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Top Ten Tech Trends 2018: Could A New Interoperability Wrinkle Solve Healthcare’s Biggest Challenge?

August 29, 2018
by Rajiv Leventhal, Managing Editor
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There has been much debate on the possibility of mandating providers to participate in health information exchange activities to stay in Medicare

Editor’s Note: Throughout the next week, in our annual Top Ten Tech Trends package, we will share with you, our readers, stories on how we gauge the U.S. healthcare system’s forward evolution into the future.

 

For a few years now—from the latter part of the Obama administration through the first 18 months of Trump’s presidency—federal health officials have been adamant about moving from an era of EHR (electronic health record) adoption to one in which these technology systems will make it easier for providers and patients to share health data across the care continuum.

Of course, healthcare interoperability has been a great pain point to date with one of the primary barriers being the lack of a true business incentive to compel providers and EHR developers to be “open” with this ever-so-important data. To this end, in recent proposed regulations, federal health leaders have clamped down, perhaps harder than ever before, in their ongoing effort to guide stakeholders to a world in which seamless health data exchange is the norm, rather than a rarity.

There may have been no greater evidence of this than the Centers for Medicare & Medicaid Services’ (CMS) proposed updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) in April. In the rule, CMS proposed to re-name the federal EHR Incentive Program, or meaningful use, choosing to now call the program “Promoting Interoperability.” But just how far the federal agency will go beyond “promotion” is what’s particularly fascinating.

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CMS wrote that it will be seeking public comment, via an RFI (request for information) on whether participation in the government’s Trusted Exchange Framework and Common Agreement (TEFCA) initiative—a federally-constructed plan released in January to jolt interoperability among providers—could be used as a vehicle to mandate providers to share data.

Indeed, more specifically, in the proposed regulation, CMS said it will be soliciting feedback on if the agency should revise its “Conditions of Participation” for hospitals that would require them to perform health information exchange activities such as: electronically transferring medically necessary information upon a patient discharge, sending discharge information to a community provider via electronic means; and making information available to patients or third-party apps. And if providers did not meet these Conditions of Participation, if they were to be revised, the consequence would be that they would not be able to participate in Medicare.

How Are Stakeholders Reacting?

As one might imagine, seeking comment on whether or not interoperability should be a requirement for Medicare participation has elicited a wide array of responses across the sector. Comments on the RFI were due to CMS by the end of June, and there was no update from the agency when it published the final Promoting Interoperability rule in early August on what the next steps might be. But as one health IT expert, Jeff Smith, vice president of public policy at the Bethesda, Md.-based AMIA (the American Medical Informatics Association), points out, it could be some time before there are actual interoperability mandates.

“You have to keep in mind the realities of the process. What you need to remember is that the Conditions of Participation aspect of the [proposed rule] was specifically called out as an RFI. And the RFI tries to get information that the agency could consider for potential future rulemakings,” explains Smith.

In other words, CMS did not include the potential Conditions of Participation revision as part of the proposal; rather, the RFI is the step leading up to a potential proposal. And “potential” is the key word to keep in mind, Smith says.

Jeff Smith

Nevertheless, health IT trade groups were keen to give their feedback on the RFI in their public comments. While some stakeholders were adamantly against the possibility of revising Conditions of Participations to revive interoperability, others were strongly in favor.

Kelly Hoover Thompson, CEO of SHIEC (the Strategic Health Information Exchange Collaborative), a national collaborative that represents health information exchanges (HIEs) and their partners, believes that imposing regulatory requirements is not the best solution to the interoperability problem. “I don’t think it has to go as far as what CMS [could be proposing], but I do think that it’s an indication to the industry, on a good level, that so many people are [thinking about] how to make things better,” says Hoover Thompson. Other major industry trade groups, such as AMIA, the American Hospital Association (AHA) and the College of Healthcare Information Management Executives (CHIME), similarly attested in their comments that CMS is taking the wrong approach.

Kelly Hoover Thompson

That said, others feel differently. A letter signed by more than 50 organizations, representing plans, providers, patient groups, ACOs (accountable care organizations) and health IT companies, has called on CMS to take more aggressive action to promote interoperability and advance health information exchange. Some of these signed groups include prominent industry names such as Beth Israel Deaconess Care Organization, Blue Shield of California, the New York eHealth Collaborative (NYeC), and Aledade.

Valerie Grey, director of one of the signing organizations of the letter—the New York eHealth Collaborative—says that NYeC supports potentially changing the Conditions of Participation with an incremental step.  Grey says that more vendors and providers have been willing to make data available for shared patients, but further progress is necessary.

More broadly, though, Grey points out that not every hospital can afford the EHRs that are enabling some of that interoperability today. However, being that NYeC’s role is to promote and enable information exchange, it is natural for the organization to support efforts that seek to promote information sharing, she says.

Will Business Incentives Change?

In the end, just as the previous administration changed incentives to encourage EHR adoption, the current one will have to find ways to inspire the next stage of interoperability: the efficient movement of health data. But it’s a delicate balance and it becomes a question of where to apply the pressure and how to incentivize the kind of behavior that is desired, AMIA’s Smith says.

Another piece of the puzzle is an information blocking rule from the Office of the National Coordinator for Health IT (ONC), which was originally expected in April, but now has been delayed until September [and has not been published at the time of this story]. It’s this rule, coupled with TEFCA, that experts believe could move the needle on incentivizing providers and EHR developers to interoperate.

“The hope was that the information blocking rule would be the definitive answer to the business incentive piece to the interoperability puzzle,” says Smith, noting that there are plenty of questions that need to be answered even within that rule itself. For instance, he contends, “data availability—when it comes to matters of life and death are issues of public health. But data availability for non-matters of life or death, or matters of an individual, comes down to more business questions—such as do I need to share the data for everyone who asks for it?”

Regarding TEFCA, officials are likely to put out a second draft version and another public comment period will follow, says John Kansky, the CEO of the Indiana Health Information Exchange, and appointed member of the Health Information Technology Advisory Committee (HITAC), which has had a lot of influence in making TEFCA recommendations to ONC. “It’s fun to think about and I feel privileged in having a front row seat in helping advise ONC, but we don’t know how the regulation will evolve,” Kansky admits.

That said, it’s not helpful or informative that opinions on TEFCA are all over the board, he adds. There are two buckets of folks that are thinking about and opining on this regulation, Kansky says: those who are strongly in the camp of advocating for consumer access and being in control of their data; and those who have been working on creating industry interoperability, be it through EHR vendors or HIEs, and trying to make it a reality. “Those two groups tend to have different views on regulation,” he points out.

John Kansky

Going forward, Smith asserts that the key will be how these policies that the industry has been expecting for some time now will intertwine with one another. “What I am hoping beyond hope is that the reason these policies are not yet publicly available is because the powers that be are still trying to make sure that there is harmonization and a logical inter-reliance across them,” he says.

Meanwhile, Kansky believes that the interoperability space is “ripe for bold change and opportunity. ”A few years into the future, he predicts, between the EHR interoperability approaches that will be prevalent, in addition to HIEs and regulations like TEFCA, the ecosystem will find a way for everything to work together. “Even when one sees the other as competition or making the way of life more challenging, this is what we do in the free market in the U.S.,” he says. “We throw a bunch of different approaches at a problem and sometimes we make a mess, but in the end we figure out a solution. And the solution isn’t one thing, pure and simple; oftentimes it’s a complicated ecosystem—but it works.”


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CommonWell Officials: Carequality Connection Now “Generally Available” for Members

November 16, 2018
by Rajiv Leventhal, Managing Editor
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CommonWell’s executive director said this latest step “breaks down another interoperability barrier”

Connection capabilities to the Carequality framework, by members of the CommonWell Health Alliance, are now “generally available,” according to officials who made an announcement today.

CommonWell, a trade association providing a vendor-neutral platform and interoperability services for its members, announced in August that it 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. This marked a key step in a collaborative effort to increase health IT connectivity across the country by enabling CommonWell subscribers to engage in health data exchange through directed queries with Carequality-enabled providers, and vice versa.

In just the first two weeks of a few CommonWell-enabled providers being connected, Jitin Asnaani, CommonWell Health Alliance executive director, said there were more than 4,000 documents bilaterally exchanged with Carequality-enabled providers.

Since then, by leveraging the technological infrastructure built by CommonWell service provider Change Healthcare, members Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, officials stated today.

Now, since the connection went live in July, officials noted  that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide.

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“We are proud to break down yet another barrier to interoperability by making this much-anticipated connection available to our members and their clients,” Asnaani said in a statement today. “This increased connectivity will serve to empower providers with access to patient health data critical to their healthcare decision-making.”

In December 2016, CommonWell and Carequality, an initiative of The Sequoia Project, announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past two years, teams at both organizations have been working to establish that connectivity.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. More than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network.

Carequality is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. It brings together electronic health record (EHR) vendors, record locator service (RLS) providers and other types of existing networks from the private sector and government, to determine technical and policy agreements to enable data to flow between and among networks and platforms.

CommonWell Health Alliance operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Services include patient ID management, advanced record location, and query/retrieve broker services, allowing a single query to retrieve multiple records for a patient from member systems.

Following the August announcement of the limited bi-directional data sharing capabilities, Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative said, “This is the ‘golden spike’ moment, connecting the two big railroads, like when AT&T and Verizon finally got connected. This is building that bridge.” Tripathi, who also directly observes and participates in conversations with Carequality and CommonWell, added, “It will take a while for all of the production sites and different vendors to get up and running. That will probably take a couple of years. But you have to have the bridge to connect them to begin.”

One key element in this progression is that currently, EHR giant Epic is not a member of CommonWell, despite other major EHR vendors pushing Epic in that direction. “Because sharing among Epic customers is already universal, when CommonWell connects to Carequality, the entire Epic base will become available, creating instant value for most areas of the country,” a recent KLAS report on interoperability stated.

Interestingly, Tripathi noted in August that once there is “general availability” of the data sharing services for all Carequality and CommonWell members, the competition factor will become less important. “It makes both networks more valuable,” Tripathi said at the time.

It appears as if that “general availability” time has now come. “Thanks to the CommonWell-Carequality connection, our patients can have access to their medical records regardless of the EHR a health care facility uses,” said David Callecod, president and CEO of Lafayette General Health, a Cerner client located in Lafayette, La. “When data is made readily available, providers can make diagnostic and treatment decisions more quickly, and patients can recover sooner. Better data means better communication with our patients and providers, better care and better outcomes. This is a very powerful tool!”

Officials also noted that with the connection officially in production, additional CommonWell members, including Brightree, Evident and MEDITECH, are in the process of subscribing to the connection and taking it live with their provider clients.


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Advancements in Healthcare: Interoperability, Data Exchange, and More

Tuesday, December 4, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

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 an inside look at the most significant interoperability trends that are happening nationwide and will discuss varying interoperability and data exchange efforts fit together in the bigger picture of U.S. healthcare.

Tripathi will also discuss the future of data exchange, advancements of standards such as FHIR, the reality of information blocking challenges, and more in this latest Healthcare Informatics webinar, which gives a high-level view on the many market forces that impacting nationwide interoperability.

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Epic Lowers App Orchard Program Fees, Introduces New Low-Cost Tier

November 1, 2018
by Heather Landi, Associate Editor
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Verona, Wis.-based Epic plans to lower program fees for health IT developers participating in its App Orchard program, and will launch a new entry-level program tier, called Nursery.

Epic announced the App Orchard updates at its App Orchard conference last week at its Verona headquarters, according to reporting from Politico published Oct. 26.

In an email statement, Brett Gann, App Orchard director, confirmed the company is reducing and simplifying the costs associated with participating in the app developer program. The three tiers of the program will see program fee reductions ranging from 33 to 80 percent as part of the update, Gann said.

Epic launched its App Orchard in 2017 as an online marketplace for third-party developers with 13 applications.

To date, more than 350 companies in the healthcare industry participate in Epic’s app developer program, where they have access to hundreds of application programming interfaces (APIs), documentation, testing tools, individual technical support, training, conferences, and integration with the Epic community, Gann said,

Gann also said the program updates announced last week at the annual App Orchard Conference in Verona will “engage a broader community of developers and increase access to APIs through simplified and reduced costs.”

The updates will help drive healthcare innovation as interested developers have the opportunity to build on top of Epic’s health record platform, using emerging industry standards such as FHIR (Fast Healthcare Interoperability Resources), Gann said.

Epic also announced a new program tier, Nursery, that will enable early-stage startups to enroll in the app developer program to access Epic’s public API documentation, tutorials, and sandboxes. Early-stage startups also will have access to FHIR, SMART on FHIR, and CDS Hooks, Gann said.

Enrolling in the Nursery program tier will cost participants $100 per year, Gann said, and when a company is prepared to go to market with its product, it may graduate to one of the other three tiers.

Nursery members will have access to Epic’s FHIR sandboxes, classroom and online learning opportunities, and the ability to engage with the online community of Epic, health system, and vendor developers and experts.

In addition to the program fee reductions, as part of the update, Epic will offer new program benefits to participants in the other three tiers, such as additional training opportunities, developer events, support services, sandboxes, and program accounts.

Gann also said Epic has simplified the pricing model for API-based integrations, eliminating the minimum fees, and reducing the cap. “It’s our expectation these updates will be a price reduction for nearly all program members,” he said.

Some developers, particularly smaller developers, have complained in the past that the fees to participate in the vendor app store are too steep.

Earlier this year, Politico reported the experiences of Rick Freeman, CEO of Interopion. Freeman told Politico that a family planning questionnaire app he developed for HHS’s Office of Population Health could have cost him up to $750,000 to run on Epic or Cerner for a year.

As reported by Politico in its October 26 report, in response to the program updates, Freeman said he is “very happy with the changes.”

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