Commentary: Meaningful Use of Health Information Exchange?

By John W. Loonsk, MD
02:33 PM
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The title of this commentary is pure jargon, but does express the issue at hand. An alternative title “The Most Important Health Policy Decision Hidden as an Obscure Health IT Technical Evaluation that You May Never Have Heard of,” also would have been accurate, but is grammatically unsound and too flippant for an important subject.

For either title, however, there is a need to focus attention on a report from a small working group (NwHIN Power Team) of the Health IT Standards Committee. The HIT Standards Committee advises the Office of the National Coordinator for Health IT (ONC). The report’s implications ripple out from obscure technical details, through broad HIT policy, and into the very viability of health IT to support health and health reform.

Support of health reform has been the lead rationale for the multi-billion dollar HITECH investment in Electronic Health Records and much of the focus of this administration. But despite the importance of this particular issue to the health reform agenda and somewhat belying the “meaningful use” name, this issue has - so far - been processed as a technical decision about standards readiness rather than one about health IT capabilities or health outcomes. Involved in the issue are complex considerations of SMTP, DNS, SOAP, HTTP, REST, S/MIME, XDS, XCA and other standards.

Moving the issue up one level, however, it is about what ONC will put in the next “Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology” rule that will accompany Stage 2 of meaningful use.

Will they require:

  • standards for “pushing / sending data” from provider to provider (DIRECT Project),
  • standards for “pushing as well as looking up and retrieving data” (NwHIN Exchange),
  • a combination of both standards,
  • or neither?

As a recent report of the President’s Council of Advisors on Science and Technology (PCAST) asserted, health information exchange is not moving forward fast enough. And as the national coordinator for health IT, Farzad Mostashari, put it, waiting “five years” to advance health information exchange in the implementation of yet the next stage of meaningful use (Stage 3) is “not acceptable”.

But moving the issue up still another level, it is about what kind of health information exchange is needed to support better quality and efficiency outcomes and health reform. I have written about more “advanced” exchange needed to complement EHRs for accountable care organizations (ACOs) functions.

[See The HIT that ACOs need, Part I: Analytic Data  and The HIT of ACOs, part 2: Beyond HIE.]

The issue that the HIT Standards committee is now grappling with is directly related to the kind of health information exchange that will be required in coming regulation and, resultantly, the capabilities provided by health IT in support of ACOs for a number of years to come.

From a disclosure standpoint, I should say that I was the lead for the NHIN (now NwHIN Exchange) efforts in the last administration. I helped manage the evaluation of numerous different “push and pull” prototypes for the NHIN and ran the “Trial Implementations” of the eventual NHIN Architecture. It should also be said that members of the HIT Standards Committee and people from ONC created the DIRECT initiative. The implication of all these disclosures is that the writers of the regulation will have to work hard to get neutral counsel. As many know, technology people only slightly favor their natural born children over their software progeny.

Indeed, there was very strong debate about the issue even in the HIT Standards Committee and there were many references to what sounded like heated off-line email conversations between the committee and ONC as well.

Primarily, the report focused on the evaluation of adoption and readiness of the different technical standards involved. The arguments for DIRECT flow from the implementation and acceptance of core email standards and its suggested ease of implementation. The report suggested that NwHIN standards had “moderate to high” complexity and DIRECT was only “moderately” complex. Some committee members, however, countered that this was an “apples and oranges” comparison since the “moderate to high” complexity standards covered many more functions and capabilities. Still others have pointed to the need that DIRECT has to modify the entrenched Domain Name Services (DNS) standards to support certificate retrieval as a major obstacle to its use.

The EHR Vendors Association - a HIMSS organization - weighed in on the standards issues with a strongly written letter on the subject, which points to, among other things, core NwHIN standards being “tested” by more than 100 electronic health record vendors.  DIRECT, on the other hand, is based on broadly implemented standards for email and DNS services, but standards that are not commonly used for purposes of secure exchange of processable and sensitive health data. So clearly, and not unusually, there is great debate about the technical standards.

But at the HIT Standards Committee, Marc Overhage, now from Siemens and formerly from the Indiana Health Information Exchange and the Regenstrief Institute, was one of several who sought to raise the conversation up a level.

He talked about the different uses of health information exchange saying that while “look-up and retrieve” is too often abstractly discussed as being about an unconscious patient coming to an emergency room who needs their health record retrieved, in the real world, it is critical to many uses in common clinical practice. He used the timely example of quality measure reporting to make the case that it takes looking up and retrieving data from as many as 27 different systems to fulfill quality measure requirements. In separate discussions in the HIT Policy Committee (the other ONC FACA) related concerns have been raised about how quality measures that span multiple provider organizations will be fulfilled when the complexities of data collection will be even higher.

There has been at least one discussion of the different outcomes of look-up and retrieve vs. send/push capabilities at another HIT Policy Committee meeting.

Expressed there was the concern that sending data presumes that the sender:

  • can identify all of the appropriate data users (so that he or she can send the data to all of them),
  • can anticipate the necessary information needs of the receiving providers,
  • knows and understands all possible intended uses.

The implication was that there are many circumstances in healthcare where these criteria are not met even if a send of data is reliably initiated. The discussion also touched on how to best to support “Medical Homes,” transitions in care, and better longitudinal records.

The PCAST report referenced earlier that strongly encouraged accelerating health information exchange also said that look-up and retrieve capabilities were important for health data transactions and also for important secondary data uses such as research and public health. PCAST, though, suggested still another set of technical standards to be employed to implement these functions.

As with the “meaningful use” name, all of the functional considerations beg for an evaluation of more than just the technical standards when considering health information exchange. Elsewhere, I have expressed health information exchange outcomes criteria (completeness, accessibility, reuse, management, inter-networking, and platform for growth) in “Not All Health Information Exchange is Created Equal." Whether these specific criteria are employed or others, suitable analysis of health outcomes from different exchange approaches would seem to be critical to ensuring its meaningful use in support of the major EHR investment.