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AMIA’s Doug Fridsma: Time for the Feds to Truly Open Up Patient Records to Fully Interoperable Data Use

June 13, 2016
by Mark Hagland
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AMIA CEO Doug Fridsma, M.D., Ph.D. discusses the association’s broad policy aims

Doug Fridsma, M.D., Ph.D., president and CEO of the American Medical Informatics Association (AMIA), continues to be a voice for progress and change in clinical informatics, healthcare IT, and the U.S. healthcare system. Most recently, during comments delivered at the 2016 ONC [Office of the National Coordinator for Health IT] Annual Meeting, Dr. Fridsma called on public and private stakeholders to provide patients with total access to their complete electronic health data. Just prior to his participation at the ONC Annual Meeting on Thursday, June 2, AMIA released the following statement, to be attributed to Fridsma:

“Access to information and the ability to integrate and use information has changed how individuals book travel, find information about prices and products, and compare and review services. Information can empower individuals, but health care has lagged behind other fields. It is unconscionable that in 2016 most patients are unable to obtain their entire medical record unless they print it out. 

While progress has been made in the last several years to support patients’ access to their information through various electronic means, such as Blue Button and patient portals, this is not sufficient to make patients first-order participants in their care, their health and their research efforts. Patients deserve nothing less than total access to their complete electronic health data.

Modifications to HIPAA [the Health Insurance Portability and Accountability Act of 1996] through HITECH [the Health Information Technology for Economic and Clinical Health Act of 2009] set the foundational expectation that patients have a right to an electronic copy of their health information. Guidance from OCR [the Office of Civil Rights] clarifying this right in terms of form, format and manner of access is another important step forward. Yet, the operationalization of these policies has only rendered slivers of information available for patients to use as they see fit. Patients have a right to all of their health information, not just what CMS [the federal Centers for Medicare & Medicaid Services] defines through meaningful use, or what ONC’s certification program deems necessary to meet CMS’s definition.

AMIA believes if the information is stored electronically, patients are entitled to their entire medical record in an electronic format, and not just a summary record or the limited data that a vendor chooses to make available via portal or API. Patients deserve more than PDFs, and the benefits of digitizing healthcare will only be realized when patients – and providers – have fluid, portable data. By developing a functionality as simple as “print all,” we will empower patients to more fully participate in their care by spurring an ecosystem of wellness and mHealth apps; we will improve the quality and frequency of participation in precision medicine, and other kinds of research; and we will foster a data-driven feedback loop between patients and their providers


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

We commend federal efforts to improve access, such as recent guidance from the HHS Office of Civil Rights, as well as initiatives to educate providers and patients on the rights afforded by HIPAA. But until we develop the electronic equivalent of “print all” for patients, which goes beyond PDFs and summary records, we will continue our struggle to free patient data. APIs may provide improved access over portals, but they carry forward the fundamental paradigm of closed systems with a predetermined notion of which data the patient should access.

Today, we call on the federal government to enable patients to have total control of their complete medical record by removing a prohibition found in certification that restricts the use of unstructured data, and we call on CMS and OCR to use their levers so that such functionality is broadly available to every patient by 2018.

ONC must remove the prohibition on the “unstructured document” document-level template and require certified health IT to enable patients to have a full extract of their health data. The prohibition – originally included to prevent unstructured data overload – has outlived its usefulness. Further, this prohibition has muted conversations on data portability for providers looking to switch EHRs, who currently only have access to summary records of their patients’ data. Removing the prohibition and allowing use of the entire suite of CDA templates is aligned with FHIR-based resources to support multiple modes of exchange.  Convergence is not only possible, it’s likely, given the direction of standards development.

Access to information and the ability to integrate and use information has changed how individuals book travel, find information about prices and products, and compare and review services. Information can empower individuals, but health care has lagged behind other fields. It is unconscionable that in 2016 most patients are unable to obtain their entire medical record unless they print it out.”

Following his participation in the ONC Annual Meeting, Fridsma spoke later last week to HCI Editor-in-Chief Mark Hagland about his and AMIA’s broad policy aims in the current moment in U.S. healthcare. Below are excerpts from that interview.

There are a lot of waves of policy currents washing up against each other these days. How do you see the current policy landscape right now?

We’re seeing a lot of transitions right now. We’re seeing sort of the end of the meaningful use era and the beginning of a new era focused around MIPS and alternative payment models. So you’re seeing a change in levers, in carrots and sticks. And anytime there’s significant change, it’s a time of significant risk, but also significant opportunity. We’ve tried to see this as a time where we can take what we’ve learned from previous conversations and flow it forward, and make some mid-course corrections and fill in some gaps we might have missed earlier.

Doug Fridsma, M.D., Ph.D.

Do you think that federal healthcare officials are listening to industry leaders right now?

That’s a hard question to answer, because in some situations, they may not be listening enough, and in other ways, they might be listening ‘too much’—meaning they may be focused on perspectives or groups that might be influential but don’t represent the broadest interests involved.

We need for federal healthcare authorities to be facilitating transformational change but not in a rigid way, correct?

Yes, that’s right. In our EHR 2020 report [AMIA’s “Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs”], we said we need to focus legislation and regulation on things that are important. You hear from many different kinds of voices. And if each voice says the federal government has to focus on three things, but the federal government listens to everyone, it can lead to “90” things that they’re pushing. And it can be very challenging to navigate through that space. It’s all becoming very challenging for folks to try to navigate. We’ve always advocated that the regulations should be focused on some of the key priorities you want taken care of; it’s important to pick those priorities that will involve substantive levers, towards the path of least regret.

At AMIA, we’ve been advocating for three major things. One is, we have all this activity focused on MIPS [the Medicare Incentive-based Payment System] and alternative payment models; we’re focused on registries; and interconnecting systems to other systems. But what’s missing is some kind of periodic table for health information. If we had those elemental building blocks in place, then we could mix and match. So for example, if we had standard ways in which we represented prescription information or laboratory information or numerical information versus categorical information; if we had all those fundamental building blocks, we could propose new kinds of information and new kinds of exchange. So one of the promises as well as challenge is this: vital signs and diagnoses and laboratory tests are articulated in different ways. So you have a situation where electronic health records have to represent information in different ways, to calculate all different kinds of results. So a lab test should have a name, a result, a unit of measure, and a reference range., that basically says, the normal reference range is between these two numbers.

So for example, if everybody uses a LOINC code type, and the same name for a test, and the same format for representing measurements, that’s a fundamental starting point. And we don’t always represent those things in the same way. You could have a SNOMED code or LOINC code for blood pressure, but you could represent it as a fraction—120/80, or as a Mercury measure, etc. The challenge is we don’t have agreement yet on some of those fundamental building blocks. But we’re starting to make progress in that direction. And once you’ve got that collection of different elements.

You’re talking about establishing common vocabulary standards, right?

It’s both syntax—the structure of things—as well as common vocabulary standards. So diagnoses should be either all in SNOMED or in ICD-10. Because if half of the quality measures use SNOMED terminology and half use ICD-10, or perhaps one or two other formats, then everyone has to collect the data in several formats. So we’ve got to have some consistency, and some elements, that periodic table, those building Lego blocks, so we can consistently format and define things. And FHIR [the Fast Healthcare Interoperability Resources standard] will be a big advance in that respect. Second, we’ll likely have high degrees of interoperability separated by deserts of very poor interoperability. What I mean is, we’ll have a Cerner ecosystem or an Epic ecosystem or a Meditech ecosystem, and so on. So people within those ecosystems will be able to exchange a great deal of data, but moving in between those ecosystems will be difficult. So when you’re a patient, you can request your patient record. And you may not get every single data point; but you’ll get a set of records that allows you to move your documents from one system to another. And we’ve been advocating that you should be able to have your laboratory tests, pathology reports, everything, stored in a consistent format. If it’s preserved as a consolidated CDA, it should be stored thus. And the two kinds of documents approved under meaningful use were the transitions of care document and the care summary document. But those don’t represent your full medical record. Because you’ll have your lab, pathology, and radiology reports as well. So in addition to structured information, we also need unstructured information.

Meanwhile, organizations are beginning to share structured information, but the value of that structured information has begun to wane, particularly as we allow patients to have their full medical record. We’ve said that patients are really a story or a narrative about how their disease process has affected their life and their family and how it progressed over time. And I think we lose that if we only consider structured information as important to share. I think of structured information as very useful for the delivery of care, around clinical decision support, etc. The AMIA community is very interested in advancing personalized medicine; and applying big-data analytics, particularly to create new associations of information and to find relationships in the narrative, will advance if we can share information from structured data.

And that means giving patients access to their full EHR, in a manipulable format?

Yes, that’s right: to support things like discovery of new knowledge and to support precision medicine activity, we really do need to make sure that patients have access to their full medical record, in a computable format, not just a PDF format. That’s a necessary component. And to go back to this discussion about ecosystems, the way you’ll move through the Cerner and Epic ecosystems, will not be through only through sharing structural elements, but through sharing unstructured elements—that full medical record.

So by analogy, if I look at a document through Google e-mail, I can use e-mail tags and do spreadsheets. But if I want to move something form the Google ecosystem to the Microsoft Office system, there’s a function that allows me to export all of the text, in such a way that I can import it into Microsoft Office. And vice versa. And there’s an analogy to that in healthcare. APIs will help us with exchanges of data. But to support patients, we need that full export or copy of the medical record. Because when you move from your primary care doctor to others outside your network, typically, these are in emergency room or life-threatening situations that require you to see a specialist. And that specialist will need the pathology reports and read the narrative that is the patient story—not just structured elements. So that is tremendously important for us.

Meanwhile, another important element to consider is the ability to both send information and receive the information sent. And right now, in certification, we only test the sending part, not the receiving part. And so as a result, we are challenged sometimes with interoperability, because people can use a variant of a standard. The standards have optional elements. The problem is that when you send, it can be either A or B or C. But if you truly want interoperability, the receiving systems have to receive A AND B AND C. And right now, we don’t test that. And options and complexities have a cost. And right now, those options and complexities have costs that are hidden in the system.

So those are the things we’ve been advocating for. Now, I think that ONC has both an opportunity to do some of this stuff on their own, but also to develop partnerships that would be helpful. For example, a full extract of the medical record—that’s where a full partnership with OCR, would be tremendous. OCR has already said that patients should have access to their medical records at low or no cost. So ONC could remove the certification criterion around structured data, and they could really advocate so allow the patient to be provided with a complete, computable, electronic copy of their electronic medical record. And ONC has within their purview a certification program. So they could test both the sending and receiving aspects of that. So in some cases, a copy of the full medical record in a computable format, that’s where a partnership with COR would be very strong. And the certification element, ONC could do on its own.

And in terms of APIs, one would hope that as the market begins to converge around a particular way to represent API information, that ONC can accelerate that process by really beginning to require certain elements that seem to be pretty stable, and by requiring those elements that could be the beginning of this periodic table of elements of clinical information.

That is a long list of to-do’s. Is there anything else that needs to be done, in your view, in this context?

Yes, in addition to all that, we have to make sure that we look at the whole continuum of work, so that we think about how to integrate consumer devices with EHRs, with interfaces, with all related systems. First, there’s the consumer who might have Fitbit or whatever—that needs to integrate with the 10 to the 3rd… the size of a practice is kind of at that scale. And that data needs to integrate with practice information. But also, as we think about population health, we need to make sure we’re collecting data in ways that allows us to collect billions of data points. So that what we do for research purposes and with precision medicine, we’ve got to make sure that we’ve got the data so that we can answer those discovery questions.

So we need the individual-level data; that full, computable representation of the individual chart, so that we can do discovery of the patient’s narrative and story and move between different ecosystems; and finally, we have to test for interoperability, so that both sides of the send/receive equation are working. Those are very simple things, but they’re very powerful. So those things will be important and represent the next step of that path of least regret. In other words, where this is all headed is that we need to get to that learning health system that we’ve been advocating for, and which we hope will eventually come.


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Intermountain CMIO Stan Huff on the Need for Greater Interoperability: “We’re Killing Too Many People”

December 6, 2018
by Rajiv Leventhal, Managing Editor
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About 250,000 people die per year due to preventable medical errors, and that’s the biggest motivator there is for more advanced interoperability, says one clinical IT leader

Stan Huff, M.D., chief medical informatics officer (CMIO) at the Salt Lake City, Utah-based Intermountain Healthcare for the past 31 years, has long been a top leader in his field. Working on the leadership team for a health system like Intermountain and serving as a co-chair of the HL7 Clinical Information Modeling Initiative (CIMI), while also having been a former member of the ONC Health IT Standards Committee, Huff has a wealth of knowledge coming from both provider- and standards-focused perspectives.

Huff, who represented Intermountain at a White House meeting on interoperability this week, recently chatted with Healthcare Informatics about all things interoperability, including the different types of data exchange that exist today, the greatest barriers, and how potential pending regulations could shake up the landscape. Below are excerpts from that discussion.

When you look at the interoperability landscape today, how bullish are you on where things stand, broadly speaking? Or rather than bullish, are you more concerned?

I don’t know if I am bullish or not, but I think we are making progress—and it’s significant progress. There is an incredible amount of work to be done. I’m not concerned at the progress; I am happy, but mindful of how much work is left to do to really reap the benefits that people are hoping for.

You’re currently a co-chair of the HL7 Clinical Information Modeling Initiative while also having been a member of former the ONC Health IT Standards Committee. How important is it to figure out the issues around standards before things can progress?


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

I wish it had a higher priority. Most of the time when people are talking about interoperability now, they are thinking about caring for an individual patient and thinking about sharing information between different systems that have information on that patient. They are usually thinking about EHR [electronic health record]-to-EHR for patient care—they have a very focused idea.

But there are other dimensions. There is interoperability relative to public health, meaning how we share data from an organization to a public health [entity] so that we understand what’s going on with a whole population relative to a particular disease.

There is also research interoperability, so we can share data that’s coming from research activities. And closely related to that is interoperability of clinical trial data and all of the randomized controlled trial data that comes with that.

Then there is interoperability that comes from devices and data coming from devices, which is a whole field onto itself. So you have to be careful when you talk about interoperability. This is one axis of interoperability, in that it has to do with the scope of systems you are communicating with.

The other axis of interoperability has to do with how truly interoperable you are, and there are different levels there as well. One level is the interoperability you get with the HL7 version 2 [standard], where you have a structure and people know how to send messages between systems. And there is a lot of negotiation that happens when you set up an HL7 version 2 interface to say what terminology you are using, and if you send something as two fields or one field. There is a lot that goes on there and that’s helped quite a bit when you talk about HL7 FHIR [Fast Healthcare Interoperability Resources]—it has a more defined structure and has more things specified about terminology use.

And then you can get an even better of interoperability if you are using the Argonaut [Project] profiles. But even at that Argonaut profile level, you aren’t plug-and-play interoperable. There still is ambiguity in the Argonaut definitions that lead to different implementations by different companies and organizations.

The highest level is what I would call “plug-and-play” where this no bilateral negotiation around terminology or anything like that. The standard is explicit enough so that it could be tested for conformance and you can say whether a given system is conformant or not, and the data can be used in the way it was intended. We don’t have any plug-and-play interoperability to speak of right now, and that’s what I’m trying to shoot for.

One of three biggest motivators for me is patient safety. There is really good and convincing data that shows we are killing 250,000 people per year due to preventable medical errors. And that won’t be solved by “zero harm” programs, or by “sort of” interoperable systems. In the end, the “sort of” interoperable systems means that a person still has to look at things and make a judgment. And people are not perfect information processors. So you need a situation where the data is explicit enough where I can write rules that prevent the death or improper treatment of patients.

And we are not at that level yet. How urgent is it? I think it’s incredibly urgent and you can make an argument that it’s more important than lots of other things we’re spending money on that would have less of an impact on patient care. I work in this area, so yes, I am biased.

But I’m persuaded that it’s worth an investment, and to get to where I want to get to will not be easy. This won’t be something where you make one $20 million investment and then it’s done; it will take five or 10 years, and you will make incremental progress over that period of time. Think of it like a military campaign or a crusade, because it’s that type of timeframe and scale where you need planning and infrastructure to really accomplish what we want to do in the end—which is save lives, decrease the cost of care, and reduce the burden of clinicians.

Many folks believe that until the business incentives change, stakeholders will not be incentivized to be open with their systems. Do you agree with this and how much incentive exists today?

There isn’t a whole lot of incentive yet. If the patient care and safety issues were sufficient enough incentives, then this would have been solved a long time ago because those incentives have been there. People know and understand that we’re not caring for patients in the best way possible. And it’s the financial and proprietary considerations that keep us from doing that, ultimately.

We have to be careful [with incentives] though, because there are unexpected consequences. Going back to when I was on the HIT Standards Committee, we thought that we were doing useful and good for U.S. healthcare when we set up the meaningful use measures. And while meaningful use solved the EHR adoption issue, what it taught people was how to manage measures but not manage quality.

People became incredibly good when it came to managing the measures to get paid and to meet the qualifications, but I don’t think anyone would assert that those things improved the quality of care in any measurable way. So I think we didn’t meet the goal that we were shooting for—providing better quality care at a lower cost.

The ONC annual conference took place last week, and there seemed to be significant conversations around pending regulations such as possibly making interoperability a requirement to stay in Medicare and prohibiting information blocking. How does all of this land for you?

I welcome the change; it’s a good as thing you move from meaningful use to promoting interoperability. What I don’t know is if these specific [rules] being proposed are going to accomplish what [we want]. We thought we were doing the right things back when we were doing meaningful use.

At a high level, I would agree that it would be wonderful to require interoperability as a requirement for Medicare participation. But it’s undefined. When talking about the dimensions and these things, there has to be an understood and a useful level for the interoperability that’s required. But I haven’t seen the details to know whether what’s being asked for is both achievable and valuable if it were to be achieved. But I do agree with the [overall] direction.

Intermountain is often at the forefront of health and health IT initiatives such as its sponsorship of the Opioid Community Collaborative. How can these learnings be shared so they can improve the digital healthcare ecosystem?

The thing I try to emphasize to people is that if you look at what we are doing, and you take it in aggregate across the country—the things people are applying decision support to—it’s a tiny part of what we could do. And the reason for that is we don’t have interoperability. You can create a good program at Intermountain, or at Kaiser Permanente, or at Mayo Clinic, but the only place it works well is where it was developed. You cannot move it. If you move it, you have to recreate it. Until you have interoperability, I can’t write a rule that works on top of a Cerner system and also on an Epic system, or for that matter works on two different Cerner implementations. This cannot happen until you have those platforms supplying APIs so I can hook my decision support up to their system without rewriting all of the logic in a different technology platform.

So we are doing good things, and want to continue to do good things, but wouldn’t it be wonderful if what we did, or what the University of Utah is doing with opioids, can be directly moved and used, in the same way people can buy apps for their iPhones in the app store, or any other platform.

The realization is we might be doing 150 things at Intermountain in terms of decision support applications, but there is an opportunity to do 5,000 things, and we will never get to those 5,000 things unless we get to an interoperable platform so that when knowledge is created it can be shared. That’s my real emphasis behind interoperability.


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KLAS: EHR Vendors Making Significant Progress with CommonWell, Carequality Connection

December 4, 2018
by Heather Landi, Associate Editor
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While most EHR vendors have connections to the national network, only athenahealth and Epic customers have connected en masse, KLAS reports
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With the establishment of connectivity between CommonWell and Carequality, announced back in August, as well as other interoperability advancements by electronic health record (EHR) vendors, the ability to exchange patient records is within the reach of most acute care or clinic-based provider organizations, regardless of size or financial situation, according to a new report from Orem, Utah-based KLAS Research.

In the report, “Interoperability: Real Progress with Patient Record Sharing Via CommonWell and Carequality,” KLAS researchers note that since the last KLAS report on interoperability, which was published in March 2018, the acute care/ambulatory EHR market has taken critical steps forward in sharing data via national networks. The most notable advancements include the establishment of the CommonWell-Carequality link, Meditech’s initial connection to CommonWell, and notable Carequality adoption among NextGen Healthcare customers, according to KLAS researchers.

Most of the prevalent acute care/ambulatory EHR vendors are connected to the national framework, marking significant progress for interoperability, according to KLAS researchers. The report findings come a few weeks after CommonWell and Carequality announced that the connection to the Carequality framework was “generally available.” Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, CommonWell officials said.

In August, CommonWell Health Alliance and Carequality announced initial connectivity, which is the beginning of a broader effort to increase health data exchange nationwide, and builds on an announcement made almost two years ago. In December 2016, CommonWell and Carequality announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past year and a half, teams at both organizations have been working to establish that connectivity.

Now, since the connection went live in July, officials noted that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide, as reported by Healthcare Informatics in November.


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

CommonWell, an alliance formed five years ago, operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Major vendors connecting to CommonWell include athenahealth, Cerner, CPSI, eClinicalWorks, Greenway Health and Meditech.

Meanwhile, Carequality, an initiative of The Sequoia Project that launched about a year later, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. Vendors using Carequality include athenahealth, Epic, eClinicalWorks and NextGen Healthcare. Nearly all major EHR vendors have aligned with one or both of these options, according to KLAS.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. Today, more than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network, officials attest.

This latest KLAS interoperability follows a report back in March in which KLAS researchers positioned that the CommonWell Health Alliance’s interoperability efforts were hindered by a lack of provider adoption and its interoperability services currently lacked value. However, when CommonWell and Carequality eventually connect, “instant value” will be created for users, KLAS researchers attested in that report.

Currently, Epic is not a member of CommonWell, despite other major EHR vendors pushing them in that direction. Back in 2015, athenahealth CEO Jonathan Bush famously tweeted to Epic’s CEO Judy Faulkner that his company would pay for Epic to join.

Indeed, KLAS reported in March that CommonWell will likely see a significant adoption increase with a solid Carequality connection. “Since its launch five years ago, the tendency to over-market the level of adoption of CommonWell has created apprehension and a lack of trust among potential participants and prompted this report, showing a snapshot of providers’ success,” the researchers said in the March report. KLAS researchers also claimed that when CommonWell connects to Carequality, “the entire Epic base will become available, creating instant value for most areas of the country.”

Following the publication of that report, CommonWell’s Executive Director Jitin Asnaani, in an exclusive interview with Healthcare Informatics, defended his organization’s mission and attested that the network is continuing to grow and prove its worth.

Asnaani also critiqued the KLAS report’s claim that vendors such as athenahealth and Epic give their customers a head start by enabling plug-and-play data sharing via Carequality. Asnaani called this specific critique “totally bogus,” asserting that the quality of data sharing is dependent on the vendors rather than dependent on CommonWell or Carequality.

KLAS Assessment on the Progress of CommonWell-Carequality Connection

In this latest report, KLAS researchers focused specifically on the progress EHR vendors have made in sharing patient records via the standardized (plug-and-play) networks of CommonWell and Carequality.

KLAS researchers assert that this focus is important because the “plug-and-play” option is the “only option” that allows provider organizations “avoid significant costs, delays, and organizational workload.”

KLAS also acknowledged that “virtually all major EMR vendors can successfully share patient records through the traditional point-to-point connections (a costlier approach in terms of time, resources, ongoing maintenance, and money), local HIEs (health information exchanges) and direct exchange (where records are manually sent to other providers).”

Referring to the CommonWell-Carequality connectivity as the “connection heard round the U.S.,” KLAS researchers contend that this connection should be “key in driving value and opening the floodgates so that any provider organization that desires to can exchange patient records with relative ease and little cost.” KLAS plans to measure the impact of this sharing in a 2020 interoperability report.

According to the report, this fall, two CommonWell-connected Cerner organizations tested and validated the ability to connect with Epic sites via Carequality. “Their initial reports are that the connection enables data sharing with critical partners otherwise out of their reach and adds tremendous value to their existing CommonWell exchange. The Epic sites involved indicate that they also are able to see and consume data via the new connection,” KLAS researchers wrote.

In a blog post, KLAS researcher Corey Tate, the author of the latest KLAS report, reiterated the value of the CommonWell-Carequality connection with regard to the availability of Epic data to provider organizations who connect. “Access to the Epic data is exactly what was talked about by the initial sites that tested the CommonWell connection to Carequality. Ironically enough, Epic’s intra-operability, which was initially dismissed, will likely be the catalyst that pulls widespread patient-record sharing forward. “

Currently, all but two of the other major EHR vendors—athenahealth, Cerner, CPSI, eClinicalWorks, Epic, Greenway Health, MEDITECH, NextGen Healthcare, and Virence Health (formerly GE Healthcare)—have customers connecting, according to KLAS. At this point, Allscripts and MedHost have yet to connect to CommonWell or Carequality. However, Allscripts recently announced more solidified plans to have their Carequality connection ready in Q1 2019 and to then roll it out in product updates throughout the year, according to KLAS. MedHost has been aligned with CommonWell since 2014 but has yet to have any live connections, KLAS researchers state.

While all of these vendors have connections to this national network, only athenahealth and Epic customers have connected en masse, according to Tate, in his blog post. “Each vendor has more than 90 percent of their customers connected. Cerner is next at around 35 percent. Many other vendors’ customer bases are just getting started,” Tate wrote.

“Epic and athenahealth have near complete uptake among their customers, allowing them to work on the next steps for interoperability, such as fine-tuning usability and increasing value for clinicians,” KLAs researchers wrote in the latest report. The researchers noted that plug-and-play sharing is “virtually invisible and automatic” for athenahealth and Epic customers, and “both vendors remove the big obstacles” to providers’ success.

KLAS researchers also highlight Epic’s and athenahealth’s approach to facilitating participation, via an opt-out approach, and removing governance barriers, via predetermined handling of outside data. The researchers contend that this indicates that “regardless of customer size, vendors can facilitate widespread adoption if they choose.”

NextGen Healthcare and eClinicalWorks show the most notable progress in connecting to the national framework, according to KLAS. Since NextGen Healthcare made their bidirectional connection available in Q1 2018, customers have rapidly taken up connections to Carequality. “With 80 customers connected, there is still much room for additional uptake—though NextGen has removed both financial and technical barriers to make this a reality. eClinicalWorks customers have also rapidly taken up connections, with nearly triple the number participating today (~2,500) compared to March 2018,” according to the report.

Meditech also made their first connection to CommonWell, and CPSI has made notable progress this year as well, KLAS reports. Cerner continues to actively push for customer participation and has added 35 hospital customers.

“Virence Health (GE Healthcare) has been slower to get out of the gate despite good feedback from early adopters,” the KLAS researchers wrote. “Greenway Health also doesn’t have much momentum, and overall, interviewed Greenway organizations are the least excited about their CommonWell connection.”

KLAS researchers also note that with CommonWell and Carequality linked, the biggest technical obstacle to widespread patient-record sharing has been removed, and the biggest remaining obstacle is local community adoption. “The healthcare industry is rapidly approaching the point where an organization using any of the major acute care/ambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort,” KLAS researchers state. “Many vendors have eliminated obstacles on the path to data exchange—all but Virence offer connections to customers at no cost, and all but Cerner have made this plug and play by removing technical barriers.”

“Today, the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate. Even Epic and athenahealth customers report diminished value from their connection when local exchange partners opt not to connect to the national networks,” KLAS researchers wrote in the report. KLAs also believes that until other vendors take an opt-out approach, provider organization leaders will need to be proactive in promoting local connections to the networks to ensure high value from the connection.

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5 Lessons Learned Implementing SMART on FHIR at Intermountain

November 26, 2018
by David Raths, Contributing Editor
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Challenges include differences in vendor implementations of FHIR and their data models

During a recent eHealth Initiative webinar, Laura Heerman Langford, Ph.D., R.N., a nurse informaticist, detailed some lessons learned implementing Smart on FHIR apps at Intermountain Healthcare. Because FHIR is still under development, “we are driving the car and changing the tires at the same time,” she said.

She began by noting that the Salt Lake City-based health system believes its investment in FHIR-based Innovations will help it tackle important problems for which native EHR functionality has proven inadequate.

Today we have a lot of direct interfacing between applications and EHRs, she said, “but we have a vision of tomorrow that is much more plug and play. Imagine if it didn’t matter what vendor you were using in your hospital. Imagine if you had a healthcare app store where you could reliably find an application to help you accomplish what you want to be doing.”

As an example of where it hopes to make progress, Heerman Langford spoke about Intermountain’s work on clinical decision support. Intermountain has decision support modules on topics such as ventilator weaning, MRSA monitoring and control, and infectious disease reporting to public health.

 “At Intermountain we have upwards of 150 decision support rules or modules,” she said. “But we have only picked the easy stuff – things that are low cost to implement or easy to do. There is a lot more we would like to do. We have estimated that there are 5,000 more decision support rules or modules we could be doing to help our clinicians provide better care. However, we have not found a good way to get from the 150 we have to that 5,000. We are looking at how to fundamentally change the ecosystem for healthcare IT.”


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Intermountain, which has 23 hospitals and more than 185 clinics, has a strong history of innovation in informatics. A few years ago, it began work on an implementation of Cerner, labelled iCentra.

In its contract with Cerner, Intermountain made clear it wanted to create an ecosystem that could allow it to have open-standards-based application programming interfaces (APIs). Around the time Intermountain was partnering with Cerner, SMART on FHIR was launched.

“We have integrated SMART apps into iCentra, some of them based on the demand of clinicians,” Heerman Langford said. “We included three SMART on FHIR apps and we have a fourth one in development. We have been able to share enhancements with other organizations with different EHRs.” Intermountain also has a SMART on FHIR sandbox development environment.

One example she described is a Pediatric Growth Chart App first developed by Boston Children’s Hospital. “This was desired by our clinicians because they felt it was better than what Cerner had to offer,” she said. It provides a visual display of a patient’s growth data against an appropriate cohort. “We integrated it into iCentra, using data from our EHR, such as height, weight, head circumference and BMI. We currently have it in all our NICUs and pediatric clinics and replaced the Cerner module with it. It offers a very concise, interactive view. It was more palatable to our clinicians. It offers printouts to give to families and parents.”

Heerman Langford gave a few more examples of SMART on FHIR apps from the University of Utah. One is a Neonatal Bilirubin App that pulls in a baby and mother’s EHR data. It has near-universal use in the inpatient setting. “They are estimating that it saves up to 300 physician hours per year,” she said. Another is a Procedure Capacity Management App that provides calendar visualization of capacity vs. scheduled procedures. It facilitates efficient capacity management and supports post-surgical care transitions. It is one of ONC’s High-Impact Pilot Projects.

Then Heerman Langford laid out some of the lessons learned implementing these apps.

1. The first is that although EHR vendors do provide a fairly extensive set of FHIR resources they are still somewhat cautious and conservative at this point. “They are not exactly sure how much this is going to catch on and how much they should be putting toward this,” she said. “They are paying attention. They are doing it, but not as much as we would like to see.”

2. Health systems need support for additional use cases, specifically around “write capability,” she said.  “That means if I create something in a SMART on FHIR app, I could write back to the EHR. That is one of the hardest things to do right now.”

3. Health systems still need some more expertise related to the EHR vendor data. “When we are working with Cerner data, and this is true with different vendors as well, app developers are not always sure where the data is, what they call it, and whether you are going to get back what you asked for,” Heerman Langford said.

4. There is a lack of specificity in FHIR Resources, she said. “We know that FHIR Resources need to be profiled, but the US Core FHIR Profiles have not been enough. We need to do more work on the terminologies.” Another issue is single patient/subject queries vs. working on population-based queries. “We need single patient data, but population-based data is just as important,” she said.

5. Differences in vendor implementations of FHIR and their data models creates challenges, she said.  For example, with the term suspected lung cancer, each of those elements can be stored on its own: cancer, lung, and suspected; or they could be coordinated in different ways such as suspected cancer, body site, lung. “We are running into this as we are implementing Smart on FHIR apps within the EHR. The apps may prefer it one way, but you get into the EHR and they have their way of presenting it.”

Other issues are more cultural than technical, she said. “Healthcare organizations are very much looking at their own organization. In order to make a lot of this work, we need to promote collaboration among different organizations,” Heerman Langford said.

She stressed that open source apps are not free. “It does take time, energy and investment to get them to work in your local institution. But we do believe that the more we do this, the less expensive it will get over time.”

She called this movement the real beginning of the learning healthcare system. “The prospect of this new ecosystem to support our vision is real and is worthy of investment.”




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