Thursday, February 21, 2019

HIMSS19: Are we finally unblocking patient information?

Busier as ever
More than 45,000 visitors to the worlds largest healthcare IT conference held in Orlando, Fla,
browsed through 1200 booths looking for IT solutions for their facilities and listened to the many educational sessions. There is still a dichotomy between what was shown and the real world as the IHE showcase demonstrated 12 use cases where information seamlessly flowed between different vendors, while it is not always so smooth in practice based on stories from the trenches.
Here were my observations from this conference:

Distinguished panel at Keynote
1.       Interoperability, are we there yet? The meeting was dominated by the recent information-blocking rule, which was unwrapped by the US department of Health and Human Services (HHS) literally the day before the convention started. As Seema Verma, the US CMS administrator pointed out in her key note presentation, the government has given out US $36 billion on incentives to implement electronic health records with not much interoperability to show for it, so now it is time for the industry to step up.
Former US CTO Aneesh Chopra added to this saying that the CCD’s (Continuity of Care Documents) that are exchanged right now might not be the best solution to exchange patient information, but we need to look for other means such as open APIs, which can be used to tap into any EMR for information. These open APIs will become a requirement by 2020 according to the HHS. Penalties to health information exchanges and health information networks could be up to $1 million for lacking interoperability. Maybe this will help, however the rule is expected to get pushback from some of the stakeholders. For example, the AHA was quick to point out that it disagreed with certain parts of the requirements: “We cannot support including electronic event notification as a condition of participation for Medicare and Medicaid,” stated AHA Senior Vice President for Public Policy Analysis and Development Ashley Thompson.

Open API, is that sufficient? An open API is merely a “connector” that allows information to be exchanged, however, as was noted in the same keynote speech, if the only thing that can be exchanged is the patient name, sex and race, or if the clinical information is not well encoded and/or not standardized, the API is not of much use.

That is why implementation guides based on use cases specifying the many details of the information to be exchanged are critically important. The good news is that these implementation guides are a key component of the new FHIR standard, which can be electronically interpreted and are defined according to a well-defined template. The DaVinci activity which has already defined 12 of these guides and which are part of the FHIR balloted standard will facilitate the exchange. The focus of these guides is on provider/payer interactions and includes for example medication reconciliation for post discharge, coverage requirements information and document templates and rules. The booth demonstrating these use cases was one of the busiest in the IHE showcase area.

3.       What about social determinants? Health care determinants follow the 20/20/60 rule, i.e. 20 percent of ailments are determined genetically which can increasingly be predicted by looking at your DNA sequence, 20 percent are influenced by a healthcare practitioner such as your doctor, but 60 percent, i.e. the majority, is determined by the patient through his or her own actions and social determinants. For example, if you are genetically at risk for a heart condition, and your doctor has already placed a stent in one or more of your coronary arteries to help blood flow to your heart muscle, but you don’t change your life style, you won’t be able to get any better. Now, let’s say you are homeless and depend on food that is not good for your condition, you could be in trouble. It would be good if your physician knows those social factors, which could also include where you have traveled to recently. However, there are no “codes” available to report this in a standard manner. The majority of the health care determinants (60 percent) are not encoded, therefore, there is much work to be done in this area.

Impressive number of providers
participating in Commonwell
4.       How is information exchanged between providers? The ARRA (American Recovery and Reinvestment Act) from the previous administration had put money aside to establish public Health Information Exchanges (HIE’s). Unfortunately, many of these HIEs took the grant money and folded after that ran out, notably the HIE’s in North Texas and Tennessee and many others, shutdown after failing to find a sustainable business model.
Several vendors took the initiative to establish a platform for information exchange as they figured out that the effort to string connections one-by-one between healthcare providers would be much more expensive than creating their own exchange, which is how the Commonwell non-profit started. As of the conference, they had 12,000 connections to providers, which is probably 10 percent to 15 percent of all providers, which is a good start towards gaining a critical mass. Cerner seems to be the largest EMR vendor in this alliance. Epic was notably absent and has been the main driver of a somewhat competing alliance, called Carequality with different functionality but establishing similar objectives, i.e. exchanging information between EMR’s from different vendors at the providers.
The good news is that there is now a bridge established between these two platforms, which again makes the critical mass even larger. This situation is somewhat unique for the US as other countries have government initiatives for information exchange but for those countries without an initiative, the same model might work. This will hopefully solve the problem that was mentioned by one of the providers who said that it has been relatively easy to exchange information between his EMR (which happened to be Epic) and others as long as it was an EMR from the same vendor, but very hard if not impossible to get anything out of an EMR from another vendor into his EMR. This is a great effort, which together with the anti-blocking rules from CMS, might finally allow healthcare information to be exchanged.

One of the many portals
5.       Are patient portals finally taking off? It is still a challenge to access health care information as there is not really a universal portal that collects all of the information among different providers. You might need to maintain access to the information being present at your primary physician, your specialist(s), your hospital and even your lab work provider. One of the ways to consolidate this information is to have a single provider, such as the VA for veterans, and their portal “myhealtevet,” which has been relatively successful. How this is going to work as the VA  increases its outsourcing to private commercial providers remains to be seen. If you are on Medicare or Medicaid, CMS will provide a standard interface, which is used by several (free) patient portal providers where you can log in to see all of your claims, prescriptions and other relevant information. Again, if you do not happen to be a veteran or are not covered by CMS, but are a patient between the two of these organizations, there is not so much interoperability, however those two groups cover enough patients to start having a critical mass as well.

Standing room only at cloud
6.       Are cloud providers making any progress? One of the speakers, who happened to be working for New York Presbyterian, claimed that they are planning to have 80 percent of their applications and infrastructure in the cloud. There are more advantages to the cloud than potentially reducing cost, such as easier access by patients, and the potential to run AI algorithms for clinical support, analytics and decision support. Machine learning is more effective when there is a lot of data to be learned from, hence the advance of cloud archiving.

The big three cloud providers (Amazon, Google and Microsoft) are more than happy to take your business, the Amazon booth was packed every time I passed it. However, they still have a steep learning curve, even although they claim to have open API’s and a healthcare platform with a lot of features, they have to learn in a few years what healthcare vendors have accumulated in expertise over many decades. The good news is that they have potentially very deep pockets so if they are getting serious about this business, they could become major players.

7.       Is Uberization of healthcare happening? When people talk about Uberization they typically
Get the Uber or Lyft app in your EMR!
refer to the business model that provides easy access by consumers through mobile media, accountability of the providers, and tapping into a completely new source of providers such as private drivers who suddenly become transportation providers, or, in the case of Airbnb, private home owners who become innkeepers.
This is happening in healthcare as well as there is a big increase in tele-health providers who provide phone access to patients who want advice anytime, anywhere. Speaking with a physician who does this from his home, telehealth is as easy as using Uber as a physician can sign up anytime and just log on to take calls from patients for as long as he or she decides. As I listened to one such physician’s experiences, he provided life-changing advice, especially to patients who live in remote areas and otherwise would not be able to seek medical advice because of their remoteness.
In addition to telehealth services, Uber and Lyft were also promoting their transportation business to providers, to reduce potential no-shows by patients who have trouble with transportation. A provider can contract with either one of these to serve their transportation needs.
8.       What about the wearables? Apple introduced access to medical records through its health app
Note the wearable EKG sensor
as well as monitor
at the 2018 conference through a FHIR interface. Their provider list has been growing steadily and is now close to 200, including the VA which by itself accounts for 170 medical centers and more than 1000 clinics. This is a significant number, but not even close to the number of providers in the Commonwell platform, for example, whose members exceed 10,000. Therefore, there is still a lot of progress to be made.
There was an increase in intelligent detectors that can communicate vital signs and other clinical information using blue-tooth to a mobile device, for example, to allow patients to be released earlier from a hospital back home which is safer and more cost effective.

9.       Are we Safe from hackers yet? There has been a major increase in cyber security investment, which has become a necessity as healthcare has become a major target for hackers and ransomware opportunists.
Huge Security pavilion
Healthcare providers are making big investments in personnel and tools to try to protect themselves. The cybersecurity area of the conference was indeed huge as many new companies are providing their services. The average security part of an IT budget is about 6 percent to 8 percent but there are some who spend as much as 12 percent. Imagine an IT staff of a large organization, e.g. if you have 500 IT employees, there could be as many as 50-60 staff dedicated to cyber security.

Based on recent incidents, we still have a lot of work to do in healthcare to protect patient information, especially at the periphery, as medical devices in many cases appear to provide easy access points to a hospital’s back-end. This risk is one of the reasons that the FDA has been requiring a cyber security plan to be filed with every new medical device clearance.

plenty of FAX apps
10.   When are we going to get rid of the fax machines? About six months ago, CMS publicly announced that they want to get rid of all fax machines in healthcare by 2020. This is only one
year away, however in practice it appears that by far the majority of all healthcare communication in healthcare is done through the ubiquitous fax machine. A good manner to transition might be to exchange documents using the open API, and then do Natural Language Processing (NLP) to search for medications, allergies, and other important information that can be processed and potentially imported into the receiving EMR. In the meantime, there were still many small companies that were advertising smart ways to distribute faxes and I predict that this will still happen for several years to come.

In conclusion, this was yet another great conference. The emphasis was on unblocking the information that is locked up in many healthcare information systems and, until now, can only be exchanged if you happen to have an EMR from the same vendor as its source, or if you are lucky enough to have a provider that has access to Commonwell or Carequality, or a provider who uses one of the relatively few public Health Information Exchanges (HIE’s). Hopefully the industry and providers will start to cooperate on making this happen, we’ll see next year when we are going to be back in Orlando FL again.

In the mean time, if you are baffled about some of the terminology you might consider our FHIR, IHE or HL7 V2 training publications and classes.

Sunday, February 3, 2019

Cleveland 2019 IHE connectathon: it’s all about FHIR.

The 2019 IHE connectathon drew more than 300 healthcare IT professionals to a snowy and cold
Cleveland to test interoperability between their devices using IHE defined profiles. What was new this year were the recently published profiles facilitating exchange of information using mobile communications based on the new FHIR standard, which is based on standard web protocols.
The FHIR testing emphasized querying for patient information, corresponding documents, and uploading and retrieving them. In addition, we tested the audit trails using FHIR, which is important from a security and privacy perspective.

There are still relatively few FHIR based implementations in the field due to the immaturity of the standard (most of it is still a draft), the lack of critical mass (implementing FHIR for just one application such as scheduling does not make sense), and its steep learning curve as it is sufficiently different from what healthcare IT is accustomed to. Therefore, the more that can be verified and tested in a neutral environment such as the connectathon the better it is. Speaking with the participants, they uncovered quite a few issues in their early FHIR implementations, which again is good as it is better to solve these issues beforehand than during an actual deployment.

The attendance at this year’s event seemed to be lower than previous years, which could be due to the fact that there are several local connectathons happening during the year on other continents, which draw from the same crowd, and that implementations are starting to mature (except for FHIR of course) and therefore, there is less need for debugging.

There could also be somewhat of a “standards overkill” in place if one considers the fact that for radiology alone, which is one of the 11 domains, there are 22 defined profiles and another 27 published as draft. It is hard to keep up with all of these and for vendors to deploy all of these new requirements.

As FHIR matures, which will take several years as its typical release cycle is 12-18 months, there will be a need to test these new releases between the vendors providing the medical devices and software products. There were a few new vendors present but most of them consist of the same “crowd,” which is somewhat disappointing because I believe that the real FHIR implementation breakthrough will come from outsiders such as Apple, Amazon, Microsoft and/or Google, all of which were notably absent.

In conclusion, another very successful event, giving a boost to interoperability, something we very badly need as patients, especially in the US where we are still struggling to get access to our medical records, including images, and where healthcare institutions continue to have difficulty exchanging information among themselves and other providers. In many departments and medical offices, the fax machine still is an important tool, hopefully not for long.