by Sean Slone, CSG Senior Policy Analyst
Massive health care system disruptions caused by the coronavirus pandemic re-confirm, for many, the importance of electronic health records (EHRs) and patient data. These records are crucial for optimizing care, reducing medical errors, improving coordination between providers and empowering patients to participate in their own care. But the same challenges that EHRs faced before the pandemic have also been brought into sharp relief by the current crisis.
“There are still two main gaps,” said Ben Moscovitch, project director for health information technology at the Pew Charitable Trusts, who spoke last year at the first meeting of the What’s Next? Leveraging Innovation Subcommittee, part of the CSG Healthy States national task force. “One is around interoperability, which is the exchange of health records between different facilities, and the second is around usability and patient safety. Usability refers to the design and use of the electronic health record.”
Moscovitch said some key barriers are preventing interoperability on a nationwide scale. Patient identification may be lacking, which can prompt a provider to create another record unnecessarily. Similarly, if providers or hospitals are unsure of a match, they may be unwilling to share patient records.
Pew has been studying where opportunities may exist to improve patient matching, Moscovitch said, including an idea that has been discussed for more than 20 years: a unique patient identifier.
“Give everyone a number and whenever they get care, they provide that number much like a social security number,” he said. “There are challenges to this. A typo could be entered in the number. In many foreign countries they have a unique identifier and still haven’t solved the patient matching problem. And there are some political concerns with this approach as well. There has been a ban on the creation of unique health identifiers for more than 20 years.”
Another way to improve patient matching could involve something that has become increasingly controversial in recent years despite its ubiquity: biometrics.
“We did focus groups with patients and one of the things we heard, almost to a person, was that they use their face scan or fingerprint or some other biometric to unlock their phones, get on airplanes, go to amusement parks and sporting events on a daily basis,” Moscovitch said, speaking last year, before some of those activities were disrupted. “Why can’t we just use the same approach to match their efforts so that clinicians can have the information that they need? There are a lot of technical and privacy issues to the use of biometrics. There are also some state and local policies, which are related to the use of biometrics. For example, San Francisco (in 2019) issued a ban on the use of facial recognition for certain purposes.”
The states of California, New Hampshire, New Jersey, New York and Oregon, as well as communities in Massachusetts, have all sought to ban facial recognition technologies in recent years. Washington state, on the other hand, became the first state to pass legislation to allow facial recognition, with constraints.
Moscovitch said Pew is also studying how biometrics are used in various industries, whether there may be lessons in applying them to health care and how privacy concerns might be addressed.
Steps Towards EHR Interoperability
Last month, just as the pandemic was about to disrupt American life, the Trump administration issued two final rules related to the interoperability of health records.
“At a time when the healthcare system could be under stress with the handling of the COVID virus, the urgent need for coordinated, integrated care could not be clearer,” Centers for Medicare & Medicaid Services Administrator Seema Verma told reporters, according to MedPage Today. “In a healthcare system characterized by the easy and seamless flow of information, one in which a patient’s own data follows them to the provider they choose, care for patients would be drastically improved.”
One of the rules requires health plans in Medicare Advantage, Medicaid, CHIP and on the federal health insurance exchanges to share claims data electronically with patients.
The other rule, issued by the Office of the National Coordinator for Health Information Technology, implements the clinical interoperability provisions of the 21st Century Cures Act (approved by Congress in 2016 to “accelerate the discovery, development and delivery of 21st century cures”). These provisions deal with EHRs, requiring hospitals and doctors to provide software access points so patients can download records to their smartphones. That will allow patients to connect their data with various apps to promote health.
During the What’s Next? Leveraging Innovation Subcommittee meeting last year, Moscovitch said opening up the data locked in electronic health records is like allowing companies such as Expedia and Travelocity to access the same flight data from major airlines.
“The way they do that is through something called APIs, or application programming interfaces — basically just a computer program that allows two databases to talk to one another,” Moscovitch said. “We can apply that same approach to health so that, for example, you can get all of your information from different hospitals on your phone in a single app.”
The COVID-19 Challenge
In an op-ed for STAT last month, two health care experts called COVID-19 the ultimate stress test for electronic health record systems. Interoperability remains one of the biggest reasons why.
“If this capability currently existed across all of U.S. electronic health records, the ability for health systems to securely and appropriately share information in public health emergencies would be vastly improved,” writes Dr. Eric Perakslis of Duke University and Dr. Erich Huang, chief data officer for quality at Duke Health.
That capability doesn’t exist yet, however, and Perakslis and Huang argue that interoperability on a small scale isn’t something that can be scaled-up quickly, particularly during the current crisis.
“Tracking dozens of patients in an electronic health record system is feasible in many health care systems, but current capabilities are unlikely to scale to hundreds or thousands,” they write. “During the response to Covid-19 and beyond, data must flow and conversations on interoperability must be treated like the public health issues they are, not the kind of business agenda pursued by the CEO of EPIC, who wrote a letter to hospitals opposing provisions of the 21st Century Cures Act.”
Some argued that EPIC, the nation’s largest EHR company, and its CEO, Judith Faulkner, made the effort to scuttle the new rule and block the flow of data out of its software and into apps for doctors and patients in an effort to double down on “its monopolistic hold on American health care” and protect the competitive edge of the company’s proprietary software.
In another piece for STAT, Dr. Kenneth Mandl of Boston Children’s Hospital and Harvard Medical School and Dr. Isaac Kohane of Harvard Medical School write that while most Americans believe that the information clinicians type into their EHRs is used to benefit their care in various ways, including to coordinate information across different care sites, it doesn’t really work that way.
“At the cost of millions to billions of dollars per hospital or health system, health care relies on pre-internet proprietary and non-interoperable software where, as in the old “Roach Motel” ads, data check in, but they don’t check out,” they write. “In addition, EHR software is sold under contracts that contain both hold harmless clauses to abdicate responsibility for adverse events associated with their products and nondisclosure clauses to inhibit reporting of serious adverse events.”
EPIC has been in the news a great deal in recent weeks as its products have been deployed in some of the nation’s key hotspots to deal with the overwhelming number of COVID-19 patients. The Chicago Department of Public Health and Rush University Medical Center implemented an EPIC EHR system at the city’s 3,000-bed COVID-19 alternate care facility at the McCormick Place Convention Center, Becker’s Hospital Review noted. Similarly, the New York Department of Health and NYC Health and Hospitals implemented an EPIC EHR at the 1,000-bed hospital established at Manhattan’s Javits Center, according to EHR Intelligence.
The Future of Interoperability & EHRs
EPIC and some other EHR companies reportedly explain their reluctance to support the interoperability rule and the implementation of the 21st Century Cures Act by saying they fear that poorly conceived smartphone apps that are able to access sensitive healthcare data from their software could experience leaks. But other players in the EHR space — in addition to tech giants Microsoft and Apple — have given the rule strong support.
Analysts say fully interoperable patient data exchange will only be possible if EHR vendors and providers work together to implement the new rule and APIs are deployed across the industry.
The coronavirus pandemic could be the factor that finally pushes that to happen.
But, ironically, such cooperation may have to wait until after the pandemic is well in the rearview mirror. Politico reported earlier this month that the Department of Health and Human Services was likely to pause enforcement of the new interoperability rules after health care stakeholders argued complying with the rules would be an unnecessary burden in the midst of the crisis.
In a letter to HHS Secretary Alex Azar, Pew’s Ben Moscovitch argued for implementing the rules without delay.
“While these APIs may not be immediately available, any further delay in this timeline impedes critical benefits to patients and hinders our ability to use this technology to address further disruptions in the health care system,” he wrote. “Since Congress passed Cures in 2016, patients have waited long enough to gain access to data
and ensure that their health care providers are better equipped with data to coordinate care. Therefore, we urge you to implement these rules without additional delay.”
During the What’s Next? Leveraging Innovation Subcommittee meeting last year, Moscovitch said one issue that could stand in the way of accelerating the use of APIs in the years ahead is an issue of significant interest to state governments: data ownership.
“Today, New Hampshire is the only state where legally patients own their data,” he said. “[Other states have] explicit laws on the books where health care providers own the data. [Still other states] do not speak to ownership. There are questions about whether patients do in fact need to own their data or whether it’s sufficient for them to be able to control access and exchange of that information.”
Besides who owns the data, states also face the issue of how health data is defined. Some believe the COVID-19 pandemic has shown us that the definition should be expanded.
“(It) …should no longer be limited to medical data of patients, and instead should encompass a much wider variety of data types from individuals’ online and offline activity,” wrote Niam Yaraghi, a Brookings Institution nonresident fellow, in a recent op-ed. “Moreover, the pandemic has proven that healthcare is not local. In an interconnected world, with more individuals traveling long distances than ever before, it is naïve to look at regions in isolation from each other and try to manage public health independently. To efficiently manage a pandemic like this, the scope of health information exchange efforts should not be limited to small geographical regions and instead should be done at least nationally, if not internationally.”
Last month, infectious disease specialists suggested that integrating patients’ recent travel histories directly into their EHRs might be one way to establish greater interconnection.
“We have the infrastructure to do this easily with the electronic medical record; we just need to implement it in a way to make it useful to the care teams,” said Dr. Trish Perl, chief of Infectious Diseases and Geographic Medicine at the University of Texas Southwestern Medical Center, in a news release. “Once the infrastructure is built, we’ll also need to communicate what is called ‘situational awareness’ to ensure that providers know what geographic areas have infections so that they can act accordingly.”
The What’s Next? Leveraging Innovation Subcommittee of CSG’s Healthy States National Task Force is examining such issues as data interoperability, privacy and ownership. The task force, which was created last year, will deliver its final report and policy recommendations in December.
Update: On April 22, Politico reported that HHS officially decided to delay enforcement of major parts of the new interoperability rules. The rule on patient API requirements will be pushed back about three months, according to the report. Pew’s Moscovitch tweeted his approval of what he called the “minimal timeframe changes.” Others in the tech community said enforcement discretion and a delay are “sensible given the crisis.”
- “Why the new U.S. interoperability rules matter during the COVID-19 pandemic,” Medical Economics, March 25, 2020.