EHRs Certified for Meaningful Use Program Aren't Interoperable, EHR Vendors, AMA Say

By Alex Ruoff  

July 28 — Electronic health record systems certified for use in Stage 2 of the meaningful use program are often incapable of exchanging patient health information with other EHR systems, IT vendors and health-care industry representatives said July 28.

Technology vendors told the Health IT Standards Committee's implementation workgroup that the templates often contain coding errors and variations, meaning health-care providers and hospitals can't easily exchange patient data using the templates, a Stage 2 requirement.

Vendors disagreed on the extent to which these issues were preventing the flow of data among health-care providers, but one vendor representative said that only a fraction of her company's clients have successfully exchanged data with another health-care organization.

The electronic templates—known as the consolidated clinical document architecture or C-CDA—are commonly coded improperly by EHR vendors, preventing the EHR systems from using the template to automatically exchange information between electronic record systems, Arnaz Bharucha, senior technology officer for iPatientCare, an EHR vendor and medical informatics company based in Woburn, Mass., said.

While some data can be transmitted between providers exchanging C-CDAs, the EHRs often can't process all the data automatically, forcing providers or their staff to manually input patient data sent via C-CDA, she said.

“When you're talking about interoperability, the main thing is importing the discrete data and getting value from it,” Bharucha said.

Cris Ross, chairman of the implementation workgroup, said the workgroup is considering recommendations for “constraining” the C-CDA that would prescribe stricter rules for vendors seeking to certify their systems for use in the meaningful use program. He said this could reduce the variation in C-CDA coding, but could limit vendors' ability to provide their customers with unique ways of exchanging data or incorporating it into their record databases.


Bharucha and other vendor representatives recommended that the ONC start “real-world” testing of EHR systems as part of its certification program. She said this would flag interoperability issues before they reach health-care providers, who typically purchase certified EHR systems expecting them to be interoperable with other certified systems.

EHR vendors must demonstrate that their products can read and exchange C-CDA documents in order to be certified for use by providers or hospitals in Stage 2 of the meaningful use program this year, which began in October 2013 for hospitals and Jan. 1 for providers. To qualify for Medicare or Medicaid incentive payments under Stage 2, providers and hospitals must exchange health histories for 5 percent of their patients referred to another health-care provider or organization for treatment.

The C-CDA template was designed by the health IT standards organization Health Level 7 to simplify and streamline the electronic exchange of health information among providers and hospitals. The ONC adopted the template standard for Stage 2 of the meaningful use program.

A study published in June in the Journal of the American Medical Informatics Association found that providers in the meaningful use program were consistently unable to exchange C-CDAs without generating errors due to variations in clinicians' methods for recording patient health histories.

Researchers for that study found 11 “trouble spots” in the C-CDA documents that were generating errors during the exchange of data among provider organizations. These trouble spots included misuse of the code system for reporting laboratory and clinical observations, omission of dose quantity in medication history and omission of allergy history.

Use of C-CDAs

Some EHR vendors told the workgroup July 28 that, despite variations in coding, their EHR systems are interoperable with other ONC-certified systems and their clients are regularly exchanging C-CDAs.

Charles Curran, who leads product management for technology vendor RelayHealth, which supports C-CDA processing for its parent company, McKesson, said his clients are exchanging more than 5.5 million C-CDA documents each month. RelayHealth also works with members of the CommonWell Alliance, a collection of EHR vendors that in 2013 agreed to work together to improve interoperability.

Curran said his clients are capable of parsing and aggregrating the discrete clinical information from a transmitted C-CDA to a consolidated record, meaning their EHRs can automatically incorporate data directly from the template into the physician's electronic record database, widely considered the standard for interoperability.

“Based on our extensive experience, we believe that the industry is making progress in interoperability,” Curran said.

However, he said, the use of C-CDA documents brings limitations for health information exchange without the assistance of an intermediary such as RelayHealth. Most health-care providers receive a “vendor-specific” C-CDA that is readable only by limited EHR systems, Curran said. He added that C-CDAs can be dozens of pages long and contain only basic information about a patient, such as name, address and a list of known medications prescribed to them.

Emily Richmond, senior product advisor for EHR vendor Practice Fusion, said less than 8 percent of her company's customers have sent a C-CDA document to another health-care provider and less than 1 percent of Practice Fusion customers have both sent and received a C-CDA document. According to the company's website, more than 100,000 providers use Practice Fusion EHRs.

She said the current standards required by the ONC for EHR certification and the implementation guides published by the agency “allow a great deal of variability, which results in different interpretations when developed and configured by different organizations.”

AMA Response

Health-care provider organizations have pointed to the variability of the C-CDAs as the reason many providers can't exchange them.

Matt Reid, with the American Medical Association, said C-CDAs are considered “open templates,” meaning vendors can make adjustments to their layout or add sections to the template for their customers. This option, he said, is creating the most significant barriers to exchange.

While most C-CDAs contain laboratory test results, lists of prescribed medications and a record of known allergies, some contain other pieces of data that EHRs from other vendors aren't capable of processing, Reid said.

The ONC's EHR certification program tests whether an EHR system can create the data elements required to populate a C-CDA, Reid said, but that test doesn't require the vendor to produce a C-CDA or demonstrate exchange. More rigorous testing would ensure that EHRs certified for use in the meaningful use program are interoperable with each other, he said.

The ONC, Reid said, should also publish new implementation guides and constrain the C-CDA's optionality “at a more granular level and create a site for public samples” of C-CDAs for vendors to use as guides.

To contact the reporter on this story: Alex Ruoff in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at