WEDI Innovation Summit Liora Alschuler, Lantana Consulting Group Chief Executive Officer

Liora Alschuler, CEO Background in electronic text, how to make large amounts of information usable on a computer I volunteer a lot: HL7, WEDI, HIMSS Health Story Current day job as Lantana CEO Participate in the CDA Academy ( About me

Do We Have the Right Standards and Processes for Implementing New Payment Models?

Standards and Processes ● Standards, pretty much ● Processes, not so much ● We can get there from here ●Quick tour of standards ●A look at some process barriers (& directions) Do We Have the Right Standards and Processes for Implementing New Payment Models?

● Admission, Discharge, Transfer: ADT – Been around for about 20 years – The who/when/where/what (high-level) – In well over 90% of US hospitals – Clinical exchange standards use compatible data set – More than adequate for patient identification Bird’s Eye View of Standards

● ADT ● Laboratory Results – Been around for almost 20 years – Use predominantly local codes – Under MU Stage 1, over 80% of hospitals included structured lab results into an EHR – Recent agreement on HL with LOINC Bird’s Eye View of Standards

● ADT ● Lab ● Standard Terminology – LOINC, ICD, CPT, SNOMED, NUBC, etc. – Unified Medical Language System ® (UMLS) – VSAC

Bird’s Eye View of Standards ● ADT ● Lab ● Standard Terminology ● Context: Templated elements – HL7 Reference Information Model – Constrained to Clinical Document Architecture (CDA) – Constrained by Implementation Guides: Consolidated CDA Templates for ●Data elements ●Sections ●Documents

Bird’s Eye View of Standards ● ADT ● Lab ● Standard Terminology ● Context: Templated elements/C-CDA ● Reporting: CDC’s National Healthcare Safety Network – Public reporting of healthcare associated infections – Adopted by CMS for quality reporting on Hospital Compare ● MU Standards for quality reporting – Quality Reporting Document Architecture (QRDA) – Health Quality Measure Format (HQMF)

● ADT ● Lab ● Standard Terminology ● Context: Templated elements/C-CDA ● Reporting: CDC’s National Healthcare Safety Network ● MU Standards for quality reporting ● Extensibility: There is always one more data element needed… ●Open templates ●Un-/semi-structured information ● Gaps? – Still assessing methods of validation, quality controls – Yes, still way ahead of industry capacity to implement Bird’s Eye View of Standards

Standards and Processes ● Standards, pretty much ● Processes, not so much ● Bird’s eye view of standards ● Barriers to implementation Do We Have the Right Standards and Processes for Implementing New Payment Models?

● Technical – Application infrastructure oriented to structured information ●Every enterprise has both structured and semi-/unstructured information ●That’s why we have databases & document management – Infrastructure incentives support structured information ●EHR is a database ●We need comparable infrastructure for document management ●Integration between document and data oriented resources – Impact ●Incomplete record ●Overuse of structured “summaries” in place of narrative ●Contributes to continued reliance on manual abstraction for validation Barriers to Implementation

● Technical ● Regulatory – Balance objectives within a long-range roadmap supported by a clear architecture; see GAO EHR Programs – Keep it really really simple Barriers to Implementation

Keep it really really simple Gall's Law is a rule of thumb from John Gall's Systemantics: How Systems Really Work and How They Fail:rule of thumbJohn GallSystemantics –A complex system that works is invariably found to have evolved from a simple system that worked. –The inverse proposition also appears to be true: A complex system designed from scratch never works and cannot be made to work. You have to start over, beginning with a working simple system.

● Technical ● Regulatory ● Economic – Incentives achieve limited objectives, may introduce distortion – Market value of interoperability emerging – Value needs to accrue to those who bear the cost Barriers to Implementation

Standards and Processes ● Standards, pretty much ● Processes, not so much ● Conclusions Do We Have the Right Standards and Processes for Implementing New Payment Models?

Do we have standards & process? We have standards To cover a comprehensive record, implement the simpler standards – Recent ballot for “complete” structured documents provides counter-point – HIMSS Health Story Project eliciting strong positive response Role of regulation & market forces – Regulation strong force, backed by incentives – Alignment of incentives with market required New Payment Models can provide value, encouraging and enabling the adoption and implementation of the standards and processes required – in other words, it is an iterative and symbiotic process – Payment models can incentivize new HIT management – New HIT management can support new payment models A few conclusions

Liora Alschuler, CEO