The Value of Interoperability Adele Allison, Director of Provider Innovation Strategies

October 7, 2015

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2

Disclaimer

The Value of Interoperability

• Activity

• Building Blocks

• Use Cases

• New Developments

• Questions

Interop and Workflow Redesign

4

Use Technology as a Change

Agent!

The Marshmallow Challenge

• Team-up and get 1 Kit:

• Build the Tallest Freestanding Structure

• The Entire Marshmallow Must be on Top

• Use as Much or as Little of Kit as Desired

• Break-up the Spaghetti, String or Tape as Desired

• You have 10 Minutes

The Rules

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Classroom Timer

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Ta-Da!

Lesson 1

Prototyping Matters!

− Worse Performers?

− Best Performers?

− Why?

Business School Graduates!

Kindergarten Graduates!

……………………………..

0 10 Orient Plan Build

……………………………..

Source: www.MarshmellowChallenge.com

Oh-Oh!

Iterative Design Process

Lesson 2 Diverse Skills Matter

Source: www.MarshmellowChallenge.com

0

10

20

30

Height (Inches)

Average Business Students

Lawyers Kinder- garten

Architects & Engineers

CEOs CEOs & Exe-cutive Asst.

Spec. Skills + Facilitation Skills = Success!

Lesson 3

• Incentives Magnify Outcomes

• 60% Build Standing Structures

• Add Incentive Alone?

• 100% Failed

• Add Incentive with Value of “Prototyping” and Skills?

• Conversion from “Worst” to “Best”

• Incentives alone are NOT sufficient →

Must pair with good skills (E.g.,

Specialists or Facilitator) and

knowledge

Source: www.MarshmellowChallenge.com

Incentives + Prototype + Skills = ↑ Success

In the End – Every Project has its own Marshmallow!

The Value of Interoperability

• Activity

• Building Blocks

• Use Cases

• New Developments

• Questions

• Narrative Text − Examples: Cut/Paste Dictation, Voice Recognition, Typing

− Pro: Personalizes patient encounter information, “Say it the way you want”

− Con: Not machine readable, no conducive to research and reporting

• Structured, User-Defined Fields − Examples: Customizable Drop-down Lists

− Pro: Customizable, reportable within organization

− Con: Not conducive to aggregated research and reporting

• Codified, Object-Oriented Data − Examples: ICD, CPT, SNOMED, LOINC

− Pro: Machine readable, consistent across country or world, very

researchable and reportable

− Con: Rigid structure, hard to personalize to individual patient

3 Essential Types Of Data Capture

Machines Read in Code

23

• Definition: − Standardized, machine-readable

terms

− Describes clinical problems,

procedures and other information

− Coded for easy comprehension

and consistency

Meaningful Use Defined

Vocabularies/Code Sets

Best Practice: Use codified

data capture for reporting

Block 1: Vocabulary and Code Sets

24 Adapted from HHS Interoperability Basics at

http://www.healthit.gov/public-course/interoperability-basics-training/HITRC_lsn1069/wrap_menupage.htm

Code Sets Used to Define …

OMB Standards

Race, Ethnicity

ISO 639-2 Alpha-3

Preferred Language

SNOMED CT Smoking Status

ICD or SNOMED CT

Problems

HCPCS and CPT

Procedures

RxNorm Medications and Medication Allergies

LOINC Lab tests, values and results

CVX Immunizations

Block 2: Content Structure

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• Definition: − Message format/architecture specific to the digital environment

− Delineates the information contained in the message

− Defines the structure of the information to be exchanged

− Allows disparate machines to communicate

• Used in interop and interfaces

• Examples: − HL7 2.5.1 format for Lab Results

− Clinical Document Architecture (CDA) for Care Summaries, Care Plans

− Admission, Discharge and Transfer (ADT) for Demographics

• 2014 Edition EHR Testing and Certification helps insure

capabilities, compliance

CCDA

MU2 Consolidated CDA Template

• MU2 sets forth “Clinical Concepts”

Content Structure (Block 1)

• CCDA is the document “Template”

that must be used (Block 2) o Standardizes how “Clinical Concepts”

(Words) are used / re-used

o Templates put it into a “Package”

o Packages are arranged to create a

clinical “Document” that is purpose-

oriented

Demographics Medications

Allergies Problems

Lab Results Vitals

Smoking Status

Procedures

2014 Edition CEHRT

EHR

Dat

a C

aptu

red

• Humans read in document format → CCD

• Machines read in code → CDA

Human vs. Machine Readable Data

EHR - A EHR - B

Problems

Problems

Meds

Meds

Smoking

Smoking

Human vs. Machine Readable Data

EHR - A EHR - B

Problems

Problems

Meds

Meds

Smoking

Smoking

Block 3: Transport

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• Definition: − Moves the message securely between different electronic systems

• 2 Federal Standards − Direct messaging

− Messaging through HIE participating with HealtheWay (National Exchange)

• Direct − Does not require a HIE engine

− Works like simple email → Pushes message/attachments over Internet

− Must uses a 2014 Edition Certified Health Information Service Provider

(HISP)

• The Sequoia Project f/k/a HealtheWay HIE participant − HIE does not have to be “certified”

Direct Messaging

Dr. Clay Jones c.jones@direct.acmeehr.com

Dr. Ann Smith a.smith@ABCEHRdirect.com

a.smith@ABCehrdirect.com

Integrated into EHR software

c.jones@direct.acmeehr.com

HIE Direct Messaging

Dr. Clay Jones c.jones@direct.acmeehr.com

Dr. Ann Smith a.smith@ABCEHRdirect.com

ABC EHR

HISP

Acme EHR

HISP

1. Authenticate recipient

2. Encrypt data

1. Authenticate sender

2. Decrypt data

HealtheWay Alternative

HealtheWay Example

1.EHR generates CCDA 2.EHR sends CCDA to eHealth Exchange Participant 3.eHealthExchange Participant sends to Provider B

Provider A Provider B

CEHRT

eHealth Exchange Participant (formerly NwHIN Exchange)

An eHealth Exchange Participant does not have to be certified in

order for Provider A’s transmissions to count for MU.

However, Provider A must still use CEHRT to generate a standard

summary record in accordance with the CCDA.

• Ensures that health information is safe, secure and private

• Facilitates trusted exchange over something insecure →

Internet − Locates health information exchange participants

− Uses registration and certificate authorities

− Managed by the HISP

Block 4: Security Services

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The Value of Interoperability

• Activity

• Building Blocks

• Use Cases

• New Developments

• Questions

=

User Satisfaction with Technology…

=

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Done right, interoperability should be very underwhelming!

Moving Data Between Systems

• 3 Ways to Move Data

• Point-to-Point → Interface / Direct

− When does it add complexity?

− When does it make sense?

PCP

• 2 Ways to Move Data

• Point-to-Point → Interface / Direct

− When does it add complexity?

− When does it make sense?

PCP

• Health Information Exchange (HIE)

− “Normalizes” Data

− All HIE Participants can communicate

− Requires Participation by stakeholders for “value”

− Emerging Technology

− Typically, Data Repository

HIE

Moving Data Between Systems

• To do what? → Use Case

• Provides a Business Model Framework − Step 1 – Identify the Problem (Problem Statement)

− Step 2 – What are the needs? (E.g., Care Coordination, Data

Capture)

− Step 3 – Who has the need? (Actors)

− Step 4 – Map the Solution (To meet needs for each Actor)

− Step 5 – What technology is needed? (E.g., Interface, Direct, HIE)

− Step 6 – Determine Financial and Operational Impact (E.g., Initial

and Ongoing costs, Workflows, etc.)

“I want to connect!”

2. Improve Patient Care Safety

3 Interoperability Guiding Principles

1. Improve Patient Quality of Care

3. Increase Operational Efficiency to

lower clinic costs

Use Case

Guiding

Principles

• Referral Management → PCP sends Care Summary

to SCP

• Clearly Specify Workflow

• Consider Various Technical Requirements − 2014 Edition CEHRT

− Mechanisms for patient identification / matching

− Multiple Direct addresses?

• Guiding Principles − Quality: Improves privacy/security

− Safety: Timely, reliable and precise communication

− Efficiency: Reduced phone call referrals, awaiting faxes, easily uploaded

PCP Direct Use Case

Use Case Scenarios

Patient Gets Injured PCP Physician

• Cleaning Yard • Pain in calf and knee • Over evening leg swelled • Next day → Fever • Health Home

• Performs I&D • Collects specimen • 48 hours on cultures • Determine sensitivity • Interim Antibiotic • Suspected Spider Bite • Follow-up in 48 hours • Sooner if problems • Discharged

EHR / HIE

• Antibiotics cross-referenced in EHR Rx database

• Appropriate Antibiotic • EHR confirms last date

of tetanus-diphtheria • Avoids unnecessary immunization

Source: ONC Interoperability Basics – www.healthit.gov/providers-

professionals/interoperability-training-courses

Quality,

Safety,

Efficiency

Use Case Scenarios Patient Spikes Fever

• No Follow-up • Travels with friends • Fever peaks at 104 • Ends up in ED • Gets admitted

Hospital Physician

• IV Antibiotics • Fever continues • Unknown etiology • Deep leg pain develops • New culture → +48 hrs • Results needed NOW, or • Surgical excision of infected tissue

EHR / HIE

• HIE used by Hospital • Obtains culture results

quickly from PCP • Susceptibility identified

Quality,

Safety,

Efficiency

Source: ONC Interoperability Basics – www.healthit.gov/providers-

professionals/interoperability-training-courses

Use Case Scenarios Physician

• Culture shows MRSA • Sensitive to different

Antibiotic than using • Doctor immediately

switches • Rapid improvement • Discharge home

Patient RTW

• What’s MRSA? • Didn’t know it could get so bad! • Glad my MD got a culture and results • Need to RTW asap!

EHR / HIE

• MRSA “Notifiable” Dz. • HIE send notice to State

Health Dept.

Quality,

Safety,

Efficiency

Source: ONC Interoperability Basics – www.healthit.gov/providers-

professionals/interoperability-training-courses

The Value of Interoperability

• Activity

• Building Blocks

• Use Cases

• New Developments

• Questions

• $30 Billion in federal HITECH funding

• 2014 ONC received 60 unsolicited reports of “Information

Blocking” − Dominant complaint was cost

− Examples:

EHR vendor charging > $2.00/patient/year + transactional fee for Direct

EHR vendor charging $30,000 to interface to HIE in CT

• 113th Congress → Consolidated and Further Continuing

Appropriations Act (enacted Dec. 2014) − Authorizes ONC to de-certify any EHR vendor found practicing

“information blocking”

• HIMSS15 Conference – Vendor Announcements − athenahealth and Epic to eliminate fees

Warning Against “Information Blocking”

46

• Fast Healthcare Interoperability Resources (FHIR®)

• HL7 Interoperability Standard − Leverages “Resources” a/k/a “Models” → E.g., Patient, Condition, Procedure,

Medication, Appointment, etc.

− Resource = Properties → E.g., DOB, Gender, Name under the Patient Resource

− Resources are bundled with related resources

• Resources can be: − Created (HTTP POST)

− Retrieved (HTTP GET)

− Updated (HTTP PUT)

− Removed (HTTP DELETE)

FHIR®

47 Source: Orion Health, White Paper, FHIR ignites healthcare sharing, Dr. David Hay, Mar. 31, 2015,

http://ehidc.org/resource-center/white-papers/2015-03-31-FHIR-Ignites-Healthcare-Sharing.pdf

• FHIR uses Application Programming Interfaces (APIs) → Tells

computers how to locate and exchange Resources

• Some Key Benefits − Removes some cost barriers

− Speedy to Implement

− Adaptable to changing requirements

− No vendor “lock-in” due to no proprietary interfaces

− Support mobile, device and Internet technologies

• Only a draft interop standard today, even though broadly supported − Strong industry enthusiasm

− No regulatory requirement

− Not prominent in tech vendor’s near-term product roadmaps

− 2-5 year ramp-up for industry use and availability

FHIR®

48

Sources: Orion Health, White Paper, FHIR ignites healthcare sharing, Dr. David Hay, Mar. 31, 2015,

http://ehidc.org/resource-center/white-papers/2015-03-31-FHIR-Ignites-Healthcare-Sharing.pdf;

Chilmark Research, https://www.chilmarkresearch.com/2015/07/23/new-insight-report-on-moving-to-

open-platforms-now-available/

FHIR®

49

Condition

Patient

Encounter

Procedure

Practitioner

Diagnostics

Medications

Re

sou

rce

s

FHIR

• Evolving Standards → HL7 Fast Health Interoperability

Resources (FHIR®) − Recommended by 2013 Jason task force report to ONC

− Uses open application program interfaces (APIs) with intermediary

applications

− Industry excited, but …

− All policy, legal, governance, development and business barriers must be

overcome to implement

• Patient Matching − Policy says no unique patient identifier

− Technology using algorithms with error rate of 8-20%

• Lack of resources, expertise

• Balancing process and innovation with data use ethics

Cost Not Only Barrier

50

ONC Interoperability Roadmap

51 Source: ONC, HIMSS15, Listening Session: Advancing

Interoperability and Standards

• Learning Health Network by 2024 − Patients, families, providers and stakeholders

− Send, receive, find and use health information

− Appropriately, securely, timely and reliably

• ONC → Today 6 Questions when talking about interoperability − For what purpose?

− With whom?

− With what data?

− Via what infrastructure?

− By when?

− Toward what expected benefits?

• Answer? Use Case!

ONC Interoperability Roadmap

52 Source: ONC, HIMSS15, Listening Session: Advancing Interoperability

and Standards

• CommonWell Health Alliance – Industry-driven Initiative for

“best practices” in Interoperability − Members include: Allscripts, athenahealth, Cerner, Greenway,

McKesson, Aprima, CVS Caremark, Meditech and others

− Exploring FHIR

• Carequality – Convener and Consensus point for Technical

Specifications − Public-private, multi-stakeholder collabration

− Members include: AMA, eClinicalWorks, Cerner, Epic, Greenway, Kaiser

Permanente, Surescripts, Walgreens and others

− Focused in 3 elements

Common rules

Technical Specs

Participant Directory

Industry Collaborations

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Questions?

Thank You!

Adele Allison AMAllison@DSTHealthSolutions.com

Follow me on Twitter:

www.twitter.com/Adele_Allison