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Can DirectTrust Jumpstart Open API Networks and FHIR?

May 23, 2018
by David Raths
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Developers working on using Direct to send FHIR resources or query FHIR servers and receive back information
Most people in healthcare informatics are aware that FHIR is a new standard that defines a web application programming interface (API) and related specifications for health data exchange. One question about FHIR is how to build trust networks for sharing data between FHIR servers across organizations. During a May 21 webinar, members of DirectTrust workgroups discussed their efforts to allow for the exchange of FHIR resources using its certificate-based trust framework.
 
Operational since 2013, the Direct Network has 1.67 million trusted Direct addresses involving 112,000 healthcare organizations. "It has both the technology and policy to enable a trust system for providers to work together," said Calvin Beebe, board chair of HL7 and a technical specialist at Mayo Clinic. "Because there is such expenditure involved in planning, setting up and maintaining trusted distribution networks, there is strong incentive to leverage existing networks as much as possible."
 
Addressing FHIR, the DirectTrust community has addressed two use cases, and has presented on them at recent FHIR Connect-a-thons.  The first involves sending FHIR resources in a Direct message as an attachment. “This turns out to be not that difficult,” Beebe said. “It allows you to send FHIR resources as a payload from one Direct site to another or to send a query and receive back information using Direct messaging capability.”
 
 The second use case involves using Direct’s X.509 certificates with the FHIR RESTful API to enable trust relationships to scale up. “We looked at how to take FHIR servers and establish trust between them directly,” Beebe said. “One scenario is sending attachments and the other is improving the FHIR resources so they can be trustworthy.”
 
Bruce Schreiber is chief technology officer of MaxMD, a health information service provider (HISP) and a board member of DirectTrust. He gave a brief demo of what Direct to FHIR for query-based exchange looks like. 
 
MaxMD has developed a “Direct to FHIR” solution for both patients and providers to query medical records by sending a Direct message. MaxMD says it leverages the trust-in-identity assured by a Direct Address to provide authentication and authorization of an HL7 request to a FHIR API. The user receives a response in an inbox like an ordinary Direct message.
 
Schreiber noted that the two use cases described are complementary approaches. “What we showed in example one is that Direct can be used as a transport layer, as a single onramp to transmit a FHIR payload,” he explained. “In scenario two, we showed the trust framework developed by DirectTrust can be used for authentication and authorization, and there are a number of ways this can be scaled.” 
 
Luis Maas, chief technology officer of another HISP, EMR Direct, chairs the DirectTrust Security and Trust Compliance Workgroup. He said these two scenarios are part of a body of work that has been ongoing since 2014, when talk about open APIs in healthcare started to gain steam. 
 
“Several of us in the DirectTrust community were already looking ahead at the issues of trust and scalability and how a certificate-based framework like DirectTrust could be used to jumpstart these open API networks,” Maas said. “At DirectTrust we asked ourselves what benefits of using a certificate-based trust framework we could inject into the open API ecosystem and really jumpstart that and scale trust.”
 
Among the benefits he described: 
• Validated network identity, certificate management, policy
• Confidence in exchange across organizations that might not otherwise communicate with each other. 
• Scales more easily than one-off key exchange with every counter party
• Single on-ramp model
 
DirectTrust was able to create scalable tools for Direct messaging, Maas noted, which allowed for rapid and flexible scaling in a trustworthy way. “FHIR is in need of the same thing now, so that providers can enroll once and use the same type of approach for open APIs. It goes toward the single onramp idea.”
 
One question is how well DirectTrust’s efforts with HL7 FHIR dovetail with the TEFCA framework being developed by the Office of the National Coordinator for Health IT. 
 
 
 
 
 
 
 

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EHR-Compatible Pharmacist Care Plan Standard Opens the Door to Cross-Setting Data Exchange

September 14, 2018
by Zabrina Gonzaga, R.N., Industry Voice
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Pharmacists drive information sharing towards quality improvement

Pharmacists work in multiple environments—community, hospital, long term care, clinics, retail stores, etc.—and consult with other providers to coordinate a patient’s care.  They work with patients and caregivers to identify goals of medication therapy and interventions needed, and to evaluate patient outcomes.  Too often, pharmacy data is trapped in a silo and unavailable to other members of the care team, duplicated manually in disparate systems which increases clinical workloads without adding value.

To address these issues, Lantana Consulting Group and Community Care of North Carolina (CCNC) developed an electronic document standard for pharmacist care plans—the HL7 Pharmacist Care Plan (PhCP). The project was launched by a High Impact Pilot (HIP) grant to Lantana from the Office of the National Coordinator for Health Information Technology (ONC).

Before the PhCP, pharmacists shared information through paper care plans or by duplicative entry into external systems of information related to medication reconciliation and drug therapy problems. This documentation was not aligned with the in-house pharmacy management system (PMS). The integration of the PhCP with the pharmacy software systems allows this data to flow into a shared care plan, allowing pharmacists to use their local PMS to move beyond simple product reimbursement and compile information needed for quality assurance, care coordination, and scalable utilization review.

The PhCP standard addresses high risk patients with co-morbidities and chronic conditions who often take multiple medications that require careful monitoring. Care plans are initiated on patients identified as high risk with complex medication regimes identified in a comprehensive medication review. The PhCP is as a standardized, interoperable document that allows pharmacist to capture shared decisions related to patient priorities, health concerns, goals, interventions, and outcomes. The care plan may also contain information related to individual health and social risks, planned interventions, expected outcomes, and referrals to other providers. Since the PhCP is integrated into the PMS or adopted by a software vendor (e.g. care management, chronic management, or web-based documentation system), pharmacist can pull this information into the PhCP without redundant data entry.

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The PhCP allows pharmacists for the first time to share information with support teams and paves the way for them to support value-based payment. The project goals align with the Center for Medicare & Medicaid Services’ (CMS’) value-based programs, which are part of the Meaningful Measure Framework of improved care team collaboration, better health for individuals and populations, and lower costs.

Scott Brewster, Pharm.D., at Brookside Pharmacy in East Tennessee, described the PhCP as a tool that helps them enhance patient care delivery. “From creating coordinated efforts for smoking cessation and medication utilization in heart failure patients, to follow up on recognized drug therapy problems, the eCare plan gives pharmacists a translatable means to show their value and efforts both in patient-centered dispensing and education that can reduce the total cost of care.” (The eCare plan reference by Scott Brewster is the local term used in their adoption of the PhCP).

The pilot phase of the project increased interest in exchanging PhCPs within CCNC’s pharmacy community and among pharmacy management system (PMS) vendors. The number of vendors seeking training on the standard rose from two to 22 during the pilot. Approximately 34,000 unique care plans have been shared with CCNC since the pilot launch.

This precedent-setting pilot design offered two pharmacy care plan specifications: one specification is based on the Care Plan standard in Clinical Document Architecture (CDA); the other standard is a CDA-on-FHIR (Fast Healthcare Interoperability Resources). The latter specification directly transforms information shared using the FHIR standard into CDA. FHIR is straight forward to implement than CDA, so this is an appealing option for facilities not already using CDA. The dual offerings—CDA and CDA-on-FHIR with lossless transforms—provide choice for implementing vendors while allowing consistent utility to CCNC.

What’s on the horizon for the pharmacy community and vendors? With the support of National Community Pharmacists Association (NCPA), the draft standards will go through the HL7 ballot process for eventual publication for widespread implementation and adoption by vendors. This project will make clinical information available to CCNC and provide a new tool for serving patients with long-term needs in the dual Medicare-Medicaid program and Medicaid-only program.  This is a story about a successful Center for Medicare and Medicaid Innovation (CMMI)funded project that started out as a state-wide pilot and is now rolling out nationwide as Community Pharmacy Enhanced Service Network (CPESN)USA. 

The PhCP is based on a CDA Care Plan standard that is part of ONC’s Certified EHR Technology requirements, so it can be readily implemented into EHRs. This makes the pharmacist’s plan an integral part of a patient’s record wherever they receive care. 

Adoption of the PhCP brings pharmacies into the national health information technology (HIT) framework and electronically integrates pharmacists into the care planning team, a necessary precursor to a new payment model and health care reform. In addition, receiving consistently structured and coded pharmacy care plans can augment data analysis by going beyond product reimbursement to making data available for, utilization review, quality assurance and care coordination.

Troy Trygstad, vice president for Pharmacy Provided Partnerships at CCNC, described the strategic choice now available to pharmacists and PMS vendors. “Fundamentally, pharmacy will need to become a services model to survive. Absent that transformation, it will become a kiosk next door to the candy aisle. The reasons vendors are buying into the PhCP standard for the first time ever is that their clients are demanding it for the first time ever."

The move to value-based payment will continue to drive the need for pharmacists, as part of care teams, to provide enhanced care including personal therapy goals and outcomes. Sharing a medication-related plan of care with other care team members is critical to the successful coordination of care for complex patients.

Zabrina Gonzaga, R.N., is principal nurse informaticist and director of health informatics at Lantana Consulting Group and led the design and development of the PhCP standard. 

Email:  zabrina.gonzaga@lantanagroup.com

Twitter: @lantana_group

 


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Health IT Now Pushes for Information Blocking Regulation, Says Administration “Must Uphold its End of the Bargain”

September 13, 2018
by Rajiv Leventhal, Managing Editor
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The executive director of Health IT Now, a coalition of healthcare and technology companies, is again criticizing the Trump administration for not yet publishing any regulation on information blocking, as required by the 21st Century Cures Act legislation.

In an op-ed published recently in STAT, Health IT Now’s Joel White wrote, “More than 600 days after the enactment of the Cures Act, not a single regulation has been issued on information blocking.” White added in frustration, “Health IT Now has met with countless officials in the Trump administration who share our commitment to combat information blocking. But those sentiments must be met with meaningful action.”

The onus to publish the regulation falls on the Office of the National Coordinator for Health IT (ONC), the health IT branch of the federal government that is tasked with carrying out specific duties that are required under the 21st Century Cures Act, which was signed into law in December 2016. Some of the core health IT components of the Cures legislation include encouraging interoperability of electronic health records (EHRs) and patient access to health data, discouraging information blocking, reducing physician documentation burden, as well as creating a reporting system on EHR usability.

The information blocking part of the law has gotten significant attention since many stakeholders believe that true interoperability will not be achieved if vendors and providers act to impede the flow of health data for proprietary reasons.

But ONC has delayed regulation around information blocking a few times already, though during an Aug. 8 episode of the Pulse Check podcast from Politico, National Coordinator for Health IT Donald Rucker, M.D., said that the rule is "deep in the federal clearance process." And even more recently, a bipartisan amendment to the U.S. Senate's Department of Defense and Labor, Health and Human Services, and Education Appropriations Act for Fiscal Year 2019 includes a requirement for the Trump administration to provide Congress with an update, by September 30.

White, in the STAT piece, noted a June Health Affairs column in which Rucker suggested that implementation of the law’s information blocking provisions would occur “over the next few years.” White wrote that this is “a vague timeline that shows little urgency for combating this pressing threat to consumer safety and stumbling block to interoperability.”

Health IT Now is not alone in its belief that the rule should have been published by now, nor is it the first time the group is bringing it up. Last month

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By the end of this year, ONC’s implementation and interpretation of data blocking will also be published and available for comment, as was the case with the TEFCA proposed rule. The TEFCA final rule is also anticipated by the end of 2018.

HOWEVER…there’s still time to prepare for TEFCA and the data blocking regulation, and final rules for both in the coming months will set concrete timelines, and for TEFCA it will be interesting to see how ONC reacts to stakeholder comments, internal and external.

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