A new health IT partnership aims to improve clinical data quality and thereby increase the volume of data available for care quality measurement.

The partnership will combine Chicago-based Apervita and Farmington, Connecticut-based Diameter Health’s expertise to provide payers, providers and other healthcare stakeholders with access to clean clinical data for value-based care delivery, said Rick Howard, Apervita’s chief product officer, in an email.

“The healthcare industry has no shortage of data, but the way it’s leveraged continues to be a challenge for both quality measurement and for supporting value-based contracts,” he said.

Apervita provides stakeholders with the infrastructure necessary to develop value-based care models.

Per the new partnership, the company’s quality measurement and value optimization solutions will leverage Diameter Health’s Fusion engine to clean healthcare data in multiple formats, including clinical, claims, behavioral health and laboratory data, Howard explained.

The clean data can be used to glean performance insights that are needed to develop value-based contracts between providers and payers.

Diameter Health’s technology ingests raw — that is, poorly formed, unstructured or incorrectly coded — health information from EHRs, labs and aggregators, and automatically normalizes, re-organizes, deduplicates and summarizes the data, said a Diameter Health spokesperson in an email. The technology identifies data quality errors early in the ingestion process, which makes data sharing more efficient.

“We are thrilled to be a critical and foundational component to Apervita’s platform by delivering clean, normalized, and enriched multi-source clinical data to their customers, empowering providers, payers and other healthcare stakeholders to improve quality and deliver value,” said Eric Rosow, CEO of Diameter Health, in a news release.

Healthcare data is proliferating as the industry becomes more digitized. Telehealth and remote patient monitoring services, in particular, grew exponentially amid the Covid-19 pandemic. And the data generated by these services also grew.

In addition, wearable health technology, like glucose monitors and the Apple Watch, are becoming more widely used to track patient diagnostics and encourage patient engagement, Howard said. This provides even more data for the healthcare industry to contend with.

“As the volume of healthcare data continues to grow, so will the need to have technology that normalizes the data so that it can be used to support quality measurement, value-based contracts and analytics,” he said.

Photo: Dmitrii_Guzhanin, Getty Images

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Gaining insights into social factors affecting patients’ lives can be used to augment healthcare delivery in a big way.

That’s according to Dr. Courtney Lyles, an associate professor at the University of California San Francisco, who helped create an expansive social determinants of health-focused data visualization platform. She discussed the platform and its development at the Workgroup for Electronic Data Interchange’s The Quest for Health Equity virtual conference on Feb. 23.

The platform, UCSF Health Atlas, was released last April. Focused on California-based data, it is designed to enable researchers to explore neighborhood-level characteristics and see how they relate to health outcomes. It also includes data on Covid-19.

“It’s pretty clear, and Covid has made it even more clear, that health is really impacted by place,” said Lyles, who is also co-principal investigator of the UCSF Population Health Data Initiative. “Where we live, including our physical and social environment, directly influences health outcomes.”

The interactive platform includes more than 150 social determinates of health variables at different levels of granularity down to the census tract level, which includes between 1,200 and 8,000 people. The platform draws from several sources including the American Community Survey from the Census Bureau, CalEnviroScreen developed by the California Environmental Protection Agency and the California Department of Public Health.

But one of the main challenges of developing a platform like this is deciding what publicly available data to include from the massive trove that is available, said Lyles.

To create Health Atlas, UCSF relied heavily on the Health People 2020 framework created by the Office of Disease Prevention and Health Promotion. This framework helped the UCSF team think through five domains of social factors, said Lyles. These domains were:

  • Demographic characteristics
  • Socioeconomic factors
  • Community characteristics
  • Neighborhood characteristics
  • Health and healthcare indicators

The UCSF team then went in and selected useful variables within each of the five domains. For example, within the community domain, the team selected individual variables like language and foreign-born status as well as wider variables like population density and household composition — that is, people living in households with children versus single-adult households versus seniors living alone.

“Thinking about those variables has really been interesting,” said Lyles. “[It allowed us to] think through what matters for population health and health equity risk.”

Combining all this data on an interactive map enables researchers and clinicians to drill down into granular data on any one variable, and also compare different variables, she said.

UCSF has gone a step further and made it possible to link that social determinants of health data with its EHR data. For example, UCSF combined the two to gain insights into racial disparities in hypertension outcomes. Eliminating this disparity was a pre-Covid goal for the health system, Lyles said.

First, the team extracted every single address that existed within UCSF’s EHR, and then they geo-coded those addresses onto latitude and longitude. They assigned census tract identifiers to those geo-coded addresses so that they could be linked out to the publicly available datasets. Finally, they gathered clinical and demographic data for patients with hypertension receiving care within the system.

By combining all this the system was able to track hypertension patients by race, neighborhood and socioeconomic status in San Francisco on the map and compare these variables with health outcomes, Lyles said. They found that Black patients are concentrated in certain neighborhoods, and they’re struggling with hypertension control.

“This is not showing us something that perhaps we didn’t know already about structural disparities in care or structural disparities in our society,” Lyles said.

But it does show the urgent need for including place-based strategies in health systems’ disparity reduction and quality improvement programs.

“When you put it out there in a visual display, it actually gives you even more impetus to think about neighborhoods you want to target, or [places where] you might think differently about your interventions moving forward,” she said.

Photo: GarryKillian, Getty Images

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virtual care

Next year is poised to be a banner year for people accessing their health information. In April, the Department of Health and Human Services will implement its long-awaited interoperability and information blocking rules.

Though providers were already giving patients access to their data to some extent, the new rules widen the scope of the information to be provided. As a result, providers are retooling their policies and processes around data access and working to iron out potential hurdles that may have a negative impact on patient experience. EHR vendors, on the other hand, are focusing on shoring up the technology infrastructure that will enable expanded patient access and helping to educate their provider clients. Both groups received a breather when HHS decided to push back the compliance date of the ONC’s final rule to April 5 from Nov. 2. 

What’s in the ONC’s final rule?
Together, the ONC and CMS rules implement the interoperability and patient access provisions of the 21st Century Cures Act and support the MyHealthEData initiative, which aims to provide patients control over their healthcare data so they can decide how it will be used.

The ONC’s final rule specifically establishes new regulations to prevent information blocking practices by healthcare providers, health IT developers, health information exchanges and health information networks. According to Leah Voigt, Spectrum Health’s chief compliance officer, there are two main reasons why information blocking occurs. First, complex privacy laws and regulations overlap at the federal and state levels, due to which these laws can be “over interpreted” to prevent the sharing of health information even when it is actually allowed, she said in an email. Second, the cost and complexity associated with making health information available can be a deterrent to data sharing.

“This is compounded by the first reason — it’s hard to know which law or regulation applies when, under what circumstances; and designing processes and technology solutions to make health information available in ways that comply with these laws and rules is not easy,” she said. “Often the more complex or nuanced the rules, the more costly the solution.”

The ONC’s final rule requires healthcare entities to give patients complete access to their personal health information, including clinician notes. It also establishes standards-based application programming interface requirements. APIs are the foundation of smartphone applications, and the new requirements will support the patient’s ability to securely obtain their health information from their provider’s EHR using an app of their choice.

“One of the goals of the 21st Century Cures Act is to make sure that health information is interoperable and computable, giving patients more control of their medical record,” said an ONC official in an email who declined to be publicly identified. “That seamless exchange of electronic health information and patient use of smartphone apps have the potential of delivering affordability and quality through transparency and competition.”

The law states that certified health IT developers and HIEs/HINs would be subject to penalties of up to $1 million per violation of information blocking, the ONC spokesperson said. But healthcare providers will be treated differently. The HHS is reviewing feedback on what the appropriate deterrents may be for situations where a provider is found to have engaged in information blocking.

By April, healthcare providers have to make a subset of health data available to patients. The subset called the United States Core Data for Interoperability set includes a dozen or so data elements, including information on allergies, medications and clinical notes. By October 2022, providers have to make all health data available to patients.

How health systems are preparing
Boston-based Mass General Brigham, which includes Brigham and Women’s Hospital and Massachusetts General Hospital, one of the many systems that would need to comply, set up a working group to discuss the process ahead, said Deborah Adair, executive director of enterprise health information management at the health system, in a phone interview. 

The health system was already in compliance with some of the regulations. For example, Mass General Brigham patients received their medical records on request. But to ensure compliance with the new rule, the health system now makes records immediately available via the patient portal. This includes inpatient information, as well as information related to ambulatory visits.

Other elements of the new rule, however, placed the health system in a quandary. What should they do when test results contain sensitive information? Up until now, these results were delayed to give clinicians enough time to review the results and personally contact the patient, with whom they have a relationship, to explain what the results mean and answer questions and concerns, Adair said.

But the new regulations stipulate that all test results be made available immediately and easily to patients, so the health system needed to decide how to comply while also considering how to deliver unwelcome health news to patients via the portal. 

“That was one of the biggest things we grappled with because the law requires you to share everything with the patient and we weren’t used to that, and our doctors were concerned it would cause [the patient] emotional harm if they get a cancer diagnosis without getting a call from them first,” Adair said. “And the regulation requires that you can only block a note if it’s going to cause significant physical harm or life-threatening injury. The law specifically excludes emotional harm.”

To ensure patients were not left feeling like they had to deal with traumatic diagnoses on their own, the health system decided to put a note on test results containing sensitive health news. That lets patients know that their provider would call them to discuss the results.

“It’s gone [over] pretty well,” Adair said. “I think people were nervous that there was going to be a lot of reactions from patients and phone calls and concerns and so forth. But it hasn’t proven to be that way. So, I think it’s good that patients have access to their information any time they want it.”

The information sharing is of course not a one-way street from providers to patients. With the new rule, health systems have to make provisions for patients authorizing third-party apps like Apple Health, to access their health information. Mass General Brigham however, was already prepared for this. 

The health system uses Epic EHR technology, which provides an industry standard set of Fast Healthcare Interoperability Resources (FHIR) APIs that can be used by third-party apps to access medical records it manages. Further, Mass General Brigham has a security protocol that allows third-party apps to request access to patient information in a secure way, Adair said.

Getting to compliance, wasn’t just a matter of IT tweaks and allaying physicians’ concerns. It required internal education as well. Mass General Brigham worked with its clinicians — educating them on the rule, how it affects them and what they need to do to remain in compliance, she added.

Like Mass General Brigham, Spectrum Health, based in Grand Rapids, Michigan, has also started sharing clinician notes for all types of visits with its patients, Voigt, the system’s compliance chief, said in a phone interview. Though it already had an initiative in place to share notes from ambulatory visits, it has spent the last few months providing notes from inpatient visits as well to patients via Spectrum Health’s online portal.

“Use of our EMR and an app for a portal to grant patient access is not something new to us,” Voight said. “We’ve just expanded the scope of the information we are giving patients access to.”

Over the next few months, Spectrum Health plans to monitor the new processes and understand whether any tweaks need to be made. For example, as noted above, clinicians can hold back information for patients if they feel it may cause them physical harm, but that is at the clinician’s discretion. The health system will monitor EHRs and disclosures to apps to see how often clinicians are holding back information and what their reasons are, Voigt said.

Spectrum Health will also examine other trends, such as whether the withholding of information is occurring more often in a certain specialty area or among a certain set of clinicians. This is important “so we can go back and look at those patterns to determine whether or not we need to have focused education for providers on the information blocking [regulations].” Further, it can help to determine “if there is something we need to change in our process of providing those open notes that will further help ensure compliance. So, we are really taking advantage of this time,” before compliance is required, she added.   

The EHR vendor perspective
Both Cerner and Epic — the two biggest EHR vendors in the country — make APIs available for third-party app developers so that the health information on their respective systems can be easily shared with patients. To ensure compliance with the new rule, both companies are making changes to their ongoing efforts.

“In response to the ONC’s 21st Century Cures Act final rule, we are pursuing development efforts to upgrade those APIs to the latest version of FHIR adopted as a standard by ONC,” said Dick Flanigan, senior vice president at Cerner, in an email. “We will also be overhauling our app registration and onboarding processes to ensure that apps used by patients to access their health information can connect as seamlessly and effortlessly as possible. Incorporated into these processes are industry standard privacy and security capabilities to ensure that a patient’s health information is securely transmitted and only made accessible to an app when authorized by the patient.”

In addition, the company is making enhancements to consolidated-clinical document architecture (C-CDA) documents, which are “used by providers to exchange information for referrals and other critical technologies,” he said. 

Epic already makes several APIs available to share data elements in the United States Core Data for Interoperability set, including data on medications, allergies and other information, said Stirling Martin, senior vice president and chief security officer at Epic, in a phone interview. More recently, the company added clinical notes to the set of APIs available.

For both Epic and Cerner, educating customers — the health systems which use their EHRs —is a must.

“Where a lot of our time and energy has gone [in the last six to nine months] is into educating the customer community on what the rule really requires and the scope of what it applies to,” Martin said. “[The rule] certainly applies to the data in their Epic system but it also applies to the lab system, dietary system, heck it even applies — if they exchange health information by email, it applies to that as well. As organizations get [data] requests, they need to think about what’s their workflow, what’s their process for managing those requests.”

Cerner’s Flanigan said that his company is providing education and resources to customers on how they can use the company’s software to exchange health information in different scenarios.

While health systems and EHR vendors alike accelerate efforts to comply with the new rule, it’s worth noting that it’ll likely be years before the regulations become fully integrated with the healthcare ecosystem.

It will be a “multi-year journey,” Voigt of Spectrum Health said. Industry stakeholders can expect updates and changes along the way.

Voight believes the “journey” will likely mimic other major policy changes that have been instituted.

“The one thing I would say, from a compliance officer and a privacy officer standpoint, is similar to what the healthcare industry experienced when the HIPAA rules were created…it took several years for the healthcare industry as well as the government agency that enforced the HIPAA rules, in that case the ONC, to really understand how those rules would be implemented and where those regulations weren’t so clear, or where the agency needed to provide guidance,” she said. “We know a lot more about how to comply with HIPAA now, about 20 years in, than we did [initially], and I think it’s going to take similarly that time for the healthcare industry, and ONC and CMS to understand how these regulations really work in practice.”

Photo credit: ipopba, Getty Images

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Research from Melbourne Business School and management consulting firm Kearney has found that 50 per cent of companies struggle with data reliability despite an increase in data volume of 20x over five years.

The annual Analytics Impact Index measures the impact that data analytics has on an organisation’s growth and profit.

The index surveyed 300 global companies across 33 industries with a median revenue of $US330 million.

Source: Melbourne Business School and Kearney

It found that more mature participants spent 20 per cent of their data budget on improving data reliability, which allowed them to reach 83 per cent of their data accuracy and reliability objectives. In comparison, less mature participants only spent 5 per cent and could only meet 14 per cent of their objectives.

Source: Melbourne Business School and Kearney

“In the challenging times that we currently face, organisations can leverage their data assets to compete, but the extent to which they can compete is limited by the reliability of their data assets,” said Professor Ujwal Kayande, Director of the Centre for Business Analytics at Melbourne Business School.

“The increase in data volume is not so surprising as more organisations and customers connect into the internet of things and high-speed networks. Moreover, moving data into the cloud has removed the barriers that organisations previously faced in terms of being able to access and store data.

“However, more data does not necessarily mean better insights, as data reliability continues to be a major issue for organisations around the world. Organisations face challenges in being able to aggregate data across legacy systems that don’t always talk with each other. To be able to integrate and leverage data across systems requires a strong sense of the purpose of the data. Once that is addressed, organisations find it easier to integrate and leverage data, thereby resolving reliability issues.”

The index also found that investment in AI was not predictive of a company’s success.

More mature companies (Leaders/Explorers) invested a similar amount to less mature companies (Followers/Laggards), however the Leaders/Explorers had a 4-5 times higher uplift in value from AI pilot deployment and also deployed AI pilots in half the time.

Source: Melbourne Business School and Kearney

“AI for many companies is becoming an essential capability to deliver superior outcomes. However, we have seen that currently only Leaders and Explorers are effectively launching AI pilots,” said Kearney Partner Enrico Rizzon.

“What we found was that whilst the investment in AI was similar between the two groups, only the Leaders and Explorers were reaping true value from their AI pilots. This implies that you simply can’t expect superior results just by injecting more capital into your AI program and expecting it to be successful.

“Companies need to be highly aware of other influencing factors and work on enhancing them. As an example, we found that AI pilots were successful for Leaders because of their culture of experimentation and other differentiating factors such as having leadership and buy-in from the C-suite.”

When compared to previous years’ findings, the index shows that less mature companies could potentially generate up to 81 per cent more profit if they invested more in analytical maturity.

“To compete for a customer’s business and see opportunities, an organisation needs to know what customers want and how to service those wants, which data can enable. So my expectation is that analytics is going to become more valuable to organisations, although I also expect the range of that value to increase. Some organisations will do far better, but others will do far worse,” said Professor Kayande.

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