Through the HL7 Da Vinci Project, payers and providers are working to shift legacy document-focused data-sharing efforts to FHIR implementations. At this week’s HL7 FHIR DevDays virtual meeting, Cedars-Sinai Medical Center’s Ray Duncan, M.D., described the use cases his Los Angeles-based organization has chosen to prioritize with Anthem as part of the Vivity HMO and the heavy lift the transition involves.
The Da Vinci Project is a collaborative effort based at HL7 to standardized FHIR-based interfaces between payers and healthcare organizations, replacing legacy interfaces for sharing documents. The work product is being balloted by HL7 and becomes part of the HL7 FHIR standard.
Duncan, director of technology research and development at Cedars-Sinai, is a member of Da Vinci as part of Vivity, a virtual integrated health system that includes Anthem as the payer and seven large Southern California provider organizations — among them UCLA, Huntington Memorial, Cedars-Sinai, and Dignity Health. The Vivity clinical data repository is managed by a company called CareEvolution.
“Some use cases are very complex,” Duncan said. “We picked a couple to work on that required minimal build by the Epic application teams. We were able to work on integration issues in the background without changes to provider work flow.”
Nevertheless, he said, the validation of use cases implemented with FHIR against the legacy solution is pretty labor-intensive and complex. An implementation team requires a lot of skill sets. “You need database people, systems integration people, FHIR programmers, and clinical analysts,” Duncan said. “Our existing operational teams and governance processes really weren’t nimble enough for this. It would have taken a lot longer to go through the normal project channels, so this was primarily implemented by our technology R&D team.”
The first two use cases they tackled were event notifications for primary care physicians (PCPs) and Anthem quality measures. Duncan noted that Epic does has some provisions for doing event notifications between Epic customers, “but if one of our patients was seen at another organization that wasn’t using Epic, we would not hear about that,” he said.
He described the data flow: the encounter events from the CareEvolution repository are posted to a Cedars endpoint using FHIR. Cedars then inserts it into tables in its enterprise data warehouse, and does filtering on the events to make sure it doesn’t send things to PCP in-baskets that they don’t want to see. Then it delivers the notification to the PCP in-basket via a proprietary Epic service.
“We do quite a lot of filtering to make sure in-basket noise is not overwhelming for PCPs,” Duncan said. “We validate patient identity and check the member number, and make sure the encounter types we are notifying about are clinical encounters. We don’t notify for encounters such as preregistration or outpatient labs or patient imaging. We only send the notification to the PCP if they have seen the patient in the last three years. The filtering removes quite a few of the notifications.”
Quality Measure Use Case
One way that Anthem uses quality measures is to identify gaps in care and notify the care team of gaps that need to be filled. The legacy solution for this involved a real-time HL7 ADT interface from Cedars-Sinai to Anthem, with a clinical summary and CCDA document sent to Anthem several days after discharge, Duncan explained. The delay was programmed in to make sure that the discharge note was included in the CCDA. Anthem then processed the CCDAs to extract, map and code CCDA structured data while the narrative reports had to be processed by employees.
“We picked out a subset of Anthem quality measures for California to work on,” he said. Using FHIR, they built a driver table of Cedars patients with effective Anthem coverage and run an automated query for each quality measure on a daily or weekly basis depending on the criteria and time window Anthem is interested in. “After we marshall any new observations, we format them in JSON and push them to the CareEvolution endpoint over the Internet. We have done 14 quality measures so far, and there are plenty more to do. We chose ones that were relatively straightforward to implement.”
The Da Vinci HL7 documentation is only a starting point, Duncan stressed. “Until recently, it has been kind of a moving target and still evolving. Some of the use cases have been validated, while others are still being validated or are about to be validated. You have to keep a close eye on what is happening with the standard.”