by Lynn Witherspoon, MD, System Vice President & CMIO and Kent Boyer, Chief Architect, Ochsner Health System
A cornerstone of health care reform is a new paradigm of care delivery focused on population wellness rather than disease management. As imagined in emerging Accountable Care models population surveillance supersedes individual patient visits with their providers. This model attempts to ensure that those preventive services for which evidence of efficacy exists are delivered to everyone and “at risk” individuals with chronic health problems are identified before they require emergent intervention. Accountability shifts from individuals who decide whether and when to visit their care providers to organizations focused on providing population oversight and risk stratification. Like many other large healthcare providers and insurers, the Ochsner Health System sees developing these capabilities as essential to our long term survival.
A key critical success factor for population management is access and the capability to use data to monitor the health status of the population being managed. Equally critical is the ability to partner with other providers the population receives health care services from as well as with the organizations paying for those services. This means partnering with many independent providers and insurers to monitor health status and coordinate care. Trying to do this without reasonably complete data is not a path to success. Healthcare does not have a strong track record at successfully pooling and effectively using data for population management across multiple independent organizations. Most organizations are trying to develop these competencies. Vendors with Health Information Exchange and Healthcare Analytics products promise much but very few are delivering with sustainable value.
The HITECH Act and Meaningful Use have succeeded in enabling the wide-spread adoption of electronic medical record systems. It is reasonable to expect all physicians interested in participating in population management will have current state EHRs at their disposal. As things stand today, large organizations like Ochsner whose providers share an EHR have a reasonably complete view of care patients receive within our organization. Problematically, however, information regarding visits outside our organization is sequestered in other provider’s EHR.
Insurance companies receive claims for payment for most or all of any patient’s care and may have a more complete view across services provided. The major healthcare insurance companies are each trying to deploy proprietary data capture infrastructure at the point of care. They may have some access via these health information exchange infrastructures to clinical data in EHRs that subtend individual patient’s care. If insurers had their way, a provider could end up spending hours doing duplicate data entry into disparate systems for patients they see.
In face of the urgent need for integrated population data, no clear solutions have emerged which are likely to produce significant and sustainable value. No provider currently has an integrated view of all of any patients care, never mind insights into the health status of patients who do not actively seek medical care.
In the context of HITECH and Meaningful Use, CMS has essentially mandated that all healthcare providers use EHRs that are capable of producing and consuming Consolidated-Clinical Document Architecture (C-CDA) messages. The C-CDA standard not only dictates the format of the message but also the vocabularies used to encode the individual discrete values. We propose that leveraging the C-CDA format used for the Summary of Care Document along with Direct protocols for transport is a relatively cheap and sustainable answer to a need that is acutely felt by large healthcare provider organizations and health insurance providers, regardless of what EHR product they use.
The use of C-CDA as the “interface” to transmit data from one EHR to another (or to an insurance company) all but eliminates the complexities involved in extracting and combining data from multiple incompatible systems. Health Information Service Providers (HISPs) offer a secure pathway for the data to move over without the need for multiple point-to-point connections.
There are some challenges that need to be dealt with in implementing a C-CDA solution. EHR systems are designed to support the transmission and receipt of summary of care documents in association with specific patient care events. Using the C-CDA format and HISPs for large volume data exchange requires batch processes for transmitting and receiving C-CDA messages independently of clinical workflows.
Past experience with CHINs, RHIOs, and HIEs suggests it is time to take a different tact.