Meaningful Use as an Interoperability Accelerator

I was recently interviewed about the incredible growth of e-prescribing transactions over the past year. Here's the data:

Electronic requests for prescription benefit information grew from 79 million in 2008 to 303 million in 2009.

Prescription histories delivered to prescribers grew from over 16 million in 2008 to 81 million in 2009.

Prescriptions routed electronically grew from 68 million in 2008 to 191 million in 2009.

The number of prescribers routing prescriptions electronically grew from 74,000 at the end of 2008 to 156,000 by the end of 2009 – representing about 25 percent of all office-based prescribers.

At the end of 2009, Surescripts provided access to prescription benefit and history information for more than 65 percent of patients in the U.S. on behalf of payers and pharmacies.

At the end of 2009, approximately 85 percent of community pharmacies in the U.S. were connected for prescription routing and six of the largest mail order pharmacies were able to receive prescriptions electronically.

What were the drivers?

*Alignment of incentives i.e. meaningful use requires it, private payers are offering pay for performance incentives, and it reduces labor costs in the office.

*Availability of EHR software with the capabilities needed to e-prescribe

*Increased adoption by large clinics and health systems

*Education and awareness programs.

*State and regional level initiatives

Based on this eRx experience, I believe that meaningful use will accelerate all 6 interoperability transactions required for 2011. These exchanges include:

1. ePrescribing (includes eligibility, formulary, history, routing, refill).

2. Patient engagement - sending reminders to patients, providing patients with an electronic copy and access to their records

3. Checking insurance eligibility and submitting claims

4. Capability to exchange key clinical information among care providers and patient authorized entities

5. Capability to submit data to immunization registries, provide syndromic surveillance and lab data to public health agencies

6. Quality measurement and reporting

Although vocabulary and content standards for all these transactions are well specified in the Interim Final Rule, the details of transmission are missing. The NHIN Direct project was established to prototype transmission approaches for several use cases including

*Primary care provider refers patient to specialist including summary care record

*Primary care provider refers patient to hospital including summary care record

*Specialist sends summary care information back to referring provider

*Hospital sends discharge information to referring provider

*Laboratory sends lab results to ordering provider

*Message sender receives delivery receipt

*Provider sends and receives data with minimal HIT technology

*Provider sends patient health information to the patient

*Hospital sends patient health information to the patient

*Provider sends a clinical summary of an office visit to the patient

*Hospital sends a clinical summary at discharge to the patient

*Provider sends reminder for preventive or follow-up care to the patient

*Primary care provider sends patient immunization data to public health

*Provider or hospital reports quality measures to CMS

*Provider or hospital reports quality measures to State

*Laboratory reports test results for some specific conditions to public health

*State public health agency reports public health data to Centers for Disease Control

*Pharmacist sends medication therapy management consult to primary care provider

*A patient-designated caregiver monitors and coordinates care among 3 domains

*A Provider EHR orders a test

*A patient sends a message to the provider

Once data generators - eligible professionals and hospitals - can export their data in standard formats via uniform transmission approaches, many next steps will follow:

Public Health organizations can aggregate de-identified laboratory data to follow H1N1 outbreaks.

Quality Measurement organizations can aggregate data for Physician Quality Reporting Initiative (PQRI) reporting.

Clinicians can send summaries to other providers and to patients via secure messaging approaches. Disease registries can be built as summaries are exchanged.

Once data is recorded in repositories using controlled vocabularies and standards-based metadata, novel architectures are possible.

At Harvard, the Clinical and Translation Science Awards (CTSA) funded a federated data atomic query mechanism called SHRINE.

Here's how it works.

Using a web-based graphical user interface, a clinical researcher can design an arbitrary query such as

"How many patients taking Vioxx have a diagnosis of myocardial infarction"

SHRINE first queries the metadata mapping at the border of each organization i.e. is medication name and diagnosis data available?

Once the metadata indicates a search is possible, a distributed query is launched to each site. De-identified counts of patients matching the search criteria are returned to the user. Here's an example.

The journey toward interoperability starts with electronic capture of data in standards based formats. Transmission standards for getting the information from place to place are the next step. Finally, novel aggregation and query systems will evolve as standards-based repositories are built. Many architectures will be developed to support many use cases with varied requirements.

It is all part of an evolution empowered by regulations issued by ONC and supported by the HITECH stimulus. Meaningful use will be a real driver of interoperability over the next 5 years.