Achieving Nationwide Interoperability in eHealth Exchange
Now known as the eHealth Exchange, the nationwide health information network that Blumenthal referred to in 2011 consists of standards, services, and policies for secure exchange over the Internet. As is the case for HIEs, the eHealth Exchange supports bidirectional and directed exchange (Healtheway, 2014). The eHealth Exchange standard adopted for bidirectional exchange is Integrating the Healthcare Enterprise (IHE) (Healtheway, 2014). Technically, a framework as opposed to a standard, IHE’s approach is to support the use of existing standards that are constrained by IHE profiles and are specific to a domain (IHE, 2014). When clarifications or extensions to existing standards are necessary, IHE refers the recommendations to the relevant standards bodies. As such, while IHE may be considered to cross foundational, structural, and semantic interoperability boundaries, the IHE Information Technology (IT) Infrastructure domain addresses foundational interoperability (IHE, 2013).
Shifting of Policies and Priorities
The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible healthcare professionals and organizations that adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology (CMS, 2015a). Started in 2011, Meaningful Use was initially tied to ONC 2011 certification standards (CMS, 2012a). When the Stage 2 Final Rule came out, the Program was tied to ONC 2014 standards. Progressive use of certified EHR technology is expected as providers advance in meaningful use stages (ONC, 2014g). A 2014 RAND report is critical of this program and CMS and ONC policies, describing a “striking lack of interoperability” between health IT systems in the United States, and “watered down requirements for connectivity” that effectively promoted the adoption of existing, proprietary platforms (RAND, 2014). Indeed, Meaningful Use Stage 1 included and later retracted the objective that required a test of electronic exchange of key clinical information (CMS, 2012b). Blumenthal defended HHS’s actions, stating that the “pipes needed to be built first and that they [the ONC] needed to start where they thought the industry was at.” HHS’s weak policies, the RAND report suggested, permitted health care providers to purchase EHR systems that did not have the level of connectivity envisioned by the HITECH Act (RAND, 2014).
The ONC was equally guilty of shifting focus over the years. Prior to 2010, the ONC promoted HIEs and bidirectional exchange. Beginning in 2010, they altered course, promoting private health information exchange networks and directed exchange (Lenert, Lenert, & Sundwall, 2012). Quoted from ONC’s 2011-2015 Strategic Plan (ONC, 2011): ONC is also making it easier, faster, more secure, and less expensive to transport health information. The Direct project at ONC enables a simple, secure, scalable, standards-based way to send authenticated, encrypted information directly to known, trusted recipients over the Internet. Direct is a national solution to health information exchange that can rapidly lower the cost and complexity of local interfaces between providers, laboratories, hospitals, pharmacies, and patients, in turn substantially lowering the cost of providing information exchange services. Rather than continuing to foster state and regional health information exchanges, the ONC Strategic Plan also gave their nod of support to “hospital networks and group provider practices that were developing private information exchanges and vendors who were developing ‘information networks’ for their customers” (ONC, 2011). SDEs received a program information notice from the ONC informing them that their HIE strategic and operational plans needed to be modified to include Direct (ONC, n.d. c).