Interoperability Depends On EHR Vendors: AHA

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The American Hospital Association (AHA) does not want the federal government to impose more regulations on healthcare providers to encourage health information exchange.

It would, however, like the government to demand more from electronic health record (EHR) vendors to advance interoperability at several different levels, according to an AHA letter to the Office of the National Coordinator of Health IT (ONC). The AHA sent the letter in response to the ONC's request for information (RFI) on how to increase interoperability.

From the AHA's viewpoint, healthcare payment and delivery reforms, coupled with the government's Meaningful Use requirements, are all that's required to propel providers along the path to more effective health information exchange. What stands in the way of that, however, are external barriers. Hence the AHA would like ONC "to remove barriers for interoperability and support development of a robust infrastructure for health information exchange."

[ Are poorly designed electronic healthcare record systems driving medical personnel back to paper? Read Healthcare Workarounds Expose EHR Flaws. ]

"The federal government already has a remarkable number of requirements to share information," said Chantal Worzala, director of policy for the AHA, in an interview with InformationWeek Healthcare. "If you look at the Meaningful Use stage 2 requirements, whether you're reporting to public health or sending transition-of-care documents to the next provider when a patient leaves the hospital or is referred to another physician, those requirements already exist. Also, the rules require providers to give patients access to their information via a portal."

The challenge is that providers don't have the infrastructure in place to meet existing requirements, said Worzala. "So we'd prefer that the government focus on removing the barriers to the exchange that [is] required under Meaningful Use or [is] incentivized via programs like the Accountable Care Act," she said.

Among other things, the AHA letter said that EHR vendors should be required to use the same medical terminology for 2014 certification. However, the most important such requirement in the ONC's current certification criteria -- that all EHRs use the SNOMED-CT vocabulary for problem lists -- is an issue for AHA partly because it duplicates the ICD-10 coding system that the industry must move to next year. AHA said the ONC should require the ability to "cross-walk" from SNOMED to ICD-10 in certified EHRs.

Worzala noted that SNOMED is not widely used in the U.S., even though it was developed here. AHA is concerned that providers lack the technical and educational resources and the strategic plans to implement problem lists based on SNOMED by Oct. 1, 2013, when Meaningful Use Stage 2 goes into effect for hospitals. The key challenge seems to be that doctors aren't sure how well their diagnoses will be translated into a uniform terminology like SNOMED. So healthcare organizations would like to see the mapping to SNOMED better vetted and tested. Another major conundrum for AHA is the requirement that EHRs be able to send and receive secure messages using the Direct Project email protocol. Although this is fundamental to being able to exchange clinical summaries at transitions of care in Meaningful Use stage 2, AHA is unclear on whether providers will actually be able to access these documents through Direct and incorporate them into EHRs. It would like the government to publish results of its Direct pilots with statewide HIEs.

In addition, the association wants the ONC to require vendors to incorporate the SOAP transport standard "for more robust exchange of computable data." Under the current regs, Direct capability is required but SOAP and another transport standard are optional.

Another big AHA concern is that state health departments and immunization registries might not gear up to accept electronic data from providers in time to meet the MU stage 2 criteria. The AHA urges the Centers for Medicare and Medicaid Services (CMS) to redouble its efforts in this area, while expressing appreciation for the work that's been done so far to enable nearly 1,000 hospitals to send lab data conforming to the LOINC standard to public health agencies. The association also calls on CMS to develop a website showing the ability of these agencies to receive the data that providers must send them under the MU stage 2 rules.

In addition, AHA wants the government to explore the possibility of using national provider identifiers (NPIs) to create comprehensive directories of providers for use in secure messaging. And to address the patient matching problem, which now requires provider organizations to create expensive and separate master patient indexes, the AHA suggests that HHS look into re-using the consumer ID system being developed for state health insurance exchanges. Finally, it wants the government to deal with variations in state privacy laws and strictures in the HIPAA regulations that inhibit health information exchange.

An earlier response to the ONC RFI from the College of Healthcare Information Management Executives (CHIME) requested the government to certify HIEs "via standard interfaces, standard methods for isolating sensitive information, standard means to securely transport patient care information (i.e., Direct), standard ways to accurately identify patients and standard protocols for tracking consent."

Worzala said the AHA had not spoken to CHIME about this proposal, but added, "There's a lot of agreement between AHA and CHIME on the need for technology to support interoperability."

Neither the AHA nor the CHIME letter referenced the work that is being done by the Interoperability Work Group and Healtheway to certify HIEs with the help of the nonprofit Certification Commission for Health Information Technology (CCHIT).