Will You Be Surprised By These Opportunities Within the CMS Interoperability Rule?

BookZurman has launched an exciting new video series where BZ President, Brian Book, leads a discussion with a BZ subject matter expert and a guest of their choice from the community.

In the first installment, Inside BZ: Hidden Dangers and Opportunities of Interoperability Rules, Brian Book speaks with BookZurman Chief Innovation Officer, Ioana Singureanu, and guest speaker Evelyn Gallego, CEO at EMI Advisors.

In addition to her work with BookZurman, Ioana is an HL7^SM FHIR^TM Foundation Founder, co-chair of health IT standards development organizations critical to the adoption of health IT standards consistent with the Center of Medicaid and Medicaid Services (CMS) and the Office of National Coordinator for Health IT (ONC) rules, co-chair of HL7 Conformance, HL7 Community Based Care and Privacy work group, and a member of the HL7 US Realm Steering Committee. She is an HL7 Fellow and a certified HL7 professional (HL7 V 2) and Oracle DB Administrator.

Evelyn Gallego, MBA, MPH, CPHIMS, is the CEO and Founder of EMI Advisors LLC. EMI’s mission is to deliver value-driven health data management advisory services to its government and commercial clients. EMI’s current projects center around the development of care coordination standards to support the seamless exchange of data as individuals transition from settings of care and services. EMI has worked on care planning standards over the years supporting federal health agencies. EMI has also greatly focused their work on the social determinants of health. In addition to defining data standards and policy, EMI provides boots on the ground implementation and technical assistance.

Below is an abbreviated and summarized overview of the conversation^[1], or you can watch the conversation in full here:

Brian Book: Why do interoperability rules matter so much, and why the sense of urgency now? 

Ioana Singureanu: We need overarching infrastructure that enables interoperability, rather than islands of information and standalone silos. It was about time that CMS (Centers for Medicare and Medicaid Services) looked at interoperability as a larger issue that supports different processes (billing, research, precision medicine, analysis). It’s important to approach interoperability from the ground up – not as a healthcare IT project that comes and goes. 

Brian Book: By leveraging health care IT standards, we can build infrastructure that allows people to more easily share information from one system to another without needing to create multiple interpretations to that data. So, why should provider organizations and healthcare IT leaders care? 

Evelyn Gallego: Until the HITECH Act, there wasn’t a driver … and then there was a rush to comply. Now, there are drivers including the shift from fee-for-service to value-based payment with outcome tracking of the care being delivered. This incorporates risk for providers if individuals come back into the health system. When it comes to data and interoperability, there has historically been no driver to ensure data moves seamlessly between disparate systems. Now, we have rules as part of these (federal) programs requiring the seamless exchange of data. Recently, there have been additional requirements for inclusion of data such as policies on exchanging data and what gets exchanged. Provider organizations must be thoughtful of what is being shared, when, and who they are sharing it with.

Ioana Singureanu: Unless you can measure outcomes, you can’t improve them. What’s in it for provider organizations? If they have a good handle on data, cost structure, and level of automation, they can improve outcomes. If not, improving IT systems can improve how they deliver care. This is a virtue of adopting interoperability. By adopting interoperability and replacing manual processes with automation, provider organizations can use information to make better decisions for patients and plan for capacity.

Brian Book: What opportunities come with 21^st century interoperability and complying with interoperability and information blocking rules?

Evelyn Gallego: With this comes more innovation in the market. Instead of having just one electronic health record (EHR) platform with all these capabilities, we’re seeing more solutions come into the market that support this data exchange and integration. There isn’t one size fits all, you can grow the infrastructure with different technologies and capabilities. Secondly, with more integration, you can provide lower cost interventions. One example of that is mobile phones, which can also be used as a tool to provide services and manage our own health.

Ioana Singureanu: To add to that, USDI is one element of infrastructure in coming up with core data that everyone must understand. There are also technical and standards infrastructure that must shape up out of this effort.

Brian Book: In the pursuit of outcomes and compliance to rules, do you think that provider organizations have the tools that they need to be successful?

Evelyn Gallego: The technology exists, but the challenge is people and processes—implementing into existing workflows, incentivizing providers to collect data in a standardized and structured way to exchange it with others, and for those that receive the data to actually use it. There still exists a barrier of providers accepting data that comes from the individual. Culture shift and education is still needed.

Ioana Singureanu: You need to approach the enterprise as a system of systems. Equipped with this, organizations adopt the technology in a way that makes them effective. An early adopter with know-how and wisdom does not incur all the risk of an early adopter.

Brian Book: How can the community leverage the current momentum to do more than just meet the bare minimum and to provide interoperability that is more holistic and delivers better outcomes?

Evelyn Gallego: In thinking about incentives that encourage providers and health systems to come together and share data, it is a significant driving force. The government did a fantastic job in gathering all the stakeholders first to have a top-down approach to solving the problem. Stakeholders that are even fierce competitors were encouraged to come together and agree on a solution so that when it does become a requirement, they’ve conformed it, it serves the greater good, and they are working toward the same goal. Even with standards, there are still ways that these entities can be competitive and innovative to set themselves apart.

Ioana Singureanu: We have to get to the point where vendors compete on features and capabilities but in a way where everyone is interoperable with common standards. And we can’t forget to look out for the interests of the newcomers to the industry; these new players in the marketplace can leverage this information and provide new capabilities.

Brian Book: In terms of social determinants of health, and knowing how important implementing specifications correctly is, is it difficult to find experts to create what is necessary for proper implementation?

Evelyn Gallego: Overall, there is perhaps a lack of FHIR experts in the market. The terminology work is new. While there is a lot of work out there on defining these terms, the challenge is the ability to apply that across health services.

Ioana Singureanu: It’s unavoidable that when you bring together so many moving parts (e.g., the API, LOINC, SNOMED, etc.), it gets to be very complicated; interoperability specifications and managing those moving parts can be tricky. The bad news is that since FHIR is so new, the risk of implementing FHIR is still very high. The good news is that we know what practices make for a successful implementation. We know how to do this well and how to do what it takes. In new projects, we are developing best practices as we go and we hope to see a convergence of best practices amongst these projects.

Brian Book: First wave users are going to consume the few implementation resources in the community initially so when other users come around, the resources will not be available and they will have a back log of unpaid and denied CMS claims. Are there other hidden dangers for the rules and provisions outside of a lack of expert knowledge in the community?

Evelyn Gallego: From a social determinants of health perspective, as we start sharing data and making it interoperable, we need to make sure we aren’t creating health inequities with certain populations. Issues of privacy and security and exposure of data is another ongoing activity. We are able to access our flight information in an interoperable way, for example, I’m hopeful we can get to that point with our health and wellness data as well.

Ioana Singureanu: The data quality has to be very high. In the rush to adopt the technology, I’m fearful that the data quality suffers. We also may not be judicious enough on the burden we put on people who enter the data.

Brian Book: What can provider organizations do now to start to prepare for the standards implementation that is coming with the CMS rules?

Evelyn Gallego: Overall, it’s about education and outreach and being cognizant that it’s not one size fits all—What is relevant for a clinical provider may not be relevant for a community organization. The other part is workflow—this is not a common piece of the workflow.

Ioana Singureanu: I fear that consumers (providers) don’t understand yet what is included and what is possible, and how to take advantage of it and apply it to their organization. This comes back to a self-awareness and a self-assessment to identify where you need to go and what your priorities should be.

Evelyn Gallego: To add to that thinking—What is the business case for you to share data? Why would you want to implement this standard or why would you want to share this data? The business drivers across local implementations vary depending on where they are, what infrastructures they have, who their trading partners are, etc. The business case leads to the use case which leads to the technical requirements to adoption.

Ioana Singureanu: I think it will be possible that we will have a marketplace available using standards APIs. Other important questions to ask organizations are questions like, “What do you need to be more effective? What information do you need to optimize your care? What information is your EHR already collecting?”

Evelyn Gallego: These organizations also need to have rules, even internal rules, in place so that they have the compliance in place for adoption.

Ioana Singureanu: We want to help organizations think in terms of an interoperability assessment to determine where they are, their priorities, their capabilities, and how it is beneficial to them.

Thank you to Evelyn for joining Team BZ for this engaging discussion! We appreciate everyone’s passion and dedication to the work they do in the healthcare IT standards and interoperability community. Keep an eye out for future installments of this informal video series!

Want to join a conversation or have a topic to share? Let us know!

^[1] For the purposes of this article, responses are abridged and paraphrased.

BookZurman’s team of multidisciplinary, highly specialized experts continue to drive progress and innovation in the healthcare IT community. For more information on this and other work in the areas of standards and interoperability, informatics architecture or clinical decision support, follow us on Twitter and LinkedIn.