Earlier this year, ”The Daily Show” host Jon Stewart aired an entire segment on the lack of interoperability between the electronic health record (EHR) system used by the US Department of Defense (DOD) and that of the US Department of Veterans Affairs (VA). Stewart pointed out that, while this might be expected between competitors in the private sector, it’s “not the relationship you expect from the part of the government which takes care of our disabled veterans and the part of the government that creates them.”

Gallows humor aside, Stewart’s nearly-seven-minute segment had an effect. Following subsequent coverage by Nextgov.com —“Did Jon Stewart Foil the Pentagon’s Health Records Plan?”— it appears the Military Health System has halted their plans to beef up the Armed Forces Health Longitudinal Technology Application (AHLTA), possibly opting for the Veterans Health Information Systems and Technology Architecture (VistA) to become the EHR for both the DOD and the VA.

What does this all mean? First, the idea of digital health being a means to improve health care has gone mainstream. Second, you no longer have to be in the health care industry to realize there is an inherent need for improved interoperability.

A Common Goal to Bring Data Interoperability to Health Care

It’s great to see efforts toward better health care data interoperability in the private sector, especially by the recently formed CommonWell Health Alliance, a non-profit organization represented by athenahealth, Allscripts, Cerner, Greenway, McKesson and RelayHealth. These health IT vendors are working to create industry-wide access to patient health information by the use of existing unique identifiers, such as a patient’s cell phone number, e-mail address or driver’s license. This effort by six of the nation’s more prominent health IT providers will certainly go a long way toward fostering EHR interoperability and leveraging the value of digital patient data.

A Call for Unique Patient Identifiers

The government could also play a key role in enabling interoperability in the private sector, but there’s a missing piece: Congress has actually prohibited the Department of Health and Human Services (HHS) from establishing standards for that unique patient identifier. In his petition to the Obama Administration, health IT evangelist, Brian Ahier points out that Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996, which included provisions requiring HHS to “adopt national standards for electronic healthcare transactions” and “a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the healthcare system.”

But, in 1998, Congress passed a law that prohibited HHS from spending any funds to promulgate or adopt any final standard for an individual’s unique health identifier until legislation is enacted approving the standard.

The Healthcare Information and Management Systems Society (HIMSS) has identified cost savings and safety benefits associated with a unique patient identifier and has recommended to Congress that they should permit HHS to develop standards—especially if doing so could increase efficiencies and prevent medical errors. As further pointed out by HIMSS:

“in the absence of a nationwide patient data matching strategy, the states, HIEs, large health plans, various consortiums, and individual electronic health record vendors have had to develop individual patient identity solutions that do not necessarily work well across systems. As our nation moves forward with greater urgency toward system-wide health information exchange, this essential core functionality to ensure the accurate match of a patient with his or her information remains conspicuously absent. The multitude of different solutions and the lack of a national coordinated approach pose major challenges for our health information infrastructure and result in millions of dollars of unnecessary costs. Patient safety, privacy, and security depend on getting this core element right, and soon.”

While the creation of a national unique patient identifier may not be in the immediate future (the petition had just over 100 signatures of the 100,000 required at the time I started writing this and is no longer listed on petitions.whitehouse.gov), it could complement and amplify the efforts of the CommonWell Health Alliance.

Maybe if Jon Stewart were to feature the equally challenging situation that the private sector faces with health care data interoperability, we just might see a change in government position and actions here, too.

Paul Sonnier is the Head of Digital Health Strategy at specialty consulting firm Popper and Company, Founder of the 17,000+ member Digital Health group on LinkedIn, an XPRIZE judge for the Nokia Sensing XCHALLENGE, and a mentor at digital health startup accelerator Blueprint Health.

Today, we’re taking two more steps toward our vision of building the nation’s health information backbone: athenahealth is proposing a Code of Conduct for the health IT industry and announcing our agreement to play a leadership role in the newly formed CommonWell Health Alliance.

Our proposed HIT Code of Conduct is a call to the entire health care IT ecosystem—vendors, C-suite hospital execs, policy makers, and HIT ‘influencers’—to abide by a uniform set of high standards that providers should expect as they invest in IT and services to improve care delivery. This proposed Code of Conduct includes five basic principles related to data portability, patient safety, provider freedom of choice, and Meaningful Use.

Why are we doing this? Because we agree with the National Coordinator of Health IT, Dr. Farzad Mostashari, who recently challenged the industry to “step up” and agree to a Code of Conduct, that there are fundamental principles we vendors must adhere to in order to protect patients and empower HIT to realize its full potential.

That’s where the Code of Conduct comes in—and we hope you’ll sign on in support of this mission to work together to transform health care.

The second big announcement today is that we have signed an agreement, along with other HIT vendors, including McKesson, Cerner, Allscripts, and Greenway, to form the CommonWell Health Alliance, as a step in the right direction toward the open exchange of patient data across the health care system.

See any similarities between our proposed HIT Code of Conduct and the CommonWell Health Alliance? We had already gotten started on our Code when our industry peers came knocking with this idea of an alliance, and the timing could not be more appropriate. Our Code and the CommonWell Health Alliance both support some of the same basic principles: data portability, protecting patient safety, and avoiding unnecessary and sometimes harmful vendor lock-in.

We’ve built athenahealth on the vision that health care needs an information backbone that facilitates and incents true health information exchange. However, the promise of the free flow of health information and the reality of it today are worlds apart.

We support the CommonWell Health Alliance because we believe that being open matters, especially when it comes to patient care. CommonWell’s efforts to bring major developers together to pilot patient linking and matching across IT systems and care settings is an important step in the right direction. We look forward to helping lead these efforts as a founding member of the Alliance.

Will you sign the Code of Conduct and support us in our endeavor to make health care IT open and interoperable?

You can read and sign the HIT Code of Conduct here; for those at the Annual HIMSS Conference in New Orleans, we invite you to visit the athenahealth team at Booth #7229 to learn more.

To learn more about the CommonWell Health Alliance, please visit the Alliance’s website.

As reported by Anthony Brino, researchers Arthur Kellerman, MD, and Spencer Jones at RAND Corporation recently blamed the maddeningly slow progress of electronic health record (EHR) interoperability, in part, on “misaligned incentives.”

That bit of breaking news could not have been less surprising to my colleagues at athenahealth, where we have long lamented the unintended consequences of well-intentioned (and in many ways successful) federal incentives for “meaningful use” of electronic health record technology.

Kellerman and Jones write that much EHR software currently “functions less as ‘ATM cards’… than as ‘frequent flier cards’ intended to enforce brand loyalty to a particular health care system.” This statement perfectly describes the frustration that cutting-edge innovators in EHR feel as we see the real-world implications of many of our competitors designing their products to preclude, rather than empower, interoperation.

Note the term “interoperation,” describing an activity, in place of the more common “interoperability,” a passive noun. A major shortcoming of both current and pending “meaningful use” standards is that they encourage (and eventually require) the latter instead of the former. Unless actual interoperation across vendors’ systems is mandated, we will continue to see products and services that interoperate wonderfully within proprietary silos, but not at all outside of them.

Often, this is by design. Kellerman and Jones note speculation that “major IT vendors are opposed to [real] interoperability.”  That is not speculation – it is observable, even quietly acknowledged, reality. In 2013, there is still a lot of money to be made selling static software and annual renewal licenses. While the rest of the economy moves steadily to the cloud, we in healthcare still live in the ‘CD in the mail’ world that once powered Compuserve.

In what other sector is static software, delivered on a disk with a purchased license, still the norm? When we lean over the admin desk at the doctor’s office and see an interface that belongs in a museum, why do we just accept that as “the way it is” in health care? Why do we operate in the cloud in so many areas of our consumer life – using it to manage our finances, book travel, send photos, music, and video to our friends with barely a thought – yet all but ignore its existence when it comes to health IT (HIT)?

Kellerman and Jones have a thought: “What should be a robust market for reducing administrative costs… has been skewed a bit by poor planning in the rush to meet federal Meaningful Use deadlines, resulting in the need for repeated investment in software tweaks and workflow burdens for some doctors and nurses.”

Bingo!

In other words, in the rush to get an Meaningful Use-certified EHR up and running in time to qualify for a federal pay-out, many medical providers didn’t shop around. They went with familiar brand names. As a result, too many spent millions on legacy software systems that, without an infusion of federal life support, would have been extinct long ago. Those technologies, obsolete almost on the day of installation, are demanding replacement long before their amortizations run, creating a balance sheet burden along with a huge administrative headache.

So how can we correct the problem and finally see HIT start realizing its potential to revolutionize health care delivery and contain costs?

First, let’s stop accepting the notion that it is okay for health information technology to trail the rest of the economy. Stop accepting the claim, most often voiced by sellers of obsolete technology, that the routine, seamless sharing of data that occurs in every other sector of the economy cannot possibly be achieved in health care. These things are not true.

Second, let’s adjust Meaningful Use incentives to be sure they incentivize desired behaviors. Federal money that enables the purchase of technology that must be replaced in a year or three is wasted federal money. Sure, nobody intended to subsidize technological dinosaurs with federal dollars, just as nobody intended Meaningful Use dollars to fund proprietary information silos, locking doctors and information into closed systems and driving up costs. But that is what’s happening. We need to focus the subsidies by tightening the definition of “meaningful use,” requiring actual interoperation between vendor systems.

Finally, government needs to make the changes necessary in law to enable a true market for health information exchange. Policymakers dance constantly around explicit acknowledgement that, in order for a major sea change in any learned behavior to occur, there needs to be a financial incentive for that behavior to change. What are federal incentive payments, after all, if not acknowledgement of that truth? But temporary, targeted incentives can only motivate so much change. And government, for all its largess, cannot (and should not) subsidize behaviors in perpetuity.

To empower health information exchange, we need a functioning market for health information — the ability for a custodian/curator of data to charge a fair market fee to deliver to a recipient exactly the information the recipient requests, in the form requested. Markets for such information exist all over our economy – finance, insurance, auto parts — but not in health care.

Like the industry’s technology, our conception of market dynamics in health care remains hopelessly behind the times.Under laws intended to prevent self-dealing in referrals, a fee paid for quality information could be deemed a “kickback.” As a result, virtually nobody curates the vast stores of electronic health data that we are steadily amassing, and nobody leverages the power of that data to, yes, reduce costs, increase efficiency, and improve care. That needs to change.

A functioning, two-sided market for health information exchange would not only spark a revolution in such exchange, it would also fund itself with nary a taxpayer dollar required.

In the meantime, it is great to see 2013 kicking off with some much-needed attention to the flip side of the considerable progress in EHR adoption achieved by the Meaningful Use program. Onward and upward in the New Year. The cloud is up, incidentally…

A version of this post was published on the Government Health IT website.

If you follow us on Twitter, you may have seen a recent tweet or two about the free webinar we held at lunchtime yesterday focused on getting care coordination right. You’ve missed it by now, but you can always attend our webinars on-demand, whenever you have time. For this one in particular, just register here.

If you aren’t dialed into the issues of care coordination, you should be. It matters whether you are sending patients from your practice or receiving them at a hospital, a lab, an imaging center, or a specialty practice. Changes in the current and often fast-moving health care landscape are making the efficient exchange of patient information more important than ever before.

Why? Well, that’s what the webinar is for. But until you log on, think about how the right solution can cut down on denials, redundant work, errors, and worse, compromised patient care.

At athenahealth, we’ve developed a sustainable model for care coordination that benefits everyone in the circle of care. It saves time, encourages participation and effectively “closes the loop” on patient care.

Take part in our care coordination webinar today.

I appreciate Jonathan Bush’s blog posts on creative disruption and creating a market for health information. These pieces talk about much-needed creativity in medical care in the United States.

He’s onto something, but I think there’s more. Patients need the opportunity to document their own health stories, and they should be helped by doctors, nurses, medical assistants, insurance companies and EHR vendors. When we have a chance to aggregate a patient’s data, we’ve seen interesting narratives evolve. In the same way that keeping a journal can show us things we would have missed otherwise, a health record that’s rich with data can do the same.

This comes at a time when big data is upon us whether we like it or not. On the upside, data will show us interesting trends, new connections and potential pathways for proper healing. Because of this, physicians and patients will increasingly need to be masters of data. And some of us will be more comfortable with that than others. 

Take one of my patients as an example. He’s a retired engineer with diabetes, hypertension and atrial fibrillation, who routinely brings me an Excel spreadsheet with his blood pressure, sugars and INR (blood coagulation) readings. While I appreciate his attention to detail, his devices should actually load all of this information into his patient portal so he and I can track the numbers from there. In fact, perhaps an automated system within athenaNet alerts both of us to disturbing trends, or sends a congratulatory message for any improvements.

Now, let’s say the same patient starts forgetting to enter his data and needs an imaging study of his head due to worrisome changes in his memory. As I enter his findings in his electronic health record, a sub-routine running in the background could be adding up the necessary criteria for prior authorization of the appropriate scan. When I enter the study in his assessment and plan, the criteria are automatically forwarded to the insurance company to approve the scan and send an authorization to the patient, me and the radiology center.

Meanwhile, athenaNet scans all of my patients who have his cluster of symptoms and we discover that several of them are on the same three medications. And those patients not on those same three medications rarely report any change in memory. An alert is published to me and to the Food & Drug Administration’s adverse drug reporting system so the potential association can be further investigated.

Fortunately, my patient’s scan shows no significant findings and a change in medication allows him to feel like himself again. Once he is feeling better, my patient asks if he can join a group of similar patients for meetings at my office. At the meeting, we share data that shows 85% of all of the patients from our practice have their blood pressure adequately controlled. The patients in the room who don’t have their blood pressure under control can engage in a lively conversation with the group and everyone leaves feeling like their story is part of a larger, more successful narrative.

That’s the potential.

So, here’s to the era of big data!

Dr. Dudley is an athenahealth client in Denver.