EMR dashboard designs attached is the grading Rubric

HCIN545 Healthcare Data

Lecture 7

Sharing Data through HIEs

Hoyt, Chapters 5

Lecture Objectives

Understand the history of health information exchange (HIE)

1 Discuss current and projected economic and technical barriers to health information exchange

2 Demonstrate practical, innovative and essential attributes of health information exchange and interoperability

3

A History of Healthcare Information Exchange

• Pre-internet • Patient and provider

• Letters, conversations, notes, visits

• Between providers • Letters, conversations, notes,

record copies, x-rays • Patient – hospital – provider

• Letters, conversations • Between hospitals

• Letters, lawyers, public data • Providers and payers

• Letters, record copies, checks • Everyone and The Government

• Elected representatives at all levels

A History of Healthcare Information Exchange

• Post-internet • Patient and provider

• Email, tweets, Facebook, conversations

• Between providers • Patient – hospital – provider • Between hospitals and

hospital departments • Providers and payers • Everyone and The

Government

Anyone Deal with Health Information Exchanges?

Anyone Have a Definition for Health Information

Exchanges?

HIE Definitions

HealthIT.Gov: “Electronic health information exchange (HIE) allows doctors, nurses,

pharmacists, other health care providers and patients to appropriately access and securely

share a patient’s vital medical information electronically—improving the speed, quality,

safety and cost of patient care.”

HIMMS: “HIE provides the capability to electronically move clinical information

among disparate healthcare information systems, and maintain the meaning of the

information being exchanged.”

Objectives of HIE per HealthIT.Gov:

Avoid readmissions

1

Avoid medication errors

2

Improve diagnoses

3

Decrease duplicate testing

4

Forms of HIE per HealthIT.Gov

Directed Exchange – Ability to send and receive secure information electronically between care providers to support coordinated care

Query-based Exchange – Ability for providers to find and/or request information on a patient from other providers, often used for unplanned care

Consumer Mediated Exchange – Ability for patients to aggregate and control the use of their health information among providers

HIE: Direct Exchange

• Directed Exchange is used by providers to easily and securely send patient information directly to another health care professional o For example: laboratory orders and results, patient referrals, or discharge summaries o Information sent over the internet in an encrypted, secure, and reliable way amongst

health care professionals who already know and trust each other o This form of information exchange enables coordinated care, benefitting both

providers and patients. For example: A primary care provider can directly send electronic care summaries that include

medications, problems, and lab results to a specialist when referring their patients. This information helps to inform the visit and prevents the duplication of tests,

redundant collection of information from the patient, wasted visits, and medication errors.

• Direct Exchange is also used for sending immunization data to public health organizations or to report quality measures to The Centers for Medicare & Medicaid Services (CMS)

• Direct Basics: Q&A for Providers Document

HIE: Query-Based Exchange

• Query-based exchange is used by providers to search and discover accessible clinical sources on a patient. This type of exchange is often used when delivering unplanned care. For example: o Emergency room physicians who can utilize query-based exchange to access

patient information—such as medications, recent radiology images, and problem lists—might adjust treatment plans to avoid adverse medication reactions or duplicative testing.

o If a pregnant patient goes to the hospital, query-based exchange can assist a provider in obtaining her pregnancy care record, allowing them to make safer decisions about the care of the patient and her unborn baby.

HIE: Consumer- Mediated Exchange

• Access to their health information • Allows them to manage their health

care online in a similar fashion to how they might manage their finances through online banking

Consumer- mediated exchange provides

patients with:

• Providing other providers with their health information

• Identifying and correcting wrong or missing health information

• Identifying and correcting incorrect billing information

• Tracking and monitoring their own health

When in control of their own

health information, patients can

actively participate in

their care coordination by:

HIE Types per HIMSS

• State-wide HIEs are run by the governments of their respective states, or may be the State's Designated Entity (SDE). Some state-wide (and regional) HIEs use an umbrella approach and serve as the aggregator for disparate private HIEs.

• Note: Kentucky HIE Video on Moodle • As of two years ago, all states/territories except Idaho,

Nebraska, Washington, D.C., and Connecticut have dedicated HIE systems

• Private / Proprietary HIEs concentrate on a single community or network, often based within a single organization, and include overall management, finance and governance.

• Examples may include hospital/Integrated Delivery Networks (IDN), payer-based HIEs and disease-specific HIEs.

• Some software vendors have also established HIE networks for their clients across the U.S.

• Other evolving entities such as Accountable Care Organizations (ACOs) supporting information exchange.

• Hybrid HIEs/HIOs are often collaborations between organizations, such as an ACO and a vendor network, within a state or region.

• Regional / Community HIOs are inter- organizational and depend on a variety of funding sources. Most are not-for-profit

Re-ask: Anyone Deal with Health Information Exchanges

(now that we understand definition a little more)?

HIE Network Roles

eHealth (Direct) Exchange

• Provider-centric • Peer-to-peer • Query based exchange • Central directory • Members are provider

organizations • Federal agencies, hospital

systems, large and medium HIEs

Community HIE

• Patient-centric • Use cases: alerts, query, or

analytics • Various strategies • Members are providers, labs,

payers, or researchers • Any EHR, lab, pharmacy, or

other HIT system

Important HIE Stakeholders

• People who receive care or support the care of others

• People and organizations that deliver care and services

• Organizations that pay for care

• People and organizations (governmental) that support the public good

• People and organizations that generate new knowledge, whether research or quality improvement

• People and organizations that provide health IT capabilities

• People and organizations that govern, certify and/or have oversight

• People and organizations that develop and maintain standards

Health Information Exchanges (HIE)

• Meaningful use program • Purposes of HIEs • Provided money to incent providers/hospitals to

join/create

HITECH ActHITECH Act

• States • Organizations

• HIMSS

Development of HIEsDevelopment of HIEs

HIE & States

(One Program Example from HealthIT.Gov)

March 2010, ONC announced State Health Information (State HIE) Exchange Cooperative Agreement Program

• State HIE Cooperative Agreement Program funds states’ efforts to rapidly build capacity for exchanging health information across the health care system both within and across states

Five objectives of program:

• Create and implement up-to-date privacy and security requirements for HIE oStudy in 2016 with PEW Research found that very secure

HIEs had more use and acceptance • Coordinate with Medicaid and state public health programs to

establish an integrated approach • Monitor and track meaningful use HIE capabilities in their

state • Set strategy to meet gaps in HIE capabilities • Ensure consistency with national standards

How do you share data?

Locating the right data

Sending a recognizable string

Including the right information

Formatting the message

Protecting proprietary databases

Legal issues?

An Example:

Clinical Document Architecture (CDA)

• The continuity of care document or (CCD) was developed to summarize patient care. It is one of the CDAs

• CCD accepts free text and is capable of vocabulary specific semantic interoperability

• It contains the most common information about patients in a summary XML format that can be shared by most computer applications and web browsers. It can be printed (pdf) or shared as html

Clinical Document Architecture (CDA)

CDAs are used in EHRs, personal health records, discharge summaries and progress notes. CDA delineates the structure and semantics of clinical documents, consisting of a header and body

Templates can be used for a variety of purposes; for example, CDA for History and Physical Notes, CDA for Consultation Notes, CDA for Operative Notes, etc.

Next slides shows CDA elements & template example

CDA Data Elements

Section Description Header Patient demographics Allergies, Adverse reactions and alerts Status and severity Encounters Surgeries, visits, etc. Immunizations Immunizations Medications Those prescribed by physician Care Plan Planned testing and therapy Discharge Medications Part of hospital discharge summary Reason for referral Written reason Problem List Documented diagnoses Procedures History of procedures Functional and Cognitive status List of impairments Results Laboratory results Social History Habits such as smoking, drinking Vital Signs Height, weight, blood pressure, etc. Discharge Instructions Written Instructions

CDA Template Example

Anyone in Class Use or Deal With CDAs?

Current Roadblocks to HIE

• Organized medicine

• Healthcare organizations

• State governments

• Citizens

• Federal government

Barriers to Sharing: Expectations

• Providers expect HIE to be easy and universal

• Many think Meaningful Use solved this problem….

• Transport/format standards already exist

• EDI, HL7v2, FHIR, secure messaging

• Providers and patients want more than just data sharing

• Content has to be meaningful and understandable

• SNOMED-CT, ICD-10, CPT • HIE has NOT demonstrated value

(yet)

HIE Implementation

Checklist

1. What degree of collaboration does your HIE provide?

• Can it be integrated with my EHR? • Is the HIE browser-based?

2. Does the HIE offer Direct Secure Messaging between providers?

3. What data is protected when I query the system? • Would it include minors? • Will it exchange sensitive information (super-

protected information)?

4. Which exchange service providers are available in my area?

• 4 regional health information organizations in Pennsylvania: https://www.pamedsoc.org/detail/article/healt h-information-exchanges-2

HIE Implementation

Checklist

5. Talk with your service providers. • Ask about sustainability. • What are the internal requirements of your

practice to participate in an exchange? • Does the HIE have a dedicated team to support

provider/practice training and education? • Is marketing material and patient education

provided? • What are the fees associated with joining? Start

up, monthly, annual? • What are the risks and liability? • What forms of exchange? FHIR or HL7?

6. Talk with your EHR vendor. • What are the fees associated with integration? • Do they offer interoperability? • What is the estimated timeline of integration? • Privacy and security? • Maintenance fees?

Barriers to Sharing: Functionality

• HIEs must be sustainable • Provide value to all users • Users must be willing to pay

for that value • Can be more data than

health information

Where are we now? Commercial marketplace

Exchange Interoperability Access

Amazon Email order confirmation

Quicken Download bank account data

PayPal Access account with context of purchase

travelocity See what flights are available

Where are we now? Interoperability tools

Exchange Interoperability Access

Care summary via direct messaging

Incorporated lab results

Single sign-on

FHIR

Where are we now? Status of HIE

Exchange Interoperability Access

• Mobilizing information among disparate systems • Increasingly inclusive

providers and consumers, and other stakeholders such as payers, social services

• Shifting from comprehensive information to critical / minimum necessary

• Shifting from exchanging copies to accessing data

HIE Value

With HIE:

Providers improve community outcomes • region • community • hospital system

With an EHR:

Providers focus on improving individual patient outcomes

What Do HIEs Offer that EHRs Do Not? (Per HIMSS)

Care coordination - This is a dynamic process that requires data movement across platforms and among service providers in real time. Many EHR systems do not talk to each other, creating delays and decreasing the value of the system.

Record Locator Services / Master Patient Indexes - Enable creation of one continuous community record, facilitating patient identification across multiple provider settings.

Data exchange - HIEs/HIOs provide support for vocabulary and code sets including content mapping, and enable data transactions to occur automatically across multiple providers and settings.

Data aggregation and analysis - This includes clinical data aggregation across HIE partners, as well as data analytics and warehousing.

Performance outcome management - Population-level data analysis is an essential component of pay-for-performance programs, ACOs, public health systems and other stakeholders.

Business intelligence analytics - Enable better risk analysis and better, more cost-effective care of high-risk patients.

What Do HIEs Offer that EHRs Do Not? (Per HIMSS)

Clinical messaging - Standard HIE services often include laboratory results, emergency room notes, medication lists, discharge summaries, progress notes, radiology results and surgical notes.

Support for EHR, PHR and MU adoption consultation - HIEs and HIOs facilitate the preparation of scorecards for services using claims and EHR data, and support achievement of Meaningful Use (MU) requirements.

Patient consent - Where consent is not governed by other laws or regulations, an HIE-based centralized consent management process can enable consensus among the community's stakeholders for a patient consent model.

Connectivity - HIEs/HIOs provide connectivity choices such as DIRECT Exchange, the and other connectivity services.

New care delivery methods - HIEs/HIOs can be essential components in both the development and operation of ACOs and Patient-Centered Medical Homes (PCMH) .

Data sharing - Consolidation and reduction of data interface costs by data sharing for patient demographics, Electronic Medical Record (EMR) data feeds, laboratory data, radiology data and scanned paper documents

Network Roles

• Basic interoperability at national level

• Retrieving info from places patient is known to have been seen

National

• Coordination of collaboration between stakeholders

• Interoperability at community level • Retrieving info from places patient

is not known to have been seen

Regional/Local

Government Role

• Fundamental support for HIE • Coordination through policy

and funding • Driving industry in a

coordinated direction

• Office of the National Coordinator for Health Information Technology’s (ONC’s) vision: “to better inform decision making to improve individual health, community health, and population health.”

• ONC, a.k.a. HealthIT.Gov

Coordinating Features of ONC (HealthIT.Gov)

• Coordinating and prioritizing the functionality of EHRs and HIE

• Shared Decision-Making • Ubiquitous, Secure Network

Infrastructure • Verifiable Identity, Authentication,

Authorization • Industry-wide Testing and Certification • Consistent Data Semantics and

Formats • Consistent, Secure Transport

Techniques • Accurate Individual Data Matching • Directories and Resource Location

Role of ONC Certification

Making interoperability easier… • Constrained standards provide a common

interpretation that implementers can use • Certification ensures that every implementer

uses the common interpretation the same way

Not plug-and-play, but toward plug-and-play…

ONC Goals

2018–2020

Expand data sources and users in the interoperable health IT ecosystem to improve health and lower costs.

2021–2024

Facilitate a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.

For detailed discussion, see (On Moodle)…

Connecting Health and Care for the Nation A Shared Nationwide Interoperability Roadmap FINAL Version 1.0

Bottom line: Value of HIE

• Better patient satisfaction with their healthcare experience

• Better patient outcomes through more complete information

• Better access to the right information at the right time

• Better-informed patients that participate in their wellness and health care

• Better outcomes, more efficient access, engaged patients leading to lower costs