The technology challenges facing LTPAC providers and their trading partners mirror the interoperability issues that face the overall health care industry. However, there their manifestation and possible solutions are somewhat unique to this segment. Key technology factors and trends are discussed below.
Private Health Information Exchanges and Vendor Health Information Exchanges
Private HIEs can have several organizing structures including ACOs, IDNs, and vendor networks. These approaches are more focused exchange to support the internal needs of organizations than public HIEs. The high penetration of Epic Systems Corporation and their software solutions including their health exchange product, EpicCare Everywhere, has resulted in this being a common means of exchange. Care Everywhere supports exchange that meets MU Requirements such as interoperable exchange between non-affiliated providers. For exchange between two Epic customers, Care Everywhere breaks the standard CCD and users proprietary data structures. When exchanging data with an EHR with others vendors, Epic uses standards-based approaches.
A second issue is that Epic does not support DSM and unlike most large EHR vendors does not act as a Health Information Service Provider (HISP). This means that providers who are Epic customers must go to third party vendors to for DSM services that most integrated within the Epic system. This provides additional complexity and costs for HISP to HISP interfaces, as providers select different HISP vendors and solutions. Each HISP to HISP solution and interfaces with HIEs must be individually developed.
Our interviews and site visits indicated concerns about the interoperability and dominance of Epic. In Minnesota to the extent that exchange was occurring between IDSNs, this exchange occurred through Care Everywhere between Epic customers. The concern is that this a barrier to exchange that supports continuity of care. This also makes the use of a provider portal, in this case EpicCare Link, the optimal solution for both the hospital system and the LTPAC provider.
Electronic Health Record
As non-eligible providers under MU, LTPAC providers are moving on a parallel but different path than most of their trading partners. Based upon the interviews in the project most LTPAC providers see the primary goal of exchange is the reporting of administrative data as opposed to the exchange of clinical data. The EHR vendors to the LTPAC market have responded to their customer's needs and have not focused on exchange functionality within their software solutions.
PCC, the largest vendor to LTPAC facilities and the common choice among national chains, has only recently supported for DSM and is alone among the LTPAC providers in integrating DSM with an EHR. However, this solution provides the ability to receive a CCD but not consume it or parse that data into the EHR. This is not that different than using a provider portal and printing and scanning the relevant portions into the local EHR as a document.
There is no indication that LTPAC facilities or their EHR vendors are considering the development of an interface solution with public HIEs. The cost, "one-off" nature of the interfaces, programming challenges make this approach infeasible. This means that query-based exchange is not a viable option.
There are several solutions to the constraints shaping data exchange and re-use by LTPAC providers and their trading partners. This first of these is the KeyHIE Transform tool developed under a Beacon Grant and being commercialized by Vorro Health. This elegant but simple solution converts the CMS MDS and OASIS into a CCD that can be exchanged and consumed by an EHR. This solution is being sold to and offered by public HIEs, not to LTPAC providers. The number of HIEs who have adopted Transform is not publicly available, but the interviews undertaken indicated that more than six are currently offering the service.
An alternative solution to using an exchange network is peer-to-peer solutions. Within Minnesota, under a state grant, Allina Health (an IDSN) and Benedictine (a LTPAC provider) developed a server to server solution that allowed for the bidirectional exchange and consumption of a CCD. This was between an Epic EHR and the MDI Achieve, a LTPAC EHR developed by MatrixDirect. Although the project achieved all of its goals and objectives, the exchange ended. The reasons cited were a concern about liabilities associated with externally sourced data and an absence of funding to continue software development.
The development of API solutions and standardized data formats such as FHIR (Fast Health Interoperability Resource) have the potential to bring a simplified and lower cost solution to data exchange. The development of exchangeable content as defined Resources provides a foundation for technical and semantic interoperability. Initiatives such as SMART on FHIR and DIRECT on FHIR are demonstrating how EHRs can be extended and accessible. The ability to exchange well-defined modular pieces of information as opposed to the complexity of exchange required under a C-CDA could provide a resolution to technological barriers to interoperability while providing the necessary information to support transitions in care.