As a STEM kid in the 1960s, nothing inspired me more than President John F. Kennedy's 1961 vow to land a man on the moon before the end of the decade. On July 20, 1969—just eight years and $25 billion later—astronaut Neil Armstrong took that giant step for mankind.
President George W. Bush made a less grandiose technology pledge in 2004. He promised “within the next 10 years” to create a nationwide computerized electronic health-record system that would ensure “complete healthcare information is available for most Americans at the time and place of care, no matter where it originates.”
We're now more than 11 years and $28 billion beyond that pledge. And that is just direct federal spending, not the tens of billions more spent by medical providers. So where do we stand?
Most Americans who receive care at more than one location still don't have their “complete” record in front of their attending physician. Heck, most providers can't or won't even send their patients' electronic records across town, much less to a neighboring state or across the country.
A societal failure on such an epic scale raises larger, dare we say, philosophical questions about who or what is to blame. The wise discerner asks, “Has government over the past half century completely lost its ability to create a public good?”
Not at all. For instance, all scripts by the Obama administration laid out a plan to reduce the share of the population who didn't have health insurance. Despite fierce opposition, it succeeded in making a major dent in the problem.
There are other examples. The air is substantially cleaner today than it was 40 years ago, largely because of standards set by the Environmental Protection Agency. Americans now drive cars that get 25 to 50 mpg, not the 10 to 20 mpg typical of the era before the government set fuel-efficiency standards.
Were the technical challenges of health information interoperability simply too daunting? That excuse withers under close scrutiny.
One doesn't have to go to the financial or retail worlds for examples of complicated records that are quickly and easily shared across space in real time. One can simply point to an integrated healthcare delivery system such as Kaiser Permanente to show that healthcare-record portability is easily accomplished when there aren't institutional barriers.
So why have the CMS and HHS' Office of the National Coordinator for Health IT been singularly incapable of of giving the American people portable electronic health records? The report issued by ONC this month blamed “information blocking” practices by software vendors and providers.
Their examples included IT developers charging high fees for exchanging data or building interfaces with other systems, refusing to recognize rival security precautions and, in some cases, simply refusing to play with others. On the provider side, some block information flow “to control referrals and enhance their market dominance,” the report alleged. Curiously, the 39-page document failed to mention a single name, despite receiving 60 unsolicited reports of information blocking. What might they have found if they actually went looking?
Don't think that decisions by Epic, Cerner and athenahealth to waive interconnection fees will make a difference. Does anyone charge me to send an e-mail?
The heart of the problem is that rather than seeing easy information flow as a public good, all players in the game are doing everything in their power to maintain control over the information and wield it as a competitive weapon. Until that is against the law or prohibited by rule, this nation will not achieve healthcare information interoperability.
Yet the ONC flinches from its responsibility.
When it wasn't complaining it had no power, the agency argued in the report against using the powers it does have—such as denying certification to any vendor that fails to make its software 100% interoperable. Rather, it wants to punt enforcement to the Federal Trade Commission, which is too busy chasing down non-threatening hospital-physician practice mergers in small markets to concern itself with the nationwide oligopolistic practices of the healthcare IT industry.
For the final word on this, let's return to Bush's original speech on the subject—not the one he gave Wednesday at HIMSS. “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care,” he said.
It remains a dream deferred.
