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Survey: Infrastructure, Interoperability Key Barriers to Global HIT Development

February 16, 2018
by Heather Landi
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A new survey report from Black Book Research on global healthcare IT adoption and records systems connectivity finds nations in various phases of regional electronic health record (EHR) adoption. The survey results also reveal rapidly advancing opportunities for U.S.-based and local technology vendors.

Black Book, a New York City-based research firm, surveyed 7,469 physicians, health administrators, technology managers and clinical leaders in ambulatory and inpatient settings across 23 foreign countries to identify gaps, challenges and successes in healthcare IT adoption. In addition, 2,388 providers and regional healthcare delivery organizations also responded to questions on planned health IT acquisitions, budgets, timetables and vendor awareness.

The report, “State of the Global EHR Industry, 2018” projects that global healthcare spending on EMR/EHR technology to top $25.1 billion USD in 2017 and continue growing to over $30.2 billion by 2020.

According to the survey, 90 percent of international respondents indicated there is an enduring confusion on the definition of a highly interoperable EHR system outside the United States. The majority of respondents (72 percent) stated in 2017 that their regional preferable strategy for EHRs is to link disparate systems through messaging, APIs, web services and clinical portals. Only seven percent of all international EHR survey respondents described their regional HIT system as having "meaningfully connectivity" with other providers.

The survey results indicate a pending shift from siloed EHR systems for regions of healthcare delivery organizations in Europe, the Middle East and South Asia where nearly 57 percent of respondents anticipate a move to comprehensive healthcare IT systems with data exchange and care coordination capabilities similar to the global offerings of current U.S.-based vendors by 2023.

Over half of the total survey participants were sourced from 10 highly advancing HIT regions. Of those, five foreign countries—Norway, Netherlands, United Kingdom, New Zealand and Australia—are near 100 percent EHR adoption rates and evidence of extensive use of enterprise technology tools. And, the other five countries—Germany, France, Canada, Switzerland and Singapore—with over 75 percent provider adoption rates.

Countries were scored on ICT infrastructure, secure health networking, data storage and exchange capabilities, national health technology policy, available funding and protection of privacy. Among those regions with progressive EHR adoption initiatives but significantly lacking in a major component of readiness in Q1 2018 are Japan, China, Qatar, Brazil, Taiwan, India and Russia. All these regions received a majority (51 percent-plus) of provider feedback scores that indicated current infrastructure situations prohibit EHR adoption.

New Zealand and Denmark lead the list of countries deemed to have the highest potential for progressing EHR interoperability and expanded HIT functionalities beyond their local regions, according to the survey. The report ranks those countries in order: New Zealand, Denmark, Israel, Singapore, Netherlands, Germany, Hong Kong, Norway, Australia, Canada, Sweden, Finland, United Kingdom, Switzerland and France.

“A number of countries have launched national initiatives to develop ICT-based health solutions including EHR systems and have progressed well, despite several hurdles,” Doug Brown, managing partner of Black Book Research, said in a statement. “As the obstacles are clearing with technological and non-technological interventions, approved standards and regulatory frameworks, funding and health-tech guidelines, the growth opportunities for U.S.-based global EHR vendors magnify as well.”

Vendors were ranked on 18 key performance indicators with evaluation criteria concentrated on ambulatory EHR, inpatient EHR, interoperability and health data exchange, population health, care coordination and cybersecurity and privacy capabilities. According to the survey, 83 percent of current EHR users in Europe (outside of the United Kingdom) expressed significant frustration with country-specific and local vendors that typically serve only one country with limited components, such as coding, scheduling and results reporting. 

Of those current clients, 72 percent of respondents revealed those system limitations will lead to the replacement of their local and/or country-specific EHR with a global player to support their wider needs by 2023. 

"With several U.S. EHR-based vendors continuing to focus considerable resources toward global development technology efforts in advancing healthcare economies, it is critical that foreign governments and medical-delivery organizations match their specific needs, financial situation and timetables with vendors' product roadmaps as to not be swept away by a vendor's promises to selfishly gain global market share,” Brown said.

This investment on ICT infrastructure for healthcare technology is expected to propel double-digit growth of the electronic health records market spend in these specific regions through 2026.

The report also includes surveys of system users aimed to rate the performance of healthcare technology vendors on client experience and customer satisfaction in those respective locations. The report identifies the top-ranked vendors for 2018 by region. Allscripts was rated the top vendor within the regions of South Asia (Singapore, Philippines, Malaysia, Thailand, India) and the United Kingdom.

Cerner was rated the top vendors for the following regions: Oceania (Australia, New Zealand, South Pacific Islands); Middle East (Israel, UAE, Saudi Arabia, Kuwait, Qatar); Middle East (Israel, UAE, Saudi Arabia, Kuwait, Qatar).

System users in Nordic Europe countries rated InterSystems as the top vendor; while system users in Western Europe gave ChipSoft top ranking.

Orion Health was ranked as the top vendor in Canada, everis NTT Data as the top-rated vendor in Latin America (Brazil, South and Central America, Mexico); and in Greater China (China, Hong Kong, Taiwan), system users rated Neusoft as the top vendor.

“The global healthcare sector is undergoing a wave of transformation, with digitization being the core focus area of service providers,” said Brown. “Healthcare IT products, services and systems are in high demand in nations significantly upgrading their healthcare infrastructures such as Singapore, Israel, Japan and Italy, as well as infrastructure-generating nations of India, China, Brazil, Qatar and Indo

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Report: Apple in Talks with VA to Provide Veterans Access to EHRs

November 21, 2018
by Heather Landi, Associate Editor
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Tech giant Apple is in talks with the U.S. Department of Veterans Affairs (VA) to provide portable electronic health records (EHRs) to military veterans, according to a Wall Street Journal report published Tuesday.

According to people familiar with the effort and emails reviewed by WSJ, under the plans being discussed Apple would create special software tools allowing the VA’s estimated nine million veterans currently enrolled in the system to transfer their health records to iPhones and provide engineering support to the agency, the article says.

In January, Apple announced that it was launching a feature that allows consumers to see their medical records right on their iPhone and began testing the Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Since that time, more than 100 new organizations have joined the project, according to Apple.

According to the WSJ article, top VA officials, as well as associates from President Trump’s Mar-a-Lago Club, discussed the project last year in a series of emails reviewed by the Journal. The emails show how the Trump administration wrestled early on with the project’s goals, the article says. An Apple spokeswoman said the company has nothing to announced, according to the article.

Technology companies are looking to tap into the $3.2 trillion health care market. Google recently tapped Geisinger Health System CEO David Feinberg, M.D. to assume a leadership role over its healthcare initiatives. Amazon, JPMorgan Chase & Co. and Berkshire Hathaway have formed a healthcare joint venture and tapped Atul Gawande, M.D., as CEO of the initiative.

“The VA partnership has the potential to accelerate Apple’s efforts to overcome past challenges by allowing it to tap into one of the nation’s largest, concentrated patient populations,” the WSJ article states. To date, Apple has had to take a more patchwork approach, signing agreements with hospital networks and relying on them to encourage patients to import their medical records to iPhones using the new Health Records feature.

WSJ reporters Ben Kesling and Tripp Mickle wrote, “The company’s ultimate goal is to enable patients to import their records and share them with health-related apps, which would use data to provide services like automated prescription refills, according to people familiar with Apple’s plans.” Apple would take a 15 to 30 percent cut of those subscriptions as it does with most apps offered through its App Store, Kesling and Mickle wrote.

According to Kesling and Mickle , Apple first approached the VA in early 2017, citing a person familiar with the effort. Company and VA officials were excited about the project’s promise because it would allow true interoperability and portability of health data between doctors and software platforms, the person said, according to the article.

“Apple and the VA were developing the technology among a relatively small group of experts and officials, which required non-disclosure agreements, according to an email reviewed by the Journal from Darin Selnick, a senior advisor to the VA secretary at the time,” the article says.

Some of the early discussion involved Dr. Bruce Moskowitz, a doctor affiliated with Trump’s Mar-a-Lago golf club, who wasn’t a government employee and has no official role at the VA, the article says. “Dr. Moskowitz laid out a series of goals for the technology early in the process, including the ability for veterans to find a variety of health care facilities near them by using geotagging features and to quickly share test results and track prescriptions,” the article states.

Moskowitz also envisioned a system that would allow active duty troops to take advantage of the technology, another potentially massive patient base, the article says. At the time, VA officials stated in emails that they were most interested in focusing on doctor certifications, patient control of data and development of a suicide-prevention app, according to the article.

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VA, Cerner Leaders Detail Progress on EHR Implementation, Interoperability Efforts

November 14, 2018
by Heather Landi, Associate Editor
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The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.

The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.

Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.

During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.  

The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.

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In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."

However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”

It is estimated that up to a third of VA patients receive care in the private sector.

"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”

During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address.  “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.

John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”

Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.

“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”

Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.

There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.

An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.

In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”

In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.

Progress Made in the First 180 Days

During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.

Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”

Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.

“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”

 


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