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 – Institute of Medicine (IOM) publishes;
• Crossing the Quality Chasm • Patient Safety reports
1990
present
The Time Line
“to manage the large amount of information involved and to provide rapid access to that information, computerization of the clinical data base is logical”
OIG HIPAA
3/2001
• Electronic Health Record (E H R) • Clinical Alerts and reminders • Computerized workflow
• Computerized decision support
IOM and the Committee on Quality of Health Care in America Make new recommendations to the quality of care…
“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
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
2003 Congressional Questioning of
NHIN
• Q. “What are the main protections on privacy and confidentiality in our current, largely paper-based 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 3rdparties for non-medical 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)
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
September 2004
• AHIMA • HIMSS • ALLIANCE
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
• 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
ONCHIT awards CCHIT the RFP of 3 years to develop Certification criteria and an inspection process for:
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
INTEROPERABILITY
COMMUNICATION
THE ABILITY OF SOFTWARE AND HARDWARE ON DIFFERENT MACHINES FROM DIFFERENT
VENDORS TO SHARE DATA
(http://webopedia.com/TERM/i/interoperability.html)
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
Machine organizable data (structured messages,
unstructured content)
HL7 messages and indexed (labeled) documents, images, and objects.
4
Machine
interpretable data (structured messages, standardized content)
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…”
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
SYNTACTIC INTEROPERABILITY
• Messages between computers have a commonstructural 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…”
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
• 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.
Example of HIE in operation at VA
BHIE
Contract Providers
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
EMR/EHR Interoperability with County
• 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
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
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.
EPSDT Audit History Site Location
Period
Audited Annual EPSDT (1)
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.
Program Summary Report: Client Information Victor Community Support Services
1/1/2008 to 12/31/2008 - All Ru's
Clients and Cases
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: American Health Information Management Association
ANSI: American National Standards Institute BHIE: Bidirectional Health Information Exchange CCHIT: Certification Commission for Healthcare
Information Technology EPR: Electronic Patient Record EMR Electronic Medical Record EHR Electronic Health Record
HIMSS: Healthcare Information and Management Systems Society
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/hail-to-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/
