Tinker Ready, for HealthLeaders Media , June 1, 2015
John Halamka, MD, the Beth Israel Deaconess Medical Center CIO who is co-chair of the federal HIT Standards Committee, shares his views on interoperability, information blocking, and the lifespan of Meaningful Use.
John Halamka, MD, chief information officer of Beth Israel Deaconess Medical Center, has issues with the way both Congress and the federal government see the state of health information technology. Last week he wrote in his blog about "how Congress… [has] entered the Trough of Disillusionment for EHRs and interoperability."
Halamka spoke with HealthLeaders Media on May 29 about interoperability, Meaningful Use, and information blocking. The transcript has been edited for brevity and clarity.
HLM: Interoperability has emerged as a major issue in the push for health information technology. Why isn't the system where Congress and the Department of Health and Human Services say it should be?
Halamka: Think about Meaningful Use. The idea is—Stage 1—Let's get folks to adopt electronic health records. The country had about a 20% adoption rate. Stage 2 is to get them to start exchanging data. The concept was that, by Stage 3, we would be sharing data for care coordination, population health, genomics, clinical research, and all the rest.
This has always been the plan. So people say, 'Wait a minute. Here we are in the middle of Stage 2. Where's all the interoperability?'
It was a five-year project and we're just at the beginning of where we're supposed to be. We're on course. It's all OK. EHRs are recording data electronically. Systems are sharing data for many purposes—public health, lab results, syndromic surveillance, and transitions of care. And now we get to the next step and there are a few necessary requirements.
HLM: What are those requirements?
Halamka: Suppose you are seeing Dr. Bob over in Cambridge and he needs a copy of your records from Beth Israel Deaconess Medical Center. How do I know how to reach Dr. Bob? What is Dr. Bob's electronic address?
It turns out that Massachusetts has a provider directory that provides that information. Most other states don't. So there is some enabling infrastructure that could be provided at a regional level and national level to help us route information from one place to another.
It's not information blocking. It's not HIT vendors being reluctant or hospitals holding their data hostage.
Similarly, suppose that you have a negative HIV test. In Massachusetts there is a law that says if you have an HIV result in your record, we need very special permission to exchange your record. It requires you to consent to disclose.
It also requires that for every episode of care, for every doctor, you have to have another consent for that data to be viewed. You've already said you are completely fine sharing your HIV results, but you are going to be consented every time you go to the doctor.
We have this heterogeneous fabric of privacy laws across our states.
HLM: A national patient identifier would accelerate interoperability. You suggest a program for a voluntary identifier. Is there any effort to change privacy laws preventing the creation of a mandatory identifier?
Halamka: There are always going to be some people who say, 'I don't like anything, whatever it is.' What if I had safe, coordinated efficient care, with mandatory national identifiers? 'That's too much government. I worry about my privacy, and I don't want a national identifier. I'm a human, not a number.'
There are others who say, 'If my care would be more efficient and safer and higher quality, I would very happily have an identifier for healthcare because I don't' want the wrong kidney removed.' So, with that spectrum… the only thing we can do is voluntary.
HLM: ONC and some lawmakers think that one of the barriers to interoperability is information blocking. They define it is as companies limiting data sharing, or overcharging to set it up as a way to gain a competitive advantage. Can you describe how you see this issue?
Halamka: You have policy makers saying, 'There's no interoperability.' It must be the vendors or it must be the hospitals, or it must be the standards. But, it's more complex than that.
Unfortunately, Congress, which often wields the blunt instrument of legislation, says we'll just make information blocking illegal and that will fix all the problems. No. It doesn't really help.
HLM: You describe reaction to information blocking as reaction to the Loch Ness monster—everybody is talking about it, but nobody has seen it. Do you think information blocking is a myth?
Halamka: I have never seen it. If the definition of information blocking is that the vendors have all hired Chief Information Blocking Officers who spend their nights thinking about ways to restrict information flow, I've never seen it. Find me one example.
HLM: ONC says it's gotten 60 reports of information blocking. Might it be happening in a less obvious way?
Halamka: I am guy who has no agenda. I am not dogmatic. I will evaluate any evidence that it put front of me. Maybe there's a niche vendor that's doing it, but I've never found a mainstream vendor who is going to go against the wishes of its customers to exchange data.
HLM: One complaint is not that vendors refuse to share data, but that they are charging a lot to do it.
Halamka: The question is, what's a lot of money and what is the work involved? If people complain that 'my lab interface was $5,000, well, if it's a novel lab interface that's never been done before, it is a substantial amount of work to map all the lab tests.
It actually takes me about 16 weeks to produce a lab interface. So I don't think $5,000 is unreasonable. Others may. Again, look at the data. Let's see what people want done and what's being charged for it.
HLM: You have said that companies could also use a law against information blocking to their competitive advantage. Would they do that by filing complaints to hinder competition?
Halamka: They could say, "We lost this deal to ABC vendor. They are information blockers. Let's send OIG [the Office of Inspector General] and the FTC [Federal Trade Commission] to torture them for years. "
HLM: Can you describe your objections to Meaningful Use Stage 3?
Halamka: Meaningful Use Stage 1 was a wonderful foundation. It really brought us up to a level where everyone is using electronic health records that are good enough.
Stage 2 got a little bit aggressive. It moved too fast and was too much. We didn't' have enough time between when the regulations were finalized and the reporting period began for the vendors to actually create easy to use products. They had to really rush these things through development. It was a disservice to the industry to move that fast.
Now Stage 3: With accountable care organizations and various kinds of patient-centered medical homes, we are starting to develop quality registries and interoperability. The private sector has incentives to do all this stuff. So, at this moment, we don't really need more regulation. We just need more time.
If you want to put out a few merit-based incentive programs, fine. But it's probably time to retire the Meaningful Use construct and just let the private sector, with incentives from the ACA, go forward for the next few years.
HLM: So you think Meaningful Use Stage 3 should be abandoned?
Halamka: If you want to call Meaningful Use Stage3 a small number of merit- based incentives, that's OK. But to create 731 pages of regulations that are going to co-opt the agenda of vendors and providers seems like a mistake.
HLM: Wasn't the original idea behind Meaningful Use accountability? We're going to give you money for an HIT system, but we need to make sure you are using in a way that benefits your practice, patients, and payers.
Halamka: So, do that with ACA. You are going to be paid for outcomes—keeping people healthy. You can't do that unless you've implemented IT effectively. I love the idea of payment based on outcomes. But don't prescribe—with 731- pages—the minutiae I have to do for every process to get there.
HLM: What is your advice to hospitals that are trying to make sense of all this?
Halamka: Don't listen to the rhetoric. These issues are complicated. They involve people and politics and technology. There is no magic bullet here. There is just hard work. If we all agree that we want to make patient care better in this country and that we are going to look at a roadmap and step-by-step make it better.
That's where we need to focus. Let's not eliminate this committee and form another. Let's not go blame the vendor. Those are simplistic, naïve solutions. We just need to keep our eye on the prize and make progress.