Many EHR Vendors and Providers Block Information Exchange: Study

Ken Terry

March 29, 2017

Half of electronic health record (EHR) vendors and a quarter of hospitals and health systems routinely engage in information blocking that restricts data flow between providers with different EHRs, according to officials of public health information exchanges (HIEs) surveyed by researchers at the University of Michigan.

The top motivation for EHR developers was revenue maximization, whereas the hospital systems were mainly motivated by a desire to maintain or enhance their competitive position, the authors state. The study was published online March 7 in the Milbank Quarterly.

In a report issued 2 years ago, the Office of the National Coordinator for Health IT (ONC) said there was anecdotal evidence showing that some health information technology (IT) developers and healthcare providers purposely made it difficult to exchange health information. But the Milbank Quarterly article is the first national study to investigate the frequency, forms, and motivation for information blocking among vendors and providers, according to coauthors Julia Adler-Milstein, PhD, and Eric Pfeifer, of the University of Michigan School of Information and Public Health, Ann Arbor.

They chose to survey HIEs, they said, because exchange executives are in a good position to observe information blocking and are relatively unbiased.

Sixty HIE officials responded to the survey, which was conducted between October 2015 and January 2016. Of respondents, 50% said information blocking by EHR vendors occurred routinely; 33% said it happened occasionally. Twenty-five percent reported routine information blocking by hospitals and health systems; 34% said it occurred once in a while.

Information exchange can be blocked in a number of different ways, the study shows. According to 49% of respondents, vendors routinely or often deploy products with limited interoperability; 47% cited high fees for health information exchange; and 42% said vendors routinely make third-party access to standardized data difficult.

Some EHR vendors refuse to support data exchange with specific vendors or HIEs, make data export difficult, or require unfavorable contract terms for health information exchange, the HIE officials said.

Among the approaches that hospitals and health systems routinely used to block information flow are coercing providers to adopt particular EHR or HIE technology (28% of respondents), controlling patient flow by selectively sharing patient health information (22%), and using the Health Insurance Portability and Accountability Act (HIPAA) as a barrier to patient health information sharing when it was not (15%). Another 35% of respondents said providers "sometimes" use the HIPAA as an excuse.

The top motivations for vendors to engage in information blocking were their desire to maximize short-term revenue (41% of respondents) and to increase the likelihood that providers would select their product instead of a competing EHR (44%). Among hospitals and health systems, the most frequent perceived motivation was to strengthen their competitive position in the market (47%), followed by dealing with more pressing internal priorities (29%).

The researchers attribute the difference in the frequency of information blocking between EHR developers and providers to the fact that the former are for-profit entities, whereas most hospitals and health systems are nonprofit institutions. In addition, they note, not all health systems are in competitive markets, and some hold risk contracts that incentivize them to engage in health information exchange.

Most commonly, information blocking by hospital systems is aimed at strengthening their competitive position by controlling patient flow, the researchers note. By coercing other organizations (ie, practices) to use the same EHR as the hospital, they tie those providers to that system, increasing patient referrals. By selectively sharing patient information and using HIPAA as a reason not to share data, they write, health systems make it less likely that patients will seek care elsewhere.

Will New Law Change Behavior?

The authors note that at the time of their writing, information blocking was not illegal, and they argue in favor of federal legislation that would change that. In December 2016, Congress passed and former President Obama signed the 21st Century Cures Act. This law requires developers to attest, as a condition of government EHR certification, that they have not and will not engage in information blocking.

The Office of Inspector General in the Department of Health and Human Services is responsible for enforcing this prohibition. Developers, networks, and exchanges that are found guilty of information blocking may have their products decertified and can be fined up to $1 million per violation. Providers will not be fined but will be "subject to appropriate disincentives" under federal law.

HHS must require EHR vendors seeking certification to attest that they are not engaging in information blocking within a year after the law's passage (ie, at the end of this year). However, in March 2016, a number of large healthcare systems and top EHR developers pledged not to engage in information blocking. A year earlier, following the issuance of the ONC report, Epic, the largest EHR vendor, agreed to drop fees to providers for exchanging information with other providers on different EHRs. Cerner and athenahealth, two other leading developers, also said they would not charge fees for health information exchange.

In the long term, Dr Milstein and Pfeifer say, increased transparency and value-based payments to providers should create market dynamics that foster health information exchange. But it's unclear, they note, whether Medicare's new value-based payment approaches and the evolution of accountable care organizations will create incentives for broad-based data exchange "or simply for larger islands of exchange with information blocking between them."

Milbank Q. Published online March 7, 2017. Full text

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