By Greg Otto · Wednesday, August 20, 2014 · 5:08 pm – See more at: http://fedscoop.com/ehr-interoperability-stage-2-meaningful-use/view-all/#sthash.nlk5EYZz.dpuf
It is a growing issue everywhere from the examination table in your physician’s office to your hospital system’s database to the halls of Capitol Hill. The health care system at large is trying to move your health record off of a paper chart and into the digital space. Furthermore, your electronic health record (or EHR in health care parlance) should be able to to freely move between your physician to your hospital or anywhere crucial in between. Only that increasingly isn’t the case.
Over the past few months, stories have popped up chronicling doctors’, clinicians’ or other health care providers’ headaches moving to and/or accessing EHRs. The chorus of complaints has led the Senate Appropriations Committee to submit language in a draft bill that calls for a report from the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) on what “the challenges and barriers” are to EHR interoperability.”
Whatever challenges and barriers there are, it is clear both hospitals and office-based physicians are struggling to meet HHS’ Meaningful Use Criteria, which include interoperability guidelines.
Small clinics suffer
In a study published in the September 2014 issue of Health Affairs, a number of analysts — including some working for ONC — found that while the rates of hospitals adopting basic EHRs continue to rise, only 5.8 percent of hospitals surveyed were able to meet all of 16 core objectives put forth in HHS’ Meaningful Use Criteria. The areas in which hospitals were most lacking were providing patients with the ability to view and download their information and sending care summaries between care settings.
In another study that examined EHR adoption in office settings, only four in ten physicians had any electronic exchange with other health providers, and one in seven exchanged clinical data with providers outside their organization.
Both studies found that in some respects, the more resources available to a hospital or an office, the more likely they were to have already implemented EHRs. In the study that focused on hospitals, more than half of all rural hospital respondents said they had “less than basic” EHR implementation in 2013. In the study dedicated to office-based care, solo practitioners and specialty physicians lagged behind larger practices or primary care physicians.
The lag is something ONC has tried to combat since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of 2009′s American Recovery and Reinvestment Act. The act, which designated $30 billion to build a nationwide system of electronic health records, established 62 Regional Extension Centers (RECs) to provide guidance to local health care providers.
The RECs have been beneficial on the local level. According to ONC, as of July 2013, more than 70,000 providers had demonstrated some form of meaningful use. However, as the hospital-based survey states, the RECs’ efforts are not enough to combat the lag in meeting meaningful-use standards.
Anita Somplasky, the director of measures and support at Quality Insights, a nonprofit health care company that serves as a REC in Pennsylvania, agrees that the cards are stacked against smaller practices who are trying to meet the requirements of meaningful use.
“Small and medium practices are absolutely struggling,” Somplasky said, adding that trying to meet meaningful use standards has been a “slow, slow process.”
Somplasky said she has been dealing with EHR interoperability issues for years, including one that would have allowed more than 900 providers to send secure emails to one another. But three years went by before a solution was provided by vendors.
Even with ONC and the Centers for Medicare and Medicaid Services delivering marching orders for providers to follow, Somplasky said smaller practices are considering taking the financial penalties that come with failing to meet the HHS meaningful use goals.
“Here in Pennsylvania, folks have to pay the state to do syndromic surveillance (the analysis of medical data to detect or anticipate disease outbreaks) or for the immunization registry,” Somplasky says. “That’s $4,000. If the penalty is $3,000, why would I pay $4,000 to login to the state and then another $4,500 for the patient portal? That’s just the unfortunate financial reality.”
Even small practices that have seen the first-hand upside of EHRs still have to create workarounds so their systems can communicate with others outside of their practice.
Mary Beth Byrnes, who helps manage a four-person family practice in Souderton, Pennsylvania, was an early adopter of EHRs, integrating SOAPware into her practice in 2005. Even as Byrnes invests heavily as updates roll out, she said she still has to create workarounds in order to stay on top of patient records.
Byrnes told FedScoop that while she can pull information from other sites, she’s not able to make lab orders electronically. She also said her reporting capability within SOAPware is not very robust, causing her to create a workaround to where she will manually submit queries to obtain data.
While Byrnes said this doubles her workload when working with the program, she needs to do it in order to keep up with any updates SOAPware will roll out in the future.
“Especially as a solo practice, if we don’t get on top of this, we might as well pack it up, close down and go home,” Byrnes said.
Dr. Jorge Schierer, chief medical information officer for Pennsylvania-based Reading Health System, understands that small practices like Byrnes’s face bigger hurdles than large hospitals or health systems.
“The smaller the practice is, the harder it is to do all the things that you need to do to be successful,” Schierer said. “The expense of purchasing, maintaining and optimizing electronic medical records is not insignificant. It’s not offset significantly enough by the potential dollars that you could capture from meaningful use.”
When the code should say ‘codeine’
Even with all of the burdens small practices have to overcome to meet meaningful use standards, Cathy Costello, a program manager for CliniSync, an Ohio-based regional extension center, said more could be done by all parties involved to fix interoperability problems.
“Interoperability requires ‘two to tango,’ Costello wrote in an email to FedScoop. “You can’t send [an email] to yourself and meet the interoperability standards. Although the vendors may provide the technical underpinnings for interoperability, I have yet to meet a vendor who goes out into the community and knocks on doors to make sure the receiving party is set up to accept a transmission of a transition of care document.”
Dr. Jon White with the Department of Health and Human Services’ Agency for Health Research and Quality said vendors should apply more effort in making sure providers are fully satisfied with their products.
“In general, making sure the user experience is the best it can possibly be may not have been the highest priority for the vendors,” White said.
While White said there is “a lot of ground to cover” when it comes to interoperability, he has talked with many doctors or health care systems that love how far EHRs have come over the past decade.
“Some of the most ardent skeptics have said to me that the system we have now is in many ways better than the system we had,” White said. “In a lot of ways, we do have interoperability now. I think what people are struggling with is that the interoperability we have now doesn’t match the ideal of what we all conceive it to be. My gold standard is not going to be the same as other people’s gold standard.”
There have been recent studies that disagree with White’s sentiments on interoperability. A study published in late June in the Journal of the American Medical Informatics Association found that EHR systems that have been certified for meaningful use aren’t always interoperable with other EHR systems.
The study found common errors in data that were fed into Consolidated Clinical Document Architecture (C-CDA) documents, which allow data to move through EHR systems. Some of the errors included incorrect dosage data or codes used in systems that confused penicillin for codeine.
“Data heterogeneity or omissions may impose a minimal burden in cases where humans or computers can normalize or supplement information from other sources,” the report stated. “In other cases, a missing or erroneous code could disrupt vital care activities, such as automated surveillance for drug-allergy interactions.”
In another study published in June, the RAND corporation found that meaningful use requirements for interoperability were “watered down” and promoted adoption of current technology instead of promoting emerging products.
“By subsidizing ‘where the industry is’ rather than where it needed to go, HHS rule-makers allowed hospitals and health care providers to use billions in federal subsidies to purchase EHRs that did not have the level of connectivity envisioned by the authors of the HITECH act,” the report stated.
Somplasky and Byrnes both said they have seen the “watered down” scenario play out in their own experiences.
“There are areas where [EHR vendors] squeak by on the certification and there are other areas where they have done very well,” Byrnes said.
“There is a certification process, but within that process, you had some real dogs,” Somplasky said. “We would just sit there and wonder ‘How did [this EHR vendor] ever make it through the test?”
White said one area where “there is a lot more room to work” is figuring out a post-implementation testing phase so health care providers can learn all the in and outs of the EHR system they just purchased.
“The value of an EHR is it should be able to say ‘Wait a minute, did you really mean to do that?’,” White said. “What you find is systems have a capability, but when they are implemented in a given hospital, there’s traces about what alerts you turn on and who gets that alert. What you find is as implemented, those tools may catch the things you expect them to [and] they may not.”
Yet even with flaws, White said doctors should be able to recognize basic errors that come from EHR systems.
“There’s a higher level of accountability,” he said. “A doctor should know not to subscribe 10 times the right amount of morphine for his patient.”
Even with a system that is working properly, Schierer said EHRs often take away from the amount of time doctors are engaging with patients.
“The reason doctors are not happy with meaningful use is, if you back up the clock 5-10 years ago when most physicians weren’t using [EHRs], we were all still being paid on volume,” he said. “Now, if I throw in [EHRs], we’re trying to move to a value- and quality-based system, but yet remunerated primarily on the number of patients I see per day. So now what you’ve done is you’ve made [doctors] use electronic medical records, you’re making [doctors] add medications and allergies in a structured fashion. Before, I would just check off ‘chest pain’ on a paper bill and anything I couldn’t find, I would handwrite it and my [staff] would find the code. Now the physicians have to do that, and they don’t have more time to take care of the patients, either.”
A slow prognosis
So as more hospital systems and health care providers add EHRs, what can be done to solve interoperability issues?
AHRQ tasked an independent group of scientists known as JASON to come up with a number of recommendations, which they put forth in a 65-page report in April. One of the key takeaways was a call to implement a set of open standards and APIs for EHR vendors to follow by 2017 when the final stage of HHS’ meaningful use standards kick in.
“To achieve interoperability for EHRs and to open the entrepreneurial space for software development, all of these elements must be made public,” the JASON report states. “People frequently encounter standards in their daily lives. For example, an E26 light bulb has a standard base diameter and conductor position to allow mating with a compatible socket, which also has standard properties. One uses different names for this same basic concept at different levels.”
Schierer has other ideas, including a health ID number that would act as an identifier in order to differentiate people as they move through different EHR systems. This number would differ from a social security number in that it wouldn’t be re-assigned to someone new once a person dies.
“You can’t take a chance by using an identifier that is used for a patient, and then its re-used, and then you get some dead person’s health information,” he said. “What we really need is a national health identifier number, so that your number would have 12-15 digits in it, that was unique to you forever.”
Currently, if patients move from one system to another, a complex algorithm can identify a patient, but it relies on systems being interoperable.
According to White, even as problems continue, the process of improvement will continue to be incremental.
“This is a really complex health system and there’s a lot of different needs,” White said. “I feel some of those needs are being met. I think a lot of those needs are not being met and I think they need to be worked on.”
Schierer said that while doctors and health care providers are frustrated, EHRs have given doctors access to more information than they ever previously had.
“Our memory is very, very short,” he said. “We have all forgotten those experiences of having to take care of patients without this information and having to call people on the phone and wait for stuff to come to you, now it’s all there in front of us. It’s very very powerful.”
Whatever the answer, Byrnes knows she will have to comply if she wants to stay in business.
“There’s no turning back from this,” she said. “The direction that we are trying to move in is going to take a lot of development. I don’t think the exchange of information is going to get us there.”