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

2. 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 (www.cdaacademy.com)www.cdaacademy.com About me

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

4. 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?

5. ● 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

6. ● 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 HL7 2.5.1 with LOINC Bird’s Eye View of Standards

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

8. 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

9. 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)

10. ● 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

12. 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?

13. ● 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

14. ● Technical ● Regulatory – Balance objectives within a long-range roadmap supported by a clear architecture; see GAO-14-207 EHR Programs – Keep it really really simple Barriers to Implementation

15. 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.

16. ● 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

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

18. 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

19. www.lantanagroup.com Liora.Alschuler@lantanagroup.com Liora Alschuler, CEO