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KLAS 2017 Interoperability Report: Some Progress, but Providers Expecting More

October 19, 2017
by Rajiv Leventhal
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KLAS once again analyzed data from U.S. healthcare organizations to gauge how much interoperability progress is truly being made

A KLAS examination of 420 healthcare organizations has revealed that while the number of providers engaging in “deep” interoperability has increased, the overwhelming majority are still not reporting interoperability success.

As defined by KLAS executives, “An organization is counted as having reached ‘deep interoperability’ if they indicate one of two optimal responses in all four interoperability stages. The deep interoperability rate refers to the percent of interviewed organizations within each vendor’s customer base that (1) often or nearly always have access to needed data through any interoperable means; (2) are able to easily locate specific patient records or have them automatically presented to clinicians; (3) have the retrieved patient data fully integrated into the EHR’s (electronic health records) native data fields or in a separate tab or section within the EHR; and (4) believe retrieved patient data often or nearly always benefits patient care to the extent that it should.”

The report found that the percentage of healthcare organizations reporting deep interoperability when sharing data with disparate EHRs has more than doubled, from 6 percent in 2016 to 14 percent in this year’s update. But, importantly, the remaining 86 percent have yet to report this success. Even the most successful customer base, that of athenahealth, sits at only 23 percent.

When sharing with organizations using the same EHR, Epic customers are easily the most advanced, with 51 percent reaching deep interoperability. In general, regardless of vendor, organizations sharing data with others using the same EHR maintain a head start; 26 percent have achieved deep interoperability—up 2 percent from last year, according to the KLAS data.

When sharing data with organizations on the same EHR, Epic’s 51 percent deep interoperability rate ranks significantly ahead of the next best vendor, athenahealth (34 percent). And when sharing data with providers on disparate EHRs, athenahealth’s 23 percent deep interoperability rate slightly ranks higher than the next two on the list—GE Healthcare (22 percent) and Greenway Health (20 percent).


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KLAS has been tracking interoperability progress for a few years now. In last year’s report, they key finding was that just 6 percent of providers reported that information accessed from exchange partners on a different EHR is delivered in an effective way that facilitates improvement to patient care. The research last year found that the low rate of impactful exchange started with availability; respondents reported reasonable access only 28 percent of the time. In this sense, it’s noteworthy that providers are now reporting that reasonable access has become easier.

Bob Cash, vice president of provider relations at the Orem, Utah-based KLAS Research, says that while the 6 percent to 14 percent jump is noteworthy, the more significant takeaway is probably that 86 percent of surveyed providers still are not experiencing full interoperability. “We did see tremendous progress in access [to data], and I find that really interesting,” Cash says. “So the opportunity for deep interoperability has increased, and that’s good news. The bad news is that it has not translated readily into an impact on care. And the most obvious reason for that is that people are frustrated that the data they are getting is not as useful as it could be. There is either too much, too little, or it’s unwieldy. So the challenge is now getting that information into a form that is useful,” he says.

Cash brings up the idea that providers’ interoperability expectations have increased, from even just a year ago. “Providers are probably thinking, ‘We have been at this for a while, so we ought to get information that’s more impactful. It should be easier than it is,’” he says.

Breaking Down the Vendors

Cerner, a vendor that is considered a top rival to Epic, rates seventh among all vendors for deep interoperability when providers are only using the Cerner system, while rating 8th among all vendors when providers are using disparate EHRs. That being said, Cerner and athenahealth clients have the most consistent access to outside data from different EHRs. KLAS researchers noted that some increases here have come for non-technology reasons, such as organizations joining existing HIEs (health information exchanges), establishing new exchange agreements with competitors, or increasing adoption by clinicians.

Indeed, as in previous years, public, private, and vendor-sponsored HIEs continue to be important methods for sharing data. In 2017, two complementary initiatives, CommonWell and Carequality, have brought new energy to this topic. While most EHR vendors have been long-time members of either or both initiatives, this is the first year that a significant number of provider organizations reported being live participants.

Cash says he was surprised that Cerner rated on the low end, once again pointing to users’ increased expectations with limited results to date. However, he notes that there is “still a lot of hope from Cerner customers around CommonWell. And you saw from the top-of-mind responses from folks, Cerner has far and away the most providers already using or anticipating to use CommonWell. You can tell from those conversations that some vendors or promoting these options more than others, and the difference in terms of the experience is just not prevalent yet,” Cash says.

Certainly, vendors have made a difference by providing access to new networks via CommonWell or Carequality (athenahealth, Cerner, Epic), offering multiple sharing options (Allscripts, Cerner), or simplifying interoperability workflows (athenahealth, NextGen Healthcare). Due to cost, a lack of EHR development, and insufficient vendor support, eClinicalWorks and McKesson customers saw the lowest levels of improved access, per the data.

To this point, as providers gain increased access to outside data, they begin to hit a wall in terms of the value of that data. Some customer bases that have been the most successful in gaining access, including those of athenahealth, Epic, and GE Healthcare, are less likely to feel that patient data is consistently helpful than they were in 2016. Time-pressed providers say the overwhelming volume and cumbersome format of shared data—which typically takes the form of CCDs/C-CDAs and static documents—make searching for needed data impractical. In reaction, providers identify insufficient industry standards and poor usability of tools as today’s top barriers to interoperability. Allscripts and NextGen Healthcare customers “buck the trend” of higher access resulting in low impact; Allscripts customers tout dbMotion’s facilitation of care, and NextGen Healthcare’s clients give a broad range of reasons for the strong impact they achieve.

Other recent research has also pointed to the fact that few providers are able to engage in deep interoperability. A paper recently published in Health Affairs from notable health IT researcher Julia Adler-Milstein, Ph.D., and others, revealed that only about one-fifth of U.S. hospitals were engaged in all four of interoperability’s primary domains—electronically finding, sending, receiving and integrating information into EHRs. It should be noted that for this research, the data that was used was from 2014 to 2015, making it more outdated than this latest KLAS report.

This paper also concluded that, “It is also possible that the one-fifth of hospitals engaging in the four primary interoperability domains included a unique set of early adopters and that remaining hospitals are moving slowly because of limited health IT capabilities or weak incentives to share patient data.”

When asked if KLAS will dig deeper into studying the business incentives around interoperability, both from a provider standpoint and a vendor one, Cash says there are no plans in place to do so, but adds that a key point has to do with the type of provider. He explains: “If I am in an urban market and I have to interface with a lot of different healthcare organizations using different EHRs, then [interoperability] is more important. I will have more interactions and touch points, and I will have a large clinician population who uses different EHRs to interact with. That will be more prevalent in an urban setting, and less so in a rural setting,” he says. He also points out that some ambulatory setting providers still prefer using an e-fax, or even a phone call to share patient information. “So yes, the business incentive point is a valid one, but a real part of this is that we haven’t made it easy enough,” he says.



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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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Health IT Now Pushes for Information Blocking Regulation, Says Administration “Must Uphold its End of the Bargain”

September 13, 2018
by Rajiv Leventhal, Managing Editor
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The executive director of Health IT Now, a coalition of healthcare and technology companies, is again criticizing the Trump administration for not yet publishing any regulation on information blocking, as required by the 21st Century Cures Act legislation.

In an op-ed published recently in STAT, Health IT Now’s Joel White wrote, “More than 600 days after the enactment of the Cures Act, not a single regulation has been issued on information blocking.” White added in frustration, “Health IT Now has met with countless officials in the Trump administration who share our commitment to combat information blocking. But those sentiments must be met with meaningful action.”

The onus to publish the regulation falls on the Office of the National Coordinator for Health IT (ONC), the health IT branch of the federal government that is tasked with carrying out specific duties that are required under the 21st Century Cures Act, which was signed into law in December 2016. Some of the core health IT components of the Cures legislation include encouraging interoperability of electronic health records (EHRs) and patient access to health data, discouraging information blocking, reducing physician documentation burden, as well as creating a reporting system on EHR usability.

The information blocking part of the law has gotten significant attention since many stakeholders believe that true interoperability will not be achieved if vendors and providers act to impede the flow of health data for proprietary reasons.

But ONC has delayed regulation around information blocking a few times already, though during an Aug. 8 episode of the Pulse Check podcast from Politico, National Coordinator for Health IT Donald Rucker, M.D., said that the rule is "deep in the federal clearance process." And even more recently, a bipartisan amendment to the U.S. Senate's Department of Defense and Labor, Health and Human Services, and Education Appropriations Act for Fiscal Year 2019 includes a requirement for the Trump administration to provide Congress with an update, by September 30.

White, in the STAT piece, noted a June Health Affairs column in which Rucker suggested that implementation of the law’s information blocking provisions would occur “over the next few years.” White wrote that this is “a vague timeline that shows little urgency for combating this pressing threat to consumer safety and stumbling block to interoperability.”

Health IT Now is not alone in its belief that the rule should have been published by now, nor is it the first time the group is bringing it up. Last month

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Are You a Data Blocker? How to Fit into ONC’s New Interoperability Framework and Regulation

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By the end of this year, ONC’s implementation and interpretation of data blocking will also be published and available for comment, as was the case with the TEFCA proposed rule. The TEFCA final rule is also anticipated by the end of 2018.

HOWEVER…there’s still time to prepare for TEFCA and the data blocking regulation, and final rules for both in the coming months will set concrete timelines, and for TEFCA it will be interesting to see how ONC reacts to stakeholder comments, internal and external.

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