Doctors Find Barriers to Sharing Digital Medical Records

By Julie Creswell for The New York Times

As a practicing ear, nose and throat specialist in Ahoskie, N.C., Dr. Raghuvir B. Gelot says that little has frustrated him more than the digital record system he installed a few years ago.

The problem: His system, made by one company, cannot share patient records with the local medical center, which uses a program made by another company.

The two companies are quick to deny responsibility, each blaming the other.

Regardless of who is at fault, doctors and hospital executives across the country say they are distressed that the expensive electronic health record systems they installed in the hopes of reducing costs and improving the coordination of patient care — a major goal of the Affordable Care Act — simply do not share information with competing systems.

The issue is especially critical now as many hospitals and doctors scramble to install the latest versions of their digital record systems to demonstrate to regulators starting Wednesday that they can share some patient data. Those who cannot will face reductions in Medicare reimbursements down the road.

On top of that, leading companies in the industry are preparing to bid on a Defense Department contract valued at an estimated $11 billion. A primary requirement is that the winning vendor must be able to share information, allowing the department to digitally track the medical care of 9.6 million beneficiaries around the globe.

The contract is the latest boon to an industry that taxpayers have heavily subsidized in recent years with over $24 billion in incentive payments to help install electronic health records in hospitals and physicians’ offices.

While most providers have installed some kind of electronic record system, two recent studies have found that fewer than half of the nation’s hospitals can transmit a patient care document, while only 14 percent of physicians can exchange patient data with outside hospitals or other providers.

“We’ve spent half a million dollars on an electronic health record system about three years ago, and I’m faxing all day long. I can’t send anything electronically over it,” said Dr. William L. Rich III, a member of a nine-person ophthalmology practice in Northern Virginia and medical director of health policy for the American Academy of Ophthalmology.

Dr. Gelot, the ear, nose and throat specialist, uses a system made by Practice Fusion. His local medical center, Vidant Roanoke-Chowan Hospital, relies on a program built by Epic Systems.

There is no evidence that either company does a better or worse job of sharing information. But Epic and its enigmatic founder, Judith R. Faulkner, are being denounced by those who say its empire has been built with towering walls, deliberately built not to share patient information with competing systems.

Almost 18 months after an Epic system was installed at UnityPoint Health-St. Luke’s hospital in Sioux City, Iowa, physicians there still cannot transmit a patient care document to doctors two miles south at Mercy Medical Center, which uses a system made by another major player in the field, the Cerner Corporation.

Where interconnectivity between systems does occur, it often happens with steep upfront connecting charges or recurring fees, creating what some see as a digital divide between large hospital systems that have money and technical personnel and small, rural hospitals or physician practices that are overwhelmed, financially and technologically.

The University of California Davis Health System has 22 specialists installing the technology so that doctors can share patient data between its Epic system and other internal systems, like the hemodynamic monitors in its critical care unit, or with some non-Epic systems outside the hospital.

“We’re a huge organization, so we can absorb those costs,” said Michael Minear, the chief information officer at the U.C. Davis Health System. “Small clinics and physician offices are going to have a harder time.”

Separately, through its maintenance contracts and other agreements, Epic charges a fee to send data to some non-Epic systems.

Epic is not alone in charging various fees, nor is there evidence that its fees are more expensive than its peers. But the barrier created by these types of charges “affects the small and rural providers much more significantly,” Morgan Honea, executive director of the Colorado Regional Health Information Organization, a public health information exchange, said in recent policy hearings in Washington.

While nearly all of the leading companies in this area have come under fire for their inability to easily share information, Epic faced some of the strongest attacks this summer.

A research report from the RAND Corporation described Epic as a “closed” platform that made it “challenging and costly for hospitals” to interconnect with the clinical or billing software of other companies. Shortly after, Representative Phil Gingrey, a Georgia Republican and a doctor, assailed the company in public hearings in Washington for the same shortfalls.

Executives at Epic rejected the criticism, labeling it as “vendors throwing smoke screens,” but for the first time, the company hired a Washington lobbying firm to improve its image.

Epic argues that its customers — some of the biggest hospitals in the country — share more records than any other. In interviews with nearly 200 providers for a study that will be released in early October, executives at the research firm Klas said Epic’s scores were “as good or better than most of the other vendors” in its ability to share information with other systems.

Moreover, at the request of Epic executives, several customers, including the Cedars-Sinai Health System in Los Angeles, the Yale New Haven Health System, and New York’s Mount Sinai Hospital, sent emails to The New York Times saying they were able to share records through Epic.

A sort of Microsoft of the Midwest, built on a sprawling campus on nearly 1,000 acres of farmland near Madison, Wis., the privately held Epic has emerged as a leader in the race to digitize patient medical records. Its systems hold the health records of nearly half the country.

The explosion in demand under the technology incentive plan has been a windfall for Epic. Ms. Faulkner is estimated to be worth $2.3 billion.

In a rare interview, Ms. Faulkner said the industry made great strides this year and noted that Epic’s customers were sending increasing numbers of records each month.

She and other company executives argued that the company was actually one of the first to create rules around sharing information and a platform to do so.

In 2005, when it became clear to her that the government was not prepared to create a set of rules around interoperability, Ms. Faulkner said, her team began writing the code for Care Everywhere. Initially seen as a health information exchange for its own customers, Care Everywhere today connects hospitals all over the country as well as to various public health agencies and registries.

“Let’s say a patient is coming from U.C.L.A. and going to the University of Chicago, an Epic-to-Epic hospital. Boom. That’s easy,” Ms. Faulkner said. “These are hospitals that have agreed to the Rules of the Road, a legal contract, that says the other organization is going to take good care of the data.”

Careful in her choice of words, Ms. Faulkner offered muted criticism of regulators for, essentially, failing to create what she did — a contract to help providers connect to one another and a way to authenticate that only the correct person could view the patient information.

“I’m not sure why the government doesn’t want to do some of the things that would be required for everybody to march together,” she said.

Regulators responded that interoperability was a “top priority” and that they recently set out a 10-year vision and agenda to achieve it, in an emailed statement from the Office of the National Coordinator for Health Information Technology.

The office’s spokesman added that achieving interoperability “requires stakeholders to come together and agree on policy-related issues like who can access information and for what purpose.”

Dr. Gelot says he hopes interoperability comes sooner rather than later.

“The systems can’t communicate, and that becomes my problem because I cannot send what is required and I’m going to have a 1 percent penalty from Medicare,” Dr. Gelot said. “They’re asking me to do something I can’t control.”