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Buying into Healthcare’s Blockchain Hype

April 4, 2017
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Could blockchain be the fabric that ties existing data siloes together?

One of the reasons I like reporting on Healthcare Informatics’ Top Ten Tech Trends every year is that as a health IT journalist, I learn so much about tech innovations that are just coming onto the healthcare scene. A case in point this year was blockchain—an up-and-coming technology that many in our industry are fawning over, despite applications of it in healthcare still in very immature stages. Admittedly, I was a tad hesitant to take this story on as one of our Top Tech Trends this year, thinking that most healthcare experts in this area wouldn’t be able to say much about blockchain—best known for its use in the financial sector. Boy, was I wrong!

After interviewing several industry leaders about blockchain’s potential in healthcare, and after attending a few sessions at HIMSS’ all-day blockchain event in Orlando in February, I must say that it’s very difficult not to buy into the hype. At its core, blockchain would offer the potential of a shared platform that decentralizes health data without compromising the security of protected health information. This alone could make real headway in solving two of healthcare’s biggest challenges—interoperability and data security.

Healthcare Informatics’ blockchain coverage essentially started last summer when Senior Contributing Editor David Raths penned an excellent article in which he interviewed Micah Winkelspecht, founder and CEO of Gem, a Venice, Calif.-based startup developing blockchain application platforms. You all should read the piece yourself, but this is what Winkelspecht said about how blockchain could work for a patient who had recently seen a few doctors: “Blockchain would point me to a universal patient case file, with a universal identifier for me as the patient. So no matter which doctor is interfacing with the system, they are recording information against the same universal patient identifier, which is recorded on the blockchain,” he said.

In more recent months, the blockchain “buzz” has only continued to grow. Wired ran a terrific piece in February in which the author, Megan Molteni, mainly spoke with John Halamka, M.D., CIO at Boston-based Beth Israel Deaconess Medical Center. Here’s what Dr. Halamka said, giving a specific example of how blockchain would work with prescriptions. “Say that one medical record shows a patient takes aspirin. In another it says they’re taking Tylenol. Maybe another says they’re on Motrin and Lipitor. The problem today is that each EHR [electronic health record] is only a snapshot; it doesn’t necessarily tell the doctor what the patient is taking right now. But with blockchain, each prescription is like a deposit, and when doctor discontinues a medication, they take a withdrawal. Looking at a blockchain, a doctor wouldn’t have to comb through all the deposits and withdrawals—they would just see the balance.”

When you hear experts such as Winkelspecht and Halamka discuss how blockchain could be used in healthcare, it’s easy to see why many are so bullish. It’s hard to compare it to anything we have seen in healthcare in the past, though the closest match could be health information exchanges (HIEs).

For my story, a few sources brought up the blockchain/HIE comparison, noting that one key difference is that HIEs hold the electronic patient data all in place, whereas with blockchain, separate entities each hold a “token” on the chain. Put in other words, if you as a patient go to four different hospitals, that data is being held separately; no single place is containing all of your information. And, no single entity has a complete view of your information unless you initiate a request and all parties agree to it. On the other hand, with an HIE, various different agencies are submitting data to that centralized exchange, meaning a hack of that information could have catastrophic impacts.

Adding to this thought, Vince Vickers, KPMG’s healthcare technology leader, said, “Blockchain effectively takes out the middle man; conceptually you would not have these health information exchanges that have struggled to get to mainstream. There have been a lot of good efforts in certain states, and some HIEs have done well, but in relative terms, [compared] to the financial services industry—where I can go to an ATM, no matter where I am in the world, and get my money—patient data obviously is very limited in that way. And the HIEs are very slow moving. So blockchain is a really interesting disruptor. When you put it in those terms, that it could potentially, not necessarily eliminate HIEs, but at least change them structurally and provide a new value proposition.”

It’s thus no surprise that a December Deloitte report found that the healthcare and life sciences industries have the most aggressive blockchain deployment plans of any sector, with 35 percent of surveyed respondents saying that their company plans to deploy the technology in production within the next calendar year. And in January, it was announced that IBM Watson Health and the FDA inked a two-year agreement to jumpstart a research initiative aimed at defining a secure, efficient and scalable exchange of health data using blockchain technology. Specifically, IBM and the FDA will explore how a blockchain framework can potentially provide benefits to public health by supporting important use cases for information exchange across a wide variety of data types, including clinical trials and "real world" evidence data. 

With all this being said, it’s important to take a step back and realize that full scale development of blockchain applications in healthcare is probably a few years away. The sources I spoke to noted that buy-in from EHR vendors is not a given, trust issues will have to be worked out, and quite frankly, there needs to be more of an understanding about the technology’s many complexities.

To this end, that same Deloitte report revealed that across various sectors, many senior executives still know little or nothing about blockchain. The report implied that there seems to be a general feeling that organizations would be at a competitive disadvantage if they failed to adopt blockchain. But that really shouldn’t be reason enough to push forward; there needs to be a granular understanding of the technology. As KPMG’s Vickers said, “If I went out and asked my innovative CIO friends if they know about blockchain in the healthcare industry, eight out of ten wouldn’t know what I’m talking about.”

So in the end, while there are plenty of issues to be ironed out, it’s hard for me to be anything but optimistic on the potential of blockchain in healthcare. Now, in no way am I advocating for blockchain as the magic bullet to solve all of healthcare’s core problems—the biggest being that $3.36 trillion number of total healthcare spending in 2016. But if you’re telling me that it could be the fabric that ties existing data siloes together? In that case, sign me up.

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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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