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QHIN Questions

February 28, 2018
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Exclusion of many current HINs called ‘arbitrary’

In late January when I wrote a story about an ONC presentation on its draft Trusted Exchange Framework and Common Agreement (TEFCA), I chose the headline, “What Will TEFCA Mean for Regional HIEs?” because right away it seemed obvious to me that HIEs might see this as more of a threat than an opportunity.

As the public comments came pouring in to ONC, I noticed that several zeroed in on the definition of Qualified Health Information Network (QHIN). During the webinar I covered, Genevieve Morris, principal deputy national coordinator for health information technology, said  “What we want to hammer home a bit is that a single regional HIE is unlikely to be a QHIN. Likewise, a single EHR vendor network would likely not qualify as a QHIN. Again, that has to do with trying to create fairness in the marketplace as well as seeking to have a very small number of QHINs to support scalability.”

I want to highlight a few of the critiques, questions and recommendations that one HIE and another interoperability group sent in. Some focus on HIE financial sustainability. Great Lakes Health Connect (GLHC), the statewide HIE for Michigan, noted that, “hundreds of millions were spent collectively over a number of years to establish the core interoperability capabilities within HIEs and other interoperability frameworks across the country.”

“Recreating many of these capabilities in another network layer, further removed from end participants, would take another large number of millions to implement with no context to end-participant value or willingness to pay going forward,” GLHC wrote.

“Further, it is not accounted for in the proposal how this duplicative investment would affect HIEs working with end participants on solving the full local interoperability puzzle. GLHC recommends that ONC leverage the interoperability investments made over the years and not establish a significant financial burden within the industry through a new interoperability layer without an eye to how it would be funded. It is true that QHIN organizations may ‘figure it out’ or just fund it out of their own or sponsor profits. However, if ONC encourages an environment where deeper-pocket organizations with a focus on just one piece of the interoperability puzzle creates sustainability challenges for the very nonprofit HIE organizations making interoperability real in local communities all over the country, we will have gone substantially backwards in many ways.”

The Sequoia Project, the nonprofit organization that houses the eHealth Exchange network and Carequality, also focuses in on the definition of QHIN, and finds it wanting. “As currently defined, with a narrow, standardized and prescriptive definition, it is unclear whether any existing HIN could qualify as a QHIN due to the specific architecture prescribed for query-based exchange and the use cases contemplated,” the Sequoia Project writes. “We and others in the field believe that such TEF provisions, as proposed, may discourage HINs from participating as QHINs.

The existence of too few QHINs could have several negative consequences, including excessive QHIN market power and too few recipients for queries and other exchange models, it noted.

Sequoia also wonders whether there is sufficient demand for the narrow definition of QHIN services among prospective participants and end users. “Forcing such demand through likely pressures/incentives to sign the TEFCA, without adding flexibility, may result in added costs in the healthcare system and ‘bake in’ a very specific architecture, with a likely reduction of innovation and experimentation.”

And although it said it agrees with the principle of participant neutrality, Sequoia questioned ONC’s move to exclude existing HINs (for example, a statewide HIE or a vendor network) that already support query-based exchange at nationwide scale and that could engage in a TEFCA model as a QHIN, from being permitted to participate as QHINs.

“Excluding a single-state HIE but allowing two single state HIEs to collaborate as a QHIN, or excluding a vendor network that has a Connectivity Broker and is willing and able to comply with the Common Agreement seems arbitrary,” Sequoia wrote. “Such an exclusion would force many providers and HINs to change from their existing approach, revise their architecture, and redirect transactions through a QHIN. For providers and HINs that leverage federated approaches, for instance, this requirement would likely add another layer of cost and overhead and could potentially disrupt current exchange, with little additional value from connection to a QHIN.”

(By the way, on Thursday March 1, at 1 p.m. Eastern time, the Sequoia Project is holding a webinar to go over its TEFCA comments.)

As Managing Editor Rajiv Leventhal mentioned in a previous article, several industry groups, including CHIME, suggested that ONC open up an additional comment period this year before finalizing the TEFCA. Although there is general approval of the concept, many stakeholders have expressed concern about the timeline and specifics. Perhaps extending the comment period wouldn’t be a bad idea if ONC really wants buy-in.



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Carequality Seeks Input on FHIR-Based Exchange

October 12, 2018
by Rajiv Leventhal, Managing Editor
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Carequality is seeking input from the healthcare community as it looks to add support for FHIR (Fast Healthcare Interoperability Resource)-based exchange.

According to an announcement from Carequality—national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks—member and non-member stakeholders from across the healthcare continuum are encouraged to participate in the new FHIR Implementation Guide technical and/or policy workgroups. The former will concentrate more on specifications and security, while the latter will focus on the “rules of the road,” officials said.

With much of the healthcare industry either starting to implement FHIR at some level, or planning to do so, the Carequality community is thinking ahead to the type of broad, nationwide deployments that Carequality governance can enable, officials noted.

The new policy and technical workgroups are expected to work in concert with many other organizations contributing to the maturity and development of FHIR, and officials attest that the workgroups will not duplicate the work that is underway on multiple fronts, including defining FHIR resource specs and associated use case workflows. Instead, the workgroups will focus on the operational and policy elements needed to support the use of these resources across an organized ecosystem. 

“Carequality has demonstrated the power of a nationwide governance framework in connecting health IT networks and services for clinical document exchange,” said Dave Cassel, executive director of Carequality.  “We believe that the FHIR exchange community will ultimately encounter some similar challenges to those that Carequality has helped to address with document exchange, and likely some new ones as well.  We’re eager to engage with stakeholders to map out the details of FHIR-based exchange under Carequality’s governance model.”

Cassel added, “We believe that adoption of FHIR in the Carequality Interoperability Framework can advance all of these goals by improving the availability of useable clinical information, expanding the scope of exchange, and significantly lowering the costs of participating in interoperable exchange.”

In August, Carequality and CommonWell, an association providing a vendor-neutral platform and interoperability services for its members, announced they 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.

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New ONC Analysis Reveals Progress on FHIR Adoption, Implementation

October 2, 2018
by Rajiv Leventhal, Managing Editor
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The 10 biggest health IT vendors all use at least “FHIR 2” as their API standard

Adoption and implementation of the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standard in health IT is steadily progressing, according to a blog post from leaders at the Office of the National Coordinator for Health Information Technology (ONC).

The post, penned by Steven Posnack, executive director of the Office of Technology, and Wes Barker, noted that using CMS (the Centers for Medicare & Medicaid Services) and ONC data, the health IT agency analyzed how health IT developers used FHIR to meet 2015 Edition certification requirements. Additionally, they assessed how hospitals and clinicians’ access to 2015 Edition certified-APIs vary across the U.S. Based on this analysis, they found:

  • Approximately 32 percent of certified health IT vendors said that they are using FHIR, specifically the “FHIR Release 2” API (application programming interface) standard.
  • Nearly 51 percent of health IT developers appear to be using a version of FHIR combined with the OAuth 2.0 standard

As the ONC officials pointed out, while the 32 percent figure may seem “low” at face value, the estimated market share of the health IT developers using FHIR is large. They explained that the 10 certified health IT vendors with the largest market share across hospitals and clinicians (eligible for participation in the CMS Promoting Interoperability Programs)—and which encompass about 82 percent of hospitals and 64 percent of clinicians—all use at least the FHIR Release 2 as their API standard. These vendors include some of the biggest industry names such as Epic, Cerner, Allscripts, athenahealth, and others.

As such, overall, of the hospitals and Merit-based Incentive Payment System (MIPS) eligible clinicians that use certified products, ONC found that almost 87 percent of hospitals and 69 percent of MIPS-eligible clinicians are served by health IT developers with products certified to any FHIR version. When estimated for just FHIR Release 2, the hospital percentage remains the same while the clinician percentage drops a bit to 57 percent.


In 2015, ONC issued the 2015 Edition certification criteria that included functional API certification criteria, but no specific standards were required for the API. Just prior to that, The Argonaut Project kicked off as a market-driven FHIR accelerator to develop industry consensus around a set of FHIR Release 2 implementation specifications that could be used to meet the 2015 Edition’s API certification criteria.

Today, many companies have gone into production with FHIR Release 2 profiled according to the Argonaut implementation specifications. Apple (with a FHIR-based “client” app) may be the most notable, but there are indications that many other big tech companies are also planning to use the standard, the ONC blog stated.

What’s more, CMS has reaffirmed in its rules affecting the Promoting Interoperability Programs (formerly known as the EHR Incentive Programs) that the 2015 Edition will be required in 2019. Also, CMS has also invested in FHIR through its own Blue Button 2.0

In a responding statement to the ONC analysis, Blair Childs, senior vice president of public affairs at the Charlotte, N.C.-based Premier, Inc., noted that while it’s promising that many app developers appear to be coalescing around developing consumer apps using FHIR, “we urge the administration to prioritize achieving a similar degree of development across provider-facing applications.  These applications will support providers with predictive analytics, clinical decision support and other workflow technologies.”

Childs’ statement continued, “A strict focus on consuming-facing apps provides a limited view into the state of interoperability. It gives false hope of reaching the tipping point for free and unencumbered data exchange in healthcare. The reality is that we are nowhere near reaching our goal of a data-enabled health system. We need an immediate focus not just on consumer-facing technologies, but on those relied on by the provider community as well. This is why we continue to press for the timely implementation of 21st Century Cures Act interoperability and data standards provisions.”

Childs added, “Until all data is unlocked from EHRs and integrated into clinical workflows, we will continue to face walled gardens of vital information.”

ONC’s Posnack and Barker admitted themselves in the post, “While these data are encouraging, it’s not time to pop any champagne. Industry-wide, much work remains from standards development to implementation.”

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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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