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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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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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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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