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Tag: Interoperability

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.
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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.

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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

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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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Defining Interoperability: An Interview with Grahame Grieve

flying cadeuciiGrahame Grieve is a long-time leader within HL7 and one of the key drivers behind FHIR. He chats with Leonard Kish about what’s been happening and what’s ahead for interoperability.

LK: First tell me how you got into standards… it’s kind of an odd business to get into.  Why have you chosen this and why are you excited about it?

G: It happened by accident.  I was working for a vendor and we were tasked with getting some exchanges and I wanted them to be right the first time.  That was the philosophy of the vendor.  If we did it right the first time, then we wouldn’t have to keep revisiting and that meant that using the standards correctly.  The more I got involved, the more I discovered that it wasn’t obvious how to do that…and that the standards themselves weren’t good.  I felt personally that we need really good standards in healthcare.  So it became a personal mission and I got more involved through the company I was working for and eventually I left so I could continue doing what I wanted doing with the standards – I enjoy the community aspect of the standards and feel very strongly that it’s worth investing time in and I had the opportunity to build a business out of it, which not many people do. So now I freelance in standards development and standards implementation.

LK: There’s a lot of talk in Congress about the lack of interoperability and everyone probably has their own definition. Do you have a working definition of interoperability or is there a good definition you like for interoperability?

G: The IEEE definition to get data from one place to another and use it correctly is pretty widely used.  I guess when you’re living and breathing interoperability you’re kind of beyond asking about definitions.

LK: Are there ways to measure it then?  Some people talk about different levels; data interoperability, functional interoperability, semantic interoperability.  Are there different levels and are there different ways to measure interoperability?

G: We don’t have really have enough metrics.  It’s actually relatively easy to move data around.  What you’ve got to do is consider the costs of moving it, the fragility of the solution, and whether the solution meets the user’s needs around appropriateness, availability, security, and consent.  Given the complexity of healthcare and business policy, it’s pretty hard to get a handle on those things.  One thing that is key is that interoperability of data is neither here nor there in the end because if providers continue with their current work practices, the availability of data is basically irrelevant, because they treat themselves as an island. They don’t know how depend on each other.  So I think the big open area is clinical interoperability.

LK: Interoperability in other verticals mostly works.  We hear talk about Silicon Valley and open APIs.  There’s perhaps less commotion about standards, maybe because there are less conflicting business interests than in healthcare.  Why is healthcare different?

G: First of all – from an international perspective, I don’t think other countries are by and large better off or different (where incentives are different).  They all have the same issues and even though they don’t have the business competition or the funding insanity that you do in the US, they still have the same fundamental problems.  So I hear a lot of stuff from the US media about that and I think it’s overblown.  The problem is more around micro level transactions and motivations for them and fundamentally the same problem around getting people to provide integrated clinical care when the system works against them doing that.                  

LK:  So can you give me an example of how things are maybe the same with NHS or another country vs. the US in terms of people not wanting to exchange clinical data?

G: In Australia, there’s a properly funded medical health care system where the system is overwhelmed by the volume of work to be provided.  No one get’s any business benefit from not sharing content with other people. Still, because you have to invest time up ahead to exchange data and other people get the benefits later, there’s very low participation rates for any kind of voluntary data sharing schemes that you set up. There’s scandalously low adoption rates.  And that’s not because it’s not a good business idea to get involved but it’s because the incentives are misaligned at the individual level (and the costs are up front).

LK: Right, so it’s maybe it’s also a lack of consumer drive?  It’s there data and you’d expect the incentives to align behind them, but they don’t ask and don’t get, maybe because we (or our providers) only access your record when we really need them.  It’s not like banking or email or other things we use on a daily basis?    

G: Probably that’s part of it, but from a consumer’s point of view, what does it do for them getting access to their data?  Continue reading…

ONC’s Interoperability Plan: a Day Late and $19bn Short

Screen Shot 2015-10-21 at 8.40.34 AMEarlier this month, the Office of the National Coordinator for Health Information Technology released an update to Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. The roadmap was first announced back in January, and the changes shared this month aren’t significant.

Ultimately, it calls for all healthcare providers nationwide to be able to send and receive electronic clinical information by the end of 2017.

This is a good plan on the surface, although it comes six years and millions of dollars late, and like other programs it may be more cumbersome that it first seems. Essentially, there are three facets:

1) Data standards to format and request/receive data

2) Incentives (again!)

3) Governance

Despite the intention to move data across the Union, each state will have the right to create its own unique rules on how to manage the exchange of information. This is a problem as we have seen before in the simple Case of e-prescription routing. A few states make it almost impossible to send e-scripts and layer on their own special form of bureaucracy. This inhibits the ultimate goal of reducing costs and errors and increasing Efficiency at the expense of both providers and patients.

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ONC Report on Health Information Blocking: A Solid Double, But NOT a Home Run

flying cadeuciiLast Friday ONC (the Office of the National Coordinator for Health IT) released a long-awaited Report On Health Information Blocking. The ONC blog capsulizes the report:

Health information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. Our report examines the known extent of information blocking, provides criteria for identifying and distinguishing it from other barriers to interoperability, and describes steps the federal government and the private sector can take to deter this conduct.

We were struck with two major reactions to the ONC Info Blocking Report:

  • It’s a solid double: it does a credible job of recognizing that the major problems of interoperability and blocking are not technical or due to a lack of standards, but rather due to business practices and business models. The report also proposes a baseline of potential solutions.
  • It’s not a home run: the report misses the opportunity to describe a comprehensive approach to combat information blocking.Continue reading…

The Blocking of Health Information Undermines Interoperability and Delivery Reform

The secure, appropriate, and efficient sharing of electronic health information is the foundation of an interoperable learning health system—one that uses information and technology to deliver better care, spend health dollars more wisely, and advance the health of everyone.

Today we delivered a new Report to Congress on Health Information Blocking that examines allegations that some health care providers and health IT developers are engaging in “information blocking”—a practice that frustrates this national information sharing goal.

Health information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. Our report examines the known extent of information blocking, provides criteria for identifying and distinguishing it from other barriers to interoperability, and describes steps the federal government and the private sector can take to deter this conduct.

This report is important and comes at a crucial time in the evolution of our nation’s health IT infrastructure. We recently released the Federal Health IT Strategic Plan 2015 – 2020 and the Draft Shared Nationwide Interoperability Roadmap. These documents describe challenges to achieving an interoperable learning health system and chart a course towards unlocking electronic health information so that it flows where and when it matters most for individual consumers, health care providers, and the public health community.

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