Study Critical of Federal EHR Programs, Says Interoperability Requirements ‘Watered Down'

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By Kendra Casey Plank  

June 17 — In the rush to meet legal deadlines in the Health Information Technology for Economic and Clinical Health (HITECH) Act for paying incentives to doctors and hospitals for adopting electronic health records, the federal government encouraged the uptake of existing technologies rather than promote the development of new products that would be better meet future demands for interoperability, researchers said in a new RAND report.

A case study of EHR adoption in the report, which is critical of federal initiatives to promote health IT adoption, said the meaningful use program has spurred growth in the EHR market but that adoption of health IT in the U.S. still lags behind other countries.

“The theoretical case for EHRs is strong, but the technology's promised impact is currently blunted by limitations in its design, uptake and use,” according to the report.

The case study cites several challenges to health IT adoption, including provider readiness and data privacy and security concerns. But, the lack of interoperability is one of the biggest hurdles to clear for widespread data sharing, the key to improving quality and efficiency of health-care delivery, according to the report.

“The health IT systems that currently dominate the market are not designed to talk to each other,” the researchers wrote. “This problem might have been avoided if the federal government had pressed the issue when meaningful use standards were being drafted. Instead, interoperability standards were watered down, and vendors were allowed to apply for meaningful use certification post market. It is unclear how many, if any were rejected.”

“[I]nteroperability standards were watered down, and vendors were allowed to apply for meaningful use certification post market.”

—RAND report

Rather than promote interoperability—which was Congress's main goal with HITECH Act—federal health IT initiatives have instead “accelerated the uptake of existing EHRs,” the researchers wrote. That “low bar” for interoperability also has thwarted efforts health information exchange initiatives, they added.

“Instead of using federal incentives to spur development and sale of interoperable EHRs, the Office of the National Coordinator for Health IT sought to bring the health care industry on board,” the researchers wrote.

Disappointing ROI

Among other concerns raised in the case study was that EHR adoption has had a disappointing return on investment for many health-care organizations, with many citing a gap between the perceived and realized benefits of health IT.

Among disappointments the report cited was the high cost to purchase and upgrade EHR systems to meet meaningful use requirements, coupled with the ongoing costs to maintain those systems.

And, the researchers noted, those costs typically are not fully covered by federal EHR incentives.

The report said the lack of EHR usability likewise has contributed to a lack of ROI for adopters as well as the failure by health-care organizations to redesign workflows to accommodate new technologies.

Market Concerns

The case study also was critical of one of the EHR market's largest players—Epic.

Epic provides EHR systems—and other software products—to many of the top health-care systems in the country, including Cleveland Clinic and Kaiser Permanente, the report said.

But, the researchers wrote that because Epic is a closed platform it is difficult for data to be shared with other EHR systems, even if they're developed by Epic.

“One of the biggest concerns with Epic is its relative lack of interoperability,” according to the report. “Although the company has a strict structure and retains tight control of its software and data, it does customized installations for each client. This allows health care systems to tailor Epic's applications and functionality to meet their own needs.”

That customization, the report said, means that interoperability between EHR systems is difficult.

By contrast, the report said the Department of Veterans Affairs VistA (Veterans Health Information Systems & Technology Architecture) system—which is the EHR system for the military veterans—is an open platform that allows for easier sharing of health data.

The EHR case study was conducted by Dr. Enesha Cobb and Dr. Kori Sauser, both fellows at the Robert Wood Johnson Foundation. They both also are affiliated with the VA Center for Clinical Management and Research at the Ann Arbor VA Healthcare System.

To contact the reporter on this story: Kendra Casey Plank at

To contact the editor responsible for this story: Patty Logan at

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