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CommonWell, Carequality Agree to Collaborate for More Advanced Interoperability

December 14, 2016
by Rajiv Leventhal
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Interoperability guru Micky Tripathi says this agreement serves as “the last core building block” for health information exchange from a technical and network perspective

CommonWell Health Alliance and Carequality have announced connectivity and collaboration efforts that will aim to provide additional health data sharing options for stakeholders.

The agreement specifically has three core aspects, according to officials in a joint press release announcement today:

  • CommonWell will become a Carequality implementer on behalf of its members and their clients, enabling CommonWell subscribers to engage in health information exchange through directed queries with any Carequality participant.
  • Carequality will work with CommonWell to make a Carequality-compliant version of the CommonWell record locator service available to any provider organization participating in Carequality.
  • CommonWell and The Sequoia Project, the non-profit parent under which Carequality operates, have agreed to these initial connectivity efforts and will explore additional collaboration opportunities in the future.

Officials noted that while future collaboration could touch on many different areas within healthcare IT, the immediate focus of the work between Carequality and CommonWell will be on extending providers’ ability to request and retrieve medical records electronically from other providers. Some types of information exchange capabilities, such as electronic prescribing and electronic lab results delivery, are already widely adopted. However, variation in data exchange implementation is still a challenge for some providers looking to exchange medical records with others across the care continuum, they said.

CommonWell Health Alliance operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Services include patient ID management, advanced record location, and query/retrieve broker services, allowing a single query to retrieve multiple records for a patient from member systems.

Meanwhile, Carequality, an initiative of The Sequoia Project, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. It brings together electronic health record (EHR) vendors, record locator service (RLS) providers and other types of existing networks from the private sector and government, to determine technical and policy agreements to enable data to flow between and among networks and platforms.


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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 noted.

Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, who was heavily involved in the facilitating and negotiating of the agreement as he sits on the board of directors of The Sequoia Project and also does project management work for CommonWell, notes that the arrangement is “akin to AT&T and Verizon Wireless cell phones finally being able to talk to each other.” Tripathi says that as it previously stood, there was a lot of development and network formation, and maturity on both sides, but in siloes. “Providers were facing issues on the ground level.”

He adds, “A large provider organization I know is switching from Cerner to Epic. So Cerner is in CommonWell but not in Carequality, and [vice versa] for Epic. And the CIO said to me six months ago that he’s not looking forward to the conversations he will have to have with his clinicians, which is  that you have great interoperability with your current system and your future system but the bad news is you won’t have the interoperability with the same people. Now he doesn’t have to say that to his doctors anymore since [they all] are connected to the same people regardless of what network you are on,” Tripathi says, speaking to the impact of the agreement.

Adding more specificity, Tripathi notes the core interoperability functionalities that people are able to do now, such as sending lab results and the direct sending of email messages from one provider to another. “This ability to query from one system to another was the last core building block, and at least from a technical and network perspective, that is now solved.”

Tripathi further explains that CommonWell was built with an understanding that patient identification is a huge issue that needs to get solved among the different vendors in the clinical sites. And in order to do that properly, there is the need for a central infrastructure. “If everyone were to do that on their own at a robust level it would cost a lot more money compared with polling resources and building a central infrastructure. So in a sense [vendors] outsourced that to CommonWell to build that centralized infrastructure for patient matching and record location,” he says.

Meanwhile, Carequality doesn’t have record matching in the middle, as it’s a framework, Tripathi continues. “So they are basically saying that there is a phonebook of provider organizations, and you can look up a provider in that phonebook and ask them if they have X person’s medical records. No central infrastructure is needed for that.” Tripathi explains that a part of the reason for this is due to large vendors like Epic having only 300 customers or so but vendors such as athenahealth and eClinicalWorks having some 30,000 customers sprinkled around.

As such, for Epic, when they were designing their architecture 10 years ago, “they were thinking mostly about connecting to relatively smaller numbers of sites” in the beginning rather than connecting up to large numbers of other sites, Tripathi says. “In Cleveland there are four large Epic installs, so do I really need to set up a central infrastructure for record location or is it more efficient to set up a system where each of the four sites can ask the others for records and send them to each other? That’s basically how Carequality works; they still do record location but because there are fewer records, they decide to do it in a more efficient way for them. But for an athenahealth, you can’t send out a blast message to 10,000 different sites. So that vendor needs a central infrastructure that passively collects information from all sites on patient encounters. You have these two parallel paths based on different assumptions on what’s needed in the market and based on their customers, and they are now merging,” he says.

There is also another subtlety to the agreement that Tripathi points out as being significant: per this arrangement, an Epic customer, for example, who wants to purchase the CommonWell record locator service will now have it be available to them within Epic’s platform, serving a layer on top of the vendor's Care Everywhere interoperability software. “It’s almost like using Internet Explorer, Chrome, or Firefox,” says Tripathi. “An Epic customer can purchase the Surescripts record locator service or the CommonWell record locator service, or both. Epic and others have committed to being indifferent; they will offer it in their platform integrated into the workflow of the provider based on what service the provider wants to purchase,” he says.

Tripathi adds now that the query problem is solved, the next step is to improve on the content challenge. He notes that right now, the vehicle for exchanging multi-type clinical information is the continuity of care document (CCD) and clinicians aren’t happy with that for a variety of reasons such as too much optionality and not enough standardization. “So this agreement doesn’t solve the content issue,” he says.  “In a way all it does is make it easier for you to get that thing that you weren’t happy about to begin with. That’s the next challenge—how do we actually improve on that content so you’re happy with what you get back?”

What's more, both Carequality and CommonWell officials spoke to the importance of this agreement. “Collaboration and inclusion are the keys to success in health data sharing and interoperability,” explained Dave Cassel, director of Carequality, in a prepared statement. “The Carequality Interoperability Framework was developed by a group of diverse healthcare stakeholders, including members of CommonWell, determined to establish health data sharing as the standard of care by powering connectivity between and among health data networks of all types. With the promise of heath data sharing across Carequality’s participating networks and the CommonWell network, we continue to advance toward that goal. It’s a win-win-win for patients, providers, and their networks.”

Jitin Asnaani, executive director of CommonWell Health Alliance, added, “To achieve nationwide interoperability that truly improves patient care, two things are required:  collaboration across the healthcare industry and the will to take real action. We’re doing both.” He continued, “Our vision has always been for a patient’s health data to follow him/her regardless of where care occurs, and in turn give providers and caregivers increased access to critical health data when and where it is needed. We believe this connectivity between CommonWell and Carequality will continue to move the country forward on its path to achieving nationwide data exchange by bringing together such a sizeable majority of providers and patients that there will be no turning back for American healthcare.”

Officials from Watertown, Mass.-based EHR vendor athenahealth, a member and implementer of both CommonWell and Carequality, additionally weighed in, noting that healthcare providers on the majority of the country’s EHRs will now be able to electronically request and retrieve patient medical records from one another in a consistent, standard format. They added, “This alliance brings together otherwise competing market players, which is necessary for data sharing, but not sufficient for creating a fully-connected, integrated healthcare workflow. True interoperability is not just a matter of moving bits across the wire and deluging providers with every care note and encounter. True interoperability will be achieved when information can follow the patient in an unencumbered way.”


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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. 


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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