Memo to the President: US Electronic Medical Record Interoperability

TO: President Joseph R. Biden

FROM: Alexa Letizia, MD/MPH Candidate

Date: December 10, 2024

SUBJECT: US Electronic Medical Record Interoperability

The US healthcare system has many pressing issues, including quality and access, but I will argue that the lack of interoperability between Electronic Medical Record (EMR) systems is a critical problem with many downstream consequences. I will discuss how the lack of interoperability between EMRs prevents adequate information exchange and inhibits healthcare coordination. I will present a policy to address the interoperability dilemma, enabling providers to have timely yet secure access to patient health data. This proposal will not only improve the efficiency of the healthcare system and cut spending, but it will also improve patient outcomes. Please consider addressing this important issue during the remainder of your term.

The Critical Lack of EMR Interoperability

The presence of over one hundred EMRs in the US, which are adopted by thousands of hospitals and outpatient clinics, creates a fragmented system of patient health record data. Healthcare providers struggle to access their patients’ medical records from systems outside their own, inhibiting the information sharing necessary to support coordinated healthcare (Braunstein, 2018). EMRs sequester patient information from providers, and the process of accessing it is laborious, outdated, and time-consuming. The onus usually falls on physicians to use fax to request and receive outside records. Research demonstrates that this administrative burden is not just cumbersome but a contributor to physician burnout (Wang et al., 2018). I have personally seen how providers, when faced with the arduous clerical task of hunting down records, are forced to choose between detracting from their clinical time or forgoing the search entirely. Many doctors choose the latter or are forced to make timely healthcare decisions before receiving a response with their patient’s information. This means that doctors may miss critical patient history or test data, which would alter their treatment plan.

Retrieving outside medical records is wildly inefficient, costly, and directly harmful to patients. Repeat tests expose patients to undue risk, and they often delay definitive care (Wang et al., 2018). A systematic review of studies investigating the consequences of the lack of EMR interoperability found that “redundant, disorganized, disjointed and inaccessible medical information” was linked to worse patient outcomes (Torab-Miandoab et al., 2023). Patient Safety Events (PSEs) are incidents that could have or did harm a patient, and these are more common when there is a need to obtain information from different EMR systems (Li et al., 2022). Specifically, the interoperability problem leads to drug mix-ups and missed diagnoses (Wang et al., 2018). While there is no data suggesting how many lives could be saved with greater EMR interoperability, medical error is the third leading cause of death in the US, and annually, 400,000 of these are preventable (Makary & Daniel, 2016). Therefore, it is likely that greater interoperability between EMR systems would save thousands of lives. Not only does the interoperability dilemma contribute to the incredible cost of human lives, but data also shows how the errors and waste arising from the lack of efficient health data access are significant contributors to exorbitant healthcare spending. A report by the West Institute non-profit estimates that waste from the lack of interoperability between EMRs systems and between EMRs and medical devices totals $35 billion annually due to the costs of adverse events, redundant testing, manual data entry, and increased length of stay from delays in access to data (West Health Institute, 2013). More specifically, one study demonstrated that missing EMR data is predictive of hospital readmissions, a known driver of increased healthcare spending (Samal et al., 2016).

The burden that the lack of interoperability between EMRs places on the US healthcare system is a pressing problem and is only worsening. As the population ages and the average number of chronic diseases per person increases, more specialists will need to collaborate to care for each patient (Braunstein, 2018). It will become even more vital that primary care providers and specialists have all the information about their patients so that they can treat them successfully. This will be increasingly difficult and sometimes impossible if providers do not have secure access to medical records outside their practices or networks. In sum, the lack of EMR interoperability exacerbates healthcare issues, including the administrative burden, burnout, medical errors, and spending. Resolving this problem requires coordinating information exchange between healthcare groups to create a system that allows for better patient care.

I was tasked with suggesting ways you could address the lack of EMR interoperability in the US healthcare system through policy. There are several proposed ways to solve this issue, but not all are adequate or feasible. I will first describe several solutions I believe would be unsuccessful and then recommend the most ideal way to integrate the health information system.

Policy Recommendations

It is unlikely that EMR companies will take the initiative to enable the transfer of patient medical records between their systems, which is why a policy is necessary. One potential solution is to incentivize EMR companies to become interoperable. However, this is unlikely to be successful because any incentive will be insufficient to motivate these companies to invest the time and money necessary to become interoperable. Even if some companies take advantage of the incentive, there is no guarantee that healthcare providers will preferentially use these companies, especially if their EMRs become more expensive due to these changes.

Another option is to leave it to the states to implement their own universal EMR systems or enforce EMR interoperability between the EMR companies in the state. Unfortunately, state-level changes would be unhelpful because many patients travel across the country for healthcare. For instance, interstate travel is common for specialist care, such as cancer treatment and opioid maintenance therapy (Kumari & Chander, 2024). Furthermore, millions of women can only receive essential reproductive healthcare hundreds of miles from home. Thus, interoperability must be accomplished through federal policy. While a federal mandate requiring a single EMR system would make sense, it would not be an attractive strategy. Giving a monopoly to an EMR company would violate antitrust law and disrupt a more than $30 billion-a-year industry (Nguyen et al., 2022; Gamal et al., 2021). Furthermore, a universal EMR system does not necessitate all healthcare facilities using the same platform. As long as information can be retrieved from their choice of EMR, providers can choose an EMR provider (Charles, 2008).

The best way to work towards greater interoperability among EMRs is to expand upon an existing policy in the area: The Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH has successfully encouraged the adoption of EMRs since its implementation in 2009, but it has yet to achieve its secondary aim of creating a secure infrastructure for health information exchange (Braunstein, 2018). Thus, I propose amending HITECH to strengthen its ability to facilitate EMR integration. First, I suggest altering HITECH to provide a five-year financial incentive to providers who adopt an EMR system that allows real-time information exchange. This will require an upfront investment, which could come from tax breaks, but it will be feasible for two reasons. First, the incentive will only be temporary to allow flexibility to become compliant with the new interoperability standards that will become mandatory shortly thereafter. Second, this money and more will be earned back when the benefits of EMR interoperability come to fruition (Schilling, n.d.). Specifically, the government will benefit from lower healthcare spending by Medicare and Medicaid recipients.

After about five years, I propose mandating interoperability compliance as a prerequisite for receiving Medicare reimbursement, which will bring most remaining providers into the system. This pathway from incentive to mandate gives leeway for healthcare administrators to either find an existing system that meets the requirements or wait for an update from their current EMR. EMR companies will be incentivized to upgrade their systems to remain competitive.

Summary

In sum, it is essential to establish interoperability between EMRs because timely yet secure access to health data can optimize efficiency, decrease costs, and improve health outcomes. You can start the US on a path toward greater EMR interoperability through the HITECH Act. This is an important issue that would be worth devoting your time to initiate before the end of your term.

Thank you, I appreciate your consideration of this critical issue and the potential solution. I can be reached at alexa.letizia@stonybrookmedicine.edu for any clarifications and questions about the scope of this problem and my recommendations.

Regards,

Alexa Letizia

References

Braunstein, M. L. (2018). Health care in the age of interoperability: The potential and challenges. IEEE Pulse, 9(5), 34–36. https://doi.org/10.1109/MPUL.2018.2856941

Charles A, S. (2008). Developing universal electronic medical records. Gastroenterology & Hepatology, 4(3), 193–195. https://www.ncbi.nlm.nih.gov/pubmed/21904496

Gamal, A., Barakat, S., & Rezk, A. (2021). Letter to Editor (Response from author): Toward a universal electronic health record system. Journal of Biomedical Informatics, 117(103770), 103770. https://doi.org/10.1016/j.jbi.2021.103770

Kumari, R., & Chander, S. (2024). Improving healthcare quality by unifying the American electronic medical report system: time for change. The Egyptian Heart Journal : (EHJ): Official Bulletin of the Egyptian Society of Cardiology, 76(1), 32. https://doi.org/10.1186/s43044-024-00463-9

Li, E., Clarke, J., Ashrafian, H., Darzi, A., & Neves, A. (2022). The impact of electronic health record interoperability on safety and quality of care in high-income countries: Systematic review. Journal of Medical Internet Research, 24(9), e38144. https://doi.org/10.2196/38144

Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ (Clinical Research Ed.), i2139. https://doi.org/10.1136/bmj.i2139

Nguyen, K.-H., Wright, C., Simpson, D., Woods, L., Comans, T., & Sullivan, C. (2022). Economic evaluation and analyses of hospital-based electronic medical records (EMRs): a scoping review of international literature. Npj Digital Medicine, 5(1), 29. https://doi.org/10.1038/s41746-022-00565-1

Schilling, B. (n.d.). The federal government has put billions into promoting electronic health record use: How is it going? The Commonwealth Fund. Retrieved November 25, 2024, from https://www.commonwealthfund.org/publications/newsletter-article/federal-government-has-put-billions-promoting-electronic-health

Torab-Miandoab, A., Samad-Soltani, T., Jodati, A., & Rezaei-Hachesu, P. (2023). Interoperability of heterogeneous health information systems: a systematic literature review. BMC Medical Informatics and Decision Making, 23(1), 18. https://doi.org/10.1186/s12911-023-02115-5

Wang, C. Y., Zenooz, A., Sriram, R. D., Samitt, C., Karney, M., Johnson, W., Goldman, J., Gettinger, A., Fridsma, D. B., Bono, R. C., Palmer, S., Johns, M. M. E., & Pronovost, P. (2018). Why interoperability is essential in health care. National Academy of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK594855/

West Health Institute. (2013). The Value of Medical Device Interoperability. West Health. https://westhealth.org/wp-content/uploads/2015/02/The-Value-of-Medical-Device-Interoperability.pdf