Welcome to this three-part series examining healthcare interoperability in the United States and the reasons for its slow progress. In Part 1, we delve into the fragmented healthcare landscape and the technical challenges that impede seamless data exchange.
The Fragmented Healthcare Landscape
The need for interoperability in healthcare can be attributed to the fragmented landscape of the industry. In the United States, the healthcare ecosystem comprises a wide range of organizations, including hospitals, clinics, and specialty practices. Each operates with different electronic health record (EHR) systems, infrastructure, and data models, creating significant interoperability gaps.
The fragmented landscape hinders the seamless exchange of patient data and poses a barrier to efficient care delivery.
Technical Challenges
Technical challenges play a crucial role in impeding healthcare interoperability. One of the major obstacles is the diversity of data formats and standards used by different healthcare systems and EHR vendors. Historically, proprietary data formats were implemented by vendors, resulting in compatibility issues and difficulties in exchanging information between systems.
We have made strides in improving interoperability but are not where we need to be. It’s a complex issue that requires collaborative efforts among stakeholders to overcome technical and policy challenges. These technical challenges include data standardization, data exchange protocols, and semantic interoperability.
Legacy systems also contribute to the lack of interoperability. Many healthcare organizations still rely on outdated systems not designed with interoperability in mind. These legacy systems may need more capabilities or face compatibility issues with newer technologies, making sharing and exchanging patient data challenging.
The impact of legacy systems on interoperability remains a significant hurdle in healthcare. The lack of standardized data exchange and the presence of proprietary systems hinder the seamless flow of information, impacting care coordination and patient outcomes.
Electronic health records (EHRs) have revolutionized the healthcare industry, streamlining patient care, improving efficiency, and enhancing communication among healthcare providers. Here, we explore the history of EHRs, highlighting the obstacles overcome throughout their development and implementation, as well as the challenges that persist for this transformative technology.
The Emergence of Electronic Health Records
The concept of electronic health records began to emerge in the 1960s with early attempts to digitize medical records. However, it wasn’t until much later in the century that technological advancements paved the way for the modern EHR systems. Standardization of medical terminologies and coding systems played, and continue to play, a crucial role in enabling data exchange and interoperability.
Overcoming Obstacles
Technical challenges
One of the initial obstacles in developing EHRs was the lack of interoperability among various systems. Different healthcare organizations and providers used a number of technologies and formats from a number of vendors, making it difficult to share and exchange patient information. In some cases, this is still the case.
Efforts have been made to standardize medical terminologies and coding systems, such as the International Classification of Diseases (ICD) and the Systematized Nomenclature of Medicine (SNOMED), to facilitate data exchange, but other efforts are required.
Privacy and security concerns
The digital nature of EHRs raised concerns about patient privacy and data security. Protecting sensitive health information and ensuring data integrity became critical challenges. Legislation, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, was introduced to address these concerns and impose strict privacy and security regulations.
Robust encryption methods, access controls, and audit trails were implemented to safeguard patient data, among other protocols.
By Bill Chartnetski, EVP health system solutions and government affairs, PointClickCare.
For too long, long-term and post-acute care (LTPAC) facilities have not benefited from the same health IT investments or incentives as other care sectors.
Since the U.S. government introduced the meaningful use program as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, LTPAC organizations – notably nursing homes – and the vulnerable patients they serve have been left behind. As a result, these provider types sit outside of current interoperability and health information exchange efforts, and have been slow to adopt electronic health records (EHRs) due to a lack of government incentive programs. In fact, recent data show that only 18% of skilled nursing facilities (SNFs) integrate patient health information electronically.
The lack of investment impairs the necessary exchange of health information, exacerbates care fragmentation and disables the ability to transmit a patient’s critical health and demographic data across the trajectory of care. Patients of LTPAC providers are more likely to have chronic health conditions or behavioral health needs.
The complex nature of their health history and requirements makes care coordination more difficult as they transition between settings. So, why are we depriving the providers that care for them of critical infrastructure investments, especially as other sectors have received similar investments and adoption incentives in recent years?
Long-term care facilities are suffering from long-existing shortcomings exacerbated by COVID-19. On a daily basis, they contend with staffing challenges, infection control, oversight and regulation. Yet they are resilient and unwavering in their commitment to care.
Technology presents enormous opportunities to alleviate these issues, namely staffing challenges and the burden of administrative tasks that often take them away from caring for patients. One study, for example, found that six months after implementation of an EHR, nurses were spending significantly more time engaging patients in their rooms with purposeful interactions and less time at a nurse station. Using health information technology to capture resident health information in real time can also substantially reduce staff fatigue, burnout and the burden of relying on short-term memory, while also improving patient safety by enhancing the accuracy of the patient information.
Federal healthcare organizations, such as CMS, have spent billions of dollars over the years trying to bridge the gap between medical data and quality patient care with interoperability requirements and data integration, the mesh used to try and bridge the gap. Many government rules have been written to address the type of mesh needed and many EHR companies have claimed to meet these government requirements and claim the throne of the ultimate mesh maker.
However, hospitals and clinics found the mesh contained many holes, such as enabling hospitals to customize EHRs, but only if the EHR customers purchased the EHR systems for the manufacturers for millions of dollars that hospitals could ill afford. Also issues such as proprietary connectivity to their own brands that left the hospitals’ other EHR systems to serve as dead-end data silos. Rules and solutions came and went, but few had any teeth until now.
Anyone for A Slice Of PI?
To end the lack of interoperability morass and data duplication, the Department of Health and Human Services (HHS) issued 1,883 pages of proposed changes to Medicare and Medicaid. The changes rename the Merit-Based Incentive Payment System (MIPS) Advancing Care Information performance category to Promoting Interoperability (PI).
CMS announced the change as part of a proposed rule that will transform the EHR Incentive Programs commonly known as meaningful use under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The proposed policies are part of the MyHealthEData initiative, which prioritizes patient health data access and interoperability improvements.
But this time the name change wasn’t just that. For the first time a new CMS rule specifically requires providers to share data to participate in the life blood of hospital reimbursement—Medicare and Medicaid. The rule also floats the idea of revising Medicare and Medicaid co-pays to require hospitals to share patient records electronically with other hospitals, community providers and patients — a clear-cut demand for interoperability.
PI also reduces hospital interoperability requirements from 16 to six, revamping the program to a points-based scoring system and is requiring that hospitals make patients’ EHRs available to them on the day they leave the hospital beginning in 2019.
Does Your EHR Have the Right Stuff?
While this news from CMS appears to be a step in the right direction to solve a problem that has plagued the healthcare industry for many years, it must first be made a reality by those ultimately responsible for its implementation—hospital HIT organizations. The days of data obstruction and silo logic must end with a focus on new EHR markets built on interoperability.
Interoperability requires multiple layers to demonstrate an EHR system can be accessed. Meanwhile, every EHR system claims to support some form of interoperability, ranging from web interfaces to API protocols or to the lowest and highest cost HL7. However, healthcare systems will have to demonstrate their operability to CMS to abide by PI and therefore allow access of their EHR systems. Hospitals and clinics can encounter many challenges with this, such as HIPAA compliance and support for their infrastructure for open secure access, requiring an HIE and the funds to support data synchronization and IT support.
Guest post by Marie Murphy, managing director of health solutions, CTG.
Marie Murphy
Since the inception of meaningful use in 2011, healthcare organizations have been implementing technology designed to help protect and improve the quality, safety, and efficiency of patient data. Three years after the launch of meaningful use, organizations that claimed to reach Stage 2 were given patient portal requirements to help achieve the Institute for Healthcare Improvement’s Triple Aim Initiative: To improve the patient experience of care, improve population health, and reduce the per capita cost of healthcare.
The premise behind the Triple Aim was that if patients had better access to information about their health, along with the ability to schedule appointments and better communicate with their providers, their satisfaction and outcomes, and thus costs, would improve. While 90 percent of hospitals offer portals as a result of the requirements, actual usage by patients is stagnant, reaching a meager 15 percent. Understandably, healthcare providers are frustrated by this, and as a result of their frustration have become intent on showing the symbiotic benefits of these patient portals.
Ironically, higher performing organizations, like Kaiser Permanente, have reported much higher rates of patient portal use—upwards of 45 percent adoption by patients in some cases. This supports the case for the patient portal by demonstrating its direct correlation to satisfying Triple Aim initiatives, yet healthcare organizations still struggle to engage their patients. For many organizations, limited functionality and the use of multiple portals with multiple log-in requirements from the same hospital system are a big barrier to patient adoption. To encourage portal usage, healthcare organizations need to address the root of the problem – selecting the wrong patient portal for your organization.
Here are five keys to selecting a patient portal solution that will encourage adoption and help healthcare organizations achieve the Triple Aim:
Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
Richard Loomis
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
In virtually every context that question might be asked, we struggle to give an honest, accurate answer.
It Works If You Believe It Works
Is the medication working? Difficult to say–it may be the placebo effect, it may be counteracted by other medications, or we may be monitoring the wrong indicators to recognize any effect. Is “working” the same as “having an effect,” or must it be the desired effect?
Alternative medicine confounds the balance of expectations and outcomes even further. Right at the intersection of evidenced-based medicine and naturopathy, for instance, we have hyperbaric oxygen therapy, or HBOT. These devices are as much in vogue among emergency departments (to treat embolisms, diabetic foot ulcers, and burns) as holistic dream salesmen (to prevent aging and cure autism, if you believe the hype). When the metric being tracked is as fluid as the visible effects of aging, answering whether the treatment is working is about as subjective as you can get.
As though the science of pharmaceuticals and clinical medicine weren’t confounding enough, you can hardly go anywhere in healthcare today without politics getting added to the mix. In the wake of Trump’s victory in the 2016 presidential election, you have observers and stakeholders asking of the Affordable Care Act (ACA): is it working?
There’s Something Happening Here
It is definitely doing something. It is measurably active in our tax policy, for instance: 2016 returns are heavily influenced by the incremental growth of the ACA’s financial provisions. Of course, the point of this tax policy (depending on who you ask) is to influence behavior. As to this point, there are some signs that, again, something is happening: among young people, ER visits in general are down, while emergency stays due to mental health illness are up. We changed how healthcare is insured, and that changed, in turn, how we access our care. But is it working?
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
Abhinav Shashank
According to a survey almost 50 percent of the physicians do not understand MACRA. With less than five months to full implementation of MACRA, are we ready to embrace one of the most elaborate laws of US? And, most importantly, will it produce the needed positive outcomes? The program is expected to improve the current standards, sort the most persistent problems and create opportunities to rework and revise Medicare. How will all this happen?
With MACRA in place, there won’t be two digit payment cuts like in the current Sustainable Growth Rate (SGR) formula. Besides enhancing the use of electronic health records, MACRA is expected to increase the relevance of Medicare to the real world and reduce the administrative burden from physicians’ shoulders.
Decoding MIPS
MIPS stands for Merit-Based Incentive Payment System. It will streamline the three independent programs Physician Quality Reporting System (PQRS), meaningful use, and value-based modifier to ease the burden on the clinicians. The three components in MIPS will replace these programs. Besides this, one more component will be there to bring improvements in practice. Namely following components will be there in MIPS:
1.) Quality: This component will replace the Physician Quality Reporting System (PQRS). Under MIPS the methods of reporting and the various quality measures have been adopted from the old programs PQRS and VBM. There are some changes in the reporting methods and for the registry, EHR, and Qualified Clinical Data Registry (QCDR) reporting methods, a clinician can select minimum six measures which could be a combination of any quality domain. If the clinician faces patients, then he has to select in such a way that one of these measures is cross-cutting measure (cross-domain-cutting), and one is outcome-based measure. If there is no outcome-based measure, then a high priority measure has to be selected.
Besides these six measures, CMS will calculate two or three more measures depending on the size of the group of physicians. For instance, if there is an individual physician or a group less than 10 then two measures and if more than that then three measures. Additionally, for QCDR and registry reporting methods, the “data completeness” standard has been changed. The number of patients to be reported within a measure denominator has been raised from 50 percent to 90 percent.
2.) Advancing Care Information: According to MIPS the meaningful use program will see a lot of changes. Currently, the meaningful use program is everything-or-nothing; i.e., if one clinician achieves a performance rate of 20 percent on meaningful use measures and another achieves 90 percent then they both get rewards in a similar fashion. However, under ACI the latter one gets 10 out of 10 points, and the former gets three points.
More than 100 ACI performance points have been defined out of which base 50 are base points given for reporting either “yes” or a non-zero numerator. The performance scores are up to 80 points based on the performance on eight measures. Rest bonus points are awarded for reporting any other public health registry.
