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Data Exchange Update


Meeting meaningful-use requirements for EHRs will demand interoperability between data systems. Do you have a strategy for connecting online with pharmacies, labs, other physicians, and patients? Here’s our primer for achieving connectivity and meaningful use.

Roughly half of the government requirements for “meaningful use” of EHRs are related to electronic connectivity. Therefore, to obtain federal subsidies for your purchase of an electronic health record (read “EHR Incentives Update,” February 2010, at you must have a strategy for connecting online with pharmacies, labs, other physicians, and patients.

Internist and hematologist/oncologist Edward Gold, a partner in Old Hook Medical Associates in Emerson, N.J., says his group has such a strategy. The 22-doctor practice has been using an EHR from Sage Software for several years, so it has already gotten through the hard part of adapting its work flow to the program. Most area pharmacies are accepting the doctors’ online prescriptions through the Surescripts network, and the practice receives most lab results electronically from its in-house lab and the Quest and LabCorp reference labs.

That’s the easy part, says Gold (although as we’ll see, it’s not so easy for every practice). What’s going to be hard for Old Hook is sending online referrals and transmitting health maintenance alerts and copies of records to patients electronically. For example, when Gold wants to refer a patient for a CT scan, he generates the referral in his EHR and prints it out with the diagnosis, the reason for the test, and his instructions. Then he hands it to the patient, who takes it to an imaging center. Gold doesn’t send referrals electronically, because no one else in his area can receive messages through the secure messaging service that Sage offers.

Old Hook is currently adding the Sage patient portal, which will allow the doctors to communicate online with patients. That will satisfy another meaningful use requirement.

Gold is sure that his practice will qualify for federal subsidies. But he notes that it has taken the group years to get to this point, and he wonders how physicians who are new to EHRs will be able to show meaningful use. “EHRs don’t come out of the box that way,” he says. “They come out of the box with some components loaded and a lot of things that have to be done by the practice itself.”

Nevertheless, physicians who have full-featured EHRs or acquire them in the near future should be able to meet the connectivity requirements - if they take certain steps. Remember, however, the criteria could change when the Department of Health and Human Services (HHS) issues its final regulations in a month or so.

Electronic prescribing

HHS’ “Notice of Proposed Rulemaking” for the first phase of meaningful use states that physicians must send at least 75 percent of their prescriptions - excluding controlled substances - online to pharmacies. Depending on where you live, this should be simple to achieve if you have an EHR with electronic prescribing capability. According to Surescripts, a company formed by the pharmacy trade associations to connect physician offices with pharmacies, 85 percent of chain pharmacies and 62 percent of independent drugstores now accept electronic prescriptions. The physicians interviewed for this article had no trouble in this respect. But make sure that most of the pharmacies you deal with are online with Surescripts.

Second, check with your vendor to make sure that your EHR connects with Surescripts, either directly or through a secure messaging service. Although you don’t need to look at a patient’s eligibility, plan formulary, or medication history in the first stage of meaningful use, you should ask your vendor whether those Surescripts features are available. They’re useful now and may be required in the future.

Lab connectivity

The Stage 1 regulations require practices to show that at least 50 percent of the lab results they receive are stored in their EHR in structured form. This means that those values must be in the proper fields in your EHR; it’s not sufficient to scan in faxed reports. And, because it’s so expensive and time-consuming to enter these results manually, you will need interfaces with your main labs to meet this criterion.

Ideally, these should be two-way interfaces that can be used to send orders as well as receive results. Initially, physicians have to enter 80 percent of their orders into their EHRs, but don’t have to send them electronically. Later, however, the government will require electronic orders. Leading EHRs can already transmit orders to labs that are able to accept them.

Luckily for physicians, the big national labs - Quest and LabCorp - will pay for EHR interfaces and are already integrated with the top systems, according to Bruce Kleaveland, a Seattle-based health IT consultant. But these companies control only about 30 percent of the total lab business. The rest consists of regional, hospital, and internal labs in practices.

Regional lab companies might not build an EHR interface unless a practice provides sufficient volume, Kleaveland notes. The willingness of hospitals to interface with practice EHRs varies greatly; depending on factors such as the EHR and the size of the practice. But not all small practices are excluded. For example, Grove Medical Associates in Worcester, Mass., which includes three internists and an endocrinologist, has an interface between its eClinicalWorks EHR and the Meditech system at the local hospital lab. The hospital was willing to provide the interface because Grove sends most of its tests there.

To help practices achieve meaningful use, vendors have been increasing the number of labs with which their systems interface. In addition, many hospital systems use secure messaging services such as RelayHealth, Axolotl, Medicity, and Kryptiq to deliver results to the EHRs of staff physicians. And there are other companies that facilitate results delivery. For example, Emdeon, the largest claims clearinghouse, provides a hub that allows Old Hook Medical Associates to connect with Quest, LabCorp, and its in-house lab through a single interface.

To ensure you have sufficient lab connectivity, you should find out what’s available to you - and how much the vendor will charge to build an interface to your in-house lab, if you have one. Factor this into your thinking when you pick an EHR.

Physician-to-physician messaging

The Stage 1 rules require you to perform one test of clinical data exchange with another physician or healthcare entity that has an EHR that’s different from yours. That doesn’t seem like a lot, but it can be difficult to do.

Moreover, the government promises that it will expand this requirement once the necessary infrastructure is in place across the country. Among the “key clinical information” sets you may send to another physician are problem lists, medication lists, allergies, and diagnostic test results. The regulation doesn’t specify the format for these clinical summaries, but the one that leading EHRs use is called the Continuity of Care Document (CCD). This is a standardized electronic document that includes all of the above data and that can be exchanged by disparate EHRs.

The problem with the CCD is that few practices are using it yet. “I have the operational capability to send CCDs, but it doesn’t happen much,” says family physician Christopher Crow of Village Health Partners in Plano, Texas. “We securely message documents to other practices all the time. But the CCD hasn’t become a standardized way of exchanging data, at least in our area.”

Crow doesn’t need to exchange CCDs to meet the meaningful use test. By using the Kryptiq messaging service attached to his GE Centricity EHR, he can already do online referrals. But this is not the case yet in most areas. Kryptiq is imbedded in a few EHRs such as Centricity and Sage Intergy, but only physicians who use Kryptiq can exchange messages. Axolotl, Medicity, and RelayHealth also provide secure messaging to the staffs of their hospital customers. But if you’re outside of their networks, you’re out of luck. In addition to this kind of fragmentation, the paucity of physicians who have EHRs and secure messaging explains why CCDs are so little used in doctor-to-doctor communication.

So what can you do to ensure that you’ll meet this requirement? First, talk to your vendor. Most companies are guaranteeing that new customers will be able to show meaningful use, so challenge them to help you do that. (You should also ask them about the requirement that physicians test electronic links with public health agencies and immunization registries. Few such links exist yet, but NextGen is already offering interfaces to registries from its EHR. It also provides a tool to show that doctors have tested interoperability with public health systems.)

Second, do everything in your power - which, admittedly, may not be much - to encourage the formation of health information exchanges (HIEs) in your area. The federal government has earmarked nearly $600 million for state efforts to build HIEs, and there are roughly 200 HIEs in various stages across the country.

Before communitywide HIEs are widespread, hospital systems will take the lead in providing connectivity to physicians on their staffs. That won’t necessarily include private-practice doctors, however.

Tom Landholt, a partner in three-doctor family practice in Springfield, Mo., has firsthand experience of this. Like Grove Medical Associates, Landholt’s group sends most of its labs to the local hospital, which built an interface to its EHR for lab results. But, although he has secure messaging in his Centricity EHR, he can’t send orders electronically or refer online to any of the physicians employed by the hospital. They all have an EHR, but it doesn’t communicate with nonhospital-owned practices. The same is true for the other area hospital, which uses a different EHR. With federal funds being dangled in front of them, however, the hospitals are finally starting to talk about a communitywide HIE, and Landholt is involved in the discussions.

Health maintenance alerts

If you’re an EHR user, you probably think of health maintenance alerts as pop-ups that remind you to check on preventive or chronic care when a patient visits. But the meaningful use rules require something more. You must send reminders for preventive and follow-up care to 50 percent of patients who are 50 years old or older.

Generating these reminders from your EHR is a challenge in itself. For example, Landholt’s Centricity EHR can create lists of patients who need particular services, such as HbA1c tests or retinopathy exams, and send them messages. But he doesn’t have e-mail addresses for all of his patients. Even if he did, the EHR doesn’t automatically generate reminders that trigger messages at set intervals. In contrast, Gail Cetto, administrator of Grove Medical, says that her practice’s eClinicalWorks EHR can do that.

The other challenge is that you need a patient Web portal and a secure messaging system to contact patients online. (However, some EHRs generate letters, and, of course, phone calls are always an option.) The top EHRs do have these portals and some kind of secure communication link to let patients know when they have a message from their doctor on the portal. That message might concern a health maintenance alert, a lab result, or general information about immunizations or wellness programs. In addition, patient portals can be used for appointment and refill requests, previsit questionnaires, and online consultations.

Online medical records

Meaningful use requires physicians to provide electronic copies of medical records within 48 hours to 80 percent of patients who request them. One way to do that would be to send patients CCDs through secure messaging or give them an encrypted USB key. (Grove Medical is considering the latter.) Few practices outside of behemoths like Kaiser Permanente and Cleveland Clinic are uploading data from their EHRs to personal health records that are stored on a patient portal or on a service like Microsoft HealthVault or Google Health. But Crow says that when he enters certain data into his EHR, it automatically populates fields on the patient portal.

Leah Canvasser, director of IT for Infinity Primary Care in West Bloomfield, Mich., says it’s rare for patients to request copies of their entire medical record online. Most often, they ask for lab results, immunization records, and blood pressure readings, and Infinity can send that data from its NextGen EHR to a patient portal.

The key to meeting this meaningful use requirement is to find out whether your EHR can generate a CCD or some other kind of clinical summary and automatically send it to the patient portal. Otherwise, choose some other method to give patients electronic copies of their records.

Some physicians are skeptical that small practices in particular will be able to meet these connectivity requirements unless they’ve been using an EHR for some time. Medical societies and the Medical Group Management Association have expressed similar concerns. But if you pick the right EHR, ask the right questions, and are in the right situation for connectivity, you can satisfy the meaningful use criteria for 2011. Be sure to do your homework so that you won’t be disappointed when it comes time to queue up for the government incentives.

Ken Terry is a New Jersey-based freelance writer and the author of the book “Rx for Health Care Reform.” He can be reached at Physicians Practice.

This article originally appeared in the June 2010 issue of

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