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Stage 2 Meaningful Use: Surfing the Waves of Interoperability, Part I

by Jitin Asnaani, Director of Technology Standards and Policy

For years, medical practices have acted like silos of patient information, unmotivated and unable to share clinical data with anyone beyond their organizations. It’s an issue that our CEO Jonathan Bush recently addressed in an interview with EMRandHIPAA.com . Stage 1 Meaningful Use did not do much to help this situation, nor is it supposed to. But Stage 1 did push data from the paper chart to an electronic medical record (EMR), and that’s a start. Stage 2 Meaningful Use is supposed to enable that data to flow by breaking down barriers, encouraging and mandating greater patient engagement. But is this the path to successfully opening up those silos? Are the thousands of patients, caregivers, payers, provider networks, entrepreneurs and technology innovators—the surfers standing dejectedly on the shores of the motionless sea of opportunity—still staring out in vain?

Clearly the jury is still out, with Stage 2 Meaningful Use only going into effect during the end of 2013 for hospitals and the beginning of 2014 for ambulatory care practices. But the progress is promising and, if you squint your eyes just right, you can see several waves starting to form on the horizon—nascent, yes, but accelerating towards us.

Let’s start by looking at the direct influence of Stage 2 on interoperability. Among its many requirements, a handful stand out as true enablers of a variety of health information exchange (HIE) use cases:

  • Support of Consolidated Clinical Document Architecture (CCDA)
    This technical requirement may be the game-changer for HIE over the next 10 years, and is the product of a prodigious effort on the part of the Office of the National Coordinator’s (ONC) Standards and Interoperability (S&I) Framework. This single standard for communicating summary of care records is prying open the doors of the silo’d practice by enabling the sharing of clinical care information in the most common care scenarios: inpatient-to-outpatient, primary care physician (PCP)-to-specialist, provider-to-patient and, soon, provider-to-ACO. CCDA also facilitates easier EHR-to-EHR transition of clinical data, helping providers free themselves of the shackles of sub-par EHR experiences.
  • Enabling Direct Project
    Where CCDA focuses on standardizing the content and structure of the clinical summary, Direct Project focuses on standardizing the “transportation” mechanism, with the ambitious aim of replacing the fax machine as the industry choice for sending and receiving data. In layperson terms, Direct Project is a specification for secure email, building directly on top of email as we know it today, but adding in stricter requirements necessary for the security of health care data. While there is broadly shared expectation that this may be “health care’s answer to the universal power socket” for information exchange, vendor adoption of Direct Project has been slow—analogous to a flock of penguins standing at the ocean’s precipice, knowing that the delicious fish are only a few feet away, but not wanting to jump until others jump in too. Stage 2 will be the force that pushes them all in.
  • Support of Lab Results Interfaces (LRI)
    As CCDA standardizes the content and structure for care summaries, LRI standardizes it for lab results messages moving from labs to providers. The real power of LRI is not in the work it will enable today, but that it will enable more seamless end-to-end workflow (i.e., from electronic order to electronic result) when ONC’s Lab Orders Interfaces (LOI) project is completed later this year. Because both LRI and LOI will use a common set of identifiers and make compatible assumptions about which data is included in each, for the first time, we as an industry are on the verge of automated electronic structured data being exchanged between labs and providers.

Stage 2 of Meaningful Use is paving the way for real interoperability, commoditizing HIE, and facilitating the emergence of powerful, transformative incentive models, such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes. However, Stage 2 is not perfect. For example, it forces providers to use Direct Project and CCDA during a patient’s transition of care (e.g., from PCP to specialist) in order to receive their incentive dollars, despite the fact that some leading-edge providers are already actively and effectively using alternative standards for the same purpose. A healthy alternative would have been to require that those standards be available for use through the EHR, but also enable providers to use any other viable alternative standards to enable that transition of care. Stage 2 also forces incorporation of structured lab results without imposing any requirement (or incentive) on independent labs to send data electronically, thus placing the burden solely on the provider.

From the vendor perspective, an obvious shortcoming of Stage 2 is the lack of a specific Provider Directory standard. This is problematic because by mandating usage of Direct Project at scale, vendors are forced to figure out directory solutions that enable providers to know the secure email addresses of their recipients; the basic, “back-of-the-business-card” approach first used when email started gaining adoption does not work when everyone suddenly needs to use it.

It turns out there were great reasons why the ONC did not want to impose a standard for Provider Directories—namely, there were no credible options—but by mandating the use of Direct Project, the ONC created a scale issue for which the industry is scrambling to invent solutions. There will be a lot of turmoil in the year ahead.

On the whole, Stage 2 Meaningful Use will likely drive a new era of clinical interoperability, and the health care industry will be thankful as they can take advantage of these capabilities to move the needle on costs and quality. Our own cloud-based electronic health record (EHR), athenaClinicals, is certified as a 2014 Complete Edition EHR meaning that every athenaClinicals provider is already on an EMR that’s certified for Stage 2 interoperability measures. Of course, interoperability always takes two to tango, and it is encouraging to see our trading partners preparing to support that functionality as well.

Stay tuned for Part II of this discussion on Meaningful Use and interoperability; we’ll outline how Stage 2 is stirring up new waves of interoperability in the form of industry collaboration such as the CommonWell Health Alliance, ecosystems like our More Disruption Please program and, of course, even more government-driven initiatives aimed at Stage 3 Meaningful Use.

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