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Healthcare’s Latest Interoperability Push

January 17, 2017
by Rajiv Leventhal and Mark Hagland
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Recent collaboration among big-name EHR vendors signals a new push towards greater health information exchange, although barriers in the market still remain

Across the healthcare ecosystem, it’s hardly a secret that providers struggle to get pertinent medical information from exchange partners who use a different electronic health record (EHR) from their own. And if the provider wants to do something impactful with that health data—say receive it in a way that facilitates improvement in patient care, for example—the struggle becomes even more real.

These viewpoints were confirmed in KLAS’ Interoperability 2016 report last October which found that, based on a previously-developed interoperability measurement tool, providers are reporting very low rates of impactful data exchange. In the report from the Orem, Utah-based KLAS, which included interviews with more than 500 EHR end-user clinicians, providers were quick to say that interoperability is more than just access to outside patient records. For interoperability to truly move the needle on better care, outside records must be (1) available, (2) easy to locate, (3) situated within the clinician workflow, and (4) delivered in an effective way that facilitates improvement in patient care. But KLAS found that true “home runs” in which all four criteria are met were only reported by 6 percent of providers surveyed.

Indeed, the concern that “real” interoperability in healthcare has yet to be accomplished is not new. But recently, there have been developments on at least one major front: big-name EHR vendors have shown an increased willingness to collaborate as their hospital and health system clients ramp up the pressure for patient data to be made available whenever and wherever they need it.

To this end, early on in 2016, five major health IT vendors—athenahealth, Epic, eClinicalWorks, NextGen Healthcare and Surescripts—signed on to be the first to implement Carequality’s framework for interoperability and data sharing principles. Carequality, a Washington, D.C.-based public-private collaborative and an initiative of The Sequoia Project, released its interoperability framework the previous December, which consisted of multiple elements, including legal terms, policy requirements, technical specifications, and governance processes. Prior to the framework, health information exchange was preceded by one-off legal agreements between individual data sharing partners, which involved lengthy and costly negotiations and inconsistent experience in the quality and quantity of data exchanged.

This partnership was also particularly noteworthy as there have been rifts between the Verona, Wisc.-based Epic Systems and the CommonWell Health Alliance, a vendor-led interoperability initiative, of which athenahealth is a founding member. Epic had until recently refused to cooperate with CommonWell; but, publicly anyway, that quarrel seems to have been quashed. 


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

More evidence of vendor collaboration is the very recent agreement between Carequality and CommonWell that will make CommonWell 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 also work with CommonWell to make a Carequality-compliant version of the CommonWell record locator service available to any provider organization participating in Carequality.

Indeed, the effects of these efforts could ripple through the industry as 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. More than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network.

How else will this agreement spur interoperability progress? According to Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, the arrangement is “akin to AT&T and Verizon Wireless cell phones finally being able to talk to each other.” Tripathi, 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, says that as it previously stood, there was a lot of development,  network formation, and maturity on both sides, but in siloes. “Providers were facing issues on the ground level,” he says.

Tripathi mentions a large provider organization he knows that is switching from Cerner to Epic. Previously, that organization’s switching from Cerner to Epic could have led to complications, as Cerner is in CommonWell but not in Carequality, and vice versa for Epic. “The [organization’s] 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.”

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 as 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.

Upping the Ante

Representatives from both Carequality and CommonWell, and plenty of other health IT associations, were present at KLAS’ most recent Keystone Summits as leading providers and vendors came together to first adopt a set of metrics to measure interoperability and then go out into the field and get clinicians’ perceptions and experiences around health data exchange.

The aforementioned interoperability report that was a result of these meetings and surveys found that while Epic customers “are in a league of their own” when it comes to sharing with each other, success is average when exchanging with different EHRs. athenahealth came out on top when it came to its ability to share data with different EHRs, and that’s largely due to the Watertown, Mass.-based vendor “having made a strong pitch as a company to have interoperability be a differentiating characteristic for them,” notes Tim Zoph, chair of the KLAS Interoperability Measurement Advisory Team (IMAT), long standing healthcare CIO and client executive and strategist with Impact Advisors. “They won’t charge for interfaces and they are advanced in building their architecture,” Zoph says.

Zoph continues, “Everyone feels like their vendor can certainly do more, and what’s fair and what came from the KLAS conference is that vendors want to make sure that if they are going to build their [systems] with this capability, there needs to be a commitment from the provider side to take advantage of the capability and make interoperability a priority,” Zoph says. “So the net of it is, this will require a collective industry effort—yes, more functionality, and data into the workflow that’s more easily navigated by clinicians, but it also will require providers making it more of a priority to interoperate.”

Tripathi agrees with Zoph, noting that vendors have said they have done what they can for where the industry stands right now. “Vendors are saying, ‘you are connected now, so now it’s up to you.’ There are no more excuses from a technology perspective for not doing it.”

Still, there is some skepticism regarding exactly how data is being exchanged, even via these initiatives. Michelle Mattson-Hamilton, a U.K.-based associate principal at consulting firm ST Advisors, says that she recently was speaking with an executive from a large health information exchange (HIE) organization who said while the public PR around these interoperability efforts is positive, the way they actually work tells a different story. “For a patient to opt-in to CommonWell, you have to go to every single location that has the service and physically opt-in to the CommonWell network. That’s how it works now. But is that [sustainable] long-term?”

Expanding on this point, Mattson-Hamilton notes that data blocking in healthcare is not making the front page news as frequently as it was in 2015, and “while many vendors have made voluntary interoperability pledges and are moving slowly towards improved interoperability, there are few disincentives for slow movement,” as a small number of penalties and barriers are competitively beneficial for some vendors, she says.

Nonetheless, Zoph points to initiatives such as CommonWell and Carequality as ways to “build regions.” In fact, in the aforementioned KLAS research, providers reported optimism about the potential of these initiatives to dramatically improve nationwide interoperability. These organizations reported nearly universal optimism that CommonWell is a “game changer.” Mattson-Hamilton agrees that these efforts are overall very beneficial, noting that CommonWell and Carequality are continuing to gain members and footprint, and are “moving data [mostly] for very little cost or for free.”

Standards and the Future

Tripathi adds that now that the query problem is solved via the CommonWell/Carequality agreement, 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 if I get a CCD from Allscripts and one from Epic, they are not the same. There are weird quirks. 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?”

There has been no shortage of hype surrounding the potential of the [Fast Healthcare Interoperability Resources] standard that can enable providers to package discrete bundles of data rather than entire documents. FHIR represents a shift away from a document-centric approach to a data-level access approach using application programming interfaces (APIs), thus making it attractive to all interested parties—vendors, providers and app developers.

Mark Pasquale, principal at Chicago-based The Chartis Group, and a former healthcare CIO and CTO, says FHIR indeed allows for more atomized data sharing. He notes that the FHIR and IHE (the Integrating the Healthcare Enterprise) standards still have a ways to go in maturity, however. “Some of the resources have reached a fairly mature level, but others are still developing. But once they mature and incorporate the FHIR standards, we’ll get to true interoperability. It’s definitely picked up pace, especially in the last year.”

Other industry experts agree with Pasquale on both the potential of FHIR, as well as on its current rudimentary state. Richard C. Howe, Ph.D., executive consultant at Colleyville, Texas-based HCG Healthcare IT Consulting, says FHIR-based apps—which could enable one app to be connected to a data repository, like the EHR, underneath it, “will help from a technical point of view.” But, he adds, “The physician in an office practice doesn’t even know what we’re talking about. It gets down to the physician or practice manager saying, what’s in it for me? There are a lot of benefits, such as connecting to specialists; it’s just a matter of convincing the primary care practices of the value.”

Howe says that undeniably, one of the problems with interoperability is the lack of a firm set of standards. “Without those standards, we’re kind of talking different languages on both sides of the fence. I remember when HL7 [Health Level Seven International] came along and this was going to be the standard that would solve all of this, but 100 different variations emerged, so it didn’t solve the problem. So we need firm standards. But I think FHIR will help solve a lot of the problems. If it works technically and it’s easy, physician groups will pick it up.”

To this end, Tripathi says that throughout the CommonWell/Carequality negotiations, there were discussions around moving to FHIR right now, but it was decided that as much as stakeholders would love to “flip the switch,” it’s simply not ready yet. “We need to lay the groundwork for the legal framework, get the trust model in place, and get the data flowing with the methods we have now, and as FHIR matures, we can evolve to the enablement of it,” he says. Tripathi notes that vendors such as athenahealth, Cerner and Epic are all funders and sponsors of HL7’s The Argonaut Project, so they are “putting their money where their mouths are, are willing to do it when it’s ready and are paying to advance it.”

Pasquale says, “As each one of the different service modules in the FHIR standard goes through a maturity process, and as each of these services goes through a maturity model, the vendors themselves will have to put the same web services into products. So you’ll see these vendors in their releases coming out with more of the FHIR standards, and when you combine that with more mature processes, I see the path as really wide open now.” He predicts that over the next two years, interoperability will improve even more, and adds, “I believe within a few years, we’ll have true interoperability.”

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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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