Interoperability – The Key to Healthcare Innovation or Just Tilting at Windmills?

Written by: Brian Mack

Late last week, the Centers for Medicare & Medicaid Services (CMS) finalized a rule change.  This rule intends to overhaul the Meaningful Use program (now known as “Promoting Interoperability”) and advance electronic health data exchange.

The document outlining the rule change itself is huge, nearly 2,600 pages. According to CMS Administrator Seema Verma, the changes are collectively intended to reduce unnecessary paperwork and “remove the obstacles getting in the way of quality care and positive health outcomes”.

A major component of the rule change, as reported by Rajiv Leventhal for Healthcare Informatics, was a request for information (RFI) from interested parties on the potential requirements making eligible hospitals and providers accountable for achieving interoperability, and tying some percentage of Medicare reimbursement to accomplishing these goals.

As one might expect, this proposal was met with vocal, but conflicting reactions. These differing perspectives were illustrated in two articles from different publications that were both published on June 27,2018. This was right after the closing of the comment period. One article, titled ”AHA opposes linkage of interoperability to Medicare participation”, was written by Fred Bazzoli for Health Data Management. The other was penned by Evan Sweeney for Fierce Healthcare, under the banner “Coalition of ACOs, IT organizations throw support behind a CMS data-sharing mandate”.

At the time that these articles were published, it seemed clear that the battle lines for debate were drawn. Predictably, the opinions, both in favor and opposed to the change, aligned neatly with the self-interests of the engaged parties. Hospitals, represented by the American Hospital Association (AHA) in the Health Data Management piece, are strongly opposed to the proposal on the grounds that such conditions would be an ineffective method for advancing health information exchange. Contrastingly, a broad coalition of Accountable Care Organizations (ACOs), insurers, and health information technology (HIT) vendors came out in favor of the proposed action. They argue that it presents a unique opportunity to address the fragmentation of our healthcare delivery system by requiring that providers share data to enhance patient care.

Both sides make valid points. These assertions come down to whether they stand to benefit or suffer financially from such the change. In the final ruling, CMS only adds to the drama. Again, according to Rajiv Levethal’s well written synopsis, the exhaustive document DOES NOT include any update on the RFI. Their explanation, noted in a fact sheet, said that the RFI was only “to obtain feedback, which will inform next steps”.

As I waded through all of this, and the storm that was created, I was not moved by the pros and cons of the argument. Rather, my reaction was, “are we STILL talking about Interoperability?!?” I can’t escape the notion that we are collectively caught in the grip of “Don Quixote Syndrome”. The powers that be in healthcare seem bound and determined to “slay the interoperability windmill at all costs.”

Don Quixote de la Mancha by Fabricio Moraes

Don Quixote de la Mancha by Fabricio Moraes

For those who were not English majors or whose recollection of the Classics is a little rusty, here is a refresher: Don Quixote (pronounced key-oh-tay) is an iconic fictional epic, written by Miguel de Cervantes in 1615. The story follows the misadventures of a Spanish nobleman who, influenced by too many romance novels and his slow spiral toward insanity, imagines himself to be a knight. In this guise, he sets out on a quest to revive chivalry, right wrongs, and restore justice with sometimes humorous and sometimes tragic results. In one memorable scene, Quixote sees 30-40 windmills on the horizon. In his altered mental state, he imagines that they are giants and attacks them. He only manages to be swept into the air and promptly slammed back to earth, narrowly escaping severe injury. The expression “tilting at windmills” is a reference to this passage in the novel. It describes the well-intentioned and enthusiastic pursuit of an inaccurate goal, with misapplied justification and potentially negative consequences.

Sound familiar?

In April of 2016, in a post for The Exchange, I made a case for why national interoperability, while certainly a good and noble goal, is perhaps not the most pressing issue limiting the advancement of healthcare reform and innovation today. At the very least there are several outstanding issues that need to be resolved before a seamless system for national interoperability is even possible. The Trusted Exchange Framework and Common Agreement (TEFCA) released by the Office of the National Coordinator last January, was (it was thought) intended to bring clarity and define a path forward for national interoperability, but has instead just added more uncertainty and the promise of additional layers of bureaucracy.

Unfortunately, after many years, a name change, reams of paper full off bureaucratic language, and no small amount of angst and gnashing of teeth by patients, providers, payers, and politicians, we seem not much closer to achieving interoperability than when we started. Is it possible that we might make more progress by focusing our attention and energy on defining and establishing some fundamental standards for information sharing that are achievable for everyone as a first step?

Or maybe I’m just tilting at windmills …