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In Briefing with Trade Press, Dr. Vindell Washington Affirms ONC’s Data Sharing Priorities

September 19, 2016
by Rajiv Leventhal
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For the first time since being appointed National Coordinator for Health IT, Vindell Washington, M.D., spoke to the HIT press about a multitude of industry issues
Vindell Washington, M.D.

During a small gathering with health IT trade press on Sept. 19, Vindell Washington, M.D., newly-appointed National Coordinator for Health IT, reiterated the Office of the National Coordinator for Health IT’s (ONC) overarching goal to improve healthcare interoperability through a variety of initiatives.

Dr. Washington, who previously served as the president of the Baton Rouge, La.-based Franciscan Missionaries of Our Lady Health System (FMOLHS) Medical Group and as the health system’s CMIO, and who just recently took over for Karen DeSalvo, M.D., as National Coordinator for Health IT, spoke for the first time to about a dozen members of the trade press, some in person in Washington, D.C., and others via teleconferencing. While Washington answered a myriad of questions covering various health IT issues, the main takeaway from the session was that most of the federal agency’s core goals are centered around improving health information sharing across the care continuum.

Washington noted that ONC primarily focuses on three major areas regarding interoperability: using national, federally-recognized standards that come up through the environment; changing the way care is paid for, which involves work the agency is going doing with its partners at the Centers for Medicare & Medicaid Services (CMS); and third, working towards cultural changes around the sharing of health data, which involves work with the government’s Office for Civil Rights (OCR) as they look to make sure that patients know their rights around information exchange. “These initiatives fit under that [interoperability] effort, and we are focused on them as they are most likely to move forward the information sharing that’s desired in the health ecosystem,” Washington said.

Washington touched further on standards specifically, as healthcare leaders continue to look for a common language to enable interoperability between systems and devices. In the past, ONC has gotten criticized for having regulations that deter marketplace innovation. But Washington pointed to a testimony he gave to the Senate Health Committee, in which he recommended a public/private approach, with the Interoperability Standards Advisory being the best example of that. “If you look at the Standards Advisory that was recently released, it’s organized about the use case,” Washington said. “So this depends on what information is being passed, for what usage it’s being passed, and what the standards should be. You see areas of evolution in the Standards Advisory. As the government moves forward and as those standards mature, you have a move in that direction that underscores the specificity of standards that are necessary for passing information. You draw a line in road but allow enough room for innovation in our sector,” he said.

Health IT’s new National Coordinator say went on to say that the work ONC is doing around data sharing goes hand in hand with a number of the Obama Administration’s priorities. “[Data sharing] is important for delivery system reform, for the Precision Medicine Initiative, and for the Cancer Moonshot. Even though those are large and in some ways longer-term strategies, the work in the short term is around increasing this flow of information, empowering patients in this space to be able to use information and send it forward for purposes they choose. The work we are doing is in particular aimed in those areas,” he says.

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Washington also stated that ONC is working with CMS to provide technical help for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) final rule and working with OCR around the concept of patient information, meaning what data should be available and clarifying Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules. “We want to get that word out, and pushing that forward in the last few months [of the Obama Administration] is very important,” he said. He also mentioned funding opportunities where the agency is funding folks to do work on the patient-facing side, meaning apps using Fast Healthcare Interoperability Resources (FHIR} application program interfaces (APIs) with the goal of demonstrating an ecosystem or app store environment. “Standards will always be a whiteboard exercise until they are in wide and deep use,” Washington attested. “We are particularly interested in having relatively specific use cases, and some of that catalyst work helps us get to standards,” he said.

To this end, when asked about current interoperability initiatives in healthcare such as CommonWell, Carequality and the eHealth Exchange, Washington said that ONC approves the commitment in those sectors to move interoperability forward. “Our general approach is to applaud the sharing of information to be available when and where patients need it. We are also focused on making sure the playing field is level and that folks are not left out,” he says. “We have encouraging evidence in the field about exchange that’s working either by these efforts or by a local HIE [health information exchange]. There is an opportunity to do it more broadly, and that’s our focus.”

Overall, Washington believes there “is great promise and opportunity in interoperability.” He talked about a recent trip to Oklahoma in which competing health systems—Hillcrest HealthCare System and St. John Health System in Tulsa—as well as a Blue Cross Blue Shield vendor all worked together on CMS’ Comprehensive Primary Care federal initiative. “I dropped by [to talk to] one of the doctors at Hillcrest, and he told me that he’s never had this kind of information on patients he was caring for. So there are clearly areas where this is going well,” he said.

But, Washington also brought up a situation at his health system before he joined the government that points to data sharing struggles. He said he has had shifts in the ED where he has managed critical care patients with doctors who were remote and writing orders. “We both were reviewing charts at the same time, and then an hour or two later I would have to get a fax from the hospital down the street to continue the care for the patient. So I would say in some instances, it is about how broad and deep the exchange is.”

Addressing Docs’ Concerns

Meanwhile, Washington had other interesting comments regarding quality measurements and documentation for physicians—often sore points for doctors who complain that these requirements impede their ability to practice medicine. While the ONC chief couldn’t speak directly to CMS’ portion of setting up federal programs about payment, Washington attested that there “is a need to make sure care is provided is within guidelines,” adding that when he was a CMIO, “we had questions about where we stand about quality.” He said, “If you close the door with no payers in the room and discuss with providers how they will demonstrate the level of care they’re providing and improve upon that care, it becomes a complicated situation. You have limited ability in some instances to measure true outcomes such as quality-adjusted life years, improvement, and the overall health status of individuals. Those are the end goals but they are also difficult to measure.”

So, Washington pondered, what is needed in healthcare to lead to those outcomes? “Maybe I can keep my diabetic patient from having a bad complication. The best guess is to measure [the patient’s] Hemoglobin A1c in a certain range, so you are measuring that but what you really want is to have them not lose a limb or eye sight. There is a juxtaposition of what you can measure easily versus what the ultimate outcome is,” he said, adding, “This idea of quality measurement generally is not an easy scenario. It’s also multifactorial. Whether or not I had an asthmatic patient with multiple visits may be related to him or her living in a polluted area, or if the patient took medicine or used an inhaler. So we are operating in an imprecise environment while trying to reach these laudable goals of measurement,” Washington said.

Washington was also asked about a recent study published in the Annals of Internal Medicine which found that during office hours physicians spent nearly 50 percent of their time on electronic health record (EHR) tasks and desk work, and outside office hours, they spend another one to two hours of personal time each night doing additional computer and other clerical work. To this, Washington noted that there are pockets where technology is evolving well in physician practices, and pockets where it isn’t. He said he has had providers who implement their systems, do well with them, have great patient encounter times, and go home on time or even early, but  he also knows instances of providers who document at home rather than spend time with their families. He did say, “I don’t hear stories anymore about ineligible orders from physicians or [documentation] with missing information as we used to hear. My impression is that when the picture is so diverse, it means we are in an evolutionary phase when it comes to the ultimate usability of the record,” he said.

In the end, Washington is pleased with ONC’s role as its name implies—a coordinator. “Some of the best work we do is around coordination and collaboration among different movers in the environment,” he said. He lauded the effectiveness of the Meaningful Use program, as some 98 percent of hospitals and three-quarters of doctor practices are now digitized, noting that foreign delegators have asked the ONC how it has gotten such high levels of adoption.

“Now we need to pivot more to information sharing,” he said. “When I was a provider, one of the things I valued the most about being digitized was the support I got from my EHR to help me avoid errors but also the information I could get on fingertips to provide better care. Broadly speaking, [focusing on] information sharing—termed interoperability—is the right place for ONC.”

 


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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?

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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.

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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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