At a time when provider organizations are collectively—but also individually—embarking on their complex interoperability journeys, one local health system in Virginia is doing its best to keep it simple, operating under one basic premise: making it about the patient by helping physicians access the patient data they need when they need it.
Of course, healthcare interoperability is more complicated than that, but Centra Health System, a Lynchburg, Va.-based healthcare system comprised of six hospitals, centers and medical groups, and 53 ambulatory practices, has taken the challenge head on with the help of strong leadership centered around physician engagement. Centra began its interoperability journey in 1995; initially, it began building inpatient medical records that were made available to all providers and staff with patients within the organization’s system. By 2007, Centra was utilizing the Alpharetta, Ga.-based McKesson’s RelayHealth network to build out the local health information exchange (HIE).
With the help of RelayHealth—the McKesson business unit that focuses on improving clinical connectivity—Centra has succeeded with more than 33,000 orders accessed by more than 400 providers and 37,000 patients, with a more recent focus on creating a consolidated clinical document architecture (C-CDA), says John-Paul Jones, M.D., chief medical informatics officer (CMIO) at Centra, and also a practicing emergency room (ER) physician, family doctor, and local medical examiner. “We have always taken a community view that the information be centered around the patient; that’s our medical group slogan,” Jones says. When rolling out the HIE, that’s come to the forefront even more. The data must be patient-centric, wherever or whenever that encounter or that information is collected—be it a pneumonia vaccination at CVS or a critical care ICU stay. It’s all important,” Jones attests.
Centra’s inpatient acute care EHR is McKesson, while the organization uses Allscripts in the emergency department, and throughout all of its ambulatory practices, there is a mix of systems, Jones says. “You have a big variety. Expanding out even more, in Virginia, many hospitals are on Epic, but we see Cerner as well. It really depends how far you go out, and you don’t have to go out very far to get a big mix. For RelayHealth, our primary focus has been local, for developing an accountable care organization (ACO), for communication, for patient engagement, and for the patient. The majority of care will be with providers in the immediate community. We are connecting, or interconnecting with a variety of practices, with the priority being local,” he says.
John-Paul Jones, M.D.
Being a provider himself, Jones fully understands that most physicians want their tools to be bigger, better, faster, and stronger, as well as having them integrate better into their workflows. “I’m a physician, and all I want is everything,” Jones jokes. “For providers, I have what I call a two-second rule. If it takes more than two seconds for a page to come up to access the information, then we will move on, look elsewhere, or just fill in the blanks. The dirty little secret of providers is that we will use what’s accessible—but easily accessible. If it takes too many steps, too many clicks, and too much time, we will kind of have to move on,” Jones says.
To this end, providers have an array of challenges when it comes to accessing information in their technology systems. One such issue is perceived completeness, meaning that sometimes the information is there, but it’s like finding needle in a haystack. Oftentimes it requires some digging, and that’s tied into the response time and accessibility of the data,” Jones says. What’s more, another challenge for providers is relevance to the encounter, as Jones puts it. “So as an ER doc, there are bits of information that are important. That’s completely different than when I am a family practitioner, and different still than when I am wearing the hat of a local medical examiner,” he explains.
“[Can a system bring up] a particular type of encounter for a particular specialty, and tell me what’s important and what’s not important? That’s hard to do, as in most health systems, most EHRs default to just having everything in there and have the provider figure it out. EHRs 3.0 will start developing the ability to filter things for more defined roles such as an anesthesiologist vs. a general surgeon vs. a coder vs. an ER doctor. I think part of the level of dissatisfaction is not being able to identify what is important to that particular provider,” Jones says.
Indeed, Jones says that the “easiest” challenge of health information exchange is the technical aspect, while the next tier up is time and money. The biggest barrier by far though, is physician engagement, buy-in and the willingness to allow data exchange to happen, he says. “We have had an open policy regarding access to our inpatient EHR ever since it was enacted. Now with the HIE rolling out, there has been some resistance from places about sending data out of their EHRs. They are happy to take it in, but not send it out. We were surprised by that,” Jones says.
Jones adds that three practices in the network actually stopped sending out results and orders, not because of resources or any issues being caused, but because of local political reasons. “They didn’t want to collaborate, and part of the reason was that there was a longstanding distrust as well as a change in leadership on their part. That is really unfortunate, since I believe it’s all about the patient and the patient should have ownership to their data, access to it, and the ability to share it whenever or whenever without restriction,” Jones says. As such, according to Arien Malec, vice president of data platform and acquisition tools for RelayHealth, it took strong leadership at the CIO and CMIO level to convene the EHR vendors in the community and let them know how important it is to open up their interfaces for interoperability purposes. “It’s been a great partnership, with Centra’s leaders having a strong voice in the community,” Malec says.
In July 2015, Jones and other practicing physicians presented to Congress what they thought were the biggest barriers to interoperability and how the industry could get it right. In a more recent interview with Healthcare Informatics, Jones gave more insight into the themes that were highlighted on Capitol Hill:
- Take the time to make sure it’s right. Interoperability is incremental and it’s about how you define it. Each gain is a major step, but too many people focus on what we cannot do. We need time and resources to optimize what it technically can do right now.
- Reduce regulations so the industry can look for innovative solutions to put in place rather than checking the boxes on doing it one way. We need to consolidate the massive amounts of regulations that we’re expected to follow.
- Put a universal ID in place. A universal ID would be enormous for indentifying patients and for the reduction of errors. We can do that now with providers by having a national provider index as well. Just putting something in place for how you identify providers in your EHR can go a long way.
- Don’t just listen to the bigger names. Congress and the media tend to listen to the bigger names—your Kaisers and your Geisingers. They carry weight and you have easy access, but most care is actually in smaller practices outside of the big systems. Get the input from the frontlines in the smaller towns and the mid-sized cities, outside of New York, Chicago, and the West Coast, to see what works, what doesn’t work, and what ideas they have. It’s about finding a buffet or menu of solutions rather than a single silver bullet.
Jones stands strong in the belief that the industry is on its way to successful interoperability. It’s already been proven that a little can go a long way, he says. He tells the naysayers of health information exchange that “It’s inane to say there’s no value [in HIE], because what you’re really saying is that there’s no value to patient data. If it is truly about the patient, you need access to the most relevant and current information you have to make solid clinical decisions.”
Jones adds, “Unless you are saying that you will provide every bit of care for that patient and every follow up—be it an ER visit or a wellness check—then you need access to that data across the entire spectrum. It’s not just limited to the walls of your practice. How about I take away half of your charts and results? That’s what you are asking for when you criticize the value of HIE.”