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Misadventures in Interoperability


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Presentation by Megan Douglas, JD for the Third Annual Policy Prescriptions® Symposium

She is the associate director of Health Information Technology Policy in the National Center for Primary Care at Morehouse School of Medicine.

The symposium is designed for clinicians, healthcare workers, and healthcare executives interested in exploring the major themes that will emerge in health policy throughout the year. This year, the symposium will emphasize value in healthcare, health information technology, gun violence, insurance choices, the Affordable Care Act, and the viewpoints of the Presidential candidates on health care.

Published in: Health & Medicine
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Misadventures in Interoperability

  1. 1. Almost-Standard Gauge: Misadventures in Interoperability Megan Douglas, JD Associate Project Director, Health IT Policy Morehouse School of Medicine 3rd Annual Policy Prescriptions Symposium Houston, TX June 11, 2016
  2. 2. The Following Presenters Have Disclosed Relevant Financial Relationships: Cedric Dark, MD MPH FAAEM FACEP Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship Seth Trueger, MD MPH Emergency Physicians Monthly, Employee, Salary The Following Presenters Have Disclosed No Financial Relationships: Megan Douglas, JD Elena M. Marks, JD MPH Laura Medford-Davis, MD Bich-May Nguyen, MD MPH The Following Planners Have Disclosed Relevant Financial Relationships: Cedric Dark, MD MPH FAAEM FACEP Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship The Following Planning Committee Members and Staff Have Disclosed No Relevant Financial Relationships: Emily DeVillers, CAE Kay Whalen, MBA CAE Janet Wilson, CAE
  3. 3. The project described was supported by the National Institute on Minority Health and Health Disparities (NIMHD) Grant Number U54MD008173, a component of the National Institutes of Health (NIH) and Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIMHD or NIH. Official Statement
  4. 4. Learning Objectives • Define interoperability as distinguished from health information exchange • Describe the current status of interoperability at a national level • Assess organizational and policy barriers and facilitators to interoperability
  5. 5. Setting the Stage • No Matter Where – • Ideal vs. Reality • Evolution, NOT revolution
  7. 7. Health Information Exchange (HIE*) Ability of two or more health information systems to exchange clinical information to provide access to longitudinal information *Not to be confused with HIE (governance entities that facilitate HIE)
  8. 8. HIE (the concept) Three types of HIE: • Directed exchange: ability to send & receive secure information electronically between care providers • Query-based exchange: ability for providers to find and/or request information on a patient from other providers • Consumer-mediated exchange: ability for patients to aggregate and control the use of their health information among providers Mr. Jones has an appointment with the cardiologist on Friday. Here are his latest test results. Has Mr. Jones been to the ED for his asthma lately? Mr. Jones has been monitoring his blood sugar for the last 30 days. He has submitted his reports through the patient portal.
  9. 9. HIE (Governance entities) • State, regional, system-based – Every state has different strategy/model – Public, private, public-private partnership • Direct participation vs. network of networks • Services offered – DIRECT messaging (HIPAA- compliant e-mail) – Query-based searches – Automatic notifications • Distinguish between adoption & utilization – How much data is actually flowing?
  10. 10. Interoperability Ability of a system to exchange electronic health information with & use electronic health information from other systems without special effort by the user -Institute of Electrical and Electronics Engineers (IEEE) Includes concepts of: standardization (transport + vocabulary/terminology), integration, cooperation, and technical specifications Bottom line: Integration is automated & actionable Basic Advanced
  11. 11. Interoperability vs HIE • Electronic Health Record (EHR) is necessary for electronic HIE • HIE is necessary for interoperability • HIE is not sufficient by itself to achieve interoperability EHR Adoption Health Information Exchange Interoperability
  12. 12. Electronic Health Record ClinicalDecision Health Information Exchange Advanced Interoperability Basic Interoperability Clinical Care Document (CCD)
  13. 13. STATUS
  14. 14. The Interoperability Unicorn “Many have heard about it, but few have seen it”
  15. 15. Numbers...? • We don’t know how many providers have “interoperable” systems • But we do know:
  16. 16. Proportion of physicians who reported electronically sharing health information, 2013 and 2014 SOURCE: 2013 and 2014 National Electronic Health Record Surveys;
  17. 17. Proportion of physicians who electronically shared any patient health information with other providers, 2014 SOURCE: 2013 and 2014 National Electronic Health Record Surveys;
  18. 18. Transitions with a Summary of Care Record
  19. 19. Percent of non-federal acute care hospitals that electronically exchanged with providers outside their organization: 2008-2014.
  20. 20. Clinical care summary exchange among hospitals and outside providers between 2010 and 2014.
  21. 21. Percent of U.S. Hospitals that Routinely Electronically Notify Patient's Primary Care Provider upon Emergency Room Entry Dashboard -
  23. 23. Why is interoperability so hard? Technical? Business? Moral?
  24. 24. Moral For the “public good” – Increases efficiency – Reduces costs to the system – Patients prefer record sharing – Improves care coordination – Improves health outcomes – Improve population health Privacy/security – Data breaches
  25. 25. Technical • Many transactions – A single EHR system at one large hospital (the Mayo Clinic in Rochester, Minnesota) processes over 660 million HL7 messages a year, or about 2 million messages a day Benson, T. (2012). Principles of Health Interoperability HL7 and SNOMED. Available at • Many data sources – Clinical health records (primary care, specialty, hospital) – Billing (payment information and history) – Patient-generated health data – Pharmacy and prescription information – Patient and family-health history – Genomics – Clinical-trial data • Many languages – EHR systems and clinical systems use different language to describe the same piece of data (ex: sex/gender; female/woman; heart attack/myocardial infarction) BUT NOT THE BIGGEST BARRIER!
  26. 26. Business (aka ) • “It is usually in each vendor’s financial self-interest to provide a proprietary nonstandard interface to a customer, even though they know well that this is ultimately creating an interoperability nightmare” Benson, T. (2012). Principles of Health Interoperability HL7 and SNOMED. Available at • Patient “ownership” – system competition • Data ownership • Inadequate ROI/business case • Liability – Data protection – chain of custody (“typically addressed in layers of complex legal agreements between vendors and healthcare facilities”) Munro, D. The Healthcare IT Quote Of 2015. Available at
  27. 27. State Initiatives • Laws – North Carolina Session Law 2015-241 s. 12A.4 and 12A.5 • As of February 1, 2018, all Medicaid providers must be connected to the HIE in order to continue to receive payments for Medicaid services provided. By June 1, 2018, all other entities that receive state funds for the provision of health services, including local management entities/managed care organizations, also must be connected • Funding – ONC has 56 cooperative agreements with states/territories • Governance
  28. 28. • Public-private partnership – Texas Health Services Authority (THSA) partnered with InterSystems in 2013 • Network of networks (favored, not mandatory) • Services – Clinical Document Exchange (Treatment) – Federated Trust Framework (Security/Confidentiality/Accuracy) – Patient Consent Management (opt-in or opt-out) – eHealth Exchange • Fees (based on size of HIE) – Implementation fee: $20-$130k – Annual fee: $15-$110k
  29. 29. • State HIN, public-private partnership • Network of networks • Members – Payers – State agencies – Regional HIEs • Services – Direct messaging – Query-based record retrieval • Mission-based Service Area HIE – Focus on small, rural providers, practices, hospitals • Services – Query-based record retrieval – Direct messaging – Medication management – Quality performance dashboard
  30. 30. Federal Initiatives ~$30 billion over 6 years
  31. 31. MACRA – Quality Payment Program Current Volume-Based System • Fee for Service • Provider revenue increases with number of services performed MACRA’s Value-Based System • Payments to providers will vary based on factors like: – Quality measures met – Participation in APMs – Resource use – Clinical practice improvements • Payments will be linked to quality and value – and will increase/decrease with performance
  32. 32. Merit-Based Incentive Payment System (MIPS) Proposed Rule • Meaningful Use  Advancing Care Information • 25% of Composite Performance Score (Quality, Resource Use, Clinical Practice Improvement Activities) • Focus on Patient Electronic Access, Coordination of Care through Patient Engagement, Health Information Exchange • Bonus for submitting clinical quality measures (CQM) electronically
  33. 33. Health IT is in its...