Normally, you would assume that by the time you reach Stage 3 of a three stage technology implementation process, you’re close to the end of the process.

At the very least, it seems reasonable to assume that the technology in question is both technologically advanced and fully and expertly used.

But with meaningful use, are any of those assumptions safe?

Two articles lead us to that question. The first announces that while implementation of Meaningful Use Stage 3 is still “three and one-half to four years into the future”, it’s increasingly on policymakers’ minds.

What’s in store? “Simply put: Physicians and hospitals will need to integrate more clinical decision support (CDS) into their practices and coordinate care more extensively to meet meaningful use measures in 2016.”

Digging in a little deeper, the article points out that “many of the measures in Stage 3, such as sharing care summaries and care plans, rely on health information exchange, which is proposed in meaningful use Stage 2 requirements. However, a number of committee members said that exchanging information, especially beyond vendor boundaries, is very difficult. . . . Exchanging data is expensive to take from one system and put it in another system, without addressing underlying problems in support, cost and safety issues and an inability to secure data when moving between different standards and processes. The core problem is standards, for data, transport and patient identification.”

Now let’s jump to the musings of this doctor and informaticist. He’s wrestling with how much is involved in moving EHRs forward technologically.

For example, “There are no definitive guides on fundamental clinical algorithms, clinical data structures, or design patterns that are common to clinical software. We have SNOMED, HL7, ASTM and the like, but little about how to design, build, and test systems. In other words, there is no handbook of clinical software engineering.

“Lacking such guides, where can one find the expertise required to create better clinical software? The obvious answer is the growing pool of clinical informaticists. However, this addresses only part of the problem. Sure, clinical informaticists understand clinical concepts, but how many have been trained to understand and communicate the computational aspects of clinical concepts to software engineers? Acting as a resource requires sharing a common vocabulary. When programmers ask questions informaticists must understand what is being asked and vice-versa.”

So here’s the question: Given the apparent difficulty – in terms of expense and the level of necessary collaboration – in achieving, say, the level of interoperability desired for MU Stage 3, what’s the point of the timeline? Perhaps more importantly, what’s the point of what lies beyond the MU timeline, which are the penalties for those Medicare providers who haven’t yet made the digital leap?

OK, that’s more than one question, but you see where we’re going. The HITECH incentive program is nicely structured to have three levels of implementation goals followed by a period of penalties for those who haven’t figured out how, or decided not, to achieve those goals. But it seems starkly clear that the complicated reality of health IT development and implementation renders that structure seriously unrealistic.

Or are we missing something? If so, please let us know.

Jeff Rowe blogs regularly at EHRWatch.com.