Meaningful Use Stage 3: An Urgent Checklist for Public Health

The clock is running for public health advocates to advise what should be included in Stage 3 of the Electronic Health Records (EHR) Incentive Program (“Meaningful Use” (MUse)).

January 14, 2013 is the deadline for comment on the Health IT Policy Committee’s recommendations for Stage 3.

  • A key issue is whether EHRs should be certified in Stage 3 to generate electronic public health reports using a new, standardized approach.   The Public Health Reporting Initiative is finalizing both a harmonized data element profile and a Clinical Document Architecture implementation guide in the next few weeks.*   These are based largely on the Cancer Registry reporting standard that appears in Stage 2 MUse rules and on implementations already in place for the National Healthcare Safety Network (NHSN) and recommended for Stage 3.  Adopting the PHRI approach need not require change to existing MUse reporting activities like electronic laboratory reporting, immunization registries or syndromic surveillance.  However, it provides a reusable, modular, and extensible methodology that could be leveraged by these and many other types of reporting (for example, communicable disease case reports, product safety reports, birth and death reports) into the future.
  • The public health (and health IT) communities should examine the PHRI documents to decide if they represent an achievable step toward more generic interoperability between EHR and public health surveillance systems.  If so, they will have to make their voices heard during the comment period, because MUse Stage 3 certification is NOT recommended by the HIT Policy Committee (rather, it is recommended for some future, unspecified time).
  • The Centers for Disease Control and Prevention (CDC), which funds much US public health surveillance, needs to decide and announce whether it will support pilot implementations, full-scale implementation, and health department migration to the new approach going forward.
  • The Office of the National Coordinator and CDC need to ensure that PHRI products  are harmonized with similar initiatives across the ONC Standards and Interoperability Framework, and curated and maintained over time.
  • Other important issues in the Stage 3 recommendations include EHR data capture of information like occupation and disability; whether NHSN hospital reporting should be included as a new objective; and whether additional public health registries should be offered as choices in the incentive program.
Unfortunately, these decisions are being made at a time of significant vacancies and uncertainty in the decision-making structure at CDC.   Representatives of local and state health departments, who are critical stakeholders in this process, will need to study, act and advise CDC, rather than depend on the agency.  But the CDC Meaningful Use program is sponsoring a half-day Virtual Conference on public health and Meaningful Use Tuesday, December 18 beginning at 12ET.   This should provide a good orientation to Stage 2 changes, and set a foundation for discussion of Stage 3.
Meanwhile, the urgent deadlines of MUse and ONC (sometimes labelled the “Office of No Christmas” for its December demands) loom.  Inaction over the holidays might lead to a lump of coal in the public health stocking for Stage 3.**
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* Disclosure: Author was a lead team member of the of the Public Health Reporting Initiative from October 2011-September 2012.
** References to Christmas are for humorous purposes only and do not imply an endorsement of any particular holiday or religion.  Happy holidays to all, whichever you celebrate.

The “X-Factor” for Health Information Exchange: Is competition toxic?

Early in the Wisconsin Health Information Exchange (WHIE) we realized a high likelihood of finding information for a local provider or patient was key to a successful business case.  (Techies call this “network dependency.”)  So I wasn’t surprised November 28 to hear market share penetration labeled the single item that best distinguishes sustainable from struggling HIEs by the HIE Learning Network of the National eHealth Collaborative (NeHC).  What is surprising is that HIE policy often disregards this vital factor.

At Technology Crossroads, Jeffrey Rose (ICG Group) and Delaware Health Information Network (DHIN) CFO Michael Sims presented factors identified by the Learning Network that distinguish profitable from unprofitable HIEs.  (Other factors in addition to high market share penetration are aggressive pricing and investment in product development.)  DHIN is verging on both 95% market penetration and long-term black-ink performance.  (For more on this and other Learning Network lessons, join the December 17 NeHC University webcast.)*  [Update: Dec 18: the Learning Network report has been published.]

Meanwhile, many HIEs around the country are struggling.  The eHealth Initiative’s 2012 HIE survey lists sustainability as the top obstacle, and found that over half are encountering competition from other HIEs.  They are also competing with HIT vendors providing exchange technologies directly to provider networks.

For example, the November 21 IHealthBeat reprinted a story from the Oct. 18 Tampa Tribune detailing how a public HIE serving hospitals is competing with a private HIE serving physicians.  Meanwhile, in several states, new HIE entities created by the Office of the National Coordinator (ONC) State HIE grant program compete with pre-existing regional efforts.  (Most early regional HIEs focused on medical marketplaces defined by referral patterns, not state lines.)  Adding to the confusion are statements from ONC leaders that put exchanges developed inside Accountable Care Organizations (ACOs) on the same footing as regional “all-provider” HIEs.  This fails to acknowledge that such private entities may aggressively compete, including taking information hostage.  A recent New York Times story details how increasing provider consolidation (neither citing ACOs nor excluding them) can block clinical communication with competing providers.

Perhaps, at least initially, competition is toxic for successful health information exchange.  In a 2007 eHealth Initiative report on HIE sustainability, we described social capital (resilient relationships among HIE stakeholders) as a key element for success.

An alternate scenario is that each electronic health record system will contain its own exchange capabilities (like the Direct “push” standard).  But this model still works best with a “central switchboard” managing directories, authentication, record locators, and other services that an HIE can provide.

It seems that HIE resembles mail service, electrification, telephony, highways and fire services, possibly requiring a period as publicly-regulated, public service monopolies.  Once the infrastructure is well established, competition can be introduced to accelerate innovation and price competition.   Today, however, regional HIEs are competing with Federally-funded state HIE designated entities, which are competing with for-profits and ACOs.  Meanwhile, market share is elusive, and network dependency can kill.

*Disclosure: I am currently on the NeHC University Advisory Board and a former NeHC board member.