VA-DoD: Winning the (Ongoing) Battle for Interoperability | Dave Levin, M.D. | Healthcare Blogs Skip to content Skip to navigation

VA-DoD: Winning the (Ongoing) Battle for Interoperability

January 22, 2018
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Pursuit of a broad, robust, API-based approach to interoperability will be crucial to delivering on the promise of world-class care that our active military, veterans and their families deserve

Recently, there’s been a perfect storm of bad news for the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD) and their efforts to modernize their electronic medical record (EMR). Both the DoD and the VA plan to standardize on Cerner’s EMR. The hope is that this will provide a more complete longitudinal health record and make the transition from DoD to VA more seamless for active duty, retired personnel and their dependents. It’s a laudable goal and we can all agree that those who serve our country deserve the best healthcare we can provide.

However, these efforts are running into significant problems:

  • The DoD recently announced it would pause the rollout of their new EMR known as MHS Genesis. The pilot project began in February 2017 at Fairchild Air Force Base and concluded when Madigan Army Center, the fourth pilot site, went live in October 2017. Reports vary on why this pause is occurring but seem to center on workflow problems and results retrieval.
  • After announcing in June 2017 that they had selected Cerner in a no-bid contract, the VA has now halted the contracting process due to concerns about interoperability. According to reports, the concerns are not around how well Cerner's system would work within the VA's network, but rather, if it would be fully interoperable with private-sector providers who play a key role in the military health system.
  • Scott Blackburn, CIO of the VA, recently injected important realism into the discussion about how long it will take to complete the transition from VistA, the VA’s legacy EMR, to Cerner. According to Blackburn, “The Cerner implementation will take about a decade. If it’s starting in the northwest quadrant of the country and moving east, those on the Eastern Seaboard are going to be using VistA for about 10 years [more] or so...”

I wish I could say I’m surprised by these events but, I am not. I shared my concerns in this article back in August 2017. To be very clear, I am not criticizing the DoD, VA or Cerner. They are trying to do the right thing and provide an EMR that will better serve everyone. The challenges the VA and the DoD are encountering are endemic to healthcare and highlight a set of problems that are also affecting the civilian health system. At the heart of this challenge are two fundamental issues: an anemic definition of interoperability and the inevitable short comings of a “one platform” strategy.

Single Platform Strategies Usually Fall Short

The “one platform to serve them all” approach is seductive. In theory, if all patients and providers are on the same EMR, interoperability will become a minor issue. I used to believe this, too. I was wrong for several reasons:

  • Every implementation of an EMR is different and even same-brand EMRs do not seamlessly connect. Limits in scalability and/or health system mergers can result in multiple instances of a specific EMR and those different instances do not easily interoperate.
  • It takes time to roll out a new EMR. It’s not like you can flip a switch and the legacy EMR is instantly replaced by the new one. Thus, Blackburn’s reminder that it will be at least 10 years before the legacy system is retired.
  • It’s difficult to completely retire a legacy EMR. They have lots of important historic information that will be needed well into the future (if not forever). Some, but not all of that information will be imported into the new EMR. Ask a clinician what information they might need in the future and you will hear some version of, “I can’t predict. It could be almost anything at any time.” 10-year-old information can make a huge difference when trying to figure out if that change on a recent EKG or chest X-ray is new or long-standing. If you are admitted to the emergency department with chest pain, you want your doctors to have that information instantly available. It could literally be a matter of life or death and time is of the essence.
  • The DoD cared for 9.3 million active military patients in 2016, while the VA cared for 9 million veterans in 2014. It’s a complex delivery system comprised of the DoD, VA and private facilities and providers. As a result, even when the DoD and VA complete their conversion, there still won’t be a common electronic medical record. This is a key reason the VA is currently focused so intently on interoperability between the military and civilian systems.
  • For a variety of reasons, some providers do not want to switch from their own EMR to one offered by their local health system. Look at almost any healthcare market in the US and you will find at least one important group—like Cardiology, Oncology, Nephrology or OB-GYN—that are firmly committed to keeping their own EMR. This is further exacerbated in markets that have more than one large health system using different EMRs.
  • On the civilian side, one platform solutions tend to focus on hospital and office based services. This leaves a huge gap when it comes to skilled nursing, rehabilitation, mental health, home care and the like. These services typically rely on their own specialty-specific EMR’s and, for good reasons, are reluctant to give them up.

In short, consolidation to a shared EMR platform has clear benefits, but it is not a panacea. Like any strategy, it has advantages and disadvantages. Some disadvantages can be solved over time, but some are likely to be with us for a very long time. This situation relates to, and gives us a great view into the other key problem: an anemic vision and approach to interoperability.

Robust interoperability is about much more than simple records portability.

The ability to move a patient record from one place to another is an important aspect of interoperability, but is only one feature. Robust interoperability enables a symphony of applications that connect, exchange and collaborate. This can mitigate many problems associated with the one platform strategy. Legacy systems can be tapped on-demand to retrieve important historic information in real-time. Military and civilian community-based providers and health systems can connect and share within and across their respective domains from the comfort of their own EMR.

Equally important, and as demonstrated in other industries, robust interoperability based on proven API technology encourages innovation by enabling market-driven competition to produce the best applications at the best price. Without this kind of interoperability, customers become highly dependent on their EMR vendor’s ability to innovate and are limited by that vendor’s talent, resources and priorities. This can stifle innovation and negatively impact usability, satisfaction, efficiency and clinical outcomes.

It’s Time to Soldier On

The VA and DoD deserve a lot of credit for taking on the difficult challenge of updating and integrating their EMR platforms. However, this will not, in and of itself, solve the interoperability problem. The civilian health system faces similar challenges which extend way beyond data exchange for simple records portability. Military and civilian health systems must be free to select the most innovative applications and seamlessly connect them with core EMR systems. Likewise, they need to connect different EMRs with each other.

Pursuit of a broad, robust, API-based approach to application integration and interoperability can mitigate the shortcomings of a single platform strategy and will be crucial to delivering on the promise of world-class care that civilians and our active military, veterans and their families rightfully deserve.

Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email DaveLevinMD@gmail.com.

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Study: EMR Interventions Help in Providing High-Value Medical Care

October 19, 2018
by Rajiv Leventhal
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By implementing electronic medical record (EMR)-based interventions, Boston Medical Center was able to reduce unnecessary diagnostic testing while increasing the use of postoperative order sets.

These actions signal two markers of providing high-value medical care, according to hospital officials. Indeed, the data from Boston Medical Center’s efforts demonstrates the impact of deploying multiple interventions simultaneously within the EMR as a way to deliver high-value care, they attest. This study was published in the Joint Commission Journal on Quality and Patient Safety.

The focus on providing high-value medical care was renewed in 2012 with the release of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation that identifies common tests and procedures that may not have clear benefit for patients and should sometimes be avoided. Many institutions have responded to this campaign by developing EMR-based interventions that target individual recommendations.

Boston Medical Center (BMC) specifically focused on five areas in the Choosing Wisely recommendations:  the overutilization of chest x-rays, routine daily labs, red blood cell transfusions, and urinary catheters, and underutilization of pain and pneumonia prevention orders for patients after surgery. To do this, the researchers worked with the hospital’s IT team to incorporate new recommendations into the EMRs that would alert the provider to best practice information. The researchers examined data between July 2014 and December 2016 to look at how the interventions played out clinically.

At six months following BMC’s intervention, which was activated hospital-wide for specific patients using the Epic EMR, the proportion of patients receiving pre-admission chest x-rays showed a significant decrease of 3.1 percent, and the proportion of labs ordered at routine times also decreased 4 percent. Total lab utilization declined with a post-implementation decrease of 1,009 orders per month, the study revealed.

The researchers found no significant difference in the estimated red blood cell transfusion utilization rate or the number of non-ICU urinary catheter days, but the proportion of postoperative patients who received appropriate pain and pneumonia prevention orders showed an absolute increase of 20 percent, according to the researchers.

“The results from our interventions suggest that they alone show promise in improving high-value care, but using only an electronic medical record intervention may not be adequate to achieve optimal outcomes emphasized by Choosing Wisely,” said Nicholas Cordella, M.D., the study’s corresponding author, a fellow in quality improvement and patient safety at BMC, and an assistant professor at Boston University School of Medicine.

Cordella added, ““In order to move the needle on reducing unnecessary healthcare costs, we need to consider multi-pronged approaches in order to engage providers in ways that can truly make a difference in how we deliver exceptional, high-value care to every patient.” He suggested that future efforts aimed at increasing high-value care should consider other elements, such as clinician education, audits and feedback, and peer comparison.

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Industry Groups Urge ONC to Reorient Goals of EHR Reporting Program, Focus on Health IT Safety, Security

October 18, 2018
by Heather Landi, Associate Editor
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Many healthcare industry groups would like to see the Electronic Health Record (EHR) Reporting Program for health IT developers include a strong focus on patient safety-related usability, EHR training, transparency on EHR vendors’ cybersecurity practices as well as cost transparency.

This feedback came in response to a request for information (RFI) issued by the Office of the National Coordinator for Health IT (ONC) in late August seeking public input on reporting criteria under the EHR Reporting Program for health IT developers, as required by the 21st Century Cures Act. The public comment period ended Oct. 17.

ONC issued the RFI on criteria to measure the performance of certified electronic health record technology (CEHRT). The Cures Act requires that health IT developers report information on certified health IT as a condition of certification and maintenance of certification under the ONC Health IT Certification Program.

According to the Cures Act, the EHR Reporting Program should examine several different functions of EHRs and reporting criteria should address the following five categories: security; interoperability; usability and user-centered design; conformance to certification testing; and other categories, as appropriate to measure the performance of certified EHR technology.

In its comments to ONC, the Bethesda, Md.-based American Medical Informatics Association (AMIA) questioned what it views as the “constrained scope” of the EHR Reporting Program to “provide publicly available, comparative information on certified health IT,” to “inform acquisition upgrade, and customization decisions that best support end users’ needs.”

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Rather, AMIA urged ONC to develop the EHR Reporting Program to measure performance to improve CEHRT security, interoperability, and usability, and not be used simply to provide data for “acquisition decision makers.”

“Especially when viewed alongside the additional provisions in newly developed CEHRT Conditions of Certification, the EHR Reporting Program should be leveraged to bring transparency to how CEHRT performs in production environments with live patient data,” AMIA stated.

“ONC should develop an EHR Reporting Program that more closely approximates a post-implementation surveillance ecosystem, not a government-sponsored ‘consumer reports’,” AMIA wrote in its comments.

Such an ecosystem, AMIA stated, would “illuminate CEHRT performance used in production and would generate product performance data automatically, without users having to submit reporting criteria.”

As proof of concept, AMIA pointed to ONC’s existing nascent surveillance and oversight program for CEHRT that could be leveraged for the EHR Reporting Program. The group also referenced the Food and Drug Administration’s (FDA) Digital Health Software Precertification Program as another example of a federal program that looks to utilize real-world production data.

In addition, AMIA recommends ONC develop interoperability reporting criteria for the EHR Reporting Program by building on previous RFIs meant to “measure interoperability,” including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and ONC’s “Proposed Interoperability Standards Measurement Framework.”

And, the industry group also urged ONC to prioritize an additional measure that demonstrates a capability to provide patients with “a complete copy of their health information from an electronic record in a computable form.” “This focus would align with top-level HHS priorities to improve patient access to their data,” AMIA noted.

AMIA also recommends alignment between the EHR Reporting Program and other aspects of the Cures-mandated Conditions of Certification.

“The EHR Reporting Program is one more vital piece in improving both EHR performance and care quality,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “We have a tremendous opportunity to leverage Cures provisions if we hone our focus on EHR performance in the real world.”

In its comments, the College of Healthcare Information Management Executives (CHIME) advises ONC against establishing any complex rating methodologies for scoring vendors. ONC should also consider establishing benchmarks by which to monitor interoperability progress among vendors, CHIME wrote. The organization noted that patients need better education on the risks of using application programming interfaces (APIs), and ONC should partner with their federal partners and stakeholders on this issue, CHIME said.

Many organizations, including CHIME, would like more information about vendors' ongoing support practices, such as the estimated costs of maintenance and software. The Medical Group Management Association (MGMA) recommended making software pricing structures for upfront and ongoing software, training and maintenance costs part of the Reporting Program, as well as all interoperability “connection” fees. MGMA also urged ONC to consider incorporating into the Reporting Program testing criteria that focused on the effectiveness of the EHR’s integration with practice management system software, and costs associated with it.

The American Health Information Management Association (AHIMA) recommended that comparative information made publicly available under the EHR Reporting Program should also contain reporting criteria that reflects the entire lifecycle of the certified health IT product, including acquisition, implementation, ongoing maintenance, upgrades, additional product and/or application integration, and replacement.

Focus on Patient Safety-Related Usability and EHR Training

In its comments, AMIA also urged ONC to view health IT safety as a measurable byproduct of usable CEHRT deployed in live environments. “To understand CEHRT usability performance in situ, ONC should supplement user-reported measures with measure concepts that reflect the safety of health IT,” AMIA wrote.

MGMA recommended that the Reporting Program report on the ability of the software to identify and address patient safety issues. “Poor usability and inefficient clinician workflow can not only fail to prevent adverse events but can actually contribute to them,” the organization wrote.

In comments it submitted to ONC, Pew Charitable Trusts noted that the establishment of the EHR Reporting Program “has the potential to give health care providers, EHR developers, and other organizations better data to address barriers in the effective, efficient, and safe use of health information technology, and improve systems accordingly.”

“In particular, this program could unearth key details on how clinicians utilize EHRs to meet ONC’s goal of reducing clinician burden while improving patient safety. ONC should ensure that the reporting criteria focused on usability—which refers to the design of systems and how they are used by clinicians—also incorporate safety-related provisions,” Pew wrote in its letter.

Pew recommended reporting criteria focus primarily on testing EHR usability to promote patient safety. To this end, Pew identified four principles to guide usability-related reporting criteria—the adoption of a life-cycle approach to developing usability-related criteria; incorporating quantitative, measurable data; limiting burden on end-users; and ensuring transparent methods that prevent gamesmanship.

Pew also provided ideas for existing sources of information that could be adapted into or utilized as safety-related usability reporting criteria, such as the Leapfrog CPOE tool, safety surveillance data from ONC, the ONC SAFER Guides or a 2016 health IT safety measure report from NQF.

“As ONC implements this program, the agency should ensure that the usability aspects of the program focus on the facets of EHR usability that can contribute to unintended patient harm. To achieve that goal, ONC should consider the aforementioned principles in identifying reporting criteria, and data sources that could become part of the program,” Pew wrote in its comments.

Orem, Utah-based KLAS Research and the Arch Collaborative recommended the EHR Reporting Program include criteria focused on EHR training, as better clinician training is critical to EHR usability and clinician satisfaction, the two groups said. The Arch Collaborative is a KLAS-affiliated initiative comprising 5,000 providers.

The KLAS-Arch comment cited research findings based on responses by more than 50,000 physicians from more than 100 provider organizations around the globe that suggests EHR satisfaction and usability are directly related to the extent and quality of training users have received. The research indicates that organizations that focus on training to support clinician workflows have higher EHR satisfaction than those that don’t. What’s more, the higher the levels of personalization tool use by the clinicians, the higher the EHR satisfaction score, according to KLAS.

“EHRs are not simple enough to be operated efficiently without ample instruction. It is essential that new providers spend enough time learning how to use the EHR, and it is requisite that providers have the option to participate in ongoing training each year,” Taylor Davis, vice president of innovation at KLAS Research, wrote in the letter. “When an EHR training program is well designed, there will be a demand to attend. A trend that has been noted is that success begets success; when providers share how EHR training has improved their efficiency, their peers become more likely to participate. The key is that the providers must have the option to choose what works for them.”

Need for Greater Focus on Security Posture

The Healthcare and Public Health Sector Coordinating Council's cybersecurity working group highlighted, in its comments on the RFI, the need for more transparency on EHR vendors' cybersecurity posture as part of the criteria of the EHR Reporting Program.

“The challenges to our sector are abundant and we believe these attacks pose direct threats to patient safety,” the group wrote in its comments. The group urged ONC to factor into the EHR Reporting Program the growing incidences of cybersecurity attacks on the sector and the need to work collaboratively to address the threats.

The group outlined a number of items that would better inform providers of a vendors’ security practices, such as access to an auditor’s statement regarding the security posture of the vendor and its products, upon provider request, as well as a software security analysis, whether two-factor authentication is in use, information on role-based access controls and how roles are configured, and, with each release and update, the number of patches provided to address security-related issues.

The group also recommended ONC consider developing a more standard way for vendors to report vulnerabilities with health IT upgrades and releases.

 


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UnitedHealth Group Plans to Unveil Health Record for Members, Providers in 2019

October 17, 2018
by Rajiv Leventhal, Managing Editor
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Health insurer UnitedHealth Group will be unveiling a “fully integrated and fully portable individual health record,” CEO David Wichmann said on the on the company’s third-quarter earnings call yesterday.

Speaking to the insurer’s broader digital health strategy, Wichmann stated on the earnings call that the company’s consumer digital health platform, Rally—which is a website and mobile app—is now serving over 20 million registered users and will leveraged to help develop the health record.

“Rally is synthesizing information and engaging people to better manage their health, helping consumers save money by selecting the highest quality care providers, understanding their out-of-pocket costs up front, and in some markets even scheduling appointments for care. We will soon be releasing at scale a first-of-kind, fully integrated and fully portable individual health record that delivers personalized next-best health actions to people and their caregivers,” Wichmann said on the call.

While many more details are not yet known about the health record, Wichmann did say that by the end of 2019, the insurance giant has the goal of developing individual health records for the 50 million fully benefited members that it serves, as well as for their care providers.

He noted, “We would use the Rally chassis…to provide individuals in a way in which they can comprehend a tool, if you will, not only outlining their individual health record, but also giving them next-best action detail. That's what I mean by when I say it's deeply personalized. It's organized around them, not based upon generic criteria. It also assesses to what extent that they've been, and how they've been served by the health system broadly, and whether or not there's been any gaps in care that have been left behind.”

Giving a little bit more information about the vision UnitedHealth Group has in regard to the health record, Wichmann said, “You might imagine what that could ultimately lead to in terms of a continuing to develop a transaction flow between the physician and us and the consumer and us, as we us being the custodian to try to drive better health outcomes for people, but also ensure that the highest level of quality is adhered to.”

As of now, the platform appears to be more geared toward consumers than providers. Steven Halper, an analyst for financial services company Cantor Fitzgerald, noted in an update that “The Rally EHR should be able to tap into different EHRs that use APIs [application programming interfaces] and other interoperability standards, which are being more-widely adopted. Rally EHR should be viewed as a consumer engagement tool and not as a threat to legacy provider EHR products.”

UnitedHealth Group already has its Optum business line, a health innovation company that provides health services in an array of different ways, including through its growing data analytics capabilities.

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