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Focus on Interoperability

Interoperability: Health IT's hardest problem is (finally) at an inflection point

<div>With FHIR 4, Open APIs, Carequality and CommonWell reaching a milestone of sorts and the finalized information blocking rule from Health and Human Services coming, the table is set for notable advancements in health information exchange.</div>
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<div>During April, we'll talk to experts and thought leaders about what's really happening in interoperability, present original HIMSS Media research on the state of data exchange, delve into the newly proposed rule from HHS and share insights about what the future holds.</div>

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ONC extends comment period for interoperability rules, updates TEFCA

The Office of the National Coordinator for Health IT made interoperability news on several fronts Friday: granting a much-requested 30-day extension for public comments on its proposed data exchange, information blocking and patient access rules and publishing the second draft of its Trusted Exchange Framework and Common Agreement. WHY IT MATTERS ONC says the new due date for public comments, now June 3, will allow additional time for the public to review the proposed rules. "The Centers for Medicare & Medicaid Services and ONC understand that both rules include a range of issues having major effects on healthcare," the agency noted. "The extension of the public comment deadline will maximize the opportunity for meaningful input and further the overall objective to obtain public input on the proposed provisions to move the healthcare ecosystem in the direction of interoperability." Healthcare industry groups such as Premier, which had requested the extension alongside organizations such as CHIME, AMA, MGMA, AHIMA and others in March, immediately applauded the move, saying the ONC regs are "too important to not get right." Stakeholders now have plenty of regulations to digest, as ONC on April 19 also published the second draft of its Trusted Exchange Framework and Common Agreement for public comment, meant to advance nationwide, network-to-network exchange of health information. "Specifically, the documents being released for comment are: (1) a second draft of the Trusted Exchange Framework, (2) a second draft of the Minimum Required Terms and Conditions for trusted exchange, and a first draft of a Qualified Health Information Network Technical Framework," ONC explained. "These documents will form the basis of a single Common Agreement that QHINs and their participants may adopt." This goal of the common agreement is to "create baseline technical and legal requirements for sharing electronic health information on a nationwide scale across disparate networks," according to the ONC, which is focused on three goals: providing a single "on-ramp" for system connectivity across the country; ensuring that electronic health data flows freely where and when it's needed, and making sure that connectivity is scalable nationwide. The public comment period on the TEF, MRTCs, and QHIN Technical Framework ends on June 17, 2019. "We expect that the implementation of the Trusted Exchange Framework and the Common Agreement, will bring us all that much closer to achieving the administration’s goals of nationwide interoperability," said National Coordinator for Health IT Dr. Donald Rucker. THE LARGER TREND In an interview with Healthcare IT News earlier this month, Rucker had initially said that the comment period on the proposed interoperability rules – which was originally scheduled to close on May 3 – would not be extended. "The issue with delay is you have to balance whatever additional input you might get, versus the impact on the public from the delay," he explained. But Rucker noted the importance of public feedback, and said that every comment on the rules is read and considered. "Under the Administrative Procedure Act, with a notice of proposed rulemaking there is an entire process of analyzing everybody's comments," he explained. "They're all read. When I used to be on the other side of the fence, writing comments, I was always wondering, is anyone going to read what we've spent so much effort putting together? But they're all read, are all processed and then, where there should be changes in the public interest, we incorporate those, and that goes through another large internal clearance process before the final rule." ONC's extension of the comment period would seem to be a recognition of the importance of the rules, which should have sweeping implications for the continuing evolution of healthcare interoperability at a pivotal moment. As Dr. Doug Fridsma, CEO of AMIA and former chief scientist at ONC told us this month, his organization takes the public comment process very seriously. "We as an organization have developed three response teams that are meeting every week for the next five weeks," he said. "So we've got kind of about 30 hours of work from our members, times about 30 or 40 members. So we'll have a lot of eyes and thought into this. I'm hopeful that we'll be able to produce something that is thoughtful and constructive, because this is really what's going to define health information exchange and the health IT space for the next five to 10 years." ON THE RECORD The two proposed rules, which follow the interoperability mandates of the 21st Cures Act, were first published at the outset of HIMSS19 on February 11. They're meant to "increase choice and competition while fostering innovation that promotes patient electronic access to and control over their health information," according to ONC. "Together the proposed rules address both technical and healthcare industry factors that create barriers to the interoperability of health information and limit a patient’s ability to access essential health information. Addressing those challenges will help to drive an interoperable health IT infrastructure across systems, enabling healthcare providers and patients to have access to health data when and where it is needed. For evidence of the importance of public feedback when it comes to rule shaping, Rucker noted that the updated draft of TEFCA came after ONC "considered the more than 200 comments we received on our previous draft," and incorporate suggested changes such as the updating the purposes for which information can be exchanged, adding a "push" method of data exchange, adding a technical framework for QHINs, and extending timelines for participating entities to implement changes that will be required by the Common Agreement. The future agreement, said Rucker, "will provide the governance necessary to meet the interoperability demands of diverse stakeholders, including patients, healthcare providers, and health plans." Twitter: @MikeMiliardHITN Email the writer: mike.miliard@himssmedia.com Healthcare IT News is a HIMSS Media publication.

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What you need to know about healthcare APIs and interoperability

Application programming interfaces enable information systems to communicate and transfer data among each other. Depending how it is configured, an API can enable a system to send or retrieve data that can update an individual’s record or provide collective data that can be used to create reports. An API also can send information from one system to another. A healthcare provider organisation, for example, can input a patient’s information into a system that works with insurance companies and nearly automatically determine the patient’s coverage for a specific procedure or medication. That is enabled by an API. APIs have a big part to play in health IT interoperability in the years ahead, especially as the data exchange rules of the 21st Century Cures Act encourage their standardisation and proliferation across the healthcare ecosystem. Here, some API experts point the way forward for APIs and describe where they can be of most help. THE STORY BEHIND HEALTHCARE APIs Interoperability, at its core, is a reflection of the healthcare industry’s need to coordinate care for patients across an increasingly large subset of players in a way much better than it currently can, said Jeff Becker, Senior Analyst of Healthcare Strategy at consulting giant, Forrester Research. “Prior to EHRs, interoperability was managed through phone calls and fax machines,” he noted. “For example, physician practices would call the local hospital to schedule an elective procedure, fax the patient’s chart over, and then coordinate pre-surgical screening for the patient. On the morning of the surgery, the patient’s paper chart would have a copy of their presurgical test results alongside a history and physical examination performed by the surgeon in the days or weeks leading up to the procedure.” Today, this use case has significantly expanded in complexity. Health systems may be running one EHR in the office, a second in the hospital, the anesthesiology department may be leveraging a third, and before the patient even leaves the OR, their vital clinical data is spread across a multitude of disconnected data silos. “When that patient rolls into the recovery unit, even today, the full clinical picture of what has happened to the patient thus far is not always clear,” Becker explained. “At discharge, this patient may go to an inpatient rehabilitation unit, a skilled nursing facility, or home under the purview of a home health agency or a remote monitoring program, further fracturing the full, end-to-end clinical story of this patient’s encounter into more data silos.” As financial reimbursement continues to be more directly pinned to outcomes improvements and reduced readmissions, each of these post-acute healthcare delivery organisations will want a full picture of the patient story, and for that, the industry needs more robust interoperability standards, Becker contended. ENTER APIs “Enter APIs,” Becker said. “The FHIR API framework is a common language that all of these disparate players can use to facilitate more meaningful exchanges between these systems. A babel fish in your intergalactic cantina.” APIs also are being deployed within business intelligence platforms to create a centralised, 360-degree view of the patient. While far from perfect, these APIs represent a framework for solving complex clinical problems, Becker contended. They also offer a space where business cases for future interoperability capabilities can be discussed and designed, he added. One can look at APIs in another way. For example, some of the most successful technical specifications like HTTP are adopted across the developer community and all Internet-enabled apps are using the HTTP/Internet standard; it just works, said Daniel Kivatinos, COO and Co-Founder of DrChrono, a vendor of EHR, revenue cycle management and practice management technology. “Healthcare should have a standardisation like this at an API level,” he said. “Apps should be able to get data from any other app through a known protocol and standard. In doing so, antiquated old formats like HL7 will fall away, saving costs.” API CHALLENGES While APIs may seem like a panacea to many interoperability problems, there are challenges to working with them, and they alone won't be able to cure those ills. “It goes without saying that APIs have closed the gap in many ways on how information is sent, retrieved and processed,” said Jay Bercher, Deputy Program Manager at Solutions By Design II, an IT system modernisation company that has helped the Department of Health and Human Services with application transformation and other IT services. “However, some technological gaps have appeared. As there is a lack of data standards in the industry and multiple technologies, APIs must be created custom to the need of the service it is providing for each system.” That means that it’s likely that a system may have multiple APIs, each connecting to a different service, he explained. The work may or may not be heavily involved, but the management of that API can be tedious as systems are upgraded and replaced, he added. “Data sources, attributes and technologies can change with upgrades and replacements, thus creating the need to reinvent the ETL – extract/transform/load – scripts,” Bercher said. “And if a system utilises a lot of APIs, transforming data into a readable form can take months or years.” Additionally, API testing can be a challenge. In addition to the headache of coordinating tests among different companies and agencies, healthcare systems can have a complex data flow across multiple environments that may not be replicated in test environments, he added. “Therefore, developers and architects must determine a method of testing the API to ensure it provides accurate downstream results,”  Bercher said. OLD METHODS There still are on-premise EHR vendors that continue to do everything through remote log-in and transferring data sets through secure FTP flat files; this is an older way of accessing medical records and moving data from place to place, Kivatinos of DrChrono said. “One challenge across the industry is that many vendors are using and still buying older technology that is not API-enabled,” he said. “It is imperative that we move away from a locally only installed on-premise model to more of a cloud-based model where the health tech industry can enable APIs.” Another challenge is standardisation. The most significant limitation to APIs is the lack of standardisation around how they are implemented, Becker of Forrester Research said. “Implementation standards are available for frameworks like FHIR, but not enforced or widely adopted,” he said. “EHR vendors are free to implement subsets of an API framework, and within the subset that is implemented, there is variation within what specific data elements will be returned when called. A lack of control over implementation of these standards will leave CIOs needing to create one-off solutions based on the broad variation in API implementations.” And another challenge Becker identified is backward compatibility. “Standards like FHIR are only just now becoming backward compatible, leaving CIOs and vendors unsure of whether resources leveraged in a solution today will still work when the next version is released,” he explained. “With an 18-24 month update schedule, this causes perpetual instability in software designs. This problem has the attention of the HL7 community and with this year’s release of version 4, the first resources within FHIR were made backward compatible.” THE FUTURE OF APIs AND INTEROPERABILITY A few years down the road, healthcare APIs will have evolved into an even more helpful tool, the experts contended. “Business cases for next-generation data exchange are driving the future of APIs,” Becker said. “Expect FHIR to work toward a fully backward compatible standard, while the industry at large pressures vendors to adopt a standardised implementation model. Beyond this, compelling new work groups are emerging such as the DaVinci project, to support payer-provider data sharing.” These resources will enable payers and providers to more effectively coordinate care at the chronic disease management and population health levels, he added. The same demand for interoperability support will emerge as life sciences vendors continue to pursue outcomes-based reimbursement models and advanced post-market surveillance capabilities, he said. The healthcare industry cannot optimise interoperability without creating data and adhering to data standards; this initial step can take the industry to a whole new level of interoperability and consumption, Bercher of Solutions By Design II said. “The result of standardised data is an easy-to-use and easy-to-understand, cohesive data set,” he explained. “This data can provide a new level of insight into the needs of patients, providers, producers and facilities, which can help the industry make more informed decisions than they currently can. This data can then guide the industry to standardise new data points, which will continue to the path of increased insight.” More important, though, is the impact that this data can have on policies that provide guidance and regulate the industry, he added. Through APIs, the healthcare industry will allow patients to move from one place to another, easily transferring data from place to place, allowing patients and doctors to get more insight about a patient’s health, Kivatinos said. “APIs will allow a true Internet of Things experience where patients can use a device like a blood pressure cuff or glucose meter, allowing the patient to transfer the data into their medical record and other places with ease,” he said. “Various data sources like genomics and lab data will be transferable because of APIs," he added. "Providers will be able to give more precise care based on all of the data being accumulated from APIs coming in from apps and hardware. APIs have a bright future in healthcare.” This article first appeared in the global edition of Healthcare IT News.

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CommonWell Connector Program offers new way to connect with interoperability network

CommonWell Health Alliance on Tuesday announced the new CommonWell Connector program, which offers access to the data exchange network for care providers and electronic health records who may not necessarily be CommonWell members. WHY IT MATTERS Through the program, specific CommonWell vendor members who make integration platforms can offer the alliance's interoperability services to their customers, officials said. Those EHR companies who link up via a connector wouldn't be required to become a CommonWell member or certify their products on its network, because the member serving as the connector will have a certified product and act as an intermediary. CommonWell said it will enable certified CommonWell Connectors to "minimally pass-through its flow-down terms to their connected EHRs while enabling those CommonWell Connectors to include additional services, as needed by their customers." This will be useful for hospitals and health systems looking to manage the requirements of an array of new regulations, such as the CMS Promoting Interoperability Programs and the Trusted Exchange Framework & Common Agreement. Among the CommonWell members who are the first CommonWell Connectors: Health Gorilla and InterSystems, each of whom plans to roll out connectivity service later this year. InterSystems will allow users of its HealthShare suite to link up with CommonWell, getting a more "comprehensive view of the patient (that) drives care toward the triple aim," said Don Woodlock, vice president of HealthShare for InterSystems. Health Gorilla CEO Steve Yaskin said that broader access to clinical data can help "rally the entire ecosystem to improve access to high quality care, especially in underserved markets like Puerto Rico." THE LARGER TREND As it stands, CommonWell, whose members include some of the biggest EHR vendors and their health system clients, offers a wide footprint for its interoperability services. In combination with Carequality – the two rolled out general connectivity to their members this past November – the hope is, when that connection is fully live, some 80 percent of physicians will be able to share data, irrespective of which EHR they use, as Micky Tripathi (who sits on the board of both CommonWell and The Sequoia Project, which oversees Carequality) explained. There's clearly big value in such a network, allowing the "ability to exchange patient records within the reach of most acute care or clinic-based provider organizations, regardless of size or financial situation," as KLAS put it this past December, in a report encouraging more providers to sign on with those efforts. The new CommonWell Connector Program offers another way in for those hospitals and practices who may not yet be full-fledged members. ON THE RECORD "The CommonWell network enables participating practitioners to meaningfully engage in data exchange to provide the best care possible for their patients," said CommonWell Health Alliance executive director Jitin Asnaani in a statement. "With this new option, organizations interested in connecting to CommonWell, such as EHRs, can dramatically reduce the development effort required to connect to the CommonWell network and enable their clients to participate in – and derive value from – this data sharing." Twitter: @MikeMiliardHITN Email the writer: mike.miliard@himssmedia.com Healthcare IT News is a HIMSS Media publication.

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HL7 gives a glimpse of FHIR 5

Organization says 5 will build on FHIR 4 with more normative content, support for apps that use multiple versions of the spec and other advancements.