“HITECH/MACRA-era policy efforts, from technical requirements of EHR certification to payment incentives in APMs, have failed to meet the goal of national interoperability by 2018.”—Journal of the American Medical Association
A new investigation by the Journal of the American Medical Association (JAMA) asked two questions: how are hospitals making progress on EHR interoperability and how are alternative payment models (APMs) making it easier. The answers? Slowly and no.
Less than half of the nearly 4,000 hospitals surveyed between 2014 and 2018 achieved interoperability in all areas. Hospitals cited “technical and governance challenges,” including the nuances of EHR vendors and none that APMs alone can solve. Payers should take note of the proliferation of not only APM models, but also point-of-care solutions focused on health plans that generate data and require EHR workflow integration to achieve cost savings and efficiency at large scale.
the JAMA The study was based on existing research and metrics, specifically the American Hospital Association (AHA) Computing Supplement which, since 2014, follows the Interoperability Domains defined by the HHS Office of the National Coordinator for Health Information Technology (ONC). It is the ability to: query, send, receive and integrate EHR data. As the JAMA the findings state, “Congress designated 2018 as the goal for nationwide interoperability, and policymakers hoped that aligning financial incentives through alternative payment models (APMs) would help achieve that goal. .”
the JAMA the researchers compared “progress in interoperability… between hospitals that participated and did not participate in APMs.” The study looked at three types of APMs: patient-centered medical homes (PCMHs), bundled payments, and accountable care organizations (ACOs). The study included various hospitals to avoid bias based on size, location, EHR provider and other factors. The interoperability domains themselves were “feature-based… [and] technology independent.
Only 45% of hospitals demonstrated interoperability in all four areas. And while interoperability was higher in 2018 for APM hospitals (55.4%) compared to non-APM hospitals (37.2%), these results were below expectations and the pace of growth in interoperability was similar for non-APMs. Although the APMs contributed to a slight increase in “interoperability commitment,” they fell far short of Congressional expectations regarding both nationwide interoperability and the role that innovative financial incentives would play. to achieve this.
The ability to query and integrate data lagged the most – areas associated with unplanned care and more advanced information exchange, respectively. Unplanned care is often the most expensive and most likely to be not only out of the network, but beyond the scope of an APM contract.
Why APMs Didn’t Accelerate Progress
The assumption was that there would be a natural link between increasing interoperability and “risky population and episode-based APMs” (e.g., PCMHs, Bulk Payments, and ACOs). the JAMA However, the study directly links weak/unaligned incentive design to barriers to hospital interoperability, specifically:
- Weak APM incentives are not enough to drive investment in interoperability or behavior change.
- Competition focuses on other initiatives, preventing APMs from playing a larger role in improving interoperability.
- While care coordination is common to APMs and interoperability, the study notes that it does not generate enough ACO cost savings or hospital revenue to create a meaningful link.
“Technical and governance issues” were the most common impediments to interoperability. Examples include data sharing between providers, partners unable to receive data, and the inability to match providers and patients across different data sets. the JAMA The study concludes, “APM hospitals may encounter these barriers more often as they are incentivized to fill information gaps for care coordination. This suggests that value-based payment models have aligned incentives financial resources for data sharing, but that technical barriers have impeded progress in interoperability.”
How to progress
Despite the disappointing results, it’s unlikely the US health care system would have made so much progress without federal mandates. These must continue, argue the JAMA authors, and through the “continued development of 21st century processing policies,” including the creation of application programming interface (API) standards that help reduce friction between different EHR vendor systems.
The API is one example of the patchwork of EHR workarounds that have proliferated since the HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 first mandated adoption. and EHR interoperability. And that’s understandable. In technology, the first solution is rarely the best solution, and minimum viable products are needed to cost-effectively test solutions that can eventually be improved and scaled.
But just as data alone is not power, connectivity alone is not progress. It is uncertain whether more accessible information leads to better decisions and therefore to downstream improvements in quality, access, affordability and equity. Similarly, better opportunities to build interoperability through APMs will only be as good as the incentives themselves.
Laura Beerman is a staff writer for HealthLeaders.