INTEROPERABILITY 1. What is Interoperability? a. National interoperability issues and standards b. State interoperability issues and standards 2. Discussion of the Types of Interoperability 3. What does this mean to Providers, Clients, Vendors a. Specific Provider Challenges 4. Current Standards and Legislative Initiatives The E H R Journey 1990 The Time Line present OIG HIPAA 1990 Institute of Medicine (IOM) publishes; Crossing the Quality Chasm Patient Safety reports to manage the large amount of information involved and to provide rapid access to that information, computerization of the clinical data base is logical
3/2001 IOM and the Committee on Quality of Health Care in America Make new recommendations to the quality of care Electronic Health Record (E H R) Clinical Alerts and reminders Computerized workflow Computerized decision support there must be a renewed national commitment to building an infrastructure to support health care delivery, consumer health, quality measurements (and improvements) public accountability, clinical and health services research and clinical education And Health Information Technology (HIT) is formed HIT begins a committee on Electronic Patient Records (E P R) The consumer would have electronic access to their own records
And Health Information Technology (HIT) is formed 2003 HIT presents first report Less than 10% of all facilities in the US meet the minimum levels of the 4 criteria BH field extends beyond the medical services Social, vocational, support services BH reimbursement is extremely complex 8% of the BH budget is spent on IT infrastructure 2003 SAMSHA becomes engaged Represent BH to begin to meet the criteria of IOM and HIT vision Launch a National initiative Decision Support 2000+ User data User tools User resources
Decision Support 2000+ redefines the initiatives Full public health model Adoption of data standards for software State data infrastructure grants Work directly with the consumer community on P H R* Disk Writeable CD chip *Created the National Health Information Network (NHIN) NHIN s Vision A National, comprehensive, interoperable, longitudinal system of individual electronic health records together with individual clinical decision support and analytical aggregation capability.
NHIN benefits Remote access P H R Emergency access Elimination of repetitive history taking Elimination of possible error in patient recall Elimination of medication adverse effects NHIN woes Privacy Confidentiality Security Data leaks Dilution of federal privacy rules
2003 Congressional Questioning of NHIN Q. What are the main protections on privacy and confidentiality in our current, largely paperbased health records system? A. Fragmentation, inefficiency, illegibility and general chaos. Q. What are the main risks to privacy and confidentiality in the NHIN? A. Elimination of the chaos and diffusion of greater levels of information including 3 rd parties for nonmedical uses. 2004 President George Bush outlines his initiatives A national health information infrastructure initiative Establishes the Office of the National Coordinator of Information Technology (ONCHIT) Places them in DHHS as a direct report
ONCHIT vision Promote the development of the nation s health information infrastructure to improve patient care Senator Kennedy introduces legislation to support ONCHIT adding them to the Affordable Health Care Act through Title XXIX ONCHIT was now funded 2004 President Bush Continues April 27, 2004 the President issues an Executive order for widespread deployment of health information technology within 10 years to help realize substantial improvements in safety and efficiencies May 6, 2004 Dr. David Brailer is appointed the first National Coordinator Supported was a direct report to Dr Leavitt of DHHS
Mission of ONCHIT crafted Technology standards Interoperability Adoption of technology Policy and research An RFP was immediately released for a certification body focused on the mission for E H R with future development of the E P R AHIMA HIMSS ALLIANCE September 2004 Meet to create an organization called the Certification Commission for Healthcare Information Technology (CCHIT)
July 2005 CCHIT activities as a voluntary, private sector, organization CCHIT released their draft of certification standards for an E H R. They lack the critical needs of BH; - Assessments - Treatment planning - Progress note - Medications - Reimbursement /scheduling The needs of a physical E H R differ greatly from BH needs September 2005 ONCHIT awards CCHIT the RFP of 3 years to develop Certification criteria and an inspection process for: Ambulatory E H R s for office based physicians or providers Inpatient E H R s for hospitals and health systems The network components through which they interoperate
May 06 CCHIT completes the E H R certification standards Product functionality 129 criterion Lacks Assessments, Treatment Plans, Progress Notes, Outcomes, Medication to BH Interoperability 1 - Receiving of Lab results Security 24 criterion HIPAA holds fast to security rules Reliability 15 criterion 3/07 CCHIT selects BH HL-7 moves to accreditation Electronic Health Record Functional Model Work began 3/05 42CFR2 compliant Privacy Confidentiality Patient / Consumer access to their own records as a default condition
E H R today Ambulatory standards are now in place The first rounds of audits have generated questions BH software vendors under pressure Complex billing engines ANSI standards Clinical requirements that are standard driven Scheduling functions that require linking capabilities BH providers invest less then 10% of their budgets to IT needs. CCHIT announces MH standards to be published 2010 2014 moves closer everyday INTEROPERABILITY WHAT IS IT?
INTEROPERABILITY COMMUNICATION THE ABILITY OF SOFTWARE AND HARDWARE ON DIFFERENT MACHINES FROM DIFFERENT VENDORS TO SHARE DATA (http://webopedia.com/term/i/interoperability.html) INTEROPERABILITY In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged. http://en.wikipedia.org/wiki/electronic_medical_record#cite_note-5 ^ Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601)
Levels of Data in Which HIE May Take Place Level Data Type Example 1 Non-electronic data Paper, mail, and phone call. 2 Machine transportable data Fax, email, and non-indexed documents. Levels of Data in Which HIE May Take Place Level Data Type Example 3 4 Machine organizable data (structured messages, unstructured content) Machine interpretable data (structured messages, standardized content) HL7 messages and indexed (labeled) documents, images, and objects. Automated transfer from an external lab of coded results into a provider s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.
LEVELS OF INTEROPERABILITY Electronic health information can be shared at different levels. The level of sharing depends on what is available, what is permitted and what needs to be done with the information at the receiving end. Levels of Sharing Lower level sharing (Technical Interoperability): Information is shared in a human readable format. One may view the information such as a signed document or laboratory report. Individual data elements are not available for further action.
Levels of Sharing Lower level sharing (Technical Interoperability): Example: Making signed releases of information or treatment plans available for viewing and for maintenance as part of the permanent record without altering the document or further using the information for computing purposes. Levels of Sharing Higher level sharing (Semantic Interoperability): information is shared in a human readable and computable format. The individual laboratory result can trigger an alert and be entered into a specific field for graphing trends. Individual data elements are available for further action within the receiver system.
Levels of Sharing Higher level sharing (Semantic Interoperability): Example: Sending a medication list to a client PHR as an update to the specific list, in the receiving list format. Levels of Sharing Highest Level of Sharing (Process Interoperability) the best practices for healthcare including protocols, guidelines, care plans, and rules [would be] transferable from one organization to another http://geekdoctor.blogspot.com/2009/01/hail-to-chief.html
Levels of Sharing Highest Level of Sharing (Process Interoperability) Example: Quality Assurance Checkpoints in [the] in house system would be [eliminated or require duplicate entry] able to track from information received TECHNICAL INTEROPERABILITY The ability to send a human readable record from place to place A fax machine, secure email, and sending of free text from EHR to a PHR are examples of technical interoperability May also be called Basic Interoperability http://geekdoctor.blogspot.com/2009/01/hail-to-chief.html
SYNTACTIC INTEROPERABILITY Messages between computers have a common structural definition (format) Refers to the spelling and grammar of a programming language. Computers are inflexible machines that understand what you type only if you type it in the exact form that the computer expects. The expected form is called the syntax. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028714.pdf#page%3d2&search%3d%22interoper ability%22 SEMANTIC INTEROPERABILITY The ability to send human readable and computable records from place to place An electronic health record with vocabulary controlled, structured problem lists, medications, labs, and radiology studies sending this data into structured lists within a personal health record is an example of semantic interoperability http://geekdoctor.blogspot.com/2009/01/hail-to-chief.html
PROCESS INTEROPERABILITY A future concept? (can) best practices for healthcare including protocols, guidelines, care plans, and rules be transferable from one organization to another? Sending a clinical summary from one organization to another would immediately result in event driven medicine based on all the new data provided http://geekdoctor.blogspot.com/2009/01/hail-to-chief.html IMPACT of INTEROPERABILITY STANDARDS on CLIENTS Continuity and Coordination of Care, EHR portals, PHR interfaces, empowerment, client-provider messaging PROVIDERS Client history and current care information, Coordination of services, laboratory or radiology results, eligibility information, accurate medications, consultations or transfers of care, client-provider messaging
IMPACT of INTEROPERABILITY STANDARDS on: Providers and Regulatory Agencies Performance measures, outcomes reporting, CSI, CalOMS, Fiscal or QA audits Process flows and QA Tracking PAYORS Eligibility information, claims, audits, remittance advisements Example of HIE in operation at VA BHIE Outpatient pharmacy data, allergy data, patient identification correlation, laboratory result data (including surgical pathology reports, cytology and microbiology data, chemistry and hematology data), lab orders data, radiology reports, problem lists, encounters, procedures, and clinical notes http://en.wikipedia.org/wiki/bhie
Example of HIE in operation at VA BHIE BHIE is currently integrated into the VistA EMR (electronic medical record) system used nationwide in Department of Veterans Affairs hospitals. This integration is able to provide increased efficiency in healthcare for veterans. Veterans Hospitals have regional specialized capabilities, and veterans often travel to receive specialized care. Their VistA medical records are able to be transmitted in their entirety using this protocol. Contract Providers Victor Family of Services
What would access to current electronic client information do for Contract Providers within the Referral, Intake, and Delivery of Services processes? Referral Process Complete historical information that would allow more thorough assessment for appropriateness of placement Faster access to information associated with the referral process More private, secure, recordable, and efficient method of sharing confidential information Complete medication history for Psychiatric Services Assessment More complete medical history profile for clients served
Intake Process Simplify the process Minimize redundant data entry/management processes Continuity of quality information Streamline and improve quality of the intake experience for clients and their families Lessen administrative burden for initiating/actualizing service delivery More efficient and effective Treatment Authorizations process to minimize disruption of services Contract Providers and Counties can work together more efficiently and effectively in providing quality services to clients and their families Delivery of Services Standardize the documentation of the services we provide (SB785) More effective focus of Clinical and Medical Staff Consistent electronic documentation environment Less time spent on administrative tasks and more quality time delivering clinical services Maintain focus on improving the quality of services provided Reduce the costs that are incurred to provide services to clients and their families Custom Reporting Requirements would go away
EMR/EHR Interoperability with County California EMR/EHR Software Vendors Anasazi Askesis Development Group Claim Trak Systems Cerner Clinicians Gateway Clinivate Credible Behavioral Systems DeFran Systems The Echo Group Exym Foothold Technologies HSIS systems Infinity/Civerex InfoMC NetSmart Technologies NextStep Solutions Qualifacts Systems Sequest Technologies Sierra Systems UNI/CARE Systems Welligent
Given the lack of Semantic and Process Interoperability status in the State of California, what are some challenges that stand in the way of providing patient centered cost effective services to clients and realizing the benefits of a unified EMR/EHR from the Provider perspective? Challenges Service Delivery Challenges End user training for multiple systems throughout the state Initial On-going Multiple county variations in their EMR/EHR processes for like services End user buy in Internet Connectivity Problems/Loss and the problem resolution process and delay exceptions/alternative processes
Challenges - Continued Chart Management Challenges What about items that are represented in a paper chart that are not a part of an EMR/EHR? Records from the court Supplemental Information for charting purposes Assessments Outcomes (County required and Provider required) Victor Family of Services is adopting the CANS Assessment JV220 s (Court Authorizations for Psychotropic Medications) What is the chart of file for auditing, consumer release, or subpoenas? Role clarifications for paper chart vs.- the EMR/EHR Challenges - Continued Process and Fiscal Management Challenges Quality Assurance Checkpoints we have in our in house system would be eliminated or require duplicate entry MediCal vs.- Non MediCal based services Fiscal Services Reconciliation/Financial Reporting/Cost Accounting Eligibility Verification Treatment Authorization Process Change Management process with multiple counties Managing Costs
Challenges - Continued Interoperability Challenges Standardized Secure Network Interfacing with Counties Systems/Data reconciliation Interoperability within Software Solutions Interoperability amongst Software Solutions Privacy and Security User Management Fiscal/Clinical Quality Assurance Gaps Not accounted for in current EMR/EHR resulting in redundant data management Examples: Case Plans & Reports requirements tracked, with billing lockout for overdue Client Plans. Juvenile Hall and/or Hospital days tracked per client, with billing lockouts applied when client is ineligible. MediCal eligibility tracked per client, with billing lockouts applied when client is ineligible. Limits on Med Support minutes, billing lockout prevents billing for med support services in excess of the allowable amount per client. Service logs and summaries of all services used to track staff service delivery percentages, service minutes/ru, MediCal and non-medical service minutes, MHSA minutes, other.
Victor Community Support Services, Inc. Site Location Period Audited Annual EPSDT (1) EPSDT Audit History Sample Claims Total Units of Time Disallowed Error Rate Recoupment $$ Fiscal Year 2003-2004 County A Apr 04 - Jun 04 $2,867,832 5,000 (2) 0 0.00% $0.00 County B Apr 04 - Jun 04 $3,234,018 16,989 60 0.35% $141.60 Fiscal Year 2004-2005 County B Jul 04 - Mar 05 $3,181,825 16,782 0 0.00% $0.00 County C Jul 04 - May 05 $1,172,000 11,438 75 0.66% $181.50 County D Jul 04 - Jun 05 $2,172,737 14,738 361 2.45% $548.62 Fiscal Year 2005-2006 County E Jul 05 - Jun 06 $1,597,134 17,558 77 0.44% $154.17 County D Jul 05 - Jun 06 $2,501,999 14,194 92 0.65% $183.90 County B Jul 05 - Jun 06 $3,085,187 16,782 22 0.13% $47.32 County A Jul 05 - Jun 07 $4,529,688 16,198 414 2.56% $901.03 TOTALS $24,342,420 129,679 1,101 0.85% $2,158.14 (1) Annual EPSDT $$ reported are contract amounts for the period audited. (2) Sample Claims Total is estimated. Clients and Cases Program Summary Report: Client Information Victor Community Support Services 1/1/2008 to 12/31/2008 - All Ru's Clients with Open Cases During Reporting Period 691 Clients Open Cases During Reporting Period 860 Cases New Cases Opened During Reporting Period 573 66.63% Open Cases Receiving No Services In The Last 30 Days 27 3.14% Case Funding Clients Percent Medi-Cal Cases 642 75% Non-Medi-Cal Cases 218 25% 26.5(AB) Cases 0 0% (Total May Be More Than 100 Percent) Client History Clients Percent Clients with Substance Abuse History 449 65% Clients with Trauma History 396 57% (Total May Be More Than 100 Percent) Referral Source Category Cases Percent County Mental Health 113 13% Human Services 7 1% Other 440 51% Probation 194 23% Self/Family 35 4% Unknown 71 8% Client Ethnic Category Clients Percent African American 197 29% American Indian or Alaska Native 8 1% Asian 18 3% Caucasian 210 30% Hispanic/Latino 213 31% Native Hawaiian or other Pacific Islander 10 1% Other 35 5% Primary Language Category Clients Percent Asian 5 0.72% English 676 97.83% Middle Eastern 3 0.43% Other 2 0.28% Spanish 5 0.72% Male Male Female Female Total Total Age Groups by Gender Clients Percent Clients Percent Clients Age 0-5 90 13.02% 76 11.00% 166 24% Clients Age 6-12 122 17.66% 89 12.88% 211 31% Clients Age 13-18 196 28.36% 110 15.92% 306 45% Clients Age 19-22 5 0.72% 2 0.29% 7 1% Gender Totals 413 59.77% 277 40.09% 690 99.86%
State Leadership, County Leadership, Software Vendors, and Providers would prioritize co-developing practical standards and methodologies for Semantic and Process Interoperability of data systems/information for delivery and documentation of all medical services. INTEROPERABILITY ACRONYMS AHIMA: ANSI: BHIE: CCHIT: EPR: EMR EHR HIMSS: HIT: American Health Information Management Association American National Standards Institute Bidirectional Health Information Exchange Certification Commission for Healthcare Information Technology Electronic Patient Record Electronic Medical Record Electronic Health Record Healthcare Information and Management Systems Society Health Information Technology
INTEROPERABILITY ACRONYMS HITSP: Healthcare Information Technology Standards Panel HL7: Health Level 7 (An ANSI standard for healthcare specific data exchange between computer applications.) IOM: Institute of Medicine NHIN: National Health Information Network ONCHIT: Office of the National Coordinator of Health Information Technology SAMHSA: Substance Abuse and Mental Health Services Administration WEDI: Workgroup on Electronic Data Interchange RESOURCES http://www.lctjournal.washington.edu/vol3/a 016Dunlop.html#top Discusses legislation, current and pending that impacts interoperability and EHRs http://geekdoctor.blogspot.com/2009/01/hailto-chief.html Discusses types of interoperability, provides definitions, great blog on EHRs in general
RESOURCES http://www.himss.org/asp/topics_integration.asp EHR issues, discusses interoperability and integration. Provides current standards and legislation information. http://www.hitsp.org/default.aspx Developing and adopted standards, FAQs, news and events. RESOURCES http://www.cchit.org/ Provides information on EHR related standards, including interoperability, for ambulatory http://www.ahima.org/ Provides resources on all areas of health information management
RESOURCES/LINKS http://ansi.org/ http://wedi.org/ http://www.hl7.org/index.cfm