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Appendix C: Background on the Market Landscape Pertaining To Exchange of Health Information

Information Blocking

In 2015, at the request of Congress, ONC produced a report on information blocking, including the extent to which information blocking occurs and what a comprehensive federal-level strategy to address information blocking might include.121 According to the report, information blocking refers to “persons or entities knowingly and unreasonably interfering with the exchange or use of electronic health information.” Information blocking may occur directly, meaning that information is held back or not shared with other entities as a primary business practice, or indirectly, meaning that entities employ creative business practices and policies that make it unreasonably difficult to share information. For example, EHR vendors can indirectly block information through pricing strategies that make it cost prohibitive for providers to purchase interoperable systems or services.

In the current environment, to retain or expand market share of EHR services, health IT vendors may fight to retain market share by asserting that their data cannot be interoperable with competitors’ systems without the creation of complex, often costly interfaces.122 Vendors may technically adhere to certain standards that allow for exchange on a foundational level (as opposed to syntactic or semantic interoperability) but still provide data in highly inefficient formats.123 For instance, a provider using vendor X’s EHR who makes a request for information about a patient from a different provider who uses vendor Z’s EHR may receive a single PDF-like file that vendor X’s EHR can generate but cannot fully ingest without manual data entry.124

Many IT vendors want to expand their service offerings, particularly by providing analytics services.125 As EHR and HIO vendors enter the analytics market, those vendors have an additional disincentive to share data with potential business competitors. By limiting access to data, a company can establish leverage as the least complex choice, both operationally and legally, for analytics contracts.

Similarly, providers themselves may refrain from participating in exchange or limit access to their data to retain proprietary control. Under the current economic model, data exchange creates an opportunity for providers to develop market advantages over their competitors that may reduce providers’ willingness to share data. For example, if clinical data are flowing in real time about the services patients are using, competing providers could use such information to attract these patients to their institutions (for example, a competing health system “stealing” patient volumes).126 Moreover, providers may have proprietary protocols or systems of care that allow them to distinguish themselves within a market, and sharing clinical data may facilitate the “reverse engineering” of such protocols by competitors.127

As the ONC report notes, there are many valid reasons why providers and IT vendors may refrain from participating in data exchange, and the distinction between what is valid and what constitutes information blocking can sometimes be difficult to discern.128 Whether a practice or policy constitutes information blocking is typically determined on a case-by-case basis. Additional work needs to be done to establish a clear threshold or standard for identification and enforcement of information blocking.