This
week,
a
New
York
City-based
startup
decided
to
wage
its
own
David
vs.
Goliath-style
battle
in
the
healthcare
technology
world.
Following
a
months-long
dispute,
data
platform
Particle
Health
sued
EHR
behemoth
Epic.
The
startup
filed
an
antitrust
lawsuit
against
Epic
in
the
Southern
District
of
New
York
on
Monday,
alleging
that
the
EHR
vendor
is
using
its
dominance
in
the
market
to
prevent
competition
in
the
payer
platform
space.
The
payer
platform
space
refers
to
the
emerging
market
for
digital
platforms
that
allow
payers
to
access
and
analyze
patient
data
at
scale
for
a
variety
of
purposes,
including
improving
care
coordination,
designing
population
health
programs
or
streamlining
claims
processing.
Particle’s
complaint
alleges
that
Epic
is
preventing
the
startup
from
competing
in
this
space
by
cutting
off
Particle
customers
from
accessing
Epic’s
EHR
data.
Particle
believes
the
lawsuit
is
an
“unprecedented
challenge”
to
Epic’s
market
power.
Epic
thinks
the
startup’s
claims
are
without
merit.
The
payer
platform
market
Particle,
founded
in
2018,
seeks
to
help
its
customers,
including
providers
and
health
plans,
access
and
understand
patient
data
held
by
Epic
and
other
EHR
systems.
Essentially,
Particle
acts
as
a
middleman,
using
an
API
to
enable
health
data
access
between
Epic
and
its
own
customers.
The
startup
participates
in
several
nationwide
health
data
exchanges,
such
as
Carequality,
CommonWell,
and
eHealth
Exchange.
Particle
put
itself
on
“a
meteoric
growth
path”
when
it
began
offering
its
services
to
payers
last
year,
the
complaint
read.
The
startup
made
its
move
into
the
payer
market
because
it
noticed
that
an
increasing
number
of
payers
were
becoming
“payviders,”
meaning
they
provide
healthcare
services
to
their
members.
For
instance,
UnitedHealth
Group,
the
nation’s
largest
healthcare
insurer,
is
the
largest
employer
of
physicians
in
the
country
through
its
Optum
subsidiary,
and
Humana,
also
a
payer,
has
a
senior
care
unit
called
CenterWell
Primary
Care.
“Particle
was
the
first
to
realize
that
payers
offering
these
services
legitimately
needed
records
to
assist
physicians
with
providing
treatment,
and
could
therefore,
under
certain
circumstances,
utilize
the
centralized
exchange
networks
to
obtain
medical
records
through
the
most
efficient
means
currently
available,”
the
complaint
read.
Under
the
rules
of
HIPAA
and
health
information
networks,
those
same
payers
are
allowed
to
use
the
records
for
“secondary”
purposes,
such
as
population
health
analytics
or
processing
claims,
the
complaint
stated.
By
giving
payers
access
to
this
information,
Particle
entered
into
competition
with
Epic,
said
Adam
Wolfson,
one
of
the
lawyers
representing
Particle.
Epic
launched
its
payer
platform
in
2021,
allowing
insurers
to
request,
receive,
store
and
analyze
health
records
at
scale.
When
Particle
decided
to
compete
in
2023,
Epic
had
firm
control
of
the
emerging
market,
including
contracts
with
the
seven
largest
health
plans
in
the
nation,
according
to
the
complaint.
“In
the
payer
platform
market,
[Epic]
was
the
only
game
in
town
for
several
years,”
Wolfson
remarked.
While
Epic
may
be
dominant
in
the
space,
other
companies
like
Zus
Health,
Clarify
Health
and
Health
Gorilla
also
aim
to
satisfy
payers’
appetites
for
patient
data.
Zus
Health
and
Health
Gorilla,
like
Particle
Health
and
Epic,
are
also
part
of
Carequality’s
exchange
network.
When
did
the
dispute
begin?
In
March,
Epic
filed
a
formal
complaint
with
Carequality,
a
health
information
exchange
that
supports
the
exchange
of
400
million
clinical
records
per
month.
The
complaint
alleged
that
Particle
was
sharing
patient
data
with
payers
that
weren’t
using
the
data
for
treatment
—
and
therefore
violating
HIPAA.
Epic
also
sent
its
customers
a
notice
informing
them
that
the
company
was
cutting
off
data
access
for
Particle
Health.
“This
poses
potential
security
and
privacy
risks,
including
the
potential
for
HIPAA
Privacy
Rule
violations
in
the
event
disclosures
of
protected
health
information
were
made
under
the
Treatment
Permitted
Purpose
when
the
requesting
entities
did
not
have
treatment
relationships
with
the
patients
to
whom
the
records
related,”
Epic
said
in
a
notice
to
its
customers,
which
was
obtained
by
CNBC.
Particle
released
a
blog
post
on
April
12
stating
that
Epic
had
stopped
responding
to
data
requests
from
a
“subset”
of
Particle’s
payer
customers
“without
a
clearly
stated
reason
or
explanation.”
Particle
also
said
that
it
“began
addressing
this
issue
immediately”
and
wanted
to
work
with
Epic
to
restore
access
for
these
customers.
Additionally,
Troy
Bannister,
Particle’s
founder,
released
a
statement
refuting
Epic’s
claim
that
the
startup’s
customers
were
requesting
patient
data
for
purposes
other
than
treatment.
“To
our
knowledge,
all
of
the
affected
partners
directly
support
treatment.
They
pull
data
for
providers
at
the
point
of
care
and
subsequently
share
data
back
with
the
Carequality
network.
These
partners
were
all
reviewed
by
Carequality
prior
to
onboarding
and
they
are
entitled
to
fair
and
transparent
treatment
by
the
network
and
other
implementers,”
Bannister’s
statement
read.
The
disagreement
underscored
the
need
for
greater
transparency
in
health
data
exchange
networks,
noted
Brendan
Keeler
—
who
has
held
leadership
positions
at
healthcare
data
companies
like
Zus
Health
and
Redox
—
in
an
article
he
wrote
at
the
time
of
the
initial
dispute.
In
his
view,
the
conversation
shouldn’t
center
on
whether
or
not
Particle’s
customers
are
using
data
solely
for
treatment
purposes
—
because
there
are
a
lot
of
other
legitimate
reasons
for
which
healthcare
organizations
would
seek
data.
For
instance,
health
navigators
and
insurance
brokers
require
data
to
help
patients
select
the
best
providers
and
plans,
and
pharma
companies
need
data
to
maximize
the
success
of
their
clinical
trials,
Keeler
pointed
out.
At
present,
EHR
companies
like
Epic
get
to
arbitrate
which
requests
are
appropriate
and
which
requests
should
be
denied.
But
Keeler
thinks
health
information
exchanges
and
regulators
need
to
come
together
and
build
a
more
transparent
system
that
allows
stakeholders
to
see
the
exact
use
cases
for
which
payers
are
requesting
data.
“The
best
possible
action
is
to
act
with
increasing
unfettered
transparency
—
publish
your
customers’
use
cases,
make
their
directory
entries
granular
and
clear,
and
communicate
the
intended
purposes
of
use,”
Keeler
argued.
What
does
the
lawsuit
allege?
Particle’s
antitrust
lawsuit
alleges
that
Epic
“is
engaged
in
a
scheme
to
stamp
out
competition
in
an
important
new
market
by
misusing
power
that
it
has
due
to
its
control
over
electronic
health
records,”
stated
Wolfson,
one
of
Particle’s
lawyers.
The
complaint
claims
that
Epic
has
been
blocking
Particle
customers
from
data
—
and
therefore
stifling
Particle’s
entry
into
the
payer
platform
market
—
for
the
past
six
months
that
have
continued
following
the
initial
dispute
in
the
spring.
“Between
80-94%
of
people
in
the
country
have
at
least
one
Epic
electronic
health
record
in
their
file.
So
if
Epic
is
refusing
to
provide
those
records
for
treatment
requests,
then
you’re
not
getting
someone’s
full
medical
health
history.
We
allege
that
gives
Epic
a
ton
of
power
over
those
who
need
to
get
those
full
medical
histories,”
Wolfson
explained.
Particle
CEO
Jason
Prestinario
released
a
statement
and
video
testimonial
on
LinkedIn
this
week
declaring
that
the
lawsuit
is
not
just
a
business
dispute,
but
rather
also
a
move
to
protect
patients’
rights
to
their
health
data.
In
the
six
months
following
Particle’s
initial
dispute
with
Epic,
the
EHR
vendor
“caused
real
patient
harm”
and
damaged
Particle’s
reputation
with
its
“false
allegations”
of
HIPAA
violations,
he
said
in
the
video.
“We’re
concerned
about
what’s
to
stop
them
from
doing
that
to
more
patients,
to
us,
or
to
any
other
competitor
that
emerges,”
Prestinario
remarked.
By
filing
the
lawsuit,
Particle
seeks
monetary
damages,
injunctive
relief
and
to
put
an
end
to
Epic’s
alleged
information
blocking
practices.
The
startup
also
filed
a
formal
information
blocking
complaint
with
the
ONC,
which
has
now
been
referred
to
HHS’
Office
of
the
Inspector
General,
Prestinario
noted.
The
lawsuit
also
aims
to
create
more
room
for
competition
in
the
payer
data
platform
market,
he
added.
“We
need
to
ensure
a
level
playing
field
where
companies
like
Particle
—
but
not
just
Particle
—
can
continue
to
innovate,
where
providers
and
payers
have
choices,
and
where
patients
ultimately
benefit
from
better,
more
efficient
care,”
Prestinario
declared.
An
Epic
spokesperson
called
the
lawsuit’s
claims
“baseless”
in
a
statement
sent
to
MedCity
News.
“This
lawsuit
attempts
to
divert
attention
from
the
real
issue:
Particle’s
unlawful
actions
on
the
Carequality
health
information
exchange
network
violated
HIPAA
privacy
regulations.
Particle’s
complaint
mischaracterizes
Carequality’s
decision,
which
in
fact
proposes
banning
Particle
customers
that
were
accessing
patient
data
for
impermissible
purposes,”
the
statement
read.
Carequality
told
MedCity
News
that
it
“would
not
be
appropriate”
to
comment
on
the
ongoing
litigation
between
Particle
and
Epic
because
it
is
not
a
named
party
in
the
lawsuit.
“What
we
can
say
is
that
Carequality
is
committed
to
the
integrity
and
transparency
of
our
interoperability
framework.
We
feel
confident
in
our
independent
and
non-biased
dispute
resolution
process,
which
considers
all
the
information
in
meticulous
detail
to
reach
an
outcome
that
preserves
trust,
improves
our
network,
and
reaches
the
best
outcome
for
our
community.
That
process
resulted
in
a
resolution
that
is
still
being
considered
by
the
parties
and
therefore
we
will
not
comment
on
the
specifics,”
the
emailed
statement
read.
What
does
this
mean
for
the
future?
In
the
comments
section
of
Prestinario’s
LinkedIn
post,
Lisa
Bari
—
CEO
of
Civitas
Networks
for
Health,
a
national
organization
representing
regional
health
information
exchanges
—
echoed
Keeler’s
comments
from
earlier
this
year
about
the
need
for
greater
transparency.
“Just
reading
the
complaint,
it
seems
like
there
is
a
bit
of
a
misunderstanding
(to
say
the
least)
about
the
treatment
use
case
under
Carequality
as
it
relates
to
payers
and
plans
(and
TEFCA,
although
this
is
not,
at
present,
directly
about
TEFCA).
From
my
perspective,
I’m
looking
forward
to
discovery,
to
bring
more
of
these
complaints
into
the
public
domain.
Transparency
is
key
to
trust,”
she
wrote.
The
Trusted
Exchange
Framework
and
Common
Agreement
(TEFCA)
is
a
federal
initiative
designed
to
create
a
standardized,
nationwide
framework
for
the
exchange
of
healthcare
data
between
various
systems
and
organizations.
The
lawsuit
also
draws
attention
to
the
fact
that
patients
often
bear
the
brunt
of
the
harm
when
it
comes
to
the
industry’s
messy
data
exchange
practices.
Unrestricted
access
to
healthcare
data
is
crucial
for
improving
the
quality
of
patient
care,
pointed
out
Mitesh
Rao,
CEO
of
OMNY
Health,
a
national
data
ecosystem
that
facilitates
biotech
and
medical
research.
“Healthcare
is
increasingly
a
data-driven
industry.
Access
to
the
wealth
of
insights
buried
in
the
troves
of
data
we
generate
can
help
rapidly
improve
both
quality
and
safety
in
clinical
care.
Data
can
also
serve
as
a
foundation
for
providers
to
collaborate
in
improving
patient
outcomes,”
he
remarked.
The
free
flow
of
data
helps
physicians
better
identify
and
address
patients’
health
complexities,
deliver
appropriate
medications
and
care
plans,
and
shape
the
future
of
medical
research,
Rao
added.
It’s
uncertain
whether
Particle’s
lawsuit
will
make
it
to
trial.
Whether
or
not
the
underdog
triumphs
or
fails,
this
legal
battle
underscores
a
larger
struggle
for
patient
data
access,
as
well
as
the
right
to
compete
in
an
EHR
market
dominated
by
giants.
Photo:
AndreyPopov,
Getty
Images
Editor’s
note:
This
story
was
updated
to
include
commentary
from
Carequality.
Chris
Jordan
The
