Care Coordination and Interoperable Health IT Systems Unit 8: Exchange of Health Information Lecture d – Future Directions for Health Information Exchange Welcome to Care Coordination and Interoperable Health IT Systems, Exchange of Health Information. This is Lecture d, Future Directions for Health Information Exchange. This material (Comp 22 Unit 8) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

Exchange of Health Information Learning Objectives Objective 1: List the quality problems in health care that the exchange of health information is intended to remediate (Lecture a) Objective 2: Describe the nature of health information technology assets that the exchange of health information is designed to interconnect (Lecture a) Objective 3: Explain the motivations, capabilities, and challenges of health information exchange organizations (HIEOs) (Lecture b) Objective 4: Explain the motivations, capabilities, and challenges of using Meaningful Use and Direct to advance the exchange of health information (Lecture c) Objective 5: Describe the future directions for the exchange of health information exchange (Lecture d) The learning objectives for the exchange of health information unit are: number one, to list the quality problems in health care that health information exchange is intended to remediate; two, describe the nature of health information exchange technology assets that health information exchange is designed to interconnect; number three, explain the motivations, capabilities, and challenges of health information exchange organizations; number four, explain the motivations, capabilities, and challenges of using Meaningful Use and Direct to advance health information exchange; and number five, describe the future directions for health information exchange.

General status of health information exchange (HIE) In general, despite some progress due to the development of regional health information organizations (RHIOs), as well as some progress due to Direct, electronic HIE is not yet widespread in the United States Besides government – funded efforts, the electronic health record (EHR) vendor community is making some efforts to advance HIE In general, despite some progress due to the development of regional health information organizations (RHIOs), as well as some progress due to Direct, electronic health information exchange is not yet widespread in the United States. Besides government-funded efforts, the electronic health record (EHR) vendor community is making some efforts to advance health information exchange. Health IT Workforce Curriculum Version 4.0

Commonwell Health Alliance Founded in 2013 by Allscripts, athenahealth, Cerner, Evident, Greenway Health, McKesson, and Sunquest Goal: Embed services into their products to enable health information exchange One example of efforts being put forward by the EHR vendor community to advance health information exchange is an initiative known as the Commonwell Health Alliance. This initiative was founded in 2013 by the EHR vendors Allscripts, athenahealth, Cerner, Evident, Greenway Health, McKesson , and Sunquest. The goal of this initiative is to embed services into these organizations’ EHR products that enable health information exchange. Health IT Workforce Curriculum Version 4.0

Commonwell Health Alliance (Cont’d – 1) Envisioned services: Person identification (enrollment) and linking Record locator, data query, and retrieval Consent management Certification, authentication and auditing to facilitate trusted exchange In this initiative, the envisioned services that the EHRs would create would include patient identification and record linking; record locator and record retrieval services; consent management services; and certification, authentication, and auditing to facilitate trusted exchange. Health IT Workforce Curriculum Version 4.0

Commonwell Health Alliance (Cont’d – 2) Technical approach: master patient index and record retrieval services similar to a RHIO Vendors are providing organizational leadership rather than requiring provider organizations to take the lead Vendors are facilitating the interface development The technical approach the Commonwell Health Alliance will take is to develop master patient index services and record retrieval services, very similar to those provided by a regional health information organization. In this case, however, these services would be provided by the vendors themselves instead of a separate organization. Under the Commonwell Health Alliance, the vendors are providing organizational leadership directly and are facilitating the interface development, rather than requiring the provider organizations to take a lead role in these activities. Health IT Workforce Curriculum Version 4.0

Commonwell Health Alliance (Cont’d – 3) Current state: demonstration projects Ability to reach “critical mass” is still to be determined For more information on the Commonwell Health Alliance, please go to their homepage at: www.commonwellalliance.org/. Commonwell Health Alliance is still in a very early stage and currently , demonstration projects are being carried out. Whether this initiative will achieve critical mass for health information exchange in the United States at a broad level is still to be determined. For more information about this initiative, please go to their homepage at www.commonwellalliance.org.   Health IT Workforce Curriculum Version 4.0

The Sequoia Project Non – profit organization to advance nationwide health information exchange Three initiatives eHealth Exchange network CareQuality framework for interconnecting health information exchange networks RSNA Image Share Validation Program For more information, go to The Sequoia Project’s home page at http://www.sequoiaproject.org/ The Sequoia Project is a non-profit organization with the mission of advancing nationwide health information exchange. The Sequoia Project consists of three initiatives. The eHealth Exchange is a network of organizations in the United States that use common standards and common legal agreements to share clinical information over the Internet. The use of common approaches eases the burden of inter-organizational data sharing. Participants in the eHealth Exchange agree to common approaches for (i) finding and requesting copies of healthcare information from other participating organizations, (ii) sending health information to other participating organizations, (iii) matching patients without a national patient identifier, and (iv) being able to receive updates about a patient’s health information. The eHealth Exchange is growing and includes extensive number of hospitals, medical groups, federal agencies and other health care provider organizations. Care Quality is a framework for allowing health information exchange networks to exchange data with each other. The Care Quality framework provides legal agreements and technical specifications to enable exchange of patient information across health information exchange networks. The RSNA Image Share Validation Program is a collaboration between the Radiological Society of North America and the Sequoia Project to assure that vendors of radiology information systems and image archiving systems are adhering to standards that will enable exchange of radiology data. The initiative was launched in late 2016. For more information on the Sequoia Project, go to The Sequoia Project’s home page at www.sequoiaproject.org/ Health IT Workforce Curriculum Version 4.0

Strategic Health Information Exchange Collaborative National trade association for health information exchange organizations Statewide, regional, and community health information exchanges Supports exchange of ideas, education, and advocacy In early 2017, there were 47 members For more information, go to the Strategic Health Information Exchange Collaborative’s home page at http://www.strategichie.com/. The Strategic Health Information Exchange Collaborative is the national trade association for health information exchange organizations. It is a national consortium of statewide, regional, and community health information exchanges that assists its members through the exchange of ideas and business practices as well as through public education and advocacy. As of early 2017, there were 47 members of the collaborative. For more information, go to the Strategic Health Information Exchange Collaborative’s home page at www.strategichie.com/. Health IT Workforce Curriculum Version 4.0

The Argonaut Project Purpose: develop application programming interface (API) and data services specification to enable information sharing Another initiative to advance health information exchange at the national level is an effort known as The Argonaut Project. The purpose of The Argonaut Project is to develop application programming interface, or API, and data services specifications to enable information sharing. These APIs would allow health information technology vendors to more easily interoperate by sharing data in a provider organization. Health IT Workforce Curriculum Version 4.0

The Argonaut Project (Cont’d – 1) Uses Fast Healthcare Interoperability Resources (FHIR) Data specifications for commonly used health care data elements (e.g. medication list, problem list, etc.) Simpler than specifications for an entire summary of care Uses well – accepted standards for transport of data, user authorization, etc. Refer to unit 5 for more information about standards for interoperable health IT The Argonaut Project uses a draft standard known as Fast Healthcare Interoperability Resources, or FHIR. FHIR is a set of data specifications for commonly used health care data elements, for example, the medication list, the problem list, etc. There are many situations in which transmitting just class of data, rather than an entire summary of care record, is sufficient to provide value. For example, a health information technology vendor that is providing an application to support medication reconciliation would require only the patient’s medication list, not the entire summary of care record. The FHIR specifications for a medication list are simpler than the specifications for an entire summary of care, FHIR would simplify the transmission of the medication data. Health IT Workforce Curriculum Version 4.0

The Argonaut Project (Cont’d – 2) Some successful pilots Next steps: More demonstration projects Ability to write back into an EHR For more information, go to The Argonaut Project’s home page at http://argonautwiki.hl7.org/ In addition to the data representation standards, FHIR also uses well-accepted standards for transport of data, user authorization, etc. Currently, there are some successful pilots for the use of FHIR standards. One example is extracting pediatric growth chart data from an EHR and displaying it in a specialized visualization tool. The next steps for The Argonaut Project are to carry out more demonstration projects and to demonstrate the ability to write back into the EHR, and not just retrieve data from an EHR. Health IT Workforce Curriculum Version 4.0

Interoperability measures KLAS Keystone Summit (October 2015) 12 vendors Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, GE Healthcare, Greenway, Healthland, McKesson, MEDHOST, MEDITECH, NextGen Healthcare Another initiative to advance interoperability nationally, is an effort to be able to measure the state of interoperability. For example, how would we know whether we have achieved interoperability at a broad scale nationally? To advance these activities, the organization called KLAS organized a summit in October 2015. Twelve vendors were present at the summit. The vendors that were there are: Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, GE Healthcare, Greenway, Healthland, McKesson,  MEDHOST, MEDITECH, and NextGen Healthcare.   Health IT Workforce Curriculum Version 4.0

Interoperability measures (Cont’d – 1) Agreed to draft measures of health information exchange to serve as basis for understanding nation’s current position and trajectory The approach that was proposed is that health care providers would complete an assessment of their EHR’s ability to support health information exchange These vendors agreed to draft measures of health information exchange to serve as the basis for understanding the nation’s current position on interoperability and its trajectory. The approach that was proposed was that health care providers would complete an assessment of their EHR’s ability to support health information exchange. Health IT Workforce Curriculum Version 4.0

Interoperability measures (Cont’d – 2) Measures could include: Ease of finding out whether patients have records elsewhere Ease of obtaining records Methods of delivery and display Breadth of available data Barriers to successful sharing Congress is requiring interoperability metrics KLAS metrics may be a starting point See component 14 unit 1 for more information about KLAS The measures that were proposed include: the ease of finding out whether patients have records elsewhere; the east of obtaining those records; the methods of delivery and display of those records; the breadth of available data; and the barriers to successful sharing of the data. As part of recent legislation, Congress required the Department of Health and Human Services to establish metrics for interoperability by July of 2016 that could be used to determine the extent to which the widespread exchange of health information is being achieved. It is possible that the metrics outlined at the KLAS summit would be the starting point for the metrics that the Department of Health and Human Services will finally select. For more information about KLAS, please see component 14 unit 1.    Health IT Workforce Curriculum Version 4.0

ONC 10 – year interoperability road map goals Another initiative to advance health information exchange at a national level is a report that was released from the Office of National Coordinator (ONC) in October 2015. In this report, the ONC laid out a 10-year interoperability road map. This road map had goals divided into 3 phases. The first phase, which is from 2015 to 2017, is that there would be capabilities to send, receive, find, and use priority data domains to improve healthcare quality and outcomes. In the second phase, which is from 2018 to 2020, the number of data sources and the number of users in the interoperable health IT ecosystem would also be expanded to improve health and lower costs. Rather than be a specific set of activities that would be funded by the federal government or other sources, this roadmap is more of a general framework for other stakeholders in the environment such as EHR vendors and healthcare provider organizations to use as they develop their visions for health information exchange and direct their activities. For more information about ONC’s 10-year interoperability roadmap, see unit 3c. 8.11 Figure (Kuperman, G., 2016). See unit 3c for more information on ONC’s 10-year interoperability roadmap Health IT Workforce Curriculum Version 4.0

National interoperability initiatives at a glance This lecture discussed five national interoperability initiatives. The Commonwell Health Alliance started in 2013 and is driven by EHR vendors to enhance their products. In 2008, The Sequoia Project started for providers to share clinical information. The Argonaut Project has been developing application programming interfaces (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards since 2015. Vendors and KLAS have drafted interoperability measures starting in 2015. Also in 2015, ONC published an interoperability roadmap that provides a three-phase framework for vendors and health care providers. 8.12 Figure (Kuperman, G., 2016) Health IT Workforce Curriculum Version 4.0

Unit 8: Exchange of Health Information, Summary – Lecture d, Future directions for health information exchange Regional health information organizations (RHIOs) and Direct are contributing to the advancement of health information exchange (HIE), but more progress is needed This concludes lecture d of Exchange of Health Information, Future Directions for Health Information Exchange. In summary, RHIOs and Direct are contributing to the advancement of health information exchange, but more progress is needed.

Unit 8: Health Information Exchange, Summary – Lecture d, Future directions for health information exchange (Cont’d – 1) Some commercial efforts to advance HIE are underway, but these are early and it is unclear how they will evolve The ONC has developed a 10 – year roadmap for nationwide interoperability, which indicates that they believe this will be a long – term effort Health information exchange (HIE) will be an evolving and dynamic field for several years to come Some commercial efforts to advance health information exchange are underway, but these are early and it is unclear how they will evolve. The Office of the National Coordinator for Health Information Technology  has developed a 10-year roadmap for nationwide interoperability, which indicates that they believe this will be a long-term effort. Health information exchange will be an evolving and dynamic field for several years to come.

Unit 8 Summary: Exchange of Health Information Health information exchange (HIE) can contribute to improvements in the quality of care There are many health care scenarios where HIE could be beneficial There have been two major approaches to HIE since the mid – 2000s: regional health information organizations (RHIOs) and Meaningful Use. Each has had some success, but more progress is needed This concludes unit 8, Exchange of Health Information. The summary of this unit is that health information exchange can contribute to improvements in the quality of care. There are many health care scenarios where health information exchange could be beneficial. There have been two major approaches to health information exchange since the mid-2000s: regional health information organizations, or RHIOs, and Meaningful Use. Each has had some success, but more progress is needed.

Unit 8 Summary: Exchange of Health Information (Cont’d – 1) Some commercial approaches to health information exchange (HIE) are emerging, but are in early stages The ONC has laid out a 10 – year interoperability roadmap This will be a dynamic area for years to come Some commercial approaches to health information exchange are emerging, but are in early stages. The ONC has laid out a 10-year interoperability roadmap. This will be a dynamic area for years to come.

Health Information Exchange References – Lecture d Argonaut Project. www.argonautwiki.hl7.org Commonwell Health Alliance. www.commonwellalliance.org Office of National Coordinator for Health Information Technology. Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. Draft Version 1. Accessible at www.healthit.gov/sites/default/files/nationwide-interoperability-roadmap-draft-version-1.0.pdf. Sequoia Project. www.sequoiaproject.org No audio. Charts, Tables, Figures 8.11 Figure: Kuperman, G. (2016). ONC 10-year interoperability roadmap goals. Used with permission. 8.12 Figure: Kuperman, G. (2016). National interoperability initiatives at a glance. Used with permission.

Unit 8: Exchange of Health Information, Lecture d – Future Directions for Health Information Exchange This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004. No audio. End.