Health Information Exchange: Are We At An Inflection Point?

Jody Cervenak, a Pittsburgh-based principal with the Denver-based Aspen Advisors consulting firm, agrees, adding that “The reality is that I think that the major underlying obstacle comes down to aligning incentives, because if we align incentives” among stakeholders, “progress on standards and models will take place.” Offered the metaphor of a long aisle of cereal brands at the grocery store with regard to all the different IT infrastructures in HIEs right now, she says, “I love your mentioning the choices in the cereal aisle at the grocery store. You’re right, there are so many types of cereal at the store, right? But they’ve all agreed to put standardized UPC [universal product code] codes on their cereal boxes, for improved efficiency of store management. That standardization was created because everyone in the food industry had aligned incentives: they wanted to get the product to the consumer, faster, cheaper, better. What needs to happen in healthcare,” she says, “is to break down the silos of patient health information and data. And that would mean that my height, weight, age, problem list, allergies, etc., would be presented in some standardized fashion across all the different databases in healthcare. The problem is that we have technology vendors that may not yet have aligned incentives.”

THE CDA AND THE C32: TECHNICAL OBSTACLES TRIPPING UP HIE LEADERS

Meanwhile, interoperability and standardization continue to be a core challenge at the technical-operational level. Tony Gilman, CEO of the Austin-based Texas Health Services Authority, which facilitates health information exchange at the state level, helping the 12 HIEs in Texas share data among each other, puts it this way: “Interoperability and standardization continue to be a problem, particularly as we’re working with providers using products that existed before meaningful use and thus have deployed pre-meaningful use standards. Those products are making progress, but aren’t moving fast enough. ONC and CMS [the federal Office of the National Coordinator for Health IT and the Centers for Medicare & Medicaid Services] are really focusing on the consolidated CDA”—the Clinical Document Architecture, an HL7 standard—“and they’ve focused on that standard for patient summary exchange.”

Federal approval of broad standards is in itself a good thing, Gilman says. “But the problem is that the vendors aren’t there yet, and the systems in place [products] don’t support that. So a lot of them can exchange a C32 document”—the HITSP 32 Summary Document using the HL7 Continuity of Care Document standard— “but that document often doesn’t include problem lists, allergy information, or the level of detail you would expect; a lot of it is just demographic information.” In other words, Gilman notes, there is a level of standardization of approach at the broad policy level, but that has not yet translated into true ground-level interoperability.

In other words, there remains rather a large gap between policy-level and EHR-level adoption of standards across the U.S. healthcare industry. Many HIE leaders agree that the transmission of CDA-level data across organizations continues to stumble when it comes to moving the data in such informational packets into EHRs, because of ongoing differences in display presentation at the individual data field level. Or, as Mark Frisse, M.D., professor of biomedical informatics and director of regional informatics initiatives at Vanderbilt University in Nashville, puts it, “Most EHRs can’t really fully accept documents. They can receive lab results, but when they receive inbound documents, the question arises, whose record do we attach an inbound document to?”

Further, Frisse asks, “How do I make sure Joe Smith’s inbound documents get to Joe’s record? If there’s a request, then I get it in my world. But do I put it in my record or not? Presumably, you could take a whole CDA and throw it in there as a PDF blob, but most institutions have policies that say, it’s not a part of my legal medical record. There are just a million logistics issues on the ground. The problem there is when the Stage 2 regs say that 10 percent of my summaries have to go out in electronic form that means that 10 percent of my referring docs have to receive it in electronic form. People are saying, OK, if you can receive it as a fax, that’s OK”—which means that some of the hoped-for automated patient data flow is still not happening. “People in the policy arena believe that can you solve 30 years of issues around clinical practice with a few conference calls and meetings,” Frisse adds.