The New York eHealth Collaborative (NYeC), the state designed entity for the Statewide Health Information Network for New York (SHIN-NY), recently announced that SHIN-NY, a “network of networks” that links New York’s eight regional Qualified Entities (QEs) throughout the state, now holds healthcare records for more than 40 million patients, processes over 2.8 million transactions a month, and has over 62,000 users.
Indeed, NYeC works in partnership with the New York State Department of Health (NYSDOH) to improve healthcare through health IT. Founded in 2006 by healthcare leaders, NYeC receives funding from state and federal grants to serve as the focal point for health IT in the state of New York. NYeC coordinated the creation of the SHIN-NY to allow the electronic exchange of clinical records between participating healthcare providers.
But despite the healthcare data that is in-house and the high volume of transactions per month via the health information exchange (HIE), state health IT leaders still face the core challenge of making the data it has, from stakeholders throughout the state, usable. This was a key topic of discussion at the New York HIT Summit, sponsored by Healthcare Informatics, on Sept. 27. The panel discussion on health data exchange and interoperability, held at the Convene in New York City's downtown financial district, included notable health informatics experts with connections in the state: Paul Wilder, CIO, NYeC; Christie Allen, technical program advisor, Office of Quality and Patient Safety (OPQS), NYSDOH; Carole Cusack, vice president of emerging business, 3M Health Information Systems; and Lin Wan, chief technology officer, Stella Technology. Moderating the panel conversation was Mark Hagland, Editor-in-Chief, Healthcare Informatics.
Wilder noted that the eight QEs in the state, which serve as the backbone to SHIN-NY, are designed to collect data from patient care organizations, primarily hospitals, and then send the data up through the HIE. Wilder said that NYeC doesn’t worry about who has access to the data until someone tries to query it, and they aren’t concerned about consent until someone looks about it. “So the good news is that you can build a system if the upload is frictionless,” he said. He said that about 90 percent of hospitals in the state are providing some data to the HIE, and about 45 percent are sending what they call “a minimum data set.” But Wilder noted, “There is still a lot of work to do. We find that data is missing and that data is hiding inside documents.”
As such, Wilder said the greatest challenge is getting the data in a place where the system can do something actionable with it. He added that while people talk a lot about document standards such as the Health Level Seven International (HL7) standard, as well as complete, widely accepted document formats, such as continuity of care documents (CCDs) and the HL7 consolidated clinical document architectures (C-CDAs), the problem is that while a human who is looking at the document can find something with relative ease, getting it from an electronic medical record (EMR) via XML format can be “an impossible task” as it can't “screen-scrape” the information out of free text-based areas in a CCD.
Wilder added that it only takes one “bad actor,” or in this case, one patient care organization, along the care continuum, to take it from a “nice, coded spot” and put it in a “non-coded spot.” In sum, Wilder said that NYeC “has a lot hooked up, and has 2 million people looking at data.” But he noted that much of the volume that takes place right now is in the form of clinical alerts that will say an inpatient event happened at X facility at Y time, and then gives a phone number to call. While these alerts are certainly important and good for people who are underserved and on the hospital readmissions track, overall, Wilder admitted that “there is good usage, but we want more.”
NYSDOH’s Allen added that while SHIN-NY was a concept for a long time, all eight of the QEs went live by October 2015, resulting in a “built infrastructure.” To this end, interoperability played a big part since all of the QEs needed to take information from each other and understand what to do with it, Allen said. “Now it's about making use of the data. The data content itself is not standardized, even though we have a standard format.” She agreed with Wilder in that “All it takes is one hospital along the way entering information [differently] that will lead to inconsistencies. Fields have to be filled in; you can't ‘tab past it.’ Now we are pulling back the curtains to look inside, and we are figuring out how to make the data usable. We need good data so we can find the quality measures. So the perspective of the state is that we have built the infrastructure, but now we are growing and assessing,” Allen said.
Allen noted that CCDs have been flowing within the state’s QEs, and now every entity in the state has this capability. She said, “Now we have a set of minimum data, and the DOH has said that in order to accommodate the data needs, there has to be a minimum set of data that QEs need to have available. This means they have to go to their participants and get the data.” She said that the state is trying to align itself with the Meaningful Use program in terms of the minimum data set that it also requires. “If we are going to get the data, we want to reuse it for a quality measurement and then for something else, too,” Allen said. “So we are trying to be thoughtful about what the needs are around quality measurement, but also what the patient needs. Did a physician order a test for the patient already? By enforcing the minimum data set, we will get closer to the reality of lower costs and better care.”
Wan, from Stella Technology, a San Jose, Calif.-based company that builds HIE platforms, and worked on the SHIN-NY platform, agreed with Wilder and Allen: “Everyone across the nation is trying to peel back the curtain, look at the data and say, now that we have the data pipes built, what do we do with it?” She said that the next steps are patient risk calculation, analytics, and quality and performance measures, but all of this requires good data. “We just heard this phrase, ‘dirty data.’ Lots of folks realize they need the complete data in the right place,” she said.
Also speaking to the issue of getting freer flow of data, 3M’s Cusack said there is an obvious need to adopt a standard, and that there are multiple out there. “There is a wealth of information in the EMR that current standards don't address, and that's the unstructured data,” she said. “Many EMR companies struggle with bolting on NLP [natural language processing] to their product. And this is critical when you think about community providers. We have community benefit organizations in New York City that are huge part of treatment [for patients]. You need data from those systems as well, and they may not be EMRs. So you need to look beyond standards for structured data and start tackling the unstructured data,” Cusack stated. “We need to be interoperable at the EMR level. We put the data in the enterprise data warehouse, and if you have that you can apply NLP to it. That's the way we have chosen to look at it.”
The panelists were in agreement that moving forward, EMR vendors must be part of the conversation in terms of plunging ahead for greater interoperability. Hagland brought up the notion that Epic, a widely-known leader in the EMR vendor market, openly states that its platform has HIE capabilities within its community, which brings upon a strange intersection in which there could be different vendors with different solutions that may or may not support interoperability. Said Cusack: “The EMR vendors need to be at the table. They are sometimes prohibitive in what they allow you to do. They assess large fees to allow [access] in some cases, and that's not a sustainable model.”
Allen said that the NYSDOH has welcomed EMR vendors in the conversation as it pertains to New York State’s Delivery System Reform Incentive Payment (DSRIP) Program. “Bringing them in and talking to them is the beginning of the conversation, and we are trying to leverage the power of New York State to help move the cost.” Meanwhile, NYeC’s Wilder didn’t seem to put much stock into Epic’s market share—at least yet. “Getting to a standard happens in many different ways. Market dominance often fixes a standard since you have a market dominator and you all go towards it, like with Microsoft Office,” Wilder explained. “I think Epic has too low of a market share to actually affect the market yet. Cerner and MEDITECH have more installed systems than Epic, if you go by the quantity of hospitals. And I'm not saying that we should get to a point in which Epic gets there, but I don't see the ‘evil’ of this just yet.”