Maryland Unfair Competition May Be Proved by Cures Act “Information Blocking” (Without a Federal Private Right of Action) and Requires Good-Faith “Cannot Reach Agreeable Terms” Under the Manner Exception

I. Introduction

Real Time Medical Systems, Inc. v. PointClickCare Technologies, Inc. is a Fourth Circuit interlocutory decision affirming a preliminary injunction that stopped an electronic health record (“EHR”) platform vendor, PointClickCare, from using “indecipherable” CAPTCHAs and related account lockouts that allegedly cut off a third-party analytics provider, Real Time, from patient record access authorized through mutual customers (skilled nursing facilities).

The central dispute was not over patient ownership of records (which the opinion treats as a given), but over whether PointClickCare’s access restrictions—implemented as it began competing in the analytics space—likely constituted “information blocking” under the 21st Century Cures Act, and whether that alleged statutory violation could support state-law tort relief (Maryland unfair competition) despite the absence of a private federal right of action.

Key issues included: (1) whether the injunction preserved the “status quo” (thus not a disfavored “mandatory” injunction); (2) whether Real Time showed likelihood of success on a Maryland unfair-competition theory premised in part on Cures Act information blocking; (3) whether Cures Act exceptions (manner, health-IT performance, security) were established; and (4) whether irreparable harm, equities, and public interest favored injunctive relief.

II. Summary of the Opinion

The Fourth Circuit affirmed. It held that the injunction was status-quo-maintaining because the “last uncontested status” preceded PointClickCare’s escalation to indecipherable/unsolvable CAPTCHAs and lockouts. On the merits, the court agreed Real Time was likely to succeed on Maryland unfair competition because the record supported an inference that PointClickCare used access controls to harm a competitor and that the conduct likely constituted Cures Act “information blocking,” with no proven regulatory exception. The court further held:

  • A state tort claim may rely on a federal statutory violation as evidence even if the federal statute lacks a private right of action, so long as the state claim is not a disguised federal enforcement action.
  • The Cures Act did not preempt the state-law unfair competition claim on the presented “obstacle preemption” theory.
  • The burdens at the preliminary injunction stage track trial burdens, so PointClickCare bore the burden to prove the Cures Act exceptions it invoked.
  • “Cannot reach agreeable terms” in the manner exception requires more than unilateral refusal; it implies reasonable, good-faith efforts and articulable reasons for impasse.

The remaining Winter factors were met: Real Time faced imminent loss of goodwill/customer relationships and potentially existential harm; PointClickCare showed no comparable harm from prohibiting only “unsolvable” CAPTCHAs while leaving other security tools intact; and the public interest favored continuity of a program associated with reduced hospitalizations and potential lives saved in nursing facilities.

III. Analysis

A. Precedents Cited

1. Preliminary injunction framework and “status quo”

  • Winter v. Nat. Res. Def. Council, Inc. supplied the four-factor test (likelihood of success, irreparable harm, balance of hardships, public interest). The Fourth Circuit applied it through circuit precedent.
  • League of Women Voters of N.C. v. North Carolina and Pashby v. Delia provided the operative definition of “status quo” as “the last uncontested status between the parties which preceded the controversy.” This supported treating the injunction as prohibitory rather than a “mandatory preliminary injunction.”
  • Pierce v. N.C. State Bd. of Elections was cited for the disfavored nature of mandatory preliminary injunctions; the court distinguished the injunction here.
  • Roe v. Dep't of Def. was used both for the “clear showing” standard on likelihood of success and for the principle that success on one claim can sustain an injunction.
  • Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal and Ramirez v. Collier anchored the burden allocation principle that preliminary-injunction burdens track trial burdens, including for affirmative defenses.
  • Miranda v. Garland, Metro. Reg'l Info. Sys., Inc. v. Am. Home Realty Network, Inc., and U.S. Dep't of Lab. v. Wolf Run Mining Co. reinforced preservation/forfeiture principles for appellate arguments in the preliminary-injunction posture.

2. Maryland unfair competition: breadth beyond trademark, and “unfair methods of any sort”

  • Balt. Bedding Corp. v. Moses supplied the core Maryland definition: harming another’s business by “fraud, deceit, trickery or unfair methods of any sort,” and the case-by-case nature of the tort.
  • Edmondson Vill. Theatre v. Einbinder contributed the cautionary balance: courts must prevent unfair practices while not punishing legitimate competition or expanding “unfair competition” to merely “unethical yet not illegal” acts.
  • Trimed, Inc. v. Sherwood Med. Co. was pivotal: it recognized Maryland unfair competition extends beyond trademarks and, importantly, that Maryland “has never required an unlawful act as an essential element” of the tort—undercutting PointClickCare’s argument that lack of fraud or deception defeats the claim.
  • Command Tech., Inc. v. Lockheed Martin Corp. (Md. Ct. Spec. App.) was used for the “minimum standards of conduct” framing and for the idea that whether a party had a “legal obligation” can inform whether conduct is unfair.
  • Mascaro v. Snelling & Snelling of Balt., Inc. supported the proposition that “fraudulent deception” is not essential under Maryland’s rule.
  • Paccar Inc. v. Elliot Wilson Capitol Trucks LLC and Delmarva Sash & Door Co. of Md. v. Andersen Windows, Inc. were used as persuasive federal applications describing the tort’s flexibility and its applicability to interference with key business relationships.
  • Scotch Whisky Ass'n v. Majestic Distilling Co. served as contrast (prototypical trademark/unfair competition scenario) to emphasize the tort’s broader reach.

3. Using federal statutory violations in state claims; limits on “end-runs” around no private right of action

  • Coll. Loan Corp. v. SLM Corp. supplied the central rule: “the lack of a statutory private right of action does not, in and of itself, bar a plaintiff from relying on violations of that statute as evidence supporting a state law claim.” The court relied on it to allow Cures Act violations to serve as evidence of “unfairness” under Maryland law.
  • Medtronic, Inc. v. Lohr (Stevens, J.) and Silkwood v. Kerr-McGee Corp. were invoked (via College Loan) to support the idea that state remedies may be especially important where no federal private remedy exists.
  • Bauer v. Elrich provided the limiting principle: state law cannot be used as a shell to enforce federal law where the claim’s “core” is direct federal enforcement. The court distinguished Real Time’s unfair competition claim as genuinely state-law based.
  • Astra USA, Inc. v. Santa Clara County was cited through Bauer for the idea that a claim “in substance one and the same” as enforcing a federal statute cannot proceed as an artful substitute. Again, the court found Real Time’s case different.
  • Guthrie v. PHH Mortg. Corp. and Burrell v. Bayer Corp. reinforced the continued viability of using federal standards as part of state-law claims and the availability of state remedies despite absent federal private rights.
  • Magee v. DanSources Tech. Servs., Inc. (Md. Ct. Spec. App.) was cited as Maryland intermediate authority permitting reference to federal law as satisfying a state-law element in another tort context.
  • Intus Care, Inc. v. RTZ Assocs., Inc. was cited as persuasive authority that a Cures Act violation can qualify as independently wrongful conduct supporting a state interference claim, notwithstanding no private right of action.

4. Preemption doctrine

  • N. Va. Hemp & Agric., LLC v. Virginia and Arizona v. United States were used for the presumption against preemption and the “clear and manifest purpose” requirement for conflict preemption findings.
  • Abbot ex rel. Abbot v. Am. Cyanamid Co. (quoted via College Loan) reinforced the stronger presumption against preemption of state remedies when federal law supplies no private remedy.
  • Guthrie v. PHH Mortg. Corp. was again used to reject the notion that broader state remedies inherently obstruct federal schemes.

5. Irreparable harm and public interest

  • Multi-Channel TV Cable Co. v. Charlottesville Quality Cable Operating Co. and Air Evac EMS, Inc. v. McVey supported treating loss of goodwill/customers as irreparable harm.

B. Legal Reasoning

1. The injunction was prohibitory, not mandatory

Applying League of Women Voters of N.C. v. North Carolina, the court identified the relevant “status quo” as the period before PointClickCare introduced unsolvable CAPTCHAs and lockouts. Real Time’s consistent objection and quick recourse to court once the practice resurged supported that the injunction merely restrained contested conduct and did not compel a new relationship.

2. Likelihood of success on Maryland unfair competition based on alleged Cures Act information blocking

The court treated Maryland unfair competition as intentionally flexible (Balt. Bedding Corp. v. Moses), and not limited to deception or trademark misuse. Critically, it rejected PointClickCare’s argument that absence of “fraud or deception” is fatal, emphasizing Maryland’s “unfair methods of any sort” formulation and the principle that “fraudulent deception” is not essential (Mascaro v. Snelling & Snelling of Balt., Inc.).

On the federal-law component, the court drew a line between (i) using a federal violation as evidence of a state tort (permitted under Coll. Loan Corp. v. SLM Corp.) and (ii) repackaging a barred federal cause of action as a state claim (barred in Bauer v. Elrich, applying Astra USA, Inc. v. Santa Clara County). Real Time’s claim fell in the first category: it sought to prove “unfairness” under Maryland common law, with the Cures Act violation serving as a key factual/legal indicator that the competitive method was improper.

3. No obstacle preemption on the theory advanced

The court rejected the argument that allowing state tort relief would “interfere with” Congress’s enforcement choices. It noted the presumption against preemption (N. Va. Hemp & Agric., LLC v. Virginia), especially strong against preemption of state remedies where no federal private remedy exists (Coll. Loan Corp. v. SLM Corp.). It also found it significant that the statute contemplates “applicable State or Federal law” in describing information blocking practices, undercutting an inference of exclusivity.

4. Cures Act information blocking: burden and exceptions

PointClickCare conceded that unsolvable CAPTCHAs and lockouts facially interfered with access and thus constituted information blocking absent an exception. The court then:

  • Allocated burdens: Because exceptions functioned as defenses to information-blocking liability, and because preliminary burdens track trial burdens (Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal), PointClickCare had to prove an exception applied.
  • Interpreted “cannot reach agreeable terms” in the manner exception to require more than unilateral refusal. The court read “cannot” as implying good-faith engagement and reasons for impasse; otherwise, the “technically unable” prong’s “very high bar” would be rendered meaningless.
  • Rejected security and performance exceptions on this record: the court found the bot-prevention practice not shown “consistent and non-discriminatory,” the performance evidence thin and temporally remote (two charts from April 2023), and the security rationale too generalized and not “tailored to the specific security risk.”

5. Remaining Winter factors

The irreparable-harm analysis relied on goodwill/customer erosion principles (Multi-Channel TV Cable Co. v. Charlottesville Quality Cable Operating Co.), with evidence that widespread lockouts could cause immediate, repeated service outages and threaten Real Time’s business viability. The equities favored Real Time because the injunction was narrow (targeting only “unsolvable” CAPTCHAs) and left PointClickCare substantial security measures. The public interest favored continuity of patient-care analytics tied to reduced readmissions and potential mortality impacts in nursing facilities.

C. Impact

  • State tort leverage over interoperability disputes: The decision recognizes a practical pathway for injured market participants to seek judicial relief grounded in state law where the Cures Act provides no private cause of action—so long as the claim is genuinely state-law based (not an “end-run”).
  • Constraining “stonewalling” under the manner exception: The interpretation of “cannot reach agreeable terms” as requiring good-faith efforts and articulable impasse makes it harder for an “actor” to invoke the manner exception through unilateral non-engagement.
  • Burden clarity for Cures Act exceptions in injunction practice: By tying exception burdens to the defendant at the preliminary stage, the opinion encourages defendants to come forward early with concrete, contemporaneous evidence of security/performance risks and consistent implementation.
  • Health IT competition and access controls: The factual framing—EHR vendor entering the analytics market and then restricting a rival’s access—signals that courts may scrutinize security/performance justifications where timing and negotiation conduct suggest exclusionary intent.

IV. Complex Concepts Simplified

Preliminary injunction
A temporary court order entered early in a case to prevent likely harm before trial. The movant must satisfy the four Winter factors.
Status quo vs. mandatory injunction
A prohibitory injunction preserves the “last uncontested status” (League of Women Voters of N.C. v. North Carolina). A mandatory injunction forces affirmative change and is disfavored.
Information blocking (Cures Act)
Practices by certain health IT actors that are likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information, unless a regulatory exception applies.
Manner exception and “cannot reach agreeable terms”
If the actor cannot provide information in the requested way, it may provide it in an alternative manner—but “cannot reach agreeable terms” is not satisfied merely because the actor refuses to negotiate; it implies bona fide efforts and a real impasse.
Obstacle preemption
A type of conflict preemption where state law is invalid if it stands as an obstacle to Congress’s objectives. The opinion applied a strong presumption against it, especially where federal law lacks a private remedy.
Using federal law without a private right of action
A plaintiff cannot sue “under” the federal statute, but may sometimes use the federal violation as evidence that a defendant’s conduct meets an element of a state-law tort (Coll. Loan Corp. v. SLM Corp.), provided the suit is not a disguised attempt to enforce federal law (Bauer v. Elrich).

V. Conclusion

The Fourth Circuit’s decision establishes a consequential practical rule in health IT litigation: alleged Cures Act “information blocking” can be used to support a Maryland unfair-competition claim even though the Cures Act lacks a private right of action, and such claims are not lightly preempted on “obstacle” theories. On the regulatory merits, the opinion reads the manner exception’s “cannot reach agreeable terms” to require more than unilateral refusal, and it places the burden on the alleged blocker to prove exceptions at the preliminary-injunction stage. Combined with the court’s skepticism of generalized security/performance narratives unsupported by concrete evidence, the case signals meaningful judicial scrutiny of access restrictions that coincide with competitive entrenchment in EHR-adjacent markets.