Epic Systems feeling heat over interoperability

Epic Systems' August decision to retain a Washington lobbyist was widely seen as a sign that the leading electronic health-record system vendor is feeling political heat based on the perceived lack of interoperability between its EHR systems and other systems.

At a House Energy and Commerce Committee hearing in July, Epic was singled out for criticism by U.S. Rep. Phil Gingrey (R-Ga.), a physician, who cited a RAND Corp. report asserting that Epic's systems were “closed records.” Gingrey argued that the federal program providing incentive payments for healthcare providers to install EHRs was intended to promote interoperability. “Is the government getting its money's worth?” he asked. “It may be time for the committee to take a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer.”

Epic's new lobbyist, Brad Card, CEO of Card & Associates, confirmed that Epic officials and some of its competitors held meetings in August with staffers from the Senate Finance Committee and the Health, Education, Labor and Pensions Committee to discuss the possible shape of the third stage of meaningful-use rules for EHR systems, particularly the interoperability requirements. Card is the brother of Andrew Card, former chief of staff for President George W. Bush.

An Epic spokesman said the meetings were “productive and informative.” But an official from an Epic rival, who did not want to be identified, said Senate staffers did not respond favorably to Epic officials' arguments about its record on interoperability.

Epic officials blame the negative perception on misinformation being spread by rival EHR companies. Carl Dvorak, Epic's chief operating officer, wrote in testimony for an Aug. 13 conference call hosted by the Office of the National Coordinator for Health IT that the “presumption of abuse” is “based on a false and disingenuous narrative of unidentified origin.”

Some experts say it's hard to objectively compare the interoperability of Epic EHR systems with those of other vendors. But Epic's spokesman said that in August alone, the firm's customers exchanged more than 500,000 records outside of Epic, and 5 million records between one Epic system and another.

Julia Adler-Milstein, an assistant professor of information at the University of Michigan, said one key question is how much Epic clients had to pay to achieve this level of exchange. High fees, she said, are a barrier to effective sharing of patient data.

Healthcare providers complain that they often pay high fees for interfaces connecting different types of EHR systems. The practice of charging for interfaces is widespread in the healthcare IT industry, Mark Christensen, a co-founder of WebChartMD, a Johnson City, Tenn., technology services provider, told Modern Healthcare last year. Christensen said he's heard many complaints about this from his customers.

But the Epic spokesman said those fees are more than offset by the cost savings achieved from electronic records interchange. “By our calculations, an enterprise Epic hospital will most likely pay a few thousand dollars a year for interoperability while saving probably tens or even hundreds of thousands of dollars in manual work costs.”

Adler-Milstein was skeptical. “While I don't know for certain, I would be shocked if the average interface is only a few thousand dollars,” she said. She suspects that hospitals have to pay more to share data with its peers using different EHR systems.

While interface fees are common across the EHR industry, some observers say Epic's leading role in the EHR market means it has a disproportionate negative effect on interoperability.

AMA president-elect Dr. Steven Stack said many physicians worry about moving their practice's data when they switch EHR vendors. They find that their EHR vendor contracts are not transparent regarding what data will be moved and what data will be lost in transition. The incumbent vendor often charges large and unreasonable fees for moving the data to the new system, he said.

Of particular concern to Stack is the standard for so-called CCDA, or consolidated clinical document architecture. A 2013 code of conduct from the EHR Association pledged to allow physicians to move their data from one vendor to another. But that promise only involved moving data in summary formats such as CCDA.

Stack said the CCDA format often leaves out key information and corrupts data in transit. He would like to see vendors embrace a higher standard of sharing that includes information such as prescribing history and patient allergies.

Ross Koppel, a health IT sociologist at University of Pennsylvania, said Epic's CCDAs might be worse for moving data than other vendors' CCDAs because Epic adds several proprietary “suffixes.” As a result, Koppel said, Epic clients that want to switch to another EHR vendor may find it more difficult to transfer records to a new system.

All large EHR vendors are frustrating, said Dick Escue, CIO at Valley View Hospital, Glenwood Springs, Col. If a hospital wants a third-party application or outside connection, he said, vendors often charge a high upfront price along with an annual fee to maintain it. He estimated the potential upfront cost at $80,000 and the annual fee at $10,000. Even with those fees, vendors often delay providing the services. “They're either unwilling or unable,” he said. “It never gets accomplished.”

University of Pennsylvania's Koppel said that Epic has improved in allowing third-party software developers who are seeking to develop add-on software such as clinical decision support access to their data through an open application programming interface. Epic previously made data available with a time lag, Koppel said, rendering it useless for many applications. Still, Epic's API instructions are not user-friendly, he added.

Koppel expressed concern about the effect of Epic's growing market dominance among large hospitals and systems on the development of new technologies.

One example is in burgeoning field of remote patient monitoring, where many large firms are attempting to aggregate data from sensors—such as scales or blood pressure cuffs—and export them to an EHR. Several major technology firms are focusing on the area. Samsung aggregates data and puts it on its smartphones but hasn't yet identified an EHR partner. Both Verizon and Qualcomm have their own, FDA-cleared solutions in the aggregation-and-export area.

The biggest player might be Apple. Its HealthKit is trying to make the iPhone a hub for device data. It has announced Epic as an EHR partner for its HealthKit aggregation system.

In written comments presented at a March event held by the Federal Trade Commission on healthcare competition, Verizon said EHR vendors are difficult to work with because the interfaces they need to handle the export of data from Verizon's Converged Health Management system to the EHR often take too long and are too expensive to build. The letter said Verizon's product is “impeded by the lack of standards governing how biometric values from remote monitoring devices will be displayed or where the information will be stored in EHRs.”

As a result, tech developers like Verizon need to integrate the data either on their own or with help. “The typical time to integrate with an EHR is between 14 and 24 weeks,” the letter said. “Verizon has had to hire the services of a systems integrator for its [Converged Health Management product], adding a costly and inefficient layer that could have been avoided had there been standards in place to facilitate the exchange of information.”

Koppel said he suspects Verizon was referring to Epic in its letter but didn't want to single any firm out for business reasons. “There is one very large vendor well-known for that kind of behavior,” he said.

Verizon declined to comment.

Judith Faulkner, Epic Systems' founder and CEO, was quoted in the New York Times Wednesday saying the EHR industry has made progress on interoperability this year and that Epic's customers were sending increasing numbers of records each month. She said Epic has created rules and a platform for sharing information, called Care Everywhere, which she said connects hospitals nationwide. She also criticized regulators for failing to create a system that facilitates sharing of data.

Follow Darius Tahir on Twitter: @dariustahir



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