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Key to Multi-Sector Data Sharing: Meaningful, Long-Term Partnerships

June 5, 2017
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The National Center for Complex Health and Social Needs hosts execs working on making data-sharing connections
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One of the Top Tech Trend stories I wrote this year for Healthcare Informatics focused on data sharing across sectors to better cope with patients’ complex medical, behavioral, housing, educational and social needs. Last week I saw a webinar presentation sponsored by the National Center for Complex Health and Social Needs on key lessons for collaborating on data sharing. Several organizations presented on working at the grass roots level to make those connections, both interpersonal and in terms of interoperable data. They provided some very interesting examples of how setting up data-sharing arrangements requires ingenuity and persistence.

One of the people I interviewed for that earlier story is Alison Rein, senior director of evidence generation and translation for Academy Health in Washington, D.C. She leads the Community Health Peer (CHP) Learning Program, a partnership with the Office of the National Coordinator for Health IT (ONC) to establish a national peer learning collaborative of 15 communities to address specified population health management challenges through increased sharing and use of electronic data.

She told me that health systems don’t have as big an impact as they think they do on the real things that drive cost. Instead, she said, “They need to figure out how to work with others outside their system if they really want to thrive in a few years. It is no longer OK to spend an increasing proportion of our gross domestic products on healthcare services without getting any better outcomes.”

One of last week’s presentations was by an organization that is part of the CHP Learning Program. The Providence Center for Outcomes Research and Education (CORE) in Southwest Washington state is building a shared data system that will aggregate public records, insurance claims, and public health data for community-based population health management. They are creating the infrastructure to conduct a multi-sector analysis that brings together data on healthcare encounters, housing assistance, school attendance, and corrections to identify at-risk populations.

The Providence team isn’t starting from scratch. They are working with the Healthy Living Collaborative of Southwest Washington, which has been working as cross-sector coalition for some time. Nikki Olson, associate director of CORE, said the collaborative was proud of the work it had already done, but it never had data to shape, drive and evaluate its work.  “So there was an impressive level of cohesion and trust already,” she said. “They have almost 60 partners working to design initiatives that promote health equity and improve outcomes.

They began stitching together siloed systems  — connecting a system that tracks homelessness in the community with the school district. “When we started talking about data with them, they were very ready to use it to drive their work,” Olson said. The CORE team started with site visits with each entity to learn what data they had, what data they had authority to share, and what data they wanted from other organizations.  “We then selected a subset that were key organizations that had right administrative data we could begin connecting. A key thing was readiness to engage with what is a heavy lift.”

Sarah Bartelmann, CORE’s development program manager, said this led to a series of conversations about existing data and sharing rules. What did their data warehouse currently look like? What elements did they have? What data is shareable under federal and state law? Washington state has more stringent privacy protections than the federal government, and many agencies have their own interpretations, she said. As they looked at overlapping populations between groups working on homelessness, healthcare and education, each group had its own definitions of priority populations it wanted more data about. Some organizations wanted help with their own data as well as cross-sector data use cases.

Another person I spoke to for the Tech Trend article is Andrew Hamilton, chief informatics officer of the Alliance of Chicago Community Health Services, and he also spoke at this online meeting in a presentation about the Alliance’s Childhood Lead Hazard Project. He and Nivedita Mohanty, M.D., the Alliance’s chief research officer and director of evidence-based practice, gave a presentation about their work to bring lead exposure prevention to federally qualified health centers in their region. They worked with the Chicago Department of Public Health to bring several data sets together to map lead exposure and created alerts. When infants and children come into a clinic from one of those neighborhoods, the provider gets an alert and can begin abatement strategies. “This focus is proactive by sharing data early on to predict risk for lead poisoning,” said Mohanty. This involves combining several data sources to drive a predictive model based on the child’s current address. “We take that model and give it to providers to run risk analyses from the clinical decision support tools in the EHR,” she explained. A form in the EHR also will make risk data available to prenatal providers, so they can know if their patient is in a high-risk lead area.

The final example came from the Camden Coalition of Healthcare Providers in Camden, N.J., where they are working to share data between health providers and jails.

Stephen Singer, senior manager of analytics and information  architecture, said one key to success is trying to engage stakeholders as long-term partners. “We look for multiple ways to involve them in meaningful pieces of the interaction,” he said, “not just to get their data. If you are new to the process of cross-sector data sharing, it can look kind of intimidating, he added. There are technology challenges, privacy and security issues, and some loss of control. “So we have to be not just taking data in, but also giving some out. Data can help facilitate the relationships.”

Here is the use case Camden Coalition sought to solve. It had a team of clinicians in a “housing first” program working on homelessness issues. When they went looking for their clients, sometimes they found out they were in jail. So they wondered how they could get ready access to jail arrest, booking and release data. 

“Instead of talking to lawyers about how to share the data, we got at the jail data by making public records requests,” Singer explained. “In New Jersey, that data is a public record, but we had to get it in a form we could actually use it. A third party vendor runs the database for admissions and discharges. They got the training manual for that software and went through the data fields to capture what they needed. “Simple, basic, tedious spade work created the new knowledge to link systems,” he said. “There was useful information in the jail data. It helped us with linking the same individuals across systems, and the jail had something we had nowhere else — several aliases that clients went by.”  That gave the clinicians a wider set of names and made it possible to link people across hospitals. “We didn’t have a full picture unless we knew when they were incarcerated,” he said. “It gave us a much richer picture of those clients."

A conference on the topic will be held this fall in Los Angeles. “Putting Care at the Center" is the annual conference of the National Center for Complex Health & Social Needs. It will run from Nov. 15-17.






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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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