New technology a 'push' toward EHR future

There is a push going on for push messaging, a likely first step in rolling out a proposed national health information network in time for healthcare organizations to use electronic health-record systems in a “meaningful manner” and qualify for federal EHR subsidy payments under the American Recovery and Reinvestment Act of 2009.

In late October, David Blumenthal, head of the Office of the National Coordinator for Health Information Technology at HHS called for pause in the planning of the NHIN.

Earlier this week, in testimony before a federal healthcare IT advisory panel, on blogs and postings to online discussions, what is beginning to emerge is the outline of what the healthcare IT world was put on hold to wait for, an outline of a “lighter” NHIN than has been the focus of much planning and development work in the past.

It is an NHIN still based on the Internet but with, in the short run at least, a reduced scope. The new, revised NHIN will focus on ready access and ease of use by healthcare providers who will be under the gun to purchase, implement and then “meaningfully” use by 2011 EHRs in time to receive the first subsidy payments under the Medicare portion of the program.

The stimulus law, defines meaningful use rather simply. To achieve meaningful use, providers must use a “certified” EHR for electronic prescribing, reporting quality-improvement measures and performing health information exchange “to improve the quality of healthcare, such as promoting care coordination.”

It is in meeting the health information exchange requirement where the new emphasis on so-called “push technologies”—for example, the movement of a care summary “pushed” from a primary-care physician's EHR to a specialist—could come to the fore. The tools and techniques needed for these sorts of messages are less complex and will be far more readily available to a broader range of providers than so-called “pull” technologies, an example of which would be the system required for an emergency room physician to search for and pull copies of a patient's medical records scattered across many provider organizations via a query placed to through a regional health information organization.

During the portion of an NHIN work-group meeting Wednesday that was open to the public, Farzad Mostashari, an ONC senior adviser, said that the government's focus with the NHIN will be on basic clinical messaging. Mostashari, a physician and the former New York assistant health commissioner, said push technology will be adequate for many of the likely transactions providers will need to perform electronically to demonstrate meaningful use. Mostashari wwas unavailable to comment for this story

The NHIN work group is part of the Health Information Technology Policy Committee, an HHS federal advisory committee created pursuant to the stimulus law.

The healthcare IT world still awaits release of a first, official set of fleshed-out definitions of what constitutes meaningful use.

Rule writers at the CMS, which will run separate and slightly different EHR reimbursement programs under Medicare and Medicaid, are expected to have something out in writing by the end of December. The stimulus law requires HHS to publish standards for EHR certification and other IT policies by Dec. 31. The law says the standards may be in the form of an interim final rule.

Wes Rishel is a vice president and distinguished analyst in healthcare provider research practice at Gartner, an IT consultancy. Rishel also serves as a member of the Health Information Technology Standards Panel, a twin sister advisory panel to the Health IT Policy Committee, also created pursuant to the stimulus bill.

On Dec. 15, Rishel posted on his blog an extended explanation, complete with diagrams, of a proposed “health internet” that would run parallel to the current Internet.

The health internet, Rishel wrote, would have its own domain names and domain name registries, with large organizations operating servers to create health “nodes” through which traffic will flow to health internet members. Members would each have their own health domain names. Health internet registrars would assign those names and compile health domain name registries.

The health internet would create a platform for basic messaging between its registered users, but would allow for growth, such as accommodating e-mail attachments, which “opens up the opportunity for health e-mail messages to be used for intersystem communications, such as receiving structured lab results, transmitting CCDs from one practice to another and transmitting information to vaccination or chronic care registries.”

CCDs in this context are clinical messages in the “continuity of care document” format developed by the Ann Arbor, Mich.,-based standards development organization Health Level 7.

“This proposal does not yet address certain features that are important for computer-to-computer transmissions including guaranteed delivery and irrefutable records of transmission and reception,” Rishel wrote. “Using this framework for e-mail and computer-to-computer messaging assures that the framework will meet specific needs and many imaginative uses not yet conceived.”

Peter Basch is the medical director for ambulatory clinical systems with MedStar Health, a member of the newly formed HIT Policy Committee work group on privacy and security, and a frequent contributor to the listserv operated by the Association of Medical Directors of Information Systems, a professional association for physicians involved in applied medical informatics.

Basch said it's hard to foresee what this new federal push toward push technology will mean or how it eventually will fit into a broader national healthcare communications scheme, but clearly, “the drive to an alternate pathway is because docs need to by 2011 to be able to talk to one another to satisfy meaningful use.”

Basch said the biggest barrier to setting up the more complex and comprehensive health information exchange organizations hasn't been technological, but social, including establishing the needed legal and trust relationships among participants.

“It takes time,” Basch said. “While it's moving in that direction, it's not going to be ready in time.”

Meanwhile, “this focus on a health internet and a method for physicians and patient to communicate with one another might be a way to accomplish much of the work that a health information exchange might do. Unlike health information exchanges, which you have to explain to people, this is just sending a report or a document to another physician via e-mail and fax, only it will be more secure.”

“No one is talking about eliminating” HIE organizations, Basch said. But most doctors “aren't doing anything right now” electronically, he said, so a small step toward basic messaging could be the right place to start.

“Is this the ultimate solution?” Basch said. “I don't know, but it is certainly something to get people moving. And the nice thing about getting people moving is, taking the next steps could be easier.

“It may be we use a hybrid model, something for pull and something for push, or maybe none of the above as something comes up as a more feasible idea,” Basch said. “The point is, you don't have to do one to the detriment of the other. The marketplace of ideas will determine what wins out.”

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