What kind of interoperability governance framework is key to the transition to a FHIR API landscape? During a recent HL7 Da Vinci Project roundtable discussion, several stakeholders described the underlying data governance processes that are helping them make the transition from legacy approaches to data sharing.
In 2018 the Da Vinci Project was born as a multi-stakeholder effort led by payers, providers and health IT vendors to address use cases in value-based care. One goal is to cut down on custom one-off work between payers and providers, and reduce the need for unique solutions. Use cases include Data Exchange for Quality Measures and Coverage Requirements Discovery.
Charlotte Morris is the data governance program director for MultiCare Connected Care, an accountable care organization in Washington state. She started by noting that data governance is really a journey, not a singular destination. “It's not just something you check the box and move on. We started formalizing our path on this journey many years ago. We're adding standards such as DaVinci, as well as some more complex processes and technology along our pathway to maturity, which is an ever-evolving thing, because it's a very iterative process.”
Morris defined governance as the process of managing and improving data for the benefit of all stakeholders. “That's the whole concept. It's really simplistic, but yet the complexity underneath it is huge,” she added.
The MDM Institute definition describes it as orchestration of people, processes and technologies to enable an organization to leverage its data as an enterprise asset. Morris and other speakers used a musical analogy. It is an “orchestration bringing all the siloed pieces in groups together. You have instruments doing their thing and playing solos, but how does it sound when you put it together? It's really that nuance of having it all fit nicely together and come out with a complete vision and sound for the organization,” she said. “At the core of our governance journey is really relationships. The rules and policies and standards don't work if you don't have the relationships built in, because the business partners are where it's at,” she said. “They're the ones that design and enforce and monitor all of that information.”
Her team routinely engages leaders and subject-matter experts throughout the business units. “We set up that cadence so that we're always in touch with them so that we can meet and not only guide where we're going, but decide on the fly what has to be done immediately and prioritize and reprioritize,” Morris explained. “We use advisory councils, both in population health and within our own ecosystem, if you will, for the healthcare system, because we have a lot of independent practices that are part of us. We also have acute care hospitals, and many, many clinics. With the Enterprise Data Governance along with population health-specific data governance, we work together and it comes together in concert. We establish weekly stakeholder meetings, so that they all serve as a governance team, and they're all accountable for the decisions and become the champions of the work. They're our allies who have partnered with us to remove barriers. They're genuinely invested and excited to be a part of the story that we're creating.”
These governance groups forge the path to becoming a highly reliable organization, Morris said. “We know that takes really four main components: we first have to develop the actionable fluid data that leads to downstream improvement, which includes clinical decision making and patient safety. Then we have to have to create this space where there's data agility that can quickly and efficiently support a multitude of situations that arise. If that data is agile, then we can really use it to pivot and do what we need and answer questions that enables this semantic interoperability level, where that data retains its context and the meaning, which is essential for this last piece which is a huge pillar in our world. High-quality data with shared structures, and a common language is what Da Vinci is all about. So that is how we have stood up data governance at MultiCare, and we have a long way to go on our journey. But it's all about evolving and trying to reach that maturity path.”
In one use case, MultiCare and Regence Blue Cross Blue Shield focused on medication reconciliation. It enables MultiCare to send proof that a patient’s medication history had been verified upon hospital discharge. This data is submitted daily and directly to Regence, with the goal of reducing administrative burden, costs and improving quality. This reconciliation is often conducted during transfers of care as an important value-based care quality and patient safety measure.
In another use case, Regence is working with MultiCare Connected Care to implement a FHIR-based approach to share key information needed for member attribution in value-based arrangements.
Governance at UC Davis Health
Michael Marchant, director of health information exchange at UC Davis Health, said that as a first step, you have to think about what skills, technologies and processes you have in place to support legacy interoperability. That will help you get from where you are today to where you need to be to support the more web-friendly architecture, with a different technology and a different triggering mechanism for requests and responses to data that may be outside of the norm of what your staff is dealing with today. “You really want to make sure your staff is well trained, and they have the resources that they need, and they understand the goal of the change,” Marchant said. “At our organization I've been talking about FHIR APIs since the summer of 2019. You've got to acclimate, and people need to hear things a few times to understand the impact.”
He added that it is important to have workgroups tackling key issues. “A big one for us is legal or compliance, especially with 21st Century Cures and allowing patients access to data, or what Mickey Tripathi is now wanting to call the information sharing rule and not the information blocking rule. I'm trying to move to that nuance,” he said. “With this particular regulation, we want to make sure that everybody's on the same page in terms of what information is being shared, how it's being shared, what the impact is.” You need to understand which constituencies are impacted in your organization, who should be informed, and who should weigh in, Marchant added.
Part of being knowledgeable about what kind of governance processes you need to have in place for the future is really understanding what you what you have in place today, Marchant said. There are lots of different silos — parts of the organization that may be dealing with EDI or external transactions versus HL7 v2 transactions, or secure file transfer transactions. These are different groups with different technologies and different processes for governing, prioritizing those data interoperability technologies for your organization. “You want to make sure you have a good inventory of that — where date is, where it's going, how it's going there, as you make these transitions,” he said, “and it's clear to your organization what the impact is. If you look at it holistically for your organization of everything that moves from point A to point B and look at that possible transition from the legacy interoperability to the FHIR API technologies, over time, you really need to have that inventory. As we move forward with 21st Century Cures enforcement, which they haven't done to date, some of that could really impact organizations if they don't have everybody organized and working in concert to make sure those things are addressed.”
Some organizations are working on what they call a digital front door. “For us,” Marchant explained, “we're trying to build an architecture with a single entry point for our FHIR access for external partners. I like alliteration, so I started with partners, payers, patients, and providers. Essentially what we're trying to do is create an environment where we have a technology stack that, regardless of who you are or how you come in, we have a single entry point with role-based access to technologies on the back end and the data on the back end to make sure that that's an integrated approach, a standard approach, it's well thought out and really making sure that we're able to deliver all electronic health information consistently to any of those entities based on their role and their right to that access.”
Like MultiCare’s Morris, Marchant said having this technology stack in place means nothing if you don't have people in place to manage it. “They understand the architecture; they understand how these different technologies and the different input methods may be coming to you, and how you transition.”
The payer perspective
From the payer perspective, Michael Gould, business lead – interoperability for the Blue Cross Blue Shield Association, said that as a national association, it has a bit of a different role in interoperability than most health plans or provider organizations that deal directly with administering benefits or coverage or delivering care to patients.
Each Blues plan across the country is an independent entity and has to deal with the considerations of how they implement FHIR APIs for patient access and interoperability. The Association plays a consultative role, and can also influence governance by the relationship that it has with plans, and the expertise and the knowledge sharing that happens across the Blue Cross Blue Shield plans, Gould said.
In addition to participating in the DaVinci Project, the Association also participates in other HL7 FHIR accelerators such as the FHIR at Scale Task Force accelerator. It has worked to modernize its technology in terms of how it can govern interoperability among Blue plans, and between individual Blue plans and providers.
“Many of our plans have experts in these areas who handle things like reference data management and master data management,” Gould added, “but we also have the policy base with the Association that helps govern how things happen between and among plans. Understanding that Blue plans are really just a microcosm of the industry at large, we need to also work with the rest of the industry regulators and our provider community as well. And HL7 and the Da Vinci Community is an excellent place for us to get that going. We've seen how we've collaborated in regards that may not necessarily have been identified as interoperability governance, but that we're starting to find our way into it,” he said, “and that in the near future we can continue to formalize it.”