We have recently written about proposed rules that are intended to mandate interoperability between EHR systems and allow patients to let 3rd party apps use their health data. In the past ten years, since the meaningful use mandate, EHR vendors have raced to grab as much of the market as possible. They have walled their systems off from exchanging data with competitors to guard their share. Now the government and parts of industry are working to address the oversight with rules to enforce data sharing.

The rules are aimed at adopting standards that allow "health information... to be accessed, exchanged, and used without special effort" by healthcare institutions. They also prohibit information blocking and any restrictions on communications by the EHR vendors. HHS has been taking feedback from healthcare stakeholders including technology companies looking to enter healthcare information exchange such as Apple, Google, and Amazon.

Interoperability is a complex endeavor, requiring careful consideration to protect patient privacy. We, and many others in healthcare, believe that the rules should be implemented sooner rather than later. But one of the biggest vendors, Epic, has taken a stance of opposition to the rules and is making an argument to delay them.

Epic is based in Verona, Wisconsin, a small town outside of Madison. The founder and CEO, Judy Faulkner says she came up with the idea for a prototype of what would become Epic in the 1970's. Since then it has grown to have about a quarter of the share of the EHR market (58% of institutions of more than 500 beds use Epic; its closest competitor, Cerner has 28% of institutions). It remains a private company with about 10,000 employees, owned by Faulkner, her children and some stock owning employees. They reported 2.9 billion in revenue in 2018 and claim to be growing at 14% per year.

Faulkner wrote an email to hospital executives urging them to speak out against the rule by signing a letter of disapproval. The email claims Epic's position on the rule: "We are concerned that health care costs will rise, that care will suffer and that patients and their family members will lose control of their confidential health information." Faulkner also claims they have already achieved interoperability, with the following statement from the email:

"We all fully support helping patients have access to their data."

• Your patients have been able to download their health information since 2010.
• Your patients have been able to share their health information with anyone in the world that has internet since 2017.
• Care Everywhere allows you to interoperate with other health systems and was developed years before Meaningful Use required interoperability.
• Epic interoperates with thousands of third-party products/apps (CNBC).

Epic executive Sumit Rana explains that the proposed rules would require Epic and other EHR companies to "share their intellectual property with venture capitalists and others seeking to monetize patient data." This statement seems ironic because they make billions per year capturing patient data. The reference to sharing intellectual property points to the true concern.

On the other side of the argument, The Carin Alliance is a private sector collaboration made up of major health insurers, providers, health IT companies and tech giants. They have been meeting with the government entities to encourage finalizing and releasing the rules without further delay. This includes Epic's largest competitor, Cerner, as well as Microsoft, Apple, and Google. Their vision as stated on their website is "to rapidly advance the ability for consumers and their authorized caregivers to easily get, use, and share their digital health information when, where, and how they want to achieve their goals.” A question we have is why is Cerner a part of this group and Epic is not?

We share the concerns about big tech and their motives. Microsoft, Apple, and Google already know so much about our behavior and their businesses have been built on monetizing personal information. What are they hoping to gain from participation in healthcare? Could it really be as altruistic as it appears on the surface? Will the data be exploited for profit? These concerns should be scrutinized, but should not stop interoperability. Pursuing interoperability does not prevent also pursuing data protections.

Why is Epic going against the direction of change? From our perspective, it looks like Epic wants to protect its market share by delaying rules that would enforce data sharing. The system did attract many users by offering the best available interface but challengers are coming forward. When EHRs can share data freely, the organizations that use them can more easily (and never truly easily - it is always such a huge undertaking) change systems and providers. Epic points to Care Everywhere which does allow for information sharing - between institutions that use Care Everywhere. This can be compared to the CommonWell Health Alliance which promotes information sharing between different systems. Epic claims interoperability with thousands of apps through the App Orchard, but those apps are of Epic's choosing. App Orchard participants have to pay to connect to the system. There is some degree of interoperability: internal to Epic customers and partners, and Epic controls the terms.

Knowing the technology and the players, we believe that Epic will be hurt by taking this stance. And we hope that patients, medical practitioners, and medical institutions will benefit. Better solutions are being made and tested as interoperability becomes standard practice. Sooner or later the new rules will pass. Will Epic continue to fight against change and fade into EHR history? Or accept interoperability and be challenged by the competition to become a better EHR system? We will be following the progression and posting more soon.