AMIA Developing Informaticists' Vision for EHRs of the Future
Providers are questioning Meaningful Use’s directions, and the feds appear to be listening.
By Neil Versel
As hospitals and physician practices struggle to meet Stage 2 standards for Meaningful Use (MU) of EHRs, the federal government is getting ready to write the rules for Stage 3. With interoperability – a centerpiece of Stage 2 – lagging, providers are questioning the direction of the whole program, and federal officials appear to be listening.
“We need to think past the MU program,” Erica Galvez, interoperability and exchange portfolio manager at Office of the National Coordinator for Health Information Technology (ONC) said during last month's American Medical Informatics Association (AMIA) annual conference in Washington, D.C. However, that does not mean that MU has become irrelevant. “It's one of a number of tools” for achieving interoperability, Galvez said.
Galvez referenced the 10-year interoperability roadmap that ONC is developing. “Don't think of it as a final product,” she said. “Think of it as a starting point.”
With that in mind, AMIA, representing medical informatics professionals and academics, is working on its own vision for the future of EHRs. At the conference, members of the organization's “EHR-2020” task force presented ideas for what EHRs should look like in 2020, and solicited input from its membership.
Dr. Thomas Payne, medical director for information services at the University of Washington's UW Medicine health system and chairman of the EHR-2020 task force, said to expect formal recommendations from AMIA before the end of winter.
The task force has the stated goal of developing recommendations “to assure EHRs fit well into evolving workflow of healthcare delivery, support team-based care, enhance productivity and safety, and are as easy as possible to adopt.” They are supposed to highlight areas where AMIA and its membership might be able to act on the recommendations.
The preliminary framework presented at the meeting delved generally into: how to simplify and speed documentation; refocusing regulation; increasing transparency; and fostering innovation.
“We hope to inform policy and inform vendors and payers about the direction that experienced users and implementers want to take,” said panel member Dr. Sarah Corley, chief medical officer of NextGen Healthcare Information Systems.
Corley, who also is vice-chair of the HIMSS EHR Association, suggested that ONC “back off” on some of the functional requirements of EHR certification, an opinion seeming to gain popularity this year.
(Later, in the same session in which Galvez presented, Elisabeth Myers, policy and research lead in the CMS Office of E-Health Standards and Services, noted that Centers for Medicare and Medicaid Services is offering flexibility with certification this year and also officially put off the start of Stage 3 until 2017. Since the AMIA conference ended, CMS has extended the deadline for hospitals to attest to MU in 2014 by a month, to Dec. 31.)
“We want to shift away from some of the functional measures that get in the way,” said Dr. David McCallie Jr., director of the Cerner Medical Informatics Institute, and a co-chair of the ONC JASON task force that did the groundwork for the ONC interoperability roadmap.
McCallie, a member of the AMIA task force, discussed a bit of a paradox: the possibility that federal officials relax some EHR regulation while also adding more with the advent of a public application programmer interface, something ONC is strongly considering at the urging of the JASON committee.
To be useful, apps built on a public API must fit widely adopted standards, McCallie suggested. “An app isn't a very fungible thing if it has to have a different style guide for each company,” he said.
One audience member commented that there was no consensus about what interoperability really means. McCallie responded by noting that the JASON report called for definitions of interoperability as well as transparency in data reporting.
Julia Adler-Milstein, assistant professor of health management and policy at the University of Michigan, questioned from the audience whether there is truly a market for health IT in place.
“There are enough market forces out there if MU standards are simplified,” responded task force member Dr. William Tierney, president and CEO of the Regenstrief Institute in Indianapolis.
Session attendee Dr. Joel Lafleur, CMIO of Pen Bat Medical Center in Rockford, ME, joked that his hospital, an affiliate of MaineHealth, has a “computer-assisted” medical record, rather than a fully computerized one. He said his physicians are “not getting the right data” out of the Continuity of Care Document, an interoperability standard that helps providers achieve MU, but little else. As a result, users print and scan a lot of documents. “That's not interoperability,” Lafleur said.
“Clinicians are not content with structured data,” Lafleur added. “They still want narrative text.” He was not alone in expressing this opinion.
In the joint ONC-CMS session, Dr. Clement McDonald, director of the National Library of Medicine's Lister Hill National Center for Biomedical Communications, said that interoperability requirements in MU are “too ambitious” and should be simplified to give doctors only the information they need to care for patients. “Push labs, rads and meds to physicians,” he said.
“Aim big, start small,” said McDonald, who developed the Logical Observation Identifiers, Names, Codes (LOINC) standard for reporting laboratory results while he was at Regenstrief.
Some members of the AMIA EHR-2020 task force touted Fast Healthcare Interoperability Resources (FHIR), a standard being developed by Health Level Seven International, as an answer for many interoperability problems. Corley noted that FHIR is a draft standard and probably not ready for inclusion in MU Stage 3. “We don't want to require something before its time,” she said.
FHIR seems unlikely to show up in the first draft of Stage 3, due out in the spring. Galvez said that ONC has heard one clear message in response to its draft 10-year roadmap: “Please, please, please do not adopt national standards until they are tested.”