At iHT2 Boston, Micky Tripathi's Refreshing Take on Interoperability | Rajiv Leventhal | Healthcare Blogs Skip to content Skip to navigation

At iHT2 Boston, Micky Tripathi's Refreshing Take on Interoperability

June 28, 2016
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During a closing keynote presentation last week at the iHT2 Boston Health IT Summit, Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative (MAeHC), debunked certain healthcare interoperability “myths” while offering a positive outlook on the future of data exchange.

The event, from the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella), took place at the Aloft Seaport Hotel in Boston on June 23-24, and closed with Tripathi’s Friday keynote on healthcare interoperability.

In addition to his role at MAeHC, a collaboration of Massachusetts provider, payer, and purchaser organizations, Tripathi wears various of other health IT hats: he is chair of the Information Exchange Working Group and co-chair of the Privacy and Security Tiger Team (both of the federal Health Information Technology Policy Committee), a director of the New England Health Exchange Network (NEHEN), and a director and past board chair of the eHealth Initiative. Simply put, when it comes to interoperability and standards, no one in health IT is better well-versed than Tripathi. I compare it to the NBA, when players who consistently can score the basketball are labeled “go-to guys.” For healthcare, Tripathi is the go-to guy for all things interoperability.

Tripathi opened his presentation by asking two questions to the room full of attendees: first, if they believe information blocking significantly exists in healthcare; and second, if they think that the healthcare sector is woefully lagging behind other industries in terms of being interoperable. Predictably, the majority of hands raised in affirmation to both questions. Knowing this would be the likely answer to his two questions, Tripathi moved on in an attempt to debunk these “myths.”

Indeed, looking at other industries, Tripathi noted how he gets Google Calendar invites all the time that don’t sync well in Microsoft Outlook. Or, he said, books purchased at Barnes and Noble don’t play on the Amazon Kindle. He gave several more examples of how in other businesses, companies don’t always “play nice” with one another: Apple isn’t interoperable with anyone; Netflix and Verizon recently had a fight about who should pay for the infrastructure for Netflix consumers, resulting in poor streaming quality; Fitbit has said that it’s not connecting with Google Fit, choosing to create its own network; and finally, consumers can no longer use another coffee cup in a Keurig anymore.

“Interoperability problems are rampant across all industries, public safety included,” Tripathi attested. “I'd argue that [these examples] are no different than what's happening in healthcare. In some ways, since we have higher expectations in healthcare, we are actually doing better. We need to exchange data; other industries might not have to.” Tripathi then touched on how these interoperability issues get “resolved” in other industries, offering the example of universal product codes (UPC) in grocery stores that adopted them after having problems with inventory control. “Grocery stories created UPCs with a bunch of other grocery stores and vendors. They wanted to all purchase the same machines and get value from them,” Tripathi explained.

Thus, as HIE [health information exchange] matures, it is starting to organize itself like other industries, Tripathi said. Now the question becomes, how are these data exchange networks going to form? The early notions were of a single, federal top-down network, and that collapsed as an idea. But now, networks are starting to form, he said. “It’s not about connecting an EHR [electronic health record] to an EHR, but about being a part of a network and connecting a network to a network. That's how the rest of the economy has solved the issue in literally every instance.”

Tripathi pointed to several examples of separate networks forming and connecting in healthcare today. He brought up the eHealth exchange for government data, the Mass HIway for local, state-based, lightweight exchange in Massachusetts, Surescripts, for e-prescribing, DirectTrust for secure email, and Carequality as an emerging framework that allows query-based exchange among different participants. “We have so many different ways to communicate with one another based on the kind of communication we want, so we have different networks—just like any other industry. The original notion was to have one way of health information exchange, but there are very few examples where that has worked,” Tripathi said.

He continued, “What type transaction do you want to make? DirectTrust is nationwide interoperability of secure email, and it doesn’t do anything else. But it's something that has been carved out from the broader picture.” This is different than the all-or-nothing approach, or “HIE 1.0,” in which data would be dumped into a repository for everyone to be able to use for multiple purposes, Tripathi said.

Tripathi then noted how the marketplace is just beginning to see solutions for point-to-point query exchange, so a provider can query someone else’s system to get a record document, and then query another system. Carequality and CommonWell are starting to solve this problem, Tripathi said, adding that pretty much every major vendor except Epic, NextGen and GE are on board. And regarding Epic’s exclusion in these interoperability frameworks, Tripathi reminded folks that while there is not yet interoperability between CommonWell and Epic (Epic’s Care Everywhere product is for Epic users only), looking at other industries as a precedent proves that it will eventually happen in healthcare, too. “These are the beginnings of a nationwide network to solve the point and retrieve issue,” he said.

FHIR is Just a Standard

While Tripathi repeatedly pushed the idea that healthcare is not as in much trouble as people like to say in terms of it users’ ability to exchange data, he did caution that the FHIR (Fast Healthcare Interoperability Resources) standard, while certainly a big part of health IT’s future, is not the magic bullet to solve all interoperability problems. “Have we hit the peak of the hype curve?” Tripathi asked. “FHIR is being talked about as the universal magic bullet. I am amazed by the hype of it. People are looking for an answer, and need a magic bullet,” he said.

But more than that, FHIR is a genuine data-level interface that allows a provider to ask another provider just for allergies for patient X, for example, Tripathi added. Right now, he noted, a provider might receive an entire C-CDA (consolidated-clinical document architecture) document even though he or she just needed the allergies. “With FHIR, you can say ‘here are the allergies.’ So that's why there's excitement around it. It gets us closer to the data integration goal that we all want.”

Nonetheless, Tripathi referenced a KLAS interoperability survey from last fall which found that FHIR was the top thing people were excited about. “But I'd bet that 90 percent of those people can't tell you much about FHIR at all,” he estimated. “I'm a big proponent of FHIR, but people will realize that it's just another standard, and it won't solve problems like money, legacy systems, and things like that.”

Tripathi is the project manager of the Argonaut Project—an initiative launched by Health Level Seven International (HL7) to accelerate the development and adoption of FHIR— where leaders there are currently writing app-enabled implementation guides in which a person would be able to take a mobile app or host of applications and be able to have those apps connect in a seamless way. That's the hope of FHIR, and it’s based on RESTful application program interfaces (APIs), which the rest of the Internet is based on, Tripathi noted. “Once you base it on something like that, you bring in a lot of other brains that are willing to experiment. There is a whole economy of developers out there right now that don't want to enter healthcare world because they think standards we use are 25 years old. And they're right.”

One of FHIR’s challenges, Tripathi continued, is that a whole ecosystem has to form. “People get excited about the notion of having apps and just connecting them. Providers want the apps, and EHR vendors also like the idea of apps because they can't keep up with the demand,” he said. “Medicine is way too complex, so a Cerner or an Epic can't implement those things. So they like idea of plugging your app into their system. But an ecosystem needs to form around that. How does that work?” He mentioned the Apple store or the Google Play store which act as intermediaries where a user can go find those apps, following basic usability and quality principles, and some security principles. But Tripathi wanted to know where this happens in healthcare and who will ultimately step up to the plate.  

He added that there are several options of how this can occur in healthcare, and who the app store pioneer will be is still up for debate.  Possibilities, according to Tripathi, include: Geisinger or a similar health system; major EHR vendors; a third-party company; or the SMART (Substitutable Medical Applications & Reusable Technologies) on FHIR app gallery, which as of today, is the closest we have come to a vendor-neutral app environment. That could be the place that becomes trusted first, Tripathi acknowledged. However, the one organization that the industry cannot afford to do it is the federal government, he said. “There was talk about it, but we absolutely don't want that. That can go down a bad path, and really quickly.” Tripathi himself is betting on EHR vendors and provider organizations who will lead the way.

Certainly, listening to Tripathi’s keynote was particularly fascinating for me, since I’m mostly told how it will be years before we see true interoperability in healthcare, an opinion that was hammered home at a recent iHT2 event in April. To this end, I wrote a blog earlier this month about how 2015 data exchange numbers amongst U.S. hospitals—particularly the ability of providers to perform all of the core functions of interoperability—were nothing to write home about.

It’s certainly possible that it will take five to 10 years, or perhaps even more, for healthcare interoperability to catch up to other industries. But I don’t think that was Tripathi’s point with his keynote last week in Boston. Rather, he wanted to call out the improvements that we have seen over the years, and prove that healthcare is far from the only sector with system connectivity problems. It was extremely refreshing to hear Tripathi’s expert and balanced take on the topic. Once again, healthcare’s interoperability “go-to guy” delivers.

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Intermountain CMIO Stan Huff on the Need for Greater Interoperability: “We’re Killing Too Many People”

December 6, 2018
by Rajiv Leventhal, Managing Editor
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About 250,000 people die per year due to preventable medical errors, and that’s the biggest motivator there is for more advanced interoperability, says one clinical IT leader

Stan Huff, M.D., chief medical informatics officer (CMIO) at the Salt Lake City, Utah-based Intermountain Healthcare for the past 31 years, has long been a top leader in his field. Working on the leadership team for a health system like Intermountain and serving as a co-chair of the HL7 Clinical Information Modeling Initiative (CIMI), while also having been a former member of the ONC Health IT Standards Committee, Huff has a wealth of knowledge coming from both provider- and standards-focused perspectives.

Huff, who represented Intermountain at a White House meeting on interoperability this week, recently chatted with Healthcare Informatics about all things interoperability, including the different types of data exchange that exist today, the greatest barriers, and how potential pending regulations could shake up the landscape. Below are excerpts from that discussion.

When you look at the interoperability landscape today, how bullish are you on where things stand, broadly speaking? Or rather than bullish, are you more concerned?

I don’t know if I am bullish or not, but I think we are making progress—and it’s significant progress. There is an incredible amount of work to be done. I’m not concerned at the progress; I am happy, but mindful of how much work is left to do to really reap the benefits that people are hoping for.

You’re currently a co-chair of the HL7 Clinical Information Modeling Initiative while also having been a member of former the ONC Health IT Standards Committee. How important is it to figure out the issues around standards before things can progress?

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I wish it had a higher priority. Most of the time when people are talking about interoperability now, they are thinking about caring for an individual patient and thinking about sharing information between different systems that have information on that patient. They are usually thinking about EHR [electronic health record]-to-EHR for patient care—they have a very focused idea.

But there are other dimensions. There is interoperability relative to public health, meaning how we share data from an organization to a public health [entity] so that we understand what’s going on with a whole population relative to a particular disease.

There is also research interoperability, so we can share data that’s coming from research activities. And closely related to that is interoperability of clinical trial data and all of the randomized controlled trial data that comes with that.

Then there is interoperability that comes from devices and data coming from devices, which is a whole field onto itself. So you have to be careful when you talk about interoperability. This is one axis of interoperability, in that it has to do with the scope of systems you are communicating with.

The other axis of interoperability has to do with how truly interoperable you are, and there are different levels there as well. One level is the interoperability you get with the HL7 version 2 [standard], where you have a structure and people know how to send messages between systems. And there is a lot of negotiation that happens when you set up an HL7 version 2 interface to say what terminology you are using, and if you send something as two fields or one field. There is a lot that goes on there and that’s helped quite a bit when you talk about HL7 FHIR [Fast Healthcare Interoperability Resources]—it has a more defined structure and has more things specified about terminology use.

And then you can get an even better of interoperability if you are using the Argonaut [Project] profiles. But even at that Argonaut profile level, you aren’t plug-and-play interoperable. There still is ambiguity in the Argonaut definitions that lead to different implementations by different companies and organizations.

The highest level is what I would call “plug-and-play” where this no bilateral negotiation around terminology or anything like that. The standard is explicit enough so that it could be tested for conformance and you can say whether a given system is conformant or not, and the data can be used in the way it was intended. We don’t have any plug-and-play interoperability to speak of right now, and that’s what I’m trying to shoot for.

One of three biggest motivators for me is patient safety. There is really good and convincing data that shows we are killing 250,000 people per year due to preventable medical errors. And that won’t be solved by “zero harm” programs, or by “sort of” interoperable systems. In the end, the “sort of” interoperable systems means that a person still has to look at things and make a judgment. And people are not perfect information processors. So you need a situation where the data is explicit enough where I can write rules that prevent the death or improper treatment of patients.

And we are not at that level yet. How urgent is it? I think it’s incredibly urgent and you can make an argument that it’s more important than lots of other things we’re spending money on that would have less of an impact on patient care. I work in this area, so yes, I am biased.

But I’m persuaded that it’s worth an investment, and to get to where I want to get to will not be easy. This won’t be something where you make one $20 million investment and then it’s done; it will take five or 10 years, and you will make incremental progress over that period of time. Think of it like a military campaign or a crusade, because it’s that type of timeframe and scale where you need planning and infrastructure to really accomplish what we want to do in the end—which is save lives, decrease the cost of care, and reduce the burden of clinicians.

Many folks believe that until the business incentives change, stakeholders will not be incentivized to be open with their systems. Do you agree with this and how much incentive exists today?

There isn’t a whole lot of incentive yet. If the patient care and safety issues were sufficient enough incentives, then this would have been solved a long time ago because those incentives have been there. People know and understand that we’re not caring for patients in the best way possible. And it’s the financial and proprietary considerations that keep us from doing that, ultimately.

We have to be careful [with incentives] though, because there are unexpected consequences. Going back to when I was on the HIT Standards Committee, we thought that we were doing useful and good for U.S. healthcare when we set up the meaningful use measures. And while meaningful use solved the EHR adoption issue, what it taught people was how to manage measures but not manage quality.

People became incredibly good when it came to managing the measures to get paid and to meet the qualifications, but I don’t think anyone would assert that those things improved the quality of care in any measurable way. So I think we didn’t meet the goal that we were shooting for—providing better quality care at a lower cost.

The ONC annual conference took place last week, and there seemed to be significant conversations around pending regulations such as possibly making interoperability a requirement to stay in Medicare and prohibiting information blocking. How does all of this land for you?

I welcome the change; it’s a good as thing you move from meaningful use to promoting interoperability. What I don’t know is if these specific [rules] being proposed are going to accomplish what [we want]. We thought we were doing the right things back when we were doing meaningful use.

At a high level, I would agree that it would be wonderful to require interoperability as a requirement for Medicare participation. But it’s undefined. When talking about the dimensions and these things, there has to be an understood and a useful level for the interoperability that’s required. But I haven’t seen the details to know whether what’s being asked for is both achievable and valuable if it were to be achieved. But I do agree with the [overall] direction.

Intermountain is often at the forefront of health and health IT initiatives such as its sponsorship of the Opioid Community Collaborative. How can these learnings be shared so they can improve the digital healthcare ecosystem?

The thing I try to emphasize to people is that if you look at what we are doing, and you take it in aggregate across the country—the things people are applying decision support to—it’s a tiny part of what we could do. And the reason for that is we don’t have interoperability. You can create a good program at Intermountain, or at Kaiser Permanente, or at Mayo Clinic, but the only place it works well is where it was developed. You cannot move it. If you move it, you have to recreate it. Until you have interoperability, I can’t write a rule that works on top of a Cerner system and also on an Epic system, or for that matter works on two different Cerner implementations. This cannot happen until you have those platforms supplying APIs so I can hook my decision support up to their system without rewriting all of the logic in a different technology platform.

So we are doing good things, and want to continue to do good things, but wouldn’t it be wonderful if what we did, or what the University of Utah is doing with opioids, can be directly moved and used, in the same way people can buy apps for their iPhones in the app store, or any other platform.

The realization is we might be doing 150 things at Intermountain in terms of decision support applications, but there is an opportunity to do 5,000 things, and we will never get to those 5,000 things unless we get to an interoperable platform so that when knowledge is created it can be shared. That’s my real emphasis behind interoperability.

 


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KLAS: EHR Vendors Making Significant Progress with CommonWell, Carequality Connection

December 4, 2018
by Heather Landi, Associate Editor
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While most EHR vendors have connections to the national network, only athenahealth and Epic customers have connected en masse, KLAS reports
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With the establishment of connectivity between CommonWell and Carequality, announced back in August, as well as other interoperability advancements by electronic health record (EHR) vendors, the ability to exchange patient records is within the reach of most acute care or clinic-based provider organizations, regardless of size or financial situation, according to a new report from Orem, Utah-based KLAS Research.

In the report, “Interoperability: Real Progress with Patient Record Sharing Via CommonWell and Carequality,” KLAS researchers note that since the last KLAS report on interoperability, which was published in March 2018, the acute care/ambulatory EHR market has taken critical steps forward in sharing data via national networks. The most notable advancements include the establishment of the CommonWell-Carequality link, Meditech’s initial connection to CommonWell, and notable Carequality adoption among NextGen Healthcare customers, according to KLAS researchers.

Most of the prevalent acute care/ambulatory EHR vendors are connected to the national framework, marking significant progress for interoperability, according to KLAS researchers. The report findings come a few weeks after CommonWell and Carequality announced that the connection to the Carequality framework was “generally available.” Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, CommonWell officials said.

In August, CommonWell Health Alliance and Carequality announced initial connectivity, which is the beginning of a broader effort to increase health data exchange nationwide, and builds on an announcement made almost two years ago. In December 2016, CommonWell and Carequality announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past year and a half, teams at both organizations have been working to establish that connectivity.

Now, since the connection went live in July, officials noted that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide, as reported by Healthcare Informatics in November.

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CommonWell, an alliance formed five years ago, operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Major vendors connecting to CommonWell include athenahealth, Cerner, CPSI, eClinicalWorks, Greenway Health and Meditech.

Meanwhile, Carequality, an initiative of The Sequoia Project that launched about a year later, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. Vendors using Carequality include athenahealth, Epic, eClinicalWorks and NextGen Healthcare. Nearly all major EHR vendors have aligned with one or both of these options, according to KLAS.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. Today, more than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network, officials attest.

This latest KLAS interoperability follows a report back in March in which KLAS researchers positioned that the CommonWell Health Alliance’s interoperability efforts were hindered by a lack of provider adoption and its interoperability services currently lacked value. However, when CommonWell and Carequality eventually connect, “instant value” will be created for users, KLAS researchers attested in that report.

Currently, Epic is not a member of CommonWell, despite other major EHR vendors pushing them in that direction. Back in 2015, athenahealth CEO Jonathan Bush famously tweeted to Epic’s CEO Judy Faulkner that his company would pay for Epic to join.

Indeed, KLAS reported in March that CommonWell will likely see a significant adoption increase with a solid Carequality connection. “Since its launch five years ago, the tendency to over-market the level of adoption of CommonWell has created apprehension and a lack of trust among potential participants and prompted this report, showing a snapshot of providers’ success,” the researchers said in the March report. KLAS researchers also claimed that when CommonWell connects to Carequality, “the entire Epic base will become available, creating instant value for most areas of the country.”

Following the publication of that report, CommonWell’s Executive Director Jitin Asnaani, in an exclusive interview with Healthcare Informatics, defended his organization’s mission and attested that the network is continuing to grow and prove its worth.

Asnaani also critiqued the KLAS report’s claim that vendors such as athenahealth and Epic give their customers a head start by enabling plug-and-play data sharing via Carequality. Asnaani called this specific critique “totally bogus,” asserting that the quality of data sharing is dependent on the vendors rather than dependent on CommonWell or Carequality.

KLAS Assessment on the Progress of CommonWell-Carequality Connection

In this latest report, KLAS researchers focused specifically on the progress EHR vendors have made in sharing patient records via the standardized (plug-and-play) networks of CommonWell and Carequality.

KLAS researchers assert that this focus is important because the “plug-and-play” option is the “only option” that allows provider organizations “avoid significant costs, delays, and organizational workload.”

KLAS also acknowledged that “virtually all major EMR vendors can successfully share patient records through the traditional point-to-point connections (a costlier approach in terms of time, resources, ongoing maintenance, and money), local HIEs (health information exchanges) and direct exchange (where records are manually sent to other providers).”

Referring to the CommonWell-Carequality connectivity as the “connection heard round the U.S.,” KLAS researchers contend that this connection should be “key in driving value and opening the floodgates so that any provider organization that desires to can exchange patient records with relative ease and little cost.” KLAS plans to measure the impact of this sharing in a 2020 interoperability report.

According to the report, this fall, two CommonWell-connected Cerner organizations tested and validated the ability to connect with Epic sites via Carequality. “Their initial reports are that the connection enables data sharing with critical partners otherwise out of their reach and adds tremendous value to their existing CommonWell exchange. The Epic sites involved indicate that they also are able to see and consume data via the new connection,” KLAS researchers wrote.

In a blog post, KLAS researcher Corey Tate, the author of the latest KLAS report, reiterated the value of the CommonWell-Carequality connection with regard to the availability of Epic data to provider organizations who connect. “Access to the Epic data is exactly what was talked about by the initial sites that tested the CommonWell connection to Carequality. Ironically enough, Epic’s intra-operability, which was initially dismissed, will likely be the catalyst that pulls widespread patient-record sharing forward. “

Currently, all but two of the other major EHR vendors—athenahealth, Cerner, CPSI, eClinicalWorks, Epic, Greenway Health, MEDITECH, NextGen Healthcare, and Virence Health (formerly GE Healthcare)—have customers connecting, according to KLAS. At this point, Allscripts and MedHost have yet to connect to CommonWell or Carequality. However, Allscripts recently announced more solidified plans to have their Carequality connection ready in Q1 2019 and to then roll it out in product updates throughout the year, according to KLAS. MedHost has been aligned with CommonWell since 2014 but has yet to have any live connections, KLAS researchers state.

While all of these vendors have connections to this national network, only athenahealth and Epic customers have connected en masse, according to Tate, in his blog post. “Each vendor has more than 90 percent of their customers connected. Cerner is next at around 35 percent. Many other vendors’ customer bases are just getting started,” Tate wrote.

“Epic and athenahealth have near complete uptake among their customers, allowing them to work on the next steps for interoperability, such as fine-tuning usability and increasing value for clinicians,” KLAs researchers wrote in the latest report. The researchers noted that plug-and-play sharing is “virtually invisible and automatic” for athenahealth and Epic customers, and “both vendors remove the big obstacles” to providers’ success.

KLAS researchers also highlight Epic’s and athenahealth’s approach to facilitating participation, via an opt-out approach, and removing governance barriers, via predetermined handling of outside data. The researchers contend that this indicates that “regardless of customer size, vendors can facilitate widespread adoption if they choose.”

NextGen Healthcare and eClinicalWorks show the most notable progress in connecting to the national framework, according to KLAS. Since NextGen Healthcare made their bidirectional connection available in Q1 2018, customers have rapidly taken up connections to Carequality. “With 80 customers connected, there is still much room for additional uptake—though NextGen has removed both financial and technical barriers to make this a reality. eClinicalWorks customers have also rapidly taken up connections, with nearly triple the number participating today (~2,500) compared to March 2018,” according to the report.

Meditech also made their first connection to CommonWell, and CPSI has made notable progress this year as well, KLAS reports. Cerner continues to actively push for customer participation and has added 35 hospital customers.

“Virence Health (GE Healthcare) has been slower to get out of the gate despite good feedback from early adopters,” the KLAS researchers wrote. “Greenway Health also doesn’t have much momentum, and overall, interviewed Greenway organizations are the least excited about their CommonWell connection.”

KLAS researchers also note that with CommonWell and Carequality linked, the biggest technical obstacle to widespread patient-record sharing has been removed, and the biggest remaining obstacle is local community adoption. “The healthcare industry is rapidly approaching the point where an organization using any of the major acute care/ambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort,” KLAS researchers state. “Many vendors have eliminated obstacles on the path to data exchange—all but Virence offer connections to customers at no cost, and all but Cerner have made this plug and play by removing technical barriers.”

“Today, the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate. Even Epic and athenahealth customers report diminished value from their connection when local exchange partners opt not to connect to the national networks,” KLAS researchers wrote in the report. KLAs also believes that until other vendors take an opt-out approach, provider organization leaders will need to be proactive in promoting local connections to the networks to ensure high value from the connection.


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5 Lessons Learned Implementing SMART on FHIR at Intermountain

November 26, 2018
by David Raths, Contributing Editor
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Challenges include differences in vendor implementations of FHIR and their data models

During a recent eHealth Initiative webinar, Laura Heerman Langford, Ph.D., R.N., a nurse informaticist, detailed some lessons learned implementing Smart on FHIR apps at Intermountain Healthcare. Because FHIR is still under development, “we are driving the car and changing the tires at the same time,” she said.

She began by noting that the Salt Lake City-based health system believes its investment in FHIR-based Innovations will help it tackle important problems for which native EHR functionality has proven inadequate.

Today we have a lot of direct interfacing between applications and EHRs, she said, “but we have a vision of tomorrow that is much more plug and play. Imagine if it didn’t matter what vendor you were using in your hospital. Imagine if you had a healthcare app store where you could reliably find an application to help you accomplish what you want to be doing.”

As an example of where it hopes to make progress, Heerman Langford spoke about Intermountain’s work on clinical decision support. Intermountain has decision support modules on topics such as ventilator weaning, MRSA monitoring and control, and infectious disease reporting to public health.

 “At Intermountain we have upwards of 150 decision support rules or modules,” she said. “But we have only picked the easy stuff – things that are low cost to implement or easy to do. There is a lot more we would like to do. We have estimated that there are 5,000 more decision support rules or modules we could be doing to help our clinicians provide better care. However, we have not found a good way to get from the 150 we have to that 5,000. We are looking at how to fundamentally change the ecosystem for healthcare IT.”

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Intermountain, which has 23 hospitals and more than 185 clinics, has a strong history of innovation in informatics. A few years ago, it began work on an implementation of Cerner, labelled iCentra.

In its contract with Cerner, Intermountain made clear it wanted to create an ecosystem that could allow it to have open-standards-based application programming interfaces (APIs). Around the time Intermountain was partnering with Cerner, SMART on FHIR was launched.

“We have integrated SMART apps into iCentra, some of them based on the demand of clinicians,” Heerman Langford said. “We included three SMART on FHIR apps and we have a fourth one in development. We have been able to share enhancements with other organizations with different EHRs.” Intermountain also has a SMART on FHIR sandbox development environment.

One example she described is a Pediatric Growth Chart App first developed by Boston Children’s Hospital. “This was desired by our clinicians because they felt it was better than what Cerner had to offer,” she said. It provides a visual display of a patient’s growth data against an appropriate cohort. “We integrated it into iCentra, using data from our EHR, such as height, weight, head circumference and BMI. We currently have it in all our NICUs and pediatric clinics and replaced the Cerner module with it. It offers a very concise, interactive view. It was more palatable to our clinicians. It offers printouts to give to families and parents.”

Heerman Langford gave a few more examples of SMART on FHIR apps from the University of Utah. One is a Neonatal Bilirubin App that pulls in a baby and mother’s EHR data. It has near-universal use in the inpatient setting. “They are estimating that it saves up to 300 physician hours per year,” she said. Another is a Procedure Capacity Management App that provides calendar visualization of capacity vs. scheduled procedures. It facilitates efficient capacity management and supports post-surgical care transitions. It is one of ONC’s High-Impact Pilot Projects.

Then Heerman Langford laid out some of the lessons learned implementing these apps.

1. The first is that although EHR vendors do provide a fairly extensive set of FHIR resources they are still somewhat cautious and conservative at this point. “They are not exactly sure how much this is going to catch on and how much they should be putting toward this,” she said. “They are paying attention. They are doing it, but not as much as we would like to see.”

2. Health systems need support for additional use cases, specifically around “write capability,” she said.  “That means if I create something in a SMART on FHIR app, I could write back to the EHR. That is one of the hardest things to do right now.”

3. Health systems still need some more expertise related to the EHR vendor data. “When we are working with Cerner data, and this is true with different vendors as well, app developers are not always sure where the data is, what they call it, and whether you are going to get back what you asked for,” Heerman Langford said.

4. There is a lack of specificity in FHIR Resources, she said. “We know that FHIR Resources need to be profiled, but the US Core FHIR Profiles have not been enough. We need to do more work on the terminologies.” Another issue is single patient/subject queries vs. working on population-based queries. “We need single patient data, but population-based data is just as important,” she said.

5. Differences in vendor implementations of FHIR and their data models creates challenges, she said.  For example, with the term suspected lung cancer, each of those elements can be stored on its own: cancer, lung, and suspected; or they could be coordinated in different ways such as suspected cancer, body site, lung. “We are running into this as we are implementing Smart on FHIR apps within the EHR. The apps may prefer it one way, but you get into the EHR and they have their way of presenting it.”

Other issues are more cultural than technical, she said. “Healthcare organizations are very much looking at their own organization. In order to make a lot of this work, we need to promote collaboration among different organizations,” Heerman Langford said.

She stressed that open source apps are not free. “It does take time, energy and investment to get them to work in your local institution. But we do believe that the more we do this, the less expensive it will get over time.”

She called this movement the real beginning of the learning healthcare system. “The prospect of this new ecosystem to support our vision is real and is worthy of investment.”

 

 

 


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