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Our ONC Interoperability Pledge

by Stephanie Zaremba, Director of Government and Regulatory Affairs

Today athenahealth joined a number of other health IT vendors signing on to the latest government-orchestrated ‘private sector commitment to interoperability’ in healthcare. Congratulations to us, and to every other company that took the bold step of allowing our company names to be added to a list appended to an HHS press release.  

We have no doubt whatsoever that ONC, whose dedicated staff devoted countless hours to corralling signatories for today’s commitment, remains wholeheartedly dedicated to reaching full interoperability in health IT.  The intentions are good and correct: the pledge aims to achieve open, connected care through consumer access, transparency and standards by putting the companies responsible for the relevant health IT products and services on record supporting those broad goals. The trouble is, one would be hard-pressed to find a stakeholder in our industry that is not already rhetorically committed to those goals. Until very recently, however, tangible progress has been decidedly lacking. With respect to today’s pledge as it relates to that recent progress (which, by the way, came independent of any government pledge, or even any direct government action), there are two sides to the coin. 

athenahealth is committed to the shared goal of widespread interoperation among health IT systems and achieving the same ubiquitous information exchange that is commonplace elsewhere in the information economy.  We are already living up to today’s pledge, and will put our record of actual, tangible results up against anyone. We didn’t need a mandate or a pledge to drive us; the design of our services assumes an interconnected healthcare system. We have worked toward that goal since day one of our corporate existence, nearly 20 years ago.

In just the past two years the private sector has made tremendous strides toward fully interoperable health IT systems—more progress than in all of the prior years combined.  In the past year CommonWell has grown exponentially, and athenahealth has built countless new integrations and connected with Epic through the Carequality framework.  The winds are shifting to focus on the quality of care delivered through the value of a vendor’s services.  All this has happened, in a relatively short period of time, without a government-leveraged ‘pledge’ from the industry. And the progress that is finally happening in healthcare tracks the trend that drove modernization in other sectors.  Seamless interoperability in other information industries (Mint.com, Facebook’s API, Google Flights) is a direct result of market forces and growing consumer demand.  I don’t recall a pledge to make all flights searchable and price transparency signed by Google, Kayak and Expedia. 

So what’s the issue?

It is probably clear that we don’t have very high expectations for the impact of today’s interoperability pledge. If forcing companies explicitly on record creates some kind of measurable new momentum in our industry, then hey, we are all for it. Our fear, though, based on plenty of recent historical precedent, is that key actors in our industry will use the pledge not as an impetus to progress, but as a substitute for it. “Of course we are dedicated to interoperability—didn’t you see we signed the pledge??!” The maxim about the relative volume of words and actions leaps to mind.

More specifically, the third enumerated commitment in the pledge calls for companies to “implement federally recognized” technical interoperability standards.   That is troubling, and is something that we strongly and unsuccessfully urged ONC to drop. The requirement of any “top down” government mandated standard sets the bar far too low and is a great way to slow private sector progress.  It is inconsequential how we arrive at the industry wide shared vision of a fully interoperating health IT ecosystem.  The last thing anyone involved wants, including ONC, is to limit the potential of future improvements in data quality, exchange and usability by allowing our industry to settle into convenient reliance on today’s gold-standard, which most certainly will be obsolete before you can say “C-CDA.”

The greatest risk in government’s reliance on today’s well-intentioned pledge is that there will be unintended consequences that curb the remarkable private sector progress on interoperability (see, e.g., the Meaningful Use program). Picture a situation where a vendor or provider organization responsible for millions of medical records could say, with a straight face, they are living up to their commitments because they can transmit C-CDAs (the MU-created low bar) while the rest of the industry is working on more advanced API-based query and retrieve of discrete data elements. Health IT’s innovation curve is steepening, and a heavy handed government approach can and will pull this innovation curve down.  We’ve seen it in the past with MU and certification. 

In order for the pledge to be more than impotent words on a page, two things need to happen.  First, ONC should acknowledge that they will best serve the industry by taking a step back and allowing the private sector to continue coalescing around a “bottom up” approach to interoperability.  Second, the entire private sector must strive to exceed expectations by publishing API’s for developer use, actively contributing to its own interoperability initiatives and supporting industry leading and emerging standards.  Signing this pledge must not be regarded as an accomplishment or milestone for athenahealth, our peers, the government, or health IT.   Let’s have more action and fewer words.

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