Setting the stage for the Jan. 29 joint hearing of the federal HIT Policy Committee and HIT Standards Committee on health information exchange (HIE) challenges, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, described how the industry has evolved to “HIE 2.0.”

Micky Tripathi

Tripathi, chair of the policy committee’s information exchange work group, described the current state of health information exchange as a complex array of approaches driven by business needs.

HIE 1.0, he noted, strived to solve a wide variety of rich use cases through comprehensive interoperability. They dealt with complex legal, business, and technical requirements.  Despite pockets of success and lots of hard work, many of those efforts got bogged down in complexity.

“We have moved to HIE 2.0, where the focus is much more on the verb exchange rather than the noun,” he said. Driven by the limited success of the previous model, these types of exchange may or may not be mediated, Tripathi said. They tend to be more tactically focused and demand-driven, meeting needs from the bottom up. They tend to be led by any organization that has a business need and the capability to marshal financial, technical, and organizational resources. These efforts are also being spurred by, among other things, meaningful use incentives and value-based purchasing.

The fastest-growing approach to information exchange, he said, is “visual integration,” in which a hospital system providers physician practices a view into its clinical system at point-of-care, with no exchange of data or documents. For instance, Beth Israel Deaconess Medical Center in Boston provides that type of access to physicians in the Atrius Health, a nonprofit consortium of medical groups. It is an increasingly common approach to solving an immediate need without interfacing and application workflow redesign, Tripathi noted.

He also said that there has been explosive growth of exchange between providers on the same vendor’s clinical platform, with the vendor playing intermediary. For instance, Epic is currently handling 2.2 million CCD/CDA query-based exchanges for 385,000 unique patients per month. That volume has doubled over the previous year.

Use of the Direct protocol for exchange holds a lot of promise but is not proven yet, Tripathi said. How EHR vendors implement Direct following meaningful use Stage 2 requirements will determine whether it is paradigm-breaking or just another little-used standard, he said. The jury is still out.

In conclusion, Tripathi said that HIE activity is starting to flourish from the bottom up. Heterogeneity will be the hallmark of HIE activity in the coming years, he said, as multi-layered HIE modes seem to be developing as business practices mature.

With meaningful use Stage 2 and accountable care initiatives, a seedbed has been laid to allow many HIE areas to proliferate on their own.

Tripathi identified threeareas where more policy and standards are needed to spur market innovation:

• Labs: There has been relatively little progress on making lab data transmission electronic. Organic motivation for standardization is difficult in the current market structure. Meaningful use Stage 2 may not be enough of a spur to significantly increase electronic delivery from hospitals. It does not require electronic delivery, and standardization of electronic delivery is a menu set item.

• Lightweight ‘Directed Query’: The ability to have cross-system query without having to deploy elaborate legal and technical infrastructure.

• eMeasures and eCPOE: The ability to enable enterprise-level dispersal of measure and decision support algorithms to give leverage to ACOs.

Opening the meeting, Farzad Mostashari, M.D., national coordinator for health IT, said Stage 2 of meaningful use will put many of the key pieces in place to allow electronic health records to speak to each other and share care summaries in structured and coded ways.

“Stage 2 has set the stage to accelerate to HIE, and we are all part of the solution to making that real. That includes working through the cost, benefit and trust issues. “The stakes are too high for us not to push each other and every part of the system to make this happen, so that when a patient shows up in the emergency room, the information physicians need is there and can be used. Let’s take that on.”