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Health IT Expert Tripathi Digs Deep on Impact of Epic’s Share Everywhere Release

September 15, 2017
by Rajiv Leventhal
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Micky Tripathi feels that patients driving the innovation is the important takeaway from the big Epic news this week

Earlier this week, when Epic Systems Corporation, the Verona, Wis.-based electronic health record (EHR) vendor—a health IT giant company whose platform some 190 million patients have an electronic record on—announced its latest technology upgrade that will allow patients to grant access to their data to any provider they want, there seemed to be an overall sense of optimism amongst industry observers in terms of what this means for interoperability growth.

Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, is perhaps as well-connected as anyone when it comes to health information exchange (HIE) and interoperability. Tripathi sits on the board of directors of The Sequoia Project (of which the Carequality interoperability framework is part of) and also does project management work for the CommonWell Health Alliance, which operates a health data sharing network of its own. Tripathi has been a part of countless meetings, conversations and project work within and for these organizations, with the broad goal always being to advance nationwide interoperability.

Tripathi caught up with Healthcare Informatics’ Managing Editor Rajiv Leventhal after the Epic news was released to talk about its impact, what’s specifically unique about it, and more wide-ranging interoperability issues at hand. Below are excerpts of that interview.

What were your initial takeaways from this announcement as it relates to how it could spur interoperability, given the market share presence that Epic has right now?

I think it’s a great, incremental addition to functionality and it [continues] what Epic has already been doing, which is contributing a lot to interoperability growth across the U.S. There isn’t new technology here and I don’t see it as a huge driver of interoperability. I actually think they are doing other things that are better and more important for interoperability that they don’t get as much credit for, such as pushing forward into [efforts] like Carequality, and [helping with] the connection between Carequality and CommonWell. Those things are very critical for interoperability and will have a lot more impact on interoperability compared to this [announcement].

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That being said, what’s really cool about this is that Epic is very good at being practical about saying where they are now, and [realizing] what’s an important step to take forward that’s isn’t necessarily trying to be bleeding edge, but rather will offer real value to people in a practical way that they recognize. So let’s implement this in a solid way that we have high confidence people will use, it won’t break anyone’s workflows, and we’re not expecting anyone to do anything heroic. But it does push people to do things differently and think about where these types of technologies can take us.

What I think is really great about this is that Epic, along with other vendors, have always had the ability to allow portal access to a patient’s medical record information for providers who are not using that vendor’s EHR. So that part isn’t unique—the ability to say, you’re not an Epic user but here is a way to issue you credentials so you can log into a portal via a  basic browser and see a patient’s information regardless.  And the vendors all sort of have that; that’s part of the Community Connect solution in Epic.

But that’s something that’s always been provider-driven. The provider himself or herself says, ‘My patient is going to a cardiologist, I know they’re not on Epic, I am going to reach out and see if they’d be willing to get a username and password to come into this portal so they can see this important medical record for this patient who we share.’ And that’s for providers who aren’t able to partake in the interoperability that Epic already has in place, like through Care Everywhere or Carequality.

So the important innovation here is that it’s not the provider who is driving it, but the patient. So you have the patient who might be at the ED and the physician wants to know which medications the patient’s daughter might be allergic to. But the patient can’t remember all of them. Now, that patient can go into the MyChart app, get a code, give it to that provider, and he or she can log onto the Share Everywhere website, type in that code, and up will pop the medical record summary that the patient could have gotten through his or her MyChart portal, but now the provider can look at it. And the provider can also now look at it and type into a text box whatever he or she want, and that [note] will go back to the provider who has the patient’s medical record, and who can then decide if it should be incorporated into the medical record. I think that’s a really cool innovation—the patient is driving it, the patient can decide who gets it, and another provider gets access to it when he or she wouldn’t have before.

You mention that even before this, Epic has had the ability allow portal access even for those who are on another system. That’s interesting since Epic has long been criticized for not being motivated to interoperate with non-Epic users. Do you see this as a false narrative?

I can’t speak to the history of it, but I do think there is a little bit of a false narrative there. If you look at what they’re doing with respect with to their active participation in Carequality, their active participation in the connection between Carequality and CommonWell, and that Care Everywhere is not an open network, but does have transactions with other EHRs, yes, I think there’s bad rap on them which is probably related to the fact they are so large and easy to pick on. And yes they have competitive juices flowing, as does Cerner and Meditech and Allscripts, but in general I wouldn’t put them in the category of being prime suspect number one of impeding nationwide interoperability. They have done a lot to continue interoperability, and they are a key driver—not a blocker—for where we are and where we’re going in the next 18 to 24 months.

A big part of this news is that interoperability will be more in the hands of patients, as you alluded to. Is this a direction where more interoperability efforts will be going in the future?

I think it’s a question of [patient] willingness, and that’s an important point. So that’s why I don’t think [this news is] a big driver of interoperability, but an important capability to put out there for those patients who want to do it. It also pushes the market a bit more; it’s another example of the market to say, here is another incremental step forward to putting more power in the patients’ hands—and that’s a good thing for everyone. This is not groundbreaking technologically, but it moves us one step closer to the world we want, which is patient-controlled apps. This specifically doesn’t preclude that or do that, but offers an incremental step towards that by saying patients aren’t teaming with apps right now, but I can offer something in a portal that can be helpful.

For the most part, the majority of patients at any given time don’t want to do this type of thing. They want their providers to be connected; they don’t want to be in the middle of it. At any given time, 10 to 15 percent of us have chronic conditions and have to think about the sharing of our records every day, but that’s not even close to half of all of us. Providers have to think about this every day, while patients necessarily do not. They come and go in terms of their episodic need for this kind of thing.

When you think about the interoperability initiatives out there right now, with CommonWell and Carequality, with CommonWell having sparred with Epic before, how might other vendors in CommonWell react to this?

I want to give credit to the other major vendors who are also leaning forward into interoperability. It’s not just an Epic thing; all vendors are doing important work—Cerner, athenahealth, Surescripts, Allscripts, [and others], too. You can point to Congressional testimony and tweets sniping back and forth between different entities, but I really think that’s completely behind us.

The work [I am talking about] that’s going on right now, and I can attest this since I directly observe and participate in conversations with Carequality (which includes Epic) and CommonWell (which includes Cerner), when we had the agreement last December, we’re now talking actively about where we are in implementation. The market needs this, so let’s keep track of it. By the end of the calendar year is the commitment goal for implementation at the first production site. We had a check-in last week and everyone is still committed to it. So it’s water under the bridge. Epic and Cerner are working cordially and collaboratively. And yes they are head-to-head competing, of course. That’s part of the [business].

When I say that I’m bullish on nationwide interoperability, if you asked a person not involved in health IT that we will, in the next 18 to 24 months, have live a system where most (80 to 85 percent) providers in the U.S. will be able to securely send a medical record to most other providers anywhere in the U.S.; and that most providers will be able to request and receive a medical record from most other providers in the country, would you consider that nationwide interoperability? And I’d bet most people would say yes. I am confident we will have all this in the next 18 to 24 months.


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DirectTrust Touts 2018 Growth in Data Exchange Volume, Participants

January 23, 2019
by Rajiv Leventhal, Managing Editor
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DirectTrust, a nonprofit organization that supports health information exchange via the Direct message protocols, has announced continued steady growth in the number of healthcare organizations using its interoperability services during 2018.

The organization also noted an upsurge in the number of Direct message transactions, patient use, and addresses. According to year-end 2018 metrics:

  • There were nearly 274 million Direct message transactions between DirectTrust addresses in 2018, a 63-percent increase over the 2017 total of 168 million transactions. There were more than 110 million Direct messages transmitted during the fourth quarter of 2018 alone.
  • The number of patients/consumers involved using Direct increased approximately 35 percent to nearly 248,000.
  • The number of healthcare organizations served by DirectTrust accredited health information service providers (HISPs) increased 30 percent to nearly 139,000, compared with approximately 107,000 at year-end 2017.
  • The number of trusted DirectTrust addresses able to share PHI across the DirectTrust network increased 16 percent to more than 1.8 million since the end of 2017.
  • Eleven healthcare organizations joined DirectTrust during 2018, bringing the organization’s total membership to 115.

Last July, DirectTrust named former Cerner executive Scott Stuewe its new CEO to replace founding CEO Dr. David Kibbe. In a recent interview with Healthcare Informatics, Stuewe spoke about working more closely with EHR vendors and expanded opportunities for his organization’s trust framework.

He told Healthcare Informatics at the time that his organization could make more headway by engaging with the EHR (electronic health record) vendors who so far have not been very engaged with DirectTrust. “There are some gaps in features among the EHRs that frankly are the same gaps we saw in query-based exchange in CommonWell. There are usability problems; the way a given feature surfaces in one EHR is so different than another that you can’t even do the same work flow across the two systems,” Stuewe said.

Stuewe also noted that DirectTrust’s technical trust framework is about “stretching the highest security mechanism across identity-proofed endpoints,” which, he said, “is kind of a unique model.”

A recent data brief from the Office of the National Coordinator for Health IT (ONC) revealed that about four in 10 surveyed hospitals participated in more than one nationwide health information exchange network, such as Surescripts, the e-Health Exchange, DirectTrust, CommonWell, or Carequality. Surescripts was the most commonly network used; 61 percent of hospitals participated. The next highest participation rates were in DirectTrust and the e-Health Exchange; about a quarter of hospitals participated in each.

 

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Hospitals Outline Agenda to Accelerate Interoperability

January 22, 2019
by Heather Landi. Associate Editor
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Hospitals and health systems are making progress in sharing health information, with 93 percent making records available to patients online, but collaboration across many private and public sector entities, including technology vendors and policymakers, is necessary to achieve comprehensive interoperability, according to a new report from national hospital associations.

The report reviews the current state of interoperability, which show promises but is still a patchwork system, as well as outlines current challenges and provides an agenda for steps to take to improve interoperability among health IT systems. The report was compiled by seven national hospital associations—America’s Essential Hospitals, American Hospital Association (AHA), Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, Federation of American Hospitals and the National Association for Behavioral Healthcare.

“We see interoperability in action all around us. Mobile phones can call each other regardless of make, model, or operating system. The hospital field has made good headway, but it’s time to complete the job. We are united in calling for a truly interoperable system that allows all providers and patients to benefit from shared health records and data, leading to fully informed care decisions,” AHA President and CEO Rick Pollack said in a statement.

“For the best care today, it’s the data stupid. Quality care depends on having the right information at the right time, so our patient’s records need to be available in the hospital or wherever our patients receive care. Hospitals are joining together to support improving interoperability because it is the key to assuring the best for our patients,” Federation of American Hospitals President and CEO Chip Kahn said in a prepared statement.

The report highlights that hospitals and health systems are making progress in sharing health information, with 93 percent making records available to patients online, up from 27 percent in 2012. What’s more, 88 percent of hospitals are sharing records with ambulatory care providers outside their system, up from 37 percent in 2012. And, 87 percent of hospitals enable patients to download information from their health record, up from 16 percent in 2012.

“We are inching closer to, but still short of, the ideal of seamless interoperability. In health care, this refers to the capacity to send and receive a patient’s health information from multiple sources between different systems and locations with its integrity intact,” the report authors wrote. “The information communicated must be useful to the receiving care provider, patients and families, and result in the care decisions that are best for them. Today, interoperability is a partially-achieved aim, working well in some but not all settings.”

The report authors note that the key to leveraging health data’s full potential for improving patient care is the establishment of a framework for compatible technical and linguistic (semantic) standards adopted by all parties that “lead us to a generic, vendor-neutral data exchange platform.” “We currently lack universally agreed upon ways of sharing and using information — “rules-of-the-road” that make possible the uncorrupted transfer of patient data between differing (and often proprietary) health record systems,” the report authors wrote.

Looking at progress made to date, hospitals and health systems have invest hundreds of billions over the past decade in electronic health records (EHRs) and other IT systems that record, store and transfer patient data securely among medical professionals. In 2017 alone, hospitals and health systems invested $62 billion in these IT systems.

According to the Office of the National Coordinator for Health Information Technology (ONC), the vast majority of hospitals use multiple mechanisms to share health information, and more than half must use four or more. Furthermore, most hospitals devote significant resources to manually matching patient records, since we do not have a national patient identifier, the report states.

And, according to 2010 AHA survey data, only 16 percent of hospitals had a basic EHR system in place. By 2017, 97 percent of surveyed hospitals had adopted a certified EHR system.

What’s more, hospitals and health systems have made efforts to link via health information exchanges (HIEs), however, the report notes while HIEs do deliver on some of the promises of interoperability, the exchangeable data is often limited to a regional or statewide scale. “In addition, some HIEs cannot reliably carry out full data exchange within a health system among different source technologies, or data

 

 

exchange across health systems including ambulatory or post-acute settings,” the report authors wrote. Also, HIEs may not enable individual patients to access their data.

The report authors also outline the ongoing barriers to comprehensive interoperability. According to an AHA analysis on barriers to health data exchange and interoperability, 63 percent of respondents cited the lack of capable technology as the biggest barrier. That survey also identified difficulties matching or identifying the correct patient between systems also as additional costs to send or receive data with care settings and organizations outside their system as significant interoperability barriers as well.

“Barriers to interoperability must be addressed in order to support the level of electronic sharing of health information needed to provide the best care, engage people in their health, succeed in new models of care, and improve public health. Doing so requires collaboration across many private and public sector entities, including hospitals and health systems, technology companies, payers, consumers, and federal and state governments,” the report authors wrote.

The report also outlines “pathways” to advance interoperability with a particular focus around privacy, security, standards and infrastructure as well as industry stakeholders committing to share best practices and lessons learned.

Among the report’s recommendations, new standards are needed to overcome the significant gaps making communication difficult between systems. “For example, APIs (application programming interfaces), including those based on the FHIR (Fast Healthcare Interoperability Resources) standard, allow for more nimble approaches to accessing needed data. Health care will benefit most from use of standard, secure, non-proprietary APIs that minimize the added costs associated with proprietary solutions and gatekeeping. API access should support both patient access to information from providers and other stakeholders, and the use of trusted third-party tools to support clinical care,” the report authors wrote.

“While we have made much progress, at present, we have the incomplete outline of a national data-sharing system in place, one that lacks the agreed upon rules of the road, conformance, technical standards and standardized implementations to ensure that all HIE platforms can communicate correctly with each other,” the report authors concluded.

The report authors note that true interoperability that advances improved health care and outcomes is within reach with effective federal policies and key stakeholders doing their part. The report calls on health systems to use their procurement power to drive vendors toward compatibility in systems design and lend a voice to the development process.

EHR and IT vendors, in turn, should commit to more field testing and consistent use of standards, the report authors wrote, and avoid pricing models that create a “toll” for information sharing. Vendors also should offer alternatives to expensive, labor-intensive workarounds that drain providers’ time and energy.

 

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HL7 Model Identifies Clinical Genomics Workflows, Use Cases

January 16, 2019
by David Raths, Contributing Editor
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Domain Analysis Model covers pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics

HL7’s Clinical Genomics Work Group has published an HL7 Domain Analysis Model (DAM) to identify common workflows and use cases to facilitate scalable and interoperable data standards for the breadth of clinical genomics scenarios.

The Domain Analysis Model (DAM), which has underdone a rigorous ISO/ANSI-compatible balloting process, covers a myriad of use cases, including emerging ones such as pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics.

The effort “builds on the DAM Clinical Sequencing work that is already being used to design precision medicine workflows at hospitals across the country,” said Gil Alterovitz, Ph.D., an HL7 Clinical Genomics Work Group co-chair, in a prepared statement. He also serves as a Harvard professor with the Computational Health Informatics Program/Boston Children’s Hospital.

The Clinical Sequencing DAM fueled the design of FHIR Genomics, the subset of HL7’s FHIR standard designed to communicate clinical genomic information. “By extending to broader domains, it can serve as a standard going forward to aid in the design of workflows, exchange formats as well as other areas,” Alterovitz added,

The document presents narrative context and workflow diagrams to guide readers through the stages of each use case and details steps involving the various stakeholders such as patients, health care providers, laboratories and geneticists. This contextual knowledge aids in the development and implementation of software designed to interpret and communicate the relevant results in a clinical computer system, especially a patient's electronic health record.

The HL7 Clinical Genomics Work Group developed several new applications and refinements in the Domain Analysis Model beyond its original scope of clinical sequencing. One notable addition is the analysis of the common workflows for pre-implantation genetic diagnosis (PGD). For those undergoing in-vitro fertilization, advanced pre-implantation genetic screening has become increasingly popular as it avoids the implantation of embryos carrying chromosomal aneuploidies, a common cause of birth defects. Implementers can follow the workflow diagram and see the context for each transfer of information, including the types of tests performed such as blastocyst biopsy and embryo vitrification.

As the clinical utility of proteomics (detecting, quantifying and characterizing proteins) and RNA-sequencing increases, the DAM also outlines clinical and laboratory workflows to capitalize on these emerging technologies.

HL7 notes that future challenges arise from uncertainty about the specific storage location of genomic data, such as a Genomics Archive and Computer/Communication System (GACS), as well as the structure of a patient’s genomic and other omics data for access on demand, both by clinicians and laboratories. Best practices in handling such considerations are being formulated within HL7 and include international input from across the spectrum of stakeholders. In parallel, the HL7 Clinical Genomics Work Group has been preparing an implementation guide for clinical genomics around many of these use cases, to be leveraged alongside the newly published HL7 FHIR Release 4 standard.

 

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