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Tag: Interoperability

ONC & CMS Proposed Rules | Part 2: Interoperability

By DAVE LEVIN MD 

The Office of the National Coordinator (ONC) and the Centers for Medicare and Medicaid (CMS) have proposed final rules on interoperability, data blocking and other activities as part of implementing the 21st Century Cures Act. In this series, we will explore the ideas behind the rules, why they are necessary and the expected impact. Given that these are complex and controversial topics open to interpretation, we invite readers to respond with their own ideas, corrections and opinions. You can find Part 1 of the series here

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In 2016, Congress enacted the 21st Century Cures Act with specific goals to “advance interoperability and support the access, exchange and use of electronic health information.” The purpose was to spur innovation and competition in health IT while ensuring patients and providers have ready access to the information and applications they need.

The free flow of data and the ability for applications to connect and exchange it “without special effort” are central to and supported by a combination of rules proposed by ONC and CMS. These rules address both technical requirements and expected behaviors. In this article, we look at specific technical and behavioral requirements for interoperability. Future articles will examine data blocking and other behavioral issues.

Compatible “Plugs and Sockets”

The proposed rules explicitly mandate the adoption and use of application programming interface (API) technology (or a successor) for a simple reason: APIs have achieved powerful, scalable and efficient interoperability across much of the digital economy. Put simply, APIs provide compatible “plugs and sockets” that make it easy for different applications to connect, exchange data and collaborate. They are an essential foundation for building the next generation of health IT applications. (Note: readers who want to go deeper into APIs can do so at the API Learning Center).

APIs are versatile and flexible. This makes them powerful but can also lead to wide variations in how they work. Therefore, ONC is proposing that certified health IT applications use a specific API based on the Fast Healthcare Interoperability Resources (FHIR) specification. FHIR is a consensus standard developed and maintained by the standards development organization (SDO) Health Level–7 (HL7). Mandating the use of the FHIR standard API helps to ensure a foundational compatibility and basic interoperability. This gives API technology suppliers (like EHR vendors) a clear set of standards to follow in order to fulfill the API requirement. It also ensures “consumers” of that API (like hospitals and health IT developers), have consistency when integrating applications.

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Interoperability and Data Blocking | Part 1: Fostering Innovation

By DAVE LEVIN MD 

The Office of the National Coordinator (ONC) and the Centers for Medicare and Medicaid (CMS) have published proposed final rules on interoperability and data blocking as part of implementing the 21st Century Cures act. In this series we will explore the ideas behind the rules, why they are necessary and the expected impact. Given that these are complex, controversial topics, and open to interpretation, we invite readers to respond with their own ideas, corrections, and opinions.

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Health IT 1.0, the basic digitalization of health care, succeeded in getting health care to stop using pens and start using keyboards. Now, Health IT 2.0 is emerging and will build on this foundation by providing better, more diverse applications. Health care is following the example set by the rest of the modern digital economy and starting to leverage existing monolithic applications like electronic health records (EHRs) to create platforms that support a robust application ecosystem. Think “App Store” for healthcare and you can see where we are headed.

This is why interoperability and data blocking are two of the biggest issues in health IT today. Interoperability – the ability of applications to connect to the health IT ecosystem, exchange data and collaborate – is a key driver of the pace and breadth of innovation. Free flowing, rich clinical data sets are essential to building powerful, user-friendly applications.  Making it easy to install or switch applications reduces the cost of deployment and fosters healthy competition. Conversely, when data exchange is restricted (data blocking) or integration is difficult, innovation is stifled.

Given the importance of health IT in enabling the larger transformation of our health system, the stakes could hardly be higher. Congress recognized this when it passed the 21st Century Cures Act in 2016. Title IV of the act contains specific provisions designed to “advance interoperability and support the access, exchange, and use of electronic health information; and address occurrences of information blocking”. In February 2019, ONC and CMS simultaneously published proposed rules to implement these provisions.

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The Futility of Patient Matching

By ADRIAN GROPPER, MD

The original sin of health records interoperability was the loss of consent in HIPAA. In 2000, when HIPAA (Health Insurance Portability and Accountability Act) first became law, the Internet was hardly a thing in healthcare. The Nationwide Health Information Network (NHIN) was not a thing until 2004. 2009 brought us the HITECH Act and Meaningful Use and 2016 brought the 21st Century Cures Act with “information blocking” as clear evidence of bipartisan frustration. Cures,  in 2018, begat TEFCA, the draft Trusted Exchange Framework and Common Agreement. The next update to the draft TEFCA is expected before 2019 which is also the year that Meaningful Use Stage 3 goes into effect.

Over nearly two decades of intense computing growth, the one thing that has remained constant in healthcare interoperability is a strategy built on keeping patient consent out of the solution space. The 2018 TEFCA draft is still designed around HIPAA and ongoing legislative activity in Washington seeks further erosion of patient consent through the elimination of the 42CFR Part 2 protections that currently apply to sensitive health data like behavioral health.

The futility of patient matching without consent parallels the futility of large-scale interoperability without consent. The lack of progress in patient matching was most recently chronicled by Pew through a survey and a Pew-funded RAND report. The Pew survey was extensive and the references cite the significant prior efforts including a 100-expert review by ONC in 2014 and the $1 million CHIME challenge in 2017 that was suspended – clear evidence of futility.

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Hoarding Patient Data is a Lousy Business Strategy: 7 Reasons Why

By VINCE KURAITIS & LESLIE KELLY HALL

Vince Kuraitis

Leslie Kelly Hall

Among many healthcare providers, it’s been long-standing conventional wisdom (CW) that hoarding patient data is an effective business strategy to lock-in patients — “He who holds the data, wins”. However…we’ve never seen any evidence that this actually works…have you?

We’re here to challenge CW. In this article we’ll explore the rationale of “hoarding as business strategy”, review evidence suggesting it’s still prevalent, and suggest 7 reasons why we believe it’s a lousy business strategy:

  1. Data Hoarding Doesn’t Work — It Doesn’t Lock-In Patients or Build Affinity
  2. Convenience is King in Patient Selection of Providers
  3. Loyalty is Declining, Shopping is Increasing
  4. Providers Have a Decreasingly Small “Share” of Patient Data
  5. Providers Don’t Want to Become a Lightning Rod in the “Techlash” Backlash
  6. Hoarding Works Against Public Policy and the Law
  7. Providers, Don’t Fly Blind with Value-Based Care

Background

In the video below, Dr. Harlan Krumholz of Yale University School of Medicine capsulizes the rationale of hoarding as business strategy.

We encourage you to take a minute to listen to Dr. Krumholz, but if you’re in a hurry we’ve abstracted the most relevant portions of his comments:

“The leader of a very major healthcare system said this to me confidentially on the phone… ‘why would we want to make it easy for people to get their health data…we want to keep the patients with us so why wouldn’t we want to make it just a little more difficult for them to leave.’ …I couldn’t believe it a physician health care provider professional explaining to me the philosophy of that health system.”

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Ensuring that the 21st Century Cures Act Health IT Provisions Promotes Interoperability and Data Exchange

By KENNETH D. MANDL, MD; DAN GOTTLIEB;
JOSH C. MANDEL, MD

Josh Mandel

Kenneth Mandl

Dan Gottlieb

The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”

After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.

Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.

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In Search of Intra-Aero-Bili-ty

Another one of my favorites, although this one is much more recent than those published so far–dating back to only March 2015. It was the written version of a talk I gave in September 2014 following the birth of my son Aero on August 26, 2014. So if we are discussing birthdays (and re-posting classics as, yes, it’s still THCB’s 15th birthday week!) we might as well have one that is literally about the confluence of a birthday and the state of health IT, health business, care for the underserved and much more!

Today is the kick-off of the vendor-fest that is HIMSS. Late last week on THCB, ONC director Karen De Salvo and Policy lead Jodi Daniel slammed the EMR vendors for putting up barriers to interoperability. Last year I had my own experience with that topic and I thought it would be timely to write it up.

I want to put this essay in the context of my day job as co-chairman of Health 2.0, where I look at and showcase new technologies in health. We have a three part definition for what we call Health 2.0. First, they must be adaptable technologies in health care, where one technology plugs into another easily using accessible APIs without a lot of rework and data moves between them. Second, we think a lot about the user experience, and over eight years we’ve been seeing tools with better and better user experiences–especially on the phone, iPad, and other screens. Finally, we think about using data to drive decisions and using data from all those devices to change and help us make decisions.

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This is the Cal Pacific Medical Center up in San Francisco. The purple arrow on the left points to the door of the emergency entrance.

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Cal Pacific is at the end of that big red arrow on the next photo. On that map there’s also a blue line which is my effort to add some social commentary. To the top left of that blue line in San Francisco is where the rich people live, and on the bottom right is where the poor people live. Cal Pacific is right in the middle of the rich side of town, and it’s where San Francisco’s yuppies go to have their babies.
Slide49
Last year, on August 26, 2014 at about 1 am to be precise, I drove into this entrance rather fast. My wife was next to me and within an hour, we were upstairs and out came Aero. He’s named Aero because his big sister was reading a book about Frankie the Frog who wanted to fly and he was very aerodynamic. So when said, “What should we call your little brother?” She said, “I want to call him Aerodynamic.” We said, “OK, if he comes out fast we’ll call him the aerodynamic flying baby.” So he’s called Aero for short.

Slide51
Thus began the Quest for Intra-Aero-Bili-ty –a title I hope will grow on you. The Bili part will become obvious in a paragraph or two.

Something had changed since we had been at Cal Pacific three years earlier for the birth of Coco, our first child.

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If you look carefully at the top of Amanda’s head, there’s now a computer system. Like most big provider systems, Sutter–Cal Pacific’s parent company–has installed Epic and it’s in every room or on a COW (cart on wheels). Essentially we have spent the last few years putting EMRs in all hospitals. This is the result of the $24+ billion the US taxpayer (well, the Chinese taxpayer to be more accurate) has spent since the 2010 rollout of the HITECH act.Continue reading…

Health in 2 point 00, Episode 9

Jessica DaMassa asks Matthew Holt his thoughts after the week that was HIMSS18. All in 2 minutes (well almost!). We hit on the speeches from all 3 head honchos at the new administration (Azar, Verma, Gottleib), Chrissy Farr’s article on interoperability and how very tall Magic Johnson is…

If you want to send in questions for next week, tweet @JessDaMassa or @boltyboy.

A New Pothole on the Health Interoperability Superhighway

On July 24, the new administration kicked off their version of interoperability work with a public meeting of the incumbent trust brokers. They invited the usual suspects Carequality, CARIN Alliance, CommonWell, Digital Bridge, DirectTrust, eHealth Exchange, NATE, and SHIEC with the goal of driving for an understanding of how these groups will work with each other to solve information blocking and longitudinal health records as mandated by the 21st Century Cures Act.

Of the 8 would-be trust brokers, some go back to 2008 but only one is contemporary to the 21stCC act: The CARIN Alliance. The growing list of trust brokers over our decade of digital health tracks with the growing frustration of physicians, patients, and Congress over information blocking, but is there causation beyond just correlation?

A recent talk by ONC’s Don Rucker reports:

One way to get data to move is open APIs, which the 21st Century Cures Act mandates by tasking EHR vendors to open up patient data “without special effort, through the use of application programming interfaces.”

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Independent Decision Support at the Point-of-Care for Both Patients and Physicians

flying cadeucii“We did not spend $35 Billion to create 5 data silos.” This was said by Vice President Biden at the beginning of Datapalooza on Monday and repeated by CMS’s Andy Slavitt on Tuesday. On Wednesday, at the Privacy and Security Datapalooza at HHS, I proposed a very simple definition of electronic health record (EHR) interoperability as the ability for patients and physicians to access independent decision support at the point of care regardless of what EHR system was being used.

Over the three days of Datapalooza, I talked to both advocates and officials about data blocking. In my opinion, current work on FHIR and HEART is not going to make a big dent in data blocking and would not enable independent decision support at the point of care. The reasons are:

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Interoperability: Faster Than We Think – An Interview with Ed Park

Screen Shot 2015-11-10 at 9.34.40 PM

Leonard Kish, Principal at VivaPhi, sat down with Ed Park, COO of athenaHealth, to discuss how interoperability is defined, and how it might be accelerating faster than we think.

LK: Ed, how do you define interoperability?

EP: Interoperability is the ability for different systems to exchange information and then use that information in a way that is helpful to the users. It’s not simply just the movement of data, it’s the useful movement of it to achieve some sort of goal that the end user can use and understand and digest.

LK:  So do you have measures of interoperability you use?

EP: The way we think about interoperability is in three major tiers. The first strata (1) for interoperability can be defined by the standard HL7 definitions that have been around for the better part of three decades at this point. Those are the standard pipes that are being built all the time.  So lab interoperability, prescription interoperability, hospital discharge summary interoperability. Those sort of basic sort of notes that are encapsulated in HL7.  The second tier (2) of interoperability we are thinking about is the semantic interoperability that has been enabled by meaningful use. The most useful thing that meaningful use did from an interop standpoint was to standardize all the data dictionaries. And by that I mean that they standardized the medication data dictionary, the immunizations, allergies and problems.

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