A failure of information exchange?

By John W. Loonsk, MD
02:41 PM

As part of its response to the PCAST report, the Office of the National Coordinator for Health Information Technology (ONC) charged a review committee to analyze the PCAST recommendations.

The President's Council of Advisors on Science and Technology (PCAST) called for greatly accelerated health information exchange and development of an increased focus on population health objectives. The report also recommended technologies for a Universal Exchange Language (UEL), Data Element Access Services (DEAS) and granular access controls.

That review committee has presented its findings. It is tempting to use the words of one of the review committee members who said the 10-second synopsis would be that "we did not like the PCAST report."

That synopsis, however, would not capture the complex dynamics in play nor fully explain why this important report, commissioned by the president to review the status of the huge federal investment in health IT, faces very real challenges in having an impact.

At stake is the leverage of the federal investment, through Meaningful Use stages II and III, to substantially accelerate health information exchange and the concern that without more robust exchange, it will be hard to achieve meaningful health IT in the near term.

Imperfect information

There seems to have been imperfect information exchange of the PCAST recommendations to advance health information exchange. The difficulties started with a high-level committee like PCAST doing a deep dive into specific technology possibilities, in addition to beseeching for the high-level programmatic objective of accelerating health information exchange.

Unfortunately, specific technology recommendations frequently become mired in the passions of technologists and befuddle policy people into sideline roles. True to form, the technology possibilities suggested by PCAST dominated the review committee's discussion and their report.

Even though PCAST stated they did not want to dictate specific technical implementation and stated that any technical path should incrementally build on what already exists, their technical possibilities have put the broader messages of their report at risk. Compounding the problem, Internet blogs have suggested that some PCAST committee members had a conflict of interest between their technical suggestions and products their companies sell.

In addition, the recently departed national coordinator for health information technology, David Blumenthal, interestingly asked that the review committee, not provide recommendations. They were asked to only provide options for implementing the PCAST approach – particularly in the context of Stage II and Stage III of Meaningful Use. Dr. Blumenthal seemed, at first, to hear the broad message for advancing health information exchange above and beyond technical approaches.

Push or pull?

However, the focus on the PCAST technology possibilities and the long lead-time specific technical approaches need before they can be considered part of regulation seem to have now boxed the broad recommendations out of Meaningful Use Stage II.

Many of the difficulties in information exchange on these subjects were on display during last week’s report out by the review committee. There were at least three other discussions that were very germane to the PCAST message, but were not clearly connected to it. First, there was the acknowledgment of the diminishing leverage of the meaningful use criteria. Faced with coordinated industry pushback on the challenges of Stage 1, ICD 10, and health reform, there was a discussion focused on approaches to delaying and weakening Stage 2.

Second, there was the dynamic, anticipated by PCAST, that the health reform legislation would overlap and trump meaningful use in the area of healthcare quality measurement. PCAST suggested that meaningful use should not use its diminishing leverage for quality measurement, as it did in Stage 1, as much as advancing health IT. In fact, PCAST suggested there was actually a need for CMS and health reform activities to help ensure that the stubbornly resistive health IT issues be resolved instead.

Third, there was an epiphany about health information exchange. There were several clear articulations of why focusing on “pushing” data from one healthcare provider to another will not accelerate health information exchange enough nor adequately support population related outcomes. “Pushing,” it was said, assumes that the sender knows who needs the information and what information they need. PCAST focused on the fact that “looking-up” or “pulling,” like searching the Internet, is a much more powerful tool and better accelerant of exchange.

The review committee proposed several possible prototypes of the PCAST technologies. All prototypes focus on the universal exchange language (UEL), data element access services (DEAS) and granular consent components of the report. None of them would impact Meaningful Use stage II. Despite the blogs that suggest conflict of interest, there are two new transcendent concepts underneath these acronyms that brilliantly address longstanding healthcare IT problems.

First, securely exposing data for crawling and query has the potential to make notoriously brittle and expensive healthcare systems interfaces obsolete. Second, there is a corollary capability to externalize semantics and ease the pain of prevalent local codes. These concepts are certainly worthy of prototyping and evolving.

But prototypes are not the answer to the clear PCAST call to accelerate health information exchange with the diminishing leverage of meaningful use. There is a clear recognition that accountable care organizations, medical homes, and other population data users, need more than faxes or fax workflows to carry out their missions. They need the ability to get information that other providers may not have thought they needed.

Next step responses from ONC should show whether the new national coordinator, Dr. Farzad Mostashari, hears this PCAST call or continues to focus on trying to “push” data from provider to provider or provider to personal health record.


John Loonsk, MD FACMI, is chief medical officer for CGI Federal. From 2006-2009, he was director of interoperability and standards in the Office of the National Coordinator for Health Information Technology.

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