In one of my many discussions with people at HIMSS 10 we started talking about EHR interoperability standards. The person I was talking to worked as an engineer for a vendor that’s entire work is interoperability of EHR data. As we talked, I made the comment that it seems like CCD has won the battle for EMR interoperability. He gave me a kind of blank stare and said, yeah. Basically his response was like yeah everyone knows that. Almost as if there weren’t any other real EMR interoperability options out there. Well, I guess someone better let Google Health know too.

As I went through the HIMSS showroom floor, I got the same feeling.

The good thing is that I think the people behind CCR are satisfied with this result since CCD is a derivative of sorts from CCR.

The interoperability showcase is a really interesting part of HIMSS. They have 80 organizations and vendors that are participating in a wide variety of interoperability scenarios. It’s such a great idea to bring these vendors together to show interoperable EMR.

The problem I have with this concept is that they had the same showcase at HIMSS 09, no? Have we seen any real progress towards interoperability? I guess the question is a bit open for debate, but I can’t say that I’ve seen any huge progress towards interoperability since the last showcase. Is that because there are political and funding issues that are blocking the interoperability from happening?

I guess the point is that the interoperability showcase seems to show that interoperability is possible from a technical standpoint, but it must be something else that’s stopping its success.

Does that mean that we’re focusing on the wrong problem (the technical) when it comes to EMR Interoperability?

“Physician order entry and decision support I believe offer the most chance of improving healthcare delivery. There are a lot of information systems with bells and whistles that don’t focus on physicians’ real needs.” – Neil R. Powe, MD, MPH, MBA, Chief of Medical Services, San Francisco General Hospital source

I previously posted about the benefits of EMR interoperability. The above quote touts Physician order entry and clinical decision support as the most likely to improve healthcare. Are these the three most promising features of an EMR or is there something they’re missing? What’s the killer feature of an EMR that will make every doctor implement an EMR whether they like it or not?

“Looking for savings in hospitals that use EMRs is short-sighted. The real payday for use of EMRs will come with interoperability. Measurable savings will be realized as middleware is installed that will allow for the electronic transmission and translation of patient records across different proprietary systems between delivery networks.” – Jim Lott, Executive Vice President, Hospital Council of Southern California, Los Angeles source

“EMRs don’t save money in standalone situations. However, EMRs will absolutely save significant money (and improve care and safety) when connected and sharing clinical information.” Johnny Walker, MBA, CPA, Founder and past CEO of Patient Safety Institute, Plano, Texas source

These two quote remind me a lot of my previous post about the real long term benefits of EMR. Interoperability is one of those benefits that we won’t see right away. In fact, we’ll see little benefit from them until we hit a critical mass of EMR implementations that it’s almost futile to share information between EMR software. Kaiser and the VA are always held up as examples of successful EMR implementations and one of the main reasons for that is that they have such broad EMR adoption that they can share the clinical information across all of their clinics.

So, YES! there is a real benefit to EMR adoption long term and it comes dressed in the name “EMR data sharing.” However, it’s worth pointing out that this doesn’t diminish the very important more quickly seen EMR benefits.

I recently read a Healthcare IT article that talks about some of the challenges with the EMR stimulus money. Here’s a couple of the challenges discussed with my commentary.

Albert L. Strunk, MD, representing the American College of Obstetricians and Gynecologists, said ACOG is concerned that the measures, while clinical in nature, are not related to adoption of electronic medical records. “The meaningful use measures for ARRA should determine whether a physician has met the objectives shown in the meaningful use matrix, not whether the EMR is being used to report clinical quality measures that rarely apply to that physician’s patients,” he said.

I think this is an interesting analysis. Clinical quality measures are one of the main goals of having an EMR. However, very few doctors look at it that way. I think they will get the incentives wrong if they focus on the clinical quality measures and not on the features of an EMR that benefit the doctor. I’m still sticking with my original analysis that the government really wants doctors to have an EMR so they can improve the Medicare reimbursement rates (in their favor of course).

Another section about interoperable EMR software:

Experts at the hearing testified that providers are willing to wait to purchase a HIT system until they know it will be interoperable. They said physicians from small practices often interact with more than five community hospitals and several labs, each with a different system. Doctors need to know that whatever electronic health record they buy will work with the systems the labs and hospitals have.

I don’t personally get the feeling that most doctors care about interoperability when making their EMR selection. Ok, let me clarify. They want it to connect with their lab and hospital. However, most don’t worry about it interacting with other doctors offices in a true interoperable fashion. The problem is that interoperability between a doctors office and hospitals/labs is not the same as what most people consider an interoperable EMR. I’m talking about EMR software talking to other EMR software (or an RHIO or HIE). Most doctors don’t care about this. At least not more than all the other financial issues related to EMR.

Healthcare data sharing is one of the hottest topics when talking about the importance of EMR software. Some people call it healthcare data portability. One of the problems I have with these discussions is that everyone has different goals for why they want to share the information. Here’s a partial list of reasons people may want to share healthcare data between various EMR respositories (in no particular order):

• Clinical data sharing for reimbursement purposes
• Quality data sharing for broader research goals
• Quality data sharing to meet ARRA requirements/reimbursement
• Data shared for continuity of care between providers

There are probably other reasons to have EMR software be able to share clinical data. However, you get the basic point. There are a lot of reasons why people want the ability to share healthcare related data from an EMR. One problem in the discussion of EMR data portability is that the conversation often gets convoluted when clear lines aren’t drawn for why the EMR data is being shared. Kind of reminds me of what it’s like to discuss EMR and not differentiate between a hospital EMR and ambulatory EMR. There are important similarities, but there are also important differences which always seem to confuse the discussion.

One of my readers pointed out that NaviNet was offering their Health Information Exchange (HIE) solution to state governments for free. Here’s a short part of the press release:

NaviNet (formerly NaviMedix), America’s largest real-time healthcare communications network, today announced the NaviNet Health Information Exchange (HIE), a solution that combines the NaviNet Provider Network of more than 770,000 providers nationwide, and NaviNet technology and services. The NaviNet HIE is now available to all state governments and U.S. territories at no cost, enabling more efficient implementation and expansion of local health data exchange. Adoption of NaviNet HIE minimizes technology investment requirements, providing states and territories a rapid and cost-effective way to offer their own branded health information exchange to electronically connect physicians, hospitals, insurers and existing HIEs in their regions. NaviNet is already used by two out of every three U.S. healthcare providers, and leading national, commercial and Blues health plans, resulting in significant costs savings to the industry.

I always find it interesting when someone starts offering something for free. I always have to ask myself the question of why they would offer it for free. I don’t know NaviNet that well, but it seems like this free offering is 2 fold. First, it seems like they probably want to sell the HIE to people other than government. Second, I think that they probably want participants in the HIE to also use NaviNet’s billing services.

What’s really interesting to me also is that it seems like NaviNet is basically a billing company (although, I don’t know them that well). I find this really interesting since I’ve often seen the argument that we’ve been exchanging billing information electronically in healthcare for a while. Since this is the case, many people have wondered why we couldn’t also exchange other healthcare information. Is this offering from NaviNet, the realization of this principle?

Free EMR has been going well for a while. We’ll see how Free HIE goes.

I recently got the following email which highlights my point that the EHR stimulus money should have been focused on things like interoperability standards and not funding EMR adoption the way it is doing it. He also makes some interesting comparisons worth considering:

I see an uncoordinated money pot out there, attracting uncoordinated work on EMR. — about as effective technically as HDTV (since mid-80′s), W3C, the space station. Non-profit efforts seem to generally fail, or to work so slowly as to be irrelevant.

EMR standardization would likely benefit from an authoritative organization (similar to IEEE) that would work with existing systems as provided by Kaiser, Walmart, GE, etc. and grind out a solution acceptable to these and other major (and minor) players. Then a de facto standard would exist in a well-defined form, and other players would join the effort.

I may be wrong, but I don’t see this happening. Everyone seems to be drawing out the money and just going on their separate ways. People like me that try to help doctors into the electronic age thus have to develop their own protocols, as anything resembling a portable data standard simply doesn’t seem to exist.

Of course, whenever I think about and post something like this, I feel like it’s too late too change anything. The legislation is what it is and we have to make the most of it. It’s just really sad to consider what it could be.

I guess maybe the message to consider is that we can still start having EMR working together even if it’s not government funded.

A few years ago there was this really funny thread over on the EMR Update forum that asked if doctors would one day display a sign that said “Got EMR?” (this was before the term EHR became in vogue) The concept was asking the question about whether patients would ever demand that their doctor us an EMR or they’d go to another doctor for care. The comparison was made to online banking. I remember online banking being on my list of requirements for a bank. Why couldn’t EMR be on your list of requirements for a doctor?

However, I don’t think most patients really know enough about EMR to want their doctor to ask for it. Maybe if EMR companies and independent studies of EMR really showed a stark improvement in patient care by those using an EMR this would change. Until then, don’t expect patients to start requesting doctors that use an EMR.

With that said, patients may start demanding other things which would tangentially require a doctor to use an EMR. For example, a patient may want their doctor to be interoperable. Patients may want to be able to easily schedule an appointment with their doctor online. Patients may want to start getting script refills done online. Of course, we could talk for hours about patients eventually wanting to actually have the patient visits done online, but we won’t start down that path in this post.

Each of the above patient requirements really needs to have an EMR. We’re definitely not at the point now that patients are demanding these types of features. I wonder if we’ll ever reach this point or if there are just so many patients and so few doctors that even if the patients start asking for these features doctors can continue to do business as usual.

We’re all still sitting here waiting for the government to finally decide two key terms in regards to gaining access to the $18 billion in stimulus money in the HITECH act (ARRA). I’ve been interested in the subject myself since before it was even settled that we’d call it meaningful use as opposed to meaningful EMR user. From the looks of that post back in February, there was still a lot of confusion about “meaningful use” and “certified EHR.”

Turns out that a few months later, we still have very little clarification about what these two terms mean. Certified EHR discussion has really revolved around CCHIT certification or some other alternative. We’ll try to leave that discussion for other posts. What has been interesting is in just the past week or two there has been a literal flood of people offering their perspective on meaningful use. Sometimes I like to be on the cutting edge of these definitions (like I was in the link above) and other times I like to sit back and let them play out. This time I’ve been letting it play out and it’s really interesting to see the multitude of perspectives.

I’m not planning on writing my own plan for how they should do meaningful use. I may do that at a later time if so inclined. For now, I’ll just focus on highlighting points from what other people have suggested and provide commentary that will hopefully enhance people’s understanding of this complicated mandate (yes, that means this post will be quite long).

I think it’s reasonable to first point you to the NCVHS hearing on “Meaningful Use” of Health Information Technology. This matters, because at the end of the days hearings like these are where most of the information are going to come. Then, with the information from these hearing decisions will be made. The other sources like blogs won’t carry nearly as much weight (although it’s unfortunate that more politicians aren’t listening).

John Chilmark on Meaningful Use
Next, I’ll go to one of my newly found favorite bloggers named John Chilmark (any coincidence we’re both named John). John from Chilmark Research commented that HHS is bringing together the “usual suspects” to discuss “meaningful use. Chilmark also states that the following criteria are what’s required for meaningful use:

1. Electronic Prescribing
2. Quality Metrics Reporting
3. Care Coordination

I’m not sure where he got this list, but this list feels kind of weak if you ask me. In fact, John suggests that these requirements will be simple and straightforward and first and then ratcheted-up in future years. Interesting idea to consider. I hope that they do draft the requirements for meaningful use in a way that it can be changed in the future if it turns out to not be producing the results it should be producing.

John Halamka on Meaningful Use
Next up, the famous John (another John) Halamka, Chief of every Health IT thing (at least in Boston), calls defining “meaningful use” “the most critical decision points of the new administration’s healthcare IT efforts.” He’s dead on here. In fact, it might not be the most critical decision for healthcare IT, but for healthcare in general as well. Here’s John Halamka’s prediction for how “meaningful use” will be defined:

My prediction of meaningful use is that it will focus on quality and efficiency. It will require electronic exchange of quality measures including process and outcome metrics. It will require coordination of care through the transmission of clinical summaries. It will require decision support driven medication management with comprehensive eRx implementation (eligibility, formulary, history, drug/drug interaction, routing, refills).

Basically, he’s predicting inter operable EMR software and ePrescribing with a little decision support sprinkled on top. I won’t be surprised if this is close to the final definition. The only thing missing is the reporting that will be required to the government. The government needs this data to fix Medicare and Medicaid (more on that in another post).

Blumenthal Comment to Government Health IT
Government Health IT has a nice quote from David Blumenthal that says: “The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT.”

I think there’s little doubt that David Blumenthal has a good idea of the importance of the decisions ahead. What should be interesting is to see how involved Obama is in these very important decisions. I’m guessing Obama won’t do much more than sign a paper to make it happen. I just hope I’m wrong.

HIMSS Definition of Meaningful Use
Here’s a short summary of the HIMSS definition of “meaningful use”

According to HIMSS officials, EHR technology is “meaningful” when it has capabilities including e-prescribing, exchanging electronic health information to improve the quality of care, having the capacity to provide clinical decision support to support practitioner order entry and submitting clinical quality measures – and other measures – as selected by the Secretary of Health and Human Services.

Basically, e-prescribing, interoperability and clinical decision support. Turns out a BNET Healthcare article suggested the same conclusion “The consensus of physician and industry representatives was that meaningful use should include interoperability, the ability to report standard quality measures, and advanced clinical decision-making.”

I think we’re starting to see a bit of a pattern here. I should say that these are all very good things, but the challenge I see is that any requirement needs to be easily and consistently measured. Interoperability and clinical decision support are both very difficult to measure. Just wait until they see the variety of software that tries to do those two things. It’s very difficult to measure it consistently across so many EHR software.

Wow!! I barely even got started on this subject. Instead of belaboring the point, let me just point you to some other interesting readings about the HITECH Act, ARRA, and “meaningful use.”

• Fred Trotter’s Open Source Perspective
• Blackford Middleton’s Comments on “Meaningful Use”
• Steve Beller’s Definition of “Meaningful Use”
• Human Factors and “Meaningful Use”
• AHIMA Comments on “Meaningful Use” (pdf)
• Markle Foundation Framework (PDF)

Please let me know if there are other good sources for perspectives on defining “meaningful use.” This really is a landmark decision for healthcare IT.