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Consumer Data Liquidity – The Road So Far, The Road Ahead – #HITsm Chat Topic

Posted on August 23, 2017 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re excited to share the topic and questions for this week’s #HITsm chat happening Friday, 8/25 at Noon ET (9 AM PT). This week’s chat will be hosted by Greg Meyer (@Greg_Meyer93) on the topic of “Consumer Data Liquidity – The Road So Far, The Road Ahead.”

As my summer tour of interoperability forums, lectures, and webinars winds down, patient engagement/data liquidity is arguably the hottest talk in town.  This leads me to a time of reflection looking back to my own personal experience over the last 10-15 years (yes, I’m still a fairly young guy) starting with early attempts to access my own family’s records, moving on to witnessing the consumer revolution of Dave deBronkart and Regina Holiday, and finally tracking the progression of HealthIT and public health legislation.  We’ve come a long way from the ubiquity of paper and binders and Xerox (oh my) to CDs and PDFs to most recently CDAs, Direct, and FHIR with the latter paving the way for a new breed of apps and tools.

With the lightning speed of change in technology and disruption vis-à-vis consumer devices, one would expect a dramatic shift in the consumer experience over the past 10 years with nirvana in the not too distant future.  Contrary to intuitive thinking, we haven’t come as far as we would like to think.  Even with legislation and a progression of technology such as C-CDA, OpenNotes, Direct, BlueButton, FHIR, and the promise of apps to bring it all together, pragmatically a lot of same the core broken processes and frustrations still exist today.  In July, ONC released a study on the health records request process based on a small sampling of consumers and 50 large health organizations.  Although most of the stories include modern technical capabilities, the processes reek of variance and inefficiencies that have persisted since the long lost days of the house call.

Not to put the whole state of affairs in gloom, there is still a potentially bright future not too far ahead.  With the convergence of forces from contemporary technical standards and recent legislation like the 21st Century Cures Act, consumer data liquidity is staying in the forefront of public health.  And let’s not forget the consumer.  It is partly because of the consumer revolution and patients demanding portability of their records that is forcing providers and vendors to open their systems as platforms of accessibility instead of fostering silos and walled gardens.

This week’s chat will explore the progression of health data access from the consumer’s perspective.

Here are the questions that will serve as the framework for this week’s #HITsm chat:
T1: Describe your perception/experiences of consumer data access 10-15 years ago. #HITsm

T2: Contrast your previous experience to today. Is your experience better, worse, or the same? #HITsm

T3: What gaps exist between what is available today (data, apps, networks, etc.) vs what you would like to have? #HITsm

T4: Would you prefer to manage/move your data yourself or expect HealthIT to do it for you. #HITsm

T5: Beyond FHIR, APIs, and apps, what is the future of consumer access and data liquidity? #HITsm

Bonus: Remember “Gimme My DaM Data?” What would be your slogan for consumer access? #HITsm

Upcoming #HITsm Chat Schedule
9/1 – Digital Strategies for Improving Consumer Experience
Hosted by Kyra Hagan (@HIT_Mktg_Maven from @InfluenceHlth)

9/8 – Digital Health Innovation in Pharma
Hosted by Naomi Fried (@naomifried

We look forward to learning from the #HITsm community! As always, let us know if you’d like to host a future #HITsm chat or if you know someone you think we should invite to host.

If you’re searching for the latest #HITsm chat, you can always find the latest #HITsm chat and schedule of chats here.

ONC’s Interoperability Standards Advisory Twitter Chat Summary

Posted on September 2, 2016 I Written By

The following is a guest blog post by Steve Sisko (@ShimCode and

Yesterday the Office of the National Coordinator for Health Information Technology (ONC) hosted an open chat to discuss their DRAFT 2017 Interoperability Standards Advisory (ISA) artifacts.  The chat was moderated by Steven Posnak, Director, Office of Standards and Technology at Office of the National Coordinator for Health Information and used the #ISAchat hashtag under the @HealthIT_Policy account. The @ONC_HealthIT Twitter account also weighed in.

It was encouraging to see that the ONC hosted a tweetchat to share information and solicit feedback and questions from interested parties. After a little bit of a rough start and clarification of the objectives of the chat, the pace of interactions increased and some good information and ideas were exchanged. In addition, some questions were raised; some of which were answered by Steven Posnak and some of which were not addressed.

What’s This All About?

This post summarizes all of the tweets from the #ISAchat. I’ve organized the tweets as best as I could and I’ve excluded re-tweets and most ‘salutatory’ and ‘thank you’ tweets.

Note: The @hitechanswers  account shared a partial summary of the #ISAchat on 8/31/16 but it included less than half of the tweets shared in this post. So you’re getting the complete scoop here.

Topic 1: Tell us about the ISA (Interoperability Standards Advisory)
Account Tweet Time
@gratefull080504 Question: What is the objective of #ISAchat?   12:04:35
@onc_healthit To spread the word and help people better understand what the ISA is about 12:05:00
@gratefull080504 Question: What are today’s objectives, please? 12:08:43
@onc_healthit Our objective is to educate interested parties. Answer questions & hear from the creators 12:11:02
@johnklimek “What’s this I hear about interoperability?” 12:12:00
@cperezmha What is #PPDX? What is #HIE? What is interoperability? What is interface? #providers need to know the differences. Most do not. 12:14:41
@techguy Who is the target audience for these documents? 12:44:06
@healthit_policy HITdevs, CIOs, start-ups, fed/state gov’t prog admins. Those that have a need to align standards 4 use #ISAchat 12:46:18
@ahier No one should have to use proprietary standards to connect to public data #ISAchat 12:46:19
@shimcode Reference Materials on ISA
Ok then, here’s the “2016 Interoperability Standards Advisory”
@shimcode And here’s “Draft 2017 Interoperability Standards Advisory” 12:07:38
@stephenkonya #ICYMI Here’s the link to the @ONC_HealthIT 2017 DRAFT Interoperability Standards Advisory (ISA): 12:10:57
@techguy Question: Do you have a good summary blog post that summarizes what’s available in the ISA? 12:52:15
@onc_healthit We do! Authored by @HealthIT_Policy and Chris Muir – both of whom are in the room for #ISAchat 12:53:15
@healthit_policy Good? – The ISA can help folks better understand what standards are being implemented & at what level 12:06:29
@healthit_policy Getting more detailed compared to prior versions due largely to HITSC & public comments 12:29:48
@healthit_policy More work this fall on our side to make that come to fruition. In future, we’re aiming for a “standards wikipedia” approach 12:33:03
@survivorshipit It would be particularly helpful to include cited full documents to facilitate patient, consumer participation 12:40:22
@davisjamie77 Seeing lots of references to plans to “explore inclusion” of certain data. Will progress updates be provided? 12:50:00
@healthit_policy 1/ Our next milestone will be release of final 2017 ISA in Dec. That will rep’snt full transition to web 12:51:15
@healthit_policy 2/ after that future ISA will be updated more regularly & hopefully with stakeholder involved curation 12:52:21
@bjrstn Topic:  How does the ISA link to the Interoperability Roadmap? 12:51:38
@cnsicorp How will #ISA impact Nationwide Interoperability Roadmap & already established priorities? 12:10:49
@healthit_policy ISA was 1st major deliverable concurrent w/ Roadmap. Will continue to b strong/underlying support to work 12:13:49
@healthit_policy ISA is 1 part of tech & policy section of Roadmap. Helps add transparency & provides common landscape 12:53:55
@healthit_policy Exciting thing for me is the initiated transition from PDF to a web-based/interactive experience w/ ISA 12:30:51
@onc_healthit Web-based version of the ISA can be found here: We welcome comments! 12:32:04
@techguy Little <HSML> From a Participant on the Ease of Consuming ISA Artifacts
So easy to consume!
@healthit_policy If I knew you better I’d sense some sarcasm :) that said, working on better nav approaches too 12:43:36
@techguy You know me well. It’s kind of like the challenge of EHRs. You can only make it so usable given the reqs. 12:45:36
@shimcode I think John forgot to enclose his tweet with <HSML> tags (Hyper Sarcasm Markup Language) 12:46:48
@ahier Don ‘t Use My Toothbrush!
OH (Overheard) at conference “Standards are like toothbrushes, everyone has one and no one wants to use yours”
Topic 2: What makes this ISA different than the previous drafts you have issued?
Account Tweet Time
@cnsicorp #Interoperability for rural communities priority 12:32:40
@healthit_policy Rural, underserved, LTPAC and other pieces of the interoperability puzzle all important #ISAchat 12:35:33
@cnsicorp “more efficient, closer to real-time updates and comments…, hyperlinks to projects…” 12:47:15
@shimcode Question: So you’re not providing any guidance on the implementation of interoperability standards? Hmm… 12:21:10
@gratefull080504 Question: Are implementation pilots planned? 12:22:51
@healthit_policy ISA reflects what’s out there, being used & worked on. Pointer to other resources, especially into future #ISAchat 12:24:10
@ahier The future is here it’s just not evenly distributed (yet) #ISAchat 12:25:15
@healthit_policy Yes, we put out 2 FOAs for High Impact Pilots & Standards Exploration Awards 12:25:56
@healthit_policy HHS Announces $1.5 Million in Funding Opportunities to Advance Common Health Data Standards. Info here:
Topic 3: If you had to pick one of your favorite parts of the ISA, what would it be?
Account Tweet Time
@shimcode The “Responses to Comments Requiring Additional Consideration” section. Helps me understand ONC’s thinking. 12:45:32
@healthit_policy Our aim is to help convey forward trajectory for ISA, as we shift to web, will be easier/efficient engagement 12:47:47
@healthit_policy Depends on sections. Some, like #FHIR, @LOINC, SNOMED-CT are pointed to a bunch. 12:49:15
@gratefull080504 Question: What can patients do to support the objectives of #ISAchat ? 12:07:02
@gratefull080504 Question: Isn’t #ISAChat for patients? Don’t set low expectations for patients 12:10:44
@gratefull080504 I am a patient + I suffer the consequences of lack of #interoperability 12:12:26
@healthit_policy Certainly want that perspective, would love thoughts on how to get more feedback from patients on ISA 12:12:35
@gratefull080504 What about patients? 12:13:03
@gratefull080504 First step is to ensure they have been invited. I am happy to help you after this chat 12:13:57
@survivorshipit Think partly to do w/cascade of knowledge–>as pts know more about tech, better able to advocate 12:15:21
@healthit_policy Open door, numerous oppty for comment, and representation on advisory committees. #MoreTheMerrier 12:15:52
@gratefull080504 I am currently on @ONC_HealthIT Consumer Advisory Task Force Happy to contribute further 12:17:08
@healthit_policy 1 / The ISA is technical in nature, & we haven’t gotten any comments on ISA before from patient groups 12:08:54
@healthit_policy 2/ but as we look to pt generated health data & other examples of bi-directional interop, we’d like to represent those uses in ISA 12:09:51
@resultant TYVM all! Trying to learn all i can about #interoperability & why we’re not making progress patients expect 13:09:22
@shimcode Question: Are use cases being developed in parallel with the Interoperability Standards? 12:13:28
@shimcode Value of standards don’t lie in level of adoption of std as a whole, but rather in implementation for a particular use case. 12:16:33
@healthit_policy We are trying to represent broader uses at this point in the “interoperability need” framing in ISA 12:18:58
@healthit_policy 2/ would be great into the future to have more detailed use case -> interop standards in the ISA with details 12:19:49
@healthit_policy Indeed, royal we will learn a lot from “doing” 12:20:40
@shimcode IHE Profiles provide a common language to discuss integration needs of healthcare sites and… Info here: 12:29:12
@techguy I’d love to see them take 1 section (say allergies) and translate where we’d see the standards in the wild. 12:59:04
@techguy Or some example use cases where people want to implement a standard and how to use ISA to guide it. 13:00:38
@healthit_policy Check out links now in ISA to the Interop Proving Ground – projects using #ISAchat standards. Info here: 13:02:54
@healthit_policy Thx for feedback, agree on need to translate from ISA to people seeing standards implemented in real life 13:01:08
@healthit_policy Commenting on ISA Artifacts
We want to make the #ISA more accessible, available, and update-able to be more current compared to 1x/yr publication
@cperezmha #interoperability lowers cost and shows better outcomes changing the culture of healthcare to be tech savvy is key 12:35:10
@healthit_policy One new feature we want to add to web ISA is citation ability to help document what’s happ’n with standards 12:37:12
@shimcode A “discussion forum” mechanism where individual aspects can be discussed & rated would be good. 12:39:53
@healthit_policy Good feedback. We’re looking at that kind of approach as an option. ISA will hopefully prompt debate 12:40:50
@shimcode Having to scroll through all those PDF’s and then open them 1 by 1 only to have to scroll some more is VERY inefficient. 12:41:25
@shimcode Well, I wouldn’t look/think too long about it. Adding that capability is ‘cheap’ & can make it way easier on all. 12:43:48
@shimcode Question: What Can Be Learned About Interoperability from the Private Sector?
Maybe @ONC_HealthIT can get input from Apple’s latest #healthIT purchase/Gliimpse? What do they know of interoperability?
@healthit_policy > interest from big tech cos and more mainstream awareness is good + more innovation Apple iOS has CCDA sprt 12:22:59
@drewivan Testing & Tools
I haven’t had time to count, but does anyone know approximately how many different standards are included in the document?
@healthit_policy Don’t know stat off had, but we do identify and provide links for test tools as available. 12:56:31
@drewivan And what percentage of them have test tools available? 12:54:38
@shimcode According to the 2017 ISA stds just released, a tiny fraction of them have test tools. See here: 12:58:02
@shimcode I take back “tiny faction” comment on test tools. I count 92 don’t have test tools, 46 do. No assessment of tool quality though. 13:08:31
@healthit_policy Testing def an area for pub-private improvement, would love to see # increase, with freely available too 12:59:10
@techguy A topic near and dear to @interopguy’s heart! 12:59:54
@resultant Perhaps we could replace a couple days of HIMSS one year with #interoperability testing? #OutsideBox 13:02:30
Walk on Topic: Promotion of ISA (Thank you @cperezmha)
What can HIE clinics do to help other non-users get on board? Is there a certain resource we should point them too to implement?
Account Tweet Time
@davisjamie77 Liking the idea of an interactive resource library. How will you promote it to grow use? 12:35:57
@healthit_policy A tweetchat of course! ;) Also web ISA now linking to projects in the Interoperability Proving Ground 12:39:04
@davisjamie77 Lol! Of course! Just seeing if RECs, HIEs, other #HIT programs might help promote. 12:40:44
@healthit_policy Exactly… opportunities to use existing relationships and comm channels ONC has to spread the word 12:41:28
@stephenkonya Question: How can we better align public vs private #healthcare delivery systems through #interoperability standards? 12:42:23
Miscellaneous Feedback from Participants
Account Tweet Time
@ahier Restful APIs & using JSON and other modern technologies 12:54:03
@waynekubick Wayne Kubick joining from #HL7 anxious to hear how #FHIR and #CCDA can help further advance #interoperability. 12:11:30
@resultant We all do! The great fail of #MU was that we spent $38B and did not get #interoperability 12:14:21
@waynekubick SMART on #FHIR can help patients access and gain insights from their own health data — and share it with care providers. 12:17:44
@resultant I think throwing money at it is the only solution… IMHO providers are not going to move to do it on their own… 12:20:44
@shimcode @Search_E_O your automatic RT’s of the #ISAChat tweets are just clouding up the stream. Why? smh 12:08:30
Do you see #blockchain making it into future ISA
@healthit_policy Phew… toughy. lots of potential directions for it. Going to segue my response into T2 12:28:58
@hitpol #blockchain for healthcare! ➡ @ONC_HealthIT blockchain challenge. Info here: 12:31:33
@healthit_policy That’s All Folks!
Thank you everyone for joining our #ISAchat! Don’t forget to leave comments.
PDF version

About Steve Sisko
Steve Sisko has over 20 years of experience in the healthcare industry and is a consultant focused on healthcare data, technology and services – mainly for health plans, payers and risk-bearing providers. Steve is known as @ShimCode on Twitter and runs a blog at You can learn more about Steve at his LinkedIn page and he can be contacted at

Some High Level Perspectives on FHIR

Posted on April 20, 2015 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Before HIMSS, I posted about my work to understand FHIR. There’s some great information in that post as I progress in my understanding of FHIR, how it’s different than other standards, where it’s at in its evolution, and whether FHIR is going to really change healthcare or not. What’s clear to me is that many are on board with FHIR and we’ll hear a lot more about it in the future. Many at HIMSS were trying to figure it out like me.

What isn’t as clear to me is whether FHIR is really all that better. Based on many of my discussions, FHIR really feels like the next iteration of what we’ve been doing forever. Sure, the foundation is more flexible and is a better standard than what we’ve had with CCDA and any version of HL7. However, I feel like it’s still just an evolution of the same.

I’m working on a future post that will look at the data for each of the healthcare standards and how they’ve evolved. I’m hopeful that it will illustrate well how the data has (or has not) evolved over time. More on that to come in the future.

One vendor even touted how their FHIR expert has been working on these standards for decades (I can’t remember the exact number of years). While I think there’s tremendous value that comes from experience with past standards, it also has me asking the question of why we think we’ll get different results when we have more or less the same people working on these new standards.

My guess is that they’d argue that they’ve learned a lot from the past standards that they can incorporate or avoid in the new standards. I don’t think these experienced people should be left out of the process because their background and knowledge of history can really help. However, if there isn’t some added outside perspective, then how can we expect to get anything more than what we’ve been getting forever (and we all know what we’ve gotten to date has been disappointing).

Needless to say, while the industry is extremely interested in FHIR, my take coming out of HIMSS is much more skeptical that FHIR will really move the industry forward the way people are describing. Will it be better than what we have today? I think it could be, but that’s not really a high bar. Will FHIR really helps us achieve healthcare interoperability nirvana? It seems to me that it’s really not designed to push that agenda forward.

What do you think of FHIR? Am I missing something important about FHIR and it’s potential to transform healthcare? Do you agree with the assessment that FHIR very well could be more of the same limited thinking on healthcare data exchange? I look forward to continue my learning about FHIR in the comments.

Understanding Apple Health

Posted on June 17, 2014 I Written By

Kyle is CoFounder and CEO of Pristine, a VC backed company based in Austin, TX that builds software for Google Glass for healthcare, life sciences, and industrial environments. Pristine has over 30 healthcare customers. Kyle blogs regularly about business, entrepreneurship, technology, and healthcare at

Apple recently announced Health and Healthkit as part of iOS 8, and initial responses have been mixed.

At one extreme, the (highly biased) CEO of Mayo Clinic called Apple Health “revolutionary.” At the other, cynical health IT pundits claim that Apple Health is a consumer novelty and won’t crack the enigmatic healthcare system. As a cynical health IT pundit myself, I’m more inclined towards the latter, but have some optimism about Apple’s first steps into healthcare.

For the uninitiated, Apple Health is a central dashboard for health related information, packaged for consumers as an iOS app. Consumers open the app and see a broad array of clinical indicators (e.g. as physical activity, blood pressure, blood glucose, sleep data). You can learn more about Health and Healthkit from Apple.

The rest of this post assumes significant understanding of modern health IT challenges such as data silos, EMPIs, HIEs, and an understanding of what Health and Healthkit can and can’t do. I’ll address what Apple Health does well, ask some questions, and then provide some commentary.

Apple Health does a few things well:

1) Apple Health acts as a central dashboard for consumers. Rather than switching between five different apps, Health provides a central view of all clinical indicators. In time, Health could help patients understand the nuances of their own data. By removing friction to seeing a variety of indicators in a single view, patients may discover correlations that they wouldn’t have observed before. With that information, consumers should be able to adjust behaviors to lead healthier lifestyles.

2) Apple Health provides a robust mechanism for health apps to share data with one another. Until now, health app developers needed to form partnerships with one another and develop custom code to share information; now they can do this in a standardized way with minimal technical or administrative overhead. This reduces app lock-in by enabling data liquidity, empowering consumers to switch to the best health app or device and carry data between apps. This is a big win for consumers.

Unanswered questions:

1) How does Apple Health actually work? Apple provided virtually no details. Does the patient need the Epic MyChart app on their phone? Is there custom code integrating iOS to Epic MyChart? Is there a Mayo Clinic app that is separate from Epic MyChart? If not, how does Apple Health know that the consumer is a Mayo patient? Or a Kaiser Permanente patient? Or a Sutter Health patient?

2) Does the patient give consent per data value, or is it all or nothing? How long does consent last? Must consent be taken at the hospital, or can the patient opt in or out any time on their phone? Who within the health system can access the consented data?

3) Given that there are hundreds of EpicCare silos and dozens of CareEverywhere silos, how does Apple Health decide which silo(s) to interface with? Does data go to an HIE or to an EMR? If to an HIE, can all eligible connected providers access the data with consent? If a patient has records in multiple HIEs and EMRs (which they likely do), how does Apple Health determine which HIE(s) to push and pull data from?

4) Does Apple Health support non-numerical data such as CCDAs? What about unstandardized data? For example, PatientIO allows providers to develop customized care plans for patients that can include almost any behavioral prescription. Examples include water intake, exercising at a certain time of the day, taper schedules, etc.

5) Can providers write back to a patient’s Health profile? Given that open.epic doesn’t allow Epic to send data out, how could Apple Health receive data from Epic?

7) How will Apple handle competing health apps installed on the same consumer’s phone? For example, if I tap “more diabetes info” in Apple Health, will it open Mayo Clinic’s app (and if so, to the right place in the Mayo Clinic app?) or the blood glucose tracking app that came with with my blood glucose meter? Or my iTriage or WebMD app?

8) Is Apple Health intended to function as a patient-centric HIE? If so, what standards does it support? CCDA? FHIR? Direct?


1) The Apple-Epic partnership is obviously built on open.epic, which Epic announced in September of 2013. It’s likely that Apple and Epic reached an agreement around that time, and asked the public for ideas on how to shape the program to get a sense of what developers wanted.

2) The only way to succeed in health IT is to force the industry to conform to one’s standards, or to support a hybrid of hybrids approach. Early indicators show Apple (predictably) trending toward the former. Unfortunately, Apple’s perennially Apple-centric approach inhibits supporting the level of interoperability necessary to power an effective consumer health strategy. Although Apple provides a great foundation for some basic functions, the long term potential based on the current offering is limited. What Apple has produced to date provides for sexy screenshots, but appears to fall short of addressing the core interoperability and connectivity issues that plague chronic disease management and coordination of care.

3) In a hypothetical world at some indeterminate point in the future, there would be a patient-facing, DNS-like lookup system for provider organizations (Direct eventually?). Patients should be able to lookup provider organizations and share their data with providers selectively. Apple Health provides a great first step towards that dream world by empowering patients to see and, to some extent, control their own data.

Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

Posted on March 5, 2014 I Written By

Mandi Bishop is a hardcore health data geek with a Master's in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.

Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?

Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.

The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.

None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.

None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.

Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.

Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.

But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.

So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.

1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.

Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.

Consider applying the hardship exemption deadline extension to the incentive program participants.