EHR standards proposal falls short on information exchange, expert says

EHR certification standards within the proposed Meaningful Use Stage 2 criteria is deficient in one important respect, according to John Loonsk, M.D., a former official of the Office of the National Coordinator of Health IT (ONC) who is currently chief medical officer of CGI Federal. The requirement that EHRs include SMTP messaging capability falls far short of what EHRs will need in the future, he writes in a Government Health IT commentary.

The main reason, he said, is that this venerable store-and-forward protocol, which is widely used in e-mail, is capable only of pushing messages from one provider to another. Robust health information exchange, he noted, also requires the ability to pull data by querying databases. Other data transport methods, including Web services and REST, can accomplish that, he says.

The Direct secure messaging protocol used by many providers and health information exchanges is based on SMTP, Loonsk acknowledged. But Direct could be rewritten, he said, to utilize REST or Web services, which is the transport system used for push messaging in the Nationwide Health Information Network (NwHIN).

Adding a little intrigue to this somewhat technical discussion, Loonsk said that the emphasis on SMTP in the notice of proposed rulemaking resulted from a struggle between three different camps within the Health IT Standards Committee, which advises ONC. The people who supported the non-SMTP approaches canceled each other out, so the SMTP camp won, he says.

As a result, Loonsk says, the store-and-forward infrastructure, which he views as a technological dead-end, is likely to be baked into EHRs and HIEs for years to come.

Meanwhile, ONC has launched a Query Health initiative to enable researchers and others to search the databases of HIEs and individual providers. According to a description of the initiative on ONC's Standards & Interoperability wiki, "A standardized clinical information model and a common method for querying data sources are critical to enabling and simplifying data aggregation across widely distributed EHR systems."

This model can be used to aggregate data for "quality measures, disease outbreaks, comparative effectiveness analysis, efficacy of drug treatments and monitoring health trends," the document notes. It adds that the initiative will be aligned with EHR certification criteria and Meaningful Use requirements.

The other parts of ONC's health IT strategy, laid out in a recent Health Affairs paper, include "directed exchange," such as Direct Messaging, and "patient-mediated" exchange, which allows patients to obtain their own health records online.

To learn more:
- read Loonsk's commentary
- see the S&I wiki description of Query Health
- check the Health Affairs paper

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