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FHIR DevDays to Provide Snapshot of Interoperability Progress on Several Fronts

June 5, 2018
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Devices on FHIR, Argonaut projects, IHE collaboration to be highlighted
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The upcoming FHIR DevDays meeting in Boston June 19-21 brings together the community of health IT executives working on implementing the HL7 interoperability standard. The agenda provides a snapshot of progress on several fronts. I asked Wayne Kubick, HL7’s chief technology officer, for a preview of seven presentations that sounded intriguing.

• IHE Profiles and FHIR. In a very new development, HL7 has been talking to IHE (Integrating the Healthcare Enterprise) about a new project, code-named Gemini.We have agreed to collaborate to try to encourage the use of FHIR in IHE profiles and exchange knowledge and information, but we haven’t formalized it yet with a charter,” Kubick said. “It is in a very early stage. Our missions and visions are similar. We have complementary strengths. Seeing the benefits FHIR can offer for interoperability, IHE wants to get on board, too, and get it embedded in IHE installations around the world.”

• Devices on FHIR. HL7 notes that for decades accessing information from healthcare devices has been both challenging and expensive. Todd Cooper, who has a background in standards-based medical device informatics and co-founded the HL7 Health Care Devices and IHE Patient Care Devices groups, will describe the progress so far on the Devices on FHIR (DoF) initiative – a collaborative effort between HL7, IHE & PCHA – to leverage FHIR to make the exchange and use of device-sourced content just as simple as any other type of information. Cooper launched the Devices on FHIR initiative in the summer of 2016 and serves on the HL7 FHIR Foundation Board. 

“It makes perfect sense for device interoperability to use FHIR more extensively than it is right now, but they are moving kind of slowly,” Kubick admitted. “It hasn’t move quite as quickly as we would like. It comes down to getting the direct engagement from device manufacturers, who aren’t quite embracing the promise of interoperability as much as they could yet.” The Devices on FHIR initiative is looking at how they can use the power of the FHIR specification to streamline device interoperability and make it more common between all kinds of devices. “We have a lot of specialized APIs in place today,” Kubick said, “so that is the conflict we have in the devices world. I don’t think we have achieved the traction and maturity we want to see. We expect it will happen soon enough.”

The technology has been successfully demonstrated at three connect-a-thons — proofs of concept connecting different types of devices, so the technology isn’t really the limitation, Kubick explained. “It is pretty obvious the benefit of a common API, especially one that is also used for other types of health information. We went through a similar thing with EHR vendors. They developed custom APIs and have been migrating to FHIR. It has been great, but it took a while to do that. You have a sunk cost fallacy. It is hard to justify it until you have enough momentum to carry it along, which is what the Argonaut Project achieved in the EHR world. We don’t quite have an Argonaut in the device world yet, but we are hoping that will come up.”

• Argonaut Projects. There will be a few sessions describing Argonaut projects at FHIR DevDays. One session will provide an overview of Argonaut initiatives: Provider Directory, Scheduling, Data Query, Document Query. Another will go in-depth on the FHIR Version 3.0.1 based Argonaut Scheduling Implementation Guide use cases and operations for searching for availability, holding, booking, searching, and cancelling appointments by both patient- and provider-facing applications. It will review the early adopt experience, challenges and future steps.

Concerning Argonaut, Kubick said the big splash came a few years ago with the Data Access Framework, the original Argonaut implementation guide, which was the fundamental building block for common APIs from the EHR system. “That one was big,” he said. The subsequent projects they have done have been more tailored and focused. The same year they published the DAF implementation guide, they also published the provider directory, but it wasn’t quite as visible, he said. In year two, they did Scheduling and the CDS Hooks piece. (CDS Hooks is an emerging standard that leverages both FHIR and SMART to provide open and interoperable decision support in the EHR.) “CDS Hooks is really a transformative technology that may be premature for being widely adopted yet,” Kubick said. “But to be able to have an underlying technology to actually sit within the EHR system, be aware of events, and trigger actions is a huge component for clinical decision support.”

At FHIR DevDays, Kevin Shekleton, a vice president and distinguished engineer at Cerner, will lead a session on CDS Hooks. He will demonstrate how you can use it to provide guidance to the clinician such as a better medication to order, critical information about the patient, or push a SMART app that should be run.

In year three, Argonaut is focused on three main projects. One focuses on unstructured Clinical Notes. It involves taking the unstructured information buried within the EHR and being able to encapsulate it and present it through the API. “Not only can you get structured information about a patient, such as their medications, but also collect the contextual notes that the clinicians have entered and is really important,” Kubick said. “That is very important to the Office of the National Coordinator. It extends the flexibility and scope of what you can get out of an API.”

Another huge piece is Bulk Data Export, which will support value-based care, analytics and quality of care by being able to send a collection of data for an entire population, so that would include public health activities. As HL7 notes, today bulk export is often accomplished with proprietary pipelines that are difficult and expensive to maintain. Josh Mandel and Dan Gottlieb of Boston Children’s Hospital will present on a new effort by SMART and HL7 to bring the FHIR standard to bear on these challenges of bulk-data export.

• The Da Vinci Project is a multi-stakeholder effort led by payers, providers and HIT vendors to address use cases in value-based care. “They have a project manager and a technical lead,” Kubick said. “They are having a kickoff meeting right after the DevDays meeting in Boston. They have identified use case and are planning to move quickly.” One initial use case involves 30-Day Medication Reconciliation Post-Discharge. Viet Nguyen, M.D., chief medical officer for the Health Services Platform Consortium, will give an overview of the project.

Finally, in one keynote speech, Google’s Eyal Oren’s with talk about how FHIR lies at the core of the information infrastructure of Google Brain in healthcare. 




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Epic Plans Meeting for Non-Epic Users on Data Sharing Capabilities

August 16, 2018
by Heather Landi
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Verona, Wis.-based Epic is inviting healthcare provider organizations that don’t use Epic’s electronic health record (EHR) to its “un-Users Group Meeting” at its Verona headquarters to learn how to exchange data with Epic.

The event, planned for September 26, will provide information to healthcare provider organizations about how to exchange charts with providers in their community who use Epic, even if providers use a different EHR— or no EHR at all.

According to Epic’s unUGM website, the event is for “executives and strategic leaders of provider organizations who want to learn and discuss how to exchange with providers in their community who use Epic.”

“Access to a patient’s information, regardless of where he or she has been seen, helps providers deliver the best patient care. The first Un-Users Group Meeting (unUGM) is another way we’re reaching out to the leaders of health systems using other EHRs—or even no EHRs—to help them get connected to the Epic users in their communities,” Dave Fuhrmann, Epic’s vice president of interoperability, said in a prepared statement.

According to the event agenda, topics of discussion include options for exchanging patient data with providers through Carequality, Care Everywhere, health information exchange (HIE) and Direct messaging, as well as patient-directed options, including MyChart, Share Everywhere, Lucy, and Blue Button.

There will also be discussion about interoperability success stories, using both non-Epic and Epic EHRs, and the current state of coordinated care in the U.S. and the use of existing tools to close care gaps, improve communication, and reduce costs.

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Amazon, Google, IBM and Other Tech Giants Pledge to Remove Barriers to Interoperability

August 14, 2018
by Heather Landi
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Six of the world's biggest technology companies, including Microsoft, Google, IBM and Amazon, made a joint pledge at the White House Monday to remove interoperability barriers and to make progress on adoption of health data standards.

The announced came during the Blue Button 2.0 Developer Conference in Washington, D.C. where Microsoft joined with Amazon, Google, IBM, Salesforce and Oracle to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project. They also pledged to remove interoperability barriers, particularly as it relates to the adoption of technologies enabled through the cloud and artificial intelligence (AI).

Dean Garfield, president and CEO of the Information Technology Industry Council, said in a statement, “Today’s announcement will be a catalyst to creating better health outcomes for patients at a lower cost. As transformative technologies like cloud computing and artificial intelligence continue to advance, it is important that we work towards creating partnerships that embrace open standards and interoperability.

“We commend the White House Office of American Innovation for their leadership in being a catalyst for moving health care beyond siloed systems and varied data standards. As well, we celebrate Amazon, Google, IBM, Microsoft, Oracle, and Salesforce for their commitment to helping to advance open healthcare standard. The opportunity to unleash greater innovation in health care is here and working together we can seize it,” Garfield said.

In a joint statement, the technology companies made a commitment to remove barriers to “frictionless data exchange,” noting that they share “the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.”

The commitment specifically states:

“In engaging in this dialogue, we start from these foundational assumptions: The frictionless exchange of healthcare data, with appropriate permissions and controls, will lead to better patient care, higher user satisfaction, and lower costs across the entire health ecosystem.

Healthcare data interoperability, to be successful, must account for the needs of all global stakeholders, empowering patients, healthcare providers, payers, app developers, device and pharmaceuticals manufacturers, employers, researchers, citizen scientists, and many others who will develop, test, refine, and scale the deployment of new tools and services.

Open standards, open specifications, and open source tools are essential to facilitate frictionless data exchange. This requires a variety of technical strategies and ongoing collaboration for the industry to converge and embrace emerging standards for healthcare data interoperability, such as HL7 FHIR and the Argonaut Project.

We understand that achieving frictionless health data exchange is an ongoing process, and we commit to actively engaging among open source and open standards communities for the development of healthcare standards, and conformity assessment to foster agility to account for the accelerated pace of innovation.”

Gregory J. Moore M.D., Ph.D., vice president of healthcare, Google Cloud, said in a statement, “We are pleased to join others in the technology and healthcare ecosystem in this joint commitment to remove barriers and create solutions for the adoption of technologies for healthcare data interoperability. This will enable the delivery of high quality patient care, higher user satisfaction, and lower costs across the entire healthcare ecosystem.”

Patients should have access to their data, said Mark Dudman, head of global product and AI development, IBM Watson Health, in a statement following the announced commitment. Patients also should have the flexibility to use products and services across different healthcare systems, with confidence that they all are working seamlessly for their care, he said. “We are proud to participate in this pledge and look forward to working with industry and the developer community to ensure appropriate access to data and the use of that data to support vibrant communities and solve health challenges for people everywhere.”

In a blog post, Josh Mandel, chief architect, Microsoft Healthcare, notes that interoperability is an overlapping set of technical and policy challenges, from data access to common data models to information exchange to workflow integration – and these challenges often pose a barrier to healthcare innovation.

Mandel, who previously worked at Google Life Sciences and on the research faculty at Boston Children’s Hospital where he worked on the SMART Health IT Platform, notes that support for the Meaningful Use Common Clinical Data Set grows and it is becoming easier to plug new tools into clinical workflows, analyze clinical histories, collect new data, and coordinate care.” Many of these technical capabilities have been available within small, tight-knit health systems for a long time – but developing these capabilities has required complex, custom engineering and ongoing maintenance and support. Driving toward open architecture makes adoption faster, easier and cheaper,” he wrote.

True interoperability in healthcare requires end-to end solutions, rather than independent pieces, which may not work together, Mandel wrote. “Transforming healthcare means working together with organizations across the ecosystem. Today’s joint interoperability statement reflects the feedback from our healthcare customers and partners, and together we will lay a technical foundation to support value-based care.”


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Industry Stakeholders Urge ONC to Move Forward on Information Blocking Rules

August 8, 2018
by Heather Landi
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In a strongly worded letter to National Coordinator Donald Rucker, M.D., several healthcare and health IT industry groups expressed frustration with the Office of the National Coordinator for Health IT’s lack of progress in publishing information blocking regulations, as required in the 21st Century Cures Act.

“It has been 601 days since the 21st Century Cures Act was signed into law. Every day that the administration delays implementation of these critical provisions places patients at risk of harm,” the letter states. Stakeholders including Health IT Now, Research!America, Oracle, the American Medical Informatics Association (AMIA), the American Academy of Family Physicians, Cambia Health Solutions and Claim Your Health Data Coalition signed the letter dated August 6.

In the letter, addressed to both Dr. Rucker and Daniel Levinson, inspector general of the Department of Health and Human Services (HHS), the stakeholder groups note that the 21st Century Cures Act, which was enacted in December 2016, requires the HHS Secretary to “issue regulations to prevent information blocking and to also identify reasonable and necessary activities that do not constitute information blocking.” Further, the law requires ONC to implement a standardized process for the public to submit reports on claims of health information technology products or developers of such products not being interoperable or resulting in information blocking and actions that result in information blocking. “The Office of the Inspector General (OIG) has enforcement authority over vendors and providers who are found to engage in information blocking,” the letter states.

The stakeholder groups also contend that “information blocking poses a significant risk to patient safety and greatly contributes to increased costs and waste in the health care system.”

According to reporting from Politico, during ONC’s 2nd Interoperability Forum this week in Washington, D.C., Rucker told the form audience that ONC is still working on the rule. The rule’s release has been delayed several times and is not expected to be released in September.

“Rucker emphasized Monday that his goal is to make protocols and standards that would let large amounts of health data flow easily between health providers, not just individual patient charts. He and other officials emphasized that ONC’s work is all being done within the confines of HIPAA,” the Politico article stated. Rucker also noted that properly defining which behaviors do and don’t constitute information blocking is “hard to sort out,” and the rule is a “work in progress,” Politico reported.

In a separate statement regarding ONC's delay in issuing an information blocking proposed rule, Douglas Fridsma, M.D., Ph.D., AMIA president and CEO, said, "Information blocking is the absence of interoperability, and there are numerous reasons why information may not flow as intended. Some of these reasons are technical, others for business or policy reasons. The socio-technical interoperability stack is complex and so too is the task of identifying which among its layers is responsible for information blocking. This rule must be critically calibrated to account for these layers, and it must be part of a larger conversation about how we will address other aspects of the socio-technical interpretability stack. Now is the time to initiate this broad conversation through release of the proposed information blocking rule."

In the letter, the industry groups also cautioned that “information blocking impedes provider access to the most current, accurate or complete information on their patients. As the administration proposes and implements new rules related to open APIs and interoperability in Medicare’s payment rules for hospitals and doctors, the lack of clear rules of the road needlessly creates uncertainty for vendors and providers alike.”

“We understand the nuance required but feel that it is past time for a proposal to be made,” the stakeholder groups wrote in the letter.

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