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A National HIE Leader on Patient Matching, TEFCA and the Future of Health Information Exchanges

September 6, 2018
by Rajiv Leventhal, Managing Editor
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Dan Chavez, CEO of San Diego Health Connect, checks in to discuss an array of challenges facing HIEs in this current moment

It’s no secret that healthcare and health IT experts feel that the lack of a nationwide patient matching strategy remains one of the largest unresolved issues in the safe and secure electronic exchange of medical data.

What’s especially troubling is that electronic health records (EHRs) across hospitals and health systems nationwide are riddled with duplicate records. According to a recent Black Book survey, the average duplicate rate across healthcare organizations is 18 percent.

What’s more, for health information exchanges (HIEs) across the U.S. today, matching and linking patient identities pose an enormous challenge due to the diversity and independence of the institutions they serve. As such, HIE leaders, such as Dan Chavez, CEO of San Diego Health Connect (SDHC), the metro area’s regional HIE, are tasked with finding a solution to the patient matching problem.

To this end, in 2016, San Diego Health Connected announced it would be using a patient matching platform from Virginia-based health technology company Verato. The HIE agreed to implement the Verato solution after a pilot employing Verato technology successfully increased the number of matched records in SDHC’s MPI (master patient index) by 110 percent, cutting down the time this outcome would typically take from years to a few short weeks.

The SDHC MPI manages the identifying information for millions of people across the San Diego region, aiming to ensure that the records belong to the correct patients. According to officials, due to stringent matching criteria, SDHC’s MPI matching algorithm excluded 187,000 patients because of unresolved patient identification. Once these same records were run through Verato, 75 percent of those mismatches were resolved. Verato then outperformed expectations when it found an additional 126,000 patient matches that the MPI had originally missed.

SDHC’s Chavez recently spoke with Healthcare Informatics about this patient matching issue, as well as broader HIE topics such as sustainability and TEFCA—the government’s proposed Trusted Exchange Framework and Common Agreement, a plan to spur interoperability among providers. Below are excerpts of that interview.

Can you outline the problem of providers not being able to properly match patients, and why this is a specific and unique challenge for HIEs?

What happens at the point of care is when a care provider is trying to provide care and pull up a record, depending on the EHR, the application, or the workflow—which all may be separate, distinct, or the same—whenever that happens, what’s presented may cause an interesting caregiver-patient interaction.

So, are you the Dan Chavez on 123 Main Street? Or do you live on street X? Are you born in 1975 or 1957? In this day and age, we expect that you should know who I am, regardless of the system you’re looking at. I can do that on Facebook and on Uber, so why are we having that conversation [in healthcare]? How can the doctor, nurse, or caregiver not know who I am? That’s an interesting conversation which can get uncomfortable. The provider might say that the system doesn’t allow for that information, or he or she doesn’t have the proper information on the patient. It’s usually some silly excuse.

But the doctor knows that the patient has been to provider X or Y, so how can you not have that information? So therein lies part of this challenge—why aren’t you seeing this information? And that could lead to a credibility issue, too. Why am I here for treatment and what treatment am I here for?

Dan Chavez

How is San Diego Health Connect working to solve this problem?

We involve the community. For a solution to be accurate, successful and well-implemented, it requires people, process and technology. We have a very engaged medical records workgroup and they work to make sure that our [medical records] are as streamlined, easy to use and factual as possible, through the HIE.

There might be as many as five patients [with the same name] in your [system]. Our goal is ideally to get that down to one. In our world, the worst case would be three, though we do have the anomaly of a five- or seven-name pick list. We work very hard to get it to one. And if we don’t have the information, it could be that the patient didn’t consent. So our goal is to take the gray and obscurity out of this process. When we do get that pick list of three, many times two of those three are the same person and we just have to combine those records. But we are diligent in removing duplications and feeding that back to the committee, along with problem information, names and organizations, and getting that pick list as short as possible.

What results can you speak to from using Verato?

We have an exception queue and it’s oscillating. Every time we add a new major [organization] with more than 10,000 patients to the HIE, it impacts the queue. We just added a health plan and that has added 4 million lives to the master patient index record locator service. So that will be a big bump to the queue and we have to socialize that participant into the MPI record locator service. Much of that is done automatically. That’s the beauty and also the challenge of an HIE—it’s a change management exercise and it never goes away. So even though you are achieving good results, once you add someone new, you blow up.

Going forward, it’s mostly about onboarding new participants to the process. Health plans now have patient volumes in six and seven figure numbers joining the HIE, so there are lessons learned based on the last health plan we added. We keep getting better every time we onboard. Every time we add a new player, there will be duplications, things will get gray and then adjustments will have to be made. But overall, we have about 98 or 99 percent [patient matching rate].

How you feel about TEFCA and its impact on HIEs such as your own?

TEFCA makes a lot of sense and we appreciate the intent; we support it. We hope it’s not too disruptive and takes advantage of the infrastructure, process, and lessons learned from what we have invested so far. How much will TEFCA formally incorporate—and we are all different—what we have done in San Diego, in the ultimate final ruling that is published? Our input is that you need a better scenario assessment of what’s out there, evaluate it, look at best practices, and incorporate as much of those good investments that have occurred as possible.

Are you concerned about the future viability of HIEs?

I can’t speak for the rest of the country; only California at best, and within there, San Diego. Dr. John Halamka [CIO, Boston-based Beth Israel Deaconess Medical Center] was out here recently speaking, and I was asking questions to him about HIEs, to which he said they are valuable, but immature. I thought that was very telling.

There was recently an article published by the CIO of Cedars-Sinai Medical Center in Los Angeles, Darren Dworkin, and the focus of the conversation was the return on investment for your EHR. He said that there are two things that maximize the ROI of an EHR, which takes 10 years to [achieve]. The two things that maximize that value are: interoperability, which is what HIEs are all about; and the second is data analytics and decision support. But you cannot get that data unless you have the interoperability.

So in my mind, and yes, it’s my job, but I fully believe that HIEs have tremendous value. It’s that commitment to the HIE in the community and how committed that community is that determines the evolution, maturity and the corresponding ROI. And that includes public health and the EHR—not just hospitals, doctors, and payers. The more that the entire ecosystem is involved, the greater utilization, sustainability, and value [for the HIE].

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Hawaii’s HIE Leveraging Technology to Improve Patient Identification

November 8, 2018
by Heather Landi, Associate Editor
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Hawaii Health Information Exchange (HHIE), Hawaii’s state-designated HIE, is taking action to improve patient identification and the accuracy of provider data for enhanced care coordination across the state.

HHIE is working with Pasadena, Calif.-based NextGate to implement an enterprise cloud-based master patient index and provider registry software to create a sustainable statewide system of accurate patient and provider data by resolving duplicate and incomplete records.

HHIE was established in 2006 to improve statewide healthcare delivery through seamless, safe and effective health information exchange. The HIE covers more than 1.2 million patients and has more than 450 participants including Castle Medical Center, Hawaii Pacific Health, The Queen's Medical Center, and the state’s largest insurance provider, HMSA.

“Accurate, comprehensive data that flows freely across boundaries is a catalyst for informed, life-saving decision making, effective care management, and a seamless patient and provider experience,” Francis Chan, CEO of HHIE, said in a statement.

Chan adds that the technology updates will help to ensure providers have “timely and reliable access to data to deliver the high-quality level of care every patient deserves.” “We are building a scalable, trusted information network that will positively influence the health and well-being of our communities,” Chan said.

“The partnership will enable HHIE to develop internal support tools to create accurate, efficient patient identity and provider relationships to those patients to support focused coordinated care,” Ben Tutor, information technology manager of HHIE, said in a statement.

Cross-system interoperability is critical to the success of HHIE’s Health eNet Community Health Record (CHR), which has more than 1,200 users and 470 participating physician practices, pharmacies, payers and large healthcare providers that contribute to over 20 million health records statewide. Deployment of the EMPI’s Patient Matching as a Service (PMaaS) solution will support HHIE’s vision of a fully integrated, coordinated delivery network by establishing positive patient identification at every point across the continuum for a complete picture of one’s health, according to HHIE leaders.

By ensuring that each individual has only one record, participants of HHIE will be able to map a patient’s entire care journey for informed decision-making and population health management, HHIE leader say.

The provider registry will synchronize and reconcile provider data across clinical, financial and credentialing systems to enable an accurate directory and referral network of providers. Using a single provider ID, the registry aggregates and maintains up-to-date information about individual providers and provider groups, such as specialties, locations, insurance options, hospital privileges, spoken languages, and practice hours. Providers can also easily identify who else is on their patient’s care team as well as what other clinicians should receive test results, lab reports and other treatment summaries.


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HIE 2.0: CORHIO’s Leaders Map a Pathway to Advanced Data-Sharing Success in Colorado

November 7, 2018
by Mark Hagland, Editor-in-Chief
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CORHIO’s leaders have been involved in intensive work to improve data quality, while expanding data-sharing more broadly

The leader of CORHIO, one of the most progressive health information exchange (HIE) organizations in the country, continue to innovate forward across a broad range of areas. The Denver-based CORHIO already connects 65 hospitals across Colorado—virtually all of the inpatient community and academic facilities in the state—and connects around 5,000 physicians statewide as well.

As the organization’s website notes, “CORHIO empowers people, providers and communities by providing the information they need to improve health. Our advanced health information exchange (HIE) technology, data analytics tools and expert consulting help healthcare providers access information that saves lives, streamlines care coordination, reduces costs, and improves clinical outcomes for millions of people.”

Recently, CORHIO’s leaders, including Morgan Honea, the HIE’s president and CEO, and Mark Carlson, its director of product management, have been pushing ahead to connect providers across the state both more broadly and more deeply—extending out into the behavioral health sphere as well as facilitating the sharing of more granular data across Colorado, through data normalization work. Honea and Carlson spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding their current initiatives. Below are excerpts from that interview.

You’ve been expanding some of your core data-sharing capabilities of late, correct?

Mark Carlson: Yes; we certainly do have some activity and infrastructure that we’ve been building out. I’ll focus in on clinical and population health first. One area we had identified a couple of years ago in terms of being able to generate information for population health, at the state level, or in partnership with ACOs, came about as the state pushed forward an initiative called “regional care collaboratives” with ACOs. As part of that initiative, we did work on packaging and bundling notifications around ED visits and hospitalizations and discharges, for providers, as well as helping smaller physician practices in that area. And we’ve been looking at expanding out that concept around clinical indicators, initially focusing on labs.

We have 65 hospitals sending data into CORHIO, and we had 30-plus representations as to how a hemoglobin a1c might be represented, in terms of vocabulary and coding. So we used NLP [natural language processing] to help us with that, to help move forward in disease management in areas like diabetes. We’ve also focused on another use case with our Department of Health in Colorado, around an influenza use case, where we’re able to flag a positive influenza use test and track for an inpatient admit that occurs within 48 hours, to map the cost of care as well as the ability to access supporting resources that hopefully would avert an inpatient admission.

That’s what we’re working on—normalization across general labs and clinical metrics; and as we expand our data types, we’re expanding towards social determinants, as well as labs that extend beyond the general labs.

Morgan Honea: I agree with everything that Mark said. I would just add that this is, really, in my opinion, kind of a second evolution around the interoperability question. We’ve got a tremendous HIE with tremendous participation here in Colorado. The important fact is that, after laying the infrastructure for a statewide HIE, it next becomes imperative move into normalization across data sources, so that you’re not changing vocabularies or nomenclature.

That sounds like “HIE 2.0,” in terms of the advanced work, doesn’t it?

Carlson: That’ll work.

What’s next or top priority now for providers?

Honea: Our top priority is to continue to expand the type of data available in the HIE. In that context, we’re facing up to the incredible challenge of continuing to integrate behavioral data into the system. We’re also working with state agencies, to make sure that folks are getting the best care coordination for the best outcomes possible. And probably the highest demand from our clients is fewer queries and more push notifications and types of functionality, greater integration into EHRs [electronic health records] and other population health-type tools, with really clean, neatly packaged data, which is where this conversation becomes more important, because as Mark said, with hemoglobin a1c, things get very messy as the volume of the data grows, if you’re constantly having to clean up the data. So providing the data in interoperable, easily usable ways, is a top priority.

Carlson: And you have to follow the money in terms of reimbursable events and other value-based areas. So as we improve our inbound CCDA-type activities, we want to improve the quality of submission at the level of formatting as well as presence of charted measures, as being able to format and report those out, from practices, including around broader performance measures.

With regard to the capture and sharing of data, are you making any use of artificial intelligence? And where is that going?

Carlson: One of our core initiatives is, how do we become more situationally aware? I’ve looked at FHIR as a path forward, in that context Whereas the CCDA is a blunt-force instrument, FHIR provides the opportunity to be a lot more precise in packaging and bundling data. For example, we’ve been working on a use case for an anesthesiology group. They want to see problems, meds, last treatments, discharge summary, they don’t want to see everything. FHIR helps us to bundle and package data, and then via an API connection, they can receive more precise information that meets their needs, rather than via all-encompassing data. More targeted, based on clinical needs.

Honea: The ability to get down the discrete data level, understand the data points and bundle and share them, is where I think things are going. A CCDA is a big, narrative summary of an encounter, and doesn’t get down to that level of granularity.

Carlson: In the media right now, there’s been a lot of discussion around where the next steps of IBM Watson should be. And we’ve had this discussion with a lot of vendors in the past, where we’ve been introduced to some very compelling functionality; but then some wonderfully designed tools absolutely choke on some of the variability of the nomenclature in the data. And that prevents us from getting to advancing the Quadruple Aim. Those learnings and market information that we’ve gathered over time, indicated our absolute need to partner with organizations that have a foundation for creating mappings that are clinically valid and reliable and backed with the expertise behind it. That can help us get to the population health insights that you’re referencing when you mention AI.

Do you think you’ll be able to incorporate some social determinants of health data into what you’re sharing?

Honea: That’s an area where I’m spending some of my time now. I have no doubt that we’ll run into the same challenges with local code sets and varying terminologies with that type of data that we’ve had with clinical data. I don’t see that that process is strictly limited to hospital and clinic data; I think it will go across all sorts of systems; and when we share from one program to another and one type of data system to another, we’ll face the same types of challenges and requirements for data standardization. So we’ll probably rinse and repeat every time we go out and get another data point.

Carlson: We are working with United Way 211, understanding how their community resources and curated content and partnerships are working, and getting insights from diabetic prevention programs and food banks—the data quality is as variable as some of the source organizations involved. I think this opens up a whole new opportunity for whole-person care, but it will pose some of the types of data normalization and use challenges as clinical data.

How do you see the next few years evolving forward at CORHIO?

Carlson: We’ve touched on a lot of priorities—ECQM work… our learnings in various areas. It’s a big lift to ingest the CCDA documents and get consistency at the data level. Our partner organizations continue to work with us and with Wolters Kluwer, to work on various types of data together. When we spoke at the HIMSS Conference earlier this year, Morgan and I talked a lot about data normalization work and about data visualization, and about being able to visualize risk across counties and the state, to identify pockets of need. And in that context, the social determinants data will help us understand where the food deserts are, and where high levels of chronic diabetics live. We have a number of mountain and rural communities that are fairly isolated, so our opportunities to impact that, are large, but so are the needs, and thus, we need to address data quality issues.

Honea: I agree with everything that Mark said. We’ve got this never-ending effort to include programmatic elements, site-specific elements, into the HIE, every kind of element—that work will never end. But I’m also continually focused on the question of how we as a state, with only 5 million people, can identify ways to leverage the infrastructure built with significant investment at the federal, state, and local levels, to advance our overall HIE efforts as a state, and minimize the risk of continually building new silos of data that will just require new efforts in the same fashion? How do we improve coordination when folks are moving across different geographies or service areas, without rebuilding existing infrastructure? How do we partner with communities to get the biggest bang for our buck? That requires a lot of planning and coordination and collaboration.

Carlson: For HIEs to provide value, Morgan and I often say, it’s data versus documents. Document exchange has a very valuable place in the broader landscape, but where the HIEs are differentiating themselves is at local-level attention and relationships and meeting community needs, and where we can operate at the data level to provide the insights to drive patient care quality forward.




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Seven HIEs Now Connected to Military Health System

November 1, 2018
by Heather Landi, Associate Editor
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Seven physician-led health information exchanges (HIEs) are now connected to the Military Health System (MHS), enabling MHS providers to have access to patients’ electronic health records to support clinical decision making at the point of care.

The Kansas Health Information Network (KHIN), the eHealth Exchange, and KAMMCO, a provider of insurance and health care technology services for physicians and other health care professionals, assisted in facilitating the connection.

With this new development, medical records can be shared across the world as military personnel and their families transition between multiple locations, stateside or overseas. Military hospitals and clinics now can quickly and securely access patients' personal health information 24/7 and have access from the physician-led HIEs in Kansas, Connecticut, New Jersey, South Carolina, Georgia, Missouri and Louisiana.

“This represents the growing capabilities of HIEs to share records in all locations from which a patient has received care,” Laura McCrary, executive director of KHIN, said in a statement.

“MHS cares for 9.4 million beneficiaries, delivering care globally in military hospitals and clinics and providing coordinated, integrated care through civilian networks," Kimberly Heermann-Do, Health Information Exchange Office Lead in the EHR Modernization Program Management Office, said. Heermann-Do added, “Through HIEs, records are available securely from the private sector if the HIE is onboarded to the MHS. Having access to records for patients across the KAMMCO network will assist MHS providers with clinical decisions.”

“The Medical Society of New Jersey (MSNJ) has a long history of supporting the healthcare needs of our active duty military in New Jersey. Sharing clinical information from our physician practices with MHS through OneHealth New Jersey furthers our support in this important area,” Larry Downs, MSNJ CEO, said in a statement. “With a large joint base located in New Jersey our physician members provide care to many active duty military and their families.” MSNJ is one of seven medical societies who partner with KAMMCO in the delivery of a physician-led health information exchange platform.

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