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Research: Interoperability Focus Needs to Shift from Moving Data to Information Usability

October 3, 2017
by Heather Landi
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Hospitals’ progress toward interoperability is slow and that progress has mainly been focused on moving information between hospitals, such as sending and receiving data, and not on ensuring the usability of information in clinical decisions, according to research recently published in Health Affairs.

In the paper, Julia Adler-Milstein, Ph.D., an associate professor of medicine in the School of Medicine at the University of California, San Francisco, and her colleagues, A Jay Holmgren, a doctoral student in Health Policy at Harvard Business School and Vaishali Patel, a senior advisor of planning, evaluation and analysis at the Office of the National Coordinator for Health Information Technology (ONC), sought to track progress in hospitals’ interoperability engagement at the national level.

In the paper, titled, “Progress in Interoperability: Measuring US Hospitals’ Engagement in Sharing Patient Data,” the researchers note that achieving “widespread interoperability” by 2018 has been declared a national objective, however, as of 2014, only about one-fifth of U.S. hospitals were engaged in all four of its primary domains—electronically finding, sending, receiving and integrating information into electronic health records (EHRs).

The researchers note that research may show that hospitals are making rapid progress, as new technologies and policies make it easier for them to engage with interoperability domains. “However, it is also possible that the one-fifth of hospitals engaging in the four primary interoperability domains included a unique set of early adopters and that remaining hospitals are moving slowly because of limited health information technology (IT) capabilities or weak incentives to share patient data,” Adler-Milstein and colleagues wrote.

Tracking interoperability over time is critical to informing a wide array of existing public- and private-sector efforts to ensure that EHRs across the United States will give providers access to complete clinical patient information. In particular, new policies such as the 21st Century Cures Act of 2016 seek to encourage data sharing in a variety of ways, and tracking hospitals’ engagement with interoperability is critical to guiding the implementation of this legislation,” the researchers wrote.

The researchers used data for 2014 and 2015 from the IT Supplement of the American Hospital Association Annual Survey based on responses from 3,538 hospitals. The study look at the four domains of interoperability, finding data, sending data, receiving data and integrating data, yet the researchers noted that integrating patient information from outside sources is the “key capability that separates interoperability from health information exchange (HIE),” or the integration of information into the EHR without manual effort. The researches also examined whether providers in a hospital routinely had electronic access to clinical information from outside sources and used that information for patient are.

Looking at the study results, fewer than 30 percent of the nation's hospitals (29.7 percent) completed all four pillars of information sharing in 2015, up from 24.5 percent in 2014 (or an increase of only 5.2 percentage points). The level of hospital engagement increased in three of the four domains but remained almost unchanged in integration.  “This is substantially slower than the annual rate of national hospital EHR adoption over the past five years, which suggests that existing policy efforts have stimulated interoperability engagement only modestly,” the researchers wrote.

The fact that engagement in one domain, integration, was stagnant over time is a concern because integration is critical to data usability, the researchers noted.

In 2015, 43 percent of hospitals reported that they had outside clinical information available electronically when necessary and 19 percent of hospitals reported that they used this clinical information for care delivery “often." Further, 29 percent of hospitals reported using outside clinical information “sometimes,” 18 percent reported using it “rarely” and 19 percent “never” used it. The researchers concluded that 35 percent of hospitals reported that information was available electronically and used it “often” or “sometimes” in the delivery of care.

The fact that almost half of hospitals have outside clinical information available is an encouraging development, the researchers note, yet there is still much room for progress.

Among hospitals that reported that they “rarely” or “never” used information received electronically from outside sources, the most commonly cited barrier (49 percent) was the fact that clinicians could not view the information in the EHR as part of their workflow. Other barriers included difficulty in integrating information into the EHR, not having the information available when needed, and not having it presented in a useful manner, the researchers wrote.

The findings also shed light on how different health IT capabilities may be supporting hospitals’ engagement in different interoperability domains. The researchers noted that while having a basic EHR system was associated with engagement in finding, sending, and receiving information, only having a comprehensive EHR system was associated with the integration of information without manual intervention.

The study also found that hospitals that were part of a health care system, privately owned and for profit, and specialty hospitals; and those that participated in a patient-centered medical home (but not an ACO) were all more likely to have outside information available and use it in patient care.

The study findings indicate that integration is a more difficult function and only the more advanced EHR systems support this functionality. Similarly, having a third-party HIE vendor and participating in a regional health information organization were positively associated with finding, sending and receiving, but not with integrating information. Overall, the findings reveal that existing health IT infrastructure has primarily focused on how to move information between hospitals, not on ensuring that the information can be integrated, which is critical for information usability, the researchers wrote in the study.

“A key enabler of integration appears to be using the same vendor for EHR and HIE, which avoids the complexity associated with integrating external information received from a third-party intermediary, and likely explains the growth of EHR-vendor HIE networks,” Adler-Milstein wrote.

In conclusion, the researchers contend that the study findings underscore the need to shift the policy focus from transmitting information to information usability. “A greater policy focus on integration, rather than on the sending and receiving of data, may help shift hospitals’ focus to making data available at the point of care when it is clinically relevant,” Adler-Milstein and her colleagues wrote. “Policy interventions, such as those in the recent 21st Century Cures Act, should therefore focus on ensuring that all hospitals are incentivized to pursue robust interoperability, with a particular focus on integration, to realize the cost savings and quality improvements that are expected to follow.”

The hospitals in the study were predominantly small (52 percent) or medium-size (42 percent), located in an urban setting (65 percent), and privately owned nonprofits (55 percent). Nearly a quarter participated in an accountable care organization (24 percent) or patient-centered medical home (23 percent), while 10 percent participated in both.

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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. 


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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