Taking Stock of Recent Innovations for Interoperability


Nov 7, 2017 - GET hospital.com/ehr/Medication? PtID=1234&Date=gt2017 ... *Implementation Guides* and *Profiles* are critical to enabling true ... A consortium of EHR vendors, HIEs, and others. • To enable patient data sharing among the users of ... EHR vendors. • Including large players: Epic, Cerner, eClinicalWorks,.

Taking Stock of Recent Innovations for Interoperability and HIE FHIR, Carequality, and CommonWell Walter Sujansky, MD, PhD

AMIA Annual Symposium November 7, 2017

What is FHIR? An internet-based application programming interface (API) characterized by: 1. “REST” model for requesting/retrieving data 2. “Resources” for standardizing the data content 3. “OAuth” for authorizing access to the data

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“REST” Model for Data Access Over the Internet  Uses HTTP Internet Protocol, same as for web browsing  E.g., “http://www.stanford.edu/hospital/homepage.html”  => HTTP Msg: “GET www.stanford.edu/hospital/homepage.html”

Information Server GET www.stanford.edu/hospital/homepage.html HTTP-Based API homepage.html Database

Web Browser Request Response Sujansky & Associates, LLC

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“REST” Model for Data Access Over the Internet  GET www.stanford.edu/hospital/homepage.html  GET www.stanford.edu/hospital/CampusMap.jpg  GET www.stanford.edu/hospital/MdContact?LName=Hopkins

Information Server HTTP GET Request HTTP-Based API

Returned Data Object Database

Web Browser Request Response Sujansky & Associates, LLC

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“REST” Model for Data Access Over the Internet  GET hospital.com/ehr/Patient?Lname=Cox&Fname=Joe  GET hospital.com/ehr/Condition?PtID=1234&Status=Active  GET hospital.com/ehr/Medication? PtID=1234&Date=gt2017

Information Client

Information Server HTTP GET Request

Application

Database

HTTP-Based API

Dynamically generated data object(s) (as XML, JSON, etc.)

Database

Request Response Sujansky & Associates, LLC

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“Resources” for Standardizing Data (Content/Structure/Optionality/Coding)  E.g., Condition resource definition =>

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“Resources” for Standardizing Data ‖~90 resources defined

(HL7 FHIR v1.0.2 - DSTU2)

‖Condition

‖Patient

‖Procedure

‖Practitioner

‖Medication

‖Organization

‖Observation

‖Location

‖Immunization

‖Encounter

‖FamilyMemberHistory

‖Appointment

‖CarePlan

‖Schedule

‖NutritionOrder

‖Device

‖Specimen

‖SupplyRequest

‖…

‖… Sujansky & Associates, LLC

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“Resources” for Standardizing Data ‖FHIR Resources are roughly analogous to…

HL7 v2.x Segments • DG1 – Diagnosis • PR1 – Procedure • OBX - Observation/Result • AL1 - Patient Allergy Info • ODS - Dietary Orders • SPM – Specimen • FAC – Facility • PV1 - Patient Visit ‖…

CDA Sections • Problem • Procedure Description • Results • Allergies • Discharge Diet • Immunizations • Encounters • Medical Equipment ‖…

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“Resources” for Standardizing Data  E.g., Condition • Resource Definition =>

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“Resources” for standardizing the exchanged data  E.g., Condition • Resource Definition =>

Hence, more specific *Implementation Guides* and *Profiles* are critical to enabling true interoperability… …and these must be implemented consistently and broadly across the health care system.

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“OAuth” for Authorizing Data Access  A standard model for *federated identity and authorization*

Trust? Request resource, using token

Information Client

Information Server Receive resource Provide secure authorization token Authenticate

Trust! Authorization Server

“User”

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FHIR – Novel Attributes for HIE  Relatively simple/inexpensive technically to implement

REST APIs • Lots of tools and expertise available in industry  Access to more granular data than with document-

based and message-based models • Relatively light-weight resources  Built-in query/response functionality ideal for “pull”

models of HIE  Federated authentication and authorization model suitable for trust networks Sujansky & Associates, LLC

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FHIR - Remaining Limitations/Challenges for HIE  Lack of needed auxiliary infrastructure to support HIE • Provider/organization directory • Patient record-locator service • Patient identity-management service • OAuth-based trust network  Substantial optionality/underspecification in resource

definitions • Mitigated somewhat by existing profiles, e.g., Argonaut  Inconsistent implementation of existing profiles

• “When you’ve seen one FHIR API implementation, you’ve seen one FHIR API implementation.” Sujansky & Associates, LLC

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What is Carequality?  A consortium of EHR vendors, HIEs, and others

• To enable patient data sharing among the users of their technologies  Two primary components

• Agreed-upon interoperability (API) protocols • Legal participation agreements

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Carequality Data-Exchange Model Directory of Participants

1

Organization Lookup

Requesting System

Electronic Address

Patient2 Discovery [IHE ITI-55] Request

Matching Patient IDs

3 Query-for-Document Request [IHE ITI-38]

Matching Document Meta Data

Responding System

4 Retrieve-Document

Request [IHE ITI-39]

Request Response

Requested Document Content

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Carequality Data-Exchange Model Carequality Organization Directory

Organization 1 1

Address Lookup

Requesting Organization

Organization 2

Request Response

Organization 3

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Carequality Data-Exchange Model Carequality Organization Directory

Organization 1

2 Patient-Discovery

Request

Matching Patient IDs

2 Patient-Discovery

Requesting Organization

Request Matching Patient IDs

Organization 2

2 Patient-Discovery

Request

Request Response

Matching Patient IDs

Organization 3

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Carequality Data-Exchange Model Carequality Organization Directory 3 Query for

Organization 1

Patient Documents

Document Meta Data

3 Query for Patient

Requesting Organization

Documents Document Meta Data

Organization 2

3 Query for Patient

Documents

Request Response

Document Meta Data

Organization 3

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Carequality Data-Exchange Model Carequality Organization Directory 4 Request for

Organization 1

Document Retrieval

Requesting Organization

Document(s)

4 Request for Document Retrieval for

Organization 2

Document(s) 4 Request for

Document Retrieval Document(s)

Request Response

Organization 3

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Carequality Data-Exchange Model  Two primary components

• Internet-based interoperability (API) protocols • Legal participation agreements – Must honor all data requests for treatment purposes without fees and conditions, regardless of requestor – Must provide identical fees, terms, and conditions for nontreatment data requests, regardless of requestor

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Carequality – Novel Attributes for HIE  Common data-sharing agreement with guaranteed

access for treatment purposes  Organization directory of all participants  Substantial interest and participation by EHR vendors • Including large players: Epic, Cerner, eClinicalWorks, AthenaHealth, NextGen

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Carequality – Remaining Limitations/Challenges for HIE  No built-in MPI or record-locator services • Option to use SureScripts’ RLS, but incomplete content  Interoperability relies on consistent implementation of

IHE protocols in pair-wise fashion among participants • Remaining vendor-to-vendor customization/testing  Specifications don’t address the types of documents

that may or must be exchanged, or the standardization of their formatting  Limited go-live implementations to date among Carequality vendor participants  Incomplete participation among healthcare organization customers live vendors Sujanskyof & Associates, LLC

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C Carequality Members and Implementers

- Live implementations Sujansky & Associates, LLC

(Valid as of 10/1/2017) 23

What is CommonWell Health Alliance (CHA)?  Another consortium of EHR vendors, HIEs, etc.

• Also for patient data sharing among each other  Three primary components

• Agreed-upon interoperability (API) protocols • Legal participation agreements • Data-exchange broker

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Carequality (for comparison) Organization Directory

Address Lookup

Requesting Organization

Request for Document Retrieval

Organization 1 Document(s)

Request for Document Retrieval for

Organization 2

Document(s) Request for Document Retrieval Document(s)

Request Response

Organization 3

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CommonWell Data-Exchange Model Organization Directory

Organization 1 Address Lookup

CHA Middleware Requesting Organization

Request Broker

for

Organization 2 Patient ID Mgr

Request Response

Organization 3

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CommonWell Data-Exchange Model Organization Directory Patient Registration Events (HL7 ADT Messages)

Address Lookup

Organization 1

CHA Middleware Requesting Organization

Request Broker

for

Organization 2 Patient ID Mgr

Request Response

Organization 3

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CommonWell Data-Exchange Model CHA Middleware

Organization 1

Patient ID Mgr Person Record

Patient Record* (Org. 3)

Patient Record* (Org. 2)

Patient Record* (Org. 1)

Organization 2

Organization 3

* Patient demographic data + list of encounters

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CommonWell Data-Exchange Model Organization Directory

Patient-Discovery Request

Organization 1 Address Lookup

CHA Middleware Requesting Organization

Request Broker

for

Organization 2 Patient ID Mgr

Request Response

Organization 3

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CommonWell Data-Exchange Model

Query for Patient Documents

Query for Patient Documents

Requesting Organization

Aggregated Document Meta Data

Organization 1

Meta Data

CHA Middleware

Query for Patient Documents

Request Broker

for

Meta Data

Organization 2

Patient ID Mgr

Meta Data

Request Response

Organization 3

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CommonWell Data-Exchange Model

Request Document Retrieval Request for Document Retrieval

Requesting Organization

Document(s)

CHA Middleware Request Broker

for

Document(s)

Request Document Retrieval Document(s)

Patient ID Mgr

Organization 1

Organization 2

Request Document Retrieval Document(s)

Request Response

Organization 3

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CommonWell – Novel Attributes for HIE  Common data-sharing agreement with guaranteed

access for treatment purposes  Technical specifications focus on exchange of C/CDA documents with attachments  Data-exchange broker • Built-in master patient index • Built-in record-locator service • Single vendor implementation reaches all live participants  Substantial interest and participation by EHR vendors

• Including large players: Cerner, eClinicalWorks, AthenaHealth, Greenway Sujansky & Associates, LLC

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CommonWell – Remaining Limitations/Challenges for HIE  Legal agreements allow exchange for treatment

purposes only • E.g., not quality measurement/quality improvement  Limited go-live implementations to date among

CommonWell vendor participants  Incomplete participation among healthcare organization customers of live vendors

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CommonWell Members and Implementers C

- Live implementations Sujansky & Associates, LLC

- In-process implementations (Valid as of 10/1/2017)

34

C CommonWell + Carequality Implementers

- Live implementations Sujansky & Associates, LLC

- In-process implementations (Valid as of 10/1/2017)

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C CommonWell + Carequality Implementers

Source: KLAS

- Live implementations Sujansky & Associates, LLC

- In-process implementations (Valid as of 10/1/2017)

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C CommonWell + Carequality Implementers

Source: CMS

- Live implementations Sujansky & Associates, LLC

- In-process implementations (Valid as of 10/1/2017)

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Thank you

Additional Slides

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Argonaut Profile for Condition

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History of eHealth Exchange, CommonWell, and Carequality

Organization

Initiative

2004

2007

2012

2014

2015

ONC (formed)

ONC

HealtheWay (transitioned)

HealtheWay

Sequoia Project (renamed)

NHIN (envisioned)

NwHIN Exchange (created)

eHealth Exchange (renamed)

eHealth Exchange

Carequality (created)

eHealth Exchange

Carequality

2013 CommonWell Health Alliance created

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