The lesson of a decade of health information technology mismanagement

Report on Health Information Blocking

The Office of the National Coordinator for Health Information Technology (ONC)
Department of Health and Human Services, April 2015

Current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. Indeed, complaints and other evidence described in this report suggest that some persons and entities are interfering with the exchange or use of electronic health information in ways that frustrate the goals of the HITECH Act and undermine broader health care reforms. These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature.


The intent of the HITECH Act was to drive the rapid adoption of interoperable technologies and services to support the exchange of electronic health information to improve care and efficiency in the U.S. health care system. While this intent was and is clear to most stakeholders, based on ONC’s experience and available evidence, the developing market for health IT products and services has, in some instances, fallen short of this charge.

The precise nature and extent of information blocking remain obscured in large part by contractual restrictions that prevent the disclosure of relevant evidence. However, based on the evidence and knowledge available, it is apparent that some health care providers and health IT developers are knowingly interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and health care. This conduct may be economically rational for some actors in light of current market realities, but it presents a serious obstacle to achieving the goals of the HITECH Act and of health care reform.

There are several immediate actions ONC, HHS, and other federal agencies can take to partially address some kinds of information blocking. In this report, ONC has outlined a number of targeted actions to deter and mitigate such conduct, within limited areas.

While important, these actions alone will not provide a complete solution to the information blocking problem. Indeed, a key finding of this report is that many types of information blocking are beyond the reach of current federal law and programs to address. Thus a comprehensive approach will require overcoming significant gaps in current knowledge, programs, and authorities that limit the ability of ONC and other federal agencies to effectively target, deter, and remedy this conduct, even though it violates public policy and frustrates congressional intent. For these reasons, in addition to the actions outlined in this report, successful strategies to prevent information blocking will likely require congressional intervention.

Information blocking is certainly not the only impediment to an interoperable learning health system. But the findings in this report suggest that it is a serious problem—and one that is not being effectively addressed. ONC believes that in addition to the actions described in this report, there are several additional avenues open to Congress to address information blocking and drive continued progress towards the nation’s health IT and health care goals. ONC looks forward to working with Congress to identify the best solutions.


On July 21, 2004, David Brailer, the then National Coordinator for Health Information Technology, released a 178 page report, “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care.” Following is my comment on that date in response to his report:

A private health care information technology system

By Don McCanne, MD
Quote of the Day, July 21, 2004

The private, competitive market has produced for us computers that are powerful yet inexpensive. Software that is used widely is quite inexpensive, and that in the public domain is essentially free after the initial development costs. With inexpensive computers and software developed in the public domain, the cost of an integrated health care IT (information technology) system should be quite modest. And the return in error reduction and administrative efficiency would far more than offset any real costs.

The Veterans Administration is far ahead of the rest of the nation in developing and utilizing an integrated IT system. And this has been developed in the public (government!) sector. Many other nations with universal health care systems have also introduced integrated IT systems primarily through the public sector.

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and being uninsured does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares. To achieve those goals, corporate behavior varies from that of a public entity that has a simpler goal of establishing an effective and efficient high quality system that serves the heath care system and its patients well. The public system does not have to be concerned about being a successful business enterprise, but the private model does.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

The health information technology report released today should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

We desperately need strong leadership from our government in developing a health care IT system that will serve us all well. But based on the current leadership that has failed to address even the fundamental issue of adequate health care coverage for all, it is unlikely that we’ll see any enlightened leadership on this in the near future.



By Don McCanne, MD

Some say that my comments of over a decade ago were prescient. They were not. The current disarray of our health information technology system (HIT) was fully predictable.

There are times and circumstances in which the private sector sector serves us well, with appropriate government oversight, and there are times and circumstances in which the government serves us well, with appropriate private partnership.

We blew this one. We turned HIT over to the private sector while failing to provide adequate government oversight. We ended up with just what I predicted a decade ago, when David Brailer was predicting a decade leading to HIT nirvana.

Right now we have a much larger problem in our health care system with an imbalance between the private sector and government. We have turned much of our health care financing system over to the private sector, especially the private insurance plans, without providing adequate government oversight. Thus we have tens of millions of individuals without insurance, many more who are underinsured, many who have impaired access to their physicians because of insurer network restrictions, many who face financial hardship when medical needs arise, and an outrageously expensive system due to the profound administrative waste of the insurers and the burden they place on the health care delivery system.

Virtually none of these problems would exist if we had the government instead of the private insurers serving us as the health care financing authority. It should be the government rather than the private insurers that distributes the funds to the private and public health care delivery systems.

It is amazing that it has taken a decade for us to discover officially that placing control of HIT in the hands of the private sector is not serving us well. What is even more astounding is that, in over half of a century, we have not seemed to learn that lesson as it applies to our health care financing.

It is not as if we have not tried. PNHP has been preaching this lesson for over a quarter of a century, especially after it became obvious that the private insurers and their managed care revolution proved to us that they should no longer be stewards of our health care dollars.

The founders of PNHP were not prescient. The need was obvious. It still is.