Free The Data: Goals For Meaningful Use Stage 3

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The Agency for Healthcare Research and Quality (AHRQ) recently posted "A Robust Health Data Infrastructure," a report from JASON, an independent group of scientists that since 1960 has advised the US government on science and technology.

For those of us who are concerned about interoperability and worry that the Meaningful Use and EHR software certification bars may have been set too low, this report presents a potentially exciting glimpse of the future -- if the recommendations survive and actually get implemented. I'll come back to that point after reviewing some of the key recommendations.

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The ONC (Office of the National Coordinator for Health Information Technology) is clearly on board. Its new director, Karen B. DeSalvo, wrote on the agency's HealthITBuzz blog:

I am pleased that this report is consistent with our intent to support nationwide interoperability in a way that supports care, health and is flexible enough to meet the challenges of the future. The ONC and the Centers for Medicare & Medicare Services (CMS) have already begun to work on many of the recommendations cited in the report -- this represents the beginning, not the end of our efforts. The JASON recommendations continue to challenge us to stay focused on the path ahead.

The ONC and CMS work together to set standards for electronic health record (EHR) technology and promote its use through the Meaningful Use program.

The report is nearly 70 pages long and very well written. I recommend you read it since I can provide only some high-level details here. In addition to recommending a future approach to interoperability, it provides an overview of some key health IT issues (such as the VA and DOD's EHR efforts and their failure to interoperate).

Here are, in my view, the key policy points:

Now some of the key technical points:

How might all of this work? The report provides an example of a patient query within the proposed architecture:

The patient wonders if Advil will interact adversely with any of his other medications. He asks this question via his smartphone application (UI app layer). The phone establishes a secure wireless connection to a health information exchange (HIE). The Authentication Server at the HIE verifies, by key exchange, the patient's identify (establishing trust). The Patient Privacy Bundle Manager checks that the patient is allowed to access the record the smartphone app has requested (managing privacy). The Key Manager generates a unique key for this transaction, and it is transmitted to the smartphone for use in the remainder of the transaction (providing security).

The smartphone then sends the key and the request to the Search Computer. The Search Index validates the key, locates the record, and sends a request to the computer storing the record. The record is accessed via the encrypt/decrypt layer. The encrypted information and key are returned to the UI app layer, which displays the answer.

The report suggests that with modern technology, all this could happen in less than a second. The report includes a diagram showing how all these elements relate to each other and to legacy EHRs.

Wouldn't you want to be able to do this so seamlessly, easily, and quickly? I know I would. So what's the problem?

The issues are, of course, economic and political. We all know that the EHR market divides roughly into two groups of vendors: those that market to health systems, and those that market to individual provider groups (usually smaller groups these days, as the larger ones get acquired by the health systems).

The health systems want to control their data. There are some good reasons for that, but there is also the reality that they want to do what the airlines have done with their frequent flyer programs: get all the business by making it easier for patients to use their providers and facilities than to go elsewhere. (Some even try to own virtually all the service area providers and facilities, leaving few, if any, local viable alternatives.)

The enterprise EHR vendors have a similar mentality -- to provide a "total solution" for their customers. Again, there are good reasons for this (seamless integration, for example), and there are not-so-good reasons (eliminating competition in their space).

The report acknowledges that implementing the architecture will be challenging, that it could take years and might have to be done incrementally. However, it also gives us a vision of how we might weld together the pieces of our now widely adopted but fragmented and non-interoperable HIT landscape into something approaching a seamless whole. To me, that's progress.

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