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HIT Leaders Track Current Progress on Interoperability, and Debate the Best Way Forward

March 6, 2018
by Heather Landi
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During the first day of the HIMSS18 conference in Las Vegas, national HIT leaders discussed the current drivers advancing interoperability in healthcare, and debated whether a great leap forward, or incremental steps, represents the best way forward.

Opening the HIMSS (Healthcare Information and Management Systems Society)/SHIEC (Strategic Health Information Exchange Collaborative) Interoperability and HIE Symposium on Monday morning was Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, who also is a project lead of the HL7 Argonaut Project and on the board of directors of The Sequoia Project, an organization working to advance interoperable nationwide health information exchange. Joining Tripathi was Ruben Amarasingham, M.D., president and CEO of Pieces Technologies Inc., a clinical artificial intelligence company.

During the morning keynote panel discussion, which was moderated by Jess Kahn with McKinsey and Company, Tripathi and Amarasingham discussed what the end goals for interoperability should be, as well as the business drivers and current efforts to advance progress on interoperability.

Conversely, during the closing keynote session for the HIMSS/SHIEC interoperability and HIE symposium, Aneesh Chopra, president of CareJourney, (formerly NavHealth), an analytics company, and Christopher Ross, Mayo Clinic’s CIO, had a lively debate about the best way to advance sustained interoperability—a great leap forward or incrementalism.

To kick off the morning session, Kahn noted that interoperable health records are still not one of the basic tools of healthcare and asked the panelists what they saw as the ultimate goal for interoperability.


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Tripathi noted that until about five years ago, there was not widespread use of electronic health records (EHRs) in the healthcare industry. “It wasn’t until 2013 that we had about 50 percent of providers, hospitals and eligible professionals using EHRs. You can’t have real interoperability until most people have the ability to electronically document and exchange with each other. We started at a very low level, so we’re doing pretty well compared to other industries. Our end goal? We will never really have an end state; it will never be, ‘We got interoperability and its done.’ We’re always going to be moving the goal line,” he said.

He continued, saying he asked a friend who is a physician, “If we had a nationwide system where most providers, 80 percent of providers, had the ability to securely send any EHR (electronic health record) to most other providers and had the ability to securely request and retrieve a medical record, would you consider that nationwide interoperability? She said yes,” he said. “In the next two to three years, because of efforts by CareQuality, we are going to be roughly there.”

He added, “I’m not saying it will solve every use case; it’s important to have realistic expectations. There are significant weight points along the way, and the first one is just here on the horizon through current efforts.”

Amarasingham says he sees the healthcare industry moving toward a more consumer-centric version of interoperability with the end goal of giving patients and end users control of the data. However, he noted that the next stage would be semantic interoperability. He also said he was excited by the entrance of Apple and other consumer-based companies into healthcare, and the potential for these companies to adopt the FHIR (Fast Healthcare Interoperability Resource)-based standard.

“I think one of the challenges for consumers has been, it’s difficult to get their records and incredibly difficult to store it and interpret it; they don’t have the semantic part. If you have 20 million phones that people can say, ‘I want my EHR,’ then press a button and get it, then there is a technological way to keep the data, and then you can have AI (artificial intelligence) systems running on the phones to interpret the data for them. That’s a total change in the power of consumers. That is creating a frictionless environment,” he said.

And, he added, “I predict it to be a milestone event. Soon mobile devices can request electronic medical records.”

Discussing the business drivers, Tripathi says value-based purchasing, in the near term, presented the best use case for interoperability as it relates to sustainability and value. “We’ve seen in just the customer base we have, organizations turn on a dime as soon as they sign an ACO (accountable care organization) contract. We get phone calls from newly launched ACOs, they want to build a ADT (admit, discharge and transfer) event notification service, they are motivated by value-based purchasing.”

Amarasingham agreed, noting that value-based contracts, which have a significant emphasis on care coordination, are one of the most manifest use cases for interoperability. “I’m encouraged by the continued movement in the government to focus on things like accountable health communities and it’s being recognized that health is not just a product of clinical care. That’s going to be significant for interoperability.”

When discussing the players in the market who have the most leverage to advance interoperability, Tripathi noted there are two big levers—EHR vendors and the federal government. “The EHR vendors, that’s where a lot of concentration is. With the top 10 EHR vendors, you’ve got 95 percent of the market right there. With the nationwide networks that are formed, CareQuality and CommonWell, the driver of that was the vendors getting together,” he said, and added, “The federal government is big in every market. Medicare and Medicaid are big in every state, and they drive the market. With the VA-DoD (U.S. Department of Veterans Affairs and the Department of Defense) project, they are leaning forward on interoperability and APIs.”

Amarasingham noted that new entrants into the market, such as Apple, will be market drivers, as these companies have not been faced with the same market forces. “With these large technology firms, whose goal is to primarily expand their market base by expanding consumer options, that’s going to cause rapid interoperability,” he said.

As part of the interoperability journey, the healthcare industry is constantly exploring new standards and opportunities for achieving industry-wide information exchange, such as the FHIR standard, APIs (application programming interfaces) and trusted frameworks.

“FHIR is huge, in the short term and long term,” Tripathi said. “What’s important about FHIR? One, it is a data level standard, as opposed to a document standard. So, with APIs, just give me that description or allergy, don’t just send me CCD-As. Second point, it is a restful API. The developers that we want to bring into healthcare are now jumping in, and they can jump on and develop against the Argonaut implementation guide. Apple is a great example. They are implementing the Argonaut implementation guide.”

Tripathi continued, “Trusted frameworks are huge. A network, in the internet economy, is about defining the rules of governance. Networks allow us to say what are common business issues we want to solve. One of the barriers on the consumer API side, is that we have APIs, but unless we have trusted frameworks, it’s still going to take us a while to get there.”

Kahn also asked Tripathi about the hype around blockchain in all this work. “If we started from scratch, we would have used blockchain, but it doesn’t solve any problems that aren’t already being solved.”

Advancing Interoperability – Great Leap Forward or Incremental Steps?

During the closing keynote, Chopra and Ross debated the way forward to advance nationwide interoperability. Chopra, who served as the first Chief Technology Officer at the White House under former President Barack Obama, said, “The great leap forward, in my view, has less to do with engineering, technology and specifications, and it’s actually more of a mindset great leap, it’s a culture change. By far, the policy foundation on which we built interoperability was on the HIPAA authorization. The other pathway is the individual’s right to access. The great leap forward to me is operationalizing information sharing or interoperability powered by individuals’ right of access. So, the mindset needs to be ‘Let’s rebuild the architecture on patients’ right of access’,” he said.

Ross countered that the argument against taking a great leap forward is the risk of unintended consequences. “If you look at the interoperability statistics, Direct says there has been 170 million health data exchange transactions, that’s a great number, but 6 billion faxes were also sent. We are not there yet. We want to go faster, but the question is, can we have the full liquidity of data and still preserve HIPAA and the underlying sense of privacy and security of data? I’m not sure we have figured out how to do both,” he said.

Ross added, “We live in a world not just of cyber crime, but also of inappropriate access. If we look at the horizon, things like blockchain could be one way to potentially do replicability, but that’s 10 years out. Our pathway from here to there, if we don’t want to run roughshod over HIPAA, to me, that is the core argument for incrementalism.”

There are substantial commercial interests in healthcare data to drive clinical insights, improve care and to develop new drugs, Ross noted. “How do we pressure test various regimes that will allow us to confidently allow these pathways from my health system or individual pediatrician to the patient or designated destination to make sure that organizations aren’t using data for inappropriate uses?”

Many interoperability efforts, to date, such as Direct exchange, have not yet led to nationwide interoperability and there remains a lot of friction in data exchange, both Ross and Chopra agreed.

“No one thought about the consumer in that roll out of the interoperability strategy, and the lack of understanding and awareness on how it works for consumers gives us an opportunity to leap frog forward,” Chopra said.


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Carequality Seeks Input on FHIR-Based Exchange

October 12, 2018
by Rajiv Leventhal, Managing Editor
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Carequality is seeking input from the healthcare community as it looks to add support for FHIR (Fast Healthcare Interoperability Resource)-based exchange.

According to an announcement from Carequality—national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks—member and non-member stakeholders from across the healthcare continuum are encouraged to participate in the new FHIR Implementation Guide technical and/or policy workgroups. The former will concentrate more on specifications and security, while the latter will focus on the “rules of the road,” officials said.

With much of the healthcare industry either starting to implement FHIR at some level, or planning to do so, the Carequality community is thinking ahead to the type of broad, nationwide deployments that Carequality governance can enable, officials noted.

The new policy and technical workgroups are expected to work in concert with many other organizations contributing to the maturity and development of FHIR, and officials attest that the workgroups will not duplicate the work that is underway on multiple fronts, including defining FHIR resource specs and associated use case workflows. Instead, the workgroups will focus on the operational and policy elements needed to support the use of these resources across an organized ecosystem. 

“Carequality has demonstrated the power of a nationwide governance framework in connecting health IT networks and services for clinical document exchange,” said Dave Cassel, executive director of Carequality.  “We believe that the FHIR exchange community will ultimately encounter some similar challenges to those that Carequality has helped to address with document exchange, and likely some new ones as well.  We’re eager to engage with stakeholders to map out the details of FHIR-based exchange under Carequality’s governance model.”

Cassel added, “We believe that adoption of FHIR in the Carequality Interoperability Framework can advance all of these goals by improving the availability of useable clinical information, expanding the scope of exchange, and significantly lowering the costs of participating in interoperable exchange.”

In August, Carequality and CommonWell, an association providing a vendor-neutral platform and interoperability services for its members, announced they had started a limited roll-out of live bidirectional data sharing with an initial set of CommonWell members and providers and other Carequality Interoperability Framework adopters.

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New ONC Analysis Reveals Progress on FHIR Adoption, Implementation

October 2, 2018
by Rajiv Leventhal, Managing Editor
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The 10 biggest health IT vendors all use at least “FHIR 2” as their API standard

Adoption and implementation of the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standard in health IT is steadily progressing, according to a blog post from leaders at the Office of the National Coordinator for Health Information Technology (ONC).

The post, penned by Steven Posnack, executive director of the Office of Technology, and Wes Barker, noted that using CMS (the Centers for Medicare & Medicaid Services) and ONC data, the health IT agency analyzed how health IT developers used FHIR to meet 2015 Edition certification requirements. Additionally, they assessed how hospitals and clinicians’ access to 2015 Edition certified-APIs vary across the U.S. Based on this analysis, they found:

  • Approximately 32 percent of certified health IT vendors said that they are using FHIR, specifically the “FHIR Release 2” API (application programming interface) standard.
  • Nearly 51 percent of health IT developers appear to be using a version of FHIR combined with the OAuth 2.0 standard

As the ONC officials pointed out, while the 32 percent figure may seem “low” at face value, the estimated market share of the health IT developers using FHIR is large. They explained that the 10 certified health IT vendors with the largest market share across hospitals and clinicians (eligible for participation in the CMS Promoting Interoperability Programs)—and which encompass about 82 percent of hospitals and 64 percent of clinicians—all use at least the FHIR Release 2 as their API standard. These vendors include some of the biggest industry names such as Epic, Cerner, Allscripts, athenahealth, and others.

As such, overall, of the hospitals and Merit-based Incentive Payment System (MIPS) eligible clinicians that use certified products, ONC found that almost 87 percent of hospitals and 69 percent of MIPS-eligible clinicians are served by health IT developers with products certified to any FHIR version. When estimated for just FHIR Release 2, the hospital percentage remains the same while the clinician percentage drops a bit to 57 percent.


In 2015, ONC issued the 2015 Edition certification criteria that included functional API certification criteria, but no specific standards were required for the API. Just prior to that, The Argonaut Project kicked off as a market-driven FHIR accelerator to develop industry consensus around a set of FHIR Release 2 implementation specifications that could be used to meet the 2015 Edition’s API certification criteria.

Today, many companies have gone into production with FHIR Release 2 profiled according to the Argonaut implementation specifications. Apple (with a FHIR-based “client” app) may be the most notable, but there are indications that many other big tech companies are also planning to use the standard, the ONC blog stated.

What’s more, CMS has reaffirmed in its rules affecting the Promoting Interoperability Programs (formerly known as the EHR Incentive Programs) that the 2015 Edition will be required in 2019. Also, CMS has also invested in FHIR through its own Blue Button 2.0

In a responding statement to the ONC analysis, Blair Childs, senior vice president of public affairs at the Charlotte, N.C.-based Premier, Inc., noted that while it’s promising that many app developers appear to be coalescing around developing consumer apps using FHIR, “we urge the administration to prioritize achieving a similar degree of development across provider-facing applications.  These applications will support providers with predictive analytics, clinical decision support and other workflow technologies.”

Childs’ statement continued, “A strict focus on consuming-facing apps provides a limited view into the state of interoperability. It gives false hope of reaching the tipping point for free and unencumbered data exchange in healthcare. The reality is that we are nowhere near reaching our goal of a data-enabled health system. We need an immediate focus not just on consumer-facing technologies, but on those relied on by the provider community as well. This is why we continue to press for the timely implementation of 21st Century Cures Act interoperability and data standards provisions.”

Childs added, “Until all data is unlocked from EHRs and integrated into clinical workflows, we will continue to face walled gardens of vital information.”

ONC’s Posnack and Barker admitted themselves in the post, “While these data are encouraging, it’s not time to pop any champagne. Industry-wide, much work remains from standards development to implementation.”

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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. 

Email:  zabrina.gonzaga@lantanagroup.com

Twitter: @lantana_group


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