interoperability for the common good · 2016. 10. 11. · “interoperability alone will not...

Day 2: Track 1 – Governing Health IT Through Public Policy

Interoperability for the Common Good

Matthew Fisher, Esq. Chair of Health Law Group

Mirick O’Connell Worcester, MA


The Orchestra by Regina Holliday: A tale of Interoperability


Why is Interoperability Important? • Improve patient care • Building block for success in alternative payment world

o Value-based care o Shared risk and shared savings arrangements o Bundled payments

• Broaden base in which healthcare information can flow • Realize promised potential and opportunity with electronic

medical records


What is Interoperability? • The technical definition (from HIMSS)

o Interoperability consists of three levels: Foundational – The first level allows data to be exchanged from one

system to another, but the system receiving the data cannot interpret the data

Structural – The second level enables data to be moved with the operational purposes and meaning of the data preserved and unaltered

Semantic – The third level allows two or more systems to exchange and use the data

o “Push beyond the ability to share/exchange information to the ability to use the information that has been exchanged.” – Tamara StClaire (@drstclaire), Chief Innovation Officer at Xerox Healthcare


Is a Component Missing? • “What’s been missing from healthcare interoperability has been

what is called task, work flow, or pragmatic interoperability. To understand pragmatic interoperability, you need to understand systematic [message structure] and semantic [message meaning] interoperability.” – Charles Webster, M.D. (@wareflo)

• Had to get baseline into place, but now need to bring it all

together o Built foundation, but keep going

• Take beyond even the HIMSS definition


What is Interoperability? • The practical perspective:

o Medical information should be accessible and usable in the system identified or used by any patient and/or provider

o Just let data be free and flow

Image from http://www.aegisiscblog.com/wp-content/uploads/2016/05/healthcare-interoperability.jpg


Interoperability: Provider Perspective • Expect patient’s data to be available, accessible and in the system

when needed • Want full picture and ability to manipulate data in response to patient

questions and issues • Data should flow almost like a “hallway” consult

o Be there when needed, without concern about access • Want technology to support and supplement, not interfere with

practice

• “I should not have to log into seven different systems to access

information. All of it should just be available and accessible.” – Dr. Stacey Beberman

• “Interoperability is not just the exchange of information, but it is also the standardization of test dictionaries, lexicons, and in fact, the way physicians characterize and observe symptoms, and disease.” – Edward Bukstel (@ebukstel), CEO Likely Medicine


Interoperability: Patient Perspective • Expect information to be everywhere and always available • Why does healthcare not act like other industries?

o Banking, retail, etc.

• Ownership or control and debate over which to have • Larger question: do majority of patients know what

interoperability really is? o Should patients have to know what it is?

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Interoperability: Vendor Perspective • Outside Perceptions

o Business model encourages creating proprietary systems o No monetary incentive to work together o Questions about why different instances of same vendor’s product will

not work together

• Reality or Practical Issues: o Not all using same system and need to continually improve capabilities

already built in old systems o Takes time to perfect and roll out o When started, no common definition of standards


Interoperability Conundrum

Image from http://xkcd.com/927/


Interoperability: IT Staff Perspective • Rely on product purchased or provided to implement • Respond to demands of providers, others in organization • Left to improvise or otherwise find solutions that work internally • Interface with most other players (providers, vendors, more) • Are demands realistic?

Image from https://www.edifecs.com/content/uploads/content_images/Interoperability-Inner-Circle.jpg


Refuting One Barrier to Interoperability • HIPAA (privacy and security requirements) often cited as preventing

interoperability • Concerns stem from misperceptions and misunderstandings

• “People frequently think that “interoperability” is inconsistent with

privacy – but that is certainly not the premise of the HIPAA regulations. The regulations presume that information will need to be used and disclosed for treatment and care coordination, to obtain payment for care, and for public health and oversight purposes – just to provide a few examples – and in order for information to be useful for these purposes, it will need to be interoperable. Perhaps even more on point, the HIPAA Security Rule doesn’t just protect the confidentiality of health information – it also helps protect its integrity and its availability, for all of the purposes for which it is needed and for which it can be lawfully used and disclosed. Privacy and security should enable interoperability – not pose an obstacle to it; nor should we think that somehow the lack of interoperability is a mechanism for keeping information private.” – Deven McGraw


What is Driving Interoperability Demand • Value-Based Care and Population Health • Government demands and expectations • Patient demands and patient centered care • Consumerism movement

Image from https://media.licdn.com/mpr/mpr/jc/AAEAAQAAAAAAAAMfAAAAJDczNmNhODhkLTYzODctNDVjNy1hNjgzLTFiYWM2NDI5YjVlZA.jpg


Value-Based Care and Population Health • “From the health system’s point of view, more and more health

systems are not accountable only for their hospital. Even independent physicians are responsible for a patient even when they leave. So I need to make sure wherever they go they are healthy. So there’s a direct benefit because payments are being adjusted by how health patients are regardless of whether or not the patient is in your specific four walls or not, which is why the demand for interoperability has been surging over the last few years.” – Jitin Asnaani, CommonWell Health Alliance Executive Director


Value-Based Care and Population Health • Value-based-care (VBC)

o Moving payments from fee-for-service to quality and outcome determined

o Track patients o Potentially financially responsible for full scope of

care o Gathering, interpreting and acting upon data

essential to success “Interoperability alone will not revolutionize healthcare. Collaboration, partnerships and a shared goal of improving healthcare across the board are critical components to meaningfully leveraging shared data in a way that has the potential to improve the healthcare of millions.” – M. Maxwell Stroud (@mmaxwellstroud), Galen Healthcare

Image from https://www.uhc.com/content/dam/uhcdotcom/en/ValueBasedCare/Images/vbc-about-circle.jpg


Value-Based Care and Population Health • Population Health

o Connected to, but different than VBC o Looking at an entire population segment and determining health

outcomes across that group Looking for trends, underlying shifts and other cumulative effects

o Challenges notions of individual approach to healthcare o To address large swath, data for all necessary

Cannot find, understand or change trends without seeing

Image from http://blogs.sas.com/content/hls/files/2015/01/PopHealthWheel1.jpg


Value-Based Care and Population Health • “A more advanced level of interoperability is required to enable

clinical quality measurement and outcomes research, which serve larger populations of patients by advancing medical knowledge that filters down to better patient care through improved practice guidelines, diagnostics and treatment options. This second order of interoperability requires additional metadata that facilitate the integration of datasets that are derived from a variety of sources, including EHR data, genomic data, patient reported data, public health data, and any other relevant data sources. Without clear metadata that define how data were collected and calculated, integrating datasets will be difficult at best and inaccurate at worst. This level of interoperability remains a work in progress.” – Janice McCallum (@janicemccallum), Health Content Advisors, Managing Director


The Government and Interoperability • Congress (Maybe Stepping In)

o Questioning vendors, providers and regulators Vendors – why are products not designed to work together? Providers – why aren’t you working together? Regulators – why did you allow this problem to remain?

o Showing frustration about barriers and perceived lack of progress o Not much action beyond hearings to date o Is congressional action needed?

Could it occur?


The Government and Interoperability • HHS and the Drive to Electronic Medical Records

o Meaningful Use (mandated by Congress, but implemented HHS through the ONC) More harm than good? Enough, or anything, to address interoperability? “I think the CMS put the cart in front of the horse by spending $35B

forcing the implementation of EHR’s before more work was done defining guidelines and standards to support interoperability; and how interoperability might be measured. And now the government is pushing the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) onto already overburdened providers and health plans. I often wonder if the CMS and its various supporting agencies even have a grand plan.” – Steve Sisko (@shimcode)

o Have government programs hindered the ability to get interoperability?


The Government and Interoperability • Signs of Hope

o ONC Interoperability Roadmap Sets out some ideals and goals Not a mandate, which allows industry freedom

o Looking to engage and get into a dialogue Not seeking to push one perspective down

o Recognition that universal buy-in and agreement needed for initiatives to succeed


Patient Demand and Patient Centeredness • Baseline expectation that healthcare information is and will be

available • See data flowing easily in daily life and in other industries

o Compare to Apple products, ATMs,

• Patient advocates highlight difficulty in getting own healthcare information o Importance set out in stories of chronic condition patients o Bring viral attention to issues

• Shift thinking to patient being in the center o Should all be centered around patient or provider/hospital? o How to align records from multitude of settings


Consumerism • What is consumerism?

o Increasing empowerment of patients to choose care alternatives and take active role in care experience

o Translation of experiences in other industries to healthcare Most often comparisons to retail

• Consumer Expectations o Want ease of use and access o Theoretically gravitate toward providers who make things easier

• Possible without data movement?

Image from http://67.media.tumblr.com/a5b21cce35ac4114fa53bf076e010549/tumblr_inline_nfvmh3dkoK1stihar.png


Interoperability Experience Task Force • Established by the Office for the National Coordinator of Health

Information Technology • Identified eight categories of need:

o Ability to effectively use health information o Ability to encode data that is syntactically and semantically interoperable o Ability to exchange health information o Ability to identify patients nationwide o Ability to locate relevant patient records o Ability to locate and identify providers o Ability to access and interpret consents and authorizations o Governance

• Provides overarching perspective


Barriers to Interoperability • With all potential good, what barriers?

o Legal HIPAA State vs. federal privacy and security requirements

o Technological Lack of standards Differences between software systems

o Business Lack of financial incentive Control client choices

• How real are the barriers?

• “We know that the technology exists...in other words that's not really

the main barrier. the barriers are the business models i.e. why should competing businesses/providers/payers/vendors share data and the ‘people’ ‘cultural’ workflow issues around the execution of sharing data. – Geeta Nayyar (@gnayyar), Fernwell Group Health, Inc. Chief Medical Information Officer


How Overcome Barriers? • Should the government fund enhanced standards to define

interoperability, or step back and let industry develop? • How can various players within healthcare industry change

standards to encourage or permit interoperability? • How can vendors be encouraged to improve interoperability to

better align with provider and/or patient priorities? • What actions can different interests take to develop a national

infrastructure that essentially creates a network of networks? • Question summarized from “Why Interoperability Matters”

(American Hospital Association, http://www.aha.org/content/15/interoperabilitymatters.pdf)

http://www.aha.org/content/15/interoperabilitymatters.pdf


How Overcome Barriers? • Let government step into less active role

o Oversee and hold players accountable

• Let patient and provider demands guide industry to response • Keep importance and purpose for interoperability in mind • Encourage cultural change for all in healthcare • Seek reform/amendment of federal and state law

Image from http://www.healthcareitnews.com/sites/default/files/breakthrough_1.jpg


Breaking Interoperability Barriers • “We need to make the standards better, and build

interoperability into HER workflow. That doesn’t require top down regulation, it takes the kind of goal-oriented interaction between providers, developers, and standards bodies that characterizes efforts like the Argonaut Project” – John Halamka (@jhalamka), Beth Israel Deaconess Medical Center Chief Information Officer


Is Interoperability the Right Question? • Is interoperability really missing right now? • What about “one record to rule them all”

o Third party platform described as “characterized by ease of access, and ubiquitously available applications that can be securely accessed from multiple endpoint devices, coupled with the use of commodity infrastructure available from service providers through software-as-a-service, platform-as-a-service, and analytics-as-a-service offerings, among other constructs.” – David Harlow, Esq., Flow Health Blog (http://blog.flowhealth.com/beyond-interoperability/)

• Does focus on interoperability shift attention from correct or right considerations?

http://blog.flowhealth.com/beyond-interoperability/


What Could be the Right Questions? • Is interoperability enough? • Does ownership of a medical record need to change?

o Patient, provider, vendor, government, or other?

• What is the best way to engage, educate and/or inform patients? • How can better data help control and reduce healthcare costs? • Would a larger, non-private framework help? • Others?

• “Interoperability: means we all have to play nice together......think

about how seamless and intuitive Google flows (gmail, gcalendar, gdocuments, ghangouts) and how easy an iPhone is to use.......it's just like that.......I'm not buying the argument that people don't have phones......and if they don’t....do you know how many iPhones and cell plans you can buy for one Epic deployment? Exactly. ;)” – Nick Adkins (@nickisnpdx),


Getting To and Beyond Interoperability • Meeting of minds of providers, vendors, patients, government

and others • What does the future hold?

o Ideally a healthcare system with no restrictions on data o Devote attention to coordinating and analyzing all available data o Unified, national system where patients can obtain care anywhere and

have data available?


Why Interoperability is Important • Everyone wants a better and improved healthcare system

o Meet needs of patients, providers, vendors, government, and others

• All components of healthcare should work together and not interfere with delivery of patient care

• “Everyone is important and the patient’s future depends on all of them playing their best.” – Regina Holliday (@reginaholliday), The Walking Gallery Founder


Closing Thought • “The tools needed to achieve full interoperability of electronic

health records are available today. Health care providers need to ask themselves: (1) Do we want to be part of a learning health care system? (2) Do we want to leverage data for the benefit of our populations – improving health, rather than just delivering health care? (3) Do we want to do well by doing good – improving performance under value-based contracts by improving the health status of patients and lowering the overall cost of care?” – David Harlow (@healthblawg), The Harlow Group

• Interoperability can be a reality today o Do we all really want it?


Contact Information • Matthew Fisher • Twitter: @matt_r_fisher • Email: [email protected] • Phone: 508-929-1648 • LinkedIn: https://www.linkedin.com/in/matthewreidfisher • Address: 100 Front Street, Worcester, MA 01608

mailto:[email protected]

https://www.linkedin.com/in/matthewreidfisher

interoperability for the common good · 2016. 10. 11. · “interoperability alone will not...

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