In a previous post from a few weeks ago, I highlighted a gap in the nation’s ability to achieve real interoperability despite tremendous advances in the development and adoption of transactional information technology by the health care sector. To be fair, I’d like to point out a number of challenges facing our pursuit of seamless health data sharing. I’m not talking about challenges like those realized when you misplace your smartphone. When this happens, you may be mortified that you no longer know how to navigate roads, you are strangely disconnected from all forms of communication (face-to-face talking is so old fashioned) and the photo documentation of every aspect of your life over the past decade is no longer at your fingertips. Come to think of it though, what if longitudinal health records and data sharing were as readily available to health care providers as all the functionality represented by smartphones?
I am hopeful that we have passed the blame-game phase of our interoperability journey where we have seen sniping back and forth between major EHR vendors, as well as Congress assigning blame through the invention of “information blocking” as the root cause of all the ills facing data exchange.
There are real challenges
- Consistency of Standards: Meaningful Use (MU) criteria has given us an abundance of technology standards to help bring uniformity across the interoperability landscape. However, standards contain optional implementation elements and ambiguities that foster variations in implementation and use. Customization of standards negatively affects seamless exchange of information by disparate systems. Standards enable seamless exchange of health information, but only when consistently interpreted, implemented, and adopted. I remember from years of implementing lab result interfaces it always seemed the HL7 message standard was the non-standard Even though HL7 was universally used by all lab systems, invariably, each interface needed tweaking to “interpret” the specific implementation of the standard. This inconsistency represents cost, development inefficiency, and maintenance challenges.
- Patient-matching strategy: Mismatched patient electronic health records can lead to errors in patient care and increase the likelihood of patient harm. Matching the correct individual to their health data is critical to their medical care. Lack of a standard data set, uniform data-capture methodology, and a consistent matching algorithm can lead to patient records not being linked to one another. This results in an incomplete health record being available to the provider. Even more concerning is the potential for different patients being identified as the same, resulting in frightening care ramifications.A report by the ONC revealed the accuracy of patient matching at 90 percent or higher for internal use in the most advanced organizations, but this accuracy drops to 50–60 percent when exchanging data across organizations.This critical building block of interoperability demands a nationwide patient data matching strategy. Such a strategy could include the adoption of standard, sophisticated matching algorithms and standardization of primary and secondary demographic elements. However, the strategy may need to go further to truly be effective. Assigning a unique patient identifier to every individual in the country is one way to greatly enhance patient matching accuracy. The notion of a national patient identifier (NPI) has been around for a while now. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 authorized the government to introduce an NPI (not to be confused with National Provider Identifier) to make health records more portable. Efforts to create an NPI have stagnated somewhat over the past several years amid active resistance from privacy advocates, yet recent policy developments and burgeoning initiatives show promise for progress in the future.
- Record locator: A patient’s records can be stored in various EHRs across numerous care providers and may be geographically widespread. Even in a broad, highly saturated network of health care providers with the ability to electronically exchange records, there remains the challenge of knowing where to look or who to ask for records on a given patient. The ability to locate and access records is paramount to the value interoperability provides. A thorough, viable record locator service provides the ability to efficiently discover where a patient’s data might be found and provides the electronic address to enable point-to-point .
- Uniform consent / privacy guidelines: In an age where people are sharing the tiniest details of their lives on Facebook and Twitter, it’s hard to believe anyone still values privacy. But, perhaps more than ever, they do. The HIPAA Privacy Rule requires protection for certain individually identifiable health information. The rule generally permits, but does not require, health care providers to give patients the choice as to whether their health information may be disclosed to others for treatment, payment, or health care operations (TPO). The assumption can’t be made that providers can freely access or share information as long as it is for TPO purposes; the patient always has a choice. Health care providers have long managed patient consent, primarily through paper-based processes. In the digital age, consent management and electronic communication of consent and data sharing have led to disparity in state-to-state regulations regarding patient consent management. In some states, consent is given for a specific provider to access health records from other providers that have a TPO relationship with the patient. In other states, consent is given for a specific provider to share records with other providers. Some states have regulations where every patient is automatically opted-in to HIE operations while others require each patient to opt-in
We are seeing some promise
Interoperability is among the top priorities, if not the number one priority, for US policy and health IT, both public and private. Interoperability could easily be considered the “secret sauce” for successful value-based care models. The 21st Century Cures Act emphasizes the urgency around open communication, calling for greater interoperability among EHRs, while also discouraging information blocking.
The Cures Act directs the US Government Accountability Office (GAO) to conduct a study on the policies and activities of the ONC and other stakeholders to ensure appropriate patient matching to protect patient privacy and security for EHRs and the exchange of electronic health information (EHI). The study will determine if ONC can improve patient matching by defining additional data elements, agreeing on a minimum set of elements to be collected and exchanged, and mandating that EHRs make certain fields required using specific standards.
Earlier this year, the ONC launched the Patient Matching Algorithm Challenge in an effort to further advance interoperability. The challenge is designed to boost transparency about the performance of patient-matching methods and promote new algorithm development. This could spur useful insights to advance nationwide patient-matching standardization.
The Centers for Medicare & Medicaid Services (CMS) is also preparing to change how it identifies Medicare patients. Starting in April 2018, CMS will replace current ID numbers, which include Social Security numbers, with an 11-digit alpha-numeric code. CMS is implementing the new Medicare Beneficiary Identifier (MBI) pursuant to a provision of the Medicare Access and CHIP Reauthorization Act (MACRA). This shift is expected to have a significant impact on the health care industry and could have potential implications regarding an NPI.
The Cures Act also requires ONC to build consensus and develop or support a trusted exchange framework and a common agreement among health information networks nationally. ONC must develop or support a trusted exchange framework for trust policies and practices for a common agreement for exchange among health information networks.
Further, the Cures Act seeks to encourage the exchange of EHI by “providing the most useful, reliable, and comprehensive index of providers possible” and requires the Secretary to establish a provider digital contact information index for health care professionals and facilities. The Secretary may initially use an existing index and must ensure that contact information is available at the individual health care provider level and the health facility or practice level.
I’m with the government…and I’m here to help
I do not mean to imply that it is solely government’s responsibility to solve all the challenges facing interoperability efforts. Technology developers, health care providers, and patients alike have a major part to play. Health IT developers that provide 90 percent of hospital EHR systems, information exchange software, and other products, along with major health care systems and leading consumer organizations have pledged to support 3 core commitments:
- Consumer Access: to help consumers easily and securely access their EHI
- No Information Blocking: to help providers share health information for care with other providers and their patients
- Standards: to implement federally recognized, national interoperability standards, policies, guidance, and practices
CommonWell Health Alliance, a vendor-led consortium, operates a health data-sharing network that enables interoperability using a suite of services to simplify cross-vendor, nationwide data exchange. Services include patient ID management, advanced record location, and query/retrieve broker services, allowing a single query to retrieve multiple records for a patient from member systems.
Epic, the Wisconsin-based EHR leader with current records on 190 million patients, provides the Care Everywhere network across all Epic implementations. The Care Everywhere interoperability platform supports millions of patient record exchanges each month. Epic, however, is not a member of the CommonWell consortium.
Carequality, an initiative of The Sequoia Project, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. It brings together EHR vendors, record locator service (RLS) providers, and other types of existing networks from the private sector and government, to determine technical and policy agreements enabling data ﬂow between and among networks and platforms. Epic has implemented the Carequality framework for 90+% of their customers.
In late 2016, CommonWell agreed to become a Carequality implementer on behalf of its members and their clients, enabling CommonWell subscribers to engage in health information exchange through directed queries with any Carequality participant, including Epic. Carequality will work with CommonWell to make a Carequality-compliant version of the CommonWell RLS available to any provider organization participating in Carequality. This “golden spike” agreement will greatly advance interoperability across the major networks, CommonWell and Care Everywhere. Combined, this represents more than 90% of the acute EHR market and nearly 60% of the ambulatory EHR market.
The smart phone has changed our behavior, sometimes for the better, as we are now able to connect and engage with more people than ever before. Smartphone-loss Anxiety Disorder is a real thing, related to the dopamine effect of every new text or tweet. Even though we may be experiencing Chronic Lack of Interoperability Fatigue Syndrome (CLIFS), thankfully there may be a cure on the horizon. Hopefully, in the not so distant future, we will live in a world of health record interoperability just as prolific as smartphones and where there is no going back.
Eddie Hedrick has more than 30 years of experience in the fields of information technology systems and health care. Hedrick provides strategic leadership and management for short and long-term goals related to Health IT aligned with Fresenius Medical Care enterprise strategy. He previously served as Vice President, Product Development for Acumen Physician Solutions.
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