For clinicians participating in the federal EHR Incentive Program (Meaningful Use), Stage 2 of Meaningful Use (MU2) is right around the corner (2014). No one yet has EHR software that is certified for MU2, given that vendors are just becoming certified this year. So, from a clinician perspective, it is hard to imagine how using current EHR technology (which is all Stage 1) will do the things being required to successfully reach the Stage 2 goals. Upgrades will be necessary, and what it will all look like remains largely unknown.

Two areas of particular importance emphasized in Stage 2 are increased patient engagement and increased messaging between clinicians across different platforms. Let’s look at each of these and see if some kind of bridging technology might achieve both goals.

Patient engagement
Some EHRs have a patient portal already; some don’t, and instead rely on pushing data out to some external platform like Microsoft Health Vault. MU2 insists that a clinical practice have a way for patients to see their records, at least in summary form, and be able to securely communicate with the practice electronically. Not all EHRs have patient portals that allow secure messaging with patients (e.g. Practice Fusion does not), while others do (e.g. Epic, eClinicalWorks, and several others).

However, even if all EHRs create patient portals that allow secure messaging between patients and clinicians, there is still the dilemma facing the patient of “too many interfaces.” Each physician can give a patient a login to view their records from that physician’s practice, and communicate with them, but, unless the patient’s health care is being delivered by an Integrated Delivery Network (IDN), such as Kaiser, where there is a single patient chart across the entire enterprise, the reality is that each specialist seeing the patient is in a separate silo, using different EHRs, and needing separate logins.

The fragmentation of health data becomes evident with “too many interfaces.” The impact on adoption from the patient’s perspective can be significant – if there are simply too many places to log into in order to communicate with each and every physician in the care team, then why bother. A phone call may be easier, which defeats the purpose of the MU2 intent.

The goal we need to achieve is a single dashboard where patients can see data gathered from each and every care team member, and can communicate with each one from a single place. Such technology does not yet exist, but will undoubtedly emerge simply due to the market need for it.

Will this come from EHR vendors? Probably not. Why should they exchange data with competitors? More likely, vendors will simply do the minimum amount of upgrade needed to “pass the test” for MU2, and not much more. Instead, such innovation will likely come from outside any given EHR vendor, but will need to interoperate with each one – that is the trick, and the hard part for such technologies. They must do this in the background, so that the patient experience is a single dashboard that pulls it all together.

Peer-to-peer clinician messaging
The other area of emphasis in MU2 is for clinicians to be able to easily message each other in a secure way, moving beyond the realm of faxes which dominate this activity today. This can take on several forms, and can be illustrated with several use-cases:

(1) peer-to-peer communication for a clinical referral, sending the recipient the needed information to make the referral useful (and include the administrative authorizations needed so that the referral gets paid)

(2) push-messages from clinical laboratories or radiology imaging services with critical lab values or positive x-ray findings

(3) notification of hospital discharges to community physicians, so that follow up can be carried out by the PCP (after all, prompt post-hospital follow up by PCPs is perhaps the most important thing that reduces 30-day readmission rates for hospitals)

Within hospitals, there is also need for secure messaging. Many hospital services are done by teams on different shifts. Emergency Departments, Intensive Care Units, hospitalist services – all are organized such that a given clinician needs to sign out all the current patients to the next shift. This is done by various secure messaging platforms (usually separate from the hospital’s EHR system), and is sometimes done by simple non-HIPAA-compliant SMS messaging (to the horror of many a CMIO).

The kinds of messages that can be transmitted are becoming more standardized. The CCD and CCR formats contain summary data that is useful, though not fully detailed for use in an outpatient referral (one needs the ability to create a narrative text describing the clinical concern in ways more useful than are captured by CCRs and CCDs). Nevertheless, this is a step forward.

In order to get information, whether a CCD, CCR, or other information (like a PDF image of an EKG, or lab values, or a text-based narrative) from one EHR system to someone else, a secure messaging protocol is needed. The Direct Project has emerged as the easiest way to get there, and is a requirement for all MU2 EHRs – it is simply a secure email-like system, where an email (with attachments) can be sent, assuming you know the recipient’s Direct email address.

The biggest drawback of the Direct Project method of sending mail is that you have to know the recipient’s Direct email address – there is no way of searching or indexing addresses, the way that Active Directory does in an enterprise email system. This means that a clinical office must call the recipient first, and ask them for their Direct email address, before being able to send anything. Additionally, Direct email addresses are served by Health Information Service Providers (HISPs), and it seems that everyone wants to host their own HISP. Hence, it is possible that, like with plain email, a given clinician may have several different Direct email addresses (one for each HISP), which can get confusing. Nevertheless, this represents an advance over the status quo.

Putting it all together
One of the more exciting areas of health IT innovation ties these two areas together. Of necessity, such “bridging technology” is emerging from companies outside existing EHR vendors.

Step one of such technology is creating easy-to-use clinician messaging that can serve within hospitals, and also can reach outside those enterprises in order to deliver messages to community clinicians. Such messages can be hospital discharge notifications, and critical lab values. The MU2 requirement for messaging across platforms for transitions of care can be satisfied this way.

Step two, then, is for ambulatory clinicians outside the hospitals to use this same platform for messaging each other, taking advantage of Direct protocols to get that done. A searchable Active Directory-like capability can be built here, so finding a colleague can be done reliably, securely, and on-line (eliminating the need for phone calls). These kinds of messages can include CCRs, CCDs, text, PDFs, JPGs of images, and even voicemail MP3 messages.

Step three is to expand this technology to include patients in the conversation. This involves securely identifying and validating patients, which is not easy but can be done with technology available today. Then, patients can be “cc’ed” on messages between clinicians, or can be messaged directly. Conversely, patients can message any of the clinicians on their care team. This can then be expanded to have a universal patient portal that includes all members of the care team, regardless of the EHR they use. Given that one of the MU2 criteria is that at least 5% of a clinician’s patients use a portal to see their records (at least once during the year), such a unifying portal can give each member of the care team credit whenever a patient signs in to their unified portal.

Conclusions
It is certainly possible to build technology, based on clinical messaging, that addresses both the peer-to-peer communication needs, as well as the patient-engagement needs required by MU2. Such technology is still in its infancy, and MU2-ready EHRs are not yet out in the market, but over the next year or two, the face of health care information technology will change dramatically. The proprietary EHR-centric walls will come down, largely due to technologies outside traditional EHR vendors, but required by MU2 policy. Clinicians and patients – in short, the market – demand that such capability be created. I remain excited at the efforts that are starting to emerge in this domain.

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Dr. Robert Rowley is a practicing family physician and healthcare information technology consultant. This article was first published on his blog. From its inception through 2012, Dr. Rowley had been Practice Fusion’s Chief Medical Officer, having created the underlying technology in his own practice, and using that as the original foundation of the Practice Fusion web-based EHR. Dr. Rowley brings a depth of experience and expertise in health care as well as health IT, having been in clinical practice for 30 years, including experience as a Medical Director with Hill Physicians Medical Group and as a developer of the early EMR system Medical ChartWizard. His family practice in Hayward, CA has functioned without paper charts since 2002.