Presentation by Megan Douglas, JD for the Third Annual Policy Prescriptions® Symposium She is the associate director of Health Information Technology Policy in the National Center for Primary Care at Morehouse School of Medicine. The symposium is designed for clinicians, healthcare workers, and healthcare executives interested in exploring the major themes that will emerge in health policy throughout the year. This year, the symposium will emphasize value in healthcare, health information technology, gun violence, insurance choices, the Affordable Care Act, and the viewpoints of the Presidential candidates on health care.

1. Almost-Standard Gauge:
Misadventures in
Interoperability
Megan Douglas, JD
Associate Project Director, Health IT Policy
Morehouse School of Medicine
3rd Annual Policy Prescriptions Symposium
Houston, TX
June 11, 2016

2. The Following Presenters Have Disclosed Relevant Financial Relationships:
Cedric Dark, MD MPH FAAEM FACEP
Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship
Seth Trueger, MD MPH
Emergency Physicians Monthly, Employee, Salary
The Following Presenters Have Disclosed No Financial Relationships:
Megan Douglas, JD
Elena M. Marks, JD MPH
Laura Medford-Davis, MD
Bich-May Nguyen, MD MPH
The Following Planners Have Disclosed Relevant Financial Relationships:
Cedric Dark, MD MPH FAAEM FACEP
Community Health Choice, Event Sponsorship; Schumacher Clinical Partners,
Event Sponsorship
The Following Planning Committee Members and Staff Have Disclosed No
Relevant Financial Relationships:
Emily DeVillers, CAE
Kay Whalen, MBA CAE
Janet Wilson, CAE

3. The project described was supported
by the National Institute on Minority
Health and Health Disparities (NIMHD)
Grant Number U54MD008173, a
component of the National Institutes of
Health (NIH) and Its contents are solely
the responsibility of the authors and do
not necessarily represent the official
views of NIMHD or NIH.
Official Statement

4. Learning Objectives
• Define interoperability as distinguished from health
information exchange
• Describe the current status of interoperability at a
national level
• Assess organizational and policy barriers and
facilitators to interoperability

5. Setting the Stage
• No Matter Where
– https://www.youtube.com/watch?v=qMurGr623Ms
• Ideal vs. Reality
• Evolution, NOT revolution

6. DEFINITIONS

7. Health Information Exchange (HIE*)
Ability of two or more health information systems to
exchange clinical information to provide access to
longitudinal information
*Not to be confused with HIE (governance entities
that facilitate HIE)

8. HIE (the concept)
Three types of HIE:
• Directed exchange: ability to send &
receive secure information
electronically between care providers
• Query-based exchange: ability for
providers to find and/or request
information on a patient from other
providers
• Consumer-mediated exchange:
ability for patients to aggregate and
control the use of their health
information among providers
Mr. Jones has an
appointment with the
cardiologist on Friday. Here
are his latest test results.
Has Mr. Jones been to the ED
for his asthma lately?
Mr. Jones has been
monitoring his blood sugar
for the last 30 days. He has
submitted his reports through
the patient portal.

9. HIE (Governance entities)
• State, regional, system-based
– Every state has different
strategy/model
– Public, private, public-private
partnership
• Direct participation vs. network
of networks
• Services offered
– DIRECT messaging (HIPAA-
compliant e-mail)
– Query-based searches
– Automatic notifications
• Distinguish between adoption
& utilization
– How much data is actually
flowing?

10. Interoperability
Ability of a system to exchange electronic health
information with & use electronic health information
from other systems without special effort by the user
-Institute of Electrical and Electronics Engineers (IEEE)
https://www.ieee.org/education_careers/education/standards/standards_glossary.html
Includes concepts of: standardization (transport +
vocabulary/terminology), integration, cooperation, and
technical specifications
Bottom line: Integration is automated & actionable
Basic Advanced

11. Interoperability vs HIE
• Electronic Health Record (EHR) is necessary for
electronic HIE
• HIE is necessary for interoperability
• HIE is not sufficient by itself to achieve
interoperability
EHR
Adoption
Health
Information
Exchange
Interoperability

12. Electronic
Health
Record
ClinicalDecision
Health Information
Exchange
Advanced
Interoperability
Basic
Interoperability
Clinical
Care
Document
(CCD)

13. STATUS

14. The Interoperability Unicorn
“Many have heard about it, but few have seen it”

15. Numbers...?
• We don’t know how many providers have
“interoperable” systems
• But we do know:

16. Proportion of physicians who reported
electronically sharing health information, 2013
and 2014
SOURCE: 2013 and 2014 National Electronic Health Record Surveys; HealthIT.gov
http://dashboard.healthit.gov/evaluations/data-briefs/physician-electronic-exchange-patient-health-information.php

17. Proportion of physicians who electronically
shared any patient health information with
other providers, 2014
SOURCE: 2013 and 2014 National Electronic Health Record Surveys; HealthIT.gov
http://dashboard.healthit.gov/evaluations/data-briefs/physician-electronic-exchange-patient-health-information.php

18. Transitions with a Summary of Care Record
http://dashboard.healthit.gov/quickstats/pages/eligible-provider-electronic-hie-performance.php

19. Percent of non-federal acute care hospitals that
electronically exchanged with providers outside
their organization: 2008-2014.

20. Clinical care summary exchange among
hospitals and outside providers between 2010
and 2014.

21. Percent of U.S. Hospitals that Routinely Electronically
Notify Patient's Primary Care Provider upon
Emergency Room Entry
HealthIT.gov Dashboard - http://dashboard.healthit.gov/quickstats/pages/FIG-Hospital-Routine-Electronic-Notification.php

22. BARRIERS & FACILITATORS
TO INTEROPERABILITY

23. Why is interoperability so hard?
Technical?
Business?
Moral?

24. Moral
For the “public good”
– Increases efficiency
– Reduces costs to the system
– Patients prefer record sharing
– Improves care coordination
– Improves health outcomes
– Improve population health
Privacy/security
– Data breaches

25. Technical
• Many transactions
– A single EHR system at one large hospital (the Mayo Clinic in
Rochester, Minnesota) processes over 660 million HL7 messages a
year, or about 2 million messages a day
Benson, T. (2012). Principles of Health Interoperability HL7 and SNOMED. Available at http://www.springer.com/gp/book/9781447128007.
• Many data sources
– Clinical health records (primary care, specialty, hospital)
– Billing (payment information and history)
– Patient-generated health data
– Pharmacy and prescription information
– Patient and family-health history
– Genomics
– Clinical-trial data
• Many languages
– EHR systems and clinical systems use different language to describe
the same piece of data (ex: sex/gender; female/woman; heart
attack/myocardial infarction)
BUT NOT THE BIGGEST BARRIER!

26. Business (aka )
• “It is usually in each vendor’s financial self-interest to
provide a proprietary nonstandard interface to a
customer, even though they know well that this is
ultimately creating an interoperability nightmare”
Benson, T. (2012). Principles of Health Interoperability HL7 and SNOMED. Available at
http://www.springer.com/gp/book/9781447128007.
• Patient “ownership” – system competition
• Data ownership
• Inadequate ROI/business case
• Liability
– Data protection – chain of custody (“typically addressed in
layers of complex legal agreements between vendors and
healthcare facilities”)
Munro, D. The Healthcare IT Quote Of 2015.
Available at http://healthstandards.com/blog/2015/12/01/quote-of-2015/.

27. State Initiatives
• Laws
– North Carolina Session Law 2015-241 s. 12A.4 and 12A.5
• As of February 1, 2018, all Medicaid providers must be
connected to the HIE in order to continue to receive payments
for Medicaid services provided. By June 1, 2018, all other entities
that receive state funds for the provision of health services,
including local management entities/managed care
organizations, also must be connected
• Funding
– ONC has 56 cooperative agreements with
states/territories
• Governance

28. • Public-private partnership
– Texas Health Services Authority (THSA) partnered with
InterSystems in 2013
• Network of networks (favored, not mandatory)
• Services
– Clinical Document Exchange (Treatment)
– Federated Trust Framework (Security/Confidentiality/Accuracy)
– Patient Consent Management (opt-in or opt-out)
– eHealth Exchange
• Fees (based on size of HIE)
– Implementation fee: $20-$130k
– Annual fee: $15-$110k

29. • State HIN, public-private
partnership
• Network of networks
• Members
– Payers
– State agencies
– Regional HIEs
• Services
– Direct messaging
– Query-based record
retrieval
• Mission-based Service
Area HIE
– Focus on small, rural
providers, practices,
hospitals
• Services
– Query-based record
retrieval
– Direct messaging
– Medication management
– Quality performance
dashboard

30. Federal Initiatives
~$30 billion
over 6 years

31. MACRA – Quality Payment Program
Current Volume-Based System
• Fee for Service
• Provider revenue increases
with number of services
performed
MACRA’s Value-Based System
• Payments to providers will
vary based on factors like:
– Quality measures met
– Participation in APMs
– Resource use
– Clinical practice
improvements
• Payments will be linked to
quality and value – and will
increase/decrease with
performance

32. Merit-Based Incentive Payment System (MIPS)
Proposed Rule
• Meaningful Use  Advancing Care Information
• 25% of Composite Performance Score (Quality,
Resource Use, Clinical Practice Improvement
Activities)
• Focus on Patient Electronic Access, Coordination of
Care through Patient Engagement, Health
Information Exchange
• Bonus for submitting clinical quality measures
(CQM) electronically

33. Health IT is in its...