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1
Overcome Challenges/Obstacles to Achieving Interoperability
Session #86 Tuesday, February 21, 2017
Kathleen Sheehan, Program Director, Universal Health Services, Inc.
Sindhu R. Kammath, MD, Clinical Informaticist, Universal Health Services, Inc.
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Speaker Introduction
Kathleen Sheehan, Program Director Acute Care Division
Sindhu R. Kammath, MD, Clinical Informaticist
Universal Health Services, Inc., founded in 1979, 240 facilities in US, Puerto Rico, the US Virgin Islands and the United Kingdom with over 70,000 employees. The focus of today’s topic are the UHS acute facilities, meaningful users under the EHR Incentive Program.
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Conflict of Interest
Kathleen Sheehan and Sindhu R. Kammath, MD
Have no real or apparent conflicts of interest to report.
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Agenda• Learning objectives
• Realized IT benefit STEPS baseline
• Introduction
• Interoperability overview
• 1st generation challenges
• 2nd generation challenges
• Next generation
• Conclusion
• Anticipated IT benefit STEPS
• Q&Q
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Learning Objectives
• Compare and contrast current CMS and ONC interoperability specification to
present-day challenges of deriving value from interoperability of health care
information across the continuum of care
• Identify and create awareness of policy, design, implementation and
adoption gaps of interoperability of health care information in its current state
• Propose more inclusive and less restrictive ways to improve the exchange of
health care information across the care continuum
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Interoperability Overview Cont’d
The HIMSS STEPS Framework Current Realized IT Benefit
• Provider Satisfaction with the eSoC/CCD
– Organization/Display/Format: 2.5
– Completeness of Information: 2.4
• Clinical/Treatment
– Relevance: 3.0
– Accuracy/Confidence: 2.5
• Savings
– Reduce Redundancy: 2.5
– Improve Practice Efficiency: 2.3
Scale 1=worst 5=best
Treatment
Provider Sat.
Treatment
Savings
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Introduction
• Interoperability is significant challenge
• Considered silver bullet
• $35.5 billion invested in healthcare IT since HITECH
• Groundwork has been laid
• Industry is positioned
• Let’s make it happen
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• Interoperability has evolved
• Foundational – the connection
• Functional – the standards
• Semantic – the output and use
Interoperability Overview
Foundational Functional Semantic
Interoperability Pillars
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Interoperability Overview Cont’d• We have first-hand experience
• Eligible hospitals – 24
• Eligible providers – 200+
• UHS’s acute division CA, NV, TX, FL, OK, SC, DC
• CEHRTs - 11 down to 8
– Ambulatory providers: 4 vendors (started with 7)
– High-Specialty providers: 2 vendors
– Acute hospitals: 1 vendor
– CAH hospitals: 1 vendor
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Interoperability Overview Cont’d
• Evolving
• 1st generation – proprietary
– Secure Email
• 2nd generation – commodity
– Federated model
• Next generation
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1st Generation – Challenges
Hospital
Provider
Home Care & Hospice
Behavioral
LTC/Nursing Home
Other Community Health
14,0001
16,4001
50,6001
5,5641
92,1112 EH Adoption Rate: ~ 90%3
EP Adoption Rate: ~ 59%
1AHA as of 20142Kaiser Family Found3HealthIT Dashboard
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1st Generation Challenges – Cont’d
0% 0%
17%19%
25% 26%
30% 30%
0%
5%
10%
15%
20%
25%
30%
35%
CEHRT1
CEHRT2
CEHRT3
CEHRT4
CEHRT5
CEHRT6
CEHRT7
CEHRT8
Spec Spec Amb CAH Amb Amb Amb Acute
2016 P
erf
orm
an
ce
HIE 2016 Performance by CEHRT
• CEHRT adoption rates of EPs hinders performance
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1st Generation Challenges – Cont’d
• Secure email (Direct) source of exchange
• Ease of use
• 3-point patient matching is weak
• HISPs don’t publish secure email addresses
• HISPs marketing exchange capability to non CEHRT providers
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1st Generation Challenges - Cont’d
Stage 2 Meaningful Use 2014 edition
• Patient Name
• Demographics
• Smoking Status
• Problems
• Medications
• Medication Allergies
• Lab Results
• Vital Signs
• Procedures
• Care Team
• Immunizations
Stage 3 Meaningful Use 2015 edition
Changes
• Removed
– Care Plan w/Goals & Instructions
• Additions
– Implantable Devices
– Assessment & Plan of Treatment
– Goals
– Health Concerns
The minimum requirement
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• Four examples – pinged our markets for samples and received four
• Let’s look at the information relative to these characteristics
– Visual display
– Usefulness
– Relevance
– Content and volume of data
– Accuracy and confidence
1st Generation Challenges – Cont’d
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1st Gen Inbound CCD Example #1
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Outbound CCD Example #2• 32 pages of information 2009 to 2016
• 52 medications - active, discontinued and expired meds
• 30 sets of vital signs
• 15 procedures not sorted by date
• 20 pages of lab results
• 8 pages of 315 diagnosis codes
• A second 4 page document containing H&P and progress note had to be sent
Procedure history
Vital Signs
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Inbound CCD Example #3
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Inbound CCD Example #4
Table of Contents Reason for Referral
Encounter Details
Active Allergies and Adverse Reactions - as of 10/20/2016
Current Medications - as of 10/20/2016
Active Problems - as of 10/20/2016
Resolved Problems - as of 10/20/2016
Immunizations - as of 10/20/2016
Social History
Medications at Time of Discharge
Plan of Care
Results
Visit Diagnoses
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• 4 examples Key Takeaways
1st Generation Challenges – Cont’d
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1st Generation Challenges – Con’t• Another example of unintended consequences of
the stimulus model
• Fragmented stores of health info
• MU example – each EP/EH has a portal obligation
– I have PCP and need 3 specialist referrals -all MUsers but do not share CEHRT. I get outpatient testing at two hospitals who are Musers but don’t share the same CERHT.
– I now have 6 portal accounts. ? ?
Card
.PC
P
GI Opt. Hospital
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1st Generation Challenges - Conclusion
• The health record is piecemealed, fragmented
• Pieces of health info are pushed from EHR to EHR, or EHR to portal each storing parts
• Where to get the full story or the right info? What source is best?
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2nd Generation Challenges
• Industry readies for Stage 3 with improved exchange mechanism
• Federated models decentralize interoperability and information sharing
• Moves healthcare from proprietary to commodity-based model
• Query-based pull model
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2nd Generation Challenges – Cont’d
• But…federated model membership is voluntary
• Again barriers
• Ideal only if membership is all inclusive
• What if my community has partial enrollment from CEHRT vendors?
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Next Generation
PP
P
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Next Generation – Cont’d
• Imagine I control my health record
• It resides in a single place
• There are no missing pieces
• It is intelligent
• It organizes, files, prepares, displays, self-corrects, reconciles, archives
• It evaluates information on context; stores and represents based on relevance
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Conclusion• Many providers not eligible for incentives across the continuum;
deal with incomplete non-digital records.
• Patient portal confusion
• Health information is piecemeal in various EHRs – how to get what I need now to care for patient?
• Federated models advance the flow of information, we need a more standard organized document.
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Stage 3 Anticipated Benefits for the Value of Health IT
• Provider Satisfaction with the eSoC/CCD
(Scale 1/worst - 5/best)
– Completeness of Information: 3.0
• Clinical/Treatment
– Relevance: 3.5
• Savings
– Reduce duplicative testing: 3.75
Provider Sat.
Treatment
Savings
29
Questions
30
Evaluation• Please complete evaluation forms