaller practices still exist and where Kubo lives, data exchange problems are even more apparent. These small practices have all the IT complexity challenges with none of the benefits. Don Lee, interoperability expert and producer of the HCBizShow, mentioned that a small practice or an independent physician simply does not have the bandwidth to deal with every type of regulation. Which of the following organizations does a small clinic need to comply with? CMS, DOH, BORM, BORN, TJC, NIST NISC, ISO, et al. If policymakers can’t keep track of all the regulations, how will an overburdened physician deal with data requirements?
According to Dirk Stanley, M.D., M.P.H., chief medical information officer of UConn Health, the framework for compliance needs to be addressed. Complexity of data requirements within organizations can require a full-time data expert. “Add the insurance companies to that mix, and you need a whole team of people just to comply with everything you need to comply with,” he said.
I wouldn't pin it all on ineterop, but 100% yes all of the tech, quality, regulatory requirements that are piled on physicians absolutely contribute to consolidation. Expense is a factor for small practices, but so is time and attention.
— Don Lee (@dflee30) August 13, 2018
Healthcare providers currently have to pay for many end-to-end point connections for data. The office of the National Coordinator for Health IT (ONC) has proposed a common “on-ramp” for data exchange. Don Rucker, M.D., the office’s head, has championed the idea of having a trusted exchange framework and common agreement (TEFCA) that will help address complexity in data transfer. Under this proposal, a small provider would not have to pay for each different connection. (The current review period for interoperability requirements for the ONC is open. Physician practices that have dealt with expensive data connections should comment here.)
Boudreau told me that small practices need “better systems and better technology” to decrease technical burden but also suggested that “if a practice lacks the bandwidth internally, some processes can be outsourced.”
“When looking at EHR vendors, have key considerations (like workflow efficiency, interoperability offerings) and key goals that your practice wants to meet. Using a hosted, cloud-based solution can reduce technical requirements within a practice. Many practices outsource coding, billing and/or collection functions to mitigate staffing needs in this area.” — Corinne Proctor Boudreau, MEDITECH senior marketing solutions manager for physician experience
Across a large healthcare delivery system, technology costs are an investment in better care coordination and health outcomes — they do represent a total savings. Can national requirements or EHR vendors provide the technology needed for smaller practices to have better data access? The “land grab” of healthcare, where large healthcare systems have a competitive advantage in terms of technology, is being driven by a lack of bandwidth to maintain a small practice. Feedback about how regulations affect small practices is needed. The question remains whether consolidation represents the death of the small practice — or whether workarounds can be found to allow these practices to still thrive in an increasingly data-driven system.
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