ONC’s New Leadership Emphasizes Shifting Priorities in Media Briefing

Via Healthcare Informatics »

EHR usability and interoperability have become the central focus for the federal HIT agency 

During a briefing with members of the industry press today, top officials at the Office of the National Coordinator for Health IT (ONC) discussed the core priorities of the agency, signaling a change in focus for the health IT branch of the federal government.

The July 11 call with health IT trade press, both in person and via telephone, included recently-appointed National Coordinator for Health IT Donald Rucker, M.D., John Fleming, M.D., deputy assistant secretary for health technology reform, and Genevieve Morris, principal deputy national coordinator for Health IT. All three top senior officials at ONC are appointees of President Trump, though Morris has worked with the federal agency in the past on various projects.

Rucker, formerly the vice president and chief medical officer at Siemens Healthcare, handled most of the responsibilities of the 90-minute call in what was his first open briefing with the trade press since taking the job this spring. The National Coordinator opened by reaffirming what Fleming had said during a keynote at a recent event—the agency’s two core priorities will largely be around electronic health record (EHR) usability and interoperability.

In prior administrations, ONC had various roles, from encouraging EHR adoption to assisting with health information exchange (HIE) infrastructure to helping with the meaningful use program, but late in the Obama administration, those priorities started to shift. And then when Tom Price, M.D., was confirmed as Health & Human Services (HHS) Secretary under Trump, federal health IT officials mainly became focused on making sure that EHRs help physicians rather than burden them—a sentiment that was a big point of emphasis in today’s briefing.

Indeed, while interoperability has been a major focus for ONC in past years, improving the usability of health IT systems is now also right up there. Rucker noted that the two laws that have been passed by Congress—MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and the 21st Century Cures Act—together “define the ONC mission.” He said, “We have spent a lot of money on these systems and there is a widespread dissatisfaction with the level of interoperability. [Now], we are trying to use the tools that we as a country have purchased to help us with value-based purchasing and quality reporting.”

Speaking further about reducing the burden, Rucker said that the agency is looking at documentation requirements for physicians as well as the whole quality framework around value-based purchasing, and other regulations related to how systems are architected. “For a lot of practices, this has become a challenge in that we have to think about what the win is for them. The expense that [comes with] complying with the quality measures [compared with] the innate value [gained] needs to be analyzed at some point,” he said.

Rucker added that he has personally been working on EHRs for a long time and that many people assumed that usability was something that should have been figured out in Silicon Valley in the early 1990s. “Now it’s 2017, so I won’t make any more predictions since my prior ones have not been very successful,” he said jokingly. He added that in a broader sense, there is a feeling in Congress that EHRs can be harnessed. “They are right now about documentation and billing, but every other industry uses its enterprise computer software to do automation to become more efficient. We are the only business to use computers to become less efficient.”

To this end, Rucker also noted that the hiring of Fleming—for a position that has never existed before in the government—signals that there is now someone in a key leadership role who stands for the many issues that small and independent practices have with technology. Fleming, a former Navy physician who then opened his own private independent practice in the 1980s, noted that when his practice got its first EHR it all started out smoothly, but over time the practice started to have the same issues that have plagued other doctors around the U.S. “You hear complaints that doctors are so focused on the different administrative requirements in healthcare today. It reminds me of when commercial aircrafts became so complex and pilots had an overload of managing those systems. But that has become more streamlined now,” he said.

Both Rucker and Fleming said that it has come directly from Secretary Price that more attention be paid to reducing the burden that health IT puts on providers. Noted Fleming, “EHRs have become symbolic with physician burden, but by no means is it the entire cause. A physician, in an independent practice, is the CEO and must manage that practice, he or she must see the patients, and now with EHRs, he or she must be the data input person, too. We get reports from doctors that they spend two to three hours a day creating documentation.”

Interoperability and Cures

Meanwhile, another core priority of ONC will be to work on a number of provisions as outlined in the bipartisan Cures Act passed late last year. Rucker said that the top takeaways from this law are that Congress wants more explicit definitions of interoperability, open APIs (application program interfaces), and that it wants to prohibit information blocking.

When asked if the agency will have sufficient budget and resources to carry out these responsibilities, Rucker said, “We think we do have the resources and time to do these tasks. Some of these things we are not legally able to work on until Congress handles certain aspects of the budget, and some of it is [the work of] other agencies like the GAO [Government Accountability Office].” But he did add that ONC will begin hosting a series of meetings later this month with the aim to establish a trusted framework and common agreement for health data exchange, as outlined in Cures. Morris added that the common agreement should be out for the public later this year or early in 2018.

Regarding interoperability, Rucker noted that it happens in pockets of the country today, and the sharing of lab results and images works well for the most part, but he pondered if the business model as it is today could extend beyond these few areas, and if there is enough of a business incentive for a patient’s problems list to be up-to-date and meaningful for all doctors to see, for example. “On the enterprise side with hundreds of providers, these problem lists are all over the place, and they go from screen to screen to screen. There is no business model to clean that up,” Rucker said. He added that ONC’s Interoperability Roadmap is a “solid path” but said there is no ETA for when some of those data sharing challenges will indeed be solved. “A lot of this is about more than just standards; it’s about business relationships,” he said.

Overall, when asked about the future vision of ONC and its role in the industry, Rucker said that philosophically speaking, ideally all of these regulations wouldn’t be needed, since that would mean many of the problems that exist today would be solved. To this point, he was asked when the meaningful use program will wind down, to which he responded that there is no date and that much of what’s to be decided is in conjunction with CMS. He did say that the focus is “not on finding more things to apply the meaningful use methodology to.” But for now, he said, for the next few years, it will be about making sure that EHRs are working so that physicians are not data clerks, but rather they can get value from the data that’s in the systems.

Fleming added that the changing reimbursement system is also a driver for much of this change. “Rather than pay for service, we need to pay for quality and outcomes. This is where CMS is putting effort and resources into, and this goes back to last administration—to their credit—in evaluating these [payment] models so people have the same incentives.” He noted, “The hope is that as we advance into better reimbursement and care models, some of these fee-for-service issues, documentation issues and usability issues begin to resolve themselves.”

What a former member of the Soviet bloc has to offer Nashville’s health leaders

Via Nashville Business Journal »

When looking for technological advancements, few look to the former USSR, but one of Nashville’s health care leaders did exactly that when searching for a way to solve what is one of the industry’s biggest problems: interoperability.

Ed Cantwell, CEO of the Center for Medical Interoperability, recently visited Estonia to learn how the former Russian republic became a digital powerhouse.

“They designed a country that is more efficient digitally than any country,” Cantwell said of Estonia.

After gaining independence from Russia in 1991, Estonia’s fledgling government created a digital society, Cantwell said. The government created an interoperability platform that allows government records to work together.

According to government websites, Estonia created a decentralized system that links together services and databases. Since the system is open, new components have been able to connect with the system as they are developed, meaning social services, legal services, health care and voting all work on the same open platform.

In contrast, Cantwell likened America’s health care systems — with all its machines and systems that don’t talk together — to AT&T phones that could only call other AT&T users.

Interoperability is one of the greatest issues facing the health care industry, which is why the Center for Medical Interoperability launched last year with the backing of local health care giants HCA Healthcare Inc., Community Health Systems and LifePoint Health, among others. Because of the size and role those companies play locally, it’s also critical for Nashville that the health care industry follows the path of Estonia and finds a solution to the question of interoperability, Cantwell said.

“Where Nashville goes, the nation goes,” Cantwell said. “The opportunity exists really for Nashville to step up.”

Center for Medical Interoperability Moves to New HQ

Via Nashville Medical News »

In April, the Center for Medical Interoperability opened its new Nashville headquarters and a one-of-a-kind testing and certification lab in the oneC1TY development off of Charlotte Pike. The new facility’s striking interior was designed around the theme of “Follow the Flow of Data.”

The center is a 501(c)(3) cooperative research and development lab founded by health systems to simplify and advance data sharing. The center’s membership consists of health systems and other provider organizations committed to eliminating current barriers to swift and seamless communication of patient information among medical devices and electronic health records.

“The opening of the headquarters and launch of the lab are enormous steps toward addressing the difficulties that health systems share in getting medical devices and electronic health records to ‘talk’ to each other,” said Mike Schatzlein, MD, chair of the Center’s board. “All too often,” he continued, “this prevents physicians and other caregivers from having complete information about a patient readily available when they make important treatment decisions.”

The new lab serves as a research and development arm for its members to improve interoperability with the center’s technical experts and visiting engineers from industry working together to develop IT architectures, interfaces and specifications that can be consistently deployed by health systems, medical device manufacturers, electronic health record vendors and others. The lab certifies devices and software that meet the Center for Medical Interoperability’s technical specifications. Clinicians have the ability to explore the impact of technologies within the Transformation Learning Center at the lab to ensure solutions are safe, useful and satisfying for patients and their care teams.

“The lab will help bring about a ‘plug-and-play’ environment for healthcare in which there is assured interoperability and connectivity inside and outside the hospital,” said Ed Cantwell, president and CEO of the Center for Medical Interoperability.

Providers face value-based care data challenges

Via Health Data Management »

The use of electronic health data for quality measurement and improvement in healthcare has not yet realized its full potential, a problem that must be addressed if the industry is to successfully transition from fee-for-service to value-based payment.

That’s the consensus among industry stakeholders who participated in a roundtable discussion hosted last week by the Office of the National Coordinator for Health Information Technology.

“We are at a critical point in how we think about quality measurements and how we think about quality improvement in general,” Robert Anthony, senior policy advisor in ONC’s Office of Clinical Quality and Safety, told the gathered group of subject matter experts.

Quality measures are vital as the industry moves from fee-for-service to value-based payment. According to consulting firm Discern Health, as much as 80 percent of U.S. healthcare spending will be linked to quality measures or value-based payment models by 2020.

Also SeeCMS proposes rule for collecting, submitting quality data

“We’re in a world where it’s not just about reporting any result, it’s about reporting your optimal result—and, payment is tied to it,” said David Kendrick, MD, chair of the Department of Medical Informatics at the University of Oklahoma’s School of Community Medicine. “We’re seeing the level of emotion about measurement go through the roof among providers, and that means they’re starting to really care about all those terminology issues and the issues in their EHRs.”

David Kendrick, MD

Despite the widespread adoption of EHRs, the mere fact that providers are using the systems does not automatically translate into improved quality of care. In addition, although health IT has the potential to greatly improve the quality of care, the evidence that HIT improves health outcomes is still relatively limited.

To help address the problem, Kendrick argued that measures must be standardized, replicable, validated, timely, as well as actionable.

“Medicare and most payers are betting the farm on measurement right now, and I’m very worried about our infrastructure to support that,” he added. “Claims data is a mile wide but only an inch deep. So, it has the unique benefit of encompassing most of what’s happened with the patient, but it doesn’t have the deep clinical variables in it (that) we would like to have, and it’s certainly not timely enough for most measurement that we would want to do for actual quality improvement.”

On the other hand, Kendrick said electronic health record data is “a mile deep, because it has all of that clinical information in it, but it’s only an inch wide.”

While EHRs “may be considered the core for data for eMeasurement, it’s really important—and I would even say essential—to integrate with other types of data in order to truly capture what’s happening at the patient level and being able to capture what happens across multiple providers and systems,” said Sarah Sampsel, vice president at Discern Health. “To improve quality of care, not just the quality of life for that person, we have to be able to capture more than what’s in an EHR.”

Speaking figuratively, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, said “it’s criminal that providers don’t have access to all their claims data—they only get it for the risk patients, if they happen to have a risk contract, but they don’t get it for everyone else.”

Another challenge cited by Kendrick is that “real patients’ care is scattered across a number of locations,” and “to do measurement appropriately, we really need to have all of this (data) so that we have the most complete picture on each patient that we’re measuring.”

Likewise, Tripathi lamented the fact that healthcare is fragmented and, as a result, so is the electronic health data.

“If you look at the distribution of patient visits across the country, 68 percent of patient visits happen in small physician practices,” said Tripathi. “When we think about quality measurement, we tend to focus on the Mayo Clinic and Intermountain Healthcare. But most of the action and therefore most of the data is in smaller settings.”

4 Initiatives Advancing Healthcare Interoperability in 2017

Via EHR Intelligence »

Healthcare organizations and health IT developers have cemented their commitment to achieving true interoperability through multi-stakeholder initiatives in 2017.

Healthcare interoperability has been a priority for vendors and providers since the advent of health data exchange.

Timely access to accurate health information regardless of health IT system or location improves provider communication and patient care delivery across the care continuum.

This year, healthcare organizations, health IT developers, and federal agencies alike have made a concerted effort to push the industry closer to its goal of true interoperability.

The following are four recent initiatives and forthcoming projects aimed at transforming interoperability in healthcare in 2017.

New Center for Medical Interoperability opens in Nashville, TN

Last month, several healthcare organizations including Ascension Health, Cedars-Sinai Health System, and Hospital Corporation of America joined forces to open the new Center for Medical Interoperability headquarters in Nashville, TN.

The new facility offers researchers and developers the resources to develop software and devices meeting the latest health IT industry standards.

“The opening of the headquarters and launch of the lab are enormous steps toward addressing the
difficulties that health systems share in getting medical devices and electronic health records to ‘talk’
to each other,” said Center for Medical Interoperability Board Chair Mike Schatzlein, MD.

In an increasingly data-driven healthcare environment, equipping researchers with the tools and facilities to advance accessible, open, and efficient health information exchange is imperative to achieving lofty interoperability goals.

“Enabling this type of seamless communication is crucial to improving patient safety and reducing clinician burnout,” said Schatzlein.

The center maintains a vendor-neutral stance in their development of new technologies.

HL7 and HSPC collaborative set to debut first joint project in June

Health Level Seven International (HL7) and Healthcare Services Platform Consortium (HSPC) recently teamed up to develop industry standards in the name of health data exchange interoperability.

Through the agreement, HL7 and HSPC have been working to develop FHIR standards to streamline exchange between EHR systems.

Specifically, the collaboration focuses on advancing standardized representation of health data through HL7 Clinical Information Modeling Initiative (CIMI) Work Group models designed to work within FHIR profiles.

“HL7 has a long history of formally collaborating with healthcare industry groups such as HSPC to advance interoperability through the adoption and implementation of standards,” said HL7 Chief Executive Officer Charles Jaffe, MD, PhD.

The initiative will also launch joint projects focused on involving clinicians in the validation of clinical data representations and standards to promote coordination of care.

“We are delighted to work with HSPC to develop detailed FHIR profiles based on our CIMI models. Together we are engaging the clinical specialty communities to develop a common set of FHIR-based solutions to simplify workflows, effectively allowing clinicians to provide better patient care,” Jaffe continued.

The team’s first joint project will take place at the Clinical Information Interchange Collaborative meeting this June.

ONC Patient Matching Algorithm Challenge to improve interoperability and patient safety

ONC also has plans to advance interoperability next month with its upcoming Patient Matching Algorithm Challenge.

The patient matching innovation challenge will invite developers to design new patient identification algorithms and increase the transparency, standardization, and methods of patient matching.

“From an interoperability perspective, the ability to complete patient matching efficiently, accurately, and at scale has long been identified as a key element of the nation’s health IT infrastructure,” wrote Director of Standards and Technology at ONC Steve Posnack, MS.

Providers receiving data from disparate systems need a way to determine which patient incoming information belongs to with maximum accuracy.

“Patient matching is almost universally needed to enable the interoperability of health data for all kinds of purposes. Patient matching also requires careful consideration with respect to its effect on patient safety and administrative costs,” Posnack said.

Top developers will have a shot at six cash prizes amounting to $75,000.

Patient matching algorithms will be evaluated based on fewest amount of mismatched patients, or best precision, and fewest amount of missed matches, or best recall.

The major prize category will award 3 cash prizes to the teams with the highest F-score based on a combined evaluation of precision and recall.

PCHAlliance and IHE continue work on conformity testing and certification

In February, The Personal Connected Health Alliance (PCHAlliance) joined forces with the Integrating the Healthcare Enterprise (IHE) initiative to develop an entirely new project aimed at improving and simplifying interoperability.

Since then, the duo has worked to improve health data exchange through conformity testing and certification.

“PCHAlliance and IHE share the same vision. That is, we believe that health information exchange is possible throughout the worldwide healthcare ecosystem and, together, we can support new innovations and create solutions to improve health outcomes, enhance understanding and help make big data possible,” said PCHAlliance VP Michael Kirwan. “We are looking forward to expanding our collaboration and working closely to further extend interoperability in healthcare.”

IHE Profiles and PCHAlliance Continua Design Guildelines, which are both standards-based, open specifications, function as the foundation for the joint effort to ensure data collected by providers or patients can enter EHRs without any format or code alterations.

The team’s three-pronged approach involves using IHE Profiles and Continua Design Guidelines to allow the organizations to collaborate on conformity testing and certification.

The organizations then use the resulting aligned tools and processes to offer communication, education, and interoperability demonstrations for providers, vendors, and standards bodies.

May 04, 2017 – With so much planned in 2017 to promote new innovations aimed at improving interoperability, the once-distant goal of nationwide seamless data exchange is a few steps closer to becoming a reality.

Jonathan Bush, other HIT Leaders Dive into Healthcare’s Interoperability Problem at World Health Care Congress

Via Healthcare Informatics »

A panel of three leaders in the health IT space, including outspoken athenahealth CEO Jonathan Bush, discussed the current interoperability landscape and what new strategies will help shape the future of healthcare connectivity.

Bush was joined in the keynote panel—part of this year’s World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C.—by Steven J. Corwin, M.D., president and CEO of NewYork-Presbyterian (NYP, New York City) and Craig Samitt, M.D., executive vice president and chief clinical officer, Anthem, Inc. The session was moderated by Dan Diamond, health policy reporter at Politico.

When asked about what the industry is doing well and where they are failing, Drs. Corwin and Samitt had rather pessimistic tones, with Corwin noting that the current electronic health records (EHRs) at NYP, which actually only account for some 40 percent of the organization’s data, are fragmented and not interoperable. “The promise of interoperability is something that has been over-promised,” Corwin said. “The idea was that that various EHRs could be perfectly compatible, but that has not been [the case]. For us, it gets down to having a single EHR, taking [out] the expense of putting them together over a multi-layered system, and then reducing the number of exchanges and linkages we need to have. At this point, our linkage exchange looks like spaghetti wires,” adding that in NYP’s interface engine there are currently 6,000 interfaces, though the goal is to cut that number down to 3,000. “We just can’t toggle back and forth between systems,” he said.

Similarly, Samitt noted that the issue isn’t a technology one, but rather one of willingness and incentives. The Anthem senior executive said he is “highly critical of our industry since other industries have figured it out.” He added, “When there’s a will, there’s a way. I think there is a way for interoperability but less of a will. Information should be a common good as it relates to population health and better care at a lower cost, but we do not treat it that way.” He went on to talk about data ownership, noting, “Payers probably have the most complete data set but it’s not timely. Doctors have the most acute data but it’s not complete. And patients have most relevant data, but it’s not actionable.”

The panelists were then asked who’s to blame for these data sharing issues, a question that usually elicits varying responses from those pointing fingers at vendors to others assigning fault to providers and policymakers. From the payer perspective, Samitt said that claims information is only a subset of the data, and that it’s challenging to get providers to share data, though he also admitted that payers are not so willing themselves. “None of us should own the information; it should be a common good. Let’s keep the information safe and pool it so we can have a true longitudinal patient record,” Samitt said.

From the vendor vantage point, Bush—who two years ago famously tweeted at Judy Faulkner, CEO and founder of Epic Systems, that he would pay the user fee for Epic if the giant EHR vendor would join the CommonWell Health Alliance, an interoperability initiative of which athenahealth is a part of—agreed that the incentives to share healthcare data are not rewarding enough for stakeholders. “For my entire career, no one has wanted to exchange information,” Bush said. “The government has made it largely illegal for providers to get paid by digitally flowing information upstream. And [the feds] do not let just any provider see Medicare data,” adding that his company went through the laborious process of filling out applications and hiring lawyers so that they could get access to this CMS (Centers for Medicare & Medicaid Services) data, only to get denied. “Historically,” Bush said, “Hospitals have said that they are the only place that data can flow so that they keep referral volume and preserve their institution.”

However, things are beginning to change, Bush continued, noting dedication from new Health and Human Services Secretary Tom Price, M.D. to reverse things. “We are [seeing] a willingness on the part of forward-thinking healthcare systems to win by being open. Last year, the 21st Century Cures Act [was passed] and that makes it illegal to block data,” he said.

Bush also called out Epic, Cerner and Meditech, which he refers to as “pre-Internet companies” for now being more open to interconnectivity, proving that there are signs of change in regards to stakeholders’ willingness. “Payers are also giving us claims data they didn’t use to give us, and that gives us information on patients that we can pull together that we weren’t able to before,” he said.

Chiming in on the topic of data blocking, Corwin said that hospitals hoarding data is a fair criticism. “People believe that data can be monetized in healthcare, and that’s particularly true with well-curated genetic information,” he said. “I’m less enamored with that idea; I think that the data [belongs] to the patients, not to the providers. But there are those [providers] out there who do think there’s a market advantage. I’m a big believer in not monetizing data unless it improves patient outcomes,” he said.

Bush further said that athenahealth is building a master patient index (MPI) and also a calendar product that would help doctors on athenaNet get more patient appointments. He referred to EDI and HL7 as standards that will “die since they are pre-Internet.” Bush said it was these outdated companies that advocated as part of HITECH (the Health Information Technology for Economic and Clinical Health Act) to eliminate interoperability as a requirement for meaningful use.

He continued, saying these pre-Internet companies “claim to be interoperable but never will be. They need to go,” he attested. Bush added, “Cloud companies can easily be interoperable. HITECH got everyone onto systems that they’re now stuck with, and the Internet was shut out of HITECH. You have 60 medical specialties and [the idea is that] any EHR will be the right one for all 60?  That is absurd. How many apps on your iPhone were written by Apple? Four of them. So [we won’t reach] interoperability until we get rid of these servers.”

Bush went on, “That means we need to invite our competition onto the platforms and be like [Jeff] Bezos [founder of Amazon]. “We must accommodate a new generation and we have to move to the Internet in healthcare. This cannot be a questionable proposition in healthcare in 2017. The new cloud-based EHR companies are coming onto our platform; the nightmare Steven [Corwin] is experiencing connecting different old systems is becoming a thing of the past, slowly.”

Samitt agreed with Bush on how the future might look, arguing that it’s not going to be about EHR-to-EHR connectivity going forward, but rather capturing data elements in the cloud to manage population health. “EHRs connecting won’t be as relevant in the future,” he said. “Data inputted is less crucial than data outputted. So the pooling of information and the analytics will be crucial, not which EHR you are on,” he said.

To close the discussion, the panelists were asked about when healthcare connectedness will no longer be an issue. Bush estimated it would take some five years. On the other end of the spectrum, Corwin predicted that interoperability will be superseded by disruptors such as telehealth, artificial intelligence and machine learning. “Interoperability won’t be solved in the short-run. Patients will demand their own data. And connecting people via regional HIEs won’t happen. I’m very pessimistic about the [prospects] of true interoperability. Samitt was more optimistic, predicting that real interoperability can be achieved in 10 years. He noted that much of it comes down to payment reform as well, pointing out that nearly 60 percent of Anthem’s payments are now tied to value. “Connectivity is not just data connectivity, but we also need to achieve alignment with the patient at the center,” he said.

The long and winding road to patient data interoperability

Via Modern Healthcare »

Most of the time when Dr. James Tcheng gets a new patient from outside of Duke Health, he starts with a bundle of paper. After his secretary receives a patient’s records—either directly from another doctor’s office or after a request is faxed—and opens them, Tcheng goes through the information, with a sheet of 8½ x 11 paper at his side for taking notes. He starts, usually, with the summary notes. Sometimes, almost all of what he reads is irrelevant. But he must go through everything nevertheless, making sure he misses nothing.

“It’s one of the things that causes me to turn over in bed at night,” said Tcheng, an interventional cardiologist at Duke Health. “I wonder, did I miss something? What should I have been looking for? What wasn’t even said?”

Interoperability, that oft-promised, long sought-after state of data fluidity, has yet to fully arrive in patient records. Too often, patient data move only after someone—a patient, a nurse, a doctor—makes a few phone calls and faxes, stumbling a few times.

True interoperability remains just out of reach, as data stays trapped in documents.

Better standards, alliances among vendors, and new interdependent technologies promise to change that, making data travel with patients as they move through the healthcare system, thereby reducing the burden on providers and achieving the patient-centric part of the triple aim.

But those changes may be more theoretical at this point than actual, and they’ve yet to be adopted across an industry whose members are trying to keep up with new software and standards—standards that themselves are evolving to become more useful. After all, interoperability isn’t just the ability to transmit information, it’s the ability to use the information, too.

Just 6% of providers surveyed by KLAS Research said information they get from outside organizations is reasonably easy to locate within their workflow and “significantly benefits patient care,” and less than one-third said they often or almost always can access data from different electronic health records. Troubles arise when information is outside the electronic health record, when the formatting is clunky, and when information isn’t available when it’s needed.

“We hear pretty regularly that clinicians are frustrated with the amount of time they’re spending documenting instead of taking care of patients,” said Bob Cash, KLAS’ vice president of provider relations.

Part of that frustration stems from the fact that health data don’t often travel as discrete pieces of information but, rather, as entire chunks. “Right now, EHRs are simply very sophisticated systems for managing documents rather than being purveyors of information captured as data,” Tcheng said.

Making data meaningful

When EHRs do successfully talk to one another and transmit data, it’s not just the conversation that matters, it’s how the conversation is structured. In other words, it’s one thing to be able to transmit data, it’s another to be able to transmit it in a way that makes the information meaningful and actionable for providers.


To make a record easily understandable, file formats must be standardized. And they are, to a degree: The Consolidated Clinical Document Architecture (C-CDA) standard—which can be used to fulfill the meaningful use Stage 2 requirements—is essentially a collection of templates (along with the requisite coding and framework), including one for documenting a patient’s allergies, medications, problem list and other information, including both structured and unstructured data.

In the end, the documents are sometimes not terribly unlike well-organized PDFs. So providers are often left to wade through pages and pages of text to find what they’re looking for. “They’re big and unwieldy,” said Micky Tripathi, CEO of the Massachusetts eHealth Collaborative. Some providers don’t even look at them.

“We need to break away from the document paradigm of medical records and move toward semi-structured and structured information that actually has pieces of data managed as data itself rather than documents,” Tcheng said. But, he said, “interoperability isn’t just the ability to move a document from one EHR to another.” When you do that, you still must know, for instance, to click on the tab in the EHR for “other information.” And that’s just another click in the seeming infinitude of clicks providers are already making.

the standardwereing. FHIR, which is vendor-neutral, allows people to transmit both documents and smaller pieces of data.

“FHIR is on a trajectory to develop a platform which makes interoperability possible in health systems around the world,” said Dr. Charles Jaffe, CEO of standards organization Health Level Seven International, which developed FHIR.

It portends a time when data aren’t locked in separate documents in separate EHRs—or in separate file folders—but are instead fluid, moving in discrete elements with patients as they go from provider to provider.

“Part of the issue now is hospital and health systems feel it’s all their records, when really we’re just stewards,” said Dr. Thomas Moran, chief medical information executive for Northwestern Memorial HealthCare in Chicago. “The patient still exists outside of the hospital and goes elsewhere, and the patient needs to be able to share their information easily no matter where they go.”


Helping data move

FHIR and similar projects are necessary because data do not move in pieces today. Instead, information is often trapped in various silos, and when it does move between them, it’s in unwieldy documents.

It’s not like this in many other parts of life. “In the financial world, in the retail world, in the social world, data is not held hostage for the benefit of someone else,” said Kerry McDermott, vice president of public policy and communications at the Center for Medical Interoperability. “You’re kind of the digital center of the universe, because if companies don’t treat you that way, you’re going to abandon them, because you have a choice.”

Often, providers and others wonder why EHRs can’t be more like ATMs. The answer, Jaffe said, is that “medicine is more complicated than an ATM.”

EHRs and standard document formats are certainly steps toward interoperability. Though fax machines are still exceedingly—and shockingly—common in healthcare, records are increasingly stored on servers, not shelves. The government essentially required the use of EHRs with the CMS’ meaningful use program, which mandates, among other technological requirements, that providers electronically transfer patients’ summaries of care for at least half the transitions of care.

“Meaningful use and the rules have pushed the market and healthcare systems to do things in a different way and drive toward that culture of sharing,” said Lana Moriarty, director of the Office of Consumer eHealth at the Office of the National Coordinator for Health Information Technology.

That will help ease the burden on providers, which is currently significant: Primary-care providers now spend about equal time—three hours or so—on office visits and “desktop medicine,” according to a recent study in Health Affairs.

That proportion may change now that the ONC is working on implementing the 21st Century Cures Act, enacted last December. Notably, the act contains a prohibition of “information blocking,” as well as requirements for EHRs to transmit, receive and accept data.

Eric Helsher, Epic Systems Corp.’s vice president of client success, worries that more regulation might increase the already significant burden on providers—the very thing the ONC and others are trying to avoid. For one, the language about information-blocking is vague enough that it might lead to “frivolous claims,” he said. As for EHR certifications, in the past “well-intended requirements created unintended consequences that lead to burdens on providers.”

He thinks the government should let the private sector solve the problem. Epic, Cerner Corp. and other EHR vendors say they’re working on it. They’ve formed groups such as Carequality, from Sequoia Project (Epic is a founding member); and the Commonwell Health Alliance (Cerner is a founding member) to promote interoperability.

“We have a moral obligation to fix interoperability and not compete on that piece,” Cerner President Zane Burke said. “Today the information doesn’t flow very easily, and the obligation is on the patient to provide that information again and again.” That can lead to multiple tests and bills. “If you can’t get something easily, the easiest way to get it when you have the patient in front of you is to reorder it,” Northwestern’s Moran said.

Carequality and Commonwell recently began working together on interoperability projects, including tackling record location so that patients could be connected to their data from different sources. “We want to get to the point where clinicians just expect to see everything, local and outside, and they don’t necessarily have to know the difference anymore,” said Dave Fuhrmann, Epic’s vice president of research and development.

For that to happen, providers—or their software—would have to know where to pull records from. Commonwell’s record location technology—which creates a “virtual table of contents” that points to the locations of patient information—is one way. Another method—that some see as the interoperability solution of the future—is blockchain, a technology borrowed from the financial industry’s bitcoin.

In healthcare, blockchain could involve a super-secure “distributed ledger” of everywhere a patient has received care. Every time you get medical care, a record of your receipt of that care would be added to the ledger. The ledger, in turn, would point to places providers need to check to create a more complete medical record.

The blockchain is mostly an idea at this point; for the technology to be useful, it’s not enough for the blockchain to simply point to where the data are. The data must be able to be transmitted—they must be interoperable.

When that happens, doctors will be able to be better at their jobs. “If it were all there in front of you,” Tcheng said, “you’d spend a lot less time shuffling through paper or clicking on different tabs,” he said. “You could spend more time actually thinking about what you’re looking at.”​

With revenue up, Cerner remains unaffected by ACA uncertainty

Via Modern Healthcare »

Cerner Corp. posted strong financial growth in the first quarter despite the continued uncertainty surrounding the Affordable Care Act and healthcare industry, the company said Thursday.

One of the nation’s largest health information technology vendors, Cerner is well positioned to help the healthcare industry lower costs through delivery reform, said Cerner president Zane Burke in an earnings call.

“It’s important to step back from the noise and consider that the dialog around Obamacare and its Republican alternatives is mainly focused on access and insurance reform, not care delivery reform,” he said.

Burke said IT is the strongest force behind lowering costs and boosting quality, and the company supports the Medicare Access and CHIP Reauthorization Act of 2015, which rewards providers for better outcomes and penalizes them otherwise.

Another key to driving better care and efficiency is interoperability, though it went unmentioned in Cerner’s earnings call. Despite vendors forming alliances like Commonwell (Cerner is a founding member) and pledging to improve connectivity, getting patient data to move freely between EHR systems remains elusive. “Without data liquidity, it’s harder for us to provide precision care for individuals and manage the health of populations,” said Kerry McDermott, vice president of public policy and communications for the Center for Medical Interoperability, in an interview.

Cerner’s first quarter revenue this year was $1.26 billion, up 11% over the first quarter of 2016. System sales and services drove much of the growth, with revenue up 14% over the previous-year quarter. System sales margins were also up.

Those results put Cerner in a good position both objectively and relative to its most direct competitor, which the company did not name but is widely considered to be Epic Systems Corp. “Overall, our competitiveness is as good as it’s ever been,” Burke said. “We believe our primary competitor continues to be in a more defensive stance as a result of numerous factors, including cost overruns.”

Can Nashville’s health care leaders solve one of the industry’s biggest challenges? They better

Via Nashville Business Journal »

If you’re thinking about the future of health care, you should be mindful of Steve Jobs. Whether that comes in the form of optimism or wariness depends on your perspective.

For Charlie Martin, a veteran hospital company CEO and the head of investment firm Martin Ventures, Jobs’ innovative ability is emblematic of the way the slow-moving health care industry will ultimately be transformed: by an outsider entrepreneur who can build something people don’t yet know they need.

In Martin’s view, one of the biggest reasons health care lags other industries and continues to grapple with technology’s inability to communicate and share data seamlessly — an issue known as interoperability — is because the existing players in the industry don’t want it to happen. And that leaves them vulnerable.

“I’m afraid the people who are running it now have too much to lose,” Martin said. “The reason we don’t have interoperability today is most of the people in the system don’t want it.”

But other health care leaders are more confident in the industry’s ability to disrupt itself and support innovation. In fact, that’s one of the ideal outcomes for the Center for Medical Interoperability, a new Nashville-based nonprofit led by some of the industry’s highest-profile executives that is working to improve communication and data sharing between a variety of health care technologies.

Steve Jobs didn’t have to invent the internet … he built on top of that utility,” said Ed Cantwell, the center’s CEO, seizing upon Martin’s analogy during a Nashville Business Journal panel Tuesday morning.

The center’s mission involves bringing together the providers who buy technology with the vendors who create it, and together finding a way to make medical devices and software communicate just as easily as bank ATM cards or a VCR and a television. With the help of a framework established by the center, Cantwell argued, innovators can more easily push health care forward, whether they’re coming from inside the industry or elsewhere.

And for HCA Holdings Inc. CEO Milton Johnson, who presented Tuesday’s keynote address, achieving true interoperability will allow the hospital giant to build on three key factors to drive health care forward: consumerism, advanced data analytics and care coordination.

All three of those factors demand the free flow of data and information in order to allow the industry to improve outcomes and efficiency — defying, in some ways, Martin’s predictions.

Nashville, Johnson said, has “unparalleled expertise” that the city’s health care community can use “to disrupt the status quo.”

“The time is right to make ourselves known for the number of lives we improve, not just the number of beds we manage,” Johnson said.

For more of Johnson’s thoughts on HCA’s ability to lead the industry’s next steps, check out this exclusive Q&A.

Health Care of the Future: Interoperability

Via HCA Today Blog »

Today I had the honor of delivering the keynote speech at the Nashville Business Journal’s Health Care of the Future event at the Music City Center. It was a challenge to tackle this vast subject in just 15 minutes. Following is the text of my speech, which focuses on three of the many factors that define the future of healthcare, consumers, advanced data analytics and care coordination, and covers some of the exciting efforts underway at HCA. I hope you find it interesting.

Thank you for the kind introduction. It’s a pleasure to be here with this esteemed group. I’d like to set the stage for today’s discussion by focusing on three main areas – the future of health care, the importance of interoperability and the opportunities that exist for Nashville.

Future of Health Care

Some people say if you want to know the future of health care, just look at the present day state of being for any other industry. Now, while it may be true that health care has ample room to improve, as CEO of one of the largest healthcare companies in the U.S., I take issue with such a broad generalization. Yes it’s true that the industry has opportunity to improve how it leverages technology, meets evolving consumer demands, and conducts business to deliver the best results possible…in the shortest timeframe…at an affordable price. But I know the exciting developments taking place within this industry, and I can tell you from firsthand experience that not all providers are created equally. I’ll talk a little more about that in a minute, but let me just narrow our focus a bit. Many factors define the future of health care, some we can control, others we can’t – Washington, D.C. and genetics are the first that spring to mind. But since we can’t spend the week here discussing this, I’m going to focus on three that are particularly relevant to the interoperability dialogue – consumers, advanced data analytics and care coordination.

First, we all know that consumer expectations continue to rise and expand. We’re not just competing within the healthcare industry, but beyond it. The seamless, convenient, secure experiences enjoyed in other facets of life – like retail, finance and transportation – are now expected in health care. It’s no longer about Provider A versus Provider B; it’s about Provider A compared against Starbucks, Amazon and Uber. This holds especially true among younger generations, who have grown up with real-time, on demand access to information. It doesn’t matter whether it’s to answer a random question, pay a bill, listen to music or get directions – accurate information is readily available…and personal information is safeguarded. Grocery shopping and buying clothes no longer require a trip to the store. You can order online or on an app and have anything shipped to your house – shopping that’s convenient for you, conducted privately, securely and on your timeframe.  Consumers expect higher levels of service to get what they want, when they want it. They also expect greater value and transparency. They want to know how much something is going to cost (before buying it) and how it’s supposed to perform (or its quality). They’ll determine for themselves what constitutes value.

So what are the implications of this for health care? When we talk of healthcare consumers, we have to consider both the patient and those who provide the care. The tools and technologies we use to take care of people have to work well together in order to be useful to clinicians and other caregivers. The more cohesive the toolset, the better able we are to meet consumer expectations – and we all know that satisfaction has real implications for the bottom line.

Health care is often thought of in two contexts – one at the individual level and one at the population level. The need to deliver person-centered care for individuals and manage the health of populations will continue to grow in importance.  At HCA, we have a 50-year tradition of providing patient-centered care, but the expectations for patients have changed. Traditionally when we have conducted consumer research about one of our facilities, satisfaction related to the overall outcome, and people tended to be generous in their assessments.  Well today, things are different.  Now patient-centric care means making my care about me. Timely care means not only when I need it, but when I want it. Convenience is about not just whether there is a hospital close enough to my home to make me feel safe, it’s about a network for multi-level care facilities that are available where and when I want to access that care. And, the care is tailored to my unique biological, genetic and social factors, as well as my cultural and language preferences. Consumers will continue to demand greater value and emphasize outcomes that are meaningful to them, especially as healthcare costs take up more of their household budgets. They will further embrace digital and social media platforms to share their experiences and increase transparency, so providers need to be prepared for growing scrutiny and readily respond to feedback. At HCA, we have developed an extensive reputation management team whose sole purpose is to monitor and engage with consumers of care from our facilities, to ensure their experiences are satisfactory, and if we fall short of the mark, to intervene – real-time – and resolve whatever issues those patients or their caregivers may have.

Population health is about the distribution and determinants of health outcomes. It focuses on illness prevention and management of illness when it is present. Aspects of population health management include nutrition guidelines, encouragement and availability of appropriate physical activity, assistance with tobacco cessation and avoidance, and addressing vulnerabilities such as poverty, literacy and access to care. Healthy consumers at the individual level lead to healthier populations, so it’s imperative that we establish meaningful relationships with those we care for and engage them in managing their health. We also seek to proactively manage entire populations rather than being reactive and treating those who present at the hospital or office with symptoms. We are fortunate in Middle Tennessee to have the support and engagement of leaders like Mayor Berry and Governor Haslam, who have initiated and advanced programs at the community and state levels, to support and encourage wellness and access to care, particularly for some of our most vulnerable populations. All of this, of course, relies on data.

This brings us to the second factor in the future of health care, advanced data analytics. Advanced data analytics fuels growth and competition, serves as a primary driver of both patient-centered care and population health management, and enables data-driven quality improvement and scientific discovery. It’s predicated on the ability to move from capturing data to creating knowledge and applying wisdom.

The term big data has become commonplace in health care. Its role is to help us see and understand the relationships within and among pieces of information. These include hidden patterns, unknown correlations, trends, preferences and other information useful to clinical care and operations. Big data are defined by the three V’s – volume, variety and velocity. Volume refers to the amount of data. HCA, for example, has generated over 120 petabytes – that’s enough to fill the planet Jupiter with data. The scale at which we can learn and make discoveries is tremendous. Variety refers to the different types of data. We have to be able to learn from both structured data, like lab results and electronic medication orders, and the more complicated unstructured data, like images and doctor’s notes. I recently returned from a health care study mission in London with the Nashville Health Care Council, and during one session we were given a presentation by a duo of researchers whose company was acquired by Google. When I asked them about their experiences with unstructured data, they indicated this was a challenging area, one that is difficult to mine for useful information.  But I will tell you that HCA is applying big data analysis in unstructured spaces, to glean information in the clinical, communications and billing spaces. We have the ability to identify lung cancer tumors that might otherwise have gone undetected because their presence in a scan was noted as a secondary care issue; we can identify the appropriate ways in which to address the concerns of patients based on stated cultural reference points that are important to them; and we can use language in billing disputes with payors that creates a greater opportunity for success.  All of these advancements stem from analysis of unstructured big data.

Velocity refers to the speed of data processing, which has been drastically reduced by advances in computing power. Our aim is to achieve consistent, real-time analytics to assist clinicians at the point of decision. You can add a fourth V for veracity, which refers to the quality of the data and our ability to trust their accuracy.

Analytics is a never-ending realm of discovery. Efforts to build the collective body of wisdom pertaining to the human condition, precisely diagnose conditions, and develop targeted treatments will continue to grow. It was groundbreaking when the human genome was sequenced in 2003. Today, researchers have expanded beyond genomics (study of the genome) to include the study of proteins, the study of metabolism, and the study of microbes. The more detailed our knowledge, the more precise the person-centered care will be.

The broader our knowledge of individuals, the better we can help them as well. Health care would benefit from greater integration of nontraditional sources of data that account for environmental and socio-economic factors affecting the people for whom we care. Your doctor doesn’t know how often you eat hot chicken and ice cream, but your credit card does. This type of information could aid, for example, in predicting which of our patients are more likely to be readmitted after surgery. It might not be the individual with the least favorable clinical metrics; rather, it’s the person with the low credit score, which could indicate they don’t have the necessary support network to aid in their recovery. If we have a more complete picture of what is going on with an individual, we can better cater to his or her needs. We also can better understand the decision tree linking care choices to outcomes.

Advanced data analytics also further our goal of providing the safest, most efficient care possible. Real-time monitoring that integrates diverse clinical data points enables us to detect problems before a patient experiences decompensation. Consider the example of sepsis, a life-threatening bloodstream infection. Detecting its onset so that early intervention can be initiated can be the difference between life and death. The symptoms on their own – quickened breathing, accelerated heart rate, unusually high or low core temperature, and abnormally high or low white blood cell count – may not trigger concern as stand-alone data points. However, when taken together, we see a different picture – one that an algorithm is better suited to detect than a busy clinician. HCA is piloting a project that assists our caregivers with detection of sepsis in patients, a capability that is offering earlier detection of as much as 24 hours, and can be a critical advantage in fighting the deadly effects of sepsis.

Let’s turn to our third factor, care coordination. The National Academy of Medicine identifies care coordination as a key strategy with the potential to improve the effectiveness, safety, and efficiency of the U.S. healthcare system. Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care. The patient’s needs and preferences are known ahead of time and securely communicated at the right time to the right people. Well-designed, targeted care coordination can improve outcomes for everyone – patients, providers and payors. It’s essential that coordination reach across all aspects of the care continuum – hospitals, physician offices, pharmacies, first responders, long-term care facilities, home health, palliative care, community-based services, and payors. The length of this list speaks to the complexity of care coordination.

Care coordination is further exacerbated by the complexity of the needs facing an aging population with a higher prevalence of chronic disease and co-morbidities. We need robust coordination to improve their outcomes and care experience. Yet, these individuals are treated in a multitude of care settings that vary in their ability to coordinate care.

Importance of Interoperability

The common thread to satisfying consumers and enabling advanced data analytics and seamless care coordination is interoperability. Interoperability is the ability of devices and systems to exchange and use electronic information from other devices and systems without special effort on the part of the user. In health care, this speaks to the capability of our technical underpinnings to support data liquidity – when patient information moves freely and securely from the point of care — be that a hospital bed, doctor’s office or someone’s home– to wherever it is needed, from a clinical decision-making app or electronic health record to an analytics engine, clinical trial repository or public health registry. Interoperability of the technologies used in patient care enables the liquidity of data, without which it is more difficult to meet our goals of providing individualized care and managing the health of populations.

Unfortunately, health care is the only major industry that lacks an agreed-upon architecture for connecting the technologies and applications used across the continuum of care. This leaves the vast majority of medical devices, electronic health records and other IT systems unable to exchange information with ease at an affordable cost. Various systems and equipment typically are purchased from different manufacturers and each comes with its own proprietary interface technology. This means hospitals have to spend scarce time and money setting up each technology in a different way, instead of being able to rely on a consistent means for connectivity. Furthermore, hospitals usually have to invest in separate “middleware” systems to pull together all the disparate pieces of technology to feed data from bedside devices to EHRs, data warehouses and other applications that aid in clinical decision-making, research, analytics and consumer engagement. Many, especially older, devices don’t even connect; they require manual reading and data entry. As a nation, we employ hundreds of thousands of people to deal with this inefficiency.

The current lack of interoperability can compromise patient safety, undermine care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year. In fact, one study found that the lack of medical device interoperability costs the U.S. health system over $30 billion a year. As you would expect, it also impedes innovation, which may be the biggest missed opportunity for health care. Innovators in health care face significant obstacles accessing data, validating solutions, integrating into highly-configured environments, and scaling implementations across varied settings. As a result, the innovation community often steers clear of the healthcare market because navigating it simply is too difficult.  So the entrenched, proprietary interests we need to disrupt for advancement become further entrenched.

By contrast, the seamless exchange of information would improve care, increase operational efficiency and lower costs. It would facilitate care coordination, enable informatics and advanced analytics, reduce clinician workload and increase the return on existing technologies. To realize these benefits, we must rethink how to connect the disparate pieces involved in end-to-end patient care both within and across care settings. We need to repair the technical architecture supporting health care so we have a solid foundation upon which to innovate and develop solutions that will transform care for our nation.

Opportunity for Nashville

This leads us to the opportunity for Nashville. Our unparalleled expertise in how to deliver care positions us to disrupt the status quo. We have the leverage of a $78 billion healthcare industry to compel change and drive innovation. The time is ripe to make ourselves known for the number of lives we improve, not just the number of beds we manage. Our healthcare community encompasses the entire continuum of care, and we can demonstrate how to make end-to-end interoperability a reality, reaping its benefits for our citizens and businesses alike.

We are fortunate that the Center for Medical Interoperability chose Nashville as its headquarters. For those less familiar with the Center, it’s a nonprofit cooperative research and development lab founded by health systems to simplify and advance data-sharing among medical technologies and systems. The Center provides a centralized, vendor-neutral approach to performing technical work that enables person-centered care, testing and certifying devices and systems, and promoting the adoption of scalable solutions. I have the privilege of serving on the board of directors alongside several Nashville healthcare leaders, including Dr. Mike Schatzlein, who chairs the board.

Nashville can be a living lab for data liquidity. Our collaborative culture, coupled with the depth and breadth of our healthcare community, enable us to better integrate the many determinants of health – genetic, biological, environmental, socio-economic, lifestyle and wellness. We can forge private-public partnerships that innovate approaches to freely and securely sharing data in service of patient-centered care and population health.

So what does this all mean?  In short, future health care will be guided by consumer expectations, informed by advanced data analytics, and supported by robust care coordination. To ensure data liquidity and the best possible outcomes, we must achieve end-to-end interoperability across the continuum of care. Nashville has unique advantages to emerge as a true leader in driving healthcare transformation, and we cannot let this window of opportunity close. Thank you.