The federal government’s Meaningful Use (MU) initiative is changing the way the healthcare industry operates. From hospitals and healthcare providers, to patients and health IT vendors, everyone is trying to navigate the brave new world of MU, EHR interoperability and what it means for the future of our healthcare delivery system.
Many in the healthcare industry have been resistant to the changes MU is instigating. It’s no wonder. MU requires healthcare providers to engage with their patients on an unprecedented level. Historically, patients had little, if any, involvement in the healthcare delivery system. MU is changing that—creating a world where patients will be fully engaged, with easy access to their health records and the freedom to transmit those health records how they see fit. In short, we’re looking at a cultural shift within the industry.
This is a good thing. The goal of MU is to improve the quality of care by improving communications between the patient and the provider, and among the providers themselves while simultaneously reducing healthcare costs. That’s a win-win for everyone. But that doesn’t mean MU is not without its challenges or that there aren’t solutions to these challenges that will help achieve the MU vision.
By Christina Caraballo, Senior Healthcare Strategist, Get Real Health
The federal government’s Meaningful Use (MU) initiative is changing the way the healthcare industry operates. From hospitals and healthcare providers, to patients and health IT vendors, everyone is trying to navigate the brave new world of MU, EHR interoperability and what it means for the future of our healthcare delivery system.
Many in the healthcare industry have been resistant to the changes MU is instigating. It’s no wonder. MU requires healthcare providers to engage with their patients on an unprecedented level. Historically, patients had little, if any, involvement in the healthcare delivery system. MU is changing that—creating a world where patients will be fully engaged, with easy access to their health records and the freedom to transmit those health records how they see fit. In short, we’re looking at a cultural shift within the industry.
This is a good thing. The goal of MU is to improve the quality of care by improving communications between the patient and the provider, and among the providers themselves while simultaneously reducing healthcare costs. That’s a win-win for everyone. But that doesn’t mean MU is not without its challenges or that there aren’t solutions to these challenges that will help achieve the MU vision.
Challenge #1: Need for a Robust Patient Mediated Data Exchange Ecosystem
There is no question that the patient-centric objectives of meaningful use and the Blue Button movement are helping to transform our healthcare delivery system by providing patients with free access to their personal health information, making them a part of their own care team. However, access to data is only one part of the puzzle. Once patients have access, they should be able to easily and securely share that data with all of their care providers or whomever else they wish. This is not the current reality of the ecosystem.
While current certification criteria under the meaningful use program supports the ability for patients to transmit outside of the enterprise systems via Direct—a secure email protocol—the functionality is often limited to the relationships for which the patients’ organization has established trusted relationships. Incredibly, there is no corresponding requirement for certified technologies to be able to receive these messages. These gaps greatly hinder the user experience by limiting the ability to transmit Direct messages from patient portals. From what we have seen, some provider organizations enable their patients to use Blue Button+, which builds upon VDT and adds automation. However, many EHR vendors are refusing to communicate using Blue Button’s trust bundles (trust bundles allow organizations that are members of the same bundles to automatically trust each other without negotiating a private trust relationship). These vendors argue that they would lose their accreditation with DirectTrust, a trust bundle that facilitates communications between clinicians, because of DirectTrust’s stringent requirements for in-person identity verification. However, that process, while appropriate for communications between clinicians, is not required or appropriate for patient-provider communications using Blue Button+. For true consumer mediated data exchange to be realized, it is imperative that DirectTrust and Blue Button+ are working in tandem. Currently, both are publicly supported by ONC and striving to open communications channels, but for different use cases.
The Solution:
Requiring that certified EHR technologies (CEHRTs) support the automation aspect of Blue Button+ is vital to creating innovation that will enable patients to seamlessly collect and disseminate data from multiple sources at their discretion. Blue Button+ should be required by certified EHR technologies in order to give patients the ability to consolidate their health data using a tool of their choosing and at their own discretion. A certification that enables a patient who has registered a Direct address with the certified EHR technology should automatically receive C-CDAs and/or other forms of Blue Button data. This will create an outpouring of innovative applications and systems that process, analyze and present data to patients in numerous useful and engaging ways.
CEHRTs should also be required to support patient-provider secure messaging through the Direct protocol. The rules should prevent CEHRTs from having to utilize the same burdensome manual identity verification process for patient-provider communications that are appropriate and suitable for provider-provider communications through DirectTrust.
If trust bundles do not work, EHRs will not receive Direct messages, and patients may or may not be notified that their message was not received. Because providers are neither required nor incentivized to receive Direct messages from their patients, the transmit functionality of VDT is limited, stifling patient-mediated data exchange.
Challenge #2: Consolidated Clinical Document Architecture (C-CDA)
This might be one of the biggest challenges of the new MU requirements, and one of the most important. For patient portals to truly provide value to the patient, they need to go beyond simply providing data and clinical summaries to taking that data and making it actionable through tools and trackers that promote engagement. If the C-CDA isn’t compliant, the EHR and HIE are not affected, but patient portals are not able to parse the valuable data contained in the C-CDA to make it useful to the patient.
Unfortunately, many EHR vendors are struggling to generate and send valid C-CDAs. This has trickled down to cause major delays in attestation and soured the market view of patient portals in general. Basically, the struggles have made many providers want to throw in the towel when it comes to using patient portals.
Additionally, many EHR vendors are only able to send C-CDAs to their own proprietary patient portal. This is making it more challenging for organizations that want to go beyond “checking the box” of MU certification and avoid portal proliferation. Patients understandably expect a single “app” in which to view all of their medical information from across the whole system. Anything less is a poor patient experience.
At Get Real Health, we have seen first-hand how the inability of CERTs to produce or deliver valid C-CDAs has hindered our clients’ ability to attest to meaningful use. Because of the EHRs lagging timelines to implement MU criteria that support true interoperability, our clients and providers across the country are taking the hit. It is the providers that will lose incentive payments and run the risk of potential penalties. This means that vendor shortcomings are punishing providers and hindering their ability to move forward with more robust, long-term patient engagement strategies.
It’s also important to note that the official compliance testing tool for C-CDAs, the NIST transport testing tool, only tests the templates and vocabularies of the C-CDA, and does not perform full semantic validation.
The Solution:
It’s critical for vendors to fully support the use of the C-CDA as the standard architecture for sending clinical documents. A single standard is vital to achieving interoperability and meaningful patient-mediated data exchange. To get there, several things need to happen.
First, better online tools for C-CDA validation must be provided, including web and web service as well as other tools that can validate the syntax and semantics of specific C-CDA types interactively and programmatically. In addition, instead of replacing C-CDAs, the existing C-CDA schema should be extended to better handle discrete data elements. Robust sets of documented, compliant sample C-CDAs must also be provided that can be used as examples by vendors to help them produce better-quality clinical documents. Finally, testing for MU compliance should be extended to include failure cases and cases with missing or NULL data to ensure that CEHRT applications can still produce proper results under these scenarios.
Challenge #3: Calculating “View” for VDT
VDT Measure 2 requires that 5% of unique patients view, download or transmit their health information. Yet interpretations about how to calculate this measure vary. The reason for this is a lack of clear, unified direction from ONC and CMS. Not surprisingly, the industry has seen significant challenges in meeting the 5% requirements, resulting in CMS publishing “FAQs” to help guide Eligible Hospitals/Critical Access Hospitals and Eligible Professionals in their calculations.
But these haven’t necessarily mitigated concerns. Take, for example, the question of whether a hospital can count toward the 5% goal a patient who accesses his/her information prior to discharge. CMS’s FAQ answers “yes,” stating, “[T]he hospital may include patients found in the denominator who access their information on or before the hospital discharge date in the numerator.” It went on to add: “For patients who access their information after the hospital discharge date, the access must take place no later than the date of attestation in order for those patients to be counted in the numerator.”
This answer led organizations to believe that if a patient logs into their patient portal while in the hospital, then the patient will count towards VDT Measure 2, even if the portal contains no health information. This directly contradicts the 2014 Edition certification that states that the CEHRT must contain personal health information that the patient can view.
The Solution:
To ensure that our product properly calculates VDT Measure 2 and maintains the integrity of our certification, patients must have an encounter during the reporting period; the C-CDA associated with the patient’s encounter that occurred during the reporting period must be available to the patient in our patient portal; and the patient must log into the portal. However, the patient does not have to physically view the C-CDA associated with the reporting period.
If the patient has health information in the portal (i.e., a historic CCD, CCR, C-CDA, etc. is available), then they would count towards the numerator upon logging into the portal and prior to the C-CDA that is associated with the reporting period being available.
What’s Next?
The fact is, MU is here to stay. Despite the challenges it presents, it also gives us enormous opportunity. True, MU puts hospitals and healthcare providers on the hook for a patient’s actions—or inaction. This, understandably, produces anxiety among providers. But it also gives us the chance to develop something that truly engages patients on a level never before seen.
It’s time for health IT vendors, hospitals and healthcare providers to work together to implement real solutions that will make MU a reality—and improve healthcare while lowering costs. We’re standing on the shore, looking at the water, knowing there’s land on the other side. Now we just need to dive in and swim.
About The Author
Get Real Health Senior Strategist, Christina Caraballo, has been appointed to the HIMSS Connected Patient Committee by the HIMSS national Board of Directors based on her expertise and passion for patient engagement. As a committee member, Caraballo will help raise the bar for patient engagement and empowering patients through the use of health information technology.
“I’m honored to accept this position. My goal for this committee is to take consumer engagement to the next level by addressing the real issues and roadblocks that are hindering progress and uptake throughout the industry,” says Christina Caraballo.
HIMMS’ committees are focused on specific settings and topics for the health information technology industry. The Connected Patient Committee centers on developing tools to make decisions on when and how to connect with patients. The committee is made of up 12 members focused on educating patients and more actively engaging them in health care through social media and online discussions. The overall goal of the committee is to develop and create tools to provide reliable information to patients. The Connected Patient Committee strives to create familiarity with health information technology tools to engage patient involvement.
Get Real Health is always looking for ways to develop patients’ involvement in healthcare. Caraballo’s appointment to the Connected Patient Committee is a big honor and we couldn’t be more proud to have one of our own sitting on the committee and leading the charge as an advocate for patient engagement. Congratulations, Christina!
