HIMSS Preview: Looking for HIE Needles in a Haystack

CIOs heading to the biggest health IT event of the year will encounter a vast array of new platforms and protocols promising health information exchange interoperability. Whether there's room for much optimism amidst the complexity remains to be seen.

As the healthcare industry prepares to head to Orlando for next week's HIMSS conference, should we be optimistic about the state of healthcare IT interoperability?

I'm not sure. So far this month, the healthcare IT news hasn't been all that promising. According to industry buzz, CMS found its Meaningful Use attestation Web site overwhelmed by traffic that made the Web site unusable from time to time, so much so that the agency postponed the deadline for 2013 attestations for 30 days to March 31, 2014.

Pessimists will point to this flub as one more foreshadowing of 2014's Stage 2 attestation requirements as a train wreck in the making. After months of pleading, CHIME has been unable to prevail upon CMS to push back the basic requirements for those providers who attested in 2011 or 2012 to attest for Stage 2 this year, and this month's CMS postponement changes nothing about that.  

And there's plenty more than can go wrong. I continue to hear persistent reports that although certified Stage 2 software has now been released by most major EHR software publishers, providers remain queued up in long lines waiting for their numbers to be called by those publishers so their software can be upgraded.  

I even hear that some EHR software certified to be Stage 2-compliant makes some basic tasks, like sending a document via the Direct protocol, convoluted. That should be remedied when the software gets patched later in the year.

All these upgrades are necessary for providers to even begin practically preparing their Stage 2 attestations. And only recently have I begun to understand how rudimentary the Stage 2 requirements are, and how even once those attestations are in hand, providers will have some distance left to go to get to cost-lowering, care-enhancing coordination of care.

Disruption as Close as Your Pocket
And yet, again and again, I hear that technology is not the key. Governance is. Even in an age when there are incentives for providers to share information and thus put the patient back at the center of healthcare, it is undeniable that information is still power. Yet too many payers and providers are still nervous about sharing that information, for fear they will lose patients, customers, volume, and market share.

I also continue to hear fundamental questions about the electronic health record model defined by the Office of the National Coordinator, source of $19 billion already spent. Disruption is coming to the EHR model we know and occasionally love. For instance, a company called Docbook MD is offering a mobile phone app that lets doctors share patient information with full HIPAA security by taking pictures of records with their smartphones and emailing them to each other.

Now, if you're carrying around a phone that's three or four years old, that might sound goofy. But having just recently gotten an iPhone 5C and seeing the incredible photos its camera can take, this app sounds quite plausible for acting like a document scanner you are always carrying. It could even transmit detailed X-rays from doctor to doctor.

Compared to the byzantine way Meaningful Use defines the protocols, standards, and services required to share a simple medical record, this sounds like a much simpler way to go, and one that didn't require $19 billion.

Yet, because providers are enrolled in the Meaningful Use incentive program, and because shared cell phone photos alone can't fix healthcare, providers are on a conveyor belt headed into fulfilling the requirements for Stage 2, Stage 3, and beyond, or face penalties. I don't doubt that some of those requirements will fit the need to coordinate care. But I also know that the devil, as always, is in the details.

Many, Many Services
Based on my discussions with providers and vendors prior to next week's HIMSS, it's clear we're entering a truly confusing period of not knowing which platforms and pieces will be the right ones for providers trying to achieve true interoperability. Consider that the HIMSS Interoperability Showcase will have a growing plethora of technological services and solutions for accomplishing basic health information exchange:

• Direct protocol, a kind of secure paperless fax that works much like secure email must be supported by Meaningful Use Stage 2 EHR software, like healthcare's own "Intel inside."
• Healtheway, descendent of the federal government's Nationwide Health Information Network, is a series of application program interfaces that allows all the secure transfer of Direct plus more sophisticated variants, such as query-based exchange, to provide more targeted information to support everything from coordination of care to preventing 30-day readmissions.
• Epic CareEverywhere, is used by large health systems running the industry-dominant Epic EHR to exchange health information with each other, and, due to an alliance between Epic and eClinicalWorks, with physicians running the eClinicalWorks EHR for small practices.
• CommonWell Health Alliance is a vendor-based consortium whose invitations to Epic have been rebuffed for the entire year of its existence. CommonWell technology, now in early pilot testing, will also be on display at HIMSS exchanging information. CommonWell  lists these vendors in its opening lineup: Cerner, Allscripts, McKesson, athenahealth, Greenway, CPSI, Sunquest Information Systems, and HIE service provider RelayHealth. 
• DirectTrust is a service for HIEs to talk to other HIEs, who must sign legal agreements and pay to establish trust relationships with each other. Not every HIE has joined DirectTrust yet, but the list is growing.
• The National Association for Trusted Exchange (NATE) is an organization trying to tie together state HIEs across the U.S., but has some distance to go to enroll all the states. The success of NATE may determine the long-term viability of some state HIEs.
• SureScripts, a new entrant, is traditionally known as the HIE limited to, but very successful in, exchanging e-prescribing health information in a trusted network. Recently, SureScripts announced a Record Locator Service, to be available this fall, built on the same provider directory that powers its e-prescribing network.

Some of these HIE systems, such as DirectTrust and SureScripts, are partnering with each other, and as mentioned, some are not. A number of vendors are setting up their own HIE infrastructures. All who are endpoints of health information are considering their options, trying to pick partners, and, if they can afford, placing some side bets.

How Good is EMPI?
Also at HIMSS, you'll hear a relatively new term: HISP, or health information service provider. Some HISPs are also HIEs, and some are not. If they're not, they may be exclusively moving Direct messages from EHR to HER. In other cases, they may be moving other kinds of information, in addition to or instead of Direct data.

All of these HIE building blocks, and many more on display at HIMSS, also rely to a greater or lesser degree on patient identification technology, often based on IBM's Initiate technology. And yet, while enterprise master patient index (EMPI) is pretty good technology, is it good enough?

(For the answer to that question, you might want to attend Overview of Identity Systems and Identity Technologies, a HIMSS pre-conference panel in which I will be participating, on Sunday, February 23 at 10:15am in Room 207C of the Orange County Convention Center in Orlando.)

All in all, the complexity of the HIE haystack will make finding the right solutions every CIO's headache this year. At HIMSS, let's keep asking how the many players can make interoperability simpler, not more complex. Talk about a challenge.