Nuance Communications and EHR giant Epic have partnered to integrate the voice and language tool vendor’s AI-powered virtual assistant into the EHR, the companies announced at HIMSS18.

Nuance launched its AI-powered virtual assistant for consumer and automotive vendors like American Airlines, Amtrak and FedEx in September. Officials said Dragon Medical Virtual Assistant will streamline clinical workflows to improve caregiver productivity and efficiency.

The partnership with Epic will put the tool into the EHR workflow.

“Technology needs to be unobtrusive and support the process of providing high-quality patient care,” David Ting, MD, Massachusetts General Physicians Organization CMIO, said in a statement. “Having Nuance’s AI-powered virtual assistant technology embedded into Epic will help make a new generation of patient care a reality – for both clinicians and patients.”

The partnership will include three product innovations. Epic Haiku for providers will create virtual assistant-enabled workflows, like asking for patient information and lab results. With Epic Rover, nurses can use the virtual assistant to interact conversationally with flowsheets to enter and confirm patient vitals.

Epic Cadence will scheduling staff, especially those with disabilities, a platform to converse with the virtual assistant to check provider schedules, and create, look up and cancel patient appointments with voice and natural dialogue.

All of the new tools will run on both iOS and Android mobile devices.

“Nuance’s AI-powered virtual assistants with conversational AI functionality expand the ways that physicians and care teams can capture and retrieve patient information,” Epic President Carl Dvorak said in a statement. “We expect them to be a catalyst for changing how and what physicians are required to document in progress notes.”

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

LAS VEGAS -- In his keynote speech at HIMSS18 on Friday, U.S. Secretary of Veterans Affairs David Shulkin, MD, confessed: "I always believed I would be the last doctor in America to go an electronic health record. I loved my paper."

Today, he sits atop an agency amid one of the largest EHR transitions in history -- with a ticket price to match. And three months ago, Shulkin hit pause on contract negotiations with Cerner because he was "concerned that way we were approaching this interoperability, the way that the industry was approaching this, was not going to get us where we needed to go.”

For the past three months, VA has been focused on working with "many in the community, and many in the industry, to get this issue of interoperability correct. This work has been extremely productive, and we'll end up with a very important result for veterans and hopefully for everyone else in the country,” Shulkin said. "This is too big of an opportunity, too big of a contract, too important to our veterans and the country, not to get this right.” 

One of the results of that effort is that VA has issued a new RFP for an API gateway, through its new Lighthouse platform.

"In addition to the EHR, we recognize that there's going to need to be new analytics capabilities to integrate this information, and we're going to work with the API gateway to accomplish this capability," said Shulkin. "I have to tell you the cooperation we've been getting from the major vendors, and particular the Cerner Corp., has been extraordinary."

He said VA is seeking a model EHR incidence, with common data standards published in the public domain, like the National Library of Medicine. 

“We're going to be able to map the electronic medical record to the FHIR APIs,” he said. “We're asking industry to help us build this API gateway, asking industry to open API access to all developers and are working with industry to stop the practice of information blocking."

Part of the momentum has to come from the provider side, and Shulkin called on them "to open your API gateways to VA, so we can access all the veteran data in a bi-directional way. We want to work together on patient mediated data exchanges, and it's essential that we work together to share all of these best practices as we do this."

He said VA is "committing to an open API pledge – committing to accelerating the mapping of health data to the industry standards, committing to make all FHIR resources, to provide APIs available to developers and to provide a common data set available to everyone who wants to work with us."

So far, 11 leading health systems – including Geisinger, Cleveland Clinic, Mayo Clinic, Rush and UPMC – that have also taken that pledge.

"We want this coalition to be much bigger, much better. Because when providers take this commitment it's a clear signal to industry that we need them to step up and move in this direction," said Shulkin. "When your organization makes this pledge, you're giving up on this belief that you can use your data in a proprietary way – that this is a business advantage to keep your patient data within your organization. You're opening things up. Once you do that, there's no looking back."

But ultimately, it's "the right thing to do," said Shulkin. "It's what's been needed for years. And if we say we need it, the industry will come along with us."

"This task at hand is not a usual task," he said. "But this is the time for us. This is the opportunity that so many of you have worked toward for years. This is the momentum we need to be able to get this done."

What began as an underground mission ...

VA is a longtime IT leader, of course, having developed its own pioneering VistA system back in the 1970s. Clinicians have been generally very happy with the EHR.

"The reason why it worked so well is that the VA administrators at first forbade it from happening," said Shulkin. "This was an underground mission by the clinicians in VA. They were called the Hardhats. And while they would see patient during the day, they would code at night, slowly building the system."

Since then, many great things have happened because of it. Shulkin cited the first barcoding of medications discovered by a VA nurse and the fact that VistA is open source, as examples. 

"If you ask many clinicians, including myself, this is a very good system," said Shulkin. "It's easy to use. It's worked extremely well and has had tremendous benefits."

But the challenge is that over the years, VistA has evolved into 130 different systems, each working a bit differently, customized to the needs of its particular clinical environment.

"Looked at in the context of today's way of operating systems, you can understand the challenges," he said. "We have been able to keep 130 systems going, but as you can imagine, that is getting more challenging. We're sort of holding them together with band-aids. It's getting extremely costly to maintain them and extremely difficult to get the coders to keep them up and running."

So Shulkin this past year used a determination of findings to make a direct contract solicitation to Cerner, to put VA on the same system being rolled out by the Department of Defense – something he said is in the public interest.

There were four reasons he made that decision, said Shulkin.

"The first is, I could not convince myself that it benefited veterans for the VA to be in the software business. That is not one of our core competencies. We have spent billions and billions of dollars trying to do that. And looking into the future, this was going to be an issue for us."

The second was that "having 130 different instances is not a contemporary approach to managing a modern healthcare system," he said. "We need to be able to start focusing on what works, and processes that are similar across the country. In order to do that, we need to go from 130 instances to one instance."

The third issue, of course, was DoD and VA interoperability: "For 17 years there have been calls from Congress, from blue-ribbon commissions, white papers, saying that we needed to have true interoperability if we're going to protect the health of our veterans as they transition out of the military,"

And the fourth reason is that "to meet veterans' needs, we are increasingly working with our community and academic partners," said Shulkin. "Today, 36 percent of care for our veterans happens out in the community. If we can't get information to our community health partners and back from them, we're not going to be able to get veterans the best care and coordinate it the way that we need to."

As it starts to roll out its own MHS Genesis project in the Pacific Northwest, DoD has been "extraordinarily helpful in sharing lessons with us," he said. But it's a "very complex implementation strategy," and that interoperability is much easier said than done.

DoD lessons so far: Workflow matters

Sharing the stage with Shulkin at HIMSS18 was Navy Vice Admiral Raquel Bono, director of the Defense Health Agency.

"The more that we can set our sights on the collective goal of integrating across all the elements of healthcare, to include the DoD and the VA, the more we're able to define what we need for interoperability and be able to leverage each other's expertise to be able move forward," she said.

Mayo Clinic Chief Information Officer Cris Ross, who interviewed Shulkin and Bono, asked her what have been some initial lessons learned from the MHS Genesis project.

There have been many so far, and "we don't have time for all of them," she said.

But two keys in the early going were that "you need to make sure that your governance process is intact, and you need to understand how you're going to make decisions about what you're going to do. That's extremely important,” she said.

"And when you talk about governance, it's not who reports to whom, or who's the boss of whom," she added. "It's how you make decisions. Make sure you're making decisions for what's best for the enterprise, not individual sites."

Another big lesson has been that "you can't do too much training for workflow adoption," she said. "Workflow adoption is the crux of the change management that's needed to successfully deploy an EHR system. One of the areas we're working on with VA is identifying those areas and making sure we have unanimity of those workflows because that will be a large part of that."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Athenahealth CEO Jonathan Bush said the company he founded with former US CTO and advisor to President Barack Obama Todd Park began with bad software. That’s right. 

“We literally built a company proudly on the fact that we had bad software,” Bush said during an interview at HIMSS18. “Little by little by little as we got bigger and bigger and bigger that bad software made it harder for even us who knew it so well to use.” 

What emerged from those early days, however, is an appreciation for design and user experience -- not just for customers but also for internal and external developers and innovators. 

“You’ve got a couple thousand developers,” Bush said. “They need a really beautiful, easy to use environment to make a big impact themselves. So that’s what we’ve been really focused on.”

That initially led athenahealth to advance its approach to innovation, connectivity and data exchange by building a platform to enable those. 

“Our dream is to get all these customers on the cloud and do our own iterative releases of our products,” Bush said. “But also to invite people who aren’t us to build products using our technical staff as a platform.”

Bush is working to orient the company toward moving all of athenanet to a series of self-contained micro services that would allow developers to work faster, but also making it possible for developers to come in and walk around athenanet “pretty hard” and build a product without breaking anything.

“I went from ‘we have to let other tech companies connect to athenanet and to the base,’ where we are now, to ‘you’ve got to actually let other people build in athenanet,”’ Bush said.

With so much talk about interoperability at HIMSS18 and year-round in the healthcare industry, Bush explained that athenahealth is connected to 96 percent of the Epic install base via a node on Epic’s Care Everywhere network. It means athenahealth has to trade with any other entity on that network.

“You can’t pick and choose,” Bush noted. Athenahealth records, in turn, are available to Epic shops such that any hospital that uses Care Everywhere on Epic has to trade with any other entity on that network. 

Today, Bush encapsulates his 20 plus years leading athenahealth, as preparing the company for challenges ahead.

“We’re coming out better on the other side,” he said, “in a better position for doing the right work.”
 

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

The concept of a "post-EHR" era is one that's been explored – on this website, at least– since the beginning of 2014, if not earlier. Four years later, an action-packed week spent at HIMSS18 offers irrefutable proof that the idea is now reality.

At this writer's first HIMSS conference, more than eight years ago, EHR technology was still sufficiently novel that HIMSS10 featured something called the "Electronic Health Record/Electronic Medical Record Pavilion and Theatre," where curious attendees could learn about this newfangled way of storing patient data, one that wasn't made of bleached wood pulp.

At HIMSS18? There was the day-long Machine Learning & AI for Healthcare event and the Blockchain Forum, HIMSS VentureConnect and Rockstars of Emerging Healthcare Technology. The Innovation Live showcase in Hall G was populated with leading-edge companies touting AI, augmented reality, biometrics, IoT and much more. And far from theoretical, many of those technologies are already on the minds of leading CIOs.

Clearly, we've come a long way in less than a decade. EHRs are old hat, a basic necessity for so much of the advanced work that's been accomplished in recent years. But a lot of problems that have been around for just as long have still yet to be solved.

To the surprise of precisely no one, interoperability remains the biggest.

Yes, the HIMSS Interoperability Showcase offered a heartening object lesson in the advances made in data exchange, with real-world use cases focused on organ transplants, cardiac events and medication management to help fight the opioid crisis.

But the big picture goal remains elusive. The frustration evinced by ONC chief Donald Rucker, MD, over lingering challenges such as purposeful information blocking was palpable: "We will be working with CMS to make sure some of the more parochial interests align for the common good," he said. (And yes, that means possible fines.)

CMS Administrator Seema Verma said it was "not acceptable to limit patient records or prevent them from seeing their complete history." Indeed, her office aims to put patients at the center of its interoperability plans, pushing patient-mediated exchange efforts such as MyHealthEData and Blue Button 2.0.

Verma appeared at HIMSS18 alongside a surprise guest, White House Senior Advisor Jared Kushner. He put out a similarly strong-voiced (if vaguely detailed) call to finally "make interoperability a reality for all Americans."

Clinician burden is a drag, in more ways than one

The Trump Administration is enamored of deregulation, of course, and ONC seems ready to take that approach when working to address another longstanding challenge for health IT: clinician burden and other complexities related to stringent documentation requirements and suboptimally designed EHR systems.

"We feel that we need fewer regulations, rather than more," said ONC's John Fleming, MD, deputy assistant secretary for health technology reform.

That may well partly be the answer after years of tightly-formulated rules related to EHR certification, meaningful use, quality reporting and other assorted box-checking and hoop-jumping for providers and vendors alike. 

Another way is to tap into more of the buzzy energy that was palpable everywhere in Las Vegas, from the tiniest corners of Hall G to the city-block-sized booths in the main exhibit hall. There were nearly 45,000 very smart and passionate people at the Venetian-Sands this past week, and many of them have some pretty good ideas that could help nudge these issues forward.

Even sprawling federal agencies like the VA are ready to leverage more innovative expertise. The agency has hit pause on its massive Cerner EHR modernization to help sort out some of the technical impediments to interoperability with the DoD and community health centers – and at the same time it's also looking for help from any number of private sector coders.

Through the VA's new Lighthouse platform, "we're going to be able to map the electronic medical record to the FHIR APIs. We're asking industry to help us build this API gateway, asking industry to open API access to all developers,” said VA Secretary David Shulkin, MD. "This is too big of an opportunity, too big of a contract, too important to our veterans and the country, not to get this right.”

Consumerism reshaping patient and physician priorities, AI is here to stay

Meanwhile, it was clear that things need to improve in other areas too. At the newly-renamed Patient Engagement and Experience Summit, for instance, Adrienne Boissy made the case that empathy and intuitive design must be brought to bear on healthcare settings.

Already, some of the biggest and most successful companies in the world are working in earnest to start bringing their own talents to the healthcare space, and there's plenty that can be learned from the revolutionary products they've proliferated.

"The Amazons and Apples of the world have mastered service, and they are coming for us," said Boissy, chief experience officer at Cleveland Clinic Health System. "We need to dream bigger."

In interviews with an array of health system execs and vendors on the show floor, it was apparent that healthcare organizations – the smart ones, at least – agree.

They're more convinced than ever that the smartphones have become our appendages, the online UX we take for granted has caused a sea change in what healthcare consumers have come to expect, and that a competitive landscape demands that they take patient and clinician experience much more seriously.

In the meantime, even as those big challenges continue to get sorted out, there was no shortage of hugely exciting innovation on view in Las Vegas – even if there was also more than a little hype.

Blockchain showed itself to already be having an impact on real-world use cases. There were precision medicine advances touted by Google, Oracle, Microsoft and others. Artificial intelligence applications – existing and predicted – were everywhere, from fetal monitoring and enterprise imaging to heart disease and clinical trials.

Keynoter Eric Schmidt, former executive chairman and current technical advisor to Google parent company Alphabet, set an appropriately optimistic tone to kick off the week.

While "EHRs are an incredibly important breakthrough in getting data in place," he said, a combination of cloud infrastructure, deep neural networks and an "explosion of data" mean healthcare is "closer than many think we are" to a fundamental transformation.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Artificial intelligence and machine learning permeated HIMSS18 such that the dynamic duo was just about everywhere in Las Vegas last week.

From expected experts such as long-time Google executive Eric Schmidt to surprise speakers, notably White House Senior Advisor Jared Kushner, discussing it on stage, the promise was palpable, the use cases more numerous than ever before. 

Add EHR vendors to that roster. Allscripts, athenahealth, Cerner, eClinicalWorks and Epic revealed big plans for adding AI into the workflow in forthcoming iterations of their electronic health records platforms.

eClinicalWorks CEO Girish Navani said its next EHR—which he explained will be launched in October, available in early 2019, and on display at next year’s HIMSS Global Conference & Exhibition — will include distinct panels for pop health, telemedicine, voice interactions and machine learning-based clinical decision support, all running on perhaps a large Microsoft Surface screen.

Anyone who hoofed it over to Microsoft’s booth may have encountered a rendering of something at least conceptually similar in the form of a Surface monitor displaying Epic’s EHR and AI running in conjunction with Microsoft’s Azure. Ochsner Health System announced that after a three-month pilot it is moving the system into production to more accurately detect health patterns so it can create more proactive preventative treatment plans.

Epic rival Allscripts also partnered with Microsoft to bring an Azure-powered EHR to HIMSS18 that CEO Paul Black described as "a bold, imaginative new EHR."

Epic on Friday also unveiled a new partnership with Nuance to integrate the latter’s AI-powered virtual assistant into the Epic EHR workflow.

Athenahealth, for its part, brought a virtual assistant called Epocrates Connect that it said improves connectivity via smartphones and in late January the company partners with NoteSwift to inject AI into the workflow with a focus on making charting easier for doctors.

Wait, should AI be free?

EHR vendors were not the only ones giving a glimpse of AI. In addition to so many startups on the HIMSS18 show floor, Siemens Healthineers showed AI features in its cloud-based imaging software and Caradigm said it is adding AI into its population health tools.

Caradigm’s CEO Neal Singh struck a bold tone about the future of artificial and machine learning, too.

“If you think about AI, most vendors say they’re an AI company — but AI should be free,” Singh said. “We want AI to be a core capability not a product. AI shouldn’t be a separate thing, it should be infused ambiently and embedded into workflows.”

Saying that AI should be free naturally evokes ‘it depends on what your definition of the word free is,’ because it makes more sense for existing tech companies than pure-play AI upstarts.

Read more Innovation Pulse colums from Healthcare IT News.

Hospitals have to pay for Caradigm’s platform or subscribe to eClinicalWorks cloud service, of course, but at least those two vendors are saying that they will not charge extra for the AI and machine learning capabilities. An Epic spokesperson said the there is a ticket price or the Nuance tool but not an additional license from the EMR maker.

It’s worth pausing to note that what we saw at HIMSS18 was marked progress on the AI and machine learning fronts — it was a beginning, not an endpoint, to incorporate the technologies into next-generation EHRs, imaging and pop health platforms.

What healthcare has now: A path forward

Whether AI ends up coming from a not-yet-known killer app that ties data sources and information together in new ways much like e-mail, the Internet and smartphones have done or from tech stalwarts incorporating it into their platforms, or some combination of both, one thing emerged at HIMSS18: Healthcare is at a critical moment for both data and innovation.

Indeed, what we actually need for AI and machine learning to advance is clean data for inward and outbound connectivity that fuels interoperability and modern data exchange. Without those, AI and analytics tools will be limited by dirty data.

“Healthcare is becoming an information science,” Google’s Schmidt said, explaining that patients have an average of 5 GB of health data, most of it in images. And the combination of cloud with deep neural networks has enabled Google and other companies to advance AI by taking a set of labeled data and feeding it into neural machine learning to get a model.

“The primary progress in the next few years for machine learning will involve EHRs, quantitative observations, applying ML to genetic variant calling, and medical imaging,” Schmidt said. “Can you imagine when we have sensor data plus continuous patient data? This data explosion is profound.” 

Yes — and one would be hard-pressed to walk away from HIMSS18 without a spark of optimism that we now have a better understanding of what’s on the road ahead to artificial intelligence and machine learning being put to practical and tangible use.

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Rumors have been swirling for the past few weeks of agency infighting at the U.S. Department of Veterans Affairs and reports have speculated that not all are happy with the leadership of VA Secretary David Shulkin, MD.

In fact, on Monday, Axios reported that even President Donald Trump has finally lost patience with Shulkin, based on a meeting last week at the White House between the secretary, his Deputy Tom Bowman, Shulkin’s Chief of Staff Peter O’Rourke and White House Chief of Staff John Kelly.

Kelly told Shulkin to just get back to work and stop causing drama, according to the report, and that meeting was followed by an Oval Office discussion between Trump and Shulkin, focused on legislation to reform the VA health system that also did not go well. 

Shulkin’s Strategic Communications Advisor Ashleigh Barry told Healthcare IT News: “Shulkin has made it clear that his singular focus is the work moving forward at the VA. He says the meeting with the President and Chief of Staff was, in fact, productive, supportive and focused solely on moving forward in the best interest of our veterans.”

The curtain lifted on the agency in the wake of revelations found in a VA Office of Inspector General report in February that alleged Shulkin misused federal funds during a European work trip. From improperly accepted tickets to Wimbledon to misusing government funds to cover his wife’s airfare, Shulkin has been under fire for more than a month.

That report tainted his image, and Shulkin has repeatedly said that he feels his own staff are conspiring to undermine his leadership. In his own defense of the OIG report, Shulkin said even the watchdog’s report “reeked of agenda.”

The way forward for Veterans Affairs

Shulkin has repeatedly said he is not stepping down and is fully concentrated on his efforts to modernize the VA. In fact, at HIMSS18 on Friday, Shulkin reiterated his focus on moving the agency’s legacy VistA EHR system to the Cerner platform to match the Department of Defense.

[Also: VA switch to Cerner EHR too big an opportunity not to get right, Secretary Shulkin says]

But the EHR contract has been on hold for three months over interoperability concerns to make sure the transition is done right. Shulkin also highlighted the need to leverage analytics and discussed the agency’s API gateway to accomplish this.

Hailing the work with Cerner as “extraordinary,” it would seem the Cerner contract could be signed at any time. And the secretary has, seemingly up until the OIG report, had bipartisanship support for his efforts. 

But what would happen to the EHR contract if Shulkin is fired or resigns?

[Also: VA, Cerner EHR deal held up after spat over interoperability definition, report says]

Especially given that Shulkin broke with government protocol by going with the non-competition award to Cerner instead of issuing requests for information and proposals, and given that the contract is still paused, the secretary’s potential departure raises questions about the future of VA’s EHR modernization work.

Shulkin has made massive strides since his appointment just over a year ago. He helped to pass 11 Congressional bills, all designed to bring change to the scandal-ridden agency.

Not only that, but he launched a 24-hour hotline for veterans’ complaints, created a platform for tracking wait times at VA medical centers, sought to ease the backlog of benefit applications and cleared the path to make it easier to fire employees involved in misconduct -- along with the ambitious Anywhere to Anywhere telehealth program and a focus on reducing veteran suicides.

Even still, the recent reports are beginning to show cracks in Shulkin’s plans and Congress has recently seemed a little less than thrilled.

During a February hearing, House VA Committee Chairman Phil Roe, MD, R-Tennessee balked at the $10 billion planned price tag for the Cerner EHR. “That doesn’t even include the costs of updating infrastructure to accommodate the new EHR, implementation support or sustaining VistA up until the day it can be turned off,” Roe said. 

Roe was glad to hear of Shulkin’s push for interoperability, but expressed doubt about whether the project could be successful -- and given recent reports that the DoD-Cerner EHR project isn’t going as smoothly as planned, the future of VA-Cerner contract may not be as close as hoped.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

First, it was called an EMR – an electronic medical record, meant to document the patient encounter at the point of care. Then, of course, the nomenclature began to change, with more and more experts preferring a broader term: electronic health record.

As the Office of the National Coordinator for Health IT saw it, EHRs did everything EMRs did, and more: "EHRs focus on the total health of the patient — going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient's care," ONC officials said back in 2011.

But this past year a new term entered the conversation: CHR. As defined by Epic CEO Judy Faulkner, the "E" in EHR is superfluous: It's "all electronic" now, she said at the company’s user group in September, proposing that what's needed instead is a "comprehensive" record that folds in social determinant data and incorporates other wellness factors that impact that 99 percent of patient time spent outside of clinical settings.

[Also: Judy Faulkner comes to HIMSS18 with CHRs on her mind]

"If you want to keep patients well and you want to get paid, you’re going to have to have a comprehensive health record," Faulkner said. "You’ll need to use software as your central nervous system, and that’s how you standardize and manage your organization."

Immediately, Epic's rivals pointed out that they too are in the CHR game.

"We’ve been discussing longitudinal health records that include social determinants and other relevant data for at least two years now, and there are more than 100 clients today using Cerner’s population health management platform," said Cerner President Zane Burke.

This past week at HIMSS18, in an interview with Healthcare IT News Editor-at-Large Bernie Monegain, Judy Faulkner doubled down on Epic's plans to broaden the capabilities of its CHR, folding in ways to depict an array of socioeconomic factors via the Epic platform.

But in a March 13 blog post from UCSF's Center for Digital Health Innovation, three experts took a closer look at the capabilities said to be inherent in a so-called CHR – taking issue with the term "comprehensive" and offering a different word for that first letter instead.

[Also: Epic CEO Judy Faulkner is standing behind switch from EHRs to 'CHRs']

"The controversy is over much more than just a name," said Aaron Neinstein, MD, director, clinical informatics at UCSF; Mark Savage, director of health policy, and Ed Martin, director of technology.

 "It reflects a debate over the goals of health information technology. Life, health and healthcare are neither static nor siloed but are constantly in motion, and one's health data must be in motion, too. We need a connected health record."

Nearly a decade since HITECH rocketed EHRs into common usage, a lot has evolved in healthcare and technology. The rise of "shared care planning and coordination, genomics and personalized medicine, population health and public health, remote monitoring and sensors" mean that the idea of an EHR as an "electronic filing cabinet" leaves much to be desired, the UCSF researchers said.

Policymakers, providers and patients increasingly recognize this, and know that an "interoperable healthcare ecosystem requires far more than point-to-point, EHR-to-EHR connections," they added.

But while vendors such as Epic and Cerner are now recasting their products as comprehensive health records, able to manage new data types and use cases, they're missing the point, the researchers said. 

"Interoperability is a national priority precisely because no single vendor EHR system is comprehensive, and there must be interoperability across myriad data types, sources, authorized users, and use cases," they write. "Given this, we say 'connected health record,' not comprehensive health record, and we are not alone."

That definition of a CHR doesn't define relevance by what data is "locked in – and out – of the record," they explain. Instead, its "completeness" comes from "focusing on the dynamic conversation, teamwork, interconnections, and diverse data sources inherent in managing health and healthcare today."

Physicians and other clinical end-users are have been complaining for years that EHRs are bulky, burdensome and unwieldy. Further populating them with more design elements to accommodate ever-increasing types of data will only exacerbate the problem.

On the flip side, the provisions for open APIs and other innovative connection points included in 2015 certified EHRs, Stage 3 meaningful use and the 21st Century Cures Act means it's easier than ever to link existing systems to an array of myriad other data sources.

"A static, allegedly comprehensive health record misses the dynamics of an interactive, learning health system," said the UCSF researchers. "Rather, patients, providers, population health agencies, registries, payers, researchers, social service agencies, community centers and accountable care organizations all need interconnected systems and records."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

U.S. Department of Veterans Affairs Secretary David Shulkin, MD, has been under fire by the Trump administration for more than a month, but the negative headlines haven’t stopped Shulkin from continuing his work to modernize the VA healthcare infrastructure and improve veterans’ care.

“I publicly acknowledge the distraction is something I deeply regret,” Shulkin said during a hearing with the House Appropriations Subcommittee on Military Construction, Veterans Affairs and Other Agencies on Thursday.

“I’ve come here for one reason, and that’s to improve the lives of veterans,” he said. “And that’s what I’m focused solely on doing. There are a lot of people that, frankly, are more interested in politics than I am. I’m interested in getting this job done.”

[Also: VA switch to Cerner EHR too big an opportunity not to get right, Secretary Shulkin says]

And that job is to improve the VA’s outdated EHR infrastructure. Shulkin reiterated much of what he told HIMSS18 attendees: that the agency is working closely with the Department of Defense to make sure they get it right.

However, Rep. Charlie Dent, R-Pennsylvania, expressed concern over modeling the VA’s EHR after the DoD MHS Genesis, given the issues plaguing the four pilot sites. But Shulkin said that the lessons learned from those pilots will be applied to the VA implementation.

“We’re using their lessons to make sure our contract reflects the issues that we’ve learned. But also that we’re going to have a smoother implementation,” said Shulkin. “I am confident that we made the right decision here.”

Shulkin has been part of two EHR projects in the past, arguably none of this size, but he explained that he’s also working with clinical leadership and VA clinicians to make sure the project is successful.

[Also: With David Shulkin under fire, what's next for the VA's EHR modernization?]

Further, VA will roll out one VistA instance at a time, while involving clinicians in the process.

“If you don’t have involvement from your clinicians, you might as well not start at the beginning,” said Shulkin. “That is the absolute key: Having this be driven through our clinical leadership and our clinicians, is going to be the factor that is successful.”

The pause on signing the contract with Cerner -- which was expected to be signed in the fall -- is being used to “make sure we have the interoperability with community providers, since 36 percent of vets receive care in private sector,” said Shulkin.

But the number of veterans receiving care outside of the VA drew ire from Rep. Debbie Wasserman-Schultz, D-Florida.

“Is anyone pushing you toward the privatization of veteran care?” she asked.

“I’ve been clear that I think this would be the wrong decision for our veterans to privatize VA care,” said Shulkin. “I’ve also been clear that VA can’t do this alone: So we have to have a rational system that allows veterans to be able to understand what the choices are… [to] be able to get the best care that they can from the VA.”

“We have problems that I acknowledge and that we have to fix,” he added. “The right choice here is a system that allows for a strong internal system that’s working properly, along with taking advantage of working with the private sector, when veterans can benefit from those services as well.”

Another notable point brought up by Shulkin and Congressional members was the price tag. Up until recently, the cost of the project was estimated at $10 billion. But Wasserman-Schultz threw out a figure of $16 billion during the hearing and House VA Chairman Rep. Phil Roe, R-Tennessee, mentioned a $15 billion budget on Monday.

Just last month, Roe balked at just a $10 billion price tag for the project, especially given the amount doesn’t cover maintenance or the cost to update the infrastructure necessary to support the new EHR.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

HIMSS TV debuted on March 6 in Las Vegas. Speakers for the inaugural broadcast included James Madara, MD, of the American Medical Association, David Harlow from the The Harlow Group, Nick van Terheyden of Incremental Health, Ashish Atreja, MD, from Mount Sinai, Susan Dentzer from The Network for Excellence in Health Innovation, Jim Douglas, the former governor of Vermont and many more. Here's a sampling of what you'll hear on HIMSS TV Global Network.

‘Where the patient exists is the truth of our healthcare system. That’s where we have to pay attention..’

James Madara, MD, and CEO of the American Medical Association, outlines his ideas about the need for rapid, secured, permission-based (and inexpensive) clinical workflow tools to relieve the administrative burden on physicians. Learn more about Analytics on HIMSS TV.

‘Security has a tendency to make it difficult to practice clinical medicine.’

David Harlow, principal at The Harlow Group and Nick van Terheyden, CEO of Incremental Health, debate the issue of balancing the need for security with the limitations it places on clinical productivity. Learn more about cybersecurity on HIMSS TV.

‘The cloud is as secure, or as less secure as any other infrastructure. If implemented correctly, it can actually be more secure and provide greater privacy than an on-premises infrastructure.’

Anand Shroff, founder and chief development officer of Health Fidelity, explains the most fundamental misconception about cloud computing in regard to data security and privacy. Learn more about Cloud Computing on HIMSS TV.

‘We are seeing aggregation, which is a sign of maturity in how the technologies are emerging.’

Ashish Atreja, MD, Mount Sinai’s chief innovation officer offers tips about finding ways to innovate and keep a finger on the pulse of emerging platforms aggregating information. More on Innovation on HIMSS TV.

‘Make the transactional experience better, with less friction to enable human interaction.’

Susan Dentzer, president and CEO at The Network for Excellence in Health Innovation and Sara Vaezy, chief digital strategy officer at Providence St. Joseph Health, discuss bringing care to patients where they are by breaking down the walls and creating virtual care initiatives. Learn more about Patient Engagement on HIMSS TV.

‘States can get the job done.’

Jim Douglas, former Governor of Vermont along with Daniel Morhaim, MD, of the Maryland House of Delegates and Jesse Topper from the Pennsylvania House of Representatives, have a candid conversation on the challenge of improving the regulatory climate for healthcare. 

‘[An app] really has to be designed in a way that consumers can understand it instantly. Don’t make it too complex. And make it relevant to their needs.’

To engage consumers, healthcare systems need to be designed so they are responsive to patients' needs says John Sharp, senior manager of  Consumer Health IT, PCHA. More about Mobile and other topics on HIMSS TV Global Network.

A new commentary from former Vice President Joe Biden says interoperability roadblocks have been standing for far too long – and that the Trump administration's current plans to fix the problem are insufficient.

Writing for Fortune, Biden alluded to HIMSS18, where Centers for Medicare and Medicaid Services Administrator Seema Verma unveiled the MyHealthEData Initiative, which aims to make patients a lynchpin of data exchange improvements, and where White House Advisor Jared Kushner said President Donald Trump is "is determined to make interoperability a reality for all Americans."

Biden's take? "Unfortunately, the announcement lacked many specific actions to effectively implement the initiative. I agree with the administration’s stated goals, but real action is needed – and now is the time."

[Also: Jared Kushner says 'Trump administration has a new plan for interoperability']

Too many EHR vendors and healthcare providers have been dragging their feet on interoperability, said the former VP.

"Many would say this was done on purpose because it meant they could lock up customers by making it time-consuming and expensive to change systems," he wrote.

It's long past time to "get serious and specific about the details to take action in the near term," said Biden. "We have now had nearly a decade to examine the consequences of how the electronic health record systems have been deployed.

"The industry has had ample opportunity to voluntarily address the issues of interoperability and putting data in patients’ hands, and they have not done so," he added. "Now is the time to do something about the data silos they have created – to improve health and extend lives."

Biden cited several Obama Administration achievements on that front, from the Blue Button initiative to NIH and ONC's Sync for Science project. But he said a more comprehensive plan was needed to fix interoperability once and for all.

[Also: Seema Verma rolls out new CMS interoperability initiatives at HIMSS18]

His work with the Cancer Moonshot and Biden Cancer Initiative have convinced him more than ever, he said, that more pragmatic and enforceable steps have to be taken to ensure that patients don't have to "jump through hoops to access and share their own data."

Among the specific ways forward Biden proposed: Healthcare organizations "should be required to provide patients with their full medical record in electronic form within 24 hours of a request, and those providers who do not comply should be held accountable by the U.S. Department of Health and Human Services for data-blocking as outlined in the 21st Century Cures Act."

He also said the Center for Medicare and Medicaid Innovation should invest in a "uniform patient data portal" that stores data from every provider patient might see along the care continuum. "The technology exists to do this," he said.

Biden called on HHS to build on existing agreements with the EHR vendors – Allscripts, athenahealth, Cerner, drchrono, Epic, and McKesson – that participate in the Sync for Science program. And he said the National Cancer Institute should "partner with their network of designated NCI-comprehensive cancer hospitals and patient groups, to launch a new cancer data trust – wherein data contributors and data users would agree to set of criteria and act as the 'trustees' of the contained EHR, diagnostic, genomic and outcomes data."

He said the Biden Cancer Initiative would "work with anyone willing to identify new solutions and to implement new actions and collaborations to make that possible," and that he wants to work with the Trump administration to help "make the specific changes necessary to truly put patients at the center of our healthcare system."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Allina Health is amid a unique and pioneering partnership with Health Catalyst and another with insurer Aetna to drive analytics and population health management initiatives. 

It's been three years, in fact, since the Minneapolis-based health system first announced a decade-long, $100 million-plus deal in which Allina – Health Catalyst's first customer – shared its own data warehousing and analytics tools, content and personnel with the Salt Lake City-based vendor, which in turn gives Allina full access to its technology to help drive system-wide process and outcomes improvements.

Each year, the two organizations develop a list of clinical and financial projects to prioritize. As Allina gets help using its data to drive efficiencies and quality gains, Health Catalyst can use the 12 hospitals and 90 clinics of the $3.7 billion health system as a living laboratory to develop new tools and services.

[Also: Health Catalyst launches Bloomberg-like decision support system]

Three years in, the health system and the vendor have together notched a series of impressive quality and safety achievements. Among those: a 12 percent relative reduction in opioid pills prescribed in outpatient settings; a 27 percent relative reduction in Allina's potentially preventable readmission rate; a 5.9 percent reduction in its ICU readmission rate for post-op atrial fibrillation, big improvements in population-level blood pressure and cholesterol numbers and more.

Jonathan Shoemaker, CIO of Allina Health, said the innovative partnership is advantageous for both organizations. 

"If we can improve care delivery and these guys can help us do it, it's a win,” Shoemaker said. “They work hard to prove that every year."

Mike Doyle, senior VP of professional services at Health Catalyst pointed, for example, to $13 million in cost avoidance that Allina's Improving Clinical Value program identified. 

"We've brought several million dollars of validated success, either in terms of cost savings or quality improvement or safety improvement initiatives," Doyle added.

The arrangements, of course, have certain challenges. In such a dynamic environment with so much going on, they have to "focus the analytics platform into helping us be successful," Shoemaker said. "Data is data and you have to actually do something with it. It's on us to figure that out, to some degree."

"We're still in a fee-for-service world. But at the end of the day, you've got to have your costs contained and have good quality outcomes."

Jonathan Shoemaker, Allina Health

Nearly a third of the way into the decade-long deal, there's a free exchange of ideas. "If we want to make changes to the partnership, it's simply a conversation,” he added. “We can fine-tune it and make some adjustments."

Right now, Allina is engaged in a series of initiatives to optimize the use of its data, said Shoemaker.

"One of the things we have to continually be focused on is waste reduction – but layered with an understanding of what does that mean related to quality and patient experience and safety," he said. "So we're taking a broader system-based approach, and fundamentally it's going to be based on data and opportunity."

Population health management is another one. "We're still in a fee-for-service world," said Shoemaker. "But at the end of the day, you've got to have your costs contained and have good quality outcomes. As we fire up our capabilities around care management in particular, there's a lot of pop health concepts there.” 

That is true of Allina’s partnership with Aetna. In January of 2017, the organizations created and jointly own the Allina Health and Aetna Insurance Company, a health plan created to offer products and services to both employers and consumers. Allina and Aetna said they would begin offering such product in 2018. 

"We have a partnership with Aetna, and as we bring new products into the market our ability to manage certain populations in that joint venture will be really important,” Shoemaker said. “We'll use analytics in that space.” 

Another top priority is clinical optimization: "How do we give time back to the providers, how do we make the data that's inside the record more meaningful," he said. "There's no magic bullet – there's lots and lots of things you've got to do all the time."

It's probably not coincidental that the data and analytics projects Allina is pursuing with Health Catalyst come as some of the most energy-intensive years of meaningful use are now in the rear-view mirror. For the first time in a while, Shoemaker said, healthcare stakeholders have been freed up to innovate and explore.

"It has eased a little bit," he said. "I think it was so much tremendous pressure that it was all-consuming – not just for care delivery groups but for vendors. Vendors are in this catch-up space where they really want to get back to optimizing their products, and everyone else is hungry for it too."

For all the advances being made with analytics, Shoemaker said the industry is still in the stage of spending more time on data input than putting that information to work. 

"The long play, ultimately, is how do I use the data, that I have tons and tons of, to make really good clinical decision support, and then feed it back to the system,” Shoemaker said. “That's a long road for us and the vendors – and I'm hopeful that it's not going to be overrun by more bureaucracy."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Intermountain Healthcare announced plans to build a genetic repository and populate it with unprocessed genetic data from companies such as 23andMe, AncestryDNA and MyHeritage that consumers will voluntarily upload.

Researchers from Intermountain Medical Center Heart Institute have begun to create a new global DNA registry based on medical histories from people around the world. Researchers are seeking existing genetic test results and electronic health histories to form the worldwide database, which they’ve named GeneRosity Registry. They aim to discover what benefits might accrue from sharing existing results today and in the future. 

“Our project is creating a resource for future studies,” Stacey Knight, a cardiovascular and genetic epidemiologist at the Intermountain Medical Center Heart Institute, said in a statement. “A person’s DNA is made up of more than 3 billion individual pairs of genetic codes, but finding specific genes that contribute to health problems isn’t easy.”

[Also: 23andMe lands $250 million to expand do-it-yourself genetics testing]

Identifying patterns of disorders among relatives helps medical researchers determine whether an individual, family members, or future generations might be at an increased risk of developing a particular condition.

“We’ll be able to use the information people submit to validate new genetic and disease findings, discover new genetic mutation and genetic profiles, and drive future studies,” Knight added.

The information will be stored in a secure database accessed only by researchers involved in the GeneRosity Registry. The project is conducted completely online and, as such, it does not require any study-related visits or phone calls, Intermountain Healthcare executives noted.

The Intermountain Research Foundation provides seed grant money for research projects like this one and others that lead to clinical applications.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

The U.S. Department of Veterans Affairs named Rasu Shrestha, MD, chief innovation officer of University of Pittsburgh Medical Center, as leader of the agency’s open API pledge.

Earlier this month at HIMSS18, VA Secretary David Shulkin, MD, announced the agency issued an RFP for an API gateway through its Lighthouse platform. Lighthouse leverages new analytic capabilities through the API gateway to integrate EHR data.

The VA is looking to create a model EHR incidence with common data standards published in the public domain. The idea is to map the EHR to FHIR APIs.

The pledge has already been coordinated with numerous major vendors, including Cerner. More than 11 providers, including UPMC, Intermountain Healthcare and Mayo Clinic, have also committed to the effort.

Shrestha will lead the initiative, which will encourage healthcare providers to commit to working with the VA to increase the speed of mapping health data to industry standards.

“There is no moment greater than now for the industry to step up and make their voices heard to push toward real and meaningful interoperability,” said Shrestha. “This is an important moment for the private sector to answer the secretary’s call and work with our vendors to make information flow and use as freely accessible as possible to make care safer and better for veterans.”

The work will kick off with a roundtable discussion to be held in April, where the group will commit to working with the VA and standards community on API implementation guidelines. Participants will also work on testing draft specifications for scheduling, clinical notes, questionnaires and encounters, along with implementing access standards for veterans and clinicians.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

President Trump on Friday signed the spending bill to fund the government. After threatening a veto, Trump moved forward with the law that includes bigger budgets for a number of health agencies than his budget proposal, which health IT experts consider to be a positive development.

Congress, for instance, demonstrated that it understands the importance of interoperability in its proposed $1.3 trillion omnibus spending bill that passed the House on Thursday to fund the government through Sept. 30.

The budget includes a considerable amount of funding for the U.S. Department of Veterans Affairs to begin the transition to Cerner for its EHR when that contract goes through. 

“That’s a good message,” said Tom Leary, Vice President for Government Relations with HIMSS, the parent company of Healthcare IT News and Healthcare Finance News. “That’s a sign from Congress that they’re interested in standards-based interoperability.”

[UPDATE: Senate passes spending bill without insurance stabilization; Trump threatens veto]

Department of Health and Human Services Secretary Alex Azar for the past two weeks has been promoting innovation and interoperability and ways his department will seek to improve both.

HHS gets an increase of $10 billion in the bill currently being debated in the House. The bill authorizes $60 million provided by the 21st Century Cures Act.

“Providers and payers from an IT perspective should feel confident that Congress is meeting the financial requirements they outlined in MACRA and 21st Century Cures,” Leary said. “It’s maintaining the U.S. on path to stay as a leader in healthcare research and technology development. Specific to the IT community, it comes down to, they’re serious about interoperability, they recognize the seriousness of the ONC.”

[Also: Trump's budget proposes deep cuts to HHS, ONC, OCR budgets and staff]

One concern is that while many HHS programs get a bump-up, the bill only restores funding to flatline levels for the Office of the National Coordinator for Health Information Technology. Still, the $60 million appropriation is better than the cut to $28 million that was originally budgeted.

“It’s a real positive for the community given the role ONC has in 21st Century Cures requirements,” Leary said. However, he said, “I’d like to see ONC not only funded but getting a plus-up for advancing 21st Century Care.”

Another plus in the budget is an increase for the Agency for Healthcare Research and Quality, Leary said. This supports research for best practices. 

“They’ve been working for the last 12 months to figure out ways to get best practices out faster,” Leary said. 

Insurers in the individual Affordable Care Act market promoted funding for cost-sharing reduction payments but were likely, not surprised to see, no appropriation for the CSRs or a reinsurance program they and providers told Congress were necessary to stabilize and lower premiums. 

“Premium reduction measures in the individual market would have ensured that Americans who buy their own coverage had more affordable choices that offer access to high-quality care,” America’s Health Insurance Plans said by statement. 

State and federal leaders support healthy markets through employer-provided coverage, Medicare Advantage and Medicaid managed care, but not the individual market, AHIP said.

Should the bill pass as is, and with states able to waive many of the requirements of the Affordable Care Act, that market is expected to remain unstable and premiums to remain at least 20 percent higher than if the government had funded the CSRs. Under the ACA, insurers are still required to help pay the deductibles and out-of-pocket costs for qualifying lower-income beneficiaries. 

CSRs and reinsurance were part of an amendment to the omnibus bill, the Bipartisan Health Care Stabilization Act of 2018, but Democrats balked at it being tied to the Hyde Amendment to prevent federal funds from going to any insurer offering abortion coverage.

Under the budget, the National Institutes of Health would receive a nearly 9 percent increase to $37.1 billion — including $100 million toward developing a universal flu vaccine and $500 million to research opioid addiction and alternative pain treatment, according to Politico. What’s more, the bill proposes to increase the Centers for Disease Control and Prevention budget by $1.1 billion to a total of $8.3 billion, a rejection of President Donald Trump's plans to drastically cut the public health agency's budget.

The pharmaceutical industry lost its battle to cut their portion of funding for the gap in the Medicare Part D doughnut hole from 70 to 60 percent.

This story has been updated to reflect final passage the bill on March 23, 2018.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com

New Jersey-based Hackensack MeridianHealth and Carrier Clinic both signed a letter of intent to explore ways to join forces on behavior health. 

The letter of intent starts the process that would create a system featuring 24-hour access to care ranging from outpatient, to urgent care, residential and inpatient care for mental health and addiction for adolescents and adults. A spokeswoman for Hackensack Meridian said the due diligence is estimated to take three to four months.

Hackensack Meridian co-CEO Robert Garrett said the arrangement would create a new model of evidence-based care that integrates behavioral health with the system’s network. 

[Also: How to put behavioral economics to work for more effective patient engagement]

The collaborators envision a multi-disciplinary team of experts, including primary care physicians, psychiatrists, and advanced practice nurses, who would closely coordinate patient needs, including addiction treatment, routine care and addressing mental health issues.

“This plan will create comprehensive care at a time of great need for expanded, enhanced, and innovative behavioral health services,’’ Carrier CEO Donald. Parker said in a statement.

[Also: Ochsner integrates opioid monitoring tool into its Epic EHR]

Hackensack Meridian and Carrier Clinic executives aim to better respond to a population in urgent need of care. In 2016, half of the increase in emergency room visits in New Jersey were related to patients’ behavioral health issues. The state is coping with an opioid epidemic that killed 2,200 people in 2016 – a record high, up 40 percent from the previous year, according to officials, who figure working together Hackensack Meridian Healthand Carrier Clinic could provide greater healthcare access and choice.

“The opioid crisis is unprecedented in its scope and intensity and this partnership would enhance our efforts to be part of the solution,’’ added John Lloyd, Co-CEO of Hackensack Meridian Health.“It would also deliver a team-based care approach to behavioral health patients who too often receive fragmented care which doesn’t yield the best outcomes.”

Hackensack Meridian Health has 16 hospitals and more than 450 patient care locations and physician offices. The network reaches two-thirds of the state population. Carrier Clinic in Belle Mead, N.J. provides short-term, acute care hospitalization for people with psychiatric illnesses and substance abuse for adolescents 12-18, and treatment for adults 18 and older. It operates a 281-bed hospital.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

What is an application programming interface? One of the more evocative definitions in recent memory comes, of all places, from the U.S. Department of Veterans Affairs:

"Think of an API as a server in a restaurant," according to the VA. "Imagine you are sitting at a table with a menu of choices to order from, and the kitchen is the part of the system that will prepare the order. What’s missing is the critical link to communicate your order to the kitchen and deliver your food back to your table. That’s where the server, or API, comes in."

Like an overworked waitress during dinner time rush, APIs have been doing a lot of heavy lifting recently as this industry tries to solve its longstanding interoperability challenges – with a lot of hungry parties expecting tip-top service.

The past few years have seen the industry looking more and more to open APIs and HL7's FHIR specification to play instrumental roles in connecting disparate parties and devices across the care continuum.

The VA, in fact, is arguably the latest and highest-profile player to embrace that ethos. Even as it works with Cerner to iron out the details of how its new electronic health record will knit together with the one that's also being built, piece by piece, by the Department of Defense, VA is betting big on contributions from smaller private sector developers nationwide, enabled by open APIs.

[Also: Execs tout APIs, asks healthcare to 'share shamelessly']

At HIMSS18, VA Secretary David Shulkin, MD, touted its new API gateway, the Lighthouse platform: "We're going to be able to map the electronic medical record to the FHIR APIs," he said. "We're asking industry to help us build this API gateway, asking industry to open API access to all developers and are working with industry to stop the practice of information blocking."

Shulkin also called for more health systems to sign the VA's Open API Pledge. Eleven participants so far – heavy-hitters including Cleveland Clinic, Geisinger, Intermountain, Mayo Clinic, Partners HealthCare, UPMC and others – have promised to collaborate with VA to map that data to "industry standards including the current and forthcoming versions of the Argonaut Project specifications of FHIR API over the next 18 months."

And, of course, open APIs are already integral to the data exchange provisions of existing regulations such as 21st Century Cures and Stage 3 meaningful use. At HIMSS18, Centers for Medicare and Medicaid Services Administrator Seema Verma unveiled another federal program, MyHealthEData, which she said will also push the specs as an instrumental way to get data to patients.

"CMS believes the future of healthcare depends on the development of open APIs," said Verma.

National Coordinator for Health IT Donald Rucker, MD, echoed the sentiment– making the case that more healthcare data sharing efforts need to look more like the comparatively effortless communication of the app-filled devices consumers use every day.

"If you look at data liquidity, you look at the rest of the world, and in that app economy, many use services that are absolute mashups, roll-ups of a variety of different app technologies," said Rucker. "We're living in an environment where the computer in your pocket or purse is creating lots of different business models. We absolutely anticipate that to happen in healthcare, and some of it already is.”

Indeed, there's big momentum among vendors and developers of all shapes and sizes as companies adjust the calculus of what patients expect from connectivity and user experience – and what health IT vendors feel compelled to give them.

[Also: Apple to launch Health Records app with HL7's FHIR specifications at 12 hospitals]

Just look at Apple, which of course is working together with healthcare companies including Cerner to make personal health information accessible on its Health Records app. HL7's FHIR specifications are key to those efforts.

In turn, Cerner President Zane Burke told us that his company is "working with a range of partners and clients to turn up the heat on the conversation about interoperability."

Despite some well-placed skepticism about just how transformative Apple's efforts might end up being, it's easy to see how that can quickly snowball into real and widespread change – why Google, which launched its own Cloud Healthcare API at HIMSS18, said APIs are key to fixing interoperability and that developers should freely borrow and share ideas to help build on the momentum they're enabling.

Technology is easy, clinical vocabulary is hard

But there are some challenges along the way to a rhythmically thrumming ecosystem of freely flowing healthcare data, bouncing from point to point via open API.

A big one is the fact that legions of app developers – however well-intentioned they are, however enthusiastic, however code-savvy – aren't always as well-versed as they could be in the complicated details of medical data and clinical workflows.

That's led to a profusion of new technologies that often have limited utility for data exchange.

With a lot of emerging apps, "either you're looking at things that don't have medical data, or you're looking at things that just have medical data," as ONC chief Don Rucker explained. "You're not looking at things that synthesize knowledge about our environment and our lives and our behaviors with medical data. That is really the opportunity here."

Few people know more about FHIR and open APIs – and specifically their clinical applications – than Russell Leftwich, MD. His Twitter handle, after all, is @DocOnFHIR.

Leftwich is senior clinical advisor of interoperability at InterSystems and serves on the board of HL7, which developed the FHIR standard. He also teaches biomedical informatics at Vanderbilt University School of Medicine.

He said InterSystems' new FHIR sandbox could offer valuable tools for those looking to create useful apps, connecting to a multisource and vendor-agnostic development environment, giving them realistic clinical data to work with.

A typical U.S. Medicare patient sees two primary care providers and seven specialists across four practices in the course of a year, according to data from InterSystems – that means that app developers who want to make a real-world impact on interoperability need to be conversant with widely varying data types, beyond from different EHR systems, settings and sources.

HL7's FHIR – it stands, of course, for Fast Healthcare Interoperability Resources – has caught on faster than any other interoperability standards since it was first unveiled more than five years ago, thanks mostly to its ease of use compared to specs such as HL7 versions 2 and 3.

"It's easy," said Leftwich. "HL7 version 3 kind of fizzled because it broke under its own complexity – you practically had to have a PhD in it to build something simple with it. Not that it isn't used some, but it was never going to take off like FHIR did."

On the other hand, with FHIR, "there are hundreds of thousands of twentysomethings with web development skills who can get the idea of FHIR in a weekend," he said. "There are FHIR hackathons where somebody walks in on a Saturday morning and doesn't know anything about it, and on Sunday afternoon they've build a little app."

That’s not necessarily to say they understand the nuances of clinical data, disease processes, the way things actually work in a hospital or workflows enough to build the next killer app in 12 hours but it’s definitely a step in the right direction. 

As developers start to understand use cases, what data they need for FHIR, how that gets represented, those apps will only become more sophisticated. 

“To be really interoperable, you need to have data vocabularies, code systems – SNOMED, LOINC, etc. – that are the way you build the model for a particular piece of data," Leftwich said. 

FHIR has already proven itself as perhaps the go-to spec for new development, and looks likely to continue to build on that momentum.

"You can see the whole data for an individual as FHIR," he said. "And you're not missing any of the data that you would be if your app was instead pointing toward a single EHR that has maybe a lot of data about that individual but not all the data. And the reality today is that a lot of data about individuals is not in the EHR. Not just social determinants, but everything: conditions, medications, etc.

Clinicians are people too

Patient-facing apps are a huge area of focus, of course, and there's enormous potential for clinical apps with FHIR and other open APIs. 

As Apple, Cerner and others have realized, patients "want to see all of their data – they don't want to see all of it at once, but they want to have access if they're interested in one thing," said Leftwich. "The same is true for clinicians. They don't usually want all the data, they just want to be able to see what's important right now."

"Interoperability is changing. It's no longer about connecting two systems inside the hospital to each other. It's about trying to get all the data for an individual in real time, the way we're used to in other domains."

Russell Leftwich, MD

By its nature, FHIR is the first standard that's able to query for a piece of data, said Leftwich, "because FHIR is, in its essence, an API – a RESTful API. And because it's a freely available standard, it's an open API."

But all the openness in the world won't accomplish much if the apps enabled by it don't speak the same language. That is a challenge.

"It does get more complicated because we need to develop the FHIR profiles – the models of the information – because two people can build something with FHIR that does the same thing, and it's not interoperable because they built it a little bit differently," he said.

Leftwich said the roadmap for FHIR is trying to address by setting up a mechanism for sharing FHIR profiles for use cases to give everybody the same representation of specific data.  

He's already been in touch with the VA, for instance, to get it some data types into the environment, to help nudge along interoperability advances envisioned by the Lighthouse initiative.

"They've created synthetic data to match their patient population, and we will be looking to get that data into our sandbox," he said. "The developers need to learn about FHIR and learn about what that real data actually looks like. Deal with the data that's the real stuff – or realistic – in the way it's represented in other systems."

So far, FHIR has been "more successful than anyone thought it would be," said Leftwich. "Unlike previous standards, where people waited to see what it's going to be like, with FHIR, people have taken it and run with it."

Very often, the applications being created with it are really cool. But the challenge is to create an ecosystem where the developers using open standards to build apps have a deep understanding of the issues they should be helping to solve – helping to up the ratio of new programs that are truly useful.

"The sky's the limit," Leftwich added. "Interoperability is changing. It's no longer about connecting two systems inside the hospital to each other. Or many systems inside the hospital to each other. It's about trying to get all the data for an individual in real time, the way we're used to in other domains.”

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

President Donald Trump still has confidence in the U.S. Department of Veterans Affairs Secretary David Shulkin, MD, despite claims Shulkin could be out as early as some point this week, according to White House Deputy Press Secretary Hogan Gidley. 

“We all serve at the pleasure of the president. If he is not pleased, you‘ll know it,” Gidley said in a Fox News interview Monday morning. “At this point in time, though, he does have confidence in Dr. Shulkin. He is a secretary and he has done some great things at the VA.”

For the past month, rumors have circulated around agency infighting and speculated that Shulkin may have fallen from Trump’s graces.

[Also: With David Shulkin under fire, what's next for the VA's EHR modernization?]

The rumors stem from a VA Office Inspector General report that alleged the secretary misused federal funds on a European work trip this summer and from Shulkin telling the media he was given the power to fire underperforming staff, although there was no approval to do so.

Shulkin just last week apologized for the distractions these allegations have caused while pushing forward on the agency’s electronic health record and other IT modernization plans.

On Sunday night, however, AP reported that sources familiar with the situation said Shulkin could be out this week.

[Also: Department of Veterans Affairs looks to private developers for innovation]

But when pressed this morning, Gidley remained firm. 

“When the president wants to make a change, he will make it. He doesn't have to try, he doesn't have to guess. He has the power to do so whether he has a replacement or not, he can still make a change,” Gidley added. “The president wants to put the best people around him to execute his policy.” 

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

Since October 2016, when it started using a new telehealth technology, ConcertoHealth has seen 73 percent of its new e-consults replace the need for patients to see specialists face-to-face.

Further, there has been a 30.3 percent reduction in the health system's rate of hospital admissions and a 17 percent drop in readmissions.

ConcertoHealth uses a platform from AristaMD that delivers access to specialty care in less than 24 hours. AristaMD was launched by a team of healthcare administrators, clinicians and payers who believed that opportunities existed to deliver higher quality, lower cost care through primary care systems. 

[Also: Intermountain creates a virtual hospital with telehealth tools and services]

In addition to AristaMD, there are vendors like RubiconMD that also conduct all-digital e-consults, and there are resources like the Association of American Medical Colleges' Project CORE that can help providers conduct specialist e-consults. What’s more, many telemedicine vendors can conduct consults with specialists through face-to-face video visits or other means.

"The e-consults provide more timely and actionable feedback for ConcertoHealth care providers," said Christopher Dodd, MD, regional medical director at ConcertoHealth and a clinical instructor in the department of global health at the University of Washington.

"For example, it is extremely difficult to get patients with behavioral health diagnoses to attend specialist consults in Washington," he explained. "Instead of waiting for a specialist to become available, ConcertoHealth primary care physicians are now empowered to engage a specialist through e-consults within 24 hours to take appropriate action."

Other areas where ConcertoHealth has seen success with e-consults include endocrine specialists for insulin-dosing regimens as part of diabetic medical management, as well as pain management. Orthopedics also is a significant area for e-consults.

Now, when patients report pain, instead of going to the emergency department for X-rays, patients visit ConcertoHealth primary care physicians first, who are then equipped to address these situations by using e-consults with orthopedic specialists.

"While the long-term benefits are avoiding unnecessary admissions and readmissions, the more immediate and tangible impact of e-consults for ConcertoHealth is the ability to avoid unnecessary referrals," Dodd said. "Timely responses are the most critical component of the primary care physician's ability to manage their patients."

The biggest challenge in the whole process for ConcertoHealth was getting clinicians to embrace this technology resource and view e-consults as a tool to help them become a "super primary care physician," Dodd observed. E-consults help primary care physicians serve as the sole provider to a patient and empower them to leverage the program and understand the nuances of making specialist recommendations for patients, he added.

"Today, ConcertoHealth providers actively notify the patient when they use e-consults," he said. "Primary care physicians are not afraid to indicate when they don't have an immediate answer, but are confident in declaring that they have a specialist on-hand through e-consults, and are equipped to provide an answer in a timely fashion."

An e-consult is a simple process for primary care physicians and patients. ConcertoHealth physicians see a patient during a typical office visit, document the encounter within the electronic health record from eClinicalWorks, log the assessment and treatment plan, and cite the specific reasons for a specialist consult.

"As the primary care physician signs the notes, they select a drop-down tab within the EHR for referrals to e-consult or AristaMD," Dodd explained. "While this was not a native feature in the EHR, it was not difficult for the EHR to be updated to integrate the e-consults feature."

By flagging an e-consult, AristaMD interfaces with the same EHR and extracts the necessary data to send to the relevant specialist. The primary care physician does not need to be actively logged into the EHR to be notified that a specialist consult has been completed.

"Once the consulting specialist provides feedback, a notification is created in the EHR and providers receive an email that contains a link directly to the AristaMD site," Dodd explained. "Because the response is available within 24 hours, the primary care physician is able to incorporate recommendations into the patient's care and treatment plan based on the consult, which significantly reduces any delays in care.

During the patient's follow-up visit with the primary care physician, the provider integrates the recommendations from the specialist into the plan within the EHR, he added.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

Phoenix Children's Hospital Chief Information Officer David Higginson has spent the past several years putting an intense focus on patient safety, using Allscripts technology to innovate new tools and processes that put patient data to work in identifying areas where different approaches can be encouraged to drive quality and safety improvements.  

Allscripts has likewise long been focused on safety, CEO Paul Black said during an interview at HIMSS18, dating back at least the past 20 years, since the publication of the Institute of Medicine's landmark 1999 report, To Err is Human: Building a Safer Health System.

"There were a lot of early adopters of electronic medical records, and that was the big push, prior to the mandate, of why you would do an EMR and computerized physician order entry," said Black. "That was sort of the thesis, behind trying to digitize 'do no harm.' From my perspective, it's what we've all been collectively working on for a really long time."

Black gestured during the interview toward Higginson: "At their place, when you talk to his CEO, that is one of the first things they talk about is patient safety. It's a cultural mandate. As well as a working mandate in terms of how they build, how they talk, how they communicate, how they have stand-up meetings, how they talk to the board. It is all centered around having a safe environment for the children."

[Also: Techies no more: Today CIOs are essential leaders in healthcare]

"It is truly something our CEO believes very strongly in," said Higginson. "I think he was tired of sitting in quality meetings, three months after the fact, with a root cause analysis. Why do I have to wait three months for this to happen? Why not figure it out? Because the data was there, many times, to prevent this. So his drive and our focus for eight years now has been to get this root cause analysis much, much closer to when things happen, and prevent them from happening."

Allscripts' open platform has been a key enabler to helping Higginson develop some inventive clinical tools. (Black joked that the EHR maker tries to help largely by "staying out of his way.")

As those new tools have been created and put into place, however, the CIO says he's learned that human factors – old ingrained habits, suspicion about new processes, resistance to new workflows – were some big speed bumps that required work to smooth over, and were just as important as the data and technology.
 
"We've been through a journey, and it's not been an easy task," said Higginson. "Part of it is that the patient safety and quality team we have are so used to retrospective chart review, just breaking that habit.

"They were great at reading a chart, and medically figuring out what was going on and putting the pieces together, but they had no concept of how to actually access the data electronically," he said. "So our very first challenge was retooling that group of people to go to data first, and only go to the chart after everything else failed. That was a two or three year change.

But the changes Phoenix Children's has been able to make to its EMR have been valuable to its life-saving patient safety efforts.

"One of them is dose range checking," said Higginson. "In an adolescent or a child, the dosing is really important, based on their weight. There were really no solutions out there, just off the shelf, that would give you all the ranges. So we analyzed nearly 18 million electronic orders for drugs to really find the normal curve – because again, there's nothing really published, you just have to find what's normal – and then we put in this range checking process in real time.

"It's not just the detection of data that shows something's not working, it's the action that happens after it. That is what we've been really hyper-focused on: Not just relying on a pop-up in the EMR."

David Higginson, Phoenix Children's Hospital

The dose-range initiative came after a root cause analysis where a patient had nearly been given 10 times the dose of a particular medication. Thankfully, someone had intervened at the last second, he explained. "But out CEO said that can never happen again. That is all human error. We just can't allow that to happen to a child."

Within a month or so, the hospital had put together a new dose range checking system.

"Again, with the Allscripts platform being fairly open, we didn't reach out to Allscripts to do it, we did the work ourselves and were able to get it into the system," said Higginson. "As physicians are ordering, there are soft and hard alerts to stop them from proceeding, and then finally it goes to the pharmacist, and the pharmacist picks up the phone and says to the doctor, 'I saw that you said you really want to do this, but it says it's 10 times over. What are you doing?' There are times you really need to do that."

Another data-driven safety initiative focuses on IV infiltration.

"Often you get an IV being put into a patient and that IV can go bad – it can start bruising, and if you're a child you don't have many veins and you might be here in the hospital for a long time sometimes," said Higginson.

While that IV problem can get worse over time, Higginson said that interjecting and correcting it can be easy.

The data was already there in the nursing documentation, but no one had put them together, said Higginson. 

"That's fundamentally where we're at with IT right now: So much data. Many, many times people just haven't put it together so it's visible and actionable."

As the IV tool rolled out, for instance, "we felt so great about ourselves," said Higginson. "We demonstrated it worked. And we sent an email to the team whose job it is to correct the IVs.

"But then we found that they were ignoring the email because they didn't trust the system," he said. "That was really irritating. Because we knew we had good data, but that last human factor was failing us."

So the hospital developed some programs to help acclimate the clinical staff to get them used to the new processes. "We've worked really hard on some techniques we've used over and over again to guarantee that last mile of delivery happens," said Higginson.

Now, "when we do these alerts we actually have reports tracking the use of them, and we're calling people up – our CMIO is literally every hour running the report to make sure someone is looking and checking," he said. "He knows once they get there they'll fix the problem – it's just a matter of getting people into the habit. So what we've learned is that we can't just create an awesome system that sounds great. We have to work on 21 days of habit forming before people get indoctrinated."

The same goes for new medication administration techniques.

"We've never really used a computer on wheels in nursing,” Higginson said. “It's clunky and we didn't want them in the room. And if you think about med admin, it's really a 30-second type of interaction. It's not, log into the computer for 20 seconds and pull up the record and spend 10 minutes documenting. You want to scan the drugs, and done. So we deployed iPhone 6 Plus with the med admin on it."

When the hospital first rolled Allscripts mobile app, it was well-received early on, he said. Even still, they noticed a drop-off from 98 percent compliance down to 90 percent. 

"People who didn't want to do it would document some reason – like the technology failed or the WiFi didn't work," he explained. "But we found out that that wasn't really the case. Once we started going to them within 30 mins and saying, 'What's wrong with your device, can we fix it?' We found out that they just didn't want to do it, and their learned behavior was to just document some random problem."

These days, if a nurse has documented three times that the scanning app didn't work, a clinical supervisor is sent to intervene.

"It's not just the detection of data that shows something's not working, it's the action that happens after it," said Higginson. "That is what we've been really hyper-focused on: Not just relying on a pop-up in the EMR."

That attention to human factors has made a big difference in the efficacy of the new safety initiatives.

"Think about it, we've put millions and millions of dollars into putting the system in and collecting the data to get an outcome," said Higginson. "And then you fail because the pop-up message didn't happen at the right time or the right place, or it was just dismissed. That closing of the loop is really important."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com