Interoperability Raises Questions for People Responsible for Patient Data

Committee members wondered about the practical effects of using certified EHRs in a larger universe that could include uncertified players, speaking at a committee meeting Friday. Only doctors and hospitals who receive payments from Medicare or Medicaid are eligible for incentive payments, so only those doctors and systems would be required to obtain certified EHRs. Neil Calman of the Institute for Family Health asked what protections patients would have and how they could know if their doctors were using uncertified systems. The incentive payment system will end in four years, he said, and afterward the result could be a free-for- all in which patients wouldn’t be protected from being listed in an interoperable system that doesn’t meet HHS requirements.

When his system exchanges data now, he knows what information is exchanged and how the other party will protect it, said Roger Baker of the Department of Veterans Affairs. But in the many-to-many world envisioned by the information exchange workgroup, if he provides information to a network he'll need to know that only authorized parties can access it and that they'll protect it, he said. If he can’t be sure everyone on the network is approved and following standards to protect information, he won’t be able to participate, Baker said.

The committee can influence a lot of the players with the policy levers it has, but not everyone, said Deven McGraw of the Center for Democracy & Technology, co-chair of the information exchange workgroup. Some players simply aren’t covered by the legislation. For example, clinicians will want labs to be able to accept information and transmit it to appropriate doctors, but labs aren’t eligible for incentives and won’t be certified, she said. Some such issues will be resolved with data-use agreements, she said, while others might end up requiring legislation.

Paul Tang of the Palo Alto Medical Foundation wondered whether the committee was spending too much time talking about the technical standards for interoperability and should instead talk about interoperable policies so the data will be protected wherever it flows. McGraw said the workgroup talked about whether certification is the right vehicle for enforcing policy and ultimately concluded it isn’t the way to ensure networks have appropriate policies in place. However, the Office of the National Coordinator has other tools it can use to promote policies, she said, such as the state grants it will disburse and membership in the Nationwide Health Information Network.

At the beginning of the workgroup presentation, Micky Tripathi, CEO of the Massachusetts ehealth Initiative and co- chair of the information exchange workgroup, said standards for certifying EHRs aren’t enough by themselves to ensure that use of health IT is happening in a meaningful way. That an EHR meets the technical requirements of meaningful use doesn’t mean clinicians will use it that way, the committee agreed. Being able to monitor transactions to see that they routinely occur according to the standards is fundamental, Tripathi said. But there aren’t necessarily functions for doing that now, he said. Medicare monitors administrative transactions, for example, but no one monitors the stream of information flowing from community hospital labs to doctors, he said.

The committee discussed setting the HHS requirements as a floor that states must meet as they create regulations for Medicaid incentives, but allowing states to craft additional regulations. But that could lead to an interoperability problem if states end up with contradictory laws, said Judith Faulkner of Epic Systems Corp. She said her company finds that its customers who aren’t moving forward with health IT are dissuaded not by the cost but by legal concerns.

The top priority now should be transport, McGraw said -- just getting information shared, even if it’s only in human- readable format at this point. Even in areas where the nation is supposedly doing well, like e-prescribing, uptake is still a mere 4 percent of eligible prescriptions in the non-federal world, Tripathi said.