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KLAS: Interoperability among Different EMRs Nearly Non-Existent

October 12, 2016
by Rajiv Leventhal
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Epic customers report “home runs” when sharing data with each other, but only average success when exchanging with other vendors

Only 6 percent of healthcare providers reported that information accessed from exchange partners on a different electronic medical record (EMR) is delivered in an effective way that facilitates improvement to patient care, according to KLAS’ Interoperability 2016 report.

Using the interoperability measurement tool defined and agreed upon by both healthcare providers and health IT vendors in October 2015, KLAS was able to publish their 2016 interoperability findings last week. In sum, more than 500 interviews revealed, in detail, something that most clinicians know today: between-organization sharing of medical records is happening only in pockets and is often frustrating for clinicians. This report, “Interoperability 2016: From a Clinician View - Frustrating Reality or Hopeful Future” focused not on the number of records shared, but on whether clinicians have the interoperability they need.

Clinicians are quick to report that interoperability is more than just access to outside patient records. For interoperability to move the needle on better care, outside records must be (1) available, (2) easy to locate, (3) within the clinician workflow, and (4) delivered in an effective way that facilitates improvement in patient care. In reality, a provider might reach any one of the four “bases” independent of the others, but a true “home run” is a best-case scenario in which all four criteria are met.

To this end, the KLAS research found that the low rate of impactful exchange starts with availability; respondents reported reasonable access only 28 percent of the time. When the aspect of easy-to-locate available records is included, the affirmative response rate drops to only 13 percent, and when the requirement of receiving and locating that data in the clinician’s workflow is added on, 8 percent of providers remain. Considering the challenges associated with access, location of records and ease of use within the workflow, the 6 percent rate of providers meeting all the previous criteria and positively impacting patient care is easier to understand, the KLAS researchers noted.

Researchers also questioned healthcare providers about their experiences with CommonWell and Carequality, initiatives designed to promote data sharing. 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. Each initiative claims thousands of participating providers, while KLAS validation efforts indicate a relatively small subset of providers are actively sharing data today.


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Further, effective sharing of information happens, on average, six times more between organizations on the same EMR product than between organizations with different EMR products. Every provider in this report who has achieved successful sharing has had less success exchanging with providers who use different vendors than their own. Some reasons for this stronger performance include compatibility, familiarity, and shared access.

What’s more, both acute and ambulatory care settings see significant and strikingly proportional deficits in usable, useful information exchange. According to the researchers, some might think that the broad scope of the acute care setting’s exchange needs compared to the more narrow focus for ambulatory care would lead to different overall success in record sharing. However, 2016 results show that clinicians in ambulatory care view interoperability to be nearly as poor as clinicians in acute care. One exception is how they view the perceived impact on care—ambulatory facilities place high value on low volumes of specific data, such as results and discharge notes.

Vendor Reviews

From a vendor standpoint, reporting unmatched results in “home runs,” Epic customers are in a league of their own when it comes to sharing with each other; success is average when exchanging with different EMRs. athenahealth and Cerner customers also show a higher level of success with same-vendor sharing, according to the data. Meanwhile, customers of athenahealth and Greenway—the two vendors whose customers report the most success sharing with different EMRs—achieve less than a 15 percent home-run rate.

The ability, or inability, of providers to reach certain bases is not always tied to EMR vendor performance. In this study, satisfaction ratings for how well vendors support interoperability were some of the lowest in any area KLAS measures. Even vendors with above average same-vendor interoperability ratings are just average when it comes to sharing with different EMRs. athenahealth has the strongest overall showing, topping the list in sharing with different EMRs and earning comparatively high marks for sharing between customers. Users of most other vendors consistently report getting less help in accessing data from different-vendor EMRs. Epic shows the most dramatic difference between the two types of sharing; this is more the result of high same-vendor success than low different-vendor experiences, according to the research.

Finally, when providers are asked what key solutions or services are facilitating exchange beyond their EMR, the most frequent response is some form of public HIE. Although public HIEs are the most prevalent, they are not the most satisfying. As a group, public HIEs are rated the lowest of the major facilitators. Providers cite challenges with integration, record location, and cost. Usage varies—some hospitals can only send data out, and clinics are sometimes unable to locate the data they need. Other exchange options, such as interface engines and HISPs, are often not top of mind but are appreciated for their simplicity and reliability. Overall, facilitator vendors are rated higher than EMR vendors for supporting interoperability.

“There is widespread agreement that a high level of interoperability across different EMRs is imperative to improving patient care. This report illustrates the considerable amount of work that still needs to be done in order to achieve impactful record exchange. We learned that challenges related to effective sharing, especially with a different EMR vendor than your own, are experienced across all facility types and across all vendors,” said Bob Cash, vice president of provider relations at KLAS. “No vendor community stood out as exceptional in consistently and effectively sharing with partners using a different EMR. The good news? Vendors and providers seem committed to working through challenges identified in the study, and this year’s findings will serve as a baseline for tracking progress in coming years.”

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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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