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Is Interoperability Worth Paying For?

A member of our extended family is a nurse practitioner. Recently, we talked about her practice providing care for several homebound, older patients. She tracks their health with her employer’s proprietary EHR, which she quickly compared to a half dozen others she’s used. If you want a good, quick EHR eval, ask a nurse.

What concerned her most, beyond usability, etc., was piecing together their medical records. She didn’t have an interoperability problem, she had several of them. Most of her patients had moved from their old home to Florida leaving a mixed trail of practioners, hospitals, and clinics, etc. She has to plow through paper and electronic files to put together a working record. She worries about being blindsided by important omissions or doctors who hold onto records for fear of losing patients.

Interop Problems: Not Just Your Doc and Hospital

She is not alone. Our remarkably decentralized healthcare system generates these glitches, omissions, ironies and hang ups with amazing speed. However, when we talk about interoperability, we focus on mainly on hospital to hospital or PCP to PCP relations. Doing so, doesn’t fully cover the subject. For example, others who provide care include:

  • College Health Systems
  • Pharmacy and Lab Systems
  • Public Health Clinics
  • Travel and other Specialty Clinics
  • Urgent Care Clinics
  • Visiting Nurses
  • Walk in Clinics, etc., etc.

They may or may not pass their records back to a main provider, if there is one. When they do it’s usually by FAX making the recipient key in the data. None of this is particularly a new story. Indeed, the AHA did a study of interoperability that nails interoperability’s barriers:

Hospitals have tried to overcome interoperability barriers through the use of interfaces and HIEs but they are, at best, costly workarounds and, at worst, mechanisms that will never get the country to true interoperability. While standards are part of the solution, they are still not specified enough to make them truly work. Clearly, much work remains, including steps by the federal government to support advances in interoperability. Until that happens, patients across the country will be shortchanged from the benefits of truly connected care.

We’ve Tried Standards, We’ve Tried Matching, Now, Let’s Try Money

So, what do we do? Do we hope for some technical panacea that makes these problems seem like dial up modems? Perhaps. We could also put our hopes in the industry suddenly adopting an interop standard. Again, Perhaps.

I think the answer lies not in technology or standards, but by paying for interop successes. For a long time, I’ve mulled over a conversation I had with Chandresh Shah at John’s first conference. I’d lamented to him that buying a Coke at a Las Vegas CVS, brought up my DC buying record. Why couldn’t we have EHR systems like that? Chandresh instantly answered that CVS had an economic incentive to follow me, but my medical records didn’t. He was right. There’s no money to follow, as it were.

That leads to this question, why not redirect some MU funds and pay for interoperability? Would providers make interop, that is data exchange, CCDs, etc., work if they were paid? For example, what if we paid them $50 for their first 500 transfers and $25 for their first 500 receptions? This, of course, would need rules. I’m well aware of the human ability to game just about anything from soda machines to state lotteries.

If pay incentives were tried, they’d have to start slowly and in several different settings, but start they should. Progress, such as it is, is far too slow and isn’t getting us much of anywhere. My nurse practitioner’s patients can’t wait forever.

This post originally appeared at


ONC’s Budget: A Closer Look

When HHS released ONC’s proposed FY2017 budget last winter, almost all attention focused on one part, a $22 million increase for interoperability. While the increase is notable, I think ONC’s full $82 Million budget deserves some attention.

ONC’s FY2017 Spending Plan.

Table I, summarizes ONC’s plan for Fiscal Year 2017, which runs from October 1, 2016 through September 30, 2017. The first thing to note is that ONC’s funding would change from general budget funds, known as Budget Authority or BA, to Public Health Service Evaluation funds. HHS’ Secretary may allocate up to 2.1 percent of HHS’ funds to these PHS funds. This change would not alter Congress’ funding role, but apparently signals HHS’s desire to put ONC fully in the public health sector.

Table I
ONC FY2017 Budget


What the ONC Budget Shows and What it Doesn’t

ONC’s budget follows the standard, federal government budget presentation format. That is, it lists, by program, how many people and how much money is allocated. In this table, each fiscal year, beginning with FY2015, shows the staffing level and then spending.

Staffing is shown in FTEs, that is, full time equivalent positions. For example, if two persons work 20 hours each, then they are equivalent to one full time person or FTE.

Spending definitions for each fiscal year is a little different. Here’s how that works:

  • FY2015 – What actually was spent or how many actually were hired
  • FY2016 – The spending and hiring Congress set for ONC for the current year.
  • FY2017 – The spending and hiring in the President’s request to Congress for next year.

If you’re looking to see how well or how poorly ONC does its planning, you won’t see it here. As with other federal and most other government budgets, you never see a comparison of plans v how they really did. For example, FY2015 was the last complete fiscal year. ONC’s budget doesn’t have a column showing its FY2015 budget and next to it, what it actually did. If it did, you could see how well or how poorly it did following its plan.

You can’t see the amount budgeted for FY2015 in ONC’s budget, except for its total budget. However, if you look at the FY2016 ONC budget, you can see what was budgeted for each of its four programs. While the budget total and the corresponding actual are identical -$60,367,000, the story at the division level is quite different.

                                   Table II
                    ONC FY2015 Budget v Actual


FY2015 Budget $ FY2015 Actuals $ Diff
Policy Development and Coordination 12,474 13,112 638
Standards, Interoperability, and Certification 15,230 15,425 195
Adoption and Meaningful Use 11,139 10,524 (615)
Agency-wide Support 21,524 21,306 (218)
Total 60,367 60,367


Table II, shows this by comparing the FY2015 Enacted Budget from ONC’s FY2015 Actuals for its four major activities. While the total remained the same, it shows that there was a major shift of $638,000 from Meaningful Use to Policy. There was a lesser shift of $195,000 from Agency Support to Standards. These shifts could have been actual transfers or they could have been from under and over spending by the divisions.

Interestingly, Table III for staffing shows a different pattern. During FY2015, ONC dropped 25 FTEs, a dozen from Policy Development and the rest from Standards and Meaningful Use. That means, for example, that Policy Development had less people and more money during FY2015.

Table III
ONC FY2015
Budget v Actual Staffing FTEs
Division FY2015 Budget FTEs FY2015 Actuals FTEs Diff
Policy Development and Coordination 49 37 (12)
Standards, Interoperability, and Certification 32 26 (6)
Adoption and Meaningful Use 49 42 (7)
Agency-wide Support 55 55
Total 185 160 25


To try to make sense of this, I looked at the current and past year’s budgets, but to no avail. As best I can tell is ONC made great use of contracts and other non personnel services. For example, ONC spent $30 Million on purchase/contracts, which is $8 million more than it did on its payroll.

ONC’s budget, understandably, concentrates on its programs and plans. It puts little emphasis on measuring its hiring and spending abilities. It’s not alone, budgets government and otherwise, are forecast and request documents. However, if we could know how plans went – without having to dig in last year’s weeds  – it would let us know how well a program executed its plans as well as make them. That would be something worth knowing.

This post originally appeared at

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