[value-based care documentation requirements], but I think the
legislators don’t understand the true complexities that we face on
the frontlines of trying to manage all of this.”
Value-based Care’s Chicken and Egg Problem
For all the talk about tearing down the siloes that keep providers
and patients from sharing data in beneficial ways, meaningful
use ended up creating more; the multitude of EHR vendors and
their inability to “talk” to each other remains a problem. Federal
health IT officials are working on proposed regulations to limit
information blocking, but health data isn’t as easy to share as it
should be, which hinders value-based care.
David Kendrick, MD, MPH, FACP, CEO of Oklahoma-based
HIE MyHealth Access Network, has been working on health IT
interoperability issues for several years. In medical school Kendrick founded a small telemedicine company that became a web-based EHR platform. Kendrick was already working with other
hospitals and clinics to meet meaningful use requirements when
MyHealth Access Network became a Beacon Community under
the HITECH Act. He sensed early on in the meaningful use process that interoperability and HIEs were going to be a focus in the
future—and he was correct, as the Affordable Care Act created
ACOs and other value-based care programs. Kendrick sees HIEs
as a vehicle for delivering quality-based care since they are able to
cover more individuals in a region and exchange more meaningful data than hospitals whose EHRs can’t communicate.
Kendrick notes that the Strategic Health Information Exchange
Collaborative (SHIEC), a nonprofit network of HIEs, recently released a report2 showing that 92 percent of the US population
is served by HIEs. It also found that HIEs are delivering more
than 1 billion clinical alerts annually, including notifications to
providers about hospital admissions, discharges, and transfers.
“So the HIEs have been sort of this quiet thing going on in the
background that has just steadily and continually built the corpus of data and the relationships and the trust arrangements
and the governance and the policy necessary for communities
to interconnect,” Kendrick says.
In his mind, the US healthcare system has a “chicken and egg”
problem when it comes to value-based care delivery.
“I always say the push for community-based health information exchanges and interoperability should have come after the
rollout of value-based payment models instead of before, because when I started, nobody knew why they needed to do these
things,” Kendrick says.
He is hopeful about the steps ONC and CMS are taking in their
proposed information blocking rules to promote the fast healthcare interoperability resource (FHIR) standards for health data
exchange. The proposed rules would mandate that covered
entities implement technologies that support application programming interfaces (APIs) capable of using the FHIR standards. Health IT developers and policymakers believe the FHIR
standards are the key to simplified health data exchange.
Donald Rucker, MD, who leads ONC, tells the Journal of AHI-
MA that he believes big changes are coming. “Once we have
consumer grade technical capabilities with APIs, I think we’re
going to have a market-based revolution,” Rucker says. “That’s
what our proposed rule is all about.”
Rucker envisions a health consumer future in which shopping
for healthcare services, and using and sharing one’s health in-
formation, is as user-friendly as ordering something from Ama-
zon. That assumes that FHIR and other standards make it possi-
ble for consumers to experience true price transparency before
they see a doctor or undergo a procedure, and that providers
find a way to comply with this regulatory mandate.
“You’ve seen shopping apps that let you see what you ordered,
when you ordered it, and what the price was,” Rucker says, not-
ing that this should be the case when it comes to acquiring
healthcare services. “It’s not exactly challenging computer sci-
ence, right? It’s challenging policy. But the computer science
part of it is straightforward once the data is made transparent.”
As Rucker notes, enabling this kind of data exchange is challeng-
ing policy, and—even with the progress that they have made since
meaningful use—EHRs may not be the best mechanism for driving
down costs and improving the health of populations just yet.
NorthShore’s Halasyamani notes that there is a wide distribu-
tion of patients who are comfortable using and interacting with
information in their portal.
“For our younger patients there’s probably greater stickiness with
these tools and communications. For our older, more complicated
patients who may have cognitive impairments, it’s probably not the
ideal way to communicate with them,” Halasyamani says. “But it
still may have utility in connecting people identified as proxies.”
That’s the paradox of the chicken and egg problem noted by
Kendrick. Do you create tools that could go unused by the population who needs them most, and hope they get used? Only time
will tell. ¢
1. Society of Actuaries. “2019 Predictive Analytics in Health Care
Trend Forecast.” www.soa.org/globalassets/assets/Files/
2. Strategic Health Information Exchange Collaborative.
“First survey of the SHIEC shows HIEs provide critical national infrastructure.” August 19, 2019. https://strategichie.
Mary Butler ( firstname.lastname@example.org) is associate editor at the Journal of
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