Interoperability in Healthcare: Are Anti-Competitive Forces Limiting Innovation and Patient Benefits?

Salt Lake City - Government Health PlanAccording to a physician in Utah, Health Information Exchanges don’t work very well yet.

Dr. Raymond Ward, MD is a member of the Utah State Legislature.  “When I try to look up patients sometimes I find them via the HIE, sometimes I don’t.”  Dr. Ward is both a practicing physician and a passionate legislator for improvement of healthcare regulations and interoperability.  Utah  is known for its leadership in interoperability and was the first in the nation to found a widely accepted and respected health information exchange (See UHIN).  Yet,  Utah health industry interoperability falls short of physician expectations.  According to Dr. Ward, “Utah has one urban area, four major hospitals that 70% of the market.”  That should make Utah a strong candidate to coordinate care via interoperability, Dr. Ward reasons, since the majority of the providers serving Utah patients are concentrated in one urban area.  “Yet, when I use the Clinical Health Information Exchange (CHIE), HCA has radiology and lab reports but not other information I need,” states Dr. Ward.

Even non-physicians can easily understand why health data interoperability is important.  If a patient is being seen by a primary care doctor, an oncologist to manage a cancer diagnosis, a behavioral health professional to manage depression, a pain management specialist for pain caused by cancer, is under treatment for substance abuse related to addiction to pain medication, has had images of their cancer taken by a radiology lab, and subsequently interpreted by a diagnostic radiologist, shouldn’t all of these providers be able to see that patient’s information electronically via a unified platform?   Though some regions like Utah have led innovation, the U.S. as a whole hasn’t achieved this goal yet.

According to  Teresa Rivera, CEO of UHIN and head of the CHIE, there are still regulatory challenges to improving data interoperability.  For example, as Ms. Rivera noted, “Substance Abuse Confidentiality Regulations 42 CFR Part 2 currently limit what may be shared.”  According to Rivera, the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) will be revisiting methods for enabling interoperability while protecting patient information, particularly for behavioral health.

Though one can understand Dr. Ward’s frustration as a care provider, Ms. Rivera has a point too.  According to current regulations (as I write this on April 6, 2016), once a patient has revokes a Part 2 consent to share their behavioral health information, that revocation should be immediately communicated to the HIO by the entity obtaining the patient’s revocation so that it implements the revocation decision and no longer transmits the Part 2 program’s protected patient information to those one or more parties. Part 2 permits a patient to revoke consent orally [fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”][42 CFR §2.31(a)(8),(c)(8)]. In an HIE environment, the revocation with respect to one or more parties should be clearly communicated to the Health Information Organization (HIO)as well as noted in the patient’s record.  Since UHIN is working with SAMHSA to improve the way this works electronically, and is arguably a leader in interoperability, why can’t we make this work across in the U.S.?

In my opinion, based on personal experience working in the Utah market as an expert witness and an advisor to health systems and health insurance firms, Utah is one of the leaders in U.S. health care data interoperability. UHIN has been a model for innovation and collaboration. So the question one may ask next is, if Utah sets the standard on interoperability, but still falls short of physician expectations, why is the U.S. healthcare industry still falling short on interoperability goals?

Some vendors have refused to open their Health IT and Electronic Health Record systems to complete bidirectional interoperability and the U.S. Health and Human Services Office of the National Coordinator (ONC) has not used enough of the hammer to enforce interoperability on EHRs and HIT vendors, according to 85% of hospital leaders, 88% of physicians and 92% of payers participating in a recent survey.

Black Book Research conducted its annual survey of hospital and health system executives, physician administrators and payer organization IT leaders to identify key interoperability trends and understand the challenges they face in their efforts to exchange patient information with other healthcare organizations.  All user types were polled to understand the importance of interoperability in their strategic planning initiatives, as well as their ongoing and new challenges in areas such as connectivity and data exchange:

  • 2,012 provider Health Information Exchange (HIE) users
  • 2,300 payer HIE users
  • 4,100 prospective HIE users

Between Q3 2015 and Q1 2016, the survey recorded :

  • growing HIE user frustration over the lack of standardization and readiness of unprepared providers and payers.
  • 26% of self-identified connectivity-ready hospitals intend to keep expanding into robust exchanges for value-based payment prospects with primed payers
  • delays by peer providers to electronically share patient data beyond Meaningful Use

“Every stakeholder in the healthcare delivery process cannot establish the infrastructure needed to support interoperability, as evidenced by :

  • 83% of physician practices responding
  • 40% of hospitals currently admit they are still in the planning and catch up stages of sending and sharing secure, relevant data

Of those still lagging behind in prioritizing interoperability, collectively :

  • only 17% place the blame on their organization’s available funding or executive interest level
  • 57% place culpability on their HIT/EHR vendors for connectivity defects and siloes or data blocking
  • 20% blame their respective government agencies for slow progress in development and standards
  • A variety of other and combined forces are found liable by the remaining 6%.

“The misalignment of requirements and protocols has hampered all the stakeholders’ interoperability efforts,” said Doug Brown, Managing Partner at Black Book. “This disorder is ushering in a new replacement revolution, this time for those HIEs failing to meet the expectations of their users, payers and providers alike”.

63% of hospitals & hospitals systems report they in the active stages of replacing their current HIE system, whether private, public, homegrown or EHR-dependent with a variety of options including middleware and more advanced HIE systems. Nearly 94% of payers surveyed intend to totally abandon their involvement with public HIEs and work directly in regions and states to create and/or bolster private enterprise HIEs which more directly meet their needs to facilitate accountable care initiatives with providers.

“The value-based payment reform concept enabled by a robust HIE requires all stakeholders including physicians, insurers, post-acute care, and diagnostic facilities, not just hospitals to reach the goals of dynamic population health,” said Brown, “Focused, private HIEs also mitigate the absence of a reliable Master Patient Index and the continued lack of trust in the accuracy of current records exchange.” According to the survey results, 39% of hospitals currently implementing or evaluating private regional networks intend to participating in regionally-centered enterprise HIEs with contracted payers to ensure greater connectivity among the stakeholders with whom they network within a geographic healthcare market. “The challenge of turning silos of medical and financial information into a linked, complete, accurate secure lifetime medical record is still tenuous,” said Brown.

90% of polled hospitals see private HIEs as a potentially more profitable model that can be sustained as the industry evolves faster towards a values-based and outcome-based healthcare delivery and reformed payment model.

Black Book™ also noted that payers have been largely absent in the development of dozens of private HIEs until late 2014 because data sharing was viewed as mainly benefitting providers.

“Public HIEs and EHR-dependent HIEs were viewed by 79% of providers as disenfranchising payers from data exchange efforts and did not see payers not as partners because of their own distinct data needs and revenue models,” said Brown.

However, 88% of hospitals and 95% of payers in Q1 2016 see secure data exchanges where all parties pay a fair share in the development and maintenance is creating a more collaborative trusting relationship.

Since 2013, the number of private HIEs involving a payer/multiprovider collaboration have increased steadily. 60% of providers that year reported they distrust payer guided HIE initiatives. In 2016, 93% of providers are considering cooperative HIE to satisfy the growing need for data particularly to manage complex patients and integrate clinical and financial data sets.

“Progressive payers are moving rapidly into the pay-for-value new world order and require extensive data analytics capabilities and interoperability to launch accountable care initiatives,” said Brown.

In response to alleviate concerns of HIEs with poor connectivity outside their IDNs and hospital systems, interoperability middleware is also a fast growing consideration according to 16% of hospital systems IT leaders with EHR-dependent HIE grievances, in particular.

“The middleware software sits within the data pipeline and translates data from disparate EHRs which shows promise for private HIEs, particularly payer-centric enterprise models,” said Brown. “It creates a business intelligence layer that provides information to all stakeholders in real time.”

Middleware is gaining popularity fast by hospitals using EHR-dependent HIE systems with extremely expensive custom development for data sharing outside the network. Black Book evaluated middleware vendors in an associated Q1 2016 user survey, ranking these vendors highest in satisfaction among new users.

  • HealthMark
  • Zoeticx
  • Arcadia Healthcare Solutions

In 2013, 82% of all payers and 60% of participating hospitals agreed that an operational national HIE is at least a decade off. In 2015, 91% of all payers and 74% of providers believe that a robust, meaningful national HIE will now be achievable by 2020 if more private or enterprise HIEs are created and a patient locator system is implemented.

Promises made in the recent interoperability pledge for three core commitments from EHR developers (providing patient access, eliminating information blocking, and implementing federal connectivity standards) won’t be the reason why interoperability succeeds, predicts Black Book’s survey results.

Key Trends:

  1. The global healthcare analytics market is projected to grow to $18.4 billion in 4 years (by 2020) and the need for that complex data will propel the interoperability needs of providers and payers. “The only way to accomplish that is robust bidirectional interoperability and that’s what will ultimately force comprehensive interoperability into reality, not government-scripted vendor pledges”, said Brown. “Value based care, payer participation in private HIEs, patient locator systems and analytics will be the real forces that push interoperability ahead next.”
  2. Patients agree on the need for medical data exchanges according to Black Book™. A Q3 2015 survey of recently discharged patients of 70 US hospitals evidenced 94% expressing the desire to have their medical and insurance information held and freely shared electronically among their personal providers and payers.
  3. 57% of providers also confirm their beliefs that the whole interoperability industry will evolve by leaps by 2018 if some basic issues are addressed, with or without a vendor pledge. “Progressive FHIR standards can allow EHRs to talk to other EHRs should standard definitions develop on enough actionable data points as we are enter a hectic period of HIE replacements, centering on the capabilities of open network alliances, mobile EHR, middleware and population health analytics as possible answers to standard HIE,” said Brown.

Thrusting HIE system replacements in Q1 2016 according to current provider users are:

  • 97% Potential for data breaches, Privacy & Security issues
  • 93% Cost of Custom Interfaces, Constrained Budgets
  • 90% Lack of connectivity with EHR Centric HIEs
  • 75% Complexity of current HIE Technologies
  • 72% Questionable sustainability of HIE vendors or agencies

Current users ranked six HIE vendors as top performers in their specialty theatres of engagement. Ranking first in their respective categories in the interoperability marketplace for 2016 are:

  • McKesson RelayHealth – Core Private Enterprise Platform and Packaged HIE Solutions
  • Infor – Complex Data Integrators and Outsourced HIEs
  • Optum – Private Payer and Commercial Insurer Centric HIEs
  • Aetna Medicity – Core Public/Government and Agency HIEs Systems
  • Cerner –EHR/HIT-based HIE, Open Networks
  • Epic Systems– Closed Network, EHR-Dependent HIE
  • Other vendors scored well in specific key HIE performance indicators were: Availity, Allscripts, CSC, Greenway, ICA, Medecision, and QSI Mirth.


Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See and for more about the company.

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