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A Look Inside KLAS’ New Approach to Measuring Interoperability

December 19, 2016
by Rajiv Leventhal
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In October 2015, Orem, Utah-based KLAS and several major health IT stakeholders collaborated toward the creation of a viable measurement tool of interoperability, which was then used as a base for KLAS’ Interoperability 2016 report this past October.

The 2016 report, inclusive of interviews with more than 500 electronic health record (EHR) end-users, focused on the “four bases” of interoperability, which were that patient 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. KLAS found that true “home runs” in which all four criteria are met were only reported by 6 percent of providers surveyed. Provider respondents were also asked about their experiences with specific health IT vendors.

Two key members of this work were Bob Cash, vice president of provider relations at KLAS; and Tim Zoph, chair of the KLAS Interoperability Measurement Advisory Team (IMAT). Zoph also spent years as a healthcare CIO and is now client executive and strategist with Naperville, Ill.-based consulting firm Impact Advisors. While the report’s core findings can be read here, and access to the full research can be gotten here, Healthcare Informatics wanted to get a “behind the scenes” look at the process in developing the tool to measure interoperability, what to take away from this year’s report, and what could be in store for future KLAS reports. Below are excerpts of interviews with both Cash and Zoph.

Last fall, KLAS and a bunch of major health IT stakeholders collaborated around a tool to measure interoperability. Then you published a comprehensive report on data sharing. Can you take me through this process?

Cash: Well, it wasn’t easy. I should give credit to four key leaders in the industry on the provider side, at least for the initial draft of the report’s questionnaire—John Halamka, M.D., [CIO of Beth Israel Deaconess Medical Center]; Dan Nigrin, M.D. [CIO of Boston Children's Hospital], Micky Tripathi, Ph.D., [president and CEO of the Massachusetts eHealth Collaborative]; and Stan Huff, M.D. [CMIO of Intermountain Healthcare]. Those four helped us put together the initial draft which we then took to the leaders of the major EHR vendors along with a group of providers last October. And there was back-and-forth battle with that—not as much about the content or context, but about making sure that what we asked would get to the issues and concerns in the industry. There was discussion around if we needed to know about the volume of transactions shared, but we opted not to ask about that. It was more about the perception and experience of people using the information.


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...

As far as the creation of the tool, last year we had about 50 percent vendors and 50 percent providers [at our Keystone Summit]. But we had a broader group this year. We had Carequality, CommonWell, HIE [health information exchange] vendors, and representatives from ONC, CHIME, AMIA, AMDIS and the Center for Medical Interoperability. Our vendor representation this year was people who are responsible for interoperability in their organizations, rather than the CEOs and presidents.

Zoph: This process started over a year ago where we put a number of things into motion at a Keystone Summit in Utah. We thought it was important that if we were to put a measurement tool together from both the provider and vendor sides, they must agree on those measurements. So we wanted a collaborative view of what interoperability is. KLAS became a convener; we saw them as a trusted third party to ultimately carry forward whatever we agreed in the measurement framework to do. They were willing to put resources behind the measurement.

We wanted to start with the interoperability around EHRs by bringing together the major providers of EHRs. They all showed up. We had some leading healthcare informaticists and CIOs put together the initial draft of a measurement framework, so there was some pre-work done leading up to the conference. But the goal of the conference was to see if we could get everyone to show up for a multi-day meeting, and use this draft framework to come up with an initial set of measures that everyone could agree on. And then we would have KLAS go out and do its 500 interviews.

We recognized that any time you lay out a first-year measure, you know you will learn things along the way. We put a measurement advisory team together that had a subset of those leaders, which I chaired. The team would be available to KLAS if they ran into issues with the survey. We knew we would learn a lot from the first year, so we decided to do the measurement first, and go back in year two and do a longer-term roadmap since we were starting with a narrow definition of interoperability. Then we could agree on a performance scoring tool which we did not want to put in the first year since it was more about just getting the data back. We got back together this fall to take a look at what it is we learned from the study, how to modify it, put together performance measurement benchmarks. and then lay out a longer-term roadmap with a broader definition of interoperability—so information exchange that wasn’t solely attributed to EHRs in the acute care environment.

As far as challenges, there was a good consensus from the group that we needed to move beyond the measurement of moving transactions around and have it more about the context of that information— how it was ingested and then presented back to the caregiver, and whether it was in the workflow and made a difference. A key concern, and KLAS has addressed this, was that a lot of their surveys typically go directly to the CIO and then gets parsed out to the director teams. But we thought for interoperability it was important to talk to clinicians and have the perspective of end users. That was probably the hardest thing—are we getting this to the right people? KLAS reached beyond the CIO for this one, as over half of those 500 conversations were with someone in a clinical role or someone who can represent clinicians.

What were your biggest takeaways from the report’s findings?

Zoph: We measured both interoperability and “intra-operability;” so we took a look at how well individual EHRs share amongst like clients. Epic was a leader in that work due to everything they do with Care Everywhere, but for the rest of the industry, it’s challenging to share information even among like records. I thought that might be easier to do but was a big challenge.

We have a long way to go when we look at the industry more broadly. We found that even when transactions are available, they’re often not in the workflow, are not easily retrievable, and people are struggling to talk about the difference it makes in care. That’s no surprise to people who are close to this.

Cash: You hear concern and frustration from clinicians. This was performed in a way to try get at least a majority of our conversations with people who could represent the clinicians’ views best, so a lot of CMIOs and CMOs who could express what their colleagues and they themselves were experiencing. The sentiment out there was that it’s not working, and we found out that to be true. Having the information available in a way that’s easy to find and in the workflow is not that common, so it’s not surprising that the impact on patient care is low, too.

The other perspective is where we are with standards. The infrastructure today that is the base of how we exchange are these HIEs, but if you look at their ratings, they’re the least valuable.  I think what’s happened is we are relying on a level of infrastructure based around these regional HIEs, and there is momentum in the industry to go to something more contemporary like FHIR [Fast Healthcare Interoperability Resources] and APIs [application programming interfaces]. We need to move through a generation of exchange and get to something more contemporary. HIEs will likely have a role still but to get where we want, we need to embrace more contemporary standards for how it is we exchange data.

What could we look for in next year’s interoperability report?

Cash: We would like to have more pieces of information that are more actionable. So if people are saying that the data they are getting is not on impactful on patient care as they would like it to be, what would make it more impactful? So we might add some questions and we might remove some that we didn’t learn much from.

Zoph: We will continue to keep the Interoperability Measurement Advisory Team together as we interact with KLAS and meet at least once per quarter. We are also sitting down with ONC to brief them directly on interoperability, as there are a lot of questions at the federal level. We will sit down with the tool every year, and ask: do the questions work, does the context work, and what can we do to improve the baseline information that we’re already collecting?

Also, we have agreed on a performance measurement tool which we think goes beyond the transactional level, and the goal is to understand if this makes a difference in care coordination and the efficiency of healthcare. We additionally want to go beyond acute care. With population health and where we are going with the continuity of care, we are going to look at interoperability challenges into post-acute care.

If you had to predict when “true” interoperability will be achieved, what timeframe would you say sounds best: within three years, three to five years or more than five years?

Zoph: I’d like to say it will come in the three- to five-year span. We will need a sustained commitment by all parties in the industry to say we will continue to make interoperability a priority, not only in the functionality in the products but how providers continue to demand it in the purchasing of the products and actually implement it when the capability is available. 

Cash: It’s a five-year journey more than a two-year journey. The numbers are low. If I were to measure optimism, and I can’t, I think it would be reasonably high. Things spurring that are the level of collaboration we are hearing and seeing from vendors and providers, the emphasis from a regulatory standpoint from entities like ONC, and then there is also optimism for these facilitating groups like Carequality and CommonWell. There just is not a lot to measure and validate that’s happening and effective. But in the few instances we were able to do that, people are positive and hopeful for what’s to come.

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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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ONC Releases Interoperability Standards Advisory Reference 2019

January 15, 2019
by Heather Landi, Associate Editor
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The Office of the National Coordinator for Health IT (ONC) has released the 2019 Interoperability Standards Advisory (ISA) Reference Edition, which serves as a “snapshot” view of the ISA.

The 2019 Interoperability Standards Advisory represents ONC’s current assessment of the heath IT standards landscape. According to ONC, this static version of the ISA won’t change throughout the year, while the web version is updated on a regular basis. The ISA contains numerous standards and implementation specifications to meet interoperability needs in healthcare and serves as an open and transparent resource for the industry.

The Interoperability Standards Advisory (ISA) process represents the model by which ONC coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, research and administrative purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA.

The newest ISA reference edition includes improvements made based on comments provided by industry stakeholder during the public comment period, which ended Oct. 1, according to a blog post written by Steven Posnack, executive director of ONC’s Office of Technology, Chris Muir, standards division director, Office of Technology, and Brett Andriesen, ONC project officer. ONC received 74 comments on the ISA this year, resulting in nearly 400 individual recommendations for revisions.

According to the blog post, the ISA contains “a variety of standards and implementation specifications curated by developers, standards gurus, and other stakeholders to meet interoperability needs (a term we use in the ISA to represent the purpose for use of standards or implementation specifications – similar to a use case) in healthcare.”

“The ISA itself is a dynamic document and is updated throughout the year, reflecting a number of substantive and structural updates based on ongoing dialogue, discussion, and feedback,” Posnack, Muir and Andriesen wrote.

The latest changes to the reference manual include RSS feed functionality to enable users to track ISA revisions in real-time; shifting structure from lettered sub-sections to a simple alphabetized list; and revising many of the interoperability need titles to better reflect their uses and align with overall ISA bets practices. According to the ONC blog post, the updates also include several new interoperability needs, including representing relationship between patient and another person; several electronic prescribing-related interoperability needs, such as prescribing weight-based dosing and request for refills; and operating rules for claims, enrollment and premium payments.

The latest changes also include more granular updates such as added standards, updated characteristics and additional information about interoperability needs.

The ONC officials wrote that the ISA should be considered as an open and transparent resource for industry and reflects the latest thinking around standards development with an eye toward nationwide interoperability.

The ISA traditionally has reflected recommendations from the Health IT Advisory Committee and its predecessors the HIT Policy Committee and HIT Standards Committee and includes an educational section that helps decode key interoperability terminology.


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ONC Report: Health IT Progress Stifled by Technical, Financial Barriers

January 15, 2019
by Heather Landi, Associate Editor
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While progress has been made in the adoption of health IT across the U.S. healthcare industry, significant interoperability hurdles remain, including technical, financial and trust barriers, according to a report from the Office of the National Coordinator for Health Information Technology (ONC).

Currently, the potential value of health information captured in certified health IT is often limited by a lack of accessibility across systems and across different end users, the ONC report stated.

The annual report from the U.S. Department of Health and Human Services (HHS) and ONC to Congress highlights nationwide health IT infrastructure progress and the use of health data to improve healthcare delivery throughout the U.S.

The report, “2018 Report to Congress: Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information,” also reflects progress on the implementaions of the Federal Health IT Strategic Plan 2015-202 and the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.

In the report, ONC notes that most hospitals and health care providers have a digital footprint. As of 2015, 96 percent of non-federal acute care hospitals and 78 percent of office-based physicians adopted certified health IT. The increase in health IT adoption means most Americans receiving health care services now have their health data recorded electronically.

However, hurdles to progress still remain. For example, ONC notes that many certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team. “Such innovation is more common in other industries. Also, lack of transparent expectations for data sharing and burdensome experiences for health care providers limit the return on investment for health care providers and the value patients are able to gain from using certified health IT,” the report authors wrote.

While health information is increasingly recorded in a digital format, rather than paper, this information is not always accessible across systems and by all end users—such as patients, health care providers and payers, the report authors note. Patients often lack access to their own health information, healthcare providers often lack access to patient data at the point of care, particularly when multiple healthcare providers maintain different pieces of data, own different systems or use health IT solutions purchased form different developers, and payers often lack access to clinical data on groups of covered individuals to assess the value of services provided by their customers.

Currently, patients electronically access their health information through patient portals that prevent them from easily pulling from multiple sources or health care providers. Patient access to their electronic health information also requires repeated use of logins and manual data updates, according to the report. For healthcare providers and payers, interoperable access and exchange of health records is focused on accessing one record at a time. “Without the capability to access multiple records across a population of patients, healthcare providers and payers will not benefit from the value of using modern computing solutions—such as machine learning and artificial intelligence—to inform care decisions and identify trends,” the report authors wrote.

Looking at the future state, the report authors contend that certified health IT includes important upgrades to support interoperability and improve user experience. Noting ONC’s most recent 2015 edition of certification criteria and standards, these upgraded capabilities will show as hospitals and healthcare provider practices upgrade their technology to the 2015 edition, the report authors state.

“As HHS implements the provisions in the Cures Act, we look forward to continued engagement between government and industry on health IT matters and on the role health IT can play to increase competition in healthcare markets,” the report authors wrote, noting that one particular focus will be open APIs (application programming interfaces). The use of open APIs will support patients’ ability to have more access to information electronically through, for example, smartphones and mobile applications, and will allow payers to receive necessary and appropriate information on a group of members without having to access one record at a time.

Healthcare industry stakeholders have indicated that many barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT,” the report authors wrote.

The report also outlines actions that HHS is taking to address these issues. Federal agencies, states, and industry have taken steps to address technical, trust, and financial challenges to interoperable health information access, exchange, and use for patients, health care providers, and payers (including insurers). HHS aims to build on these successes through the ONC Health IT Certification Program, HHS rulemaking, health IT innovation projects, and health IT coordination, the report authors wrote.

In accordance with the Cures Act, HHS is actively leading and coordinating a number of key programs and projects, including “continued work to deter and penalize poor business practices that lead to information blocking,” for example.

The report also calls out HHS’ efforts to develop a Trusted Exchange Framework and a Common Agreement (TEFCA) to support enabling trusted health information exchange. “Additional actions to meet statutory requirements within the Cures Act including supporting patient access to personal health information, reducing clinician burden, and engaging health and health IT stakeholders to promote market-based solutions,” the report authors wrote.

Moving forward, collaboration and innovation are critical to the continued progress on the nationwide health IT infrastructure. To that end, the HHS report authors recommend that the agency, and the health IT community overall, focus on a number of key steps to accelerate progress. Namely, health IT stakeholders should focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate and move their health information using their smartphones, or other devices, and healthcare providers can easily send, receive and analyze patient data.

The health IT community also should focus on increasing transparency in data sharing practices and strengthen technical capabilities of health IT, so payers can access population-level clinical data to promote economic transparency and operational efficiency, which helps to lower the cost of care and administrative costs, the report authors note.

Health IT developers and industry stakeholders also needs to prioritize improving health IT and reducing documentation burden, time inefficiencies and hassle for healthcare providers so clinicians and physicians can focus on their patients rather than their computers.


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