Meaningful Use – the state of interoperability readiness

When the ONC forwarded to the Center for Medicare and Medicaid Services (CMS) the documents which defined Meaningful Use and Certification of Electronic Health Records (EHRs), vendors have been studying the specifics of the criteria and working out ways to help physician access incentive bonuses beginning in 2011.

The criteria for Certification and for Meaningful Use break down into 25 categories, though the specific measures for each of these categories are different for ambulatory EHR systems and for hospital EHR systems. Meaningful Use can be achieved either through a comprehensive “Certified EHR” (which can address all 25 criteria categories) or through an assemblage of “Certified EHR modules” (each of which can address 1 or more criteria category).

A number of these 25 categories pertain to interoperability between a physician’s EHR system and outside organizations where patient data is found – laboratory data (criteria 10), quality data reporting to CMS or the states (criteria 12), submission of immunization data to state or local registries (criteria 23). The Criteria document describes specific data transmission methods, as well as standardized vocabularies to be used.

Much of the expectation behind these interoperability-based criteria seem to assume a point-to-point integration between the local physician practice and the local lab, or local state immunization registry, etc. This is a valid assumption when one is considering only locally-installed legacy client/server EHRs, which many of the “big iron” vendors (using technology developed in the 1990s) offer.

However, Practice Fusion as well as other emerging EHRs are web-based, meaning that there is no local installation with a local point-to-point connection to local resources. A web-based EHR removes the burden of integration from the individual physician practice, but is therefore challenged with the need to link with every lab, and every immunization registry in the country.

The issue we have encountered in this process is the highly variable state of readiness from the various outside resources. Let us use our experience working with all 64 state and regional immunization registries (referred to as Immunization Information Systems, or IIS). There is no national immunization registry; the CDC specifies the vocabulary for designating vaccines (the CVX coding system), the transport standards (HL7 version 2.3.1 or 2.5.1), and links to each of the 64 local IIS systems.

Our contact with all of these systems has shown remarkable variability in their readiness to interact with EHR systems. Traditionally, each registry has a web portal where physicians can manually enter vaccine information, and view vaccine history stored in the local registry – but Meaningful Use expects the EHR to link to them directly. We have found that some IIS systems allow upload only, others allow download only, others aren’t able to implement HL7 yet (but “are thinking about it”); still others outsource their IIS to a common vendor. Not everyone uses the same version of HL7, or implements it in the same way. The most advanced such system has even built a web-services oriented API intended to easily interoperate with web-based EHRs (like Practice Fusion).

The lack of standardization in the local-IIS community represents a significant challenge to EHR interoperability. If you’ve made one connection, you’ve made one connection. It will be different for each of the next 63.

The call to standardization made by the ONC is laudable. It should be viewed not only as a call to converge around standards among EHR vendors (which is how we have all approached it so far), but it is also a call to adopt the same standards from all the local registries. The experience with IIS systems illustrates how much work remains to be done.

My sense is that EHR vendors will have “certified products” much more quickly than the agencies on the other end of the interoperability pipeline. CMS and the ONC should offer whatever assistance is needed in order to get each of the different local agencies to “speak the same language” – implement the same version of HL7 in the exact-same fashion, and use the same vocabulary everywhere. After all, the goal is to have all of this be “plug and play” without having to create something “from scratch” for each and every connection.

Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.