Thought Obamacare was messy? Wait until electronic health records come online

EHRs' laudable openness goals will slam into reality of highly proprietary, secretive, and risk-averse health care industry

As the nation continues to fight over the Obamacare mandate that everyone have reasonable health insurance, and both proponents and opponents struggle with its complex policy and technology implementations, a bigger disconnnect is looming. The potential snafu centers on the national electronic health records (EHR) system mandated during the Bill Clinton and George W. Bush administrations and now starting to gain meaningful deployment as a key federal deadline of 2015 nears.

There are several contradictions in the EHR mandate and how the medical industry operates, as well as between EHR policies and older laws such as HIPAA (the Health Insurance Portability and Accountability Act). Although many could be anticipated, the health care industry largely has ignored them, preferring to do things as it always has. Never mind that the federal agency that sets the policies for EHRs -- the Office of the National Coordinator (ONC) in the Health and Human Services Dept. -- has been increasingly aggressive in crystallizing the rules and showing tangible approaches to foster data sharing and patient access, which often goes against the way medical providers operate.

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Even where medical providers aren't clinging to old ways, the federal mandates are proving very difficult to comply with, as privacy, security, integration, sharing, and effectiveness requirements create fundamental conflicts that technologists may not be able to resolve. In fact, an increasing number of providers are returning federal incentive dollars or accepting federal noncompliance fines because they can't figure out how to make it all work.

In the next few years, we'll see a similar breakdown in the status quo as occured several years ago when the consumerization movement, in the form of BYOD for mobile devices, both changed the relationship between IT and users and created a contradiction between compliance and effectiveness. In health care, I could see several of these collisions become visible at the recent HIMSS 2014 conference, which gathers nearly 30,000 health care practitioners, vendors, payers, and policy makers around health IT.

Bill Fera, a principal in Ernst & Young's advisory practice, sees a split emerging between the haves and have-nots in the health care industry: Organizations that have both the money and technical talent being clearly more successful in figuring out how to satisfy the mandates than those who lack one or both. He's also seeing many providers rethink their EHR efforts to be less "best of breed" and to rely on a smaller number of established vendors, similar to how the ERP industry coalesced around SAP, Oracle, and Infor. He also sees an increasing trend to outright mergers and less formal affiliations that let multiple organizations use the same technology and platforms. Finally, he's seeing ONC solidifying its requirements and model systems, because there's now enough experience to do that, versus the "theoretical" recommendations from the early days.

I believe the collision will ultimately be a good thing, but it will also be painful. The goals of the health care reforms set out 20 years ago and now being implemented are good ones -- the three standing ovations Hillary Clinton, considered the mother of health care reforms due to her controversial efforts in 1993, received when she spoke at HIMSS show the health care industry largely agrees. But achieving them is no sure bet.

Contradiction 1: Proprietary medical systems and the mandate to exchange patient data
EHRs are like ERP deployments: Even though only a handful of vendors' systems are used to create them, every one is customized to the hilt to reflect the various business and medical processes they record and facilitate. If you remember the first wave of ERP systems in the late 1990s and early 2000s, most delivered negative ROI.

Why? Because they were overcustomized, cost gobs of money, delayed deployments for years in many cases, and become too expensive to maintain, much less update. Even today, when two companies merge, the ERP integration effort becomes a big money and time sink. Though they use the same technbology platform, they're implemented too differently to be able to simply move one company to the other's ERP system as is.

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