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Overcome Challenges/Obstacles to Achieving Interoperability

Session #86 Tuesday, February 21, 2017

Kathleen Sheehan, Program Director, Universal Health Services, Inc.

Sindhu R. Kammath, MD, Clinical Informaticist, Universal Health Services, Inc.

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Speaker Introduction

Kathleen Sheehan, Program Director Acute Care Division

Sindhu R. Kammath, MD, Clinical Informaticist

Universal Health Services, Inc., founded in 1979, 240 facilities in US, Puerto Rico, the US Virgin Islands and the United Kingdom with over 70,000 employees. The focus of today’s topic are the UHS acute facilities, meaningful users under the EHR Incentive Program.

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Conflict of Interest

Kathleen Sheehan and Sindhu R. Kammath, MD

Have no real or apparent conflicts of interest to report.

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Agenda• Learning objectives

• Realized IT benefit STEPS baseline

• Introduction

• Interoperability overview

• 1st generation challenges

• 2nd generation challenges

• Next generation

• Conclusion

• Anticipated IT benefit STEPS

• Q&Q

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Learning Objectives

• Compare and contrast current CMS and ONC interoperability specification to

present-day challenges of deriving value from interoperability of health care

information across the continuum of care

• Identify and create awareness of policy, design, implementation and

adoption gaps of interoperability of health care information in its current state

• Propose more inclusive and less restrictive ways to improve the exchange of

health care information across the care continuum

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Interoperability Overview Cont’d

The HIMSS STEPS Framework Current Realized IT Benefit

• Provider Satisfaction with the eSoC/CCD

– Organization/Display/Format: 2.5

– Completeness of Information: 2.4

• Clinical/Treatment

– Relevance: 3.0

– Accuracy/Confidence: 2.5

• Savings

– Reduce Redundancy: 2.5

– Improve Practice Efficiency: 2.3

Scale 1=worst 5=best

Treatment

Provider Sat.

Treatment

Savings

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Introduction

• Interoperability is significant challenge

• Considered silver bullet

• $35.5 billion invested in healthcare IT since HITECH

• Groundwork has been laid

• Industry is positioned

• Let’s make it happen

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• Interoperability has evolved

• Foundational – the connection

• Functional – the standards

• Semantic – the output and use

Interoperability Overview

Foundational Functional Semantic

Interoperability Pillars

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Interoperability Overview Cont’d• We have first-hand experience

• Eligible hospitals – 24

• Eligible providers – 200+

• UHS’s acute division CA, NV, TX, FL, OK, SC, DC

• CEHRTs - 11 down to 8

– Ambulatory providers: 4 vendors (started with 7)

– High-Specialty providers: 2 vendors

– Acute hospitals: 1 vendor

– CAH hospitals: 1 vendor

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Interoperability Overview Cont’d

• Evolving

• 1st generation – proprietary

– Secure Email

• 2nd generation – commodity

– Federated model

• Next generation

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1st Generation – Challenges

Hospital

Provider

Home Care & Hospice

Behavioral

LTC/Nursing Home

Other Community Health

14,0001

16,4001

50,6001

5,5641

92,1112 EH Adoption Rate: ~ 90%3

EP Adoption Rate: ~ 59%

1AHA as of 20142Kaiser Family Found3HealthIT Dashboard

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1st Generation Challenges – Cont’d

0% 0%

17%19%

25% 26%

30% 30%

0%

5%

10%

15%

20%

25%

30%

35%

CEHRT1

CEHRT2

CEHRT3

CEHRT4

CEHRT5

CEHRT6

CEHRT7

CEHRT8

Spec Spec Amb CAH Amb Amb Amb Acute

2016 P

erf

orm

an

ce

HIE 2016 Performance by CEHRT

• CEHRT adoption rates of EPs hinders performance

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1st Generation Challenges – Cont’d

• Secure email (Direct) source of exchange

• Ease of use

• 3-point patient matching is weak

• HISPs don’t publish secure email addresses

• HISPs marketing exchange capability to non CEHRT providers

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1st Generation Challenges - Cont’d

Stage 2 Meaningful Use 2014 edition

• Patient Name

• Demographics

• Smoking Status

• Problems

• Medications

• Medication Allergies

• Lab Results

• Vital Signs

• Procedures

• Care Team

• Immunizations

Stage 3 Meaningful Use 2015 edition

Changes

• Removed

– Care Plan w/Goals & Instructions

• Additions

– Implantable Devices

– Assessment & Plan of Treatment

– Goals

– Health Concerns

The minimum requirement

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• Four examples – pinged our markets for samples and received four

• Let’s look at the information relative to these characteristics

– Visual display

– Usefulness

– Relevance

– Content and volume of data

– Accuracy and confidence

1st Generation Challenges – Cont’d

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1st Gen Inbound CCD Example #1

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Outbound CCD Example #2• 32 pages of information 2009 to 2016

• 52 medications - active, discontinued and expired meds

• 30 sets of vital signs

• 15 procedures not sorted by date

• 20 pages of lab results

• 8 pages of 315 diagnosis codes

• A second 4 page document containing H&P and progress note had to be sent

Procedure history

Vital Signs

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Inbound CCD Example #3

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Inbound CCD Example #4

Table of Contents Reason for Referral

Encounter Details

Active Allergies and Adverse Reactions - as of 10/20/2016

Current Medications - as of 10/20/2016

Active Problems - as of 10/20/2016

Resolved Problems - as of 10/20/2016

Immunizations - as of 10/20/2016

Social History

Medications at Time of Discharge

Plan of Care

Results

Visit Diagnoses

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• 4 examples Key Takeaways

1st Generation Challenges – Cont’d

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1st Generation Challenges – Con’t• Another example of unintended consequences of

the stimulus model

• Fragmented stores of health info

• MU example – each EP/EH has a portal obligation

– I have PCP and need 3 specialist referrals -all MUsers but do not share CEHRT. I get outpatient testing at two hospitals who are Musers but don’t share the same CERHT.

– I now have 6 portal accounts. ? ?

Card

.PC

P

GI Opt. Hospital

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1st Generation Challenges - Conclusion

• The health record is piecemealed, fragmented

• Pieces of health info are pushed from EHR to EHR, or EHR to portal each storing parts

• Where to get the full story or the right info? What source is best?

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2nd Generation Challenges

• Industry readies for Stage 3 with improved exchange mechanism

• Federated models decentralize interoperability and information sharing

• Moves healthcare from proprietary to commodity-based model

• Query-based pull model

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2nd Generation Challenges – Cont’d

• But…federated model membership is voluntary

• Again barriers

• Ideal only if membership is all inclusive

• What if my community has partial enrollment from CEHRT vendors?

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Next Generation

PP

P

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Next Generation – Cont’d

• Imagine I control my health record

• It resides in a single place

• There are no missing pieces

• It is intelligent

• It organizes, files, prepares, displays, self-corrects, reconciles, archives

• It evaluates information on context; stores and represents based on relevance

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Conclusion• Many providers not eligible for incentives across the continuum;

deal with incomplete non-digital records.

• Patient portal confusion

• Health information is piecemeal in various EHRs – how to get what I need now to care for patient?

• Federated models advance the flow of information, we need a more standard organized document.

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Stage 3 Anticipated Benefits for the Value of Health IT

• Provider Satisfaction with the eSoC/CCD

(Scale 1/worst - 5/best)

– Completeness of Information: 3.0

• Clinical/Treatment

– Relevance: 3.5

• Savings

– Reduce duplicative testing: 3.75

Provider Sat.

Treatment

Savings

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Questions

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Evaluation• Please complete evaluation forms