WEBINAR: Oncs 10 Year Vision for Connected Health

WEBINAR: ONCs 10 Year Vision for Connected Health April 20 @ 9:00 am - 10:00 am Good afternoon everyone, my name is Olivia Henze from the New England QIN-QIO and I will be your moderator for today’s webinar: ONCs 10 Year Vision for Connected Health. The New England Quality Innovation Network-Quality Improvement Organization works with healthcare providers, stakeholders and communities across New England on data-driven quality initiatives to improve patient safety, engage patients and families and improve clinical care at the community level. Thank you for joining us for today’s webinar. Before we get started, just a few housekeeping items… • This call will be recorded for training purposes • I’ll provide you with details on accessing the recording at the end of this webinar. • The phone lines will be on mute for the duration of the presentation, and if you would like to enter a question, please do so in the chat box and we will address at the end.

At this time, I’d like to introduce today’s speaker, John DeStefano, from the New England QIN-QIO. John has extensive experience with state and federal level healthcare reform initiatives and has over twenty years leading interface development and web services implementations, including development of an emerging health information exchange in a multi-hospital environment. John’s past positions include being the CTO of a state health information exchange and Director of interoperability at a large IDN. Please welcome, John. Thank you. Let's get started. Today we will discuss the 10 year vision for connected health, this is a document that was published in October 2015. It had numerous versions before it. If you're interested in reading the document it is long. But you can certainly go to the links that I will provide shortly to find the documents.

The objectives are to talk about what a learning health system is, one of the primary focuses of the ONC vision is for the nation to develop a learning health system so we'll talk about that.

We will provide an overview of the progress to date, the roadmap started in 2014 even though it wasn't really published until 2015. We will identify expected changes between now and 2024 which is the 10 year anniversary. We will go into detail around how the current CMS payment reform initiatives and the roadmap initiatives merged together or do not.

These are the documents we will talk about. I have a certain perspective on this and will have perspectives. My experience is really not as much with policy although lately more on policy but really, my experience focuses on technology so I look at this roadmap baby from the eyes of somebody who has implemented large-scale technology, at the state and local level.

I hope it doesn't skew my view too much.

We need to define a couple of things. The few things we will talk about, are definitions that are also in the roadmap document. What is interoperability? My view is more from a technical perspective. That is very narrow when it comes to developing a nationwide roadmap for interoperability and to change the way we practice healthcare in this country. The ability of a system to exchange electronic health inflation is one aspect, you can see that we also need to take into account the users of the system, all participants in an interoperable system should be able to transparently use the system to exchange data. It doesn't include hospitals or providers but it also includes patients and people who want to exchange data.

Individuals, families and healthcare providers can send, receive, and find electronic health data. Currently with the mandates of meaningful use we have send and receive as part of certified electronic health records but the find part has eluded us. Many health information exchanges have the ability to query for data but it is not as widespread as it needs to be.

Also interoperability needs to deliver the right information to all participants at the right time. This includes individuals and caregivers who are active collaborators in healthcare. A provider and the patient or person should be able to easily connect data and collaborate on healthcare.

To continue, what are some of the features? Critical public health functions including real-time case reporting disease surveillance and disaster response. This is ongoing work at the federal level does to collect data and respond quickly to disastrous and disease. We don't really havethe capability developed to the extent that it needs to be. Data aggregation for research so if we will drive change in the system we need to use the data, we have lots of data in healthcare. But it is difficult to aggregate it at the skill that needs to be to influence population.

Interoperability needs to be able to support administrative and clinical data and this goes partly with the idea of aggregating the data to be able to drive value-based payment systems.

Another definition, stakeholders, the use of people. Much of the healthcare literature today when we talk about patients we don't see that term being used as much anymore we are all patients in the system. At one time or another. The documents from the federal government really the term patient is in many cases been replaced by people. Who are the stakeholders?

People who receive care, that would include consumers, patients, caregivers, family members who may be assisting someone. And organizations that represents the stakeholders. Organizations that deliver care. This includes hospitals, pharmacies, providers, laboratories, home and community-based services.

There's also a governmental aspect, the federal state tribal and local governments, people who organize that generate new knowledge so researchers. Public health researchers.

Other types of stakeholders in the system. Organizations that provide health IT, these people are important, those of the technology providers. Those companies that provide EHR, and other health IT assets, that goes beyond the traditional EHR vendors to new innovators who are developing global applications and wearable applications for patients to monitor the health.

There's also a certification and governance of stakeholders, who provide certification and governance capabilities. Those organizations that serve would be an example.

And standard organization so HL7 is an example, they are stakeholder in this and they drive or assist in helping move the system forward through standards.

What is a learning health system? There is a link at the bottom that you can see, very interesting say if you have not seen it that goes into what makes up a learning health system, one thing is timely and actionable knowledge. Putting the right data in the right place at the right time to affect care. One of the key ingredients of a learning health system. Learning large is an interesting concept. We have a problem with data. And the way we use it we have millions of records about data. But we don't really use the data systematically and routinely like we could, to affect population health. So one of the aspects of a learning health system is to be able to use data at scale to affect patient care.

Ongoing cycles of knowledge generation, this is another aspect. How do we utilize data? How do we take data and draw lessons learned? To create a system that learns. All the stakeholders participate in a learning system so it is not just about caregivers or hospitals. It is about the people who are receiving care, everybody needs to be coordinated and in sync with each other. To have a learning health system one of the other aspects is the health IT aspect, a system is built on top of meaningful use another health IT investments that are currently in place. We do not start over, we already have a foundation in place. The foundation aspects are in place, it will shorten the care delivery, shorten the gap in care delivery. Currently there is a 17 year gap between knowledge that is generated and when it is applied. So the current systems in place, we aggregate data, we research it, before it gets back into the system, it is 17 years. A learning system doesn't have a gap in it has a much smaller gap where data is being analyzed in real time. Decisions around population health and different programs happen at a much quicker pace.

The 10 year vision. This vision includes the following points, interoperable health IT ecosystems. The right data at the right time. IT products and services that allow the healthcare system to continuously learn. Utilization of the data is key to the vision.

A learning system that facilitates lower cost of care. And improve population health. Another part of the vision. And support for critical public health functions. Real-time surveillance, data aggregation, the changeover to value-based payments, that reward quality versus quantity.

What are the guiding principles?

Focus on value. This is one of the guiding principles. We talk a lot about value, quality, quantity, about the US position in the world around where it ranks as far as quality of care, and outcomes. We've all heard about the large percentage of the GDP that goes to healthcare, we are one of the most expensive healthcare systems in the world.

We are the best in the world at taking care of sick patients. There is nobody who does it better than the US. Many individuals from other countries who can afford it will come to the US for care, if you have cancer, chronic disease, much of that care that we provide in this country is the best that you can get in the world. We are very good at taking care of sick patients. What we are not so good at doing is taking care of the population when it is well.

That cycle goes back to the sick care system which make the system expensive. If you focus on value is one of the guiding principles that the roadmap is developed for. Also person centered. We have a great resource in this country from a healthcare perspective that we do not utilize and that is the patient, they know a lot about the healthcare. We do not utilize it very well. One of the principles is to involve the person in their own healthcare. Protect privacy and security. If we cannot develop a system that is secure patients will not use it. It will be of no value.

We need to build a culture of electronic access and use. We are seeing that more and more with consumers using wearable devices, the industry around mobile applications that are healthcare related is getting quite big between now and 2019 it's expected to be over $2 billion. To develop the culture of electronic access the system needs to meet people where they are and that many times is in a mobile way. Allow patients access to the data through mobile devices.

Built upon the existing IT infrastructure, we need to not just throw out what we have, which is taking years to build, we need to leverage it so we have a good foundation to be able to move IT data forward we just need to leverage better what we have in place.

One size does not fit all. It means there needs to be a baseline of interoperability and we see some of this with meaningful use. There is a baseline to send and receive data. It is based on direct messaging. That is the baseline. Others who have more sophisticated or have more uses in ways they want to use data may develop system is on top that are much more elaborate and functional with different use cases. We still need to have the baseline so everybody can participate at some level that there are more sophisticated organizations who will develop more sophisticated ways to use data.

It needs to be simple, direct messaging. Certified EHR needs to be happening, that is a simple protocol that has been in use for many years. It is not as complicated as query- based exchanges. In many cases we need simple ways to get things started.

Maintain modularity is another interesting concept, large systems more easily to change. When it can be connected together as opposed to the system so you can think of a learning health system in this country, the federal government just put one in place. One huge monolithic hierarchal system that would not be as comparable to change as a smaller components that are wired together through standard interoperability methodology. Modularity is important. Maintained that going forward.

Consider the current environment and support multiple levels of advancement. Not every provider will get to the same place at the same time. Some providers who have the capabilities and the access to sophisticated technology may move at a much faster pace than providers who are in rural areas. We’re all going to get there at a different time. Empower individuals. And leverage the market. Demand for health IT will be a powerful driver as consumers want to have access to the data that will be a powerful driver. We need to leverage the market going forward.

What are the highlights? The plane is broken up to those broken up into milestones. Those are three milestones. They take into account different time frames, the first of these is the three-year plan.2015-2017. The hope is that every provider will be able to send, receive, and find healthcare information. We need to scale the existing approaches so we have in place direct messages we have emerging health information exchanges, the plan between now and 2017 is to scale up what we have.

Another big part of the first three-year plan is to work on the vocabulary and standardization, by the end of 2017 we should have good vocabulary so systems exchanging data understand the data. We should have good standards in place so that vendors who are building interoperable technologies can use the same standards to interoperate data.

The six-year plan use more information to improve. Quality and lower cost. The major parts of the plan are to enhance our -- interoperability. Be able to aggregate and trend data and come up with new methods to measure quality.

The third part between 2021 -2024 is the development and enhancement of the learning health system. What are the features? You need to have a connected health system, built on what has come before. Part of what we should see is that we have active individual health management. We see people managing their own health, having the ability to use mobile technology. A system that is moving from sick care to well care. We will have more evolution of standards and policy to be able to support this kind of the system. The large-scale use of data for analytics.

The fundamental moving box -- building blocks to get to the learning health system. We need core technical standards and functions. These are things like patient matching, everybody in the system should be doing patient matching the same way, so we can identify patients across healthcare organizations. We will see the emergence of directories, healthcare directory way pages, I can provide providers across the country. If you want to send a message to another provider who is on the other side of the country, you can look up an address for a way to send a provider information through a directory.

We also need a standard forward around authorization and authentication. How we decide what a particular provider is authorized to see, some of you may have been involved in data interchange noses, this is an issue. We also need to be able to identify users within the system if you think of a national system where interoperability is prevalent and providers cannot just reach out to fight patient data when they need it, you need to authorize the providers.

You need to have certification to support adoption and optimization; we have a lot of activity going on around certification of electronic health record systems, various other bodies. That process is underway.

Privacy and security, we still have many security changes, anybody who surfs the Internet, listens to the news, knows about cyber threats and that could really slow down the journey, we learning health system if we do not find ways to protect the networks.

Have a supportive business clinical and cultural environment. This focuses on the change to a value-based system. As a building block perspective, we're talking about policy levers CMS is willing to pull those policy levers, with the emerging value- based payment systems, we are seeing they are willing to pull the policy levers.

Rules of engagement and governance, there are organizations right now that are set up to provide governance for stakeholders for participation in various technology projects. Governance organizations like direct trust, an organization that governs the direct health information service providers, and ONC has set up additional organizations to help provide the governance.

There are critical pathways that need to be focused on the roadmap. Improved technical standards, the change the value-based payment, and part of the roadmap is to make the change the value-based payment quickly. Anybody who has examined the MACRA act would agree it is an aggressive and fast change from a fee for service system. Privacy alignment, from the perspective of those doing interoperability right now, privacy is not aligned. There is no real direction from the government, many states have different privacy rules when it comes to healthcare data. There are organizations that have their own privacy rules in place, so in an environment like that, it is difficult to decide or to move private data and get the data to only those individuals who should have access to it. There needs to be clarification and it needs to come from the federal level.

The stakeholder alignment is also key. That will be difficult. There are many stakeholders in this environment, to get them all headed in the right direction, it will be a difficult challenge. On to the specifics of the roadmap.

It is a large document. Dense reading. It has three sections that defines some of the components, including the drivers, the policy and technical components and the expected outcomes. If you want to count the call to action section, and appendix at the end, you can also do that. You can see in this graphic, the transition of how each of those sections would affect each other. Drivers would drive or help assist policy and technical components to get to the desired outcomes.

I'm not going to talk in detail about the policy and technical components. I will talk about the drivers.

The roadmap as we said, is broken up into these larger aggregated milestones.

The appendix is worth looking at, not to just want to examine it just to look at the size of it, and the number of calls to action that are there. It is in an aggressive timeframe, 10 years, to bring the transition to fruition. There are hundreds of calls to action. I wonder how the number of calls to action will be coordinated to realize the learning health system.

Let's talk about one of the primary drivers. This is key to the roadmap vision, that is the support of payment and regulatory environment. Currently we have a shift that we are undergoing from in an environment that is based on the four service to one that is based on value. Medicare and Medicaid are incentive programs, it is the primary motivator, we wouldn't have the number in place if it wasn't for the EHR incentive program. So CMS has demonstrated they can affect the environment when it comes to interoperability.

One of the things that we are aware of, is that business is not adequately awarded right now, to want to include a lot of electronic health information exchange. In the workflow. We hear again that data is power, they need incentives. History has shown that without the right financial incentives in place systems and technology components are built and not use, I can vouch from this from my experience. There's a lot of spend at each state. The problem is it's before its time, financial incentives to make organizations want to connect and exchange data was not there. Many of those information exchanges ended up not being successful.

Interoperability can be a significant tool in a value-based system. This is evident when you consider how providers in the future, how they are reimbursed. In the future providers will be more and more accountable for patient outcomes and total cost of care regardless of where else the individual receive care. He received care in the hospital, I am still responsible for the patient. The solution like that, exchange of information between providers and organizations will be critical. As we mentioned we need systems in place models that reward quality over quantity. That will be driven by the business case to the provider where they need to have information in place to take good care of the patients and keep them well.

Let’s talk about payment reforms. Many of you are familiar with MACRA the Medicare access and CHIP reorganization. Merit-based incentive payment system, alternative payment models, in a very short time, positions who see Medicare patients will be under the MACRA act, many of them would be any merit-based system although I do believe in the future you will see other models developing. Under these kind of situations, providers will need to use certified health IT. They will have to use in order to effectively run their business, it is part of what will be required as part of MACRA. Health IT provisions will reinforce the link, they need to use EHR certified technology as part of the scorecard for MIPS.

Another thing you will see is that a lot of providers who were not involved in the meaningful use program will still be paid under the MIPS or MACRA program. We will see more providers adopting electronic health records who in the past were not incentivized.

Why don't providers choose to share data? It goes back to the idea of they are not the business drivers, many providers have concerns around the liability of exchanging data. This is probably very well-founded because we have a HIPPA but we don't have a good or a very structured system to define what liability is an risks around exchanging data. We have HIPPA which puts emphasis on states exchange of data but from a technical perspective, have you implement HIPPA and make providers feel comfortable that the exchange they are doing is limited from a liability perspective. Many providers lack trading partners, especially in rural areas. There is not a need to trade information with a partner.

There is the idea of competition, data is a powerful thing and if you have data you can in some way affect the market in your favor. The idea of competition comes into play. And there's also the difficulties in switching EHR vendors. Some providers who might want to exchange data do not have systems that they feel are easy enough to use. And switching technology, is a difficult thing.

The next slide I want to point out the progression, in the MIPS program around professionals. You can see the first two years, eligible professionals that we are used to seeing, in the meaningful use program they will be part of the program. This program is aimed at the entire marketplace and not just a sector. Getting back to how health IT is a critical part of MIPS you can see the reimbursement scale. These numbers may have changed you can see meaningful use of certified health information technology is 25% of the score. Quality is another 30% of the score. Health IT is a critical part of the MIPS program going forward.

To give you an idea of the timeline, the MIPS or MACRA program is a winners and losers program. The program has to be budget neutral. There will be an average score nationally that will set the bar and if you're below it, you will be subject to a payment adjustment in the negative direction. You can see the program, it starts kicking in 2019, the 2019 reimbursement or disinterested will be based on 2017 data. We are close to this new payment model being put into place.

Some of the drivers, the milestones for the support of payment. You can see CMS by 2018, will administer 50% of all Medicaid payments to providers through alternative payment models. That is interesting, it seems CMS feels there will be a lot of things emerging. Another interesting thing is that by 2018 CMS would like 90% of care paid for by CMS to be tied to quality. We see a movement towards quality as opposed to fee for service.

We talked about the driver of this roadmap. We will talk about the individual policy and technical components, I will go quickly through these next slides to mention a few important details.

Share decision-making and rules of engagement, where are we right now? We have various organizations in place, that are providing policies and technical rules of engagement for all the stakeholders. Organizations like Commonwealth alliance, the Sequoia project, to provide governance for query basic change, direct trust, another organization that provides governance around direct messaging, they were given some money. Those policy components share decision-making. All the stakeholders are participating, there are various organizations in place to support that.

Ubiquitous and secure network, cyber threats are rampant, we have seen them especially recently targeted at very large retailers like target. A number of other large retailers. We see it all the time. The thing that is happening is that those retailers are getting a lot better at securing their IT environment. So moving along from a hacker's perspective, we're starting to see attacks on hospitals. A few notable cases have come out. When it is easy, a hacker will try to attack the easiest target. Some of the larger retailers, as a patch up their environment, we will see more attacks on healthcare organizations. Hospitals have the capabilities to secure their systems to a much greater extent. Over time those things will happen but once that happens, it will not be uncommon to see attacks on Physicians’ offices. This is a real concern and continues to be, from a policy perspective, we need to continue to develop ways to move data that is both safe and protected.

The verifiable identity and authentication of all participants, it is important. We have a fragmented system currently to be able to do that. Going forward, there are steps that will need to be taken to authenticate participants across the entire ecosystem.

Consistent representation to access health information, it is fragmented. Organizations that support health information exchanges have local ways to do this. They do it at a national level where patients may want to access the data. It needs work. There are a number of calls to action in the roadmap document.

The consistent understanding of information, and the permission to collect, it goes back to the idea that we need some guidance from the federal government. There are state and organizational systems or representations of data, provisions in various systems to be able to collect data, every hospital has a form for collecting data. There is not really any federal guidance. It is fragmented.

Industrywide testing and certification, we are doing well with this. There are number of organizations in place so we had vendors to implement the IP protocols. There are also the EHR incentives. The consistent data semantics is a HL7 thing. We have HL7v2 , the architecture, some ways to represent data. We will see a lot more work going forward on those. We have at least standards in place right now, they are widely used by the vendors. That is a good starting point.

Consistent data formats, we are in a pretty good place with that. Those formats need to be nonproprietary. That is evolving. We have a format around HL7 and that type of thing, standards are open source. We're making progress. Secure and standard services, the concept about healthcare API, is there a way for me healthcare perspective that we can have common APIs that all systems will use. Not only the larger healthcare IT vendors but also smaller innovators who are building applications on mobile platforms.

The larger players in the marketplace, the EHR vendors, have those types of standards in place. But they are complicated so innovators have a difficult time. We will see more emergence of healthcare APIs probably based on the prior HL7 standards that will help with this. It allows innovators to be part of the market and take up a lot of patient usage. Secure and consistent transport techniques we talked about, individual data matching. Many systems have electronic indexes, which they use to identify patients across the number of hospitals, the problem is they are localized to say health information exchange environment, when one exchange wants to talk to another, do not necessarily do the matching exactly the same. There have been certain provisions at the federal level to develop a national identifier, the problem is even though those things were put into law, they have never been funded. It doesn't look like in the near future they will be funded. We need to figure out how we identify patients across hospitals and multiple hospitals and the region.

Data directories, we have a few of them. We see some states standing up provider directories that you can go to. There are some at the federal level also. One that comes to mind is the physician directory, many physicians use SureScripts for electronic processing and that is a large network that you can go to, to look up providers across the country. We will see a lot more directories. If I want to use direct messaging I need a way to look up the secure address so I can send it to him.

The outcomes. What do we expect the outcomes to be? We expect that individuals have access to longitudinal medical data. They can also contribute back so that is a goal which involves technical technology and workflow and opinion from the provider perspective. A lot of components.

Were also providing workflows that are transparent and include the sharing of patient information, without having to think about it. There is an EHR that can use direct messaging, it is usually involve somebody actually making that happen, pushing a button. In the future it should all be transparent.

One of the outcomes is tracking and progress and measuring success. One of the outcomes is the continuous quality improvement feedback loop where we have goals, we measure success, we make changes in order to improve on the goals.

From a more visual perspective, the ONC puts out a document, it is visual. A good way to look at the journey to better health. The link is listed at the bottom of the page.

The first part of the document defines the goals by 2017. The majority of providers can send receive and find.

Challenges HIE is not standardized, we do not have the rights authentication and authorization systems in place. The payment models are not aligned. The incentive to exchange data between providers and patients is not there. The privacy laws are inconsistent. It is fragmented. There is general lack of trust. That is where we are. There have been some gains. 78% of physicians are using EHR records, and there are a number of gains around building the baseline capability. By 2020, we expect to see an expanded set of stakeholders, more that want to engage, and the exchange of data, it will focus on the patient. We want to involve patients to a much greater extent. There will be greater information sharing with public health. There are many reporting systems in place for public health. As data starts to move transparently, we will see much more public health data available to do research, and to change the system in an appropriate way.

By 2024 we have the learning health system, and we will see more stakeholders involved. You can see we're in a happy place where we have happy people, and smarter spending and better care. Some key takeaways, one of the things that we have heard is if you read the roadmap document, is getting patients involved in their own health. Higher-quality based on a change in the payment model that we have. Pay for quality as opposed to quantity. More efficiencies that can be gained through health information technology and the ability to exchange data, easily and transparently between providers and patients.

Innovative payment reform. Not only what we are seeing now as far as a shift from quantity to quality but also, as we start to gather more data, more innovative payment models may be based on APM that type of thing. Another thing more than the competition. The more demand in the marketplace for say apps more vendor competition will drive technology and innovation further.

I will stop here. I apologize for going fast. If you want to type in any questions, you can send it to all participants. I can answer those questions at this time.

Thanks, John. The slides and the presentations, will be available on the QIN QIO website.

We talked about healthcare API. A way for healthcare systems to easily be able to exchange data, between systems, and move data or put data into the hands of the stakeholders, I encourage you to take a look at the HL7 website and look for flyer. It is an emerging standard, it is based on the same kind of technology that we use right now to build web-based applications. It invites a lot more potential innovators to the party as opposed to the way we interoperate data right now tends to be complex based on IHE standards. Flyer is a different approach based on a way the web works. As that becomes more prevalent we will see a lot more innovators in the market and that will really help from the perspective of engaging patients. Patients will have more smart technology in their hand where they can aggregate or gather data about themselves, and have the ability to send it to their providers. It will be interesting how flyer evolves over the next few years.

Thank you. When you close out the evaluation will automatically pop-up on the computer, please fill this out. If you do not have time to fill this out right now, you will receive an email tomorrow morning with the link to the evaluation.

The PowerPoint presentation is posted. Within the next few days a transcript will also be added. Thank you for attending. I hope everyone has a fantastic day.