- Health data exchange has come a long way in the past decade, but many stakeholders are still dissatisfied with the current state of interoperability and data sharing between different hospitals and health systems.
A 2018 AJMC study shows diagnostic EHR data sharing still lags between hospitals part of separate health systems, and the data sharing that does occur is often incomplete. While health data exchange between hospitals part of the same health system is common and generally effective in improving patient health outcomes, data sharing between different health systems may pose a threat to patient safety.
Clinical and IT staff at Sutter Health are working to proliferate health data sharing by encouraging providers to utilize Direct exchange.
Like most health systems, Sutter Health adopted EHR technology years ago in accordance with federal mandates included in the EHR Incentive Programs — formerly known as meaningful use. The health system integrated Direct exchange capabilities into its Epic EHR in order to meet federal reporting requirements and avoid downward payment adjustments.
However, Sutter Health providers only recently began using Direct to streamline referrals.
Sutter Health Vice President and CHIO Sameer Badlani, MD, points to problems with clinical workflows as partly responsible for keeping some providers from engaging in Direct exchange.
“Meaningful use pushed the adoption of technology without any focus on workflow,” Badlani told EHRIntelligence.com. “Why are physicians still sticking to fax? It’s not because we are stuck in the dark ages. Every physician has a cell phone, uses an iPad, dreams of the day they can have an electric car with all the gadgets. The reality is that not enough attention is paid to the workflow.”
Executives at Sutter Health are keenly aware of the significant difference clinical workflow optimization can make when trying to get providers to use a new technology or EHR functionality.
Optimizing Clinical Workflows to Support Data Sharing
Sutter Health Referral Program Manager Christopher Mack and Clinical Informatics Director of Privacy, Information Security, and Interoperability Steven Lane, MD, were part of a team tasked with tailoring workflows to support the use of Direct exchange in a way that best met the needs of providers.
“The secret sauce that's allowed Sutter to be as successful as we have early on in this evolution is that we are attending to the workflow and helping to smooth that out, and really filling in the gaps in the Direct implementations,” said Lane.
“It’s not the Direct functionality that's lacking, but the implementation of that,” he added.
Mack and his team receive all the referrals coming into the hospital — including those coming in by fax — and convert them to Epic referrals. If the referring provider also has a Direct workflow with Sutter, members of the referral team can further convert them to Direct referrals.
“Conversely, if we receive a Direct referral from someone and it’s going to someone who isn’t in our workflow, we have the ability to fax it or send it through our EHR portal. We can also engage the office and tell them what Direct is, and how it can be used,” explained Mack.
“Once we actually get the referral and facilitate it, we have a concierge referral service that stays with the patient even after five or six doctors have reviewed and either accepted or declined the patient,” Mack continued.
The teams’ efforts have paid off — providers across the health system have started utilizing Direct exchange to successfully cut the length of referral processes from several weeks to a few days.
“In the past when we'd receive a referral by fax, it would take 2-3 days at least to get to us,” explained Mack. “Because of the various steps that an external referring physician would go through to hand the paper to his administrative assistant, and then get the referral to us.”
“But likely there would be missing clinical information, or demographics, or lab work,” continued Mack. “For every piece of information that was missing and every attempt to reconcile all that information, you would add on another 2 days, at least. It was an inefficient way of starting a referral process for a patient.”
In addition to speeding up the referral process, Direct exchange also gives receiving providers access to more complete patient health information for better-informed consultations and care delivery, according to Lane.
“The patient’s clinical data goes with the referral,” said Lane. “That’s really important. Every time we need to ask referring providers — ‘well, can you also send that, can you send this’ — it adds time to the process and it delays getting the patients’ needs met.”
By sending complete patient health information along with referrals, Sutter Health and other Direct users can avoid duplicative testing. Duplicative testing wastes time and money for providers and can potentially have a negative effect on patient health if repeated tests involve radiation.
Since implementing Direct, referral processes between providers part of Sutter Health generally go smoothly. The streamlined clinical workflows in place at the health system help to facilitate provider communication and referrals across the 23 hospitals, seven medical groups, and four independent physician associations part of the Sutter Health network.
However, referrals with outside health systems and hospitals are still largely inefficient despite Sutter’s efforts to promote widespread use of Direct exchange.
“We're trying to encourage our referring providers to utilize Direct because it is so much more efficient and gets us more data,” said Lane. “But we're still in the process of managing that transition.”
Part of the challenge of engaging in Direct exchange with outside health systems is the lack of standardization across organizations.
Promoting widespread standards use across health systems
Discrepancies in the way different EHR vendors and health systems implement and use Direct messaging has detracted from its efficiency.
“Our ability to receive referrals via Direct is entirely dependent on the ability of our referring providers to send them via Direct,” said Lane.
“There are real challenges in the implementation of Direct messaging by different EHR and health IT vendors,” continued Lane. “Different systems have implemented it differently. There’s key pieces that are still challenging, like the ability to automatically route messages to the appropriate recipient, the ability to forward direct messages, reply to direct messages — basic email type functionality.”
While Direct supports this basic email functionality, not all EHR vendors implemented certain capabilities because the functionality was not included as part of meaningful use requirements.
“We’ve been actively involved in trying to address these shortcomings,” said Lane. “Trying to bring all the vendors up to speed so that they can all support this basic functionality. That’s gonna allow clinicians and office staff to be more comfortable relying on this.”
Part of Sutter Health’s efforts to promote standardized use of Direct exchange across hospitals and health systems includes educating providers about the benefits of Direct exchange and offering implementation support.
“If we get a fax and we recognize that the fax is coming from a referring provider whose electronic records might have Direct messaging, we make a call out to them and try to engage them so that they understand that there might be more efficient pathways,” said Mack. “And just that explanation alone can be transformative for the referring provider.”
These outreach efforts can help to expand Direct exchange nationwide and improve interoperability and clinical efficiency for providers already utilizing the data sharing method. Direct exchange is only effective if a significant amount of health systems and providers are adhering to the standard.
“Even though someone may have the functionality to send and receive Direct, it's not as valuable until all of their principle correspondents are also on board,” explained Lane. “So you can’t be the first one. And you don't want to be the last one.”
“It’s a bit of a chicken and egg situation,” Lane added.
The need for widespread provider participation in standardized health data exchange extends beyond Direct messaging.
The success of interoperability initiatives such as the developing ONC Trusted Exchange Framework and Common Agreement (TEFCA) and the Carequality interoperability framework are also contingent upon widespread implementation.
Efforts to improve interoperability will stagnate unless providers across health systems, hospitals, and networks implement and utilize industry standards.
“That continues to be my message to other providers and their organizations,” maintained Lane. “Implement the national standard tools. And then as we move forward — if TEFCA comes to be, and as the national opportunities continue to evolve, then people can evolve with that. But they need to start with what's available today — Direct and Carequality.”
Widespread adoption of the Fast Healthcare Interoperability Resources (FHIR) data standard developed by HL7 will also help to significantly advance interoperability, Lane maintained.
FHIR is an internet-based approach to connecting different discrete data elements and allowing health IT developers to build standardized applications that allow data access across EHR systems.
“CMS, Seema Verma, ONC, Don Rucker, they're really pushing on the use of FHIR, which allows us to not just share messages and documents, but to exchange smaller bits of information when that's appropriate,” Lane stated. “And then to make that information available in more of an API app-based ecosystem.”
Sutter Health is looking to stay at the forefront of health IT innovation and standards use to enable a patient-centric healthcare system.
“There’s a lot going on in this space that is really come to fruition over the next few years,” said Lane.