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Five Tips for Seeking Greater Interoperability in 2018

January 8, 2018
by Sarath Degala, BIP Capital
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The best advice I can offer is to understand that the quest for gaining greater interoperability is a seismic shift for your entire organization

The recent merging of Aetna and CVS has me thinking about the potential implications of two disparate elements of the healthcare system—insurance companies and pharmacies—working together as part of a whole.

In my years as a hospital administrator and strategist, I witnessed firsthand the enormous burden that poorly integrated IT systems have on the state of healthcare for everyone involved. It’s all too common that separate departments within a single clinical setting use different software, making it nearly impossible to transfer data from one unit to another. In fact, Deloitte found that seven out of 10 physicians say that electronic health records (EHRs) reduce their productivity. To this end, Lewis Sandy, M.D., UnitedHealth’s executive vice president for clinical advancement, said: “I wince when I see how much physician time is devoted to data entry.”

From outdated legacy systems to intentional data blocking to mitigate risk, interoperability is one of the greatest challenges facing the healthcare system today. And, it’s also one of the most dangerous. Researchers from Johns Hopkins have found that over 250,000 deaths per year in the U.S. are due to medical error, which makes it the third-leading cause of death in the country, after heart disease and cancer.

A major part of that medical error? Uncoordinated care.

According to Martin Makary, M.D., professor of surgery at Johns Hopkins University School of Medicine: “Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in healthcare.”

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Suffice it to say that interoperability is no longer a luxury or a future dream state for healthcare. It’s a moral imperative. Still, the problem is expensive, vast and can seem overwhelming. Based on my time leading a transition team at WellStar in Atlanta and consulting on several others, I can recommend five best practices for decision-makers to consider as they guide their teams in making a transformation in their IT infrastructures.

Sarath Degala

1. Start with a stop-gap analysis

One of the biggest obstacles when updating an IT infrastructure is being prepared for all the decisions you have to make in a relatively short period of time. So, start early. Before selecting an EHR software vendor, do your research. Examine the precise functionalities the different vendors provide for both clinical and financial needs and find out how they rank against their competitors. Talk to other hospitals that have implemented their solutions. Compare your current infrastructure to your optimal goal state and document an analysis of where you are, where you want to be, and what gaps exist. A key element of this process is accurately documenting your current workflows across every department that will be affected. The task is onerous but will make all the difference in the success and longevity of your new system.

2. Plan for loss of productivity       

Naturally, the first question that arises when upgrading or replacing an IT system is cost. Set yourself up for success by being realistic about the true cost of the undertaking—financial and otherwise. Updating any hospital-wide system is going to majorly impact your organization’s entire staff. Consider cost of downtime, cost of training time and cost of decreased productivity leading up to and after the initial launch. There is typically a minimum four-to-eight-week ramp-up period from the time you introduce a new EHR to the workforce to the time your system is back to full functionality, and that is if all things go well. That lost time impacts physicians, nurses, administrators and patients, and can quickly become one of the biggest line item burdens in the project’s overall budget.

3. Involve your clinicians

In a recent white paper on interoperability, DSS Inc. found that, anecdotally, “organizational stakeholders often resist working with a system that was built without the benefit of their input …There is much to be gained by collaborating with end-users who understand the day-to-day nuances attached to their particular workflows.” To put it more simply, driving adoption is the best way to drive value—and effective change management begins with organizational buy-in. Instead of beginning with an RFP and capabilities assessment, engage your end-users as early as possible, and use their needs to drive your search.

4. Don’t let vendors guide the decision-making process

When you’re considering multiple solutions, every vendor is going to be pushing their own agenda. Be ruthless about asking questions. Grill them: What are the capabilities of this IT system to integrate with multiple others? Do you have the capability to create a data-sharing mechanism within our IT system? How easy is it to do that? Will a custom integration be required for every system pairing? The answers you’re looking for will vary from practice to practice, but it’s generally true that the less customization required, the better.

I recently spoke with Mike Schatzlein, M.D., chairman emeritus of the board of directors for the Center for Interoperability, on this very matter. “I was involved at Saint Thomas in Nashville for several years,” Schatzlein recounted. “We had somewhere between 200 and 300 custom interfaces that we maintained among and between all the different devices and EHR systems.” But that approach simply wasn’t sustainable. “The general intent should be to reduce the number of interfaces,” he advised. “If I were a healthcare administrator, one thing I would say is that ‘I’m not going to buy your thing if it requires a custom interface.’”

The major takeaway? Don’t let IT vendors be the ones to dictate how your system should function. Prioritize your end-users and find a vendor that will do the same.

5. Extend your testing time

I’ve already mentioned the immense time investment required for updating your systems. Don’t fall into the trap of rushing through the testing phase to save a few days or weeks. You might be tempted to do minimal testing, taking perhaps five claims from charge entry through to documentation. Don’t. Have the foresight to test complex claims, using real patient scenarios, and test the entire process from beginning to end. Wake Forest Baptist Health System experienced two years of eight-figure losses due to a poorly implemented transition to Epic’s EHR system. One of the major issues that led to this was insufficient testing. Learn from that mistake and trust that the time you spend rigorously testing your new system is a worthwhile investment that could save you millions down the road.

The best advice I can offer is to understand that the quest for gaining greater interoperability is a seismic shift for your entire organization. It requires examining in minute detail the way you’ve been doing things and choosing to do them differently. It also requires significant research prior to solution selection and implementation, and change management afterward. Change is never easy, but the benefits can be substantial, including a more efficient practice, greater employee satisfaction and, most importantly, providing a higher quality of care to every patient who walks through your doors.

Sarath Degala is VP at venture capital firm BIP Capital, where he leads its healthcare investment activities. He offers 16 years of healthcare administration experience achieving noteworthy operational and financial results within a variety of healthcare settings.


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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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Interoperability may seem like just a technology challenge, but in actuality it is a people, process, and technology challenge. Healthcare systems increasingly look to create high-reliability...

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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