Presentation outline by Anupam Goel, MD, Chief Health Information Officer, Clinical Services, United Healthcare presented during eHealth Initiative's Prior Authorization Workshop on October 31, 2018.

How can we move from a blame-oriented system to a learning system?

• We have to move our idea of testing new things beyond “pilotitis*.” As we test new changes, the marketplace also changes. Rather than viewing each test as an intervention without regard to other stakeholder responses (scientists, providers, patients, competitors and regulators), interventions should be considered as a trajectory of problems and solutions (i.e., more “cat & mouse,” less “pushing unilaterally”).
• In a marketplace with low-trust among stakeholders (e.g., members/patients, providers, payers), we should consider using standards that are:
  
  • Robust to different levels of technology or clinical sophistication, and
  • Modular to allow for updates to different process elements without revamping the entire system for all participants.
  • Possible standards include SMART on FHIR and DIRECT for synchronous and asynchronous communication, respectively. CDS Hooks is an emerging standard that might allow different payers to deliver their own content across the same points within the electronic medical record workflow.
• Learning systems benefit from feedback loops
  
  • Feedback to customers (employers, members/patients)
  • Feedback to partners and suppliers

Can evidence-based medicine and patient preferences supplement or replace Prior Authorization?

• Prior Authorization creates the appearance of scarcity and drives irrational behavior among marketplace participants
• Can eliciting patient preferences within the context of evidence-based medicine? At least one entity (Kaiser) thinks so.
• One warning: patient preferences can change over time, challenging static models of the “right care choice.”

What’s the goal of Prior Authorization? Maybe the goal is to change behavior.

• Changing behavior starts with the realization that what I am currently doing is not supporting who I want to be (cognitive dissonance).
• Once I experience cognitive dissonance, do I have the knowledge, skills and attitudes to make a behavioral change?
• K Anders Ericsson (Peak: Secrets from the New Science of Expertise) talks about “deliberate practice,” constantly pushing oneself beyond one’s comfort zone, following training activities designed by an expert to develop special abilities and using feedback to identify weaknesses and work on them. We need to consider this same type of deliberate practice as we consider ways to improve the Prior Authorization process.
  
  • Feedback to orthopedic surgeons from their patients (e.g., KOOS-Jr survey)

Miscellaneous thoughts

• Bundled payments may work best when used in conjunction with Centers of Excellence
  
  • Centers of Excellence identify members who are most likely to benefit from an intervention
  • Bundled payments identify those teams or facilities that perform the intervention at the highest value (quality/cost) once the decision to perform an intervention has occurred
• Care pathways may allow payers, providers and members to forecast short-term future needs (diagnostic, pharmaceutical and medical) as a patient moves through the pathway, facilitating the prior authorization process.
• Advancing Prior Authorization standards will force payers to consider other ways to distinguish themselves in the marketplace. Payer market differentiation opportunities might include facilitating prior authorization from telemedicine or telephone encounters, driving prior authorization through patient functional assessments or patient preferences, identifying providers or medical centers who deliver services tailored to a member/patient’s specific preferences.

*Pilotitis – continued emphasis on demonstrating successful outcomes from narrowly-focused interventions targeting relatively small populations (Huang F et al. “Beyond pilotitis: taking digital health interventions to the national level in China and Uganda.” Globalization and Health, 2017 13:49.

There's no need to wait years to achieve partial interoperability.

TOTAL interoperability is available today with our groundbreaking MedKaz® patient-focused personal health record. It is the only system that assembles a patient's COMPLETE record from ALL his or her providers in one place and is instantly available at the point of care whether at home or away. If you can log on to a computer, perform a search and read a document in a browser you can use MedKaz! It is updated for your following each encounter you have with a care provider.

For example, I have ALL of my records from ALL of my providers for the past 35 years on my MedKaz which I carry on my keychain. My providers were located in six cities and three state, and include every charting system you can think of— from paper charts to virtually every EMR system.

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We'll be happy to discuss it with you and even demo it for you at your convenience.

Best Practices in Making a Health System Interoperable​: Rochester Regional Health

Rochester Regional Health (RRH) is a non-profit health system of five hospitals and an outpatient care network. In bringing these hospitals and networks together, RRH was tasked with converging a number of systems, including multiple electronic health records (EHRs), other clinical systems, and the regional and statewide HIEs (Rochester Regional Health Information Organization (RRHIO) and Statewide Health Information Network of New York (SHIN-NY)). Currently, they are able to aggregate data from key sources of clinical data beyond the data found in RRH’s primary EHR system, Epic. They utilize Epic Care Everywhere for links with other Epic providers, public health information exchanges (HIEs), a private HIE, emerging networks like CareQuality, eHealth Exchange, and CommonWell, and other methods such as Direct messaging, single sign-on (SSO), and FHIR and open APIs.

RRH has invested in certain infrastructure and utilities, without which the value of interoperability cannot be attained, including:

• Using an eMPI to accurately identify patients across over 30 health system and community (RRHIO) data sources
• Using consent tracking to note who can see sensitive information and how the patient has authorized RRHIO to share their data (per NYS patient consent regulations)
• Putting forth a large data normalization tool to ensure that ‘system to system’ and ‘system to community’ exchanges have a standard set of clinical data architecture
• Integrating an internal provider identification credentialing process across the entire RRH system
• Handling referrals internally and externally with their partners through standard Epic tools
• Implementing a set of governance advisory councils and groups to guide their internal perspective and represent patients

The resulting interoperability infrastructure has provided the basis for:

• Transitions of Care – Clinicians, working in their native EHR, have a longitudinal patient record view, have a much more complete view of a patient’s encounter activity across the entire community, and not just as their native EHR views the patient.  This insures consistency in clinical data access from ambulatory, to inpatient, to post-acute, to home care.
• Business Intelligence – The collection, aggregation, and normalization of key clinical domains across its private and public HIE clinical data repository…including problems, allergies, medications, immunizations, procedures, vitals, lab results, radiology reports, and clinical documents…feeds a robust, normalized enterprise data warehouse, supporting many of RRH’s business and clinical intelligence initiatives.
• Gaps in Care – An EHR’s view of “Gaps in Care” is typically from its own clinical data repository.  However, a clinically integrated, HIE, combining the enterprise and community view of the patient, insures a more realistic view of a patient’s care needs, while reducing unnecessary, redundant, laboratory testing and imaging studies.
• Patient Engagement – The patient-provider relationship is a more productive conversation when the provider has a broad, longitudinal view of a patient’s medical record, focusing the path forward to better, comprehensive care planning.

As they move from the traditional volume-based economy to a value-based economy, RRH would like to create a value proposition and are strategically focusing on areas such as:

• Network development: Reach their communities through a vast network of touch points for all their care needs
• Patient experience: Build and deliver a signature experience for patients anywhere in their system. Patients need an experience where they are part of their own healthcare
• Operational excellence & Integration:  Strive to make the organization better, knowing that when RRH thrives, their patients thrive
• Innovation & Population Health: Improve the health and wellness of the people in their region through innovation

As the healthcare industry experiences a digital health revolution, RRH recommends the following considerations for success for turning innovation into something meaningful for the healthcare industry:

• Learn from peers and other industries outside of healthcare who are successful and leading the way
• Form new relationships at the local, state, and federal level to synch strategies
• Empower patients and clinicians
• Develop a purpose-driven approach that includes understanding the problem, engaging end-users early in the process, and tailoring the approach to fit the workflow
• Do not design technology until an organization has understood the problem, listened to customers, and thought about the workflow

These best practices and considerations for success were discussed as part of a presentation by Rochester Regional Health during eHealth Initiative’s September 2018 Technology & Analytics Workgroup meeting.

Slides and recording from 11.14.18 webinar.

Note: The first presentation contains animations not available to view in PDF. Please use recording for best viewing experience.

The open FHIR® standard is providing new avenues to build and deploy applications and services that draw on relevant clinical data. In addition to powering patient facing applications like Apple Health and provider facing applications that can run embedded within leading EHRs, the standard is being extended to support clinical decision support services and the exchange of population data to drive clinical analytics. In this session, we’ll explore the FHIR standard itself, how it’s currently being used to improve data interoperability in healthcare, and the impact it may have in the future.

This webinar will provide a primer on new healthcare interoperability technology that is currently being rolled out across hundreds of healthcare providers and is supported by leading organizations including CMS, Epic, Cerner, Allscripts, Apple, and InterSystems.

HL7® and FHIR® are registered trademarks of Health Level Seven International. The use of these trademarks do not constitute a product endorsement by HL7.

Speakers:
-Russell B. Leftwich, MD, Senior Clinical Advisor, Interoperability, InterSystems
-Dan Gottlieb, Product Specialist, InterSystems
-Laura Heermann Langford, PhD, RN, Nurse Informaticist, Homer Warner Center for Informatics Research, Intermountain Healthcare; COO, Healthcare Services Platform Consortium

Slides from presentation by Stephen Konya, Senior Innovation Strategist, Office of the National Coordinator (ONC) at eHI's 10/31/18 Prior Authorization workshop.

Presentation includes what ONC is doing with prior authorization:

• The ONC Payer + Provider (P2) FHIR Taskforce​

• 21st Century Cures Act – Report on Reduction in Clinician Burden​

• ONC is working closely with CMS to analyze PA issues and make recommendations to reduce this burden associated with health IT ​

• Working group with CMS ​

• ONC has initiated a working group with key staff from ONC and CMS to continue investigation into the PA ecosystem and identify areas for potential solutions

Presentation slides by Brett Andriesen, Standards Advisory Lead, Office of Technology, ONC. Presented at the combined Technology & Analytics and Value & Reimbursement November workgroup meeting. Brett provided an overview of the Interoperability Standards Advisory (ISA).

Slides by Charles Jaffee, MD, PhD, CEO, Health Level 7, presented at eHI's October 31, 2018 Prior Authorization Workshop.

The opportunities and challenges of data analytics in health care

This report is part of "A Blueprint for the Future of AI," a series from the Brookings Institution that analyzes the new challenges and potential policy solutions introduced by artificial intelligence and other emerging technologies.  This report specifically addresses topics such as sensitivity of care decisions, problematic data conventions, institutional practices, misaligned incentives, and ultimately concludes with policy recommendations.

The full report can be viewed at this link.  

Plugging the Gaps in the Continuum of Care

As the U.S. population ages, it becomes increasingly important to keep seniors from falling into the gaps in the continuum of care. With 86 million people expected to reach the age of 65 and beyond by 2050, private sector and community organizations will have to find new ways to collaborate and work together to help care for them.

Continuum of care is a concept involving the overarching system that guides and tracks patients during their life journey through the healthcare system. It spans all levels and intensity of care. There are seven basic categories of continuum services:

1. Extended care
2. Acute hospital care
3. Ambulatory care
4. Home care
5. Outreach
6. Wellness
7. Housing organizations

In a perfect world, the hand-off between each of these organizations and providers would be seamless. This would reduce the chance of hunger and neglect among seniors, of hospital readmission, and of the mismanagement of chronic and acute medical conditions.

The full Forbes article can be viewed at this link.