True interoperability continues to elude complex health organizations such as St. Francis, but "I think we're getting there," said Shanley. Still, it's "big challenge" making two dozen different EMRs try to talk to each other. "Each one is a separate interface that you have to work through, and what amount of data is really coming out of all these EMRs."

Being able to match and make the most of the data that exists is yet another issue. "Even with what we've learned with enterprise master patient index," she said.

"At St. Francis our EMPI duplicate rate is about 4 percent, which is really clean, considering what some other people are going through. But we're leaving off some parts of the market that we really need, like post-acute care, and skilled nursing facilities and patient-generated data. We're getting there, and that's a good thing, but we're still missing pieces."

This is not an unsolvable problem, said Suzanne Cogan, Orion's vice president of sales and client relationships.

"The interoperability standards are there, by virtue of the fact that we have our own integration engine, and we have hardware appliances that can be remote, and practices can typically do things quite efficiently with CCDs," said Cogan.

"But as Linda said, you've got such a plethora of vendors -- and each one of them charges and often a pretty high fee to actually create an outbound interface," she added. "It becomes not so much a standards barrier, but a cost barrier, especially to smaller practices."

Toward that end, Stage 2 meaningful use has actually dovetailed, rather than conflicted, with St. Francis' ACO strategy, said Shanley.

[See also: Interoperability 'taking so darn long']

"It's dovetailing because it's allowing us to do – and this is one of the strategies we're still trying to figure out – the direct messaging piece," she said. "We want to make it useful for the clinician."

Still, there are so many complications, even when it comes to a relatively simple means of communications like the Direct Project. "There's a lot of regulations now," said Shanley. "For instance, Orion can be the (health information service provider). But a lot of HISPs won't talk to other HISPs because they're not DirectTrust certified.

"From my position, I have to look back and say, 'What's the best strategy for me, to get through this next meaningful use stage, but still support my clinicians getting the easiest way to get their messages through, and how many address books do I want to keep up to date?' she said.



"Especially in my situation, where you have so many EMRs, you're trying to get them to MU Stage 2 and they have no idea what that means," she aded. "The providers are really challenged with Stage 2."

Still, helping even non-employed docs with Stage 2 is worthwhile for the large goal of care coordination, said Shanley -- as frustrating as enabling data exchange among such a motley list of vendors can be.

"I have one that just upgraded to McKesson -- they've been on McKesson Practice Partner, so they have to upgrade, and they've got RelayHealth – and then I've got Allscripts, which is hospital-owned outpatient, and I've got to use MedAllies with them," she said, by way of example. "And then I've got Orion. We've wanted to go through Orion, but we're still figuring that piece out. Then I'm putting in Epic. I know I can talk Epic-to-Epic. And I've got Epic Care Everywhere, and I've got to be able to talk to that.


"I've been through it several times to try to get it straight in my head," said Shanley. "Do I try to strategically look at this long term? Or do I need to do something short-term to meet meaningful use that is not the optimal solution? You have to sit there and weigh all this. And no one is making it easy for you."