Jitin Asnaani

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	According to the Office of the National Coordinator (ONC), hospitals have 

 to exchange information with providers outside their organization. Only 41% of hospitals had that ability in 2008 and 76% could do so in 2014. Unfortunately this growing hospital capacity is not equally matched among primary care providers or in post-acute care.  Significant barriers to interoperability remain in those care settings, creating uneven access to data across the continuum.

AsnaaniWhile many providers cite the need for costly interfaces as their foremost obstacle, a potpourri of hurdles hinder the care coordination needed to transition U.S. healthcare from volume to value.  That potpourri is too multidimensional for the hospital industry or any single sector to tackle alone.   Diverse health IT partnerships are needed to promote a free-flowing data exchange that includes the patient and all members of the care team.

	Managed care has long seen the value of providing care through community and home-based services that are less costly and more convenient for individuals.  But those services must be linked in a way that facilitates access to accurate, timely health information. 

	We all know that health is predominantly determined by social circumstances and activities that occur outside any health care institution-especially outside a hospital.   If we are to influence those activities and truly participate in population health, we must engage individuals in their own health and we must stop thinking of health IT as the exclusive purview of healthcare institutions. 

Government promoting coordination with bundled payments

	New policies set in motion by the Affordable Care Act have introduced changes in how care should be delivered and success measured.  In April, CMS introduced 

 as the first mandatory program in the plan to shift at least 50% of Medicare spending to alternative payment models by 2018.

Read: CMS confirms path toward payment reform

 patients receive ongoing care in a post-acute facility like a skilled nursing facility or rehabilitation hospital and another 33 percent receive home care.  More often than not there is little coordination between the acute and post-acute care teams. 

	Under the new program, hospitals in 67 randomly selected metropolitan areas are now responsible for all costs of care for a full 90 days after the surgery.  If patients do well and recover quickly, the hospitals and partners will reap the monetary benefit.  If not, the hospitals could end up owing Medicare. 

	The program does not mandate data exchange, but it’s clear that effective communications and data analytics is essential to success.

	Of course, bundled payments aren’t the only reimbursement program to reward disparate providers for care coordination. According to a Leavitt Partners report at the end of 2015, the number of accountable care organizations had grown to 

	This partial shift of financial risk from payer to provider is good news for payers, but only if quality outcomes are met and health improves. The need for timely data exchange seems obvious but unfortunately the solutions for assuring it are less so.  Consider the fact that when multiple physicians are treating an individual following a hospital discharge, 

 information about the individual’s care is missing. We know too, that poor care coordination increases the chance 

 that an individual will suffer from a medication error or other healthcare mistake.

Concurrent complementary interoperability efforts underway

	Provider diversity is critical to the health IT interoperability that will foster true care coordination, but health IT vendors and patient advocates must play a role as well. 

	Accordingly collaborative industry partnerships are working on complementary solutions to health IT interoperability challenges in the following ways:

 are working to improve health data exchange nationwide by building the capability to exchange health data into their software. Its membership represents health IT market leaders and technology innovators supporting care settings such as post-acute care, imaging, laboratory, retail pharmacy, care management, skilled nursing, home health, emergency services and more.

, another membership organization, engages doctors and patients in order to standardize and reform the use of health information technology. Its 2020 Roadmap provides guidance on business and clinical motivators, interoperability, and data access and use.

 is focused on developing a first-generation Application Programming Interface (API) and Core Data Services specification to enable expanded information sharing for electronic health records, documents, and other health information.

	As cross-vendor data exchange continues to improve, the industry will likely see more vendor software solutions that eliminate multi-point connections and minimize the effort required by providers to access data.

	Additionally, government funded efforts including the 

Open Behavioral Health Information Technology Architecture

, which supports the development of health IT tools for behavioral health, 

, a data segmentation and consent management tool to support information exchange in compliance with health information privacy regulations, 

, a multi-stakeholder led organization that is working toward creating the policy and trust frameworks to enable inter-network exchange, and the 

Behavioral Health Information Technologies and Standards project

, which supports dissemination of health IT tools and standards for behavioral health, will contribute key learnings and spur innovation in this new path forward.

	Physician, medical reformer and writer Oliver Wendell Holmes said it well: “Many ideas grow better when transplanted into another mind than the one where they sprang up.” This quote brilliantly illustrates how to approach the task of enhancing interoperability across the care continuum.

	As managed care leaders, better care for patients can be achieved through increased medical data exchange through diverse and collaborative organization involvement.

Jitin Asnaani is executive director of the CommonWell Health Alliance. 

Articles

As managed care leaders, better care for patients can be achieved through increased medical data exchange through diverse and collaborative organization involvement.

Diverse health IT partnerships are critical to interoperability

	The torch is being passed.  And it’s burning brighter than ever.

	From the instant that the American Recovery and Reinvestment Act was penned into law back in 2009, the federal government has advocated for nationwide health information exchange.  Some of its tactical efforts have been rather literal, such as setting up state health information exchanges (HIEs), while others have focused on putting the pieces in place to enable exchange to occur through technical standards and policy guidance. 

READ: Four ways managed care executives can advance interoperability

	Up until 2012, the government drove information exchange of its own volition (and taxpayer dollars), setting the vision and pushing forward the interoperability mandate onto the industry through programs such as meaningful use, the EHR certification program, and the Affordable Care Act. 

	The results have been tangible: In 2013, almost 

 of office-based physicians reported they adopted some type of EHR system, according to the Department of Health and Human Services. During 2014, 76% of hospitals exchanged at least some type of data outside their organization, compared with 62% the year before, according to the American Hospital Association's annual hospital survey.

	But over the last three years, the private sector has stepped into the limelight.  Vendors and providers have taken the reins on operationalizing the exchange of data, even while the government continues to express its vision through such mechanisms as the Office of the National Coordinator's (ONC's) “

Shared Nationwide Interoperability Roadmap

READ: ONC finalizes roadmap for interoperability

	Five private sector initiatives in particular are accelerating the reality of interoperability, discussed here in chronological order:

 The eHealth exchange is the oldest of these initiatives, having formed in 2006 as a Federal-led effort known as the Nationwide Health Information Network Exchange.  In 2012, the eHealth Exchange was reformed as a public-private effort under the non-profit entity “The Sequoia Project,” with a continued focus on enabling hub-to-hub exchange of data, especially between hubs set up by very large provider organizations and HIEs.

 DirectTrust.org was formed in 2012 as a nonprofit to carry on the work deferred by the Direct Project initiated by the ONC.  DirectTrust.org focuses on shared agreements and a uniform certification process that enables providers to exchange data through push-based protocols, much akin to secure e-mail.

3. Pull-based exchange embedded into providers' software.

 Launched in 2013, CommonWell Health Alliance is the first and only HIT vendor-driven interoperability initiative focused on building working infrastructure and services for person-centric health data exchange nationwide. Its members are health IT market share leaders and technology innovators for the acute, ambulatory, post-acute care, imaging, laboratory, pharmacy and other healthcare segments. 

	Since access to CommonWell services is built into member products, CommonWell promises to enable seamless record location and on-demand “pull” of clinical data across the spectrum of care providers, from large health systems to single-doctor offices, pharmacies and post-acute care settings. At press time, CommonWell was on track to enable more than 5,000 provider sites nationwide to be enrolled on its services in 2015.

Next: Standards for discrete data exchange.

 In 2014, the Argonaut Project was founded by a handful of major health IT vendors and prestigious health systems.  Argonaut is focused on defining the standards for the exchange of “discrete” data, which is in stark contrast to the current standards for health information exchange, which focus on “documents” of data. Argonaut will not build any specific infrastructure to enable the usage of these discrete data standards (known as Fast Healthcare Interoperability Resources, often abbreviated as FHIR and pronounced as “fire”). Rather, it is accelerating the official creation and publication of them through Health Level 7 (HL7),an accredited standards development organization, so FHIR can be broadly used by organizations across the healthcare industry.  It is also developing standards for the access of FHIR data from the EHR.

. Last but not least, in 2014, The Sequoia Project launched a new, separate initiative called Carequality under the assumption that, at some point in the future, the industry will be composed of a number of separate networks that will need to connect with each other.  As such, Carequality is creating the policy and trust frameworks to enable such intra-network exchange, led by health IT vendors and healthcare provider organizations.

	This is truly an exciting time to be in health data exchange, and all of these initiatives present numerous possibilities for the future of the collective “health Internet”. Direct Project is focused on the ability to “push” secure e-mail-like messages.  While eHealthExchange is trying to enable on-demand “pull” of data from large targeted data repositories, CommonWell is providing on-demand “pull” through a seamless person-centered service built into the software used across and along the care continuum.  In their midst, the Argonaut Project is trying to define standards reusable by all of these networks, while Carequality is trying to set some parameters that will enable the networks of today and tomorrow to be able to interconnect.

	At the end of the day, as the torch is passed from government to private sector, one thing is clear: The future has never looked brighter for the ultimate benefactors-the patients and providers-for whom the exchange of information will create greater likelihood of empowerment, safer care, more satisfaction, and improved health.

Jitin Asnaani, is the executive director of CommonWell Health Alliance

Here are some innovative ways EHR vendors are working to expand interoperability for providers and payers

Jitin Asnaani

Articles

Diverse health IT partnerships are critical to interoperability

Five private sector interoperability initiatives to watch