The ability to review and transfer EHRs from one doctor or hospital to another is one of the major selling points for the adoption of EHRs, and until told otherwise, most patients presume that `of course` this capability is already fully in place. In fact, full interconnectivity and interoperability of EHRs is essential to the smooth functioning of the health care system, needs to be a highest priority requirement, yet as we saw in the essay `Worse than Russian Roulette`, is very far from the present reality. So what is the current State of the Union on EHRs? And what were and are some of the critical `behind the scenes` issues and dynamics that frame the present state?

The following excerpts from the RAND report RR-308 featured in the previous essay highlight the trade-offs that were made to ensure cooperation from the business world. (Recall from the `Cheat Sheet` that the HITECH Act injected billions of dollars into the health care system to spur adoption and Meaningful Use of EHRs.) [RAND]: “HITECH’s language clearly indicated that Congress wanted HIT systems to be interconnected and interoperable so that they can readily share data between providers. … Unfortunately, the rules that the U.S. Department of Health and Human Services (HHS) issued to guide implementation of HITECH watered down the requirement for connectivity.” Then we have the following, directly from the horse’s mouth, in a document just released this past October by The Office of the National Coordinator for Health Information Technology, entitled Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. Final version 1.0. “Industry response to ONC’s request for information on the topic indicated a general desire for ONC to refrain from formal governance activity at that time and to allow nascent and emerging governance efforts in industry to take shape.” In other words, as the RAND report puts it, “The practical effect of this policy change was to promote adoption of existing EHR platforms, rather than to encourage the development of interconnected systems.” I appreciate that some compromise was initially required to entice various segments of the health care industry, particularly large vendors and many health care systems, to come to the dance. But now, we must evolve. As the RAND report goes on to say, “Provisions in the ACA [the Affordable care Act] will enhance interoperability … and should substantially increase the value of EHRs to health care providers and their patients. The shift will be less welcome to large legacy vendors because it will blur the competitive edge they currently enjoy. … Irrespective of industry ambivalence, the Office of the National Coordinator for Health IT is determined to press ahead.”

This issue has reached a critical threshold. Congress has begun to address the problem of information blocking (interoperability) in a bill denoted the `21<sup>st</sup> Century Cures Act` (HR 6), that was passed last July in the House of Representatives with robust bipartisan support (344 Y, 77 N). One key provision in this bill is that if determined to be noncompliant with interoperability criteria and standards, vendors of EHRs, hospitals and healthcare providers may be found to be `out of compliance`. Then, if bad behavior persists, they can subsequently be decertified (with a minimum exemption of one-year from the Meaningful Use Program, i.e., billing) and possibly subject to a monetary penalty.

As indicated earlier, Epic has been seen as the poster child of information blocking, and has been seen as unwilling to engage in the development of industry-wide communications standards. On the healthcare blog healthcareit.me, Colin Rhodes, a prominent expert in health care IT and a Chief Information Officer, wrote an interesting entry last May, entitled `Why Fines for Information Blocking Won’t Work` that sheds some light on this topic.  Rhodes indicates that “The reality is a bit more complicated. Epic products can interoperate with other systems. Epic offers the features and functions that are needed to work with most of the other prominent EHR providers. More importantly, the integrations use standards based protocols.”  Rhodes suggests that what’s missing from the equation are powerful enough business incentives that go beyond the `cost of doing business.`

Last March, Niam Yarhagi, a research fellow at the Brookings Institute’s Center for Technology Innovation, wrote an article for the authoritative web-based forum, The Health Care Blog, entitled `Congress Can’t Solve the EHR Interoperability Problem`. Yarhagi wrote that “Decertification is not good policy. … The threat of decertification is a bluff.” He argues that ONC cannot decertify an EHR vendor that has the largest market share [to which I’d like to add, especially at the top academic center hospitals]. At best, if the bill passed unchanged through the Senate and were signed into law, Yarhagi stated that even “in the best case scenario, after Congressional pressure, such vendors may enable data exchange, but will demand very high fees [from competitors] to overcome a plethora of technical barriers, especially if the EHR vendor has a monopoly in the market.” He concludes that “this is a complicated situation which I believe cannot be resolved through regulation.”

Also, the timeline and lack of real urgency here greatly worries me. Although the 21^st Century Cures Act was passed in the House last July, nothing firm has emerged from the Senate. There seemed to be definite interest within this chamber — last April, Senate Health Committee (HELP) chairman Lamar Alexander (R-Tenn) and Ranking member Patty Murray (D-Wash) announced a bipartisan working group specifically to address ways to improve EHRs, also notably flagging interoperability as a central focus. “It’s a great idea, it holds promise, but it’s not working the way it is supposed to,” Alexander said of EHRs. So ostensibly we have bipartisan enthusiasm to ensure interoperability, from both houses of Congress. But quite evidently, the issue was not sufficiently `burning` to rapidly progress ahead to a vote, suggesting that the usual jockeying for political credit and primacy between the House and potential Senate versions is very much in play. In this upcoming and especially volatile Presidential election year, I fear that little substantive new legislation will be passed. Further complicating matters, I am concerned that any bipartisan cooperation may be severely compromised by the politics surrounding the filling of the late Antonin Scalia’s seat on the Supreme Court. Thus I will be pleasantly surprised if anything firm on interoperability were to be ready for a Presidential signature before 18 months, at the earliest, and to be clear, I am a bit dubious that any bill will have suitable muscle to change Epic’s present business model of blocking electronic records exchange. Finally, and this is incredibly important, the aforementioned ONC document Connecting Health and Care for the Nation is a 10 year plan, and full interoperability would not be required until the 2021-2024 time-period. This length delay would cripple the emerging network utility for electronic patient care at a distance for much too long. It would continue to accelerate the attrition of many senior physicians from the core system. And it would also castrate free market competition among EHR vendors, since only a very few competitors to Epic could afford to financially survive this extended time period. Yet, barring a disruption to the present course, it would appear that the Epic’s apparent corporate model to encourage the `slow-walking` of any system-wide changes to EHR protocols will be a decisive and winning business model for them. But at what cost? And with what recourse, what anti-monopolistic protections for patients and doctors?

Several recent government and industry initiatives have been initiated, ostensibly to facilitate interoperability. Among these the CommonWell Health Alliance, which includes Cerner Corporation, McKesson and Athenahealth; Carequality, with whom Epic has aligned, along with some of its existing partners; the Argonaut Project, which is `defining and testing the next generation of interoperability standards`; and the eHealth Initiative, which has released a 2020 Roadmap to broad interoperability. Although in principle these are promising, the evident business conflicts of interests and incentives persist, and more notably, fully realized interoperability outside of any major vendor still lies primarily well into the future.