A Journey towards Clinical Interoperability
Improving service quality for each dollar spent has remained an unfulfilled ambition for the United States Healthcare industry for a long time. The first attempt in that direction was made when American Reinvestment & Recovery Act was enacted in 2009. The 'Health Information Technology for Economic and Clinical Health (HITECH)' act, which is part of ARRA, introduced the concept of 'Meaningful Use (MU)' and encouraged providers and hospitals, through incentives and penalties, to practice it. Three main components of MU are using certified EHR technology in a meaningful manner, participating in electronic exchange of health information to improve quality of care, and submitting clinical quality measures.
An Electronic Health Record (EHR) is the electronic version of a patient’s medical history which includes key details such as demography, problem, medications, progress notes, etc. Although EHRs existed before ARRA, the adoption rate among the providers was very low. With its introduction, the US EHR market size grew drastically from USD 2.8Bn in 2009 to USD 8.7Bn in 2014 with the MU mandate.
Centers for Medicare & Medicaid Services (CMS) introduced MU in three stages. The first stage was about data capture and sharing; stage two was about advanced clinical processes; and stage three was about improving outcomes. The intent was to establish simple requirements in the first stage and raise the bar higher in the later stages. CMS introduced the first stage requirements  in 2010 and the second stage requirements  in 2012. The table below provides a high level summary of the requirements in both the stages.
The key differences between the first and second stages which impacted eligible professionals and hospitals advancing from the first to the second stage are thresholds of various measures, mode and level of communication with patients, and exchange of health information with other providers. For the objectives present in the first stage, the second stage thresholds were higher.
Communication with patients was a new objective in the second stage, which mandated providers to establish a secure messaging feature using certified EHR technology to communicate with at least more than 5% of the patients. Exchange of health information is vital to meaningful use of the information. Providers were therefore required to share care records of 50% of referrals and transitions in the first stage. However, the second stage introduced additional an objective which required providers to make sure that 10% of the care records were submitted electronically, either through EHR or through eHealth exchange. Providers were also required to share at least one summary of care record with someone who uses a different certified EHR technology, or conduct a successful test exchange with CMS designated test EHR during the MU reporting period. The aim behind introducing these objectives in the second stage was to lay down foundation blocks to achieve interoperability in the future beyond MU stage three.
However today, with the MU 3 requirements  already released, the second stage compliance among providers does not look promising. As of December 2015, only 56% of all office-based physicians have shown meaningful use of certified health IT. This shows that the interest level of providers in adopting fully functional EHR technologies is not at an optimum level. The primary reason for this is that most of the providers are stuck in the first stage of MU and are unable/ unwilling to meet the second stage requirements. Many providers decided not to upgrade as they felt that the incentives are not sufficient to cover the cost and complexity. They failed to realize that the investment is important to achieve clinical interoperability. In addition to that, requirements such as communicating with at least 5% of the patients electronically, which according to providers are not in their control, discouraged them from upgrading to an MU 2 complaint system. Others who decided to upgrade, had issues in the system after it was upgraded by their EHR vendors.
The million dollar question today is whether EHR vendors will raise their standards and help providers to reap the benefits of EHR technology rather than merely ensuring compliance? Will EHR vendors act as strategic partners for providers and make their systems and processes mature enough to reap the benefits of interoperability?