Although the health systems they work for compete for patients and contracts, chief medical information officers (CMIOs) in the Philadelphia area are finding that they have plenty of good reasons to cooperate.
Speaking at last week’s AMIA Clinical Informatics virtual conference, two associate CMIOs from the University of Pennsylvania Health System (UPHS) described recent cooperative efforts among CMIOs in the Philadelphia region.
Joel Betesh, M.D., medical informatics officer at the Pennsylvania Hospital and co-chair of the UPHS enterprise-wide informatics committee, began the presentation by noting that competition between health systems often precludes collaboration. “But the reality is that when the same patient obtains care from adjacent health systems, it is in the patient’s best interest and everyone’s best interest to work together to deliver care as seamlessly as possible.”
In early 2018 three Philadelphia-area health systems all went live with the same EHR vendor. With the addition of these three, there were a total of nine health systems using the same EHR vendor in the region. “We decided the time was right to bring together the CMIOs and assistant CMIOs from these nine health systems,” Betesh said. Just within the City of Philadelphia, they could bring together Penn, CHOP, Jefferson and Temple. “You can see how easy it is for a patient to have a primary care provider in one health system and see a specialist at another,” he added. In the spring of 2018 they sent out an invitation to CMIOs and assistant CMIOS of the nine Philadelphia-area systems comprising a total of 17 hospitals using the same EHR vendor.
Their first meeting took place in July 2018 with 20 attendees. For a few people in the group, they were meeting people in person they had been e-mailing for years. The first meeting was devoted to creating a list of topics of mutual interest. These topics fell into four categories. The first was EHR enhancements that require regional cooperation to accomplish. A good example involves sharing clinical records with each other.
“We proposed making an agreement that all patients would be automatically opted in to free sharing with the rest; also communication with each other via Direct addresses across instances of our EHR, and also linking local resources to social determinants of health in our EHR,” Betesh explained. Another issue was how to get EHR data from a recently closed large academic hospital, Hahnemann University Hospital.
The second category revolved around currently used EHR features, including reconciliation of medication lists with each other, which may sound simple, but is surprisingly complex, Betesh noted. Other issues included prescription drug monitoring program integration within the EHR and sexual orientation and gender identity (SOGI) data sharing. “All of us were just getting started with SOGI, so we thought it would be very useful for us to use the same definitions so we could share data with each other.”
The third category was the potential use of new features such as real-time prescription benefits and CancelRx, which means if Penn Medicine canceled a prescription in its EHR, that information would get transmitted to the pharmacy.
Collaborating on Regulations
J.T. Howell, M.D., associate CMIO, ambulatory EHR, at University of Pennsylvania Health System, described the fourth category of mutual interest dealing with new and impending state regulations.
First, he described alignment on opt-in vs. opt-out. “Many of the systems in our collaborative required explicit patient consent to allow data sharing. That is the op-in model,” Howell said. A few systems informed patients that they would exchange the data unless the patient had expressed reservations or had data they wished to keep private. That is the opt-out model. “As we discussed this at our meeting, members become persuaded that the opt-out model was the better way to go, and it has now been adopted by all members.”
Howell also described a new regulation that was going to go into effect in January 2019 requiring letters to patients whenever radiology testing showed a finding that required follow-up. Coming later that year was a new regulation that required all narcotic prescriptions to be electronic by October 2019.
“Our legislature came up with a well-intentioned but poorly worded regulation requiring a patient to be informed of any imaging study with significant findings. But they didn’t define what they meant by imaging or the adjective significant. Was it supposed to include cardiology? Maternal fetal medicine? The Pennsylvania consortium members included a bunch of academic centers. “When we wrote to the legislators and said you have to both clarify this and give us some more time, they did both,” he said. “They were willing to give us a better definition of what they were asking and give us an additional year for implementation.”
More recently, during the COVID pandemic, there has been extensive collaboration regarding work flows and data sharing on COVID-19 results. “With regard to changes to opt-out, we have enabled extensive data exchange for purposed of individual patient care. However, research data exchange on our shared platform is governed by a much stricter set of rules of the road issued by the vendor. Late last month, our institution prevailed upon the vendor to relax the rules of the road with regard to COVID antibody testing. This applies to a focused set of lab tests during a limited interval, but it will allow research on a much larger data set to establish the validity and appropriate clinical use of COVID antibody tests.”
Howell noted that it might be tempting to ascribe their victories to the fact that they were all on the same electronic medical record, but opt-out vs. opt-in and working with the state on regulations were vendor-agnostic initiatives. “Sometimes just getting everyone in the same room or on the same call has extraordinary benefits,” he said.
Howell reiterated what Betesh said earlier: At the CEO level, their systems are competitors, each attempting to gain the largest share of business in our region. But at the CMIO level, they are collaborators. “We are all working on the same problems, many of which can be solved through better alignment. This was a dim vision at the outset, but has become increasingly apparent as we work together.”
Howell and Betesh encouraged others to adopt this model. “If you are in an ecosystem where there are other health systems around you, we encourage you to reach out to those systems,” Howell said, “whether they are on the same software or not, because there is a lot that can be accomplished through collaboration.”