Wednesday, December 12, 2012

Interoperability Gets Real

Today I'm speaking at the ONC annual meeting as part of panel discussing interoperability.

For years, patients, providers and payers have complained that EHRs "do not talk to each other"

By 2014, I expect this issue to disappear.


Do I expect that every state and territory will have a robust, sustainable healthcare information exchange by 2014?  No

Do I expect that every provider will be connected to a Nationwide Health Information Network by 2014?  No

Do I expect that a single vendor will create a centrally hosted method to share data by 2014 just as Sabre did for the airline industry in the 1960's?  No

What I expect is that Meaningful Use Stage 2 will provide the technology, policy, and incentives to make interoperability real.

Stage 2 requires that providers demonstrate, in production, the exchange of clinical care summaries for 10% of their patient encounters during the reporting period.   The application and infrastructure investment necessary to support 10% is not much different than 100%.   The 10% requirement will bring most professionals and hospitals to the tipping point where information exchange will be implemented at scale, rapidly accelerating data liquidity.

Stage 2 requires that more than 5 percent of patients with inpatient or outpatient encounters (or their authorized representatives) to view, download or transmit to a third party their information during the EHR reporting period.     The Automate Blue Button initiative is an example of this functionality.  It puts the patient in control by enabling query/response or publish/subscribe retrieval of care summary data from EHRs.   Just as the 10% threshold for exchange of summaries between providers will encourage technology and policy implementation, the 5% threshold for patient-provider exchange means that software, educational materials and processes will be put in place to engage patient and families in novel ways.   If not, hospitals and professionals will not qualify for stimulus dollars.

A subtle point in the final rule that some may overlook is the statement above "patients (or their authorized representative)".    The Social Security Administrative, with patient consent, could act as an authorized representative and retrieve medical history in support of disability claims.   Innovative third parties offering consumer oriented decision support, care management services, or home health might act as authorized representatives.    The patient access provisions will create an ecosystem of products - an app store for health.

The standards included in Meaningful Use Stage 2 are unambiguous.   Content, vocabulary, and transport standards backed by comprehensive implementation guides and resources like the National Library of Medicine's Value Set Authority Center (VSAC) eliminate the gaps in semantic interoperability that were an impediment to interoperability in the past.

Finally, in addition to stimulus payment incentives, Accountable Care Organizations/Value-Based Purchasing risk contracts make redundant testing a cost rather than a profit center, motivating hospitals and professionals to share data across communities.  

With certified technology, standards, and incentives to share data among providers and patients, 2013-2014 will usher in a new era of interoperability.

My daughter will be 21 years old in 2014.   It is my hope and belief that she will never face paper-based uncoordinated care in her adult life.    With Meaningful Use Stage 2, CMS and ONC have laid the foundation to make that possible.


Brian Phelps said...

Will the pendulum swing from enterprise back to best of breed?

GreenLeaves said...

I am assisting MLK Community Hospital prepare for its opening in 2014. MLK serves a community that is low income, largely Hispanic and 80%+ dependent on Medicaid (MediCal) and Medicare. The big challenge for us will be to overcome the challenges of computer and internet access in our community to achieve the Stage 2 requirement that more than 5% of our patients (or authorized representatives). We are pursuing an outreach and education program to help the patients understand the access to the patient portal and gain access to the portal. Any ideas for enhancing access for this demographic are most welcome.

Enjoy the holidays on the farm with your family.

John Halamka said...

Two thoughts. My experience with the Medicaid population is that although they may not have a home computer, they have a smartphone. Use mobile as a way to reach them. Also, patient portals work well on community library computers or public kiosks.

Unknown said...

Hi John,
Thanks as always.

What if we did create a Sabre for healthcare? What if we gave every doctor a Direct address and authenticated them and had open APIs for every HIE, EMR, and system to integrate?

You said we won't be there by 2014. Why don't you think so?

What are the components necessary to achieve that? I would offer you need a directory of every physician, scalable, highly usable interface tools, ability to authenticate and ID-proof (and manage those certificates), and APIs to allow institutions to take part. What else am I missing?