Health Information Exchange (the verb) requires a massively complicated boggle of policy, trust and technology issues.
In 2010 ONC chose to carve “push transactions” out of the boggle. It asked the HIT Policy Committee Privacy & Security Tiger Team to provide specific policy recommendations around pushing, which it referred to as “directed exchange.” The Policy Committee approved and forwarded the recommendations to ONC in September 2010. Three and a half years later, 97 percent of about 27.5 million transactions per month that flow through HIEs are pushed. Only about 3 percent are query-response transactions.1,2
We need more progress on queries. The same approach, carving a subset out of the boggle can work again. Epic’s Care Everywhere constitutes an existence proof that there is a workable set of queries that healthcare delivery organizations will support with automated response given the right framework of trust and operating agreements.
The open questions are whether such a capability can be expanded to multi-vendor approaches and whether it needs be operated exclusively by EHR vendors. What we don’t need is to regulate an approach based on a single vendor. We don’t even need to exactly follow the Epic model.
I am happy to report that the Tiger Team is now working on policy statements that are comparable to the 2010 effort on directed exchange. The new work targets a specific set of circumstances where health record holders may safely respond to automated queries. The policy may also support electronic transmission of the request and response even when the workflow includes a manual review of the request. As with directed query, the policy should support a number of technological solutions.
This is a very important start. Many questions remain to be answered about the appropriate standards, the degree to the industry should rely on standards vs. competitive approaches, the level of trust that must be supported and how ONC could accelerate such an effort through meaningful use Stage 3.
Notes
1These percentages were computed from data reported by Mickey Tripathi on 29 January 2013 during Tiger Team testimony on health information exchange.
2All of the pushes described in are enabled under the “directed exchange” policy. Not all of them are transmitted using the Direct protocols. Likewise, not all data sent with the Direct protocols is routed through an HIE that reports traffic to ONC. Because of the decentralized nature of Direct it is hard to assemble traffic estimates.
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