On Thursday, October 24, the Pittsburgh-based Center for Connected Medicine sponsored a webinar entitled “Improving Health Care Interoperability: Have We Reached A Tipping Point?” The Center for Connected Medicine, jointly operated by GE Healthcare, Nokia, and UPMC, facilitates connections among those who deliver, receive, and support health care, exploring firsthand how emerging models and integrated technologies can help them address the opportunities and challenges of their own organizations and regions.
Wednesday’s webinar involved a roundtable discussion led by Aneesh Chopra, president of the Arlington, Va.-based analytics company CareJourney, whose website describes it as being “founded in 2014 under the belief that our nation’s transition to value-based care is an important one, but without an ‘operating manual’ that can reliably deliver on the promise of better quality at lower cost.” Chopra is best known for having served as the first Chief Technology Officer of the United States, appointed by President Barack Obama and serving in that position from May 2009 through February 2012. Chopra was joined on the panel by Heather Cox, chief digital health and analytics officer at Chief Digital Health and Analytics officer, at the Louisville, Ky.-based Humana health plan; Steve Vogelsang, Chief Technology Officer, IP and Optical Networks, at the Espoo, Finland-based Nokia; and Kristian Feterik, M.D., eRecord Medical director, clinical informatics, and associate medical director, clinical documentation integrity, at UPMC health.
The reference point for the discussion was a report released in August by the Center for Connected Medicine, and co-sponsored by the Chicago-based HIMSS (Healthcare Information & Management Systems Society), entitled “Improving Health Care Interoperability: Are We Making Progress?” which is available on the CCM’s website.
As that report states in its introduction, “Health care’s interoperability challenges have become a major focus for health systems, government regulators, tech companies, and others who recognize that the ability to easily share, consume, and analyze data is essential to improving health care for all involved. Yet, despite this recognition and growing attention to the topic from all corners of health care, many stakeholders continue to struggle with interoperability. To better understand the challenges, the Center for Connected Medicine (CCM) partnered with HIMSS Media to conduct survey research of health systems and hospitals in June 2019. The survey focused on how well health care organizations are prepared to advance interoperability, how interoperability challenges are impacting organizational priorities, and how effectively these challenges are being addressed. Starting on a positive note, the survey found that a majority of respondents are aligning their technology plans with interoperability objectives and adequately addressing technical and non-technical aspects of interoperability. But only 69% said they are effective at sharing data within their own organizations. And fewer than four-in-10 said their organizations are successfully sharing with other health systems.”
Further, the report notes, “This obstacle is standing in the way of key organizational goals, including enabling patient-facing apps, tapping into unstructured data, and reducing the cost of care. That last point is worth highlighting. It should be troubling that only 27% of respondents said their organizations’ work to improve interoperability had allowed them to reduce the cost of care. It is well known that health care costs are a chief concern of patients and employers – both of whom are weary of ever-rising premiums and out-of-pocket costs. At the same time, the opportunity to introduce greater efficiency into health care is driving some large tech companies, which have successfully disrupted other industries, to make moves into health care.”
“I want to begin with the premise that interoperability is a verb and not a noun,” Chopra said near the outset of the discussion. “Under the Obama administration, we published a number of documents, focusing on it as a verb.” Chopra referenced a slide that appeared for the webinar audience that showed the following, with regard to directed exchange, query-based exchange, and consumer-mediated exchange:
Ø Directed exchange: the ability to send and receive secure information electronically between providers to support coordinated care
Ø Query-based exchanged: the ability for providers to find and/or request information on a patient from other providers, often for unplanned care
Ø Consumer-mediated exchange: the ability for patients to aggregate and control use of information
With regard to all three types of data and information exchange, Chopra said, it was the Obama administration’s idea to “promote interoperability as a verb.”
Then, turning to Humana’s Cox, Chopra said, “Heather, you’re on the plan side, and relatively new to healthcare; what’s your perspective on where we are on interoperability on day-to-day basis?”
“We’re best known for being a plan,” Cox replied; “but we have a very large care delivery networks, and are in the provider space in terms of our networks and our home-based care delivery services. In terms of the state of play in general, it’s not a great situation that we face today, and I think the survey says it all. I appreciate what the Center for connected Medicine is doing to put the data out there on the state of the state.”
Cox continued, “The idea is where we want to be. Aneesh, you’re familiar with what we stand for, which is that the consumer needs to be not only in charge of the data, they need to own their own data. And we need to be advocate for the free flow of data across and through the system. And that will cause a lot of headaches and concerns for those in the system, but it’s the right place to be. It will be a forcing function for [interoperability]. It’s why I joined the fight for healthcare.”
“Do you feel that [the transition] is similarly painful across all three dimensions—care delivery, the post-acute world, and the plan world?” Chopra asked.
“There’s the hype of interoperability, and then there’s the reality,” Cox said. “Progress has been made in various parts of the healthcare system. There are places where it’s nascent, and where organizations are leading. Document-sharing exists in some places in the ecosystem, and real-time data flow exists in some places. If you’re one of the scaled providers, and you have a closed ecosystem, you’re doing some amazing things at the point of care. Instead, if you’re one of the incumbent plans, you might be forced to deal in the world of claims with lagged data flow. We’ve got to even the flow of data across the healthcare system, to support all the patients who are flowing in and out.”
Perspectives from the evolution of interoperability across other industries
“I’d love to flip to Kristian and Steve,” Chopra said, turning to UPMC’s Dr. Feterik and Nokia’s Vogelsang. “This really is about the U.S. policy around how industries collaborate around standards. In the U.S. model, the U.S. government’s capable of scaling standards, and mandating interoperability in various industries, but it cannot dictate what the actual standard is that we should adopt,” Chopra said. “And one of the vexing problems in HC going back decades is that we have many standards and competing interests, and certainly at the beginning of the Obama era, we didn’t have the one standard to rule them all and drive [compliance]. At the beginning of the 20th century, when the U.S. aircraft industry was struggling, the then-Secretary of Commerce Herbert Hoover asked why we couldn’t improve production? And it was largely standards. We couldn’t build engine cowlings or airfoils.” Later, he said, “The DC-3 and Beoing747 shared a common set of standards. And the federal government invested in” collaborative development. “Steve, could you share a bit about your perspectives on industry standards?”
“Yes, in fact, I can give you a couple of different approaches,” Vogelsang said. “If you think about the global mobile[telephonic] network that’s been built, you can now take your smartphone and travel everywhere across the world—that’s built on the back of the International Telecommunications Union, which defines how you connect to the network and networks connect to each other. That’s an example of a single standard being developed. I’ll contrast that with the Internet, which isn’t like the ITU. But there is an Internet Engineering Task Force that gets together to consider ideas on how things might work, but if you have [a model] of our how to build an Internet protocol network, you build that format, and over time, if enough people use the same protocols, it becomes a standard.”
“We don’t have an ITU for healthcare, for a number of reasons,” Chopra noted. “Kristian, you live on the ground, dealing with these issues at UPMC every day. Tell us about the current state of play, and can you then contrast how the telecommunications and Internet worlds work, to the [interoperability situation] in healthcare?”
“The average physician wouldn’t care where their data was coming from,” Feterik said. “And while it’s great to see we’re moving forward collaboratively in terms of telecom, for example… in healthcare, it’s been crucial for us to fortify our operations and back end systems to help our physicians to deliver quality care. They don’t care about source, but they do care about speed. Also, what we’ve seen recently, the second Blue Button conference. When we were in the midst of trying to advance the airplane industry and the development of aircraft engines, we do not want the government to tell us which standards to use, but we could use facilitation from connect-a-thons sponsored by ONC [the federal Office of the National Coordinator for Health IT], where we can all figure out what works, and can exchange data substantively.”
Who’s moving first to create the new interoperability in the health plan world?
Per that,” Chopra said, “last week, HHS [the Department of Health and Human Services] hosted a summit on the social determinants of health, and one of Heather’s colleagues participated. With regard to that, among the interesting opportunities around interoperability has to do with the FHIR API standard”—referencing the Fast Healthcare Interoperability Resources standard—“which allows for a new era of interoperability that’s less about machines talking to other machines in the background, but rather, it allows apps that physicians can control, that nurses can control, that patients can control. And one of the interesting examples of this is that the state of North Carolina made a policy decision that they should screen every Medicaid beneficiary for social indicators, such as difficulty accessing food. The old model would have required one vendor hired by the state to deposit their software across the state; here, the NIH at no cost had been publishing a Survey Monkey-type tool for social assessments, and configured it for the social determinants of health, so that any organization can download and use this free app, and connect it to this open-API infrastructure.”
Referencing the Blue Button Developer Conference held at the White House on July 30, Chopra said, “The idea of the Blue Button Developer Conference is that CMS wants to make CMS information available to everyone—so that beneficiaries can access their MyMedicare.Gov account and use it. They’ve announced that they’ve extended that access to ACOs, and now, it’s available to any doctor in the country who has a treatment relationship with a patient to use that at the point of care. Heather, can you speak to the announcement that you made on stage?” he asked.
“That announcement was around the willingness of plans and providers to exchange data and make sure we’re opening up the ecosystem as fast as we can, ahead of any mandates,” Cox replied. “In the spirit of moving this along before we’re actually required to. And we were one of the few plans who stepped in. And it’s among big tech companies, a few provider systems, and a few plans, so we’re super-excited about the potential, but we have a significant amount of work to do, the self-organizing principle isn’t as easy as you’d like it to be.”
“Back in February, CMS extended some of the requirement that had been put in place for providers under the meaningful use program,” Chopra noted, “and said, we want to extend this to all government-sponsored plans. In fact, it was the first time this interoperability requirement would be extended to plans, and for them to meet the requirements as early as January 2020. And the vast majority of stakeholders, primarily plans, said, holy moly, this is hard, and we can’t do this. But Humana wrote a slightly different letter.”
“Yes, this was related to the mandate that by January 1, 2020, individuals could ask their data to be transferred in and out of a plan,” Cox said. “Our answer to that was that it will be challenging, but we will make sure to be ready by Jan. 1, 2020. Just a few others said they would do the same. But we made October 1 our goal. We have the capability already now, but don’t yet have people to test it with. We wanted to prove to ourselves that we could get things running internally, and we do. So this announcement at that Blue Button developer coreference was the next step: if we have the opportunity to open up the system and create ease of use for our members, what a great way to open up the ecosystem. And let’s start reducing the costs that we’re passing along to the end-users, because we can’t continue on the path that we’re on.”
Scaling interoperability up across healthcare
“That provides us with a great segue in terms of going from individual encounters to bulk,” Chopra said. “I want to bring Steve in on the telecommunications analogy. The information-blocking rule basically says, if you’re a consumer app, you’re not allowed to charge the patient or app they trust to use the data. However, if you want to extend that capability for use in bulk—a health plan seeking information from a hospital or vice-versa, the rule allows for fees, but those fees have to represent some real cost. I regard this as an extension of the old net neutrality regime. Steve, do you have comments on the information-blocking rule, and the implications for the industry? And Kristian, what does that end up looking like at UPMC?”
“Yes, the basic idea is that all traffic to and from an entity should be treated neutrally; and that’s the Internet, an open system that allows applications to run freely,” Vogelsang said. “And if you’re building one of these networks, you’re always looking for ways to monetize value. With net neutrality, the idea is that you have to find other ways to create network services, rather than restricting the flow of the data to create value.”
“The idea that the data is seen as valuable, but you have to find other ways to monetize it—Kristian, how have you thought about that in the context of the data aspects, where every stakeholder has the conception that the economic value is in the data?” Chopra asked.
“As in many examples in HC, we have two camps,” Feterik responded. “In one camp, those who believe that the information belongs to the patient, and that everything in a patient’s chart should be available to the patient at no cost. At the same time, you have people who would say, you know what? There is some cost to storage, and there should be a fee associated with it. But cost of storage is constantly declining, and our data management capabilities are improving in efficiency, and the data belongs to the patient. In terms of bulk exchange, if a hospital is sending bulk data to a payer, perhaps we should be looking at other capabilities, such as health information exchanges?”
“I just want to give a big hug through the line here to Kristian!” Cox exclaimed. “I agree: it’s the impact of the data that can be the value. There is value in what we can give back: it’s the insights we can give back, such as speeding up prior authorizations or payments. So that we can move that data as fast as we possibly can, for that patient, for that member, and take friction out of the system. And what you should know about us as a company, yes, we are an insurance company, but as Bruce Broussard says, our mission is to become a health company with insurance in the background. Insurance is what we have to do to get the system to function for people. In a world of aging and longevity we’re here to keep people in their homes and functioning longer and show up at their granddaughters’ great-granddaughters’ weddings.”
“I agree,” Feterik said, “the data belongs to the patient, and we need to give patients the tools to access it. The other thing you had announced at the Blue Button Developer Conference… if we’re able to enable those standards for the bulk exchange of data between providers and payers, no matter how we get the data to you, that’s going to mean a lot.”
“And that’s why I’m so bullish on the idea that we’re at a tipping point,” Chopra said. “If you accept the premise that the consumer has the right to the data and it’s theirs, independent of how we sort out the exchange of data, the power to the patient concept gives the community an obvious roadmap for the development of engineering standards.”
The industry conditions needed to trigger advances forward
A bit later in the webinar, discussion ensued regarding what industry conditions could trigger progress on developing the development of standards-based APIs (application programming interfaces). “When you have agreement on the supply side of standards, it creates the conditions for applications to scale, to drive end-user adoption,” Chopra stated. “Steve, what’s your view? Phones have been a pretty big driver of the adoption of standards in telecom, per smartphones. The importance of driving applications towards standards? What does it mean to see an ecosystem evolve?”
“I would again put this into two buckets,” Vogelsang said. “Getting the devices connected is the first challenge. We’ve been focusing at Nokia on getting the devices connected in a reliable way. That’s what 5G is about: we want to connect not only your personal devices, but also industrial devices, which in HC would be imaging machines, and mobile lab equipment, and have a very robust set of standards to connect the data into the network. We’ve been very focused on that. The other piece is the Internet and the IP networks themselves. You start thinking about moving bulk data across networks, security is always a huge concern. How do you tie all these systems and networks together in a secure and robust way? We’ve also been focused on that.”
“Steve, it’s really wonderful to hear that, I one-hundred percent agree with you,” Feterik said. “Heather had mentioned home-based care, and it’s not just about mobile phones, but devices that can monitor patients’ conditions in home, and we would need robust networks for that, to allow for the flow of that information.”
“I absolutely agree,” Cox replied.
Later, Chopra referenced another slide in his presentation, one that showed not only a few large integrated health systems, but also a small podiatric physician practice having connected the Apple Health solution to its patients.
“Community Health Systems is at the opposite end in terms of scale” from Family Foot Care of Texas, Chopra said. “And they created a layer, a common layer, above the EHRs, as a single point of connection to Apple Health. And once you’ve agreed it’s not a Betamax-VHS problem, you can move forward. Heather, any perspective on the complexity of migrating towards APIs? You were able to go live October 1. These standards haven’t been around that long. How did you go so fast?”
“We had an initial path, just as any large organization would, with a long timeline, big paycheck, and a lot of complexity. But if you approach it the way a modern technology organization would, it actually took a relatively small team, several weeks, and a small check to cover it. And so this took a relatively short time, even for a large, complex organization like ours. With the tools that exist today, you can move with speed and agility and deliver an appropriate product in HC. So we’re very exited, to leverage interoperability and the FHIR standard combined. It’s about getting everyone moving at the same place. The problem is that the FHIR standard is one thing, but there are different versions of FHIR, and we have to get to exactly the same standards. The problem right now, quite frankly, even with Apple Health Kit, it’s an older version of FHIR than what CMS is requiring, and it’s hard to backwards-integrate into what’s out there on the current Apple Health Kit.”
Peering into the future
Somewhat later in the discussion, Chopra said, “I do want to have a little bit of a discussion around the technical aspects. So let’s get to this one technical piece. It does seem to me we could offer a little bit of technical advice. There is this evolution upon us. As you did that work, Kristian, to turn on those six systems, with their various applications,” he said, referencing systems integration work that Feterik had helped to lead at UPMC, “as a technical matter, in the world of APIs, I do believe we’re witnessing a moment where organizations that will be involved in this will have to simplify their infrastructure. As we move from the Blue Button, and consumer-first technology, we might be able to scale that infrastructure up to scale. And I call that ‘Blue Bar.’ And the Blue Bar allows the decision as to which applications access your data, assuming the data model is a comment standard. And we have FHIR version 2 in production across hospitals and health systems right now; eventually, we’ll move to version 4, and health plans will ultimately start with version 4, so we’ll have a few version control issues. But assuming you had a universal ‘Blue Bar,’ I believe that we could configure that Blue Bar to manage consumer needs, and also allow a health plan and a health system network to collaborate together—that we could use the common infrastructure to accomplish this. Steve, have you thought about simplified architecture as a way to move across complex, diverse infrastructures?”
“I think this is a great approach, to use APIs and an API gateway, as a secure way for different entities to access data,” Vogelsang said. “We’ve used that in the telecommunications world, for telecom roaming for consumers on their smart phones. We’ve done these types of things; this is a more complicated area, because of the complexity of the data involved, but this is very promising.”
“Yes, if you’re roaming, you need to know where your contract is, etc.,” Feterik said. “There are some similarities with healthcare.”
“Yes, I think there’s a lot of promise to achieve similar things in the healthcare industry,” Vogelsang said.
“I think this is basically what we’re contemplating, and it would help to have the industry to align sooner rather than later,” Cox said. “And I do like the comparison to the telecom industry, and I do like the handshake concept; that could actually maybe get people over the hump around why they should buy into it.”
And, with regard to the broader implications of these advances down the road, “There was slide published by the Commonwealth Fund that envisioned the future of digital health advisers, and which targeted the high-need, high-cost patients, and caring for these individuals,” Chopra said. “And the spirit of this is that if we can liberate the data and enable decision support, there could actually be an empower philosophy here, that no matter who you are or where you live, you should have the same empowering data to help you. So we get everyone on the same architecture, embrace FHIR APIs, and create a common [technological layer], that we can move forward.”
“From a cultural perspective for the industry, we’ve got to get to the same versioning control sooner rather than later; that will help us get there faster, and then at the same time, aligning to the same architecture,” Cox said. “There’s also everybody getting to the same mindset sooner rather than later. Let’s all opt in, in order to drive better outcomes and drive down the cost of care. This is why technology holds so much promise. Let’s get there sooner, and together. And as a newcomer to this industry, I don’t like that the government is telling us what to do, that’s a shameful place to be. I’d rather have the government be a partner. We have the tools and technology to drive digital transformation, so let’s grab the bull by the horns here, and do it.”