Putting Health IT Interoperability into Action at CommonWell

June 19, 2017 - In matter of five years, the CommonWell Health Alliance has gone from a concept for advancing health IT interoperability to a means of enabling health data exchange between providers using various EHR technologies.

CommonWell began 2017 on a strong note. At close of 2016, the industry-led initiative reached a collaborative agreement with the Sequoia Project’s Carequality, seemingly bringing an end to the interoperability tug-of-war between Cerner and Epic Systems which supported either network exclusively.

Building on the progress, CommonWell reached two milestones earlier this year. The alliance received commitments from 14 members to expand its services nationwide through the development of new application programming interfaces (APIs) in pursuit of “ubiquitous interoperability.” Around the same time, CommonWell became the first healthcare organization to integrate the Argonaut Project’s specifications for Fast Healthcare Interoperability Resources (FHIR).

Recently, EHRIntelligence.com caught up with CommonWell Executive Director Jitin Asnaani to discuss the industry-led initiative’s recent progress and its overall work to operationalize health IT interoperability.

TRANSCRIPT

KYLE MURPHY: In your own words, what does the agreement mean for CommonWell, for Carequality, and participating members and participants of both?

JITIN ASNAANI: Mickey was absolutely right, it is a big step for national basic interoperability. What it means for participants in either network, and it actually has meaning for participants not in either network as well, but the big deal is now you can actually get exchange happening between a very wide variety of organizations — organizations who are participating in CommonWell as well as organizations who are participating in Carequality — each of these organizations has brought together a fairly large base of participants from across the industry. Together it really does start creating one national fabric for information exchange. It’s a fairly limited set of exchange capabilities that they have agreed to at this point, but even that is a big step for American healthcare and it’s certainly a stepping stone for more that they may do together over time.

I mention that it’s not just existing participants, but it’s also those organizations who are in neither of those communities who have been looking from the outside and saying well, you know, “There’s some participants in X and some participants in Y—should I join both, maybe I won’t join either, because I don’t know how they are going to shake out.” And now there’s an opportunity for them to make a more informed business decisions to join either CommonWell or Carequality or both if they still find value in that and know that they are not going to be limited in the kind of universe of exchange participants because they’re in one or the other.

MURPHY: Now from my experience, the national conversation about interoperability in healthcare has shifted away from technology itself to use cases. What does that mean for your organization?

ASNAANI: You know it’s absolutely a wonderful thing we’ve moved in that direction. For so many years, we’ve been talking about what standard are we using and what they technology will look like and how it’ll work — there’s still a lot of that work that is still being done — but I do agree with the point of view that the discussion is now shifting toward the value. What is the value we’re going to create and that naturally leads to the discussion around use cases.

In what circumstance for what group of users is there value in health information exchange particularly here as we’re talking about clinical data. And that’s great for CommonWell—it’s actually great for everybody because it means we can start talking about what’s happening for our end users and end providers and end patients and in what circumstances clinical interoperability really makes a difference to their lives or their practice or both. The technology now that we’re helping to more or less make it ubiquitous is not the place where we spend as much time focused on the differentiation and the need.

I think it’s great for healthcare. It’s really come about because of our collective experience all of our members have brought to the table and articulating those different points of view, those different use cases that we can solve together by really making that technology a non-issue—a non-discussion item over time.

MURPHY: In terms of the recent news you guys have made — it’s been around FHIR, it’s been around APIs — but taking it a step back, how would you describe the progress you guys have made since you started this thing a handful of years ago?

ASNAANI: When we first launched CommonWell—and it was launched about four years ago now—and we took a year to try to really figure out what we were doing and kind of show that our approach towards what I call person-centered interoperability, in other words really enabling the data to follow the person wherever they go for health and care and having that data available to whoever it is that’s authorized to use it—whether the person themselves or the provider or the caregiver or their parent or teacher or whoever, you know, whoever have you. We demonstrated that over our first year, we continued scaling our second year, we went live in a big way in our third year, and today here we are in our fourth year and we have more than 5100 sites that are live that are actively capable of exchange enabling data for tens of millions of patients to be exchanged in an appropriate, authorized, secure manner and kind of helping us get over the hurdles of interoperability.  

I mean these are live, working, out-in-the-real-world services five thousand one hundred sites across the country are already utilizing, and another five thousand have committed to utilize over the coming couple years, not to mention the thousands that will join as more and more of CommonWell’s members continue deploying services to the field.

So I think we’re on a beautiful path here and it is great to already see real world value being created to your question around the use cases and the clinical value of clinical interoperability.

MURPHY: So now, turning to more recent developments: CommonWell has started to support FHIR and the development of other APIs to benefit its network, and that leads me to two questions. First, what will be FHIR’s role in improving the finding, retrieving, and aggregating, and sharing of health data? So that’s one and two, how will the development of APIs complement or compete with the development of FHIR?

ASNAANI: You know the way I like to think about FHIR is FHIR is really two things—FHIR is an ability to exchange data in lightweight modern protocols for transporting and exchanging data. If you think about something like a Twitter. How do people use Twitter and actually be able to send little tweets so quickly? You send a little tweet and right away you see it, everybody sees it elsewhere on the web. It’s immediately available, it’s a super-fast transaction that’s built on very modern capabilities that really leverage the internet in a smart way. So FHIR is that, FHIR is also this ability to send really discrete data. Like not just the full clinical chart, but to actually send just immunizations, for example. So FHIR is those two things because it’s agnostic to the type of data that’s on their network, that second one you kind of get for free as long as EHR vendors are able to actually consume that discrete data, and that’s where there’s some development work that still needs to happen on the part of industry.

But now that we’re enabling the former—in other words we’re enabling this really super-fast lightweight modern transactions, we are able to help take the industry forward from this past where we’ve been bogged down with very very cumbersome, heavy transactions that take a long time to be processed, that take a lot of computing and internet bandwidth to actually communicate. And so the difference in speed, the difference in the ability for let’s say an EHR company to be able to hire a young graduate from any college and say hey I can teach you to program for healthcare is dramatically improved by us going toward this set of technology. So in terms of does this allow us to do more querying and retrieving and aggregating and sharing—you know, honestly I don’t think it allows us to do more of it. What it allows us to do is enables this industry—all of healthcare IT to bring in more talent from other parts of the world where in the past we’ve been imbued in these bespoke types of transactions where even in CommonWell base architecture we used a lot of because that’s what everybody had to start with. Now we can bring the industry forward and bring talent into our industry.

In terms of how FHIR fits in with CommonWell and if there’s been any really negative implications with the FHIR movement—the answer is totally no. We’ve had no worries about that at all and neither have folks at the Argonaut project where they’re working on developing FHIR. Because at the end of the day what FHIR is is a set of specifications to do those things I mentioned. CommonWell is an implementation organization helping to drive forward those same FHIR specifications in the form of our APIs, in the form of our connections we’re building. And by showing how FHIR works, making it work better, providing feedback to improve it, we’re really helping to bring the standard along as well. That’s not proprietary to CommonWell by any means, that’s something we do, provide that feedback back to the community so that the FHIR standard can be used not just in CommonWell but everywhere else as well that developers and providers have a need to do other type of exchange beyond CommonWell. So I think it’s extremely complementary and I know that the folks who are driving the FHIR standard are excited CommonWell has chosen to be one of the leading implementers of the standard.

MURPHY: With the focus of federal incentive programs such as MIPS, the Quality Payment Program, and Alternative Payment Models, and health IT development having been squarely on primary care up until this point, what does the future hold for expanding their reach to behavioral health and other aspects of the care continuum?

ASNAANI: Yeah, you know something really interesting, when CommonWell formed, the idea was the brainchild of a small handful of EHRs. So on day zero, we had mainly EHRs. But as early as day 1, a number of other types of health IT vendors representing other parts of the care continuum kind of knocked on our doors and said, “Listen, healthcare doesn’t just happen at the primary care facility or even just at the hospital. It happens at all these other places—it happens in the skilled nursing facility, in the home health facility, in the lab, in the pharmacy—these organizations don’t just provide some parts of service that just fit into what the primary care doctor is doing—they provide healthcare in their own rite and there’s an opportunity to improve the patient’s care in any of these settings. As you may or may not know at this point, CommonWell has more than sixty members, more than half are actually not EHRs, they provide health IT or health IT services to the rest of the continuum beyond the primary care doctor and the hospitals.

We were probably ahead of the curve in being open to this so early. But what I have noticed and what has actually given me a lot of gratification that we have chosen the right direction is that in my recent discussions with folks from the government, they have asked us more and more about not just our EHR members, which is a big part of the company, but also about our other members. What are our patient portal members doing, what are our home health and skilled nursing facilities vendors doing, for example.

There’s been a lot more questions and discussion around that because at the least ONC and probably other parts of the government are quite cognizant that the place where health and care is delivered is shifting and evolving is happening really rapidly in these places particularly in response to recent incentives.

Some types of settings—such as behavioral health—are different because the type of nature of the data and the type and nature of the care they provide is at a different level of sensitivity. I see those types of settings also becoming involved in CommonWell and other initiatives now that we’re creating this nationwide fabric there is an opportunity for those settings who have been screaming for interoperability for a long time to actually get some attention. We are going to solve the nationwide issues at least for person-centric care for primary care and hospitals and so on and actually give some focus on the use cases that certainly drive a lot of healthcare costs and clinical outcomes like behavioral health.

MURPHY: Taking this question in a similar direction, what is the role of CommonWell and similar initiatives—CareQuality being an obvious one—to promote health data exchange in building a foundation for population health and precision medicine going forward?

ASNAANI: CommonWell is trying to enable interoperability if you think about it as a city’s water utility, right? A city may decide we need water to flow to every potential place there could be a building in the city, right—you don’t care if it’s a residential building or a commercial building. Every place must have water. And now whether that water comes out a pipe or a faucet, or comes out a fountain or some other fixture, it really is a decision that the end points must make. What I see CommonWell and others doing is enabling that water to be available for a variety of these use cases.

There are some places where the requirements we put on the uses of the water so to speak, or exchange capabilities, perfectly align with the attended usage of today. For example, precision medicine is all about understanding and taking care of the individual which is exactly in line with what CommonWell advocates for and enables today.

On the other hand, other types of perfectly legitimate valuable usage like population health includes some aspects of that, so for instance population health includes things like managing the care of individuals proactively, etc., which CommonWell is perfectly aligned with, and then there are other types of population health such as mass usage of a populations data in order to drive let’s say for example analytical insights, which are less well aligned with what CommonWell is trying to achieve.

So I think overtime we’ll see that this is actually a journey the alliance and our services will take along with our members as our members will drive it. What is beautiful is that because we’re a ground up organization where our members come together to provide their collective experience and they’re building our services into their products for a variety of different users and use cases, what we’ll see is that they will drive the evolution of the alliance toward creating the most useful, valuable services that actually help us to achieve end goals as these end goals evolve.

MURPHY: One of the questions that the concept of population health and precision medicine raise for me is how CommonWell complements or works against traditional health information exchanges that are set up across the country that, with ONC support, were supposed to serve as the foundation for moving from the health of individuals to the health of populations. Where does CommonWell fit in with these other health information networks?

ASNAANI: CommonWell is trying to create a national fabric for health data exchange but it’s creating one with very specific types of exchange available with it. By specific I mean the technology, the pipes and so on, are of a specific nature, they enable a variety of use cases and end cases but they’re not meant to be the be all and end all.

If you flip that on its head and think of a state HIE or regional HIO or even just a collection of providers in a community who want to be enabled to do things with health data exchange for the benefit of their community, whatever that organizing principle is, there’s a lot of power in American communities, in the communities of hospitals and health clinics across the US, and there’s a lot of insight that they have into their own local communities that CommonWell will never have. CommonWell’s goal is to give all of those organizations another toolset, hopefully a faster, cheaper tool set for some activities that hopefully they can use to achieving their own local goals.

So when I think of regional HIO’s as an organization with a lot of insight into their local community, can design clinical programs centered on different types of exchange to provide that value to their communities, CommonWell is just another tool in their tool belt that they can use to provide data exchange within and beyond the boundaries that they serve within their communities.

It’s actually extremely complementary—when CommonWell was conceived it was never meant to be a competitive threat really to anybody. It was just trying to solve a simple problem which is wherever a patient goes, their data from wherever they’ve been—within that hospital, within that community, within that region, anywhere within the US—should be available to those taking care of that patient at that time.

I’ve found when we have discussions with those local or regional-based organizations they’re actually extremely positive because they realize we’re just another tool in their tool belt they can use to serve their communities.

MURPHY: Now, for my last question. We remember not too long ago ONC set out its strategic vision for a learning health system. It’s a ten year plan to get to that state of truer interoperability. But in your opinion, what is a realistic timeline for achieving true interoperability in American healthcare?

ASNAANI: You left the easiest one for last, didn’t you? The way I think about it is there is actually so much you’re going to want to solve over time I don’t see a final end date. I see that there will be continuous boulders we want to knock down, and as we knock down those boulders there will be new boulders ahead we’ll want to look at and target.

That seems true for very mature industries like finance where it’s only in the last few years that we’ve seen products like Mint that could’ve been conceived twenty years ago but it wouldn’t have gone anywhere because we wouldn’t have had the interoperability we needed. But now we have it and it’s a beautiful product a lot of people use and other products like Credit Karma, etc.

If I wanted to look into a crystal ball a little, one thing I’ve already started seeing that I think you alluded to earlier is that the issues around technology connectivity across the US, we can see that boulder being knocked down.

CommonWell has had a huge part to play in it and other organizations that have been alongside us. But that’s really for the set of basic data exchange capabilities—secure messaging, push-based messaging, and so on—and there’s still work to be done but that boulder is clearly on its way down.

As we look ahead, there are other interesting interoperability things we’d like to do that will now be up to the industry’s innovators including those within CommonWell to be able to tackle. Things like population health, clinical insights at the point of care and so on.

Those are the innovations that build on both the analytical capability as well as deeper and more involved exchange of information that are still not quite there yet, where the industry is still working out how do we do this, how do we accomplish it at scale, and so on.

If I kind of look into a crystal ball, the next 3 to 5 years we’re at a place where a lot of the basic interoperability boulders have really been knocked down. We now have our eyes set on providing care to individuals even before they know they need it. That’ll be where we’re really trying to bend the cost curve on American healthcare.