Panel 2: Exchange Service Providers Questions
Carl Dvorak – Epic Systems Corporation August
13, 2014
In addition to specific answers to your questions, I’ve attached an
Interoperability Status report from the Epic customer community as of July 2014
as reference.
- What exchange use cases do you
support? What challenges are inhibiting or slowing your ability to
broadly deploy/support these use cases?
Often when we discuss interoperability we focus on the more
narrow use case of patient summary document exchange. Before that discussion,
I’d like to address the broader definition of interoperability.
Epic maintains strong support for traditional interfacing
within health systems to third party modular systems. These interfaces connect
customers to pharmacies, specialty and immunization registries, lab systems, radiology
systems, billing systems, etc. Epic interfaces take many forms, ranging from
HL7 version 2 and 3 feeds, NCPDP transactions, ANSI X12 transactions, to web
services, to public APIs for consumer apps.
Today we process over 20+ billion data transactions a year through
12,000+ interfaces between Epic and 600+ other vendors’ systems as well as:
o
88 Public Health Agencies
o
18 Research Societies
o
51 Immunization Registries across 46 states
o
17 Research Registries
For Meaningful Use planned transitions of care exchanges we
support the ONC S&I Framework Direct protocol.
Additionally, for broader uses of planned and unplanned exchange
of patient summary documents Epic supports the eHealth Exchange standards which
allow CCDA and CDA exchange with a wide variety of trading partners including
the Federal government (VA, DoD and SSA).
The Epic Care Everywhere network uses these standards and sees over 4.6
million exchanges per month and growing fast.
We currently exchange approximately 480,000 CCDA documents
with other vendor products per month. This number is also growing rapidly as
other vendor products become exchange ready under Meaningful Use Stage 2
certification and their customers are mandated to share their data.
Users of our software that participate in this type of exchange
operate in all 50 states and include over 900 hospitals and 20,000 clinics.
Another 85 hospitals and 3,000 clinics are installing. Participants exchange
with each other as well as:
o
EHRs developed by 26 vendors including all of
our major competitors
o
21 Health Information Exchanges (HIEs)
o
29 Health Information Service Providers (HISPs)
o
28 eHealth Exchange members with 20 more
installing
This includes the
Department of Veterans Affairs, the Social Security Administration and the
Department of Defense. According to
HealtheWay, more Epic users are connected to the VA than users of any other
vendor.
eHealth Exchange standards allow Epic users comprehensive
support for the “Query or Pull” model of exchange. When a patient presents
unexpectedly at an emergency department, the EHR can query for her record from
another health system and then pull the information into the local EHR. The Direct standard supports the “Push” model
of exchange where a primary care physician would push a summary of a patient
record to a specialist that she is referring her patient to for care. In addition, we also support our customers as
they are required to push every encounter to a private, local or state-based HIE.
Impediments to broader
and faster adoption of interoperability: Our data show that the lack of the
following items impedes broad scale interoperability:
o
Point of care authorizations
o
Phone book containing all exchange-ready
participants
o
Single trust authority
o
Simplified governance when patient data is ONLY
used for treatment
o
Stronger ONC support for the eHealth Exchange
which supports unplanned transitions of care
Implementing a simple
phone book, certificate authority, and including Rules of the Road as an automatic
part of Epic implementations beginning in 2007 has been instrumental in
achieving industry-leading levels of standards based interoperability among the
Epic user community. A national effort around
these items would dramatically increase broad adoption of interoperability
across the nation.
In the last 12 months, the Epic user community has done 29,000,000
standards-based exchanges of patient records and our projections for this time
next year look to be in the 60,000,000 range as more standards-compliant
systems come on line with Meaningful Use requirements for users of those systems
to share their data.
We suggest that full support in Meaningful Use Stage 3 for
unplanned transitions of care using the established standards of the eHealth
Exchange (run by HealtheWay) would further advance the nation’s information
exchange.
- What policy, trust, and technical
requirements do you require be met before agreeing to exchange with
another exchange service provider? What if any assurances do you
require that your trading partners are adhering to these requirements?
Our customers each make their own decisions in what
requirements must be met since they will ultimately be held accountable for
protecting the PHI in their custody.
Generally, trading partners must:
1. Have
systems that can communicate securely using appropriate standards.
2. Sign
on to Rules of the Road, which govern appropriate use of the exchange. Currently
rules and assurances vary – they can be one to one relationships, regional HIE
membership agreements, or built into joining large exchange networks, like the
eHealth Exchange, Surescripts CI Network, and the Care Everywhere network.
3. Monitor
and control appropriate use of and access to the exchange.
Appropriate trading partners are validating using digital
certificates.
Being able to trust the identity and commitment to protect
health information is a key aspect of exchange.
We strongly suggest ONC and CMS simplify and eliminate any economic
barriers to establishing such trust.
Currently, organizations that deliver healthcare are not always able to
afford options such as DirectTrust, which is priced for large scale HIEs or HISPs,
to validate their identities. We
recommend that ONC consider supporting a simplified and vibrant market that
competes on cost to provide trust validation services to individual provider
organizations. A plurality of trust
verification services would be in the best interest of accelerating exchange.
An additional aspect that could either accelerate or impede
national interoperability is the management of consent and record
segmentation. We strongly recommend that
ONC push for a simple entire opt in or opt out for patient control of
interoperability. Should a patient
desire a more fine-grained approach to sharing only selected portions of his
record, risking significantly reduced physician trust in interoperability, he could
use PHRs to control exchange of a subset of his records. To impose a higher degree of segmentation on
the medical community would dramatically impede interoperability at this time. In addition, further facilitating patients to
consent at the point of care, using language drafted by the record holder, will
be important to enhancing national interoperability, especially in unplanned
transitions such as emergency department visits.
- What factors are limiting the exchange of
health information?
Our customers have reported that state and local HIEs have
asked for significant payments that are not aligned with their use of or need
for such HIE services given that they can also connect directly with other
providers to share information on patients they both treat.
Some of these HIEs seek legislative support to control
public health and immunization registries forcing all participants to pay the
full HIE fee even if only the immunization registry access is needed.
We strongly recommend that states provide immunization and
public health reporting as free services supported by the state without
requirements to pay for the use of a single monopolistic HIE in order to comply
with Meaningful Use. If states choose
not to do so, then ONC and CMS should consider that as an exception for those
specific MU requirements for those health systems that operate in those states.
As described above, a national phone book of exchange-ready
organizations and providers, a simplified and affordable trust validation
service and straight-forward Rules of the Road would dramatically improve
exchange.
- What, if any, actions should be taken at the
national level to help address the governance challenges that are
inhibiting the exchange of health information across entities or to
mitigate risks to patient safety and/or privacy when exchange is
occurring? What role should ONC or other federal agencies
play? What role should states play? What role should the
private sector play?
- Create a national phone book of Meaningful Use participants as a requirement of receiving stimulus payments. Also permit organizations or individuals who do not participate in Meaningful Use to voluntarily submit their addresses.
- Create a simple and affordable trust model to bring down the cost of trust validation as compared to the more expensive HIE and HISP model currently supported by DirectTrust.
- Create a simple Meaningful Use Rules of the Road for data exchange strictly for use in treatment. Protecting PHI from secondary use and sale will increase patients’ trust in a national system of exchange.
- Do not complicate exchange with artificially complex segmentation rules, given that the vast majority of those who currently use exchange services have chosen to share their entire record.
- Would it be beneficial if ONC monitored the
information exchange market to identify successes, challenges, and abuses?
If so, what methods of monitoring would be effective; and, what actions
should ONC take based upon findings from monitoring?
The presumption of abuse by vendors seems to be based on a
false and disingenuous narrative of unidentified origin. We strongly recommend ONC exercise extreme care
in differentiating political agendas and commercial competition from actual facts
and real accomplishments in this area at this important time in our healthcare system’s
evolution.
There are already control mechanisms in place for the
Meaningful Use and ONC certification programs. Existing mechanisms should be
deployed conscientiously and fairly without introducing unnecessary additional
mechanisms.
CMS has required a 10 % transition of care exchange rate to
comply with Stage 2. CMS’s current
Meaningful Use audit process should be sufficient to identify fraud in the EHR
incentive program.
Regarding certification, should an EHR product not be able
to demonstrate compliance with 2014 Edition criteria, then the product will not
be certified.
Should a healthcare organization not meet the MU
requirements, they should not be paid any incentive and should have
appropriately reduced payments based on the original HITECH legislation.
We’d recommend that healthcare systems be allowed to
voluntarily report their interoperability statistics to ONC. Many healthcare
systems would not consider this a burden and would like to educate ONC and
other government agencies about the current state of interoperability in the
country.
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