JULY That s what interoperability offers and that s what is largely missing from the status quo.

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1 IssueBrief JULY 2015 No more data blocking: Why the proposed Meaningful Use rule has potential to improve outcomes and support patient engagement Imagine a health care system in which clinicians could easily and securely send and receive information about their patients, regardless of where the patients are on the health care continuum. Imagine a world where patients have ready access to their own medical data whenever and wherever they need it. That s what interoperability offers and that s what is largely missing from the status quo. Lack of interoperability hampers the potential of EHRs to enhance health care delivery and improve outcomes, particularly as patients move across the care continuum. What s sorely needed is data portability, patient access to data, and health IT-supported care coordination. The Office of the National Coordinator for Health Information Technology (ONC) identifies interoperability as a core foundational element of better care, at a lower cost and better health for all. 1 Lack of interoperability hampers the potential of EHRs to enhance health care delivery and improve outcomes, particularly as patients move across the care continuum. What s sorely needed is data portability, patient access to data, and health IT-supported care coordination. They are all fundamental to enhancing value and improving the quality of the health care delivery system. That s the consensus among leaders of many of Colorado s health care and information technology organizations, including Rocky Mountain Health Plans (RMHP), CORHIO, Colorado Medicaid, Quality Health Network and Colorado Community Managed Care Network (CCMCN). These leaders understand the value of an interoperable health data network. Health IT can enable value-based payment models, improve coordination of care and empower patients to take charge of their health. 2 None of this is possible without access to data; in addition to collecting and reporting data, providers need to be able to share it with each other and act on it. Making data more available, accessible and 1 Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, ONC 2 A collection of papers and reports documenting this success is available at

2 actionable lays the foundation for ongoing delivery system transformation and payment reforms. Changes proposed in Stage 3 Meaningful Use (MU3) that relate to data portability, transitions of care and patient access to data go a long way to making this happen. Because these proposed changes support the use of health IT to foster better care, better health and lower costs, they align clinical quality measures with quality improvement initiatives already in place in the Western Slope and across the state, adds Patrick Gordon, associate vice president at Rocky Mountain Health Plans. Background: Meaningful Use moves forward In March 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for Stage 3 of the Medicare and Medicaid EHR Incentive Programs, commonly known as Meaningful Use. 3 Separately, ONC issued a proposed rule to improve the way electronic health information is shared among providers and with patients (2015 Edition Health IT Certification Program). The CMS rule addresses provider responsibility, while ONC addresses the technology side. Together, they focus on making health system requirements for Meaningful Use more flexible, driving the interoperability of health IT across systems and between providers and, in doing so, improving patient outcomes. 4 These changes also go a long way to limit the EHR vendor practice of data blocking. Data blocking inhibits sharing patient data across practices; that sharing supports the health of individual patients and patient populations. To improve health and health care delivery, MU3 must support sharing health information through the most flexible technological means possible; it must also support true patient engagement. 3 The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the meaningful use of certified EHR technology. To receive an EHR incentive payment, providers have to show that they are meaningfully using their certified EHR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records. 4 Department of Health and Human Services announcement, March 20, 2015 Generally speaking, the new MU3 proposed rule simplifies and clarifies Meaningful Use and its role in health care reform, explains Chloe Bailey, PA-C, chief medical information officer of CCMCN, a non-profit network of federally qualified health centers. The proposed changes are intended to encourage more providers to continue progressing through Meaningful Use and creating the technical environment for a more efficient and sophisticated health care system. Perhaps most important, the changes may promote much better health IT interoperability if implemented correctly. If you don t connect the EHRs, if they can t share data, then they re just fancy typewriters. Kate Kiefert, Colorado Health Implementation Coordinator and State HIT Coordinator Data blocking impairs interoperability It has almost become a cliché to call what seems so simple EHRs communicating and working compatibly with each other the Holy Grail of health IT. But that s what it s become. Interoperability has been a requirement of Meaningful Use from the beginning, but it s often remained more theory than practice. EHRs frequently do not talk to each other. The whole point of an evolving standard to reach Meaningful Use, according to the ONC, is to enable an interoperable learning health system one in which electronic health information is available and can be securely and efficiently shared, when and where it is needed, to support patient-centered care, enhance health care quality and efficiency, and advance research and public health. 5 But some health IT vendors and even health care providers are blocking the free flow of data between entities that use different EHRs, according to an ONC report. 6 Examples include steep charges 5 ONC report to Congress: Report on Health Information Blocking, April ONC report, op. cit. 2

3 for interfaces to permit information exchange among physician practices and preventing one vendor from accessing the code needed to talk to another system. The ONC currently lacks authority to stop the practice. 7 In that same report, the ONC makes the case for why data blocking is an issue for providers and patients: To make informed health care decisions, providers and individuals must have timely access to information in a form that is usable. When health information is unavailable, decisions can be impaired and so too the safety, quality, and effectiveness of care provided to patients. Information blocking also impedes progress towards reforming health care delivery and payment because sharing information seamlessly across the care continuum is fundamental to moving to a person-centered, high-performing health care system. Further, information blocking can undermine consumers confidence in their health care providers by preventing individuals from accessing their health information and using it to make informed decisions about their health and health care. Patient data is often isolated in separate practices in EHRs created by different vendors. By themselves, EHR systems are fine for keeping one doctor s historical record of the patient and his or her patient population. But patients see more than one doctor, and for the record to be complete, the EHRs need to connect. If you don t connect the EHRs, if they can t share data, then they re just fancy typewriters, explains Kate Kiefert, Colorado health implementation coordinator and state HIT coordinator. The appropriate patient information should automatically and securely follow patients to each provider they see. Patients should also have access to their own comprehensive medical record that compiles all of their historical health information. But this doesn t always happen, and it s detrimental to patient care when it doesn t. We routinely find that EHR vendors are charging practices more than $5,000, and as much as $40,000, to interface with an HIE using standard interface protocols already required under ONC s Health IT Certification Program, says David Kendrick, MD, MPH, CEO of MyHealth Access Network, Oklahoma s HIE. Changes proposed to ONC s 2015 Health IT Certification Standards may mitigate these issues by requiring vendors to provide the ability to securely and automatically export data in standard formats to support interoperability. When software companies block access to clinical data, we no longer have the opportunity to create system improvements driven by reliable information, explains Jason Greer, CEO of Colorado Community Managed Care Network. It impairs care without unencumbered access to the data, we lack the information about the health of our communities and we also lose the opportunity for important information to follow the patient. As written, MU3 would give physicians better access to data and the ability to send it where and when they want. It s intuitive: Proposed changes to data portability, patient access and health information exchanges push interoperability standards further, explains Bailey. These requirements would create some oversight of vendors who have either maintained technical restrictions with their products that block data sending and receiving, or have created financial barriers to sharing meaningful data. The ONC report offers several such examples, including charging high fees to establish connections and share patient information, requiring customers to These requirements would create some oversight of vendors who have either maintained technical restrictions with their products that block data sending and receiving, or have created financial barriers to sharing meaningful data. Chloe Bailey, CCMCN chief medical information officer 7 ONC report, op. cit. 3

4 Patients have the right to have their complete, accurate medical record available whenever and wherever it s needed for decision-making about their health. David Kendrick, MD, MPH, CEO of MyHealth Access Network use proprietary platforms and making it costprohibitive to change EHR systems. Sometimes, data blocking is not intentional. Often, says Kiefert, it s the result of building systems specifically to meet certain specifications rather than with a view toward patients, providers and the future. It s like teaching to the test. When you teach students simply to pass a standardized test, are they really learning? Likewise, EHR vendors are building technology to meet the regulations. As a result, they often don t allow for the sort of interoperability needed to improve continuity of care and enhance outcomes. And sometimes, this teaching to the test method approaches the absurd. She offers one example. A vendor created a system that allowed providers to attest to MU by generating a continuity of care document in their EHRs. The document, which can be hundreds of pages long, could be sent to another provider via fax. That s not the point of Meaningful Use, but it still counts, says Kiefert. For now. MU3 and the 2016 Health IT certification rules aren t the silver bullet to end data blocking, says Kendrick, but they are a good start. To that end, Colorado stakeholders RMHP, CORHIO, Colorado Medicaid, Quality Health Network and CCMCN, joined by Oklahoma s MyHealth Access Network are endorsing aspects of MU3 that support data portability, transitions of care and patient access to data. Better data access means better transitions At the heart of care coordination and improved transitions of care is this: Data must follow the patient and be available wherever and whenever needed for decision-making that can affect the patient s health. As proposed in MU3, providers may communicate summary or transition of care records through any electronic means, provided the proper security and privacy protections are in place. In addition, MU3 places requirements on those who see new patients or receive them through a transition of care to reconcile the clinical data from multiple sources. For states and communities that have them, health information exchanges are an ideal solution to support these requirements provided the HIE allows the receiving provider to ask (query) the HIE for the necessary clinical data, explains Kendrick. Aggregation of data in a query-based HIE infrastructure greatly improves the care transition process and allows the most current data to be securely and appropriately retrieved by all providers who treat that patient. The use of Direct , the preferred protocol for exchange of health information under MU2, has generated several difficulties, Kendrick says. This is evidenced by the low numbers of providers attesting for Stage 2 of MU and CMS s recent move to revise the Stage 2 MU requirements. (See sidebar for more on MU2.) Beyond the fact that there are no comprehensive directories of provider Direct accounts, many providers have raised concerns that the standard documents pushed to them in the secure are too large and add little value to the care process, he says. As currently proposed, Stage 3 of MU includes an expansion of data transport options beyond the secure push. Stage 3 proposes to allow the use of query-based health information exchange, which enables providers to access the complete record when needed, rather than having an unexpected record pushed to them, Kendrick adds. This means referring providers can make data securely available to all subsequent providers of care to each patient. The proposed changes in MU3 close the loop and make it much more likely the data is accessible to the right people at the right time. 4

5 Patient-centered health IT Among the partners in Colorado, the consensus is this: Data must follow the patient. Patients have the right to have their complete, accurate medical record available whenever and wherever it s needed for decision-making about their health, Kendrick says. They need to be able to get this information into the hands of their providers, be they specialists, primary care physicians, emergency department clinicians or trusted care-givers. And, of course, patients need to be able to get the data into their own hands so they can become active participants in their own care. This is critical to get right. Another element of MU3 directly addresses the in their own hands aspect by expanding how patients can access data. Giving patients more access to data MU3 includes a measure giving the patient access to view online, download and transmit their health information within 24 hours of its availability, or via an application programming interface (API). An API refers to simplified connectors between different software systems that allow for easier transfer of data. This means patients could collect and incorporate health information from multiple providers and have access to it via a single portal, application, program, etc. Patients will have the ability to control how they receive information and will be able to use it as they see fit perhaps incorporating data from fitness devices, for example. Because this approach enhances availability of their health information, patients are better engaged in their own health care. And ultimately, says Gordon, this can change patients health outcomes because it improves the level of activation they achieve in maintaining their own health. Health information should be shared through a range of flexible options rather than being limited to a single provider s portal. So a patient, for instance, could download data from multiple clinicians to a secure mobile app. (Concerns persist about how to measure patient access; see sidebar on next page for details.) Making data portable Interoperability demands portability. Both the patient access and transitions of care provisions in MU3 and the 2015 Health IT Certification proposed rule support data portability which, simply understood, is the ability to use (access, share, etc.) data across different systems (EHRs, patient portals, etc.). In addition, under the proposed MU3 rules, EHR systems must allow providers to export care-summary data based upon provider-defined criteria; this lets them easily configure where and when the data is sent and stored. In other words, the clinician, not the EHR vendor, gets to designate the timing or trigger for the data export, and Proposed MU2 changes would alter reporting period CMS also issued proposed modifications to Meaningful Use Stage 2 (MU2), many of which were intended to better align with Meaningful Use Stage 3. Among the proposed revisions: changing the reporting period to a calendar year instead of a fiscal year; and allowing a 90-day reporting period in 2015 (vs. a full year) to accommodate the implementation of all the proposed changes. The latter is an issue of particular importance to achieving adoption, as the AAFP noted in its comments: Without this change, we are concerned that a significant number of family physicians and other eligible professionals will not be able to achieve Meaningful Use in The AAFP strongly encourages the agency to finalize this proposal. health_it/interoperability/lt-ehrincentive pdf 5

6 the storage location. This requirement that providers be able to choose message type and export it on a schedule (or based on a specific activity, such as creating a referral order) addresses several big barriers to interoperability. Flexibility and innovation are essential for interoperability. And interoperability is essential for value-based care. Shifting perspective As part of the 2015 Health IT Certification proposed rule, ONC expands the focus of its EHR certification to health IT in general, acknowledging the increasingly important role that other kinds of health IT are playing. Lead a horse to water, but don t force a drink: Patient data Making patient data accessible is crucial, but sometimes it s impossible to make the patient access the data. In terms of creating a patient interface, Bailey and other Colorado leaders want to avoid a requirement or measure of actual access as originally required. In fact, the proposed changes to MU2 reduce the provider requirement for patients to use technology to electronically download, view and transmit their medical records to just one patient. This is of particular value to safety-net providers those who care for the uninsured and the underinsured, says Bailey. Many providers have struggled with the task of implementing a portal in a timely manner to achieve this, and many more are concerned their patients are technically unable to access the portal and/or have language barriers that make it unrealistic to expect engagement, she says. By requiring that only a single patient need access his or her data, the capacity for digital engagement can be validated. It s part of a larger vision for health information technology, says Kendrick. Looked at as a whole, and in the context of proposed MU2 changes, MU3 asserts that lots of health information technology not just the traditional EHR is important to the care of patients. Health information exchanges, home medical devices and even apps and tools on patient and provider cell phones are all playing increasingly important roles and will need to meet standards when they provide specific clinical services. This new clarity around standards for interoperability is anticipated to spur innovation in health IT at all levels. Flexibility and innovation are essential for interoperability. And interoperability is essential for value-based care. In the service of value-based care Enhancing data portability, transitions of care and patient access to health information advances the three-part aim of better health, better care and lower costs. All of this is about value-based care. We are rapidly moving toward a health care system that rewards improvement in population health through smarter payment methods, better clinical processes and deeper patient engagement, says Gordon. Colorado has positioned itself favorably for advanced transformation opportunities such as the State Innovation Model and multiple CMS Innovations programs, and to support a creative Colorado Medicaid program. Innovative health IT efforts, including Meaningful Use requirements, have dramatically facilitated Colorado s efforts to better understand populations through both the digitization of health records and the ability to share those records with patients and providers. The issue only becomes more critical as more data is included. MU3 opens the door to new kinds of 6

7 data being measured data from nonclinical settings, including patient-provided data. Information about housing, transportation or unsafe home situations could inform how care is delivered, Kiefert says. The health care system is in an interesting state of transition. If we are going to improve health quality costs, we need effective and secure sharing of data. If you can t measure, you aren t going to be able to pay for it. And you need data to measure value. For Greer, it comes back to patients. We need access to data to become a proactively run health care system. Better, more precise data on populations allows public health organizations to more efficiently target their interventions, making the most effective use of health care resources. Allowing the information to follow the patient creates a safer and less confusing health care system for patients and their families. KATE KIEFERT Colorado Health Implementation Coordinator, State HIT Coordinator KATE KIEFERT serves as Colorado s state HIT coordinator in the office of Gov. John Hickenlooper, directing multi-agency strategies to improve the collection and use of health information enabling health system transformation and innovation. Kiefert facilitates alignment of health data policies and initiatives among state agencies, private and nonprofit sector partners at state and local levels advancing long-term objectives through technologydriven strategies. Prior to joining the governor s office, Kiefert served as director of policy and public sector initiatives at Colorado Regional Health Information Organization (CORHIO). She holds a graduate degree from the University of Denver and is a certified project management professional. PATRICK GORDON, MPA Associate Vice President Rocky Mountain Health Plans PATRICK GORDON joined Rocky Mountain Health Plans in 2004 as the director of government programs. He leads the Medicaid Accountable Care Collaborative project in Western Colorado. Within RMHP, he is accountable for the operational, financial and regulatory performance of the Medicaid, Dual Eligible, CHP+ and Medigap programs supported by the health plan. He previously served as executive director of the Colorado Beacon Consortium. He has led and implemented several strategic projects for RMHP and stakeholders in Western Colorado, including the design and implementation of a performance incentive arrangement with the State of Colorado and participating physicians to achieve Triple Aim objectives; the implementation of a Medicare Part D Prescription Drug program and targeted coverage arrangements for dual-eligible beneficiaries; and a Medicare service area expansion. JASON GREER CEO, Community Managed Care Network JASON GREER is the CEO of the Colorado Community Managed Care Network (CCMCN). CCMCN is a non-profit organization governed by Colorado s federally qualified health centers (FQHCs). CCMCN administers population health and clinical quality improvement programs on behalf of its members and their regional partners. CCMCN creates partnerships with like-minded organizations. Greer participates on several non-profit boards and health care workgroups across Colorado. He has been working in the technology field since 1997 and he has spent the last 13 years on using technology and data to create system efficiencies and better management of population health and cost outcomes with the FQHCs. 7

8 DAVID KENDRICK MD, MPH, CEO of MyHealth Access Network Communities selected by the Office of the National Coordinator for Health IT. Kendrick is a member of the board of directors of the National Committee for Quality Assurance and convening faculty for the Comprehensive Primary Care initiative. DAVID KENDRICK, MD, MPH, chairs the Department of Medical Informatics at the University of Oklahoma s School of Community Medicine, and serves the OU Health Sciences Center as the assistant provost for strategic planning. Kendrick is the principal investigator and CEO of MyHealth Access Network, Oklahoma s non-profit health information network, which ensures that every Oklahoman s complete health record is securely available where and when they need it for care and health decisionmaking. MyHealth was one of the original Beacon CHLOE BAILEY, PA-C, is a family physician assistant and is CCMCN s current chief medical information officer. She began working at CCMCN in 2010 in the role of their meaningful use program director, becoming the subject matter expert for Colorado s 18 federally qualified health centers. In her current role as CMIO at CCMCN, Bailey is involved with several programs relating to health reform innovations on both the state and national levels as well as population health management and research opportunities as they present. About Rocky Mountain Health Plans Founded in Grand Junction, Colo. in 1974, as a locally owned, not-for-profit organization, Rocky Mountain Health Plans provides access to affordable, quality health care enabling its more than 229,000 members across the Western Slope to live longer, healthier lives. About the Community Western Colorado is creating an accountable community that uses health IT in a meaningful way, adopts valuebased payment models, coordinates care and empowers patients to take charge of their health. We aspire to ensure the following: High-quality health care is affordable and accessible to all. Those who purchase health care are assured that care is effective, safe and appropriate. Patient care is a team effort, with roles that are well-defined, connected and collaborative. Patients have access to the support and information they need to take charge of their health and make their own decisions. Payment reform will foster reimbursement models that support accountability for population health and resource use. Information technology supports population health, helping providers predict outcomes, prioritize interventions and prevent disease. Health data is a community resource used in a secure way to support coordinated care at the population, practice and personal levels. Investments in information technology and health system transformation will improve quality of life and economic well-being across the state. Health is a community resource that requires leadership, stewardship, individual responsibility, community support and ongoing maintenance. For more information: Call us at us at ACC@rmhpcommunity.org Or follow us on Written and produced by Health2 Resources. Copyright 2015 RMHP