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Lack of health information exchange standards slowing adoption

Regional health information organizations are finding it hard to integrate with other RHIOs due to slow development of standards for health information exchanges.

Ted Kremer, executive director of Rochester Regional Health Information Organization (RHIO), is eager to jump on board the Nationwide Health Information Network (NHIN). His health information exchange currently supports patient information sharing among Rochester Regional’s 15 hospitals, three reference laboratories and seven radiology practices.

However, many of those patients visit specialists outside the RHIO, in nearby Pennsylvania. There are also elderly “snowbirds” who reside in Florida during the winter and have one or more health care providers down there. NHIN promises to enable members of the Rochester RHIO to exchange health information about those patients with those other providers.

Due to a lack of health information exchange standards, Kremer -- and many of his counterparts at other health care organizations -- aren’t expecting this to happen anytime soon, however.

While NHIN is technically up and running, only about 20 government agencies and health care collectives are currently using it to exchange patient data. Connect, a recently released open source gateway to the network, is a preliminary version, and NHIN’s underlying standards are in “limited production mode” while the Health IT (HIT) Standards Committee “tightens them up for a larger-scale production rollout,” said Bernie Thuman, chief technology officer for health information exchange (HIE) vendor Vangent Inc.’s health care business.

A finalized version of meaningful-use criteria, due out by the end of this month, is likely to specify “clinical summary data exchange between organizations, e-prescribing (and) electronic laboratory workflow,” said John Halamka, CIO of Beth Israel Deaconess Medical Center and co-chair of the Health IT Standards Committee, charged with setting the standards for electronic health record (EHR) data exchange. “Thus, for organizations to claim their stimulus funds, they must be interoperable.”

Standards under development

Those initial specifications “are pretty firm, but I’m not sure how specific or comprehensive they’ll be,” said Rik Drummond, CEO and chief scientist at interoperability test laboratory Drummond Group Inc.

Some key areas, such as security standards, are still very much under development. In an October posting on his blog, Life as a Healthcare CIO, Halamka reported on a recent discussion of “enhancements to privacy and security standards efforts, especially for 2013,” including health care-specific XML schema and vocabulary for representing things like consumer consent.

The HIT committee’s main problem is not a dearth but an excess of available standards, said Lynne Dunbrack, a program director at IDC Health Insights. Take one example: the ANSI standard Health Level 7 (HL7), a message-based format for the transmission of health-related information. While HL7 is widely supported, different vendors support different versions. There are eight iterations of HL7 v.2, all backward compatible; and a version 3, which, unlike its predecessor, is based on XML.

The government is using a carrot-and-stick approach to motivate health care providers to deploy EHR systems in compliance with its specifications. The carrot is HITECH Act incentives, which offer up to $44,000 per doctor in reimbursements to providers whose EHR systems meet "meaningful use" requirements by 2011. The stick takes effect in 2015, when providers that have yet to deploy certified electronic medical record systems start paying financial penalties.

The HIT dilemma

This poses a dilemma for health care providers: If they go ahead and implement HIT specifications now, in their unfinished state, they risk a potentially expensive migration to the finished standards down the road. But if they hold off until the rules are finalized, they may miss the boat when it comes to collecting their incentive money.

The organizations in the best position right now, experts agree, are those that have already implemented EHR systems that support key standards like HL7. Many of them will probably just need to administer “a few tweaks” to their systems in order to meet the HITECH Act’s requirements, said IDC’s Dunbrack.

Also in reasonably good shape are RHIOs and other health care communities that have deployed HIE platforms or health-sector integration engines, as a means of connecting members’ mixed bags of proprietary and standards-based EHR systems.

As with any business to business supply chain, if you administer electronic data interchange without standards, it doesn’t work.

Ted Kremer, executive director, Rochester Regional Health Information Organization

Take the Rochester RHIO, for example, whose member EHRs use a variety of proprietary protocols, as well as four versions of HL7. Axolotl Corp.’s HIE platform, Elysium, translates the output of all these systems into a standardized format and loads it into a commonly accessible repository. Anand Shroff, Axolotl’s vice president of engineering, said his company keeps up to date with developing standards, such as HL7 v.3 and Continuity of Care Documents, which are supported by the HIT.

InterSystems Corp.’s Ensemble interface engine can take a variety of document types and formats, transform them to its own XML-based format, and “spit them out again in whatever format an EMR system uses,” said John Joseph, the vendor’s director of product management. The vendor also offers Caché, a health care data repository that is embedded in Ensemble.

Such solutions enable budget-strapped health care providers to participate in an HIE without doing drastic and expensive upgrades to their EHRs. However, the government’s American Recovery and Reinvestment Act (ARRA) program allows these companies very little breathing room before they need to migrate to HIT interoperability standards -- or pay the penalty.

Much worse off are practices that are just starting to look at an EHR, or are even waiting for standards to gel before looking. These providers won’t have a chance of making the deadline, industry experts agree. Unfortunately, these providers make up the vast majority of health care organizations. A recent HIT-sponsored survey of more than 1,500 physicians and almost 2,000 hospitals found that in 2008, only 17% of physicians’ offices and 8% of hospitals had basic e-health IT systems. Getting them online is one of the chief obstacles to setting up a truly nationwide health information network.

Software as a Service as a solution

One hopeful sign is the emergence of Software as a Service-based EHR vendors that offer low-cost and quick ways to deploy EHR systems. Some of them, like Practice Fusion, also promise to migrate customers painlessly to HIT specifications in time to meet the 2011 certification deadline for ARRA reimbursement.

Many leading EHR and health information exchange platform vendors are making similar claims. Naturally, potential customers need to check out their bona fides, asking specific questions about which standards a vendor’s system will support, when. San Francisco-based Practice Fusion, for example, provides a Certification Roadmap on its website, including exactly which HIT specifications it currently supports.

Another helpful measure of a vendor’s commitment to HIT standards is whether it has participated in standards-based interoperability demonstrations, such as the Connectathons sponsored by Integrating the Healthcare Enterprise. Such demonstrations have naturally not included the full gamut of HIT specifications, which have yet to be published, but they include many of the industry standards that HIT has adopted.

Finally, providers should ask vendors whether their EHR systems have been certified by an independent interoperability testing laboratory.

Until recently, such testing was done exclusively by the Certification Commission for Health Information Technology (CCHIT), a nonprofit, federally funded organization that has also defined the certification criteria. In October, the organization released two 2011 ARRA certification programs: a preliminary program designed to ensure a product meets minimal ARRA requirements in order to qualify for HITECH incentive money, and a more comprehensive certification product.

CCHIT Chair Mark Leavitt told that both programs may need an incremental test to ensure that products meet any standards or criteria that are added later. He added, however, that he felt comfortable that moving to the final criteria will not be too rigorous.

Recently, the government opened up the certification market to other organizations. In November, Drummond Group announced that it would submit an application to become a certifying body, as soon as the HIT’s meaningful use specifications were released. “The first step to ensuring interoperability, is having a well-constructed standard that’s testable,” said Drummond. However, standards support doesn’t guarantee interoperability, he noted: Products have to be tested to see if they can, in fact, communicate with one another using the standards.

Pressure to conform to HIT standards

Which raises the question: Can a health care provider make a claim that it has met HIT interoperability criteria without adhering strictly to HIT-endorsed standards?

Yes, it would be possible to create a nationwide health care community without imposing a single set of interoperability standards, IDC’s Dunbrack said. But it would be much more difficult and costly, both in software and overhead, since it would require some kind of middleware to perform translations. Health care organizations are increasingly pressuring proprietary vendors to move to standards, and fellow members to adopt standards-based systems, she added.

The ARRA initiative has greatly increased the pressure. However, the government’s carrot-and-stick approach may backfire, industry experts warn.

Jana Skewes, president of RHIO Shared Health Inc., said she worries that in their eagerness to qualify for HITECH incentive funding, health care providers will deploy EMR systems interoperability in a haphazard and nonstandard way. Doing so would create “a mess we have to clean up before we have a well-run, well-connected” national health network, she explained.

Furthermore, many health care vendors have been saying that their development efforts are stalled while they wait for the government to finalize its criteria, CCHIT’s Leavitt said.

Despite the difficulties small and large, industry sources generally agree that common interoperability standards are necessary in order for NHIN to get off the ground and enable the U.S. health care industry to achieve true continuity of care. “As with any business-to-business supply chain, if you administer electronic data interchange without standards, it doesn’t work,” said Kremer. “We are all looking forward to when standards are tightened and the gaps filled in, because now it takes a fair amount of technical creativity to get the job done.”

Elisabeth Horwitt is a Boston-based freelance journalist. Let us know what you think about the story; email

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