- At the start of 2018, CMS Administrator Seema Verma announced health IT innovation would be a top priority among stakeholders.
Three months into the year, this assertion has proven true: Google, Amazon, Apple, and other tech titans have sought to extend their presence into healthcare and push the bounds of innovation related to EHR systems, health data access, and other areas ripe for development.
Meanwhile, EHR companies and industry groups have continued to launch new efforts to promote widespread interoperability. While the constant proliferation of newer, faster, and more efficient technologies can help to improve patient care delivery, organizations unwilling to adapt to the changing tide may be left by the wayside.
CommonWell Health Alliance Executive Director Jitin Asnaani has always understood the importance of staying ahead of the curve.
“There will always be a new wave of interoperability,” Asnaani told EHRIntelligence.com during a sit-down at HIMSS18. “There is a migration that has to happen now, and at the end of it we’ll say, what about the next migration? And then there will be another migration later.”
Since its inception at HIMSS13, CommonWell has been an early-investor in promising innovations. For example, the alliance saw immediate potential in HL7’s Fast Healthcare Interoperability Resources (FHIR), which has quickly gained popularity among the most influential health IT developers in the industry.
FHIR and Cloud-Based Data Storage
FHIR is a health IT standard and application programming interface (API) that enables interoperability through modern, internet-based protocols.
“CommonWell has actually been using the FHIR resource for very specific transactions since Day 0,” said Asnaani. “FHIR is really three things. It’s the discrete data. It’s the notion of RESTful — just a cleaner, more modern way of building connectivity — and it’s OAuth 2.0.”
OAuth 2.0 is an open standard used to allow internet users to grant websites or applications access to their information without giving them their passwords. By leveraging FHIR and OAuth 2.0, CommonWell is able to facilitate more targeted health data exchange between providers.
“Our model is relatively unique,” said Asnaani. “We take a CCDA and only look at one element.”
Instead of exchanging complete and oftentimes lengthy electronic records, CommonWell uses FHIR for specific transactions that would otherwise be burdened by cumbersome data transfers.
In an industry intent on reducing administrative burden and physician burnout, innovating for efficiency is a top priority.
In addition to being an early adopter of FHIR, CommonWell took to the cloud from the very beginning of its existence. While many organizations still store data in on-premise clinical data repositories (CDRs), Asnaani echoed the sentiments of many healthcare industry leaders that see cloud-based EHR systems as the inevitable future for health IT and data exchange.
“On an interoperability side, it’s a no-brainer,” said Asnaani. “You have go to cloud-based interoperability. You’re going to be building more connections over time. You’re going to be doing more with that data over time.”
Several EHR vendors — including MEDITECH, Medsphere, Allscripts, and others — have recently debuted cloud-based EHR system product offerings in an attempt to cut EHR implementation costs for providers.
“That’s where a lot of your innovation is going to go whether or not you’ve planned for it,” said Asnaani.
In past years, health IT innovation has primarily centered on EHR adoption. Federal regulation played a significant role in promoting EHR adoption through HITECH.
“Meaningful use drove EHR adoption first,” said Asnaani. “Now we’re focusing more on interoperability and less on the EHR.”
Looking ahead, federal regulation will likely also play a substantial role in driving interoperability improvements. Specifically, the launch of the ONC Trusted Exchange Framework and Common Agreement (TEFCA) toward the end of this year has the potential to change the face of the HIE landscape.
TEFCA and the Changing HIE Ecosystem
The health data exchange community — especially health information exchanges — are still coming to terms with the implications of ONC’s health data exchange framework, TEFCA. The still-developing set of federal regulations will require participating HIEs, health information networks (HINs), healthcare organizations, and other stakeholders to change their business models, participant agreements, and data sharing practices to fit a new model of standardized exchange.
Thus far, the draft framework has received equal parts praise and criticism from leaders in the HIE community. While most understand TEFCA as a necessary next step toward advancing interoperability per provisions in the 21st Century Cures Act, many stakeholders believe the framework to be too prescriptive and ambitious.
TEFCA essentially seeks to foster collaboration between the public and private sector and establish qualified health information networks (QHINs) to serve as overarching facilitators of health data exchange. While the goals of TEFCA may be straightforward, organizations that opt to participate will need to invest a significant amount of time, effort, and money into fulfilling requirements.
Asnaani views TEFCA as a positive development.
“What does TEFCA call for?” he said. “Two things. First, it calls for some sort of centralized governance where it’s equal parts government and private sector. We think that’s a good idea.”
Asnaani credited the Sequoia Project with setting a good example of how to effectively connect the federal government and the private sector through joint interoperability initiatives. The Sequoia Project’s eHealth Exchange common trust framework was initially managed by ONC, while its Carequality interoperability framework functions as a public-private collaborative.
“So there is precedent for it,” he said. “The second thing closer to our hearts is that the backbone of interoperability is organizations — QHINs — who can uniquely identify patients, tell you where else the patient has records, fetch that data for you, and hand that back to you without you having to go point to point.”
Identifying patients, locating patient EHRs, and retrieving data are services already in CommonWell’s wheelhouse. Building a health data exchange ecosystem that encourages organizations to join QHINs, enables QHINs to communicate with one another, and requires QHINs to deliver a full set of data exchange services aligns well with CommonWell’s vision.
“The nice thing about that notion is that there a few different ways of implementing it,” said Asnaani. “When you do point to point connections, there will always be blind spots. With QHINs, there are no blind spots.”
By eliminating blind spots in exchange, TEFCA could help to improve interoperability and communication between healthcare organizations. However, problems with incomplete data might inhibit the effectiveness of this model. Though QHINs will provide similar services, the level of health information in each patient’s medical record may vary.
“When you do point to point connections, there will always be blind spots. With QHINs, there are no blind spots.”
Asnaani sees several ways of sidestepping problems with incomplete or erroneous information.
“There’s three things you can do,” he said. “First, you can get everyone to have a better level of data in the first place. The second thing you can do is create a process for adjudicating it so you can do better matching, like getting a person involved. Getting a patient involved or getting a provider involved who can say no, that record isn’t him — or I’m talking to him, and he’s told me that’s his record.”
“The third thing is to bring in technology,” Asnaani continued. “Anything from, ‘I’m gonna send you a set of other identifiers I have for this patient so you can match based on other identifiers, like my local record number, my system’s health record number, my state’s health record number, etc.”
Asnaani also suggested healthcare organizations could use biometrics to identify patient EHRs. Health IT security company Imprivata is going to help providers more easily identify patients across health systems, Asnaani said.
“Basically scan your name in one health system, and then a totally different health system will connect,” he said. “Even if you had a national identifier, you still need these things.”
TEFCA — in combination with new technologies — could potentially enable a new level of standardized, streamlined health data exchange. However, the healthcare system at large will only reap the benefits of these innovations if providers sign on to use them.
The Importance of Clinician Engagement
Most providers now know there exists a wide variety of tools capable of enabling better-informed clinical decision-making and more efficient care delivery. Whether providers see the need to use these tools is a different story.
“We have a high level of awareness and engagement with CommonWell,” Asnaani said. “We have a few core vendors who are live and pushing out as fast as they can. My challenge is to get more of the vendors to actually start that process. And for the providers to say yes, I want it.”
CommonWell has worked to make it as easy as possible for providers to start using their services.
“I have multiple vendors that have it set up so providers can click a button and they’re live,” said Asnaani. “And the providers aren’t clicking.”
To encourage providers to engage with CommonWell’s health data exchange services, Asnaani has made efforts to raise awareness among the clinician community about the process of using CommonWell and the benefits of exchange.
“I speak at all my vendor’s user conferences,” said Asnaani.
Ultimately, Asnaani believes many providers may simply be too busy with other daily tasks to take the time to engage health data exchange services. However, providers hinder others from utilizing CommonWell’s tools to their fullest potential by neglecting to contribute their patient’s data to the exchange.
“All providers mean to do the right thing,” he said. “On the other hand, they’re stopping everybody else.”
This is the main premise behind forthcoming laws that crack down on information blocking. By choosing not to engage in health data exchange, providers inhibit others from gaining access to certain patient EHRs.
“If you as a provider don’t want to pull in the data and change your style of medicine in terms of knowing that data to take care of the patient—that’s your prerogative,” he said. “But if someone else wants to take better care of the patient, their data shouldn’t be stuck on your system because you couldn’t click a button.”
Asnaani and others at CommonWell want to continue to encourage clinicians to engage with health data exchange so that all providers and patients can benefit from more accurate patient care delivery.
“As long as it’s good for healthcare, it’s good for us,” said Asnaani.