It's clear that there's no easy way to share patient health data, but to turn to the last resort of heavy government regulation seems an ill-considered remedy.

Even though there is ample evidence that hospital providers themselves are the biggest source of information blocking, the inability for patients' electronic health records to follow them wherever they receive care, allegation persists that EHR vendors, Epic in particular, are a major part of the problem.

The Office of the National Coordinator for Health Information Technology brought fresh credence to this allegation in its April 2015 report to Congress. "As more fully defined in this report, information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information," the report states.

Should the Feds Fix Interoperability?

"In 2014, ONC received approximately 60 unsolicited reports of potential information blocking. In addition, ONC staff reviewed many additional anecdotes and accounts of potential information blocking found in various public records and testimony, industry analyses, trade and public news media, and other sources," the report says.

It found a wide variation in fees charged by a number of EHR software providers to permit information to flow to and from their EHR software. Perhaps it comes as no coincidence that the same month that ONC issued its report, Epic announced it would waive its transaction fees for information flow, and Cerner announced it would waive similar fees to exchange data through its connections to Commonwell Alliance through the end of 2017.

Recently, I became aware of a new freely available exchange between Epic and Yale-New Haven Hospital, about six months ago. The hospital, which runs Epic, now integrates the Athenanet network with Epic's CareEverywhere record-sharing network.

Implementation is 'Challenging Work'
Today, Yale-New Haven Hospital physicians are able to see Athena-generated CCDs appear in CareEverywhere's list of organizations containing CCDs about the patient in question (albeit listed under "other organizations," rather than "Epic organizations").

"Implementing these large, integrated EMRs and making all the connections is challenging work," says Daniel Barchi, who until Monday was chief information officer at Yale-New Haven Hospital. (Today, Dec 1, is his first day as CIO of NewYork-Presbyterian Hospital, taking the place of retiring CIO, Aurelia Boyer.)

After Yale-New Haven started rolling out the Epic EHR in 2011, "and finally being up on all of our sites and physician practices in 2014, then we turned our attention to this type of interoperability, so it's not a conscious decision not to have done it before this," Barchi says.

He takes issue with a Politico story quoting him as saying that Epic is the de facto health information exchange for the state of Connecticut. In an email he sent me after our conversation, Barchi clarified:

"I said that HIEs have not lived up to their promise and that what we did at Yale New Haven Health was to leverage all of the tools we have available (HIEs, APIs, interfaces, shared access to the EMR, patient portals, and data sharing through the EMR) to share data."

"It's just now that we and other health systems around the nation are getting to this important work. It's because we really believe that the data is the patients', and we are merely stewards of that data, so if you believe that the data is the patient's data, and we're responsible for protecting it and then giving it to the people who need to use it to care for those patients."

Although Barchi does not yet have data on how many records have flowed specifically between Epic and Athena at Yale-New Haven Hospital so far, overall, the hospital has shared 131,000 patient records in the past 12 months, with more than 500 healthcare institutions across the U.S.

Patient Consent Required
"It's also important to reinforce the point that you've made that there is no easy way to share data," Barchi says. "Everywhere that you share data takes work, and it's people who are building interfaces or making the API connections, and then maintaining those. So we all wish that it was easier and more secure. Because it's not, it's upon us to do the work by building these interfaces and making these API and FHIR connections, and then maintaining them and watching to make sure that they're safe and secure."

The patient experience of records which flow slowly (if at all) is also distorted by patients' own lack of understanding that data does not flow unless there is patient consent first. A friend of mine was perturbed recently to learn that in order to get his Epic-based medical records from the Cleveland Clinic to Kaiser Permanente, he had to go not to his doctor, but to Kaiser's medical records department, to sign some consent forms.

The good news is, that once patients sign the consents, and once initial connections are established, as in the case of Athena-Epic, data then continues to flow without further patient consents being required.

Also worth noting is the fact that Epic has already enabled similar sharing with rival EHR brands eClinicalWorks and Greenway Health. It's also interesting to note that Epic and Athenahealth (along with Cerner) garnered top ratings in KLAS' inaugural interoperability report released in October.

I wish I could believe that podium-pounding elected officials in Washington haven't sometimes reduced this issue to a political one, but stories like Yale-New Haven Hospital's, and my friend's, have me believing that this issue sometimes has been over-simplified for political gain.

The danger remains that Congress will insert some sort of blunt instrument into legislation such as the 21st Century Cures Act, putting regulations in place even as the need for such heavy-handed legislation appears to be in question.

I do believe that patients and all providers need to continue to push and challenge each other to understand the underlying issues that made 2015 the Year of Information Blocking and What To Do About It. As I've noted, someone has to pay for health information exchange. In addition, the final shape of the nation's EHR-sharing networks remains more of a rough outline than a clear roadmap.

One final point. Nothing I've said here means we don't have to watch the behavior of players who wield a lot of market making-or-breaking power. That applies to technology players as well as to healthcare players. I hope that the more freely information flows, the more educated patients and physicians alike can become, and the easier it will be to take their business where they wish without interoperability issues being an impediment.

To a certain extent, the standards set forth in meaningful use stage 2, notably the Continuity of Care Document and the Direct messaging protocol, appear to be proving increasingly useful to the soaring amount of sharing now occurring. More needs to be done, but to turn to the last resort of heavy government regulation seems an ill-considered remedy at this point.

While it has been an elusive goal for years, the costs associated with not having standardization are mounting and "interoperability is becoming the main act" for healthcare leaders, says an HIT expert.

This article appears in the November 2015 issue of HealthLeaders magazine.

Interoperability of electronic health records and other healthcare IT systems remains elusive. Healthcare organizations clamor for it and the federal government voices support, but until very recently providers and vendors have lacked incentive to do more than create isolated networks. Yet many providers around the country are creating their own workarounds to achieve at least partial interoperability. These efforts take a lot of work, but technology leaders undertake them in pursuit of cost savings and patient safety.

The Institute for Electrical and Electronics Engineering defines interoperability as "the ability of two or more systems or components to exchange information and to use the information that has been exchanged," and that is the commonly agreed-on aspiration of all stakeholders in healthcare.

"There is a cost for the lack of standardization and the lack of interoperability," says Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI, who is chief medical officer and president of clinical services for Nashville-based Hospital Corporation of America, which includes 168 hospitals and 113 freestanding surgery centers in 20 states and England, and reported revenues of about $37 billion in 2014. "Organizations, ours included, are compelled to create workarounds to make different devices or different information systems share the information. We need standards that get us to plug-and-play."

In April, at the request of the U.S. Congress, the Office of the National Coordinator for Health Information Technology (ONC) issued its Report on Health Information Blocking, which concludes, "based on the evidence and knowledge available, it is apparent that some healthcare providers and health IT developers are knowingly interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and health care."

The result of so-called information blocking, which has become a cause célèbre, is an additional layer of data charges.

"Clearly, the support that the government provided created extraordinary investment in health IT with the promise and the aspiration that information would flow along a superhighway to follow and inform patient care," Perlin says. "The promise was a superhighway, not a toll road."

Beyond the road map

The ONC is focused on this problem with its 10-year interoperability road map, initially released in January. But it is difficult to pinpoint just how much the lack of more seamless interoperability is costing U.S. healthcare. Health system executives are unable to produce a firm dollar figure, and various reports tend to lump interoperability costs in with the rest of the higher costs that uncoordinated, fee-for-service care imposes upon the industry.

A Robust Health Data Infrastructure, a 2014 report prepared for the Agency for Healthcare Research and Quality by JASON, an independent scientific advisory group, estimates that if data mining and predictive analytics could work on interoperable health information, it should be possible to reduce significantly the estimated $60 billion–$100 billion of annual healthcare fraud in the United States.

And perhaps more important, the report states that "the data also will contribute to improved understanding of the economics of healthcare delivery, both in the aggregate and for particular instantiations that either outperform or underperform the aggregate in achieving beneficial outcomes."

Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, aims to reduce the over-ordering of tests and procedures. "Think of interoperability as being a key way to reduce the extra ordering of tests," says David Allard, MD, chief medical information officer of Henry Ford Health System, a five-hospital system whose flagship Detroit hospital has 877 beds. Such reductions would save Henry Ford "probably tens of millions dollars" annually by following the recommendations of the initiative, he says.

Why interoperability is difficult

Studies published in 2010 and 2014 by the President's Council of Advisors on Science and Technology list numerous scenarios where enhanced health IT interoperability could benefit the United States. So why does the nation continue to come up short on interoperability?

The answer is complex, but part of it is that interoperability already exists in many forms—much as before the Internet coalesced it was a series of networks that eventually became joined together by common protocols. The good news: Healthcare already has a set of such common protocols that routinely pass information between information systems not well-known for exchanging and using each other's information. Some of these common protocols were set in place by the federal meaningful use incentive program. The bad news: The protocols are unevenly adopted, reciprocal use agreements to "share and share alike" patient information with consent still require too much negotiation, and shared use cases often emerge only when providers discover or develop common business incentives to share information with each other. Such use cases are still rare.

"Many of our healthcare organizations don't really want to share data because they'd be sharing it with a competitor, and that would cost them money," says Dean F. Sittig, PhD, a medical informatics professor at University of Texas Health Science Center and School of Biomedical Informatics and a member of the UT-Memorial Hermann Center for Healthcare Quality and Safety.

"It's all too slow," says Marc Probst, chief information officer at Intermountain Healthcare, the 22-hospital system headquartered in Salt Lake City, which has been in the process of installing Cerner EHR software systemwide. "We're putting too much trust in the industry to pull it off on their own versus strong direction and mandates from the government. I am stating this as an über-conservative, but we are losing lives due to our inability to implement meaningful standards."

Others note that government intervention brings its own set of concerns to the interoperability debate. "More recently, we've had congressmen and senators talking about interoperability," Sittig says. "That's out of their league. A lot of our problems with interoperability surround [a] lack of agreed-upon uses. We have standards. We just don't agree to use the standards."

More than a technical challenge

"Technologically, we can share data," says Joel Vengco, vice president of information and technology and chief information officer of Baystate Health, a six-hospital system headquartered in Springfield, Massachusetts, in the state's Pioneer Valley region. "We can open up, create an API [application program interface]. The challenge is not technical, but rather about the vendor community working with its users to ensure cost-effective interoperability.

"We've got an Epic organization right now in our region," Vengco says. "They desperately want to connect to the Pioneer Valley Information Exchange, but the issue for them is that they are charged per transaction." The PVIX portal is an electronic way for member providers to access patient medical information.

A patchwork of networks—some private HIEs, some public HIEs, and some EHR vendor–operated HIEs—does allow relatively inexpensive and convenient record location services within each network. In Michigan, for instance, a high concentration of Epic EHR usage has allowed Epic's Care Everywhere platform to flow EHR data among 11 healthcare systems in the state, as well as other health
systems across the country running Epic.

"We were probably the earliest adopter in this market with Epic," says Subra Sripada, executive vice president, chief transformation officer, and system CIO of Beaumont Health, a three-hospital system in southeastern Michigan that reported total revenue of about $2.4 billion in 2013. "About three years ago, I reached out to my fellow CIOs to say, 'We are competitors in the market, but we shouldn't be competing on data.' "

Just on its own, in the first half of 2015, Beaumont shared 511,000 records with other healthcare systems in the United States via Care Everywhere, Sripada adds. "We can pull data from anybody that has Epic across the country, and they can pull data from us" due to Epic's reciprocal use agreements, which all Epic customers agree to when they activate Care Everywhere.

"We spend an awfully large amount of time trying to get records from other organizations, and we've found that we do notice a decrease in that since we've put in Epic," Henry Ford's Allard says. "We're now exchanging somewhere around 750,000 documents per quarter with other organizations [running Epic] for the purpose of getting health information on our patients that we're actively taking care of, and we're just not spending the amount of time at that [as we had to in the past]."

Common ground among competitors

When traditional competitors find common cause, technology barriers to interoperability can be overcome, even when no common EHR or HIE exists between the two. For instance, Detroit Medical Center—which includes eight hospitals, 140 clinics, more than 2,000 licensed beds, and 3,000 affiliated physicians—is in the process of negotiating a reciprocal use agreement with nearby Henry Ford that will allow each provider to exchange continuity-of-care documents, even though Detroit Medical Center runs Cerner EHR software, not Epic.

Henry Ford's pediatric practices are performed at Detroit Medical Center, says Mary Alice Annecharico, RN, Henry Ford's senior vice president and chief information officer. "We have an absolute need to be able to share clinical information with them on a regular and consistent basis," she says.

Once the reciprocal use agreement is finalized, electronic documents based on Health Level Seven International's Consolidated Clinical Document Architecture (CCDA) will begin flowing between Detroit Medical Center and Henry Ford, Allard says.

The technological foundation for such transfers was laid when both Cerner and Epic software were required to support CCDA as part of being certified in the meaningful use federal incentive program. Rather than requiring a third-party HIE, the communication will occur via existing support provided by Epic's Care Everywhere and Cerner's Resonance connectivity capabilities.

"Interoperability is becoming the main act," says Joe Francis, chief information officer of Detroit Medical Center. "We have a Pioneer accountable care organization here. I need to know everything that's going on with my patient, no matter which venue of care they're in, so interoperability becomes the underlying driver for being able to do that. We have 38 hospitals in southeast Michigan, as well as umpteen clinics. So a patient can go anywhere. Getting that information from those other organizations so you can build those missing pieces into your record of that patient—that's what I consider interoperability."

The need for a patient identifier

Lack of a nationwide patient identity standard is one area where Congress has made its own blocking law that continues to bedevil healthcare interoperability efforts. "We don't have a good way of identifying patients across systems," Sittig says. By federal law, the U.S. Department of Health and Human Services is prohibited from establishing a national patient identifier until legislation is enacted specifically approving the standard.

The blocking law was pushed by privacy advocates, but such concerns can be mitigated, Sittig says.

"We're not going to have true interoperability until we have a unique patient identifier, or at least a way for people who want to share their records to obtain a unique patient identifier," Sittig says. "The government wouldn't have to give this out. The government could just make a way for me to get one. I can get an employee identification number from my private business, so I don't have to use my Social Security number. There's lots of ways the government could give out a number, and then I could just give that number to every healthcare provider I went to, so they could share the data. It's a better solution than we've got now for sharing data."

Sittig also notes that many patients do not want their data shared. "I've always worked in hospitals or for healthcare, and I know there's a lot of employees that won't go to their own organization for healthcare because they don't want their employer to know what's wrong with them," he says.

Different routes to interoperability

Effective as a way to move beyond the privacy concerns and shortcomings of paper or faxed documents, CCDA represents one of meaningful use stage 2's major interoperability common denominators and also is in widespread use as a way to share EHR data via HIEs around the country.

Certain HIEs also offer record location services that, combined with methods of expressing patient consent to share information with other providers involved in their care, allow providers to query patient data that might reside at various hospitals or clinics. Such services are also core elements of Care Everywhere and another patient record information–sharing network, CommonWell Health Alliance, a set of services promoted initially by a group of EHR vendors, with the notable exception of Epic.

State HIEs offer their own variants. The Massachusetts Health Information Highway, known as Mass HIway, launched in 2012, initially permitting the encrypted pushing of messages containing medical records. This pushing technology leveraged the Direct protocol, an EHR secure messaging standard required of all meaningful use stage 2–certified software, for use in many short-term interoperability initiatives. In 2014, the Mass HIway then added query-and-retrieve capability throughout the state.

More than 500 organizations in Massachusetts currently participate in Mass HIway. Physicians who belong to the Mass HIway can, with a click display, request records that may reside in an incompatible EHR, which may allow the treating physicians to avoid duplicative or expensive tests when making their diagnoses.

"We've really been on a tear," says John Halamka, MD, chief information officer of Beth Israel Deaconess Medical Center—a Boston-based 649-bed teaching hospital. He also is a member of the governing health information technology council of the Mass HIway. "In April, we did 2 million transactions and we are completely financially viable."

Low cost to providers has driven adoption of Mass HIway, Halamka says. "We went to Blue Cross Blue Shield of Massachusetts and Partners HealthCare and Beth Israel Deaconess and said, 'Would you be willing to pay 10 times the cost of the service so that we can charge two-doctor practices $5 a month?' That's what we did. I'm more than happy to pay $50,000 a year because, boy, the value I get from healthcare information exchange is enormous, and by doing that, the big guys subsidize the little guys. Even at that price point, once you get enough volume, the whole thing works and the HIE, the HIway, doesn't go broke."

Another aspect of Mass HIway that lowers its operating costs: Unlike many other HIEs, the HIway does not act as a central repository of health information, leaving that job to other service providers who charge separately for those services.

Interoperability can also follow a different path to drive a sufficient number of healthcare organizations to participate on a statewide level. In Michigan, a high priority was to alert care providers when their patients were going to the hospital or the emergency department.

The solution, coordinated at the state level, arose from state legislation mandating an exchange initiated by the sender (a push exchange) of an admission-discharge-transfer (ADT) message from hospitals and emergency rooms—and the nine regional HIEs in the state to which they belonged—to doctors, specialists, therapists, and other patient-authorized providers. While not as comprehensive as some of the data exchanged via CCDAs, ADT updates are making a difference in Michigan, providers there say.

"Just getting people to send ADTs to a statewide service was prioritized by all these different groups as the No. 1 thing that everybody wanted, but then there was just a lot of pushback," says Tim Pletcher, DHA, executive director of Michigan Health Information Network Shared Services (MiHIN), a public and private nonprofit collaboration that has been formally designated as Michigan's statewide HIE by cooperative agreement between the Michigan State Health Information Exchange program and the Office of the National Coordinator for Health Information Technology.

"By packaging things up as a use case," Pletcher explains, "we were able to then ask Blue Cross Blue Shield of Michigan, one of the commercial payers in our state, 'Hey, all that money you give out in incentives—would you tie some piece of it to people doing this use case?' "

Over an 18-month period, aided by MiHIN's existing statewide patient-provider attribution service, the state was able to go from zero to collecting information on 92% of all admissions in the state. "That happened because they connected their incentives and payments to the use case as part of this population health incentive," Pletcher says.

His advice for other interoperability initiatives is to stop trying to solve so much of the interoperability problem at first. "People have been kind of swinging for the fence, and even something as simple as an ADT process has millions and millions of dollars of opportunity for people to sort of get on the same page," Pletcher says. "It is a giant bootstrapping activity to all of the next pieces. Every community has to figure out a strategy that works for them."

Rationale for federal rules

Still, the big problem for the industry is that while individual common interests and use cases may yield pockets of cooperation here and there, that is not sufficient to achieve nationwide interoperability. For years, policymakers have deliberated whether a nationwide set of reciprocal use agreements, also known as rules of the road, are necessary as well.

Such rules would define not just common data standards, but also common protocols for communicating patient consent, as well as identity matching and record location. Even between two systems such as Detroit Medical Center and Henry Ford, the agreements must be in place before any data can flow. "We just need to figure out: How do we do it safely within the construct of what we are regulated to protect? And how do we traffic that information, then store and utilize it?" Henry Ford's Annecharico says. Epic Care Everywhere and CommonWell govern certain reciprocal use within their own networks, but not with health systems in the other network.

Providers still struggle to achieve interoperability even within their own systems if they have multiple vendors' EHR software. Advocate Health Care, with the aid of a systems integrator, built a unified portal for discharged patients that draws from ambulatory settings running the Allscripts TouchWorks EHR for the 1,800-physician Advocate Medical Group, as well as the Cerner Millennium EHR running at nine of Advocate's 12 hospitals, says Mike Delahanty, vice president of information systems application projects at Advocate, which is based in Downers Grove, Illinois, and reported total revenue of $370 million in 2013.

"We wanted this to be a portal for all of Advocate," says Delahanty. "There are other EMRs besides these two in play. We came up with our own patient identifier. We came up with a scheme to get that loaded, how to match it up with our enterprise master patient index, so we knew we were getting the right person, so that we could tie them to all the different EMRs." Like other providers, Advocate has standardized on CCDA documents.

"Composable" standards allow organizations to select and assemble components in various combinations to satisfy unique user requirements. Support for Fast Healthcare Interoperability Resources (FHIR)—a composable set of data standards and APIs defined by HL7 that allows for versatile data exchange uses—is just beginning to become popular in healthcare. One such use is to permit discrete transmission of 16 elements of CCDAs instead of always sending entire documents that then must be interpreted by the receiving EHR or other health information technology.

How interoperability helps patients

Having information returned in FHIR format will simplify continuity of care for populations, according to Jeremy Marut, director of enterprise architecture at Hackensack University Medical Center, part of the 11-hospital, 1,717-licensed-acute-bed Hackensack University Health Network.

Due to its versatility, FHIR will show up in many different use cases throughout healthcare. One of the first on deck is another approach to interoperability sometimes known as the "HIE of one."

Hackensack is an early implementer of FHIR. Motivated by two concussions his daughter received, and the hassles of transporting her medical records from location to location, Hackensack's vice president and chief information officer, Shafiq Rab, MD, MPH, CHICO, recently convened a gathering of five technology vendors to implement a link between Hackensack's Epic EHR via FHIR to Hackensack's new mobile application to assemble data from various providers. When a patient presents to a new provider, as Rab's daughter did during her course of treatment, Hackensack grants that new provider access to the patient's assembled record, including ADT summaries of care and demographics.

"The beauty in the way we are doing it is we are putting the power in the hands of the patient," Rab says. Business reasons for Hackensack were not his primary motivation. "It's because my child had a concussion and we went to different doctors' offices and no information was there," he says. "Secondly, we want to empower our patients."

Rab says the move toward the "HIE of one" is a direct response to ONC's Report on Health Information Blocking, because patients cannot be denied their EHRs under the HIPAA Omnibus law. "That's why we are developing this app," he says. "It takes away the lame excuses of exchanges, the lame excuses of HIEs, the lame excuse of interfaces. All that nonsense goes away. We should fight for a common cause through selfless acts—and urgently, as our patients need us now."

By moving the results of queries away from CCDAs and toward FHIR elements, Hackensack will also enable a more usable longitudinal record query when a patient presents, Marut says. "When we have one patient present, we do a query within a 500-mile radius. So you're getting a lot of CCDs, and each one with a lot of information. And if you ask a doctor, they want to see it, but they don't necessarily want to see all the junk."

Beware unintended consequences

Indeed, one concern about interoperability falls along the lines of the familiar phrase, Be careful what you wish for. Physicians are already bombarded by electronic notifications and alerts from within their own health systems. Is healthcare prepared for even more coming from other care venues?

Detroit Medical Center's Francis acknowledges the importance of the issue. "We don't necessarily alert on every ADT," he says. "The fact that somebody is in the ED because they have a broken foot doesn't mean that I should be alerted because I'm treating them for COPD. You have to have intelligent alerts."

The changing interoperability landscape may also call into question some of the substantial investments made in traditional HIEs. Detroit Medical Center belongs to one of the local Michigan-certified HIEs to pass ADTs, lab results, immunizations, and syndromic surveillance to the state. But another implication of arrangements such as that being finalized between Detroit Medical Center and Henry Ford is the prospect that increasing numbers of interoperability solutions will not involve an HIE but instead data flowing directly between providers, aided and abetted by EHR software vendors working more in cooperation—and less at odds—with each other.

"The major EHR vendors have got the cash," Francis says. "They're willing to pull this stuff together, and it's even better, to a certain extent, than what an HIE can give you."

Providers agree the nation must also find a way to avoid making patients sign multiple consent agreements by arranging an agreement for common data sharing and rules of the road that govern all the disparate networks—whether it's Care Everywhere, CommonWell, or HIEs.

"We should have one standard, but unfortunately, it's not there yet," Rab says.

Yet another interoperability challenge is to slipstream record location and retrieval into clinicians' regular workflows, Allard says. "The trick is working it into regular workflow. If I have to go browse through a library of available information on every patient, it just sort of grinds things to a halt and it's hard to get it done. You can't just dump mail into people's inbox."

Reprint HLR115-2

Leaders are finding that recruitment from the outside can be useful but difficult, and that internally, talent can be developed to support analytics efforts.

This article appears in the October 2015 issue of HealthLeaders magazine.

Healthcare's many imperatives, including population health, require keen analytical resources coupled with a deep understanding of clinical systems and the obstacles that face healthcare's march to achieve the triple aim.

Finding and training talented staff—from line analysts all the way up to visionary chief medical information officers and chief information officers—remains a tall order. By and large, however, analytics team leaders find it is easier to train clinicians in the art and science of analytics than it is to find, hire, and train data analysts from outside of healthcare.

"It's not a skill that you can learn going through some training program outside of this industry," says Selvan Ekambaram, director of business intelligence and data warehouse at MemorialCare Health System, a six-hospital integrated delivery system in California's Orange and Los Angeles counties, with between 650 and 700 affiliated physicians. "You pretty much need to have healthcare-specific industry experience for you to call yourself a practitioner."

Often, providers such as MemorialCare must contend with job candidates who prefer to remain independent consultants, instead of coming onboard as full-time employees, "because they know the demand for this particular skill set is so high," Ekambaram says. "Recruiting and retaining these specific skill sets that are needed for running a program like a data analytics shop like we're trying to do here is not easy."

MemorialCare has had a couple of full-time positions open for nearly a year. The kind of skills required generally fall into two categories: data integration and content visualization. Data integration involves procuring and consolidating different data sources such as EHR data, claims data, and patient satisfaction data. Then that data must be visualized and deployed, Ekambaram says. All told, the MemorialCare analytics team engages 21 workers. A second branch, which serves the organization's independent physicians associations and medical groups, contains another 25 workers involved in pay-for-performance reporting and quality metrics for ambulatory settings. Six other analysts joined MemorialCare when it acquired Seaside Health Plan.

One successful strategy: Tap into talent at healthcare payers. "We recently rolled in one full-time equivalent who came in from the payer industry, although we would prefer recruits from the provider space," Ekambaram says.

The team uses an iterative process by which it presents data to clinicians and determines if that data is as useful as possible, if there might be ways to better present the data, or if it should enable clinicians to further explore the data presented—an aspect known broadly as self-service business intelligence analytics.

"Some of my colleagues are more toward the self-service side than I am," says Harris Stutman MD, chief medical information officer at MemorialCare. "But we have, within the last couple of months, put together the idea of a physician analytics program, a kind of a mini-fellowship, to take our physician leadership, certainly the folks that are responsible for leading our medical group and leading the best practice initiative within our hospitals—clinical documentation improvement, population health, those sorts of things—and train them in what data sets we have available and what tools we have available, and help them understand that we really need to ask answerable questions," he says.

"We invited 13 physicians to be in the initial mini-fellowship class, and all 13 accepted—which really surprised me, because we're not paying them to spend 2 or 3 hours a week in a classroom, learning this material. But they all felt it was sufficiently relevant and important to what they do to make time to attend those programs, and we'll see what positive outcomes develop," says Stutman.

"Vendor partners train us in the tools and the technology," Ekambaram says.

Among the quality improvement programs being driven by the analytics team are quality measures and core measures for sepsis management for MemorialCare's inpatient and pediatric populations. MemorialCare's vice president of population health is also working with the analytics team to gather palliative care metrics.

"It's very important for people to understand what sorts of business problems they're trying to solve, and to make sure that when they start really mining the data, they're doing it with specific goals in mind and not just fooling around to produce some pretty pie charts or bar graphs," Stutman says.

Another provider that has tried dual approaches to recruiting analysts from inside or outside of healthcare is Pittsburgh-based UPMC, which operates more than 20 hospitals and employs more than 3,500 physicians. "We merge the skill sets of both" externally recruited analysts and internal analysts, says Vivek Reddy, MD, chief medical information officer for UPMC's health services division. A major push has been to provide analytics training for UPMC clinicians who "we thought were up-and-comers in our organization that had an aptitude to learn a new skill set," he says. Toward that end, UPMC built a training program in conjunction with nearby Carnegie Mellon University. So far, UPMC has put 75 workers through the program, a mix of clinicians, nurses, and financial employees.

"We put them through a fairly intensive, six-hour-a-week course, with homework, set around analytics and analytics principles," he says. "We've had very strong and powerful results with a lot of our clinical folks that didn't really have a lot of exposure to the idea of using data to drive decision-making really effectively. They were good at receiving reports, but they didn't really understand how you get insight from reports and how you can actually look at data differently, so our clinical folks that go into the program do very well and learn a lot of different skills."

UPMC's next challenge has been to get these newly trained clinicians to spread this data-centric view across the rest of the organization, Reddy says.

"Our firm belief is, this is just a fundamental change in the way people think about their day jobs," he says. Even registration clerks need to understand how what they are doing on a day-to-day basis ties into UPMC's analytics program, he says.

"What we're doing by taking some of our up-and-comers and making them go through this is allowing them to then take that message and help our day-to-day operations start to embrace the idea that if we're going to become a data-driven organization, we really have to look at data integrity and data quality and really be concerned about these things and not just say, 'Oh well, sometimes it's not right' and I just move on to the next problem, or I call someone else to get a new report if I don't like the data that I see," Reddy says.

In the latest cohort of analytics trainees, UPMC is giving its program participants a series of business problems to tackle. "It's a much more practical, hands-on approach," he says. "We'll see how that goes."

At many organizations, analytics resources exist in scattered pockets. This is true for the University of Missouri Health Care, which employs 6,000 physicians, nurses, and healthcare professionals and operates 50 outpatient clinics in central Missouri that receive outpatient visits exceeding 500,000 annually.

Now, UM Health Care is in the process of consolidating such resources under its newly hired chief financial officer. "We're partnering on the academic side with our HIM department and with our master of health administration program to formulate a certificate in healthcare analytics, as well as a degree program," says Bryan Bliven, UM Health Care's chief information officer. To lead this team, UM Health Care wants to hire a registered nurse to act as its director of clinical analytics, he says.

A key objective is for this analytics team at UM Health to "step up our game" to produce more engaged conversations between UM Health leaders during bimonthly enterprisewide operating reviews, when metrics for each department and service line are reviewed and interventions planned as needed, Bliven says.

"We have a population health view, so we'll look at the different contracts we're working on, and look at our performance to that, and it's a similar approach that really helps us kind of see across the organization and catch trends and then get an idea of each organization's ability to engage on the data and where we might need to have some oversight or assistance," he says.

"All of population health management is essentially cohort analytics," says Joe Kimura, MD, MPH, deputy chief medical officer at Atrius Health, an alliance of nonprofit community-based physician groups in eastern Massachusetts and Boston that serves 675,000 patients via 750 physicians, with more than 50% annual revenue coming from risk-based contracts. Atrius is a Pioneer ACO, a pilot CMS program recently found to be saving Medicare $400 million over its first two years.

"If it's a payer-designed cohort like Pioneer, you have a set of patients that is defined by an attribution model or something along those lines, but it could be a disease-based model, just anyone with diabetes, and the question is, how are you defining diabetes in your population?" Kimura says. "Once we actually define that population, we run a whole series of analyses to help
characterize that population, not only in terms of its utilization patterns, disease characteristics, and comorbidities, but also in terms of what we generally understand as care metrics or quality metrics."

Atrius employs four levels of SQL programmers to perform data analytics queries, Kimura says. "Those folks basically take about 16 to 18 months of training to get to a place where they can sit with a business owner and generate a specific ad hoc report," he says.

Such results could also be delivered as discrete information elements in Atrius' EHR, as well as reports in Crystal Reports or Microsoft Excel. More recently, Atrius has turned to SAP Universe and Dashboard technology to provide self-service business intelligence analytics to clinicians.

"We've pivoted there because SAP has single sign-on with Epic, which made it easy to utilize that capability," Kimura says. Although a number of Atrius employees already have statistical training, its academic partnerships in the Boston area allow it to engage with consultants to build BI models in-house and deploy them. If such consultants come from academia, "it's a lot easier for us to recruit them."

Over the course of a year, Atrius currently runs three or four such BI research initiatives, and so continues to engage consultants. "We don't think we're going to invest a lot around bringing in full-time staff to do some of the advanced stuff until we get bigger," Kimura says.

One payoff for Atrius: being named the number two Pioneer ACO in the United States in terms of quality reports in fall 2014, and the top such organization in New England. "We've been able to maintain the highest quality scores in New England and be number two among all Pioneer programs in 2014 and have begun to realize financial savings from CMS," Kimura says.

Reprint HLR1015-8

Meeting the new federal meaningful use standards will require much heavy lifting. And health IT leaders should already be preparing for what comes next.

What are healthcare CIOs talking about now that ICD-10 is live?

Meaningful use deadlines took center stage at the annual meeting of the College of Healthcare Information Management Executives (CHIME) in Orlando, FL, last week. But attendees also found time to talk about what comes after meaningful use—namely, CCDA and CEHRT.

Two meaningful use dates now loom large. The first is December 15, when the 60-day comment period on the stage 3 final rule expires. While some industry observers consider the comment period to pertain just to stage 3, that isn't precisely true. Because ONC and CMS issued a single final rule covering both stage 3 and its amendments to stage 2 in the years 2015, 2016, and 2017, the public has the right to comment on anything in the final rule, says Liz Johnson, CIO of acute care hospitals and applied clinical informatics at Tenet Healthcare, the for-profit hospital operator headquartered in Dallas.

The second big date is February 29, 2016, which is both the starting day of next year's HIMSS conference and the day that all providers receiving Medicare must complete their attestation to their meaningful use of certified EHR software in 2015.

Considering that the final rules amending stage 2 came out nearly a week into the newly shortened 90-day reporting period for 2015, CIOs had to do some fancy footwork to make sure that they were gathering the necessary data starting October 1.

Among the lingering questions are challenges in meeting the public health reporting requirements in the newly modified stage 2, which will vary from state to state. Within the CHIME organization, board member Johnson is one of two experts on this devilish detail. The other is Pam McNutt, senior vice president and CIO of Methodist Health System in Dallas.

My October 7 news story on the final rule could only hit some highlights of these voluminous documents. At CHIME, McNutt celebrated the fact that the modified stage 2 rules removed the 50% measure for providing a summary of care record by any means, as well as relaxation of requirements for manual transmission, to better allow providers to tailor the contents of the summary of care document to the transport mechanism, rather than constraining transport to a certified HIE or Direct message.

The final rule "gives you more flexibility on what could be defined as a secure electronic message to your providers, and that is good news," McNutt said. "I know many people were struggling, didn't have an HIE that was functional to get to 10% of your referrals. … So this will give you some latitude to maybe be creative. However, I will tell you we're scrambling with this one ourselves right now, because the reporting period has in fact started, and if you don't have your numbers up to 10%, you've got to scramble."

McNutt and Johnson also cautioned CIOs to be prepared for the final rule's planned jumps in stage 2 patient engagement and e-prescribing metrics in 2017.

On the second morning of the CHIME conference, ONC chief health information officer Michael McCoy, MD, told attendees that alignment of financial incentives of healthcare—through value-based purchasing and ACOs—would make health IT interoperability a reality.

"Go to your board and suggest that the data should flow," McCoy said. "We should compete on our service, on our caring, and how well we score, but we shouldn't compete on the data flowing."

One questioner then asked what the most effective path would be to attain useful data exchange between providers.

The answer is Consolidated Clinical Document Architecture (CCDA), McCoy says. "The CCDA is the right path. There are revisions now coming. The challenge we have had with CCDAs is they have been branded as unusable. I have to respectfully push back and disagree. What has been lost in the [EHR] certification rules and the intent over the years is that certification is a floor for the vendors and developers to achieve, not a ceiling. As an example, transmitting information as a CCD [Continuity of Care Document] to whomever … as the sending individual, you probably don't have all the knowledge of what is desired by the receiving individual …. What's missing from the usability side is the receiver should be able to filter what's coming through, and that's more explicit, called out in the 2015 CEHRT rules …. Specialty societies have to be involved in setting some of those defaults."

I got the impression that very few CIOs so far have even begun to read those 2015 CEHRT (Certified EHR Technology) rules, which themselves delineate meaningful use's final stage. With the aforementioned comment period ending December 15, at this point providers could use a good crowdsourcing effort to fully understand and parse those 550 pages, and help an already beleaguered health IT industry catch the next wave of regulation even as the previous wave washes over it.

Wouldn't it be cool if technology could help us with that?