1 Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation Session INT3, February 11, 2019 Steven Lane, MD, MPH, FAAFP Clinical Informatics Director - Privacy, Information Security & Interoperability, Sutter Health
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Transcript
1
Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
Session INT3 February 11 2019Steven Lane MD MPH FAAFP
Clinical Informatics Director - Privacy Information Security amp Interoperability Sutter Health
2
Steven Lane MD MPH FAAFP has no conflicts of interest to report
Conflict of Interest
3
The push for advancing interoperability and increased demand for health information exchange has given rise to expanding stakeholder groupsThis has exposed a variety of gaps in data exchangeIn this session we will identify and explore what gaps exist and discuss innovative ways in which data is being exchanged to help diminish these gaps
Presentation Purpose
4
1 Identify barriers in data reciprocity and data exchange when it comes to expanding stakeholder groups
2 Recognize the impact of stakeholder gaps in regards to patient and value-based care
3 Describe innovative ways in which some stakeholders are addressing disparities in data exchange
Learning Objectives
5
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovations bull Conclusions
Outline
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
2
Steven Lane MD MPH FAAFP has no conflicts of interest to report
Conflict of Interest
3
The push for advancing interoperability and increased demand for health information exchange has given rise to expanding stakeholder groupsThis has exposed a variety of gaps in data exchangeIn this session we will identify and explore what gaps exist and discuss innovative ways in which data is being exchanged to help diminish these gaps
Presentation Purpose
4
1 Identify barriers in data reciprocity and data exchange when it comes to expanding stakeholder groups
2 Recognize the impact of stakeholder gaps in regards to patient and value-based care
3 Describe innovative ways in which some stakeholders are addressing disparities in data exchange
Learning Objectives
5
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovations bull Conclusions
Outline
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
3
The push for advancing interoperability and increased demand for health information exchange has given rise to expanding stakeholder groupsThis has exposed a variety of gaps in data exchangeIn this session we will identify and explore what gaps exist and discuss innovative ways in which data is being exchanged to help diminish these gaps
Presentation Purpose
4
1 Identify barriers in data reciprocity and data exchange when it comes to expanding stakeholder groups
2 Recognize the impact of stakeholder gaps in regards to patient and value-based care
3 Describe innovative ways in which some stakeholders are addressing disparities in data exchange
Learning Objectives
5
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovations bull Conclusions
Outline
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
4
1 Identify barriers in data reciprocity and data exchange when it comes to expanding stakeholder groups
2 Recognize the impact of stakeholder gaps in regards to patient and value-based care
3 Describe innovative ways in which some stakeholders are addressing disparities in data exchange
Learning Objectives
5
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovations bull Conclusions
Outline
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
5
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovations bull Conclusions
Outline
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
6
bull Definitions bull Degrees of Interoperabilitybull Benefits
Background
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
7
ldquoThe term lsquointeroperabilityrsquo with respect to health information technology means health information technology that ndasha enables the secure exchange of electronic health information
with and use of electronic health information from other health information technology without special effort on the part of the user
b allows for complete access exchange and use of all electronically accessible health information forauthorized use under applicable State or Federal law
c does not constitute information blocking as defined in section 3022(a) of the Public Health Service Act as amended
21st Century Cures Act
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
8
bull Interoperability is the ability of different information systems devices or applications to connect in a coordinated manner within and across organizational boundaries to access exchangeand cooperatively use data amongst stakeholders with the goal of optimizing the health of individuals and populations
HIMSS Defining Interoperability in the Health Ecosystem ndash Available for public comment until March 23 2019 ndash httpswwwhimssorglibraryinteroperability-standardswhat-is-interoperability
HIMSS
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
9
bull Technicalndash Foundational connectivity
bull Syntactic ndash Data Liquidityndash Common data formattingndash Maintain field level interpretation
bull Semantic ndash Data Portabilityndash Codified data mapped to standard vocabulariesndash Maintain meaning
bull Functional ndash Data Utilityndash Integration into local workflows clinical and analytical processes
Degrees of Interoperability
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
10
bull Triple Aimndash Value ndash Quality Costndash Health ndash individual populationndash Satisfaction experience ndash patient provider care team
bull Impact on carendash Direct patient carendash Population health management
bull Value based care Alignment of incentives gt exchange bull Patient safety
ndash 250000 deaths year due to preventable medical errors
Benefits of Interoperability
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
11
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
12
bull Interoperability Methodologiesbull Connectivity Landscapebull Evolving Capabilitiesbull Metrics
Current State
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
13
bull Telephone postal mail FAXbull Secure file transferbull HL7 Version 2 interfaces ndash PUSH
ndash Within and between institutionsndash Focused use cases Ordersresults ADT registry reporting
bull Document Exchange ndash PUSH amp PULLndash Clinical Document Architecture (CDA) ndash HL7 Version 3ndash Consolidated CDA (C-CDA) ndash 12 document types 70 sections
bull Fast Healthcare Interoperability Resources (FHIRreg) ndash PULL gt PUSHndash Modular data element exchangendash Supports Application Programming Interfaces (APIs)
Interoperability Methodologies
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
14
bull Health Information Exchanges (HIEs)ndash Centralized data stores +- value added servicesndash Regional and use-specific (eg payers research)
bull Direct Interoperabilityndash DirectTrustndash Health Information Service Providers (HISPs)
bull National networks ndash eHealth Exchangendash Single and multi-vendor networks
bull Exchange frameworks ndash Connect networksndash Carequalityndash Trusted Exchange Framework amp Common Agreement (TEFCA)
Connectivity Landscape
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
15
Evolving Capabilities
Traditional
bull Point-to-point connections
bull HL7 V2 interfacesbull Individual and
community trust agreements
bull ADT feeds to central repositories (HIEs)
bull Ad hoc CDA document query push
bull Individual accessportal PDF
Transitional
bull HIPAAHITAC MUPIbull Transitions of Carebull Treatment use casesbull Federated
architecture and trustbull Automated queries at
point of carebull Patient summary CCDbull Discrete PAMI databull Minimum necessary
challenges
bull Individual accessVDT capability CCD
Innovative
bull More bull Participantsbull Use casesbull Discrete databull C-CDA templates
bull Automationbull Pop health bulk
querybull Patient Centered
Data Homebull FHIR Read gt write
bull Individual accessapps APIs
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
16
While there are as yet no accepted standards by which to measure interoperability there have been dramatic and progressive increases in the volume of transactions and the types and utility of data exchanged
Sourcesbull Office of the National Coordinator for Health Information
Technology (ONC) reportsbull American Hospital Association (AHA) surveysbull Carequality document exchange metricsbull DirectTrust transaction volume
Metrics
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
17
ONC Measurement Framework
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
18
bull 2017 Datandash 70 of hospitals participated in nationwide HIE networksndash 51 of hospitals had necessary patient data available
from outside of their systems at point of carebull 53 of those organizations able to integrate received
health data into their EHR
bull Small rural and critical access hospitals had lower rates of using electronic methods to exchange summary of care records compared to their counterparts
ONC
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
19
Hospital Interoperability
AHA Survey
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
20
Patient Access amp Exchangebull 72 of hospitals have the capability for patients to electronically
view download and transmit their health information
AHA Survey
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
21
Carequality ndash Document Exchange
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
December 2016 - December 2018
Cumulative total = 114 M
~14M documents exchanged mo
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
22
DirectTrust ndash Transactions
0
20000000
40000000
60000000
80000000
100000000
120000000
2014 2015 2016 2017 2018
110253902
Number of Send and Receive Direct Transactions between Trusted Endpoints by Quarter
~37M Transactions month
Cumulative total = 607 M
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
23
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
24
Stakeholders Identified in TEFCA-1
PROVIDERSProfessional care providers who deliver care across the continuum not limited to but including ambulatory inpatient long-term and post-acute care (LTPAC) emergency medical services (EMS) behavioral health and home and community based services
INDIVIDUALSPatients caregivers authorized representatives and family members serving in a non-professional role
FEDERAL AGENCIESFederal state tribal and local governments
TECHNOLOGY DEVELOPERSOrganizations that provide health IT capabilities including but not limited to electronic health records health information exchange (HIE) technology analytics products laboratory information systems personal health records Qualified Clinical Data Registries (QCDRs) registries pharmacy systems mobile technology and other technology that provides health IT capabilities and services
PAYERSPrivate payers employers and public payers that pay for programs like Medicare Medicaid and TRICARE
PUBLIC HEALTHPublic and private organizations and agencies working collectively to prevent promote and protect the health of communities by supporting efforts around essential public health services
HEALTH INFORMATION NETWORKS
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
25
bull Public Healthndash Surveillance and reportingndash Clinical services health centers dental nursing EMS
disaster services shelters outreach environmentalndash Coroners
bull Federal Government Agenciesndash Clinical services
Corrections DoDDHA Indian Health Serv Schools VAndash Research administration
AHRQ CDC DoC HHS HRSA NIH NLM ONCndash Law enforcement
More than meets the eye
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
26
bull Small rural and critical access hospitals and clinics bull Pediatrics ndash Excluded from Meaningful Use incentive programbull Telehealthbull Non-physicians ndash Dentistry Optometry Audiology Podiatrybull Therapies ndash Physical Occupational Speech etcbull Behavioral Health bull Substance abuse treatmentbull DMEbull EMSbull LTPACbull Home healthbull Complementary care ndash Naturopaths chiropractors acupuncturists homeopaths etc
Included in 2019 Quality Payment Program
Providers with limited connectivity
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
27
bull Researchndash Public private academic networks
bull Pharmacyndash Retail pharmaciesndash Pharmacy Benefit Management ndash Pharma companies ndash eg post marketing surveillance
bull Insurancendash Lifendash Disabilityndash Casualty
Additional Stakeholders
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
28
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
29
bull Evolvingcompeting standardsbull Data Utilitybull Other Barriers
Gaps
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
30
bull Governance ndash Varies by technology network HIObull Security and trust ndash Varies by technology network push vs pullbull Format and transport
ndash HL7 V2 C-CDA FHIR ndash Which to usebull Content
ndash Data ndash SDOs Information modeling initiativesndash Common Clinical Data Set ndash Evolving 2014 gt 2015 CEHRT standardndash US Core Data for Interoperability (USCDI) glide path ndash 2019 and beyondndash C-CDA templatesndash FHIR ndash Argonaut profiles US Core
bull Privacyndash Varies by state data typendash Personal data beyond HIPAA covered entities
Multitude of Standards
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
31
bull Access viewbull Ingestbull Interpret bull Integrate reconcilebull Incorporate into standard workflows
WithoutSpecialEffort
Data Utility
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
32
bull Economic barriersndash Business models and practicesndash Information Blocking ndash Pending final rulemaking
bull Inefficiency ndash System designndash Procurementndash Implementationndash Integrationndash Support
- Procuring Interoperability Achieving High-Quality Connected and Person-Centered Care Washington DC 2018
Other Barriers
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
33
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
34
bull EHR certification program ndash 2015 Edition requiring patient API accessbull Interoperability Standards Advisory bull Interoperability Proving Ground ndash Implementations bull Tech Lab Standards Coordination
bull DRAFT US Core Data for Interoperability (USCDI)bull DRAFT Trusted Exchange Framework amp Common Agreementbull PENDING proposed Information Blocking clarifications
bull OCR RFI regarding potential changes to HIPAA to improve information sharing for treatment and care coordination
HHSONC Support for Interoperability
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
35
bull Meaningful Use gt ldquoPromoting Interoperabilityrdquobull MyHealthEData
ndash Blue Button 20bull Beneficiary access to CMS claims data via FHIR APIs bull Required use of 2015 Certified EHR Technology (CEHRT)bull Includes patient data access via APIs exchange of the Common Clinical
Data Set Patient-directed exchangendash Performance Measures
bull Include electronic referral loops clinical information reconciliation real time drug formulary and PDMP queries
bull Proposalsndash Require interoperability as Medicare Condition of Participationndash Require Medicare Advantage plans to provide Blue Button 20 capabilities
CMS Support for Interoperability
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
36
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Innovationsbull Conclusions
Outline
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
37
bull Directbull Consolidated Clinical Document Architecture (C-CDA) bull Fast Healthcare Interoperability Resources (FHIRreg)bull Provider-Payer data exchangebull Consumer-mediated exchange
hellipPLUS MANY MORE
Innovations to close the gaps
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
38
bull Broadly implemented to support Transitions of Care (ToC) as required by Meaningful Use Stage 2
bull Successfully implemented innovative use cases ndash Query and push based on ADT events
bull Current CCD requested by amp sent to ED upon patient arrivalbull Care team notifications at time of hospitalED discharge ndash
To PCP care manager home care teamndash Results delivery ndash without point-to-point interfacesndash Care coordination messaging between care team membersndash Closed loop referrals ndash Now required by CMS
bull Cross-organization cross-vendorndash Fax gt Direct conversion ndash improved security integration
httpswwwdirecttrustorgwp-contentuploads201811Master-List-of-Direct-Interoperability-Success-Storiespdf
Direct - Beyond ToC
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
39
bull Leverages established technical interoperability standards to facilitate closed loop ambulatory referrals via Direct
ndash Supports the exchange of clinical and scheduling information between providers
bull Successfully tested across multiple EHR vendorsndash Being demoed in the HIMSS Interoperability Showcase
bull Future focusndash Acute to LTPAC transfersndash Insurance pre-authorization
360X
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
40
bull Clinicians identified challenges related CCD quality and usabilityndash Unacceptably large documentsndash Lack of clinical notes ndash Desire for encounter-specific documents in addition to
patient summary documentsndash Need for document version management
bull Carequality-CommonWell Joint Document Content Workgroup
Improving C-CDA Exchange
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
41
bull Workgroup Recommendationsndash Implementers shall support encounter-specific documents utilizing
specific C-CDA document templatesbull Progress Note Document ndash Outpatient encountersbull Discharge Summary Document ndash Inpatient encounters
ndash Limit data included in encounter documents to bull Information generated at the time of the encounterbull Patient level data eg Problems Medications Allergies
reviewed validated during encounterndash Respect time parameters for encounter document queries
bull Supports a consolidated longitudinal view of patient records including encounters from multiple institutions and vendors
Improving C-CDA Exchange
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
42
bull Release 11 Consultation Note2 Continuity of Care Document (CCD) 3 Diagnostic Imaging Report4 Discharge Summary 5 History and Physical6 Operative Note7 Procedure Note8 Progress Note 9 Unstructured Document
bull Content Testing Program
bull Release 210 Care Plan11 Referral Note12 Transfer Summary
C-CDA Document Types
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
43
bull Implementing Direct messagingbull Improvements to CCD section contentsbull C-CCD Data Quality Initiative
ndash Analyze received documents for completeness quality adherence to standards
ndash PAMI data procedures vitalsndash Focus on critical data access and patient safetyndash White Paper Interoperability Progress and Remaining Data
Quality Barriers of Certified Health Information Technologieshttpswwwintersystemscomisc-resourceswp-contentuploadssites24Interoperability_Progress_Remaining_Data_Quality_Barriers_Certified_Health_Information_Technologiespdf
VA Innovations
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
44
bull Release 4 ndash Published January 2 2019 ndash Normative standard
bull RESTful API XML and JSON formatsbull Terminology layer conformance frameworkbull Basic data typesbull Key Patient and Observation Resources
ndash Future changes will be backward compatible
HL7reg FHIRreg reg
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
45
Heat Wave The US is Poised to Catch FHIR in 2019
87 of hospitals 57 of clinicians using EHRs certified to use FHIR Release 2
10012018
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
46
bull Use casesndash Treatment
bull Case management ndash acute chronicbull Care coordination
ndash Healthcare Operationsbull Prior authorizationbull Quality reporting ndash HEDIS STARSbull Formulary management
ndash Paymentbull Utilization and appropriateness of care reviewbull Risk adjustment ndash HCC codingbull Claims adjudication
Payer-Provider Data Exchange
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
47
bull Policy issuesndash Minimum necessary requirements ndash vary by use casendash Self-pay restrictionsndash Release restrictions confidential datandash Re-purposing data
Payer-Provider Data Exchange
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
48
bull Technology solutionsndash Central repositories
bull Manifest Medex (CA)ndash C-CDA exchange
bull Carequalityndash FHIRreg
bull ONC-led FAST Initiative ndash Governance policy bull HL7 Da Vinci Project ndash IGs reference implementations
ndash Vendor network solutionsbull Moxe Healthbull Epic Payer Exchange
Payer-Provider Data Exchange
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
49
Da Vinci Project
Interoperability Showcase9100-49
bull Leveraging FHIRreg for payer-provider data exchange bull High priority use cases to support value based care
bull Quality Measure Collectionbull Clinical Data Exchangebull Pre-order Burden Reduction
Health Record Exchange
Clinical Data Exchange
Documentation Templates and
Coverage Rules
Gaps in Care amp Information
Coverage Requirements
Discovery
Performing Laboratory Reporting
Data Exchange for Quality Measures
Prior-Authorization
Support
Risk Based Contract Member
Identification
In HL7 ballot reconciliation as draft standard
Under active development
Planned 2019 Use Cases
Future Use CaseAlertsNotification (ADT)
Transitions in Care ER
admitdischargehellip
Patient Cost Transparency
Chronic Illness Documentation
forRisk Adjustment
Health Record Exchange Payer Data Exchange
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
50
Consumer-Directed Exchange in an Evolving App Ecosystem
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
51
bull NewWave Telecom amp Technologiesndash MyCareAI app ndash ldquoStandards-based consumer-controlled health
data convergence hubrdquobull Participating providers enroll Medicare beneficiariesbull App requests claims history via Blue Button (FHIR)bull Query for clinical data from providers based on claimsbull Aggregate and assemble longitudinal patient record bull Evaluate quality metrics identify risks for patient and populationbull Feedback to patient and providers (via regional health
information network)bull Offer services
bull wwwNewWaveio HIMSS Booth 509
Leveraging Blue Button 20
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
52
bull SAFE Healthndash Initial focus on sexual health STD testing and treatmentndash Integrate with Dating Apps to incentivize regular testing and
sharing of sexual health statusndash Home-grown EHR + interoperability
bull Labs for testing gt historical data access (FHIR)bull Pharmacies for e-prescribing amp delivery (HL7 V2)bull EHRs via Carequality for bidirectional exchange (C-CDA)bull Developing to the Apple Health API (FHIR)
bull wwwSafeHealthme
Telehealth Integration
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
53
bull Beta launch - January 24 2018bull 1162019 167 healthcare organizations offering FHIR API-based
access to data from 3 EHR vendors ndash AthenaHealth Cerner Epicbull LabCorp and Quest lab data access integrationbull Recent user survey 90 of users endorsed
ldquoThe smartphone solution improved their understanding of their own health facilitated conversations with their clinicians or improved sharing of personal health information with friends and familyrdquo
Dameff C Clay B Longhurst CA Personal Health RecordsMore Promising in the Smartphone Era JAMA 2019321(4)339-340
Apple Health Records
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
54
bull Patient-facing bull Service Providers
bull Telehealth
bull Care planspatient monitoring
Apps using Health Records data
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
55bull Source httpssupportapplecomen-usHT208647 as of 01162019
Apple Health Records Market Penetration
Number of hospitals by Zip Code live with Apple FHIR API access
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
56
Patient access to EHR data via APIs
0M
73M
117M 118M134M
151M 162M181M 182M 188M 191M197M
0
50
100
150
200
250
Jan18
Feb Apr May Jun Jul Aug Sept Oct Nov Dec Jan19
Milli
ons
bull Source httpstorchinsightcom
Individuals with potential access to the common clinical data setinformation in their EHR(s) via API access
vs ~80M US iPhone users
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
57
bull Backgroundbull Current Statebull Stakeholdersbull Gapsbull Federal supportbull Improvement innovation efforts bull Conclusions
Outline
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
58
bull WE HAVEndash Stakeholder engagementndash Mature standards ndash must continue to evolvendash Increasing Connectivity ndash varies across users technologies ndash Trust frameworks
bull Federal DURSA ndash eHealth Exchangebull DirectTrustbull Carequalitybull SHIECbull NATE
ndash Government supportndash HIT investment ndash $95B in 2018
Interoperability is within our reach
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
59
bull WE NEEDndash Interoperability by designndash Vendor development and user implementation to
bull Automate exchangebull Integrate data in workflowsbull Extend APIs beyond patient access and use
ndash Continued evolution of standards C-CDA FHIR Argonaut profilesndash Clarification and enforcement of Information Blocking rulesndash Finalize and implement a comprehensive TEFCAndash Implement the proposed USCDI glide path
bull ldquoOmicsrdquo data Device databull PGHD SDoH
ndash To KillTheFax
Interoperability is within our reach
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
60
bull With CommonWell and Carequality linked the biggest technical obstacle to widespread patient-record sharing has been removed
bull The healthcare industry is rapidly approaching the point where an organization using any of the major acute careambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort
bull Today the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate
KLAS ndash Interoperability 2018
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
61
bull HHS ONC Federal Advisory Committees ndash Work Groups and Task Forcesndash httpswwwhealthitgovtopicfederal-advisory-committeesmembership-
applicationbull ONC FHIR at Scale Taskforce (FAST) ndash Tiger Teams
ndash httpsoncprojectrackinghealthitgovwikidisplayTechLabSCTiger+Teamsbull The Sequoia Project ndash Interoperability Matters Workgroups
ndash httpssequoiaprojectorginteroperability-mattersbull Carequality ndash Advisory Committee Workgroups
ndash httpscarequalityorgget-involvedbull DirectTrust ndash Task forces
ndash httpswwwdirecttrustorg
Opportunities for Participation
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
62
bull Contact information
bull LaneSSutterHealthorg
bull emrdoc1
bull wwwlinkedincominsteven-lane-md
bull Please complete online session evaluation
Questions
- Analyze the Remaining Gaps as Data Exchange is Expanded to Broader Stakeholder Groups in Support of Innovation
- Conflict of Interest
- Presentation Purpose
- Learning Objectives
- Outline
- Background
- 21st Century Cures Act
- HIMSS
- Degrees of Interoperability
- Benefits of Interoperability
- Outline
- Current State
- Interoperability Methodologies
- Connectivity Landscape
- Evolving Capabilities
- Metrics
- ONC Measurement Framework
- ONC
- AHA Survey
- AHA Survey
- Carequality ndash Document Exchange
- DirectTrust ndash Transactions
- Outline
- Stakeholders Identified in TEFCA-1
- More than meets the eye
- Providers with limited connectivity
- Additional Stakeholders
- Outline
- Gaps
- Multitude of Standards
- Data Utility
- Other Barriers
- Outline
- HHSONC Support for Interoperability
- CMS Support for Interoperability
- Outline
- Innovations to close the gaps
- Direct - Beyond ToC
- 360X
- Improving C-CDA Exchange
- Improving C-CDA Exchange
- C-CDA Document Types
- VA Innovations
- HL7reg FHIRreg
- Heat Wave The US is Poised to Catch FHIR in 2019
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Payer-Provider Data Exchange
- Da Vinci Project
- Consumer-Directed Exchange in an Evolving App Ecosystem
- Leveraging Blue Button 20
- Telehealth Integration
- Apple Health Records
- Apps using Health Records data
- Apple Health Records Market Penetration
- Patient access to EHR data via APIs
- Outline
- Interoperability is within our reach
- Interoperability is within our reach
- KLAS ndash Interoperability 2018
- Opportunities for Participation
- Slide Number 62
-
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