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Restructure and Reform Meaningful Use: Here’s a Way

Posted on February 12, 2015 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

It’s no secret that ONC’s meaningful use program’s a mess. I’m not sure there is an easy way out. In some respects, I wish they would go back and start over, but that’s not going to happen. They could do something to see daylight, but it won’t be either easy or simple. As I‘ll outline, ONC could adopt a graduated system that keeps the MU standards, includes terribly needed interoperability and usability standards, but does not drive everyone crazy over compliance.

MU’s Misguided Approach

ONC has spent much time and money on the MU standards, but has painted itself into a corner. No one, vendors, practioners or users is happy. Vendors see ONC pushing them to add features that aren’t needed or wanted. Practioners see MU imposing costs and practices that don’t benefit them or their patients. Users see EHRs as demonic Rube Goldberg creations out to frustrate, confuse and perplex. To boot, ONC keeps expanding its reach to new areas without progress on the basics.

Most the MU criticisms I’ve seen say MU’s standards are too strict or too vague. Compliance is criticized for being too demanding or not relevant. Most suggested cures tinker with the program: Eliminate standards or delay them. I think the problems are both content and structure. What MU needs is a return to basics and a general restructuring.

Roots of the MU Program’s Problems

It’s easy to beat up on ONC’s failures. Almost everyone has a pet, so I’ll keep mine short.

MU1: Missed Opportunities. MU’s problems stem from its first days. ONC saw EHRs as little more than database systems that stored and retrieved encounters. Data sharing only this:

Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically.

Compliance only required one data exchange attempt. ONC relied on state systems to achieve interoperability. Usability didn’t exist.

MU2: Punting the Problems. ONC’s approach to interoperability and usability was simple. Interoperability was synonymous with continuity of care and public health reports. Every thing else was put off for future testing criteria.

ONC’s usability approach was equally simple. Vendors defined their usability and measurement. The result? Usability’s become a dead topic.


ONC has many good things to say about the need for interoperability. Its recent Roadmap is thoughtful and carefully crafted. However, the roadmap points out just how poor a job ONC has done to date and it highlights, to me, how much ONC needs to rethink its entire MU approach.

Changing ONC

In one of his seminal works on organizations, C. Northcote Parkinson said it’s almost impossible to change a failing organization. His advice is to walk away and sew salt. If you must persist, then you should adopt the heart of a British Drill Sergeant, that nothing is acceptable. Alas, only Congress can do the former and I’m way too old for military service, so I will venture on knowing it’s probably foolhardy, but here goes.

New Basic Requirements

A better approach to MU’s core and menu system would allow vendors to pick and choose the features they want to support, but require that all EHRs meet four basic standards:

  1. Data Set. This first standard would spell out in a basic, medical data set. This would include, for example, vitals, demographics, meds, chief complaints, allergies, surgeries, etc.
  2. Patient ID. A patient’s demographics would include a unique patient identifier. ONC can use its new freedom in this area by asking NIST to develop a protocol with stakeholders.
  3. Interoperability. EHRs would have to transmit and receive, on demand, the basic data set using a standard protocol, for example, HL7.
  4. Usability. Vendors would have to publish the results of running their EHR against NIST’s usability standard. This would give users, for the first time, an independent way to compare EHRs’ usability.

All current EHRs would have to meet these criteria within one year. Compliance would mean certification, but EHRs that only met these criteria would not be eligible for any funding.

Cafeteria Program. For funding, vendors would have to show their EHR supported selected MU2 and MU3 features. The more features certified, the more eligible they’d be for funding.

Here is how it would work. Each MU criteria would have a one to ten score. To be eligible for funding, a product would have to score 50 or more. The higher their score, the higher their funding eligibility.

Provider Compliance. Providers would have a similar system. ONC would assign scores of one to ten for each utilization standard. As with vendors, implementing organizations would receive points for each higher utilization level. That is, unlike current practice, which is all or nothing, the more the system is used to promote MU’s goals the higher the payments. This would permit users to decide which compliance criteria they wanted to support and which they did not.

Flexibility’s Advantages

This system’s flexibility has several advantages. It ends the rigid nature of compliance. It allows ONC to add new criteria as it sees fit giving it freedom to add criteria as needed or to push the field.

It achieves a major advancement for users. It not only tells users how products perform, but it also lets them choose those that best fit their needs.

Vendors, too, benefit from this approach. They would not only know where they stood vs. the competition, but would also be free to innovate without having to include features they don’t want.

FHIR is on Fire

Posted on December 5, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Ever since the announcement yesterday about Project Argonaut, FHIR has been getting some widespread coverage. Although, even before this important announcement, I was hearing a lot of people talk really optimistically about the potential of FHIR for healthcare. However, with Project Argonaut, you get all of these big name organizations on board as well:

  • athenahealth
  • Beth Israel Deaconess Medical Center
  • Cerner
  • Epic
  • Intermountain Healthcare
  • Mayo Clinic
  • McKesson
  • Partners HealthCare System
  • SMART at the Boston Children’s Hospital Informatics Program
  • The Advisory Board Company

That’s quite a list of powerhouses that are investing money behind FHIR. I’m excited that the majority of major hospital EHR are represented in that list. Although, I do wonder if this is a lot of the same people who ruined CCDA. Let’s hope I’m wrong and they learned their lesson.

FHIR was also the topic of today’s #HITsm chat. Here are some of the tweets from the chat that caught my eye.

How’s that for optimism about the future of FHIR? Keith is deep in the trenches of health IT standards so he’s got a very informed opinion on what’s happening.

A very good sign since everyone I talk to seems to hate CCDA. They say that it’s bloated and really not usable.

I agree with Donald. The real question I have is whether FHIR will get us open APIs to the data we want. I need to investigate more to know the answer to that question.

I generally think this is true also, but not if it is a limited set of data. If you limit the data and don’t provide write back function, then there’s a real limit on what you can do with that data. Of course, you can start with some functionality and then build from there.

I’m still early on in my understanding of FHIR. I’m doing a whole series of posts on EMR and HIPAA around interoperability and the challenges associated with interoperability. You can be sure that FHIR will be a major part of my research and discussion. The above links look like a good place to start.

Please add your thoughts on FHIR in the comments as well.

Health Datapalooza 2014 Recap

Posted on June 9, 2014 I Written By

Julie Maas is Founder and CEO of EMR Direct, a HISP (Health Information Service Provider) whose mission is to simplify interoperability in healthcare through the use of Direct messaging EHR integration and other applications. EMR Direct works with a large developer community to enable Direct for MU2 and other workflows using a custom, rapid-integration API that's part of the phiMail Direct Messaging platform. Julie is passionate about improving quality of care and software user experience, and manages ongoing interoperability testing within DirectTrust. Find Julie on Twitter @JulieWMaas.

The Health Datapalooza conference is ripe with opportunities to inspire and be inspired.  At any given session or lunch, the developer of an emerging app is seated at your left, and the winner of some other developer challenge a few years ago is on your right.  The vibe is a bit frenetic, in a good way.

At this conference, data geeks get right down to the business of discussing controversial and innovative healthcare data issues.  Nothing is watered down.  Even the Director of NIH Francis Collins, whom everyone wanted to hear play his guitar and sing, charged right in with data-rich graphs and statistics.  Jeremy Hunt of the UK offered sobering yet transparent error figures, encouraging the use of data to learn from and improve upon our safety practices at the point of care.  Keynotes from Jonathan Bush and Todd Park alleviated any need for caffeine, even though there was plenty on hand.  Countless application developers told truly compelling stories of their solutions.  Kathleen Sebelius challenged us to reconsider “the way we’ve always done it”.

What’s not to love?

I had hoped we would dive deeper into interoperability issues such as consistent data transport and payload standards.  Or, how a sensitive dependence on initial conditions such as protocol specifications, as in chaos theory, can lead to unexpected behaviors in pairwise HISP (Direct Exchange service provider) interoperability, seemingly at random.  Our data needs to be free to move about the care continuum, in order to be the most useful to us.  Gamification was suggested as a way to help patients adhere to medications.  Perhaps it could also encourage Healthcare IT companies to better adhere to specifications?

Silo was another buzzword that was used a lot last week.  That is to say, it’s a buzzword you don’t want to be associated with.  It was reassuring that we’ve set expectations properly around interoperability.  Fortunately, silos are going the way of the beeper and the booth babe.

There were some well-received promises of intense BlueButton promotion in the fall by Dr. Oz and several others.  I was also really encouraged to see the BlueButton Toolkit site preview on Sunday.  Look for more information about this when it goes live, and be sure to send Adam Dole your suggestions.  Great work, Adam!

Maybe next year at Health Datapalooza, we’ll talk about structuring the data collected by wearable devices, since we certainly heard this year about how integral to wellness quantified self is expected to be.  Quantified self and interoperability might even be considered as separate award categories in the Code-A-Palooza contest next year.  This could lead to more diversity and creativity in developers’ solutions, while helping to spur patient engagement and data transfer.

Countless examples of knowledge gleaned from large datasets, that could be used to make better medical decisions, were cited.  But this information hasn’t yet been integrated into day to day clinical workflow in a way that’s helpful to individual patients.  There’s no single source of individualized, analytics-enabled tools for patients to guide medical decision-making today.  But there will be!

A Network of Networks – Major EHR Developments Per Halamka

Posted on October 18, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud and Modular EHR Software posts), his third major EHR development from the Technology Review article is: A Network of Networks.

Halamka basically says:
-Most people think doctors and hospitals exchange healthcare information (they don’t)
-New standards are being integrated with EHR that will make it happen
-There won’t be one large database of health records
-Many regional data exchanges are happening
-There will be multiple Health Information Service Providers (HISPs)

I agree with most of these ideas. Although, I think it still faces two major challenges.

The first challenge is the standards challenge. Sure we have CCD. Oh wait, we have CCR. Oh wait, they merged, kind of. Oh wait, now CCD has multiple flavors. Oh wait, what kind of standard is it if there are multiple standards of the standard? I think you see my point.

The second challenge is whether HISPs and the other regional data exchanges have a viable future. I’ve talked to a lot of people about these exchanges and I have yet to hear someone clearly articulate a viable model for these exchanges. My favorite was the HIE expert who told me they’d figured out the model for HIE. So, I asked what it was and they gave me some convoluted answer that made no sense to me. Maybe I’ve just missed it, but I’d love to hear someone try to describe a viable HIE model.

I do predict we’ll see Fax slowly phase out over time. Although, I think it will more likely be replaced with a fax like service on the internet (Direct Project?) as opposed to some other sort of Data Exchange. It will probably best be described as Fax 2.0.