Looking Forward in 2015

As an eternal optimist, I always look forward to the year ahead and forget the bruises of the year that has passed.

What innovations can we expect in 2015?

In previous posts, I’ve discussed the emergence of FHIR to support standardized query/response APIs for EHRs.  I’ve discussed the “post EHR era”  and the rise of new workflow tools.  I’ve emphasized the importance of social, mobile, analytics and cloud.

How is all of this going to come together in 2015?  

Let me illustrate three examples from recent discussions with industry leaders.

1.  Radiology Clinical Decision Support  - The 2014 Sustainable Growth Rate bill contained completely unrelated mandates for radiology ordering clinical decision support:

(3) MECHANISMS FOR CONSULTATION WITH APPLICABLE APPROPRIATE USE CRITERIA.—
(A) IDENTIFICATION OF MECHANISMS TO CONSULT WITH
APPLICABLE APPROPRIATE USE CRITERIA.—
(i) IN GENERAL.—The Secretary shall specify qualified clinical decision support mechanisms that could be used by ordering professionals to consult with applicable appropriate use criteria for applicable imaging services.
(ii) CONSULTATION.—The Secretary shall consult with physicians, practitioners, health care technology experts, and other stakeholders in specifying mechanisms under this paragraph.
(iii) INCLUSION OF CERTAIN MECHANISMS.—Mechanisms specified under this paragraph may include any
or all of the following that meet the requirements described in subparagraph (B)(ii):
(I) Use of clinical decision support modules in certified EHR technology (as defined in section 1848(o)(4)).
(II) Use of private sector clinical decision support mechanisms that are independent from certified EHR technology, which may include use of clinical decision support mechanisms available from medical specialty organizations.
(III) Use of a clinical decision support mechanism established by the Secretary.

(B) QUALIFIED CLINICAL DECISION SUPPORT MECHANISMS.—
(i) IN GENERAL.—For purposes of this subsection, a qualified clinical decision support mechanism is a mechanism that the Secretary determines meets the requirements described in clause (ii).
(ii) REQUIREMENTS.—The requirements described in this clause are the following:
(I) The mechanism makes available to the ordering professional applicable appropriate use criteria specified under paragraph (2) and the supporting documentation for the applicable imaging service ordered.
(II) In the case where there is more than one applicable appropriate use criterion specified under such paragraph for an applicable imaging service, the mechanism indicates the criteria that it uses for the service.
(III) The mechanism determines the extent to which an applicable imaging service ordered is consistent with the applicable appropriate use criteria so specified.
(IV) The mechanism generates and provides to the ordering professional a certification or documentation
that documents that the qualified clinical decision support mechanism was consulted by the ordering professional.
(V) The mechanism is updated on a timely basis to reflect revisions to the specification of applicable appropriate use criteria under such paragraph.
(VI) The mechanism meets privacy and security standards under applicable provisions of law.
(VII) The mechanism performs such other functions as specified by the Secretary, which may include a requirement to provide aggregate feedback to the ordering professional.

Current EHRs do not support these requirements.   However, as I wrote about previously, Decision Support Service Providers or third party apps would nicely complement existing EHR ordering features.  However, these services must be integrated into EHR workflow or if separate, offer the convenience of a smartphone user experience.

Cloud or app, the necessary functionality to integrate innovative decision support with an existing EHR would be empowered by FHIR.

2.  Closed loop handoff management

Existing EHRs are suitable for managing individual patients during an individual encounter.  Handoffs such as referral management, care management and integration with post acute providers is still clunky.    FHIR based APIs could enable third party dashboards and workflow engines to ensure referrals are pre-authorized, appointments are kept, and lab results are followed up on.  Just as with novel clinical decision support, I see closed loop handoff management as complementary to existing EHRs and could be offered in either cloud or app formats.

3.  Patient Generated Healthcare Data

As Eric Topol recently posted,  the era of the shared medical record (not an EHR/PHR arbitrary division) is upon us with patients having fluid access to their data for download/view/transmit.   Also devices in the home such as glucometers, FEV1 monitors, pulse ox, scales, and blood pressure cuffs will provide important data to manage patient wellness.   Getting such data into EHRs will require an API and FHIR is the logical bridge between cloud/app sources of patient generated data and EHRs.

In 2015, we’ll have the second FHIR Draft Standard for trial use, a single OAuth implementation guide and early adopters opening their EHRs for a new generation of cloud services and apps.   Direct and CCDA will co-exist for a few years, but eventually, simple JSON-based APIs using REST will eliminate the need for Direct.

Yes, 2015 will bring the Meaningful Use Stage 3 notice of proposed rule making, the ONC 10 year interoperability roadmap and the federal HIT Strategic plan, all of which are important.

But the real quantum leap will be the private sector’s efforts, leveraging FHIR to bring clinicians value-added services and apps (time savings, quality improvement, and efficiency gains) that EHRs have not delivered on their own.