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Jonathan Bush, other HIT Leaders Dive into Healthcare’s Interoperability Problem at World Health Care Congress

May 1, 2017
by Rajiv Leventhal
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Bush said at the annual conference in D.C. that cloud-based EHRs, rather than “pre-Internet systems,” will be the future

A panel of three leaders in the health IT space, including outspoken athenahealth CEO Jonathan Bush, discussed the current interoperability landscape and what new strategies will help shape the future of healthcare connectivity.

Bush was joined in the keynote panel—part of this year’s World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C.—by Steven J. Corwin, M.D., president and CEO of NewYork-Presbyterian (NYP, New York City) and Craig Samitt, M.D., executive vice president and chief clinical officer, Anthem, Inc. The session was moderated by Dan Diamond, health policy reporter at Politico.

When asked about what the industry is doing well and where they are failing, Drs. Corwin and Samitt had rather pessimistic tones, with Corwin noting that the current electronic health records (EHRs) at NYP, which actually only account for some 40 percent of the organization’s data, are fragmented and not interoperable. “The promise of interoperability is something that has been over-promised,” Corwin said. “The idea was that that various EHRs could be perfectly compatible, but that has not been [the case]. For us, it gets down to having a single EHR, taking [out] the expense of putting them together over a multi-layered system, and then reducing the number of exchanges and linkages we need to have. At this point, our linkage exchange looks like spaghetti wires,” adding that in NYP’s interface engine there are currently 6,000 interfaces, though the goal is to cut that number down to 3,000. “We just can’t toggle back and forth between systems,” he said.

Similarly, Samitt noted that the issue isn’t a technology one, but rather one of willingness and incentives. The Anthem senior executive said he is “highly critical of our industry since other industries have figured it out.” He added, “When there's a will, there's a way. I think there is a way for interoperability but less of a will. Information should be a common good as it relates to population health and better care at a lower cost, but we do not treat it that way.” He went on to talk about data ownership, noting, “Payers probably have the most complete data set but it's not timely. Doctors have the most acute data but it’s not complete. And patients have most relevant data, but it's not actionable.”

The panelists were then asked who’s to blame for these data sharing issues, a question that usually elicits varying responses from those pointing fingers at vendors to others assigning fault to providers and policymakers. From the payer perspective, Samitt said that claims information is only a subset of the data, and that it’s challenging to get providers to share data, though he also admitted that payers are not so willing themselves. “None of us should own the information; it should be a common good. Let's keep the information safe and pool it so we can have a true longitudinal patient record,” Samitt said.

From the vendor vantage point, Bush—who two years ago famously tweeted at Judy Faulkner, CEO and founder of Epic Systems, that he would pay the user fee for Epic if the giant EHR vendor would join the CommonWell Health Alliance, an interoperability initiative of which athenahealth is a part of—agreed that the incentives to share healthcare data are not rewarding enough for stakeholders. “For my entire career, no one has wanted to exchange information,” Bush said. “The government has made it largely illegal for providers to get paid by digitally flowing information upstream. And [the feds] do not let just any provider see Medicare data,” adding that his company went through the laborious process of filling out applications and hiring lawyers so that they could get access to this CMS (Centers for Medicare & Medicaid Services) data, only to get denied. “Historically,” Bush said, “Hospitals have said that they are the only place that data can flow so that they keep referral volume and preserve their institution.”

However, things are beginning to change, Bush continued, noting dedication from new Health and Human Services Secretary Tom Price, M.D. to reverse things. “We are [seeing] a willingness on the part of forward-thinking healthcare systems to win by being open. Last year, the 21st Century Cures Act [was passed] and that makes it illegal to block data,” he said.

Bush also called out Epic, Cerner and Meditech, which he refers to as “pre-Internet companies” for now being more open to interconnectivity, proving that there are signs of change in regards to stakeholders’ willingness. "Payers are also giving us claims data they didn't use to give us, and that gives us information on patients that we can pull together that we weren't able to before," he said.

Chiming in on the topic of data blocking, Corwin said that hospitals hoarding data is a fair criticism. “People believe that data can be monetized in healthcare, and that’s particularly true with well-curated genetic information,” he said. “I'm less enamored with that idea; I think that the data [belongs] to the patients, not to the providers. But there are those [providers] out there who do think there's a market advantage. I'm a big believer in not monetizing data unless it improves patient outcomes,” he said.

Bush further said that athenahealth is building a master patient index (MPI) and also a calendar product that would help doctors on athenaNet get more patient appointments. He referred to EDI and HL7 as standards that will “die since they are pre-Internet.” Bush said it was these outdated companies that advocated as part of HITECH (the Health Information Technology for Economic and Clinical Health Act) to eliminate interoperability as a requirement for meaningful use.

He continued, saying these pre-Internet companies “claim to be interoperable but never will be. They need to go,” he attested. Bush added, “Cloud companies can easily be interoperable. HITECH got everyone onto systems that they're now stuck with, and the Internet was shut out of HITECH. You have 60 medical specialties and [the idea is that] any EHR will be the right one for all 60?  That is absurd. How many apps on your iPhone were written by Apple? Four of them. So [we won’t reach] interoperability until we get rid of these servers.”

Bush went on, “That means we need to invite our competition onto the platforms and be like [Jeff] Bezos [founder of Amazon]. “We must accommodate a new generation and we have to move to the Internet in healthcare. This cannot be a questionable proposition in healthcare in 2017. The new cloud-based EHR companies are coming onto our platform; the nightmare Steven [Corwin] is experiencing connecting different old systems is becoming a thing of the past, slowly.”

Samitt agreed with Bush on how the future might look, arguing that it’s not going to be about EHR-to-EHR connectivity going forward, but rather capturing data elements in the cloud to manage population health. “EHRs connecting won’t be as relevant in the future,” he said. “Data inputted is less crucial than data outputted. So the pooling of information and the analytics will be crucial, not which EHR you are on,” he said.

To close the discussion, the panelists were asked about when healthcare connectedness will no longer be an issue. Bush estimated it would take some five years. On the other end of the spectrum, Corwin predicted that interoperability will be superseded by disruptors such as telehealth, artificial intelligence and machine learning. “Interoperability won't be solved in the short-run. Patients will demand their own data. And connecting people via regional HIEs won't happen. I’m very pessimistic about the [prospects] of true interoperability. Samitt was more optimistic, predicting that real interoperability can be achieved in 10 years. He noted that much of it comes down to payment reform as well, pointing out that nearly 60 percent of Anthem’s payments are now tied to value. “Connectivity is not just data connectivity, but we also need to achieve alignment with the patient at the center,” he said.


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Epic Plans Meeting for Non-Epic Users on Data Sharing Capabilities

August 16, 2018
by Heather Landi
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Verona, Wis.-based Epic is inviting healthcare provider organizations that don’t use Epic’s electronic health record (EHR) to its “un-Users Group Meeting” at its Verona headquarters to learn how to exchange data with Epic.

The event, planned for September 26, will provide information to healthcare provider organizations about how to exchange charts with providers in their community who use Epic, even if providers use a different EHR— or no EHR at all.

According to Epic’s unUGM website, the event is for “executives and strategic leaders of provider organizations who want to learn and discuss how to exchange with providers in their community who use Epic.”

“Access to a patient’s information, regardless of where he or she has been seen, helps providers deliver the best patient care. The first Un-Users Group Meeting (unUGM) is another way we’re reaching out to the leaders of health systems using other EHRs—or even no EHRs—to help them get connected to the Epic users in their communities,” Dave Fuhrmann, Epic’s vice president of interoperability, said in a prepared statement.

According to the event agenda, topics of discussion include options for exchanging patient data with providers through Carequality, Care Everywhere, health information exchange (HIE) and Direct messaging, as well as patient-directed options, including MyChart, Share Everywhere, Lucy, and Blue Button.

There will also be discussion about interoperability success stories, using both non-Epic and Epic EHRs, and the current state of coordinated care in the U.S. and the use of existing tools to close care gaps, improve communication, and reduce costs.

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Amazon, Google, IBM and Other Tech Giants Pledge to Remove Barriers to Interoperability

August 14, 2018
by Heather Landi
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Six of the world's biggest technology companies, including Microsoft, Google, IBM and Amazon, made a joint pledge at the White House Monday to remove interoperability barriers and to make progress on adoption of health data standards.

The announced came during the Blue Button 2.0 Developer Conference in Washington, D.C. where Microsoft joined with Amazon, Google, IBM, Salesforce and Oracle to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project. They also pledged to remove interoperability barriers, particularly as it relates to the adoption of technologies enabled through the cloud and artificial intelligence (AI).

Dean Garfield, president and CEO of the Information Technology Industry Council, said in a statement, “Today’s announcement will be a catalyst to creating better health outcomes for patients at a lower cost. As transformative technologies like cloud computing and artificial intelligence continue to advance, it is important that we work towards creating partnerships that embrace open standards and interoperability.

“We commend the White House Office of American Innovation for their leadership in being a catalyst for moving health care beyond siloed systems and varied data standards. As well, we celebrate Amazon, Google, IBM, Microsoft, Oracle, and Salesforce for their commitment to helping to advance open healthcare standard. The opportunity to unleash greater innovation in health care is here and working together we can seize it,” Garfield said.

In a joint statement, the technology companies made a commitment to remove barriers to “frictionless data exchange,” noting that they share “the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.”

The commitment specifically states:

“In engaging in this dialogue, we start from these foundational assumptions: The frictionless exchange of healthcare data, with appropriate permissions and controls, will lead to better patient care, higher user satisfaction, and lower costs across the entire health ecosystem.

Healthcare data interoperability, to be successful, must account for the needs of all global stakeholders, empowering patients, healthcare providers, payers, app developers, device and pharmaceuticals manufacturers, employers, researchers, citizen scientists, and many others who will develop, test, refine, and scale the deployment of new tools and services.

Open standards, open specifications, and open source tools are essential to facilitate frictionless data exchange. This requires a variety of technical strategies and ongoing collaboration for the industry to converge and embrace emerging standards for healthcare data interoperability, such as HL7 FHIR and the Argonaut Project.

We understand that achieving frictionless health data exchange is an ongoing process, and we commit to actively engaging among open source and open standards communities for the development of healthcare standards, and conformity assessment to foster agility to account for the accelerated pace of innovation.”

Gregory J. Moore M.D., Ph.D., vice president of healthcare, Google Cloud, said in a statement, “We are pleased to join others in the technology and healthcare ecosystem in this joint commitment to remove barriers and create solutions for the adoption of technologies for healthcare data interoperability. This will enable the delivery of high quality patient care, higher user satisfaction, and lower costs across the entire healthcare ecosystem.”

Patients should have access to their data, said Mark Dudman, head of global product and AI development, IBM Watson Health, in a statement following the announced commitment. Patients also should have the flexibility to use products and services across different healthcare systems, with confidence that they all are working seamlessly for their care, he said. “We are proud to participate in this pledge and look forward to working with industry and the developer community to ensure appropriate access to data and the use of that data to support vibrant communities and solve health challenges for people everywhere.”

In a blog post, Josh Mandel, chief architect, Microsoft Healthcare, notes that interoperability is an overlapping set of technical and policy challenges, from data access to common data models to information exchange to workflow integration – and these challenges often pose a barrier to healthcare innovation.

Mandel, who previously worked at Google Life Sciences and on the research faculty at Boston Children’s Hospital where he worked on the SMART Health IT Platform, notes that support for the Meaningful Use Common Clinical Data Set grows and it is becoming easier to plug new tools into clinical workflows, analyze clinical histories, collect new data, and coordinate care.” Many of these technical capabilities have been available within small, tight-knit health systems for a long time – but developing these capabilities has required complex, custom engineering and ongoing maintenance and support. Driving toward open architecture makes adoption faster, easier and cheaper,” he wrote.

True interoperability in healthcare requires end-to end solutions, rather than independent pieces, which may not work together, Mandel wrote. “Transforming healthcare means working together with organizations across the ecosystem. Today’s joint interoperability statement reflects the feedback from our healthcare customers and partners, and together we will lay a technical foundation to support value-based care.”

 

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Industry Stakeholders Urge ONC to Move Forward on Information Blocking Rules

August 8, 2018
by Heather Landi
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In a strongly worded letter to National Coordinator Donald Rucker, M.D., several healthcare and health IT industry groups expressed frustration with the Office of the National Coordinator for Health IT’s lack of progress in publishing information blocking regulations, as required in the 21st Century Cures Act.

“It has been 601 days since the 21st Century Cures Act was signed into law. Every day that the administration delays implementation of these critical provisions places patients at risk of harm,” the letter states. Stakeholders including Health IT Now, Research!America, Oracle, the American Medical Informatics Association (AMIA), the American Academy of Family Physicians, Cambia Health Solutions and Claim Your Health Data Coalition signed the letter dated August 6.

In the letter, addressed to both Dr. Rucker and Daniel Levinson, inspector general of the Department of Health and Human Services (HHS), the stakeholder groups note that the 21st Century Cures Act, which was enacted in December 2016, requires the HHS Secretary to “issue regulations to prevent information blocking and to also identify reasonable and necessary activities that do not constitute information blocking.” Further, the law requires ONC to implement a standardized process for the public to submit reports on claims of health information technology products or developers of such products not being interoperable or resulting in information blocking and actions that result in information blocking. “The Office of the Inspector General (OIG) has enforcement authority over vendors and providers who are found to engage in information blocking,” the letter states.

The stakeholder groups also contend that “information blocking poses a significant risk to patient safety and greatly contributes to increased costs and waste in the health care system.”

According to reporting from Politico, during ONC’s 2nd Interoperability Forum this week in Washington, D.C., Rucker told the form audience that ONC is still working on the rule. The rule’s release has been delayed several times and is not expected to be released in September.

“Rucker emphasized Monday that his goal is to make protocols and standards that would let large amounts of health data flow easily between health providers, not just individual patient charts. He and other officials emphasized that ONC’s work is all being done within the confines of HIPAA,” the Politico article stated. Rucker also noted that properly defining which behaviors do and don’t constitute information blocking is “hard to sort out,” and the rule is a “work in progress,” Politico reported.

In a separate statement regarding ONC's delay in issuing an information blocking proposed rule, Douglas Fridsma, M.D., Ph.D., AMIA president and CEO, said, "Information blocking is the absence of interoperability, and there are numerous reasons why information may not flow as intended. Some of these reasons are technical, others for business or policy reasons. The socio-technical interoperability stack is complex and so too is the task of identifying which among its layers is responsible for information blocking. This rule must be critically calibrated to account for these layers, and it must be part of a larger conversation about how we will address other aspects of the socio-technical interpretability stack. Now is the time to initiate this broad conversation through release of the proposed information blocking rule."

In the letter, the industry groups also cautioned that “information blocking impedes provider access to the most current, accurate or complete information on their patients. As the administration proposes and implements new rules related to open APIs and interoperability in Medicare’s payment rules for hospitals and doctors, the lack of clear rules of the road needlessly creates uncertainty for vendors and providers alike.”

“We understand the nuance required but feel that it is past time for a proposal to be made,” the stakeholder groups wrote in the letter.

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