It’s been a little over three years since the CommonWell Health Alliance, an industry trade group made up of many of the largest electronic health record (EHR) systems vendors and other health IT companies, formed at the Healthcare Information and Management Systems Society (HIMSS) annual conference with the goal to greatly enhance health data exchange. And, it’s been a little over a year since the Alliance tapped Jitin Asnaani as its founding executive director.
Asnaani has a background in public and private interoperability efforts, and joined CommonWell from athenahealth (Watertown, Mass.), a founding member of the Alliance, where he headed up product innovation and interoperability. Before that, Asnaani was involved with technical standards development at the Office of the National Coordinator for Health IT (ONC), product management at a health IT startup and strategy consulting at Deloitte.
Soon after the official appointment of Asnaani as CommonWell chief, Healthcare Informatics sat down with him to discuss his first directives as head of the Alliance, specifically in terms of interoperability and national patient identifier efforts, as well as the quarrel the trade organization was having with Epic, a hot industry topic at the time. At the core of that CommonWell/Epic feud was that Epic, despite its stature as the biggest EHR vendor in the industry, would not join the CommonWell Alliance.
A lot has changed in both the progress and perception of healthcare interoperability since CommonWell formed. As far the Alliance itself, it recently announced that as of earlier this year, its member organizations represent 72 percent of the acute care EHR market and 34 percent of the ambulatory care EHR market, even without Epic on board. Just a few days ago, Healthcare Informatics checked in again with Asnaani to discuss what’s new with the organization’s interoperability efforts, industry challenges such as data blocking, and if any headway has been made with Epic. Below are excerpts from that latest interview.
Where does the Alliance stand today, three years into its journey?
The Alliance has grown from a concept to a live network to about 4,500 live sites in the past three years, most of which have come live in the last three quarters of that time. We are speeding along, and with those sites, we are serving so many patients and providers, across all 50 states and two territories. We have a live living network; a functioning network of great scale.
From the beginning, CommonWell has been about leveraging the entire community to build the platform for clinical exchange that the country so badly needs. That began with EHRs, but doesn’t end with EHRs. We do have some great EHR companies who are members, but less than half of our members our EHR [vendors]. We also have health technology vendors across the care continuum. We announced at HIMSS that a number of our members will go live in skilled nursing facilities, home health facilities, and other [post-acute care settings].
We have proven that the model we are using works, meaning the ability to identify and search out that patient’s record in order to give him or her the best care and know exactly where he or she has been. That [information] is extremely valuable to providers, caregivers, and to the patients. But we have even more to do to make it more seamless, valuable, and have better quality data. These are the things you figure out once you have started hitting some scale.
What have been some of the most significant interoperability lessons learned in the past year?
First of all, there is a better path towards interoperability become truly achieved other than finger pointing. Before the Alliance, there was finger pointing between the government, provider groups and vendor groups, and even amongst vendors themselves, as to why was data not flowing from a facility powered by one vendor to a facility powered by another vendor. We have learned that if you give the power to those participants who have the ability to affect the change, to create value in their products, and enable interoperability from scratch in their products, like we have done through CommonWell, then you can get some amazing collaboration achieved.
Often we will have member meetings in which a new member joins us, which is a little bit like entering the Twilight Zone, in that you have people who have discussions and share with others a level of detail and information—well within legal bounds obviously—that you wouldn’t realize they are capable of sharing with each other. And the [new member] will leave meeting with saucer-shaped eyes. They will say, “I can’t believe that a company shared screen shots with their competitors.” And I say yes, that’s the way this works.
If you have one person in the room that figures it out, but no one else can, then you have one tango dance partner that is better than everyone else, which still leads to an awkward dance. Everyone else has to be dancing well, too, in order for it to work and create value. So then they get it, and they understand what “sharing” means. When the Alliance formed, I was probably as skeptical as everyone else. I used to work at the ONC, and I have seen the best and worst of vendors trying to cooperate. But the Alliance is by the vendors, so it brings out the best.
Do you think data blocking exists? If so, in what form?
What is real is the friction that exists in trying to get data from one place to another. There is real friction in terms of looking at data one way in one EHR to another way in a different EHR. There are technology hurdles and policy hurdles; there are hospitals, states, and municipalities that believe that data should be opted into in a way that is different from other hospitals, states, and municipalities think. So that friction is real.
Where I think there is an issue is when organizations take advantage of those real frictions. Rather than paving the pathway, and many pathways between two organizations do exist, they point to those frictions as reasons they can’t do it. Are people purposely making it impossible for data to flow? There are people who realize that there are architecture and infrastructure issues to be sorted out, and it’s a matter of making it an organizational priority. For the average hospital, interoperability will give them a benefit for sure, but who’s to say that other things won’t give benefits, such as a focused analytics program? People perceive data blocking [takes place] when a hospital makes it clear that it’s a low priority and that they’re okay with the frictions.
The data sharing pledge announced at HIMSS was signed by your organization, and many other major players. How do you think this agreement will play out?
I’m not sure how ONC plans to utilize that particular pledge over time. I will tell you that what it did was make it clear that this is important to ONC. If it’s clear to your regulating body as an industry, if they say it’s important that there’s no data blocking, that it’s important that the consumer be empowered if they so choose, that it’s important to do this in a way that’s standardized and doesn’t preclude anyone from participating, then it creates another signal to the industry that some things are acceptable and other things are no longer acceptable. Not so long ago in health IT, it was perfectly acceptable to make money off interfaces, and that’s somewhat still true, but generally speaking, it’s just not acceptable that that’s a barrier for the exchange of data for the care of a patient. When we saw the pledge, it was a no brainer from our perspective.
Can you discuss FHIR and your thoughts on its current and future role in healthcare?
FHIR [Fast Healthcare Interoperability Resources] is two things: there is the FHIR standard which enables you to package discrete bundles of data, and there is a thing called the FHIR transport standard which enables one application to be able to connect in a physical way with the data repository underneath it, like the EHR. That’s a big deal because there has never been a standard, secure way of connecting one app to an EHR across the industry. So if you’re an app developer, you have little hope of achieving scale since you have to build something different to connect to Cerner as opposed to Epic or athenahealth or Allscripts. So you have the ability to build a great app and it doesn’t matter what EHR is on the other side from a technology side.
To answer your question, everyone right now realizes that the discrete and transport standards were badly needed, particularly for innovators to build apps on top of EHRs. There isn’t a lot of usage of this happening broadly today. It’s right now in the stage of being piloted and tested in sandbox environments. Some leading edge provider organizations are utilizing it, but it’s still in the demo phase now as opposed to production. That’s not because of skepticism but rather because these things take time. Relative to the time standards usually take to be ironed out, FHIR is moving at a substantial pace. I think by 2017, it will be much more than norm for there to be FHIR-powered apps. FHIR as a standard that people know about is only about two years old, younger than CommonWell even.
Two big things will happen in the next two years: apps and app developers who are not stereotypically EHRs will build innovative applications and have a method to scale them across platforms; second, organizations like ours will be able to enable the data that flows on our network to be discrete packets of data, not whole clinical documents. This will help take medicine further away from an art form to a science form when that kind of data is readily available.
I have to ask you a question about Epic. Last year there was quite the quarrel between CommonWell and Epic. Where does that relationship stand today?
One of the issues we had in CommonWell was that we were formed by members and for two years we were led entirely by members, so there was no one who could speak specifically for CommonWell without having an interest in a particular member. Of course, our EHR members compete with Epic. When I joined CommonWell a year ago, I was the first and only employee—and still am—and I gave up my shares in any company that had any affiliation in this industry. When I worked with the government, I worked with all of the EHR members and their management teams. So soon after I joined, I began to extend the olive branch to other EHRs not part of the Alliance.
Historically, Epic and CommonWell have had disagreements about how the world should work. The discussions over the last year have been few, but positive. Over time, I would expect there will be further alignment between these organizations. Given my background working at ONC and with these companies, I know they have more common ground than what’s been perceived.
Is there an open invite for Epic to be a part of CommonWell?
Absolutely. There is an open invite for every organization to be a part of CommonWell. We specifically reached out to the top 20 vendors in terms of size, as well as to all of the associations that represent EHRs. I expect that in some point in time, we will figure out a pathway forward with them. [CommonWell and Epic] have been more or less apathetic with each other over the last six months or so, without much bickering. Eventually these organizations will come together—that is a strong feeling of mine.