Task force taps the brakes on interoperability

As federal officials work to develop the next generation of electronic health record standards, the jury is out on how much leverage the government will exert on vendors to ease the flow of information over proprietary systems and open those platforms to a growing ecosystem of third-party applications.

From a technical perspective, standards-based interoperability allow for the seamless transfer of health information, and allow patients to manage their own data via a growing array of apps that cover fitness, chronic disease, diet and more. But the seamless transfer of data could mean, for large incumbent providers, a loss of market advantage and the ability to act as information gatekeepers, profiting from data transactions across their systems.

This tension is playing out publicly in the deliberations of a task force of the Office of the National Coordinator for Health IT (ONC), charged with coming up with policy recommendations on interoperability by Oct. 15. The task force presented draft recommendations at a Sept. 3 meeting of the Health IT Policy Committee, after a summer spent in listening sessions and deliberations.

The consensus from the group was that the document that was supposed to guide their thinking was inadequate, out-of-date and, while well intentioned, somewhat oblivious to the business pressures affecting EHR vendors.

The report from JASON, an advisory group that consults with government on science and technology issues, asserted that "EHRs and health information exchanges (HIEs) are currently woefully inadequate in what they provide to health care professionals," and advocated moving to a common markup language, common data standards and a library of open APIs to give third party developers access to existing systems. The report also advocated eventually moving to a "unifying software architecture for the exchange of health information" that would allow for encrypted provider and patient exchange of and interaction with health data.

But the blue sky vision of the JASON report clashes with the reality of the existing medical records ecosystem, according to working group co-chairs Dr. David McCallie, senior vice president of medical informatics at EHR vendor Cerner, and Dr. Micky Tripathi, CEO of the Massachusetts eHealth Collaborative.

They're advocating a "loosely coupled architecture" that isn't centrally controlled or imposed at a high level of detail by ONC or other regulators. Instead, they say, standardized data elements and standards-based APIs will allow third party developers access to EHR platforms while allowing vendors to validate services that want trusted access to their data.

Increased adoption by medical providers of certified EHRs since work on the JASON report started has "created greater demand for interoperability than I think was the case 18 months ago," Tripathi said.

But not everyone is sanguine about the industry's ability to establish true interoperability simply because there is a market for it.  

"I think this sense that people will, for goodwill purposes, make the decision to make their data easy for other vendors to utilize has not been proven by the marketplace so far, other than perhaps in the open source community, " said Dr. Terry Cullen chief medical information officer at the Veterans Health Administration, which has an ex officio seat on the Health IT Policy Committee.

The government so far has encouraged adoption of EHRs and encouraged vendors to meet operational standards through a carrot and stick approach. The carrot, $24 billion in subsidies authorized under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) legislation that was part of the economic stimulus measure, is exhausted. The stick, for providers, comes when failure to demonstrate "meaningful use" of EHRs will hinder their ability to get compensation from large government payers like Medicare and Medicaid.

The government's leverage over vendors is to include interoperability standards in the third stage of Meaningful Use certifications, which take effect in 2017. The JASON report, which was released in November 2013, advocated just this approach, saying that "now is the time to define such an architecture, leveraging the opportunity to specify CMS Stage 3 Meaningful Use requirements to drive implementation."

However, the clock might be running out on this approach. A notice of proposed rulemaking on Stage 3 meaningful use is due out by the end of the year, and work is well underway. The task force sees Stage 3 regulations as "one of many levers" to move the needle toward fully interoperable systems, but not the only one.