Healthcare’s primary problem is not the lack of data, but the lack of fidelity and usability of the available data. The challenge is collating, interpreting, and distilling data to a usable state and getting those data to the right person, at the right time. Additionally, healthcare data is unwieldy and fractured, continuing to fracture exponentially as more care channels and options emerge. New channels generate new data silos that make safe, effective care difficult. Compounding this issue, costs of health insurance, care delivery, and medications continue to rise, placing adequate healthcare out of reach for many. As a result, the quality of care across the US continues to lag significantly behind other countries.

Patients are the reason healthcare exists, and yet, they are rarely centered in their information or care.

Also, the US healthcare is experiencing an unprecedented period of change, brought on by industry pressures, which makes an already complex system more cumbersome and perilous.

These pressures include: 

• Dramatic shifts in consumer expectations: Younger consumers are not satisfied with traditional healthcare, and consumers of all age groups are more willing than ever to try non-traditional services. Millennials and gen Z, who make up 42% of the population and 21% of healthcare services, expect convenience, affordability, transparency, and quality and are redefining how they engage in every stage of their care.
  
  
• Fragmentation: The delivery of care through established service paths (e.g., doctors, clinics, and medical centers) must now compete with non-traditional service paths that represent emerging types of service delivery (e.g., walk-in or retail clinics, outpatient surgery hospitals, virtual health, on-demand services, in-home services, or digital therapeutics).
  
  
• Increased regulatory pressures: The burden of new and existing laws regulating healthcare—such as HITECH, HIPAA, ACA, FDASIA, and MACRA/MIPS—affects providers by increasing their administrative load and by adding or increasing penalties for services that do not meet a set of prescribed quality, interoperability, and performance criteria. These burdens slow the delivery of care and reduce patient interface time with doctors and their clinical staff, alongside a host of other factors that can negatively impact care delivery, patient outcomes, and provider reimbursement.
  
  
• Hyper-specialization as the knowledge about diseases accelerates: Medical research continues to reveal the complexity behind disease causes and treatments. As research unravels the genome, microbiome, and proteome, referred to as multiomics, to understand their role in health and wellness, physicians become more specialized to turn discoveries into better outcomes for patients.
  
  

Data is duplicated and conflicting due to issues with standards

Because most health record systems do not consolidate information, numerous patient and provider-reported health records result in duplication, retention of outdated information, and leave room for error. Also, payer data often inaccurately reflects patient care and services provided due to the complicated nature of billing practices. Often, to ease workflow, patient services are billed based on a short list of memorized codes or the first code to populate a search, resulting in loss of fidelity. Therefore, providers don’t uniformly have access to accurate reference records which creates an overwhelming burden on providers trying to find the information needed to make recommendations.

Projects to enable interoperability are costly and time-consuming

Traditional data transformation and sharing methods are complex and deduplicating of the data with any precision is time-consuming and risky. Important changes in a patient’s record can take weeks or even months to emerge, as the data integration does not happen in near real time. There are existing methods of sharing more cleanly within like EMRs, but even in that method, there are issues reconciling data due to the differences in system setup (x field in system A is blood pressure, whereas it’s y field in system B).

The patient is never in control of their data

Patients are the reason healthcare exists, and yet, they are rarely centered in their information or care. They have little control of their data and, in most cases, have no concept of how the data is used and where it’s shared. Also, all too often, patient-provided information fails to be integrated with the patient’s record thereby ignoring critical pieces of information. By ignoring the patient as a vital part of healthcare and its interoperability, data sharing and cleansing become complex and diminishes the capabilities of healthcare providers to make data-based diagnoses and treatment decisions.

What can and should be done?

We should strive for a single, golden record for every person on Earth that is updated in real-time as changes happen and allows for notification of significant events to be delivered to the right person at the right time. And that record should be owned by the individual, not the system.

There have been many barriers to this in the past, but the most significant challenge has been to uniquely identify each person and all of the entities and assets they interact with.

Luckily, technologies and tools emerging on the market now can systematically address these issues through AI and machine learning. Tasks considered nearly impossible, like merging 20 medical records and distilling the information down to a single record, can now be done at scale, with the patient owning the overall outcome.

One emerging company consolidates health and wellness data into a single, standardized record under secure control of the patient that facilitates seamless data exchange amongst healthcare and life science constituents. The technology leverages syntactic, structural, and semantic interoperability techniques in addition to patient-level interventions when AI cannot resolve the data cleansing automatically.

In addition to focusing on rich medical data, this company continuously fills gaps with real-time, real-world data from multiple sources (e.g., wearable and medical devices), in conjunction with social determinants of health (SDOH) and patient-reported information.

How do we get there?

While companies like this are working to solve this problem, there are cultural barriers in the US that need to be overcome. To truly achieve patient-owned interoperability, data hoarding and profiteering concepts need to be addressed. Healthcare needs to be democratized for a more equitable landscape. Platforms that democratize health information shift people from passive to active participants within their own health outcomes. After all, it is ultimately the patient that bears the burden of adverse health outcomes, not the providers.

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In 2009, Congress allocated millions of dollars to states to spur health information exchange (HIE) nationally by enacting the Health Information Technology and Economic Clinical Health (HITECH) Act. However, although health IT has progressed exponentially in the decade since the HITECH Act was implemented, physicians are still challenged when it comes to interoperability.

The HITECH Act included the Meaningful Use program that incentivized physicians to move from paper medical records into a digital format. The program required physicians to exchange patient information, but the bar was set low, and it was not difficult to apply exceptions. Now rebranded as Promoting Interoperability under the Centers for Medicare & Medicaid Services’ (CMS’) Quality Payment Program (QPP) authorized by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the program continues to push physicians and providers toward interoperability. Participants are required to share patient information in order to meet measures that earn performance points, which are then applied to a total QPP score that may result in payment incentives or penalties. The 21st Century Cures Act of 2016 sets the bar even higher as it requires prompt sharing of health information with patients, other physicians, and providers upon request, with very few exceptions.

The Struggle With Interoperability

Physicians connected to an HIE are challenged by the value of the data received. A 2020 Texas Medical Association survey asked physicians if they are able to access all the data needed via an HIE when treating patients. Of the 1,303 respondents, only 17% said yes. In addition, low-value data can create extra work within the practice or be costly.

• Physicians do not always receive data sent or intended in the same or a consumable format. If the EHR cannot consume the data received, a PDF or similar attachment must be saved or information entered manually, or even worse, sometimes both. Interoperability should work seamlessly within the workflow and with such high value that it is the preferred option for sharing information.
  
  
• Information shared is not always necessary and relevant to what the medical team needs to take good care of the patient. Typically, what is necessary and relevant can be reduced to a couple of pages. However, physicians may receive hundreds of pages of information they must sift through to find what is necessary and relevant to deliver patient care. In addition to wasted time, the costs of electronically storing bloated records are significant, especially for physicians who own and operate a small practice with thin (if any) profit margins.
  
  
• Physicians in small practices do not typically have dedicated technology support. These physicians must have low-cost interoperability solutions that work well within the workflow and without a lot of extra technical effort.
  
  
• Physicians need assurances that they are sharing patient information with and among entities that embrace high standards for data privacy and security and not with weak links that risk exposing patient information. 

Because of these difficulties, many physicians continue to rely on computer-generated faxing because it fits within the practice workflow, is secure, and doesn’t require a special and expensive interface. A recent data brief from the Office of the National Coordinator (ONC) indicates that about one-third (35%) of physicians used only fax, mail, or e-fax to share patient health information with physicians and providers outside of their organization (ONC cited the National Electronic Health Record Survey, 2019).

As physicians evaluate various interoperability choices, some starting with the low-cost option of Direct Secure Messaging, which can be considered as a secure email. To send a Direct message, a physician must have a Direct protocol address and know the intended recipient’s address. Messages are sent in a secure, encrypted, HIPAA-compliant manner. CMS now requires that physicians update their National Plan and Provider Enumeration System account with a digital address, and a Direct Secure Messaging address satisfies the requirement. Unfortunately, physicians are not always well informed about how to get a Direct address and how to adjust and manage the practice workflow to accommodate sending and receiving messages. A good first step is to ask EHR vendors. A good second step is to ask the local HIE.

The Technology Is There – Let’s Use It

To spur interoperability, capabilities should be baked into the EHR so that once physicians sign the necessary user agreement(s), the spigot is activated, and bi-directional exchange happens within the workflow. By leveraging national networks and applying the United States Core Data for Interoperability (USCDI) and its accompanying standards, the developer community could help physicians exchange health information in a manner that does not require costly interfaces or a lot of technical effort. The technology does exist to accomplish HIE better, faster, and cheaper. The Trusted Exchange Framework and Common Agreement, or TEFCA, is helping standardize the rules of the HIE road. Industry efforts are coalescing in such a way that medical practices should be able to have one bi-directional connection that intelligently disseminates clinical data across the networks in a standardized way. High-value HIE allows physicians and providers to have relevant information, organized meaningfully, about the right patient at the point of care to make good clinical decisions.   

Physicians are increasingly frustrated with the inefficiencies of digitized records requiring extra time spent on technology-related challenges that take away from patient care. EHRs have always promised increased care quality, patient safety, and greater efficiency. It behooves us as health care technologists to keep those goals top of mind for better patient care, which requires working creatively and collaboratively to achieve them.

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It is generally agreed upon that the flow of health information between providers in the US is not where it was projected to be by now. Well-meaning stakeholders across the care spectrum and Federal regulators have been pushing against a foot-dragging EMR industry toward a set of bare minimum goals.   The explanations given as to why those goals are not being met do not address what I feel should be more of a discussion than I have seen in the discourse on the topic. There is a fundamental conflict in the system, as designed, that disincentives providers from making this a priority. Beyond the technical and financial burden of having to install and maintain interfaces, and the workflow issues with clunky patient lookups and impartial/imperfect data, there is a fundamental imbalance between the benefits of HIE to the patient, the provider, and the payer. I believe that as long as this unbalance exists, the way this initiative has been progressing, or not progressing, will continue.

A shared-savings model in which the payer must distribute a portion of their savings to the providers could offer the positive incentive the system is currently lacking while resulting in a net decrease in the total cost of care overall.

The Patient and the Payers vs. The Provider

Many in healthcare are focused on the benefit of HIE for better patient care. Having the longitudinal health record of any patient, regardless of where they present, can significantly improve the care they receive as the physicians and clinical staff have a complete picture of that patient’s medical history. This is the core will behind the push for HIE. 

There is also a clear benefit of HIE realized by the payer by lowering the cost of care. That comes not only from avoiding duplicate testing, medication reconciliation, earlier diagnosis and efficient treatment, but also through penalties in value-based care contracts that are becoming the norm. For this reason, many payers are in a powerful position when it comes to HIE.

The providers, on the other hand, are being asked to collaborate in a competitive industry. In many cases, they do so financially to their own detriment, facilitating easier transitions for patients to providers outside their organization. Moreover, the sending organization is providing uncompensated value to competitors by allowing them to use information they worked to produce (think in terms of intellectual property (IP)). On the receiving end, providers are being robbed of services they could otherwise bill for, which negatively impacts their top-line revenue. Some of the time, however, providers can conversely leverage HIEs to shift the burden of unfunded patients outbound. While that benefits those providers, in that case, the public does not benefit and it perverts the idea of HIE in that respect.

A Potential Regulatory Solution as a Thought Experiment

This imbalance in the benefit of HIE between the patient, payer, and provider could be resolved if providers can monetize their participation in HIE through fractional reimbursement, to both the sending organization for sharing test results and medical records, and the receiving organization for leveraging that information. It is true that some could argue the bundled payments of ACOs attempt to equate for this disbursement. I would argue that model has much more to do with capping payment than incentivizing providers to exchange information (although that is certainly a biproduct).   

Extracting money from the payer portion of the equation back into the actual domain of providing healthcare is a culturally acceptable idea, as payers are often seen as middlemen siphoning crucial dollars for administrative overhead (albeit at a regulated margin) away from those with skin in the game. As technology and medical advancements continue to develop more and more expensive medications, diagnostic tests, and treatments, the efficient use of those tools becomes ever more necessary to contain healthcare spending. A shared-savings model in which the payer must distribute a portion of their savings to the providers could offer the positive incentive the system is currently lacking while resulting in a net decrease in the total cost of care overall.   

Personal Health Record

I can’t discuss this topic without commenting on the disruptive and potentially game-changing factor, the portable Personal Health Record. With the ubiquity of smartphones and the necessary infrastructure already in place (see Apple’s HealthKit), the fact that each patient can become the true owner of their comprehensive health data, with full discretion and the ability to send that information to any provider they choose, is all that is needed to solve this problem once and for all.  In many cases, this is already happening, but it has struggled to gain wide use outside of the tech-savvy consumers. I would speculate that these consumers are probably also much younger and healthier as a population, which further diminishes the current impact. But make no mistake, adoption/use will continue to grow and at some point in the future, there should reach a critical mass in which it becomes the norm. If and when that happens, I believe query-based HIE fraught with patient matching issues and incomplete data will be a thing of the past.

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For the last decade, information and technology have become some of the most valuable “items” that exist. The twist is that information is not necessarily what you learn in school, or what you pick up from working on the job. The likes of Apple, Microsoft, and Garmin make their business on information and its capabilities. 

These tech companies have invested millions, if not billions, of dollars in their workforce to specifically develop new technologies to keep people engaged and maybe even make their lives a little easier in one way or another. As a result, these companies continue to create the limits on how far technology can be pushed, develop new data systems, and enhance the experience their end users have.

Historically, the healthcare sector has lagged in its adoption of new technology. Maybe some fortunate health systems have had the opportunity to purchase the latest in scope technology, or maybe some have had the latest MRI machines and communication devices or applications. Unfortunately, some are using scopes that cost thousands, but that still only offer 720p resolution output. When we look towards where healthcare is going as an industry, we now have the tools at our disposal to use information in a secure way to better serve our patients and the communities they come from.

As health systems adopt not only increased data systems but also GPS tracking, mobile applications, and remote monitoring, the opportunities in patient experience are endless.

EMR adoption across the US has surged in the past decade – with nearly 96% of acute health systems utilizing one vs 44% in 2012. We opened the door to using technology in new ways other than just clinical documentation – and we will trigger a major change in the way healthcare is provided. These EMRs are state of the art in the basics of healthcare tech – clinical documentation, provider communication, order placing, etc. These features help patients, providers, and hospital staff alike in their daily operations. In addition, they allow for clearer, more effective operations which increases quality of care and decreases the risk of error. All the while, consumers and patients continue to, justifiably, feel more protected with their health data than “big tech” at large. According to HealthIT.Gov, nearly 84% of patients feel secure that their medical information is private. It is hospital leadership’s responsibility to continue to build on this trust, and foster secure environments, to expand on how this technology supports healthcare delivery processes.

The key to EMR technology is how it will be used to push healthcare technology utility to the next level – supported by their ability to summarize clinical data securely. With some EMRs even offering apps that allow access to medical records and real-time provider and office communication tools, the health system’s role in consumerism is poised to expand significantly.

The question becomes – Where do we expand to? We expand toward using data to increase our community’s health, decrease the inconveniences of how care is provided, and create opportunities for new ways to provide care. Six Sigma teams are present in envelope-pushing health systems that use historical data, with some predictive modeling, to improve system operations, increase quality and provide cost savings. We need to go toward using data the way much of the economy figured out a long time ago: how can we make informed decisions based on outcomes that MIGHT occur in the future?

Imagine leveraging blinded, collated patient data to identify trends in patient information that may predict the likelihood of a fall, and therefore preventing that fall? What if we can leverage active patient monitoring in the home to ensure a congestive heart failure patient is escalated to the correct clinical area before they have a significant cardiac event? We can help our patients receive more effective, comfortable, and timely care – but why stop there?

We see Uber and Dominos offer real-time tracking systems for transportation and food delivery. What if we leverage this technology, and integrate it into EMR capabilities, to increase the patient experience when it comes to home-based care? We are experiencing systems successfully implement remote patient monitoring (RPM), some even providing inpatient level of care in the home with the use of advanced monitoring systems and telehealth consults from physicians. 

Healthcare won’t stop there. As health systems adopt not only increased data systems but also GPS tracking, mobile applications, and remote monitoring, the opportunities in patient experience are endless. We can bring the care to the patient in the comfort of their homes, communicate frequently with caretakers and family members, and even prevent costly hospital admissions with predictive modeling. 

This lift is not easy. It will require collaboration with vendors and health systems alike. Sharing processes, creating large databases to understand patient mix and its implications, and process sharing will be crucial. Health systems’ responsibility to maintaining the highest levels of privacy for patient information will be a pillar of the technology shift in healthcare. The result will be driving down cost of care, increasing the experience the patient has, and increasing the overall quality of care provided. With healthcare costs being a major issue in the American way of life, anything hospitals can do to decrease this burden is welcome to our communities. 

While the COVID19 pandemic was devastating to the entire world, it may have triggered the push that the healthcare industry needed to adapt to the times. Systems were forced to leverage and expand telehealth services and adopt new technologies faster than ever before. The silver lining here is that the patients will end up winning – more advanced services offered at lower prices while maintaining the outstanding quality US health systems are known for. We continue to push the envelope and this industry will change, for the better, to support our communities. The future is bright for the integration of technology into healthcare operations, and it will be exciting to see what happens when technology can support creative, new ways of providing care for our patients that the healthcare industry has never seen before.

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Our patients expect their medical care from us (providers), to be timely, of the highest quality, and value. With the digitalization of the patient chart with electronic medical records (EMR), tremendous progress has been made, and now with two decades of EMR use and a decade of incentivizing providers to make it used meaningfully with the federal ARRA act of 2009, there still remain gaps that require fulfillment to achieve our patients’ expectations. Health information exchange (HIE) is a platform to share & interoperate patient’s medical data between provider systems. It serves as one step closer to achievement. Along with the Cures act in 2016, the CMS was motivated to rebrand the meaningful use (of EMR) program to Promoting Interoperability program, which incentivizes providers to share data.

Need for HIE and the role of emerging technologies

Electronically access and share patients’ vital medical history, no matter where they have received care. With the HIE platform, we can view and exchange patient data from connected sources ranging from health care venues such as state and national registries, PACS systems for image viewing, other regional HIEs, and CommonWell Health Alliance®, regardless of EHR.

HIE capabilities also provide the functionality and standard formatting to share Immunization records, Allergies, CCDs, PDFs, HL7®messages, images, scanned documents, H&Ps, discharge summaries, and clinical notes, which can help provide safer, more effective care tailored to patients’ unique medical needs. It also minimizes gaps and errors in patient history with comprehensive medical information from multiple care settings. Shared patient information in a timelier manner, can lead to more informed decision-making.

Ongoing regulatory changes require adoption to increase accessibility to patient data.

HIE cannot be efficiently done without digital technologies, emerging technology solutions like identity management using master patient index (MPI), FHIR interface technologies for information exchange, and 3^rd party vendor system that uses AI/ML to identify the patient accurately and improve the quality of the data that is being exchanged.

Having an HIE system in place does not mean that the accessed data is usable; patient care and safety cannot be supported if the data shared are useless.

Most pressing data integration and interoperability challenges

The need for a complete set of medical information that our clinicians can assess to provide the best care for our patients. We want to make sure that the right patients are not only matched and enrolled, but also that they are seamlessly accessible to our clinical care teams.

Having an HIE system in place does not mean that the accessed data is usable; patient care and safety cannot be supported if the data shared are useless. In our organization, more than 50% of the data received through HIE is unusable without going through a data cleaning process. This may be due to incompatible data formats, incomplete data, misidentification/loss of data categorizations and labeling, and data duplication.

We have engaged clinical and technical teams that assist us to ensure that robust MPI tools and reporting are being used for patient matching and enrollment. This includes record locator and record exchange services based on accurate patient matching.

For accessibility and user adoption, we have embedded HIE access via specialized screens & pages within our EMR system. Additionally, our HIE supports federated (distributed), centralized hybrid data models to ensure data connections are established as a foundation to enable better & cleaner data exchange. In addition, the EMR and other 3^rd party vendors are releasing products that interface between the HIE and the EMR to do the cleaning, creating context and appropriate matching processes for member matching, and leveraging AI/ML for the data cleaning.

How to build a successful data integration strategy?

The following are the key pillars for the data integration Strategy

1. Organizational Business Strategy
2. Care delivery processes
3. Data Governance
4. Data Privacy & Regulatory Compliance

Beyond the federal incentive program for interoperability, improving the care and providing value for the patients is a core of our healthcare providers’ business strategy. The data integration strategy should be infused into this business strategy to successfully achieve it.

Understanding the care delivery processes, people involved, and the data generated & used by it provides answers to the questions to address in the data integration strategy.

Implementing data governance to govern data through its entire life cycle from when it is created, managed, used, and archived. The governance facets should also include the data quality, data security controls, and the data architecture for seamless integration across the systems.  

When consent for data sharing, patients should feel confident that their data privacy is maintained to the federally mandated Regulatory & compliance rules. The strategy should include automation of these regulatory and compliance processes and audit records to track the data usage.

These key pillars along with the appropriate digital technologies road map should help the organization build a strong strategy.

Once the strategy is built, the proper execution of the strategy is also vital to reap the benefits of the data integration. We found it is more successful when the strategy is broken into multiple programs and projects that can provide quick wins to show the value of the integration.

With the right integration strategy, data governance processes & using emerging technologies, we all benefit from HIE, and it is a bridge to better care for our patients.

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It is 2025; you are on your way to a 10 am appointment with your PCP (primary care provider). You receive a text with a link to their wayfinding app which provides directions to your on-site parking space. Once you park, you receive a 2^nd text that provides access to a wayfinding application that gives you turn-by-turn directions to your provider’s office. As you walk into the building, facial recognition checks you into your appointment and a 3^rd text connects you with the ‘virtual clipboard’ where you can confirm/update your demographic, insurance and clinical information, the reason for your visit, take a photo of your insurance card and generally complete any pre-visit information while you wait. Once you have completed the pre-visit paperwork, you are directed to exam room 3, where the turn-by-turn directions get you to the exam room, where you are greeted by your doctor.

The doctor has your chart up and is reviewing your recent imaging study from the local reference imaging site, as well as the lab work done last month during your pre-employment physical. They talk with you about your blood sugar, heart rates, ECG and activity levels that were sent from your apple watch. They also remind you to refill your blood pressure medication as the information received from the pharmacy/insurance company shows that you have not refilled your medication in the last 90 days (which provides only 30-day increments).

Some would consider this an ideal encounter with their provider organization and for the future patient, interoperability and health information exchange (HIE) that delivers the right data, at the right time, for the right person, to the right person, across multiple states, systems and organizations are required for that reality. All of that exchange would be done directly, between participating organizations and their IT systems, magically behind the scenes, with no manual intervention by the patient nor the provider would be the expectation, but it’s far from today’s reality.

People suggest that healthcare interoperability falls short of other industries, for example, banking, but there is no data exchange between banks until you present your ‘card’. Banking also has the credit reporting agencies – Experian, TransUnion, and Equifax – which aggregate your financial information – which is reported directly to them by the banks – there is no such corollary in healthcare.

In today’s world – information is knowledge, power, currency, and the key to ensuring you and your loved ones get the right care, at the right time, in the right setting (without additional costs).

Health Information Exchange (the verb) has been fraught with patient identity issues. Specificity the usability, timeliness, manner of transmission, workflow integration and so on – the list of barriers exceeds the list of accomplishments on many fronts, but the foundational layer of digitized health data was brought forward by the EHR incentive program rolled out in the 2010s. This program encouraged EHR adoption amongst the provider communities, supported by technical and training resources from Regional Extension Centers and sped forward with the more recent expansion of health data exchange requirements via 21st Century Cures and TEFCA. These regulatory instruments have provided additional guardrails that are moving healthcare interoperability and standards adoption forward to reduce, remove, and eliminate a number of those barriers.

The future-forward interoperability framework will need the authority and ability to identify actors, create and deliver consent, and allow for health information to be participants in every exchange.

Still to be resolved are issues around patient, provider, and organizational identities. These are foundational components necessary to facilitate health information exchange and puts data in the right place to enable the best possible care encounter for each patient (think personalized medicine). The future-forward interoperability framework will need the authority and ability to identify actors, create and deliver consent and allow for health information to be participants in every exchange.

Organization Directory services for FHIR APIs and the like still need a home as well as a vetting authority to provide a trust framework for the consortia to be comfortable with making any exchange – patient identity with a consent mechanism that enables seamless and informed exchange also needs a home. Not to mention the need for an architecture that enables a ‘single patient identifier’ that can be shared by the patient with each of the care providers/organizations at the beginning of each encounter.

This global identifier could then be connected to the overall exchange framework and enable patient notification (and consent) of any exchanges between organizations, directly by the patient. Ideally, the industry creates that capability to enable a patient with a technology that easily supports record tracking and aggregation (think longitudinal health record) where encounters with each organization and provider are ‘logged’ with the identity of the patient and connection methodology for the organization. That ‘log’ could then be accessed by the network to connect and collect appropriate data via the supported methodology for each organization.

The future of just-in-time interoperability, where the right, correct and appropriate data arrives at the right time, in the correct system workflow for each ‘data consumer’ and it will require the implementation of trusted identity services to be in place for all participants/actors who are part of the health information exchange data fabric.

The penultimate goal is to enable a health data fabric where each ‘data consumer’ participating in the exchange gets the information needed to facilitate all clinical and administrative aspects of each encounter. That exchange should not be associated with significant costs, should happen in real-time, and enhance the quality of each individual encounter. This ultimately leads to the improved overall health of the patient and reduced costs, which so far has been the ‘Moby Dick’ of health data interoperability.

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The past two decades have no doubt been transformational for health information technology, starting with the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 which catalyzed the digitization of health data through Electronic Health Records (EHRs). While the majority of attention rightfully focused on the implementation of EHRs, HITECH also kick-started the widespread adoption of Health Information Exchanges (HIEs), which were viewed as a critical tool in helping manage care across the continuum. While the Meaningful Use program (which was part of HITEC) was largely successful in the birth of regional HIEs–they were mostly targeted at acute care health systems and ambulatory groups and entire cohorts of the medical community were left behind. For example, post-acute providers were exempt from Meaningful Use requirements—setting the stage for uneven progress and creating critical data exchange gaps that persist today. 

While HITECH may be viewed as successful through the lens of adoption, how it was implemented and perhaps more importantly, where it wasn’t, serves a valuable lesson for the industry, especially as the idea of a national HIE gains momentum.

The Emergence of National HIEs

Currently, HIEs are largely regional in nature; however, as the industry evolved, the discussion has shifted towards the need for a broader information exchange network, specifically on a national level. In fact, a few notable national exchanges already exist in CommonWell and CareQuality, both of which were led by industry partners, but have been received favorably by the healthcare community.

In 2016, it was estimated that CommonWell and CareQuality represented more than 90% of the acute EHR market and 60% of the ambulatory EHR market with over 15,000 healthcare organizations having implemented the CareQuality framework or CommonWell network.However, not all health systems or provider groups have been able to take advantage of these national exchanges. Notable barriers include technical feasibility or skill deficits, conflicting regulatory mandates, and of course, financial resources as participation comes without federal or state incentives. Not surprisingly, a health “tech-quity” gap has become increasingly clear, despite well-meaning intentions.

With dwindling resources and the addition of state and federal level mandates pushing for improved health information exchange, survival for many regional HIEs rests on improved strategic and sustainable business plans.

Outlook for Regional HIEs

While federal funds to jumpstart the regional HIE movement was successful, the sustainability of those regional HIEs has been mixed at best, as the loss of state and federal financial incentives has proven to be a devastating blow to many. It was reported that the number of HIEs decreased by 25% across the US between 2012 and 2019. Additionally, the number of financially viable HIEs decreased by another 6% between 2014 and 2019.To make matters worse, healthcare organizations are also facing new mandates, such as the Office of the National Coordinator (ONC) Final Interoperability Rule and the 21^st Century Cures Act, both of which include large technical and resource investments.

While existing regional HIEs could and potentially should have played a larger role in federal interoperability efforts, in many cases, regional HIEs were unable to assist due to a lack of resourcing and technical expertise—further diminishing their position. For example, the 21^st Century CURES Act mandated hospitals to send electronic admission, discharge, and transfer (ADT) notifications from hospitals to downstream providers. Ideally, regional HIEs were well positioned to fulfill this requirement, however many healthcare organizations met this requirement through other means.

With dwindling resources and the addition of state and federal level mandates pushing for improved health information exchange, survival for many regional HIEs rests on improved strategic and sustainable business plans.

Trusted Exchange Framework and Common Agreement

As we look to the future, things do not appear to be getting any easier, as the ONC recently released its most ambitious interoperability effort to date with the release of the Trusted Exchange Framework and Common Agreement, also known as TEFCA. Established within the 21^st Century Cures Act, TEFCA was created to support a common set of standards and policies to catalyze the growth of national HIEs. Those who meet these standards, would be designated a qualified health information network (QHIN), symbolizing shared standards for data sharing across networks.

While this may be good news for more mature regional HIEs, TEFCA may strike a further blow to smaller HIEs who have already been struggling financially and potentially unable to adhere to the technical requirements necessary to become a QHIN. Furthermore, TEFCA also comes without any financial incentives, making it that much harder to participate.

Conclusion

As we imagine an equitable healthcare future, we cannot get there without the right information that is readily accessible across the care continuum. The idea of HIEs was supposed to deliver just that; however, realizing that potential has been challenging. While there have been bright spots such as the growth of CommonWell and CareQuality, and of course, the release of a national exchange via TEFCA, challenges remain, many of which we have seen before.

Based on where HIEs have been, we focus on three key lessons. First, we must not leave behind smaller community-based providers or post-acute care facilities to truly achieve nationwide data exchange. Second, healthcare remains a local experience, any information exchange efforts must have local or regional support to sustain operations, in other words, states need to take more of a vested interest in the success of their respective HIEs. Finally, there is a need for established standards to minimize the impact of fragmented exchanges. While these factors do not guarantee success, we should learn from prior experiences; otherwise, the aspirational nature of nationwide exchange will be within reach for many, and the gap will continue to widen for others.

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Health Information Technology (HIT) became a lifeline during COVID by allowing health care organizations across the United States to utilize digital tools to engage patients and provide care. Historically, many health care providers have viewed technology as adding to their workload, contributing to job dissatisfaction and impeding the patient-provider relationship. The pivot to using more digital tools has inspired many to envision the endless possibilities of connected care. Furthermore, this experience allowed many health care professionals and patients to experience the value proposition of HIT. Capitalizing on this reconceptualization of HIT can enable healthcare to move beyond solving problems only for this pandemic but lay the groundwork for what’s next. 

Prior to the pandemic, the healthcare industry struggled to keep up with staffing demands and COVID has compounded this issue, particularly now that many are leaving the healthcare profession. The combination of staffing shortages, increased life expectancies and chronic conditions are creating a perilous course for the healthcare industry. As a result, there is an urgency to develop innovative solutions to address these challenges and HIT is well poised to meet all of these challenges by building new integrated, efficient, consumer-friendly, and cost-effective digital tools. 

Technology has transformed how we interact and created a ‘new normal’ for interactions. The increased use of HIT during the pandemic allowed many to experience how these tools can fit into their daily lives and the healthcare landscape. We are seeing a level of connectivity and conducting business from our devices that has never been seen before. Patients have come to expect similar accessibility in healthcare and are increasingly deciding where they get care based on their digital experience. Traditional methods of providing in-person care have struggled to meet population health needs, particularly for vulnerable and underserved populations. Moreover, the “one size fits all” approach to care delivery has led to many health inequities and disparities. Health care organizations that don’t address these patient needs will be challenged by bigger market players that seek to attract new business and impede existing patient-provider relationships. 

Bridging the digital divide requires involvement of a diverse representation of patients throughout the product development process.

The “No Wrong Door” approach enables consumers to engage in care through the route or program that best meets their needs. Digital platforms can support the “No Wrong Door” approach by meeting people where they are through increased engagement and retention in care. HIT’s nimbleness can address patient needs more quickly, remove barriers and foster patient engagement in ways that are not possible in manual processes. Despite these promising benefits, HIT has neglected to create products that are accessible across different demographic groups. Over the years, HIT developers evolved to be more inclusive of clinical care teams throughout the product development process which has increased satisfaction and widespread adoption. Unfortunately, this approach has not translated to patient-facing digital tools. Even though the marketplace is rife with patient digital tools, these are often developed with the organizational management of these tools at the forefront rather than the patient. Moreover, product developers have neglected to engage patients throughout the development process like they do clinicians. Bridging the digital divide requires involvement of a diverse representation of patients throughout the product development process. Engaging consumers in the process helps ensure the usability and accessibility of their products. Additionally, creating consumer-friendly tools will prevent care teams from becoming their patients’ tech support and instead, they can focus on providing vital care. 

Patients who see value in using these digital platforms are more likely to utilize these systems and remain loyal to their existing healthcare organization. Instead of HIT being an impediment to provider-patient relationship, reframing the use of digital tools such that these tools can be harnessed to support patient care allowing care teams to focus on tasks that cannot be automated or digitized. Oftentimes, care teams are the gatekeepers of health information for patients (e.g., referrals to resources) which can delay access to needed services or resources. Using digital tools to provide real-time information can create a more positive patient-centered experience while addressing patient needs more quickly.  As a result, competition is increasing and organizations that respond with these new automated and patient-friendly tools will be better positioned. 

Combining HIT and data analytics can create a precision-medicine like experience for patients and clinical care teams by combining complex algorithms and automation to make personalized recommendations and move beyond the ‘one size fits’ all approach of population-based medicine. Quality measures serve an important role by recommending services or procedures a patient is due for. While these recommendations provide the necessary guidance, these broad-based guidelines have led to disparities by ignoring individual health needs (e.g., anatomy) and not factoring in other health equity issues (e.g., social determinants of health). However, innovations like machine learning can develop algorithms to assess each individual’s care needs and tailor recommendations to close care gaps. Systems that automate reminders, recommendations and information sharing to patients based on their individual needs, particularly in real-time, are likely to see improved satisfaction from both the patient and care teams. Advanced algorithms and automation can replace manual tasks, often with more accuracy, speed and at lower costs. Furthermore, tailored messaging will more likely resonate with a patient and may increase compliance with care recommendations and support better engagement in care.  

The healthcare crisis is on a precipitous course and we must pull every lever to address these challenges. The pandemic previewed how HIT can fit into the healthcare landscape, but we need to meet both patients and clinical care teams where they are. The integration of more robust, automated digital tools can address inequities, bridge the digital divide, close care gaps and reduce strain on the healthcare workforce. While HIT cannot solve all the health care problems, digital tools have immense potential to both fill the voids and enhance the health care experience.

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We are at the peak of electronic medical record (EMR) despair. We were promised a utopian future where EMRs would improve communication, reduce the burden on handwritten notes and flowcharts, make administrative tasks more seamless, and hasten clinical research. While it seems our peers in other industries are charging into the information age, we in healthcare seem stuck firmly in its infancy. While the road is long, the destination is promising; and, like objects in the rear-view mirror, closer than they appear.

Twitter is awash with clinicians complaining about the additional overhead and stress caused by clunky EMRs. Some suggest that the added burden of EMRs contributes to provider burnout. Small physician groups or solo practitioners have suffered under the financial burden—many forced to close shop or join larger physician groups. As IT professionals, we are acutely aware of the difficulty of building custom applications on top of EMRs or integrating with other systems. As a result, EMR vendors have been forced to build integration and interoperability but aren’t going down without a fight.

Is the benefit worth the cost?

Are we seeing the benefits we were promised?

The answer: yes… almost.

We are tired from climbing to the peak, but as we summit the rise of EMR despair, we have an easier journey ahead of us. This utopian future is not inevitable. It will take a concerted effort on the part of providers, developers, EMRs vendors, regulators, and the broader HIT community to move the industry forward. At the core of this revolution are API-based integration and open standards such as FHIR that will enable secure, seamless integration between applications and building-block-like microservices. Advances in machine learning, artificial intelligence, and information retrieval will help reduce the burden on the end-user to sort through thousands of irrelevant data points, highlighting the most relevant information and aiding in diagnosis, communication, and disease management. Sensors, wearables, and IoT devices will further reduce the burden on clinicians to document and interact with the EMR directly.

As artificial intelligence/machine learning becomes more ubiquitous and easier to deploy in production, these tools will become increasingly important in information retrieval and reducing the clerical burden on clinicians.

The EMR is the glue that binds various systems in a healthcare system. As such, the EMR should act more like a platform than a stand-alone product. At the heart of any platform is a set of APIs and integrations. FHIR is a promising start and essential to achieving the ultimate vision. Future development on FHIR, such as bulk patient reads, will be critical to executing this vision. The EMR should be the central touchpoint for a provider and abstract away the various services and components working behind the scenes.

As artificial intelligence/machine learning becomes more ubiquitous and easier to deploy in production, these tools will become increasingly important in information retrieval and reducing the clerical burden on clinicians.

Currently, we rely on hard-coded alerts such as critical lab values or we expect clinicians to review results manually. Manual review of results does not scale, especially as the number of inputs and the frequency of data increases. For example, to efficiently manage a large remote patient monitoring practice that may enroll thousands of patients, manual human review of the data would be inadequate. Imagine streaming data from a wearable or implanted device and reviewing heart rate, respiration, EKG, pulse oximetry, fluid status, and steps manually. To efficiently implement such a program, one would need to use machine learning to alert where a clinician may need to intervene. This series of machine learning models would need to remove anomalies (we don’t want alerts every time a patient walks up the stairs), and potentially integrate with the EMR or other clinical systems to learn the clinical context.

Artificial intelligence and machine learning will also help summarize a patient’s past medical history and current clinical conditions and should help extract the findings from the totality of their medical record that are relevant to a given clinician. Improvement in semantic search will further reduce the burden on the clinician, allowing them to quickly find results or notes that are relevant to their query.

The proliferation of sensors, wearables, digital assistants, and IoT devices will further reduce documentation burden. A smart syringe may know what medication is being drawn up by a nurse, how much of that medication, and which patient is getting the medication. Nurses will not have to document vital signs, medication administrations, and other events that can be gathered from alternative sources.

Digital assistants will be installed in exam rooms and listen to a doctor’s conversation with a patient and will be able to pre-populate notes. Not only will this reduce the documentation burden on the clinician, but it will also capture a complete record of the encounter, and allow the doctor to speak to the patient without worrying about taking notes, clicking boxes, or dealing with the EMR during the visit—we will start to bring humanity back to medicine using technology.

Hang in there! While we are currently at the peak of EMR despair, the future is bright. By focusing on building EMRs with clean, intuitive user interfaces that act as a platform for uniting other technologies, we can reinfuse humanity into medicine.

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Organizations rely on IT to deliver the right information to the right information consumers at the right time to drive information-driven decision-making. In healthcare, the information consumers include clinicians, other knowledge workers, and patients. The demand for accurate, complete, reliable, relevant, and near real-time information is higher than the supply for such information. This is due to many factors. Healthcare organizations are risk-averse, adopt new technologies late, and are concerned about the skyrocketing cost of IT. Consequently, healthcare CIOs have a demanding duty to improve the supply of high-quality actionable information.

CIOs need to lead by example, implement industry best practices, and assure that strategic and tactical decisions are driven by high-quality information. CIOs won’t be seen credible if we don’t innovate and rely on data in our own departments. Dashboards serve an important role in meeting this objective. IT and organizational leadership are the typical audiences for these dashboards. Consistent data presentation is important to compare dashboards over time. These dashboards are useful not only for managing IT but also telling a story about IT. CIOs may need multiple dashboards to show progress on a weekly, monthly, and annual basis. There is no one-fits-all dashboard. Different metrics are needed depending on the organization’s current priorities and business phase. Organizations executing a strategic transformation need different dashboards than those focusing on continuous improvement.

A weekly dashboard is used for everyday IT management. Its audiences are the executive team and IT leadership.

Annual dashboards are used for Board presentations and deliver the message of how IT adds value to the organization. An effective way of summarizing data is by presenting IT in numbers. These numbers may include computing endpoints, servers, networking equipment, user accounts, applications, and phones under management; projects completed; user tickets, and major network and security incidents resolved. If a transformation program is in progress, a high-level roadmap can show what has been accomplished, in progress, and still ahead. Strategic objectives set for the year could be presented in a table with green checkmarks showing when objectives have been met or in yellow or red if minor or major obstacles were encountered. While most of the audience will look at only the high-level dashboard, it is OK to add definitions and explanations in fine lines.

Monthly dashboards have a hybrid purpose to present strategic and tactical information. Their primary audience is the CEO, the executive team, and IT leadership. Strategic information includes the departmental mission and annual objectives. When objectives are achieved, they can be labeled with green checkmarks. Progress on a strategic transformation can be presented similar to the annual dashboard. The rest of the dashboard may include operational metrics presented as progress over time and high-level information about the project portfolio. Although the organization’s security posture is typically assessed less frequently, this dashboard is a good place to show progress over the years. For example, external auditors may score security status in the 19 HITRUST categories. Year-to-year progress can then be presented in a bar graph compared to industry averages. IT customers want to see progress on projects delivering value to their respective areas. Therefore, it’s beneficial to list major projects completed in the year and currently in progress. Month-to-month progress can be presented using various operational metrics which is important for the organization. This may include percentage of projects completed on time; changes implemented with no issues; number of hardware and application-related incidents; percentage of applications, servers, networking equipment, operating systems, and computing endpoints under vendor support; time to close helpdesk tickets; and various customer satisfaction metrics. Customer feedback can be collected by surveys attached to tickets and regular monthly surveys. Common survey questions are related to first-time resolution and professionalism. Progress on the annual budget is an important metric for managing IT. However, dependent on how widely this dashboard is disseminated, financial metrics may not be included.

A weekly dashboard is used for everyday IT management. Its audiences are the executive team and IT leadership. Availability of resources, incidents, training, helpdesk metrics, and progress on the project portfolio may be presented weekly. To facilitate understanding of the dashboard, all portions can be color-coded in green, yellow, and red dependent on whether the information presented represents preferred outcome, risks, or issues. As this is the most tactical dashboard, it’s OK to drill down to more granular details and present information by IT sections. Information on available resources may include new employees and separations. Major incidents may be listed by IT sections. The helpdesk’s operations can be summarized by the number of tickets closed or overdue broken down by major categories. To show trends over time, data on the current and five prior weeks may be presented and color-coded. In order to guide the audience, sparklines may be added and color-coded. At Howard University Hospital, we typically have 30-40 projects in progress at any given time. These projects are presented in a table with concise information on risks and issues in resources, timeline, and scope. In addition, the ETA of the project is listed and project progress is presented for the current and five prior weeks. Project scope, timeline, resources, and weekly progress are color-coded. In addition to the projects in progress, a smaller table summarizes the number of projects in various stages of the project lifecycle. Numbers of projects proposed, in due diligence, in contracting, to be scheduled, scheduled, in progress, completed, and on-hold are presented using sparklines over the six recent weeks as described above. Other categories may be presented from time to time.

These dashboards serve not only the CIO. They are communication tools within IT and also for the Board, the CEO, IT’s customers, and the executive team. Regular dissemination of these dashboards to the right audiences helps establish transparency and communicate IT’s strategy and operations.

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