In the United States connecting data between all manner of providers and health care organizations still faces significant challenges despite enormous investment in electronic health record (EHR) technology over the past decade. An enormous, dynamic and fragmented predominantly private-sector led system, American healthcare data was to be more accessible due to a number of provisions in the 21st Century Cares Act. Some prominent thought leaders, such as those associated with Pew Charitable Trusts, suggest that bridging the information gap could help expedite the fight against COVID-19. Although providers overwhelmingly use sophisticated EHRs, and with the existence of all sorts of bridging technologies, from health information exchanges (HIE) to various purpose-designed middleware platforms to care coordination systems, the data still doesn’t necessarily flow appropriately through the various systems in the way and manner that supports real-time action. Although progress has been made, data often is received in antiquated formats and the “data blocking” problem continues to impede the ongoing attempt to reach the nirvana known as interoperability. The unfortunate results are noticeable during the pandemic. While vendors on the one hand in many cases continue to invest in pragmatic approaches on the other hand health providers face a myriad of challenges, from loss of revenues and talent shortages to existing legal and compliance impediments which contribute to a lack of sufficient progress toward true system wide interoperability. Given the enforcement powers vested in HHS via the Cares Act, perhaps tailored enforcement as a means to inhibit ‘data blocking’ at least in select scenarios during the pandemic could be an answer? CrossTx suggests that onerous regulatory enforcement isn’t necessarily required due to the capability of existing provider investments, common standards and the available health network platforms, such as the CrossTx platform delivered via Amazon Web Services. We suggest that by leveraging mature, robust and economical referral network technology, providers and testing labs overcome a plethora of challenges including data blocking for purposes of select data sharing, such as that required for exchanging COVID-19 testing data with appropriate local and state health agencies.
COVID-19 Reveals Challenges
Recently a thought leader from Pew Charitable Trust, Ben Moscovitch, project director of Health Information Technology, shared https://www.pewtrusts.org/en/about/news-room/opinion/2021/01/06/to-help-combat-covid-19-federal-government-should-enforce-health-data-rules that stopping the spread of COVID-19 necessitates “…effective physical distancing, contact tracing and rapid analyses of demographic data to reveal illness clusters and populations at high risk, such as people older than 65, Latinos and Blacks.” He suggests that with this latest second wave of the pandemic sweeping across the nation that the federal government consider the 21st Century Cares Act to expedite the flow of patient data to both state and local health departments.
However, Moscovitch notes a number of impediments inhibit data fluidity and a persistent lack of interoperability. He reports in his recent prose that epidemiologists share that “..up to 80 percent of COVID-19 laboratory reports omit an individual’s address, phone numbers, or race. This information gap deprives the nation of opportunities to contain outbreaks, save lives and make data-driven policy decisions to fight the pandemic.”
Florida Example: 4 month Lag Time
For instance Moscovitch shared that one of America’s biggest commercial labs required four months to transmit a backlog of 75,000 test results to the state health agency. Of course four months during this pandemic seems like an eternity and really raises a red flag as to why with the massive investment in health informatics infrastructure we still arrive at this point. Those state leaders, badly in need of data to make the soundest decision making, must wait far too long during a deadly pandemic.
What’s the Core Problem?
Well, the technology, standards and business practices are in place for different outcomes, should health systems, providers and local and state agencies collaborate effectively. But are software systems, for example EHRs set up for success when it comes to sharing? Not always. The Pew Charitable Trust analyst asks the question: are EHRs and other systems used by providers configured for externalized sharing with testing laboratories for example? Are referral systems, reaching externally across providers and public agencies, used for this purpose?
Moreover, even in the case where providers are sophisticated enough to systematically push relevant demographic and patient identifying data to COVID-19 testing labs, are laboratory information technology systems set up and optimized to receive such data in human readable and actionable manner?
Well Mr. Moscovitch informs the reader not necessarily so. Moreover compounding the problem, some labs may actually push test results over to the appropriate government agencies in “outdated formats, unfortunately forcing the public health agencies to manually enter data, which of course is labor intensive, slow and represents an error prone process.
To a great extent the labs and public health agencies still transfer data via fax, believe it or not. This approach could have long ago been replaced by more efficient digital means of data transmission and collaboration widely available.
Consequently the analyst reminds all of the genesis of this problem: data blocking. That is whether a lab, health system, regional hospital, regional provider network or public health agency the systems and processes involved in data sharing still fail to lead to easy and accessible access to the right data by the right party.
Will top down regulatory enforcement work well?
No. While the Pew analysts acknowledges that the legal authority vested in the U.S. Department of Health and Human Services is legally empowered to overcome the data blocking problem—after all the 21st Century Cares Act banned such activity—unless a collaborative approach is embraced more top down, onerous compliance methods will probably only lead to more complications and costs in the system.
For purposes of background, the federal government last year finalized rules associated with data blocking. Moscovitch noted that “…health care facilities, labs and EHR vendors violate the law if they fail to either share patient data with authorized organizations or use commonly available standards for exchanging information electronically.”
He suggests that more command and control types of regulatory approaches could be on the horizon, especially given the COVID-19 pandemic. The HHS could wield its powers more forcefully over technology vendors, with use of stick versus carrot if needed. The stick hurts: what with Cares Act fines of up to $1 million per infraction—that’s serious and would be overly draconian for all involved. In fact rigid enforcement with penalties such as this only serves to further consolidate healthcare system ecosystems and their vendors. A dynamic, competitive free market remains essential for progress.
The government rules to drive EHR adoption, although well intentioned, also didn’t incentivize sharing appropriately upfront, hence the formation of the data blocking problem in the first place. Moreover providers face a myriad number of issues to contend with, state and federal privacy and data protection laws, competitive forces and a dynamic and unfolding mix of health delivery challenges from COVID-19. This includes up to 50% reduction in revenues form elective surgery as well as growing labor shortages. Given these constraints what would be the most efficient and effective way to promote sharing? Of course simply focusing on tech vendors, for example without true incentivization for collaboration between clinicians and labs for example could only compound problems.
A Path Forward?
Thus the Pew Charitable Trust thought leader suggests a couple goals to consider in overcoming this dilemma. Needed is a more pragmatic and sustainable means to transcend the current data blacking impediments, especially given the horrific ongoing pandemic.
First at a minimum he suggests HHS embrace a two element approach including 1) requiring that the appropriate patient data (phone number, address, race and ethnicity) be included in every testing order and report—this criteria could “mirror HHS guidance released in June for lab reports on COVID-19 tests”); and 2) require the use of electronic exchanges of data and reports between providers and labs. With well-known standards this suggests the analyst, expedites the path to a “culture of health.”
Second an enforced use of common standards such as the nonprofit Health Level Seven for interoperability and data sharing—that would streamline the sharing of data such as test orders and results between provider and lab and of course ultimately local or state health agencies.
But what about hospital and health system pushback?
Presently hospitals, regional health centers and labs are operating in crisis mode. At full capacity in many locations they also face a major drop in revenue associated with elective care due to the COVID-19 crisis as mentioned previously. Compounding the crisis, especially in the thousands of rural hospitals and health centers around the nation includes a mounting talent shortage. Such centers are facing severe need for physicians, nurses and other health care professionals. Many hospitals aren’t in the ideal position to sponsor major health technology projects at this time.
However Moscovitch notes that in many regards hospitals and centers as well as labs have already much if not all of the systems and processes in place arguing “…many [health care providers] have already deployed technology that allows facilities to send their test results to one system and then automatically route them to the correct public health department.”
Idea: Focus on COVID-19 reporting
Hence one approach to focus regulatory influence in such a way that doesn’t overwhelm hospitals for example would be to enforce use of data exchange for COVID-19 reporting only during the pandemic. This could offer a compromise position and allow providers of all types to focus efforts—it could benefit vendors as well and reduce time to deployment and costs as compared to an overreaching mandate for broader interoperability.
A CrossTx Point of View
Generally, regulatory overreach can introduce myriad unintended consequences that often disproportionately and adversely impact the smaller, less capitalized provider as well as vendor. Ultimately the incurred costs are passed on to the health consumer. Frankly, the technology does exist today to rapidly and cost effectively accomplish the goals of data fluidity and interoperability between provider, lab and health agency.
Technology vendors often carry bloated costs and contribute to data blocking via sharing “tolls” which impede sharing ongoing. Health network platforms, such as CrossTx, introduce compelling data exchange features and functions from the configuration for compliance rules to offering a more holistic and organic way to drive the desired referral behavior. For example enabling the network referral system itself to expose, securely, the necessary data for purposes of COVID-19 test reporting could rapidly help overcome the data blocking challenge. Afterall health network technology, whether it’s supplied by CrossTx or other reputable companies, seamlessly integrates with EHRs, hence removing full dependence on the siloed EHR yet ensuring the appropriate security and compliance needs of the health care provider are in place. Enabling the sharing of the necessary data in the actual referral process serves multiple purposes from improving patient experience (more efficient referral process) to bolstering quality (less errors) to greater outcomes (real time test reporting to local and state health agencies). Moreover this accelerates the move away from the dependence solely on fax or other antiquated means, a precursor to more broad based data exchange goals in the future once the pandemic passes.
Chief Business Officer, CrossTX