creating interoperability: breaking ehr barriers · breaking ehr barriers ccalac 18th annual health...

Ben Pierson – Program Manager, Health Information Exchange at OCHIN, Inc.

Aisha Iqbal – Director of HIT at the Community Clinic Association of Los Angeles County

Sandra Jaime – HIT Manager, St. John’s Well Child and Family Center

Stephen Gutierrez – Chief Information Officer, North East Valley Health Corporation

Creating Interoperability

Breaking EHR Barriers

CCALAC 18th Annual Health Care Symposium Advancing Equity, Embracing Innovation

Friday, March 1st

Objectives

1. Educate attendees on the variety of initiatives occurring nationally to create better health information exchange to enhance interoperability.

2. Teach attendees about Application Programming Interfaces (API) and their ability to create interoperability.

3. Educate attendees on how they can implement national health information exchange frameworks to exchange data with hospitals in L.A. County and beyond county lines.

4. Educate attendees on what an organization needs to keep in mind when connecting to a national exchange framework, such as patient consent forms, workflow, etc.

Annual Healthcare Symposium

Ben Pierson Interoperability & HIE Program Manager

Strategic Focus for 2019

Using and Moving Data

Improving Outcomes

Transforming Health Care

OCHIN Supports Over 500 Organizations Nationwide and Growing

OCHIN Epic 108 Organizations

OCHIN Services 403 Organizations

OCHIN Billing 23 Organizations

OCHIN Broadband 189 Organizations

OCHIN Research 34 Partners; 44 Clinics

1 3 1

2

34 350

13 4 48

1 1

29

113

6

4

2

3

1

6

3

2

6

(DC)

3

3

13

OCHIN NextGen 47 Organizations

6

3

OCHIN Offerings

2

1

2

5

4

1

2

1

1

1 2

1 1

1

1

1

1

1

2

1

3 1

2

3

11

4

1

1

1

1

1

1

1

1

25 2

1 5

1

2

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6

4 3

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This map is a representation of the overall products and services provided to OCHIN members and their clinics. The numbers indicate the states in

which member organizations are based, though they may also operate in additional states (represented with unnumbered circles).

(August 2018)

Medicaid Expansion States

Non-Medicaid Expansion States

1

1

Considering Medicaid Expansion

2 1

1

1

1 1

3

1 1

1

1

2

1

67% Female

40% Remote or

Telecommute

Technical

ProfessionalServices

Administration

Research

As of September 2018

OCHIN Employees

>100 Employees

41–100 Employees

21–40 Employees

1–20 Employees

0 Employees OCHIN Offices

405 Employees

Why: scale, exponential connections, both locally and

across state borders.

What: Access to discreet clinical information to trigger

health safety alerts in EHR.

Need: Providers, Regional and State HIE’s need to

connect to National Frameworks

OCHIN Follows a National Frameworks First Model

• APIs allow one software program to access data provided by another software program using a common language

• Banks and airlines use APIs to deliver better information to customers by allowing third-parties to aggregate their data

8

Application Programming Interfaces (APIs)

9

API Possibilities

Target Publisher Usage

Patient EHRs Health tracking phone apps (e.g. Apple Health)

Provider HIEs and other health systems

EHR-based tool for compiling a specific data set (e.g. pull medications instead of entire records)

Vendor Modules:

Epic Care Everywhere: The HIE integration module

NextGen Share: The HIE integration module

• Vendor Networks connection

• Carequality Framework connection

• eHealth Exchange connection

• Surescripts HISP connection

• FHIR API endpoint

Integration Engine:

Mirth Connect Enterprise provides data transformation

and connections to:

Labs, HIEs, Registries, 3rd Party Systems

Current Exchange connections at OCHIN

Interoperable Partners available to OCHIN members

32 M Total Clinical Summaries

Exchanged in Past 12 Months

95 M Total Clinical Summaries

Exchanged since 2010

6.2M Non-Epic Exchanges Last

12 Months

Clinical Summary Exchange Trend: At OCHIN exchange volume through National Frameworks is Doubling; HIE exchange is flat

OCHIN Epic to Non-Epic Systems Exchanges by Month

# of monthly Carequality

exchanges tripled in the last year

2M Sent to HIEs in 12

Months

0 Received from HIEs in 12

Months

Clinical Summary Exchange Trend with HIEs: Volume of HIE exchange is unidirectional

# of CCDs received from HIEs is Zero

Carequality Overview

The Network Effect How do you get nationwide connectivity?

Clinic by clinic, hospital by hospital?

Data sharing networks have already

connected many participants within

communities. The connections grow

exponentially by connecting these

networks.

If you connect six clinics, you might

reach a few dozen physicians.

If you connect six communities, you

can reach thousands of physicians.

Introduction to Carequality

A standardized, national-level interoperability framework to link all data sharing networks

Common rules of the road: In order for the varied participants to trust each other

with health information, everyone needs to have a legal obligation to abide by the

same rules.

Well-defined technical specs: Shared rules are not enough; clear standards must

be laid out in an implementation guide that all implementers can follow.

A participant directory: To connect using the common standards, systems must

know the addresses and roles

of each participant.

Carequality Implementers

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HIEs Technology Vendors Service Providers PHRs

• Implementation – Literally a “flip of a switch”

– No additional training required

– Work was primarily contract review

• Outside requests came in within minutes of enablement

• Exchanged records with 220+ other healthcare organizations in 6 months

Lessons Learned from Enabling Carequality for 5 Health Centers on NextGen

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Consent/Authorization

and Information

Blocking

Specially Protect Information:

Model is Opt-Out: All or Nothing is sent to HIE under

HIPAA requirements

Liability: HIE must indemnify provider / HIE must carry

adequate Cyber Liability insurance

42 CFR Part 2: Patient Level Authorization

• Information not included in chart unless authorized

• Patient authorizes sharing of all data to providers

• Patient authorizes sharing of information to HIEs

• Provider can limit Encounter data, but not required

Consent / Authorization

Patient Consent:

Captured in the EHR prior to data

being entered into the shared record.

Aligned with the SAMSHA Substance

Abuse Confidentiality Regulations

Separate to the consent model

required by any HIE under Consent to

Share programs

Consent / Authorization

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Trusted Exchange Framework and Common Agreement (TEFCA)

The TEFCA aims to create a technical and governance infrastructure that connects health information networks together through a core of Qualified Health Information Networks (QHIN) Recognized Coordinating Entity (RCE) is the entity that will enter into

agreements with HINs that qualify and elect to become QHINs in order to impose the requirements of the Common Agreement.

Qualified HIN (QHIN) is a network of organizations working together to share data. QHINs will connect directly to each other to ensure interoperability between the networks they represent.

A Connectivity Broker is a service provided by a Qualified HIN that provides all of the following functions with respect to all Permitted Purposes: master patient index (federated or centralized); Record Locator Service; Broadcast and Directed Queries, and EHI return to an authorized requesting Qualified HIN.

A Participant is a person or entity that participates in the QHIN. Participants connect to each other through the QHIN, and they access organizations not included in their QHIN through QHIN-to-QHIN connectivity. Participants can be HINs, EHR vendors, and other types of organizations.

An End User is an individual or organization using the services of a Participant to send and/or receive electronic health info.

Comparison of Exchange Solutions

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Network Regional

HIE Epic CE

Common-well

Care-quality

TEFCA

Type Multi-

Provider Network

Epic Network Neutral

Extensions

Multiple-vendor Neutral

Extensions

Vendor-neutral

framework

Vendor-neutral Multi-

Network

Data Available

CCDA (XCA/XCPD)

Portal

CCDA (XCA/XCPD)

CCDA (XCA/XCPD)

CCDA (XCA/XCPD)

CCDA (XCA/XCPD)

USCDI extensions

Presented Data

Multi-Provider

Provider specific

Multi-Provider

Provider specific

Multi-Provider

Uses Carequality

Available Yes Yes Yes CQ would be Participant

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Information Blocking

21st Century Cures Act – Interoperability, Information Blocking, and the ONC Health IT Certification Program

• Published by ONC • Contains important information blocking

provisions that influence providers directly

• 60 public comment window

Interoperability and Patient Access

• Published by CMS • Primarily focused on providers, patients,

and payers, but has important implications for needs from HIT vendors

• 60 public comment window

• Inappropriately requiring consent

• Incorrectly claiming that HIPAA prevents exchange

• API endpoint is provided only to specific apps/developers

• A provider has the ability to provide same-day access to data requested by patient/provider but takes several days to respond to a request

• Unreasonable or non-uniformly applied cost

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Information Blocking is Defined

Member Driven. Patient Focused.

Achieving Interoperability through National Health Information Exchange

in L.A. County Aisha Iqbal Director of HIT at CCALAC

Members: 65 non-profit community clinics and health centers Patients Served: 1.4 million patients per year Electronic Health Records: 13 types of EHRs used among the membership Services: primary health care, including medical, dental, and mental health services

Community Clinic Association of Los Angeles County

0

5

10

15

20

25

30

Electronic Health Records used in Membership

What is a National Health Information Exchange

• National HIEs allow for patient data to be securely shared between two health care organizations on different EHR systems, across county and state lines, as opposed to regional HIEs which are limited to the county in which they reside.

• National HIEs promote interoperability by breaking down data sharing barriers

between EHR vendors.

• National HIEs use Application Programming Interfaces (API) to search for patient data in a variety of systems, similar to searching for a flight on Kayak and searching multiple airlines and websites at once.

This ease of sharing for data creates INTEROPERABILITY!

“Interoperability is defined as the ability of a system to exchange electronic health

information with and use electronic health information from other systems without special effort on the part of the user.” - ONCs HIT Interoperability Roadmap


What are CommonWell and Carequality?

Two National HIEs that are helping to create interoperability are…. 1. CommonWell is a not-for-profit trade association dedicated to achieving cross-

vendor interoperability that assures provider access to health data regardless of where care occurs. http://www.commonwellalliance.org/about/

2. Carequality is a public-private collaborative that facilitates agreement among diverse stakeholders to develop and maintain a common interoperability framework enabling exchange between and among data sharing networks. http://sequoiaproject.org/carequality/what-we-do/

http://www.commonwellalliance.org/about/























http://sequoiaproject.org/carequality/what-we-do/




























1. Central Neighborhood Health Foundation 2. CHAP Care 3. Clinica Oscar Romero 4. QueensCare Family Health Centers 5. Saban Community Clinic 6. Via Care Community Health Center

Department of Health Services Hospitals & Health Centers (July) 1. Olive View Medical Center 2. LAC+USC Medical Center 3. Harbor-UCLA Medial Center 4. Rancho Los Amigos National Rehabilitation Center 5. High Desert Regional Health Center 6. Martin Luther King, Jr. Outpatient Center 7. Edward R. Roybal Comprehensive Health Center 8. El Monte Comprehensive Health Center 9. H. Claude Hudson Comprehensive Health Center 10. Hubert Humphrey Comprehensive Health Center 11. Long Beach Comprehensive Health Center Health Plans 1. L.A. Care Health Plan 2. Health Net

Adventist Hospitals (committed) 1. Glendale Adventist Medical Center 2. White Memorial Medical Center Dignity Hospitals (finishing contract process) 1. California Hospital Medical Center 2. Northridge Hospital Medical Center 3. Glendale Memorial Hospital and Health Center 4. St. Mary's Medical Center Long Beach Single Hospitals 1. Pomona Valley Hospital and Health Center (2nd Q 2019) 2. Huntington Memorial Hospital 3. Children's Hospital Los Angeles (will be up by 4/19) 4. Torrance Memorial Medical Center 5. Martin Luther King, Jr. Community Hospital 6. Antelope Valley Hospital

1. The Children’s Clinic Prime Medical Doctors 1. Centinela Hospital Medical Center MemorialCare 1. Long Beach Medical Center Single Hospitals 1. Cedars Sinai Health System 2. UCLA Medical Center & UCLA Orthopedic Center 3. Kaiser Permanente Providence Hospitals 1. Holy Cross Hospital Medical Center 2. Saint John’s Health Center 3. Saint Joseph Medical Center 4. Tarzana Medical Center 5. Little Company of Mary Medical Center in Torrance 6. Little Company of Mary Medical Center in San Pedro

1. All For Health, Health For All 2. AltaMed Health Services Corporation 3. Arroyo Vista Family Health Center 4. Asian Pacific Health Care Venture 5. Chinatown Service Center 6. Complete Care Community Health Center 7. East Valley Community Health Center, Inc. 8. Eisner Health 9. Family Health Care Centers of Greater Los Angeles 10. Garfield Health Center, Inc. 11. JWCH Institute, Inc. 12. Northeast Valley Health Corporation 13. ParkTree Community Health Center 14. Planned Parenthood - Los Angeles, Pasadena

& San Gabriel Valley 15. South Bay Family Health Care 16. South Central Family Health Center 17. Southern California Medical Center 18. Valley Community Healthcare 19. Venice Family Clinic

1. AAA Comprehensive Healthcare 2. All-Inclusive Community Health Center 3. Antelope Valley Community Clinic 4. APLA Health and Wellness 5. Bartz-Altadonna Community Health Center 6. Benevolence Health Center 7. Central City Community Health Center 8. El Proyecto del Barrio Family Health Care Clinic 9. Harbor Community Clinic 10. Herald Christian Health Center 11. Kedren Community Health Center 12. KHEIR Center 13. Los Angeles Christian Health Centers 14. Our Savior Center / Cleaver Family Wellness Clinic 15. R.O.A.D.S. Foundation 16. St. Anthony Medical Centers 17. San Fernando Community Health Center 18. St. John's Well Child & Family Center 19. THE Health and Wellness Centers 20. UMMA Community Clinic 21. Universal Community Health Center 22. Watts Healthcare Corporation 23. Westside Family Health Center 24. Yehowa Medical Services 25. Behavioral Health Services, Inc. 26. White Memorial Community Health Center

Single Hospitals 1. Valley Presbyterian Hospital (finishing contract process) 2. Citrus Valley Medical Center 3. Henry Mayo Newhall Hospital 4. Beverly Community Hospital 5. Good Samaritan Hospital

AHMC Healthcare – EHR Evident CPSI 1. Garfield Medical Center 2. Monterrey Park Hospital

Diagram Legend CCALAC community clinics & affiliates (dotted

line indicates they are a member but not live yet)

Organizations connected OR plan to connect Organizations committed to join

1. The Achievable Foundation 2. Wilmington Community Clinic

Updated 2/27/19

Contact Director of HIT, Aisha Iqbal @[email protected] for questions

1. Los Angeles LGBT Center 2. Unicare Community Health Center 3. BAART Community Healthcare (Practice Fusion) 4. Hollywood Presbyterian Hospital Avanti Hospitals 1. Memorial Hospital of Gardena 2. East Los Angeles Doctors Hospital 3. Coast Plaza Hospital 4. Community Hospital of Huntington Park Catholic Health Services/Verity Health Hospitals 1. St. Francis 2. St. Vincent's 3. Good Samaritan Hospital

*Allscripts/Practicefusion currently a member of Commonwell, but not live yet

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14

13

41

15

0

10

20

30

40

50

60

70

Health Centers Hospitals

Not Connected

Committed

Connected

Progress to Date

CCALAC Health Centers Connected = 36%

L.A. County Hospitals

Connected = 33%

National vs. Regional HIEs The current regional HIE in L.A. County is the Los Angeles Network for Enhanced Services(LANES). To date, the differences between LANES and CQ & CW are as follows. These changes will evolve over time. Also included is a comparison of the Emergency Department Information Exchange (EDIE

EDIE1 LANES Carequality & CommonWell

DATA MODEL Pushes notifications to providers based on risk in real time by criteria created, i.e. Patient must have 5 ER visits in the last 12 months, 3 different EDs in the last 2 months, care guideline in place

Centralized Model Federated Model – no central repository

DIRECT MESSAGING

No Direct Messaging capabilities Direct Messaging to local providers

No Direct Messaging capabilities

PATIENT DATA SHARED

ED visit history, primary care physician contact information, current medications, existing care plans, security alerts . Does not focus on lab values, imaging results , or case notes.

CCD data in addition to labs, images & DMH behavioral health data

CCD data and any other data participant wants to share - working on adding more data and making it consistent

GEOGRAPHICAL RANGE

Ranges from city/county to states/nations Data only from L. A. County Access to data for patients seen by providers outside of L.A. County and around the nation

INTERFACE Can work on top of existing HIEs or other databases or EHRs

Bi-directional interfaces need to be built with EHR or database

Query based API interfaces, allowing for bi-directional data pulls directly into EHR depending on EHR vendor set up

COST Depends on if you are hospital or a health center and how you are connected

Depends on if you are hospital or a health center and how you are connected

Costs currently absorbed by EHR vendors for health centers, cost for hospitals may vary


Cost Depends on EHR Many Electronic Health Record vendors are absorbing the cost right now!

EHR Vendor Cost Notes

NextGen Free Must have NextGen Share, Responder downloaded, and have upgraded version of NextGen

eClinicalWorks Free May charge if Carequality/ CommonWell increase their prices

Cerner Free Free until 2020

EPIC Free Plan to keep it free for customers

Meditech n/a Not sure

Allscripts/Practice Fusion

n/a Member of CommonWell but not live yet

Hospital Lessons Learned on the Way

Hospital are anxious to share data with our health centers, making them very receptive to my outreach.

Hospital contract process for the national frameworks is taking much longer than the hospitals expected.

• Started to speak to many hospitals a year ago who thought they would be live by now!

National hospitals are realizing they are connected but were not aware since it is so seamless in the EHR (i.e. Providence).

Health Centers are taking longer to go-live using the framework because their workflows are more robust than a health centers due to their size.

St. Johns and North East Valley Health Corporation will speak to their lessons learned from a health center perspective on two different EHRs, eClinical Works and NextGen.


Aisha Iqbal - [email protected]

mailto:[email protected]

ABOUT ST JOHN’S

• We are an independent 501(c)(3) community health center

• We serve patients of all ages through a network of (FQHC’s) Federally Qualified Health Centers and school-based clinics

– 15 clinics

– 2 mobile clinics

– New clinics coming soon

• We accomplish our work through:

– Outreach - Case Management

– Health Education - Insurance Enrollment

– Child Development - Mental Health

– Literacy Education

HEALTH SERVICES OFFERED

HEALTH IT

Sandra Jaime,

Health IT Manager

Manage day to day HIT operations, projects, enhancements and interfaces.

WHAT IS HIE/ COMMONWELL?

• Health information exchange

– Vehicle allowing to securely share and access patients’ medical information electronically

• Who can access this information?

Providers, hospitals, clinics and other organizations connected to HIE

– Connected to several entities- see last slide

• Benefits – go to HealthIT.gov for more information

– Access and sharing of vital medical information

– Eliminates unnecessary paperwork

– Eliminates redundant testing

– Discharge information available at time of visit

OUR EXPERIENCE – Barriers

• Not having consent forms available

• Training for ALL staff needed

• Time for testing/communicating/meetings

• Technical issues

– Testing examples

• Test patients created

– 2 test pts- No data

• Live patients

– Data NOT: 3 live patients

– Data SEEN: 4 live patients

– Can we see MLK data?

• YES- Once patient is linked and workflow is followed

• NO- workflow not followed

CONTINUED

– Training:

• All staff: Front desk, MA’s, Providers

• New workflow

– Pt signs consent

– FD

• add structured data option- Send/receive OR opt out

• verifies CommonWell

– patient linkage

– facility linkage- if needed

• arrives pt- sends query to CommonWell to grab data

– MA/Provider

• eEHx tab- indicator

– Provider

• Importing specific elements available

CONTINUED

– Issues

• Consents not in place

– Paper format

• Workflow not in place

– EHR

• Data not displaying

• Patients information not matching

• Multiple notes received

CONTINUED

– Consents: Forms & EHR

• Required for data exchange with external entities

• Modified to contain “Consent” or “Deny”

• Added to EHR for use with electronic signature

• Different languages needed

CONNECTING TO COMMONWELL

– Indicators

• Appointment window

– Red: needs linking or has new link -- Blue: is linked

AUTOMATIC QUERY

CONNECTING TO COMMONWELL

• Progress note

– Red triangle: when new information is available

– Red diamond on orange bar: needs linking

– Blue diamond on orange bar: is linked

CCDA EXAMPLE

IMPORTING

– Elements viewable and importable

• Problem List

• Allergies

• Medications

– Cost

• CommonWell Alliance: free if on eCW

THANKS! QUESTIONS??

“Caring for our community’s health since 1973”

INTEROPERABILITY

IN A

PRIMARY CARE WORKFLOW

55


COMPANY PROFILE

Opened First Health Center in San Fernando in 1973

Federally Qualified Health Center (FQHC)

Operate 15 Health Care sites in San Fernando and Santa Clarita Valleys

Joint Commission Accredited Organization

2017 HRSA Health Center Quality Leader

Provide both Medical and Dental Services

Provided 380,000 visits to 73,000 patients in 2018

Transitioned to Nextgen EHR in 2011.

Currently on Version 5.9.1/8.4.1

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Health Information Exchange Active Connections

Direct Messaging using Nextgen Share Platform

Query for patient activity using CareQuality/Commonwell

Web Based Portal to EDIE emergency room activity monitoring

57


Direct Messaging:

This platform sends a document from one EHR to another EHR

as a secure email. The sending EHR determines if and when a document

should be sent. The EHR system must first be registered with a secure

messaging provider and assigned an address. These address can be

assigned to an individual provider or as a group or company address. The

document being sent is packaged into a standard format called a CCD-A.

The EHR receiving the document can interpret and post to the patient’s

chart and send a notification that a new document has been received.

The Good, Bad and the Ugly:

Good: Documents are received and automatically posted to patient

chart under “Transition of Care - Referrals” and provider notified

Bad: Notification commonly sent to Plan assigned provider not PCP

Ugly: Document can be very large and takes time to Triage

58


CareQuality/CommonWell HIE:

This platform connects an EHR to a Health Information Exchange

Network through which the EHR can query the network to see if their patient has

been provided services in a defined time frame from any other members. Typically

the EHR will show a summary of where their patient has been provided care and

allow a CCD-A document t to be requested. This document can then be reconciled

and selected areas of the CCD-A posted to the patient chart. These CCD-A requests

should be electronically documented in a PHI release log.


Good: Document can be reviewed before adding to patient chart

Good: HIE access is automatically document on the PHI release log

Bad: Process takes several minutes and not all health centers on network

Ugly: Document can be very large and takes time to Triage

59


EDIE:

This platform is a Health Information Exchange data warehouse that is

connected to most emergency care hospitals. Real time data is received into the data

warehouse where the data is analyzed and the patient matched to membership roles

of Primary Care registered organizations and user defined notifications are sent.

Membership lists are submitted directly from the IPA/Plan and there is no direct

connection to a Primary Care EHR. The Primary Care organization logs directly

into a cloud based portal to review ER and Admission status of their patients for care

coordination information.


Good: System has logic than can be used to focus on specific patients/diagnosis

Bad: Does not integrate with EHR.

Ugly: Biggest financial value is to IPA/Plan not FQHC

60


NEVHC interoperability discussions and concerns

Privacy Concerns:

How to get patient consent

Notice of Privacy Practices/ Signed HIE Consent?

Blocking HIE Network Access as a default

How to limit access to sensitive services

Teen Family Planning/STD Services

BH Services

Drug Abuse Treatment (42CFR Part2)

Clinical Review of Transition of Care Document

Do you review all TOC documents received?

Do you automatically scan for HIE activity before every visit

Who reviews TOC document. Licensed vs Provider

When is the Transition of Care document part of the chart

When posted to patient record?

When a provider takes action using information from the TOC?

When Care Team scrub the chart and are informed of external health visit?

61


Interoperability Case Study

Using the ER monitoring portal, we identified an OB patient who presented at the

emergency room with a initial diagnosis of “abortion”. A follow up investigation was

performed by the WH Program Manager by querying the CareQuality Network to

obtain the full Continuity of Care Document. This document showed that the patient

experienced a spontaneous abortion. The WH Manager was able to follow up with

the patient in a very informed and sensitive manner avoiding an embarrassing phone

when the patient missed her next OB follow up appointment.

62


How is NEVHC using Interoperability

We have included the HIE consent as part of our Patient Handbook and provided

patients with instructions on how to request this sharing be blocked

We have setup a company specific Direct Messaging address

We have a licensed nurse use a CCDA Management Tool to review all documents

for Adults received via Direct Messaging.

HIE network search is configured to query 2 days before a scheduled visit

HIE results are not yet integrated into standard visit clinical workflow

Care Team only searches HIE results if requested by provider

Emergency Room monitoring is limited to Pediatric Asthma patients with

respiratory diagnosis

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