A New Look at Economic Barriers to
Interoperability
JULIA ADLER-MILSTEIN, PHD
U N I V E RS I T Y O F M I C H I G A N
JUNE 8, 2017
Policy Context

Health information exchange is critical to a well-functioning health care
system.

Electronic sharing of data between providers can lead to better care
coordination, greater efficiency

However, little consensus on how to achieve these benefits:
what approach(es) to HIE should be pursued?

HITECH provided funding as well as non-financial incentives to increase HIE,
largely allowing different approaches to HIE to exist in the market

Frustration with slow pace of progress
HIE-related MU criteria most challenging,
but also see big increase 2013-2014
Adler-Milstein et al. Health Affairs 2015
Stage 2 Transition of Care Threshold Achievement
25
Percent of Hospitals
20
15
10
5
0
0-10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100%
Percent of Patient Transitions with an SCR Sent Electronically
N=1,822 hospitals; data through April 2016
CMS 2016
My Diagnosis

Slow progress is the confluence of THREE factors
•
Little clarity or agreement on end-point
•
Numerous, difficult barriers that span domains and require coordination across
many stakeholders
•
Insufficiently strong financial incentives to overcome barriers

In particular, providers and vendors do not need to engage in (or support) robust HIE to be
competitive in the market.
Issue 1

Slow progress is the confluence of THREE factors
•
Little clarity or agreement on end-point
•
Well-defined HIE use cases versus all key stakeholders share all relevant
clinical data “in an interoperable manner”
•
Key challenge is how to pursue the former in the near-term, while ensuring that we are not
making decisions that interfere with our ability to do the latter in the long-term
Issue 2

Slow progress is the confluence of THREE factors
•
Little clarity or agreement on end-point
•
Numerous, difficult barriers that span domains and require coordination across
many stakeholders
Key Result from
National HIO Survey
(2014)
http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440
Key Result from
National HIO Survey
(2014)
Related to business case
& aligned incentives
http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440
Key Result from
National HIO Survey
(2014)
Related to technical
challenges
http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440
Key Result from
National HIO Survey
(2014)
Related to policy &
governance challenges
http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440
Key Result from
National HIO Survey
(2014)
Related to operational
challenges
http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440
Issue 3

Slow progress is the confluence of THREE factors
•
Little clarity or agreement on end-point
•
Numerous, difficult barriers that span domains and require coordination across
many stakeholders
•
Insufficiently strong financial incentives to overcome barriers
What do we know about financial and
business barriers?
Anecdotally:
◦ Hospitals perceive patient data “as a key strategic asset, tying physicians and patients to their
organization.” (Grossman et al. 2008)
◦ Complaints to ONC about information blocking
Empirically, but indirectly:
◦ For profit hospitals and those in more competitive markets substantially less likely to share
data (Adler-Milstein et al. AJMC 2011)
What do we know about financial and
business barriers? New Findings
(1) STUDY ONE:
Examines the relationship between hospital characteristics and the extent of hospital
engagement in SCR transmission for Stage 2 MU
In Press
(2) STUDY TWO:
Assesses current experiences with information blocking by those leading HIE efforts
Published earlier this year
Study One: What explains variation in Stage 2 MU
SCR Criterion?
25
Percent of Hospitals
20
15
10
5
0
0-10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100%
Percent of Patient Transitions with an SCR Sent Electronically
N=1,822 hospitals; data through April 2016
CMS 2016
Study One: Results – Technology
Continuous
Percent of Patient Transitions with an SCR
Sent Electronically
Dichotomous
Hospitals >80% vs. Hospitals <80% (Odds
Ratios)
2.60*
2.93*
2.85*
1.29
1.20
1.23
1.23
0.82
1.00
1.07
1.01
0.84
6.93**
-1.37
-4.03*
-1.27
6.64*
0.02
0.83
0.75
0.25***
0.45*
0.50
1.00
Technology Capability
Third-Party HIE Vendor
EHR Vendor as HIE Vendor
Automatic PCP Alerts
Active HIO Participation
EHR Capability (Ref: Less than Basic)
Basic EHR
Comprehensive EHR
Vendor (Ref: Other)
Epic
Meditech
Cerner
McKesson
Siemens
Available Exchange Partners
Study One: Results - Incentives
Continuous
Dichotomous
Percent of Patient Transitions with
an SCR Sent Electronically
Hospitals >80% vs. Hospitals <80%
(Odds Ratios)
Market Competition (HHI)
0.09
1.75
Market Share
0.07
1.02
Government
7.84***
6.76**
Non Profit
5.33**
6.08**
% Revenue Capitated
-0.14
0.96
% Revenue Shared Risk
-0.09
0.99
System Membership
3.45*
1.13
Network Membership
-1.08
1.63*
Incentives
Ownership (Ref: For Profit)
Both
Continuous
Percent of Patient Transitions with an SCR Sent
Electronically
Dichotomous
Hospitals >80% vs. Hospitals <80% (Odds Ratios)
-1.02
-1.95
-3.97
-1.07
7.84
-5.83*
-15.81***
0.00
-0.01
1.29
0.66
0.49*
0.97
1.94
0.39
0.13**
1.00
1.00
0.13
4.65*
0.79
0.00
0.00
0.95
1.10
1.08
1.00
1.01
Controls
Size/Teaching (Ref: Small Non-teaching)
Small Minor-teaching
Medium Non-teaching
Medium Minor-teaching
Medium Major-teaching
Large Non-teaching
Large Minor-teaching
Large Major-teaching
% Inpatient Days Medicaid
% Inpatient Days Medicare
Geographic Setting (Ref: Metro)
Micro
Rural
Hospital Beds in Market per 1000 Residents
Population in Market (in 1000s)
Hospital-Ambulatory Integration
But how do you know it’s specifically
about “exchange”?
o Meeting the criterion also requires ability to generate an SCR, know where to
send it, etc.
o What is related to higher % of all SCRs sent that are transmitted
electronically?
o
Epic (vs. “other” vendor)
o
Government or non-profit ownership (vs. for profit)
o
System membership
Discussion
o Overall low levels of HIE under Stage 2 MU
o Related to both technical capabilities and incentives (and complexity)
o No clear target for actions to increase exchange
o
Limited insights into nature of incentive-related issues
Study 2: Information Blocking

Key is to determine if EHR vendors and/or providers are making decisions
that slow or impede interoperability

And determine whether incentives are perverse or just insufficiently strong.
o
If perverse, information blocking is “real” and needs to be targeted.
o
If insufficiently strong, information blocking is concentrated within a small number of bad
actors, and the real issue is that we need to strengthen incentives for pursuing HIE.
Information Blocking
Information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or
use of electronic health information.
Interference. Information blocking requires some act or course of conduct that interferes with the ability of authorized persons or entities to
access, exchange, or use electronic health information.
This interference can take many forms, from express policies that prohibit sharing information to more subtle business, technical, or
organizational practices that make doing so more costly or difficult.
Knowledge. The decision to engage in information blocking must be made knowingly.
No Reasonable Justification. Accusations of information blocking are serious and should be reserved for conduct that is objectively
unreasonable in light of public policy.
Public policy must be balanced to advance important interests, including furthering the availability of electronic health information for
authorized and important purposes.
Information Blocking Survey

As currently defined, information blocking is only observed through
provider and vendor business practices

HIE efforts are those who most directly encounter such business practices

We are therefore surveying leaders of HIE efforts to ask about:
o
Extent to which they observe info blocking behaviors
o
Viability of policy solutions to combat info blocking
Information Blocking Survey:
Frequency
Frequency of Engaging in Information
Blocking: EHR VENDORS
Frequency of Engaging in Information
Blocking: HOSPITALS & HEALTH SYSTEMS
Routine
Occasional
Rare
Routine
Occasional
Rare
55%
30%
15%
25%
35%
37%
Frequency of Information Blocking Behaviors:
EHR Vendors
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
High fees for HIE
unrelated to cost
Making 3rd party access Refusing to support HIE
to stdized data difficult with specific vendors or
HIEs
Often/Routinely
Making data export
difficult
Sometimes
Changing HIE contract
terms postimplementation
Never/Rarely
Unfavorable contract
terms for HIE
Frequency of Information Blocking Behaviors:
Hospitals/Health Systems
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Coercing providers to adopt Controlling patient flow by Using HIPAA as a barrier to
particular EHR or HIE
selectively sharing patient PHI sharing when it is not
technology
information
Often/ Routinely
Sometimes
Never/ Rarely
Policy Strategies to Combat Information Blocking:
EHR Vendors
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Demonstration of Prohibiting gag clauses Stronger government
product interoperability
HIE infrastructure
Very effective
Make information
blocking illegal
Stronger financial
incentives
Moderately effective
Tougher Certification
Voluntary code of
conduct
Policy Strategies to Combat Information Blocking:
Hospitals/Health Systems
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Stronger incentives
from CMS
Increase
transparency in
business practice
Make information Guidance from ONC Train providers to Creation of provider
blocking illegal
identify information code of conduct
blocking
Very effective
Moderately effective
Discussion

Based on survey results, information blocking appears to be real and
harmful, but not routine among all vendors and providers

Agreement on policy actions to combat it, which focus on:
o
Strengthening incentives
o
Increasing transparency (on pricing, contracting, and product performance)
•
Part of 21st Century Cures TRUST provisions
My Diagnosis

Slow progress is the confluence of THREE factors
•
Little clarity or agreement on end-point
•
Numerous, difficult barriers that span domains and require coordination across
many stakeholders
•
Insufficiently strong financial incentives to overcome barriers

In particular, providers and vendors do not need to engage in (or support) robust HIE to be
competitive in the market.
Summary
Increase Provider
Incentives for HIEsensitive Outcomes
Lower Barriers to
Interoperability,
particularly targeting
vendors/technology
Summary
Increase Provider
Incentives for HIEsensitive Outcomes
Lower Barriers to
Interoperability,
particularly targeting
vendors/technology
Opportunities:
Opportunities:
- Higher threshold for SCR HIE in Stage 3 MU
- Stage 3 MU API requirements & associated
technical standards
- New NQF effort to develop HIE-sensitive
outcomes
- Incorporate measures into new payment
models (e.g., MIPS)
- Shift to bundled payment
Is this enough?
- TRUST provisions in 21st Century Cures
- Federal efforts related to removing policy barriers
related to consent, new patient matching
approaches
Option 2
Extra Slides
Naming Conventions
High fees for HIE unrelated to cost=Charging fees for exchange, connectivity, or access to data that bear no apparent
relationship to the vendor’s actual costs
Making 3rd party access to stdized data difficult=Using high fees, dilatory tactics, or artificial technical barriers to avoid
granting third-parties access to standardized clinical data stored in the vendor’s EHR system (especially limits on
exchanging or exporting basic CCDA documents)
Refusing to support HIE with specific vendors or HIEs=Refusing to exchange information or establish connectivity with
certain vendors or HIOs (or doing so for a price or on terms that amount to a refusal)
Making data export difficult=Refusing or charging unreasonable fees to export data at a provider’s request (such as
when switching vendors)
Changing HIE contract terms post-implementation=Changing material contract terms or business policies related to
health information exchange or interoperability after a customer has licensed and installed the vendor’s technology.
Unfavorable contract terms for HIE=Using contract or warranty terms to discourage exchange or connectivity with thirdparty certified technology, such as certified HISPs or other certified EHR systems.
Naming Conventions cont’d
Demonstration of product interoperability=Requiring vendors to demonstrate that their products interoperate with other vendors’
products “in the field.”
Prohibiting gag clauses =Prohibiting ‘gag clauses’ and encouraging public reporting and comparisons of vendors and products
Stronger government HIE infrastructure=Establishing stronger state and/or national infrastructures, policies, and standards for core
aspects of information exchange.
Make information blocking illegal=Making information blocking “illegal” and prosecuting those who engage in it
Stronger financial incentives= Stronger financial incentives for supporting providers in engaging in interoperable information exchange
Tougher Certification= Stronger interoperability EHR certification requirements
Voluntary code of conduct=Voluntary adherence to vendor “code of conduct” that prohibits information blocking business practices
Naming Conventions cont’d
Controlling patient flow by selectively sharing patient information=Attempts to control referrals or care patterns by selectively sharing patient
information
Using HIPAA as a barrier to PHI sharing when it is not=Refusing to electronically share protected health information for treatment, payment, or
operations when technically able to do so and allowed under state and federal law
Coercing providers to adopt particular EHR or HIE technology= Coercing affiliated providers to adopt a hospital or health system’s preferred EHR or
HIE technology
For Slide 24:
Stronger incentives from CMS= Stronger CMS incentives for care coordination and/or risk-based contracts
Increase transparency in business practice= Public reporting or other efforts to increase transparency of provider business practices
Make information blocking illegal= Making information blocking “illegal” and prosecuting those who engage in it
Guidance from ONC= Education and guidance from the Office for Civil Rights and ONC on privacy and security laws governing electronic health
information exchange.
Train providers to identify information blocking= Education and outreach from ONC to encourage providers to identify and stop information
blocking business practices
Creation of provider code of conduct=Voluntary adherence to provider “code of conduct” that prohibits information blocking business practices