interoperability 101: the past, present, and future · • primary care family physician and ehr...

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Interoperability 101:The Past, Present, and Future

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Steve Lane, MD, MPH, FAAFP

Clinical Informatics Director, Privacy, Information Security & Interoperability, Sutter Health

DISCLAIMER: The views, opinions and images expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Session PE4, March 9, 2020

Mariann Yeager, MBA

Chief Executive Officer, The Sequoia Project

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Clinical Informatics Director, Privacy,

Information Security & Interoperability

Sutter Health

Meet Our Speakers

Dr. Steven Lane Mariann Yeager

Conflict of Interest

Steven Lane, MD, MPH, FAAFP has no real or apparent conflicts of interest to

report.

Mariann Yeager, MBA has no real or apparent conflicts of interest to report.

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Agenda

• Health Information Exchange: a history

• Sutter Health: a present-day case study

• Trusted Exchange Framework and Common Agreement: the future of exchange

• Physicians Engagement: the role of providers in shaping health information

exchange today and tomorrow

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Learning Objectives

• Describe the multitude of health information exchange options available today

• Outline the scope of TEFCA based on the draft published by the ONC

• Identify opportunities for physician engagement in the development and

finalization of the Common Agreement and the implementation of the Trusted

Exchange Framework

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Health Information Exchange: A history

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Perspective

• Primary care family physician and EHR user x > 30 years

• Clinical informaticist x 25 years

• Interoperability focus x 10 years

• The Sequoia Project – Board

• Carequality – Steering Committee

• DirectTrust – Clinicians Steering Workgroup

• HL7 Da Vinci Project – Clinical Advisory Council

• HIMSS – Interoperability & HIE Committee

• HHS/ONC – Health Information Technology Advisory Committee

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https://www.modernhealthcare.com/article/20161213/NEWS/161209902/will-the-21st-century-cures-act-level-the-playing-field-on-hospital-readmissions

Interoperability Definitions

• 21st Century Cures Act

Health information technology that 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; allows for complete access,

exchange, and use of all electronically

accessible health information for authorized

use under applicable State or Federal law;

does not constitute information blocking

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• HIMSS

• Foundational Interoperability: System connectivity

> Exchange data

• Structural Interoperability:Field level formatting, syntax

> Exchange information

• Semantic Interoperability:Codification of data

> Meaning, interpretation

• Organizational Interoperability:Policy, workflow, functional

> Utility, benefit, outcomes

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• 1982 – Accredited Standards Committee (ASC) X12 Version 1

• Electronic Data Interchange (EDI) for financial / administrative transactions

• Named in HIPAA as required standard for specific transactions, e.g., prior auth

• 1987 – Health Level 7 (HL7) Version 2

• Point-to-point connectivity

• Intra-operability – connecting applications within institutions

• 2005 – HL7 Clinical Document Architecture (CDA)

• Human readable XML documents

• Scalable for cross organizational use

• 2011 – HL7 Fast Healthcare Interoperability Resources (FHIR®)

• Modern, flexible, purpose-built for healthcare

• 2019 – First normative release (R4)

Interoperability Standards

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• Holistic care

• Patient safety

• Care coordination

• Value – e.g. avoiding duplicate services

• Public health

• Medical research

• Innovation – Care models, services

• Patient engagement, empowerment, control of data, choice

Interoperability Promise

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• HIE/HIOs – Regional/state, proprietary

• Central data repository and access

• Connectivity and messaging – multiple stakeholders, uses

• Services – e.g., event notification

• Networks

• Nationwide Health Information Network

• Direct Project > DirectTrust

• eHealth Exchange > The Sequoia Project

• Vendor-based Networks: CommonWell, Epic Care Everywhere, etc.

• Trusted Exchange Framework: Carequality > TEFCA

Interoperability Successes

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• Everyone agrees that data access and liquidity is critical to support optimized coordinated care and population health management

• BUT…

• Significant challenges:• Clinicians drowning in data• Discrete data integration, reconciliation and use• Concerns about privacy and risk • Incentivizing data access, use, curation, and exchange• Changing federal rules and requirements

Interoperability Challenges

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• Due to:• EHR implementation • System Integration• Interoperability•New data sources•Patient-generated data•Multiple “-omics”•Claims data • Social determinants of health

Drowning in Data

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• Direct interoperability (push)

• Query-based document exchange (pull)

Standards-based Document Exchange

Direct Interoperability

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• Direct Project: launched in 2010 as part of

the Nationwide Health Information

Network (NwHIN)

• Goal: simple, secure, standards-based

method for sending health information to

trusted recipients via the Internet

• Included in 2014 EHR certification criteria

• Required by Meaningful Use Stage 2

• HISPs accredited through DirectTrust

represent more than:

• 2.3M Direct Addresses

• 238K organizations

• 299K patients/consumers

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• All ONC certified EHRs have the ability to send and receive transition of care documents via the Direct Standard

• Many providers have not routinely implemented this functionality

• Use cases:

• Transitions of care – ambulatory, inpatient, post-acute, EMS

• Closed loop referrals

• Care coordination messaging

• Push notifications – Event notification, reporting

• 67M transactions / month

Direct – Current State

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• Four Federal Agencies

• Veterans Affairs

• Department of Defense

• Social Security Administration

• CMS

• 75% of US hospitals

• 70,000 medical groups

• >50% of regional/state HIEs

• 16M documents exchanged / month

eHealth Exchange

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• 367 Epic customer organizations

• 2,032 hospitals; 45,830 clinics

• 1,689 connections to 110 unique vendors’ systems

• via eHealth Exchange, Carequality, Direct

• 150M records exchanged / month

Epic Care Everywhere

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• Core services:

• Patient ID and record location

• Document exchange

• 15K provider sites

• 66M patient records

• 60M monthly XCPD patient discovery / record locator

transactions


CommonWell

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• Policy framework and technical standards for networks and other implementers to exchange with each other• CommonWell, Epic Care Everywhere, eHealth

Exchange, HIT vendors

• 600,000 Physicians, 40,000 Clinics, 1,700 hospitals

• Working with The Sequoia Project in its role as the Recognized Coordinating Entity (RCE) to implement the national Trusted Exchange Framework & Common Agreement (TEFCA)


Carequality Framework

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Standards-based Document Exchange Volume

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Application Programming Interfaces (APIs)

* in healthcare

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• Purpose-built for healthcare

• Supports exchange of targeted data via APIs

• A user/application may request just the data (resources)

of interest in a well-defined format

• Modern web-base data structure, transport and security

• Rapid development

Fast Healthcare Interoperability Resources (FHIR®)

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Evolving FHIR Use Cases

• EHR applications• SMART – Substitutable Medical Apps, Reusable Technology (>75 apps)

• Argonaut Project – clinical notes, assessments, bulk data access

• Individual / Patient Access• CMS Blue Button 2.0 – Medicare claims data

• Apple Health Records, etc. – EHR patient portal and Laboratory data

• Payer-Provider Exchange• CMS Beneficiary Claims Data API (BCDA) and Data at the Point of Care (DPC)

• Da Vinci Project

• FHIR Accelerator Projects• Social Determinants of Health – Gravity Project

• Post-Acute Care Interoperability – PACIO

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Individual / Patient Access via APIs

• Based on HIPAA individual right of access to health data

• Early successes:

• Blue Button 2.0 – CMS claims available to Medicare

beneficiaries via API

• Apple Health Records

• Common Health for Android

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Apple Health Records

• FHIR® API-based access to health data from multiple vendors

• EHRs:

• Allscripts • Epic

• Athenahealth • MEDITECH

• Cerner • VA

• Laboratories:

• LabCorp • Quest

• 454 organizations/practices participating a/o 01/27/2020

• Health records data securely stored on user iPhones

• Individuals can choose to allow apps to access health records

data stored in HealthKit

Sutter Health: A present-day case study

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Patient Records Exchanged Monthly

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Unique Trading Partners

Patient Access via APIs – 2019

• 18,813 patients

have requested

their data using

SIX patient-

facing apps

API Calls / month15 Million

~3,000 patient

requests / day

Trusted Exchange Framework and Common Agreement (TEFCA): The future of exchange

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This project is supported by the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) under 90AX0026/01-00 Trusted

Exchange Framework and Common Agreement (TEFCA) Recognized Coordinating Entity (RCE) Cooperative Agreement. This information or content and conclusions are those of the author and should

not be construed as the official position or policy of, nor should any endorsements be inferred by ONC, HHS or the U.S. Government.

© All rights reserved.

Why Do We Need a Trusted Exchange Framework and Common Agreement (TEFCA)?

COMPLEXITY OF CURRENT PROLIFERATION OF AGREEMENTS

Many organizations have to join multiple Health Information

Networks (HINs), and most HINs do not share data with each

other.

Trusted exchange must be simplified in order to scale.


“[T]he National Coordinator shall convene appropriate public and private stakeholders to develop or support a trusted exchange framework for trust policies and practices and for a common agreement for exchange between health information networks.” [emphasis added]

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21st Century Cures Act – Section 4003(b)


TEFCA Goals

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Provide a single “on-ramp” to nationwide connectivity

Electronic Health Information (EHI) securely follows you when and

where it is needed

Support nationwide scalability

GOAL 3GOAL 2GOAL 1


How Will the Common Agreement Work?

RCE provides oversight and governance for QHINs.

QHINs connect directly to each other to facilitate nationwide interoperability.

Each QHIN represents a variety of Participants that they connect together, serving a wide range of Participant Members and Individual Users.

PARTICIPANT MEMBERS AND INDIVIDUAL USERS

PA R T I C I PA N T S

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Recognized Coordinating Entity (RCE)

• Develop, update, implement, and maintain the Common Agreement.

• Identify, designate, and monitor Qualified Health Information Networks (QHINs).

• Modify and update the QHIN Technical Framework.

• Virtually convene public stakeholder feedback sessions.

• Develop and maintain a process for adjudicating QHIN noncompliance.

• Propose strategies to sustain the Common Agreement at a national level after the

initial cooperative agreement period.


Structure of a Qualified Health Information Network (QHIN)

A QHIN is an entity with the technical capabilities to connect health information networks on a nationwide scale.

ParticipantA natural person or entity that has entered into a Participant-QHIN Agreement to participate in a QHIN.

Participant MemberA natural person or entity that has entered into a Participant Member Agreement to use the services of a Participant to send and/or receive EHI.

Individual UserAn Individual who exercises their right to Individual Access Services using the services of a QHIN, a Participant, or a Participant Member.

QHIN


What is The Common Agreement?

The Common Agreement will provide the governance necessary to scale a functioning system of connected HINs that will grow over time to meet the demands of individuals, clinicians, and payers.

The Common Agreement will be a legal document that QHINs sign. Some provisions of the Common Agreement will flow down to other entities (including providers) via contracts.

Stakeholders will be able to comment on the draft Common Agreement.

Minimum Required Terms & Conditions

Additional Required Terms & Conditions

QHIN Technical Framework

CommonAgreement


Provider Considerations

• Provider organizations will generally be either a participant or a participant member


• Providers will have to meet flow-down requirements

What Kinds of Exchange Will be Supported?

Initial Exchange Modalities:• Broadcast query (ask all)• Targeted query (ask a few)• Message delivery (push)

Potential Future Additions:• Population-level data exchange• FHIR-based exchange

Exchange Purposes

Data Exchanged:• Available electronic health

information in the US Core Dataset for Interoperability (USCDI)


Physician Engagement: Help shape interoperable health information exchange for the future

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Upcoming Events

• March 10, 2020 – 3:30 – 4:30 pm

• Public Stakeholder Session with Providers Across the Continuum•

• March 11, 2020 – 2:30-3:30 pm

• Breaking Down Barriers to Interoperability•

• March 11, 2020 – 4:30-5:30 pm

• HIMSS20 Journey to Trusted Exchange•

• Stay in touch! https://rce.sequoiaproject.org/contact/

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https://rce.sequoiaproject.org/contact/

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Dr. Steven Lane Mariann Yeager

interoperability 101: the past, present, and future · • primary care family physician and ehr...

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