Clinical, Technical, Organizational and Financial Barriers to Interoperability Task Force November 2, 2015 Paul Tang, chair

Membership 2 First NameLast nameTypeOrganization PaulTangChairPalo Alto Medical Foundation Julia Adler- MilsteinMemberUniversity of Michigan ChristineBechtelMemberBechtel Health Advisory Group JoshMandelMemberChildren's Hospital Boston BobRobkeMemberCerner MickyTripathiMember Massachusetts eHealth Collaborative LarryWolfMemberKindred Healthcare MichaelZaroukianMemberSparrow Health System

Clinical, Technical, Organizational and Financial Barriers to Interoperability Task Force - Workplan MeetingsTask September 9, 2015 – HITPC Meeting Draft recommendations to the HITPC September 11, 2015 at 12:00 ET Review of feedback from HITPC September 25 at 12:00 ET Data update – interoperability measurement Review of data blocking information October 9 at 12:00 ET Continue review of draft report ONC presentation to inform work October 23 at 10:00 ET Finalize recommendations November 2, 2015 at 3:30 ET Discuss draft report November 10, 2015 Present final report to HITPC 3

Agenda Review recommendations Discuss draft report and plans to for finalizing 4

Joint Explanatory Statement in the Congressional Record on 2015 Omnibus Bill Interoperability.--The agreement directs the Health IT Policy Committee to submit a report to the House and Senate Committees on Appropriations and the appropriate authorizing committees no later than 12 months after enactment of this act regarding the challenges and barriers to interoperability. The report should cover the technical, operational and financial barriers to interoperability, the role of certification in advancing or hindering interoperability across various providers, as well as any other barriers identified by the Policy Committee. 5

Charge Questions Pertaining to Financial Barriers What financial/business barriers to interoperability exist in the ecosystem? – Where do the barriers lie? i.e., which stakeholders? – What’s the impact of the barriers/practices on the ability of other stakeholders to interoperate? Which of these are being addressed by initiatives underway today? Where is progress being made? Where do the gaps still exist? What actions need to be taken to address these financial barriers/practices? 6

Recommendations

Develop and Use Meaningful Measures for Consumers and Payers (1) Recommendation: Develop and implement meaningful measures of HIE- sensitive health outcomes for public reporting and payment Measures are required that reflect the extent to which interoperability exists. There are many different types of measures that could be pursued – for example, measures that capture interoperable infrastructure (e.g., adoption of certain technical standards) or measures that capture volume of interoperable transactions – but these infrastructure and process measures may serve as poor proxies for what we ultimately seek: improved care that results from interoperable health information exchange. Identifying existing, or developing new, measures that can be applied to provider organizations and are sensitive to interoperable HIE would serve as a powerful basis for strengthening incentives in two ways. It is critical that measures are perceived as “measures that matter” to payers and consumers. Providers are likely to see direct value in these measures as well as they will allow them to track performance, and inform performance improvement efforts, along dimensions relevant to ACO and other value-based reimbursement models. 8

Develop and Use Meaningful Measures for Consumers and Payers (2) More broadly, agreement on a set of specific measures would allow the market to focus on designing care processes and health IT products that target those measures. Agreement on a set of high-value HIE- sensitive measures would require coordinated action among key stakeholders – which we develop further in recommendation 4. There has been some prior work to define HIE-sensitive outcome measures which capture whether care is well- coordinated and affordable. There are also examples of efforts to incorporate measures like these into provider payment (or other participation agreements). 9

Develop and Use Meaningful Measures of Vendor (1) Recommendation: Develop and implement HIE-sensitive vendor performance measures for certification and public reporting While developing HIE-sensitive outcome measures that can be applied to provider organizations may provide an indirect incentive for vendors, we believe that direct measures of HIE-sensitive vendor performance will bolster market forces behind vendor business practices that promote interoperability. It has not been shown to translate into interoperability that is affordable or easy to implement in the field. While certification could be improved (in particular, to focus on certifying capabilities to get data in and out of EHR systems) and expanded to include more robust post-market surveillance, it is likely more effective and efficient to use measurement and transparency as the primary driver. As with the prior recommendation, a coordinated, multi-stakeholder effort to define such measures is required, and it is not clear whether there is an entity likely to fund such an effort in the near term. Thus, federal resources would help speed progress towards a single set of measures that could be reported on across vendors and shared transparently to drive vendors to more heavily invest in interoperability capabilities. 10

Develop and Use Meaningful Measures of Vendor (2) Selecting measures that reflect actual use (and value) by frontline users is critical. Thus, measuring just technical capabilities that are demonstrated under controlled conditions should be avoided in favor of measures that demonstrate how access to external data contributes to decisions in daily care delivery. Below is an example of a set of measures which, when used as a complete package, would not only measure the exchange of data, but measure its impact on clinical decision making: Number of exchanges of data from external source (denominator that measures ability to exchange data with another EHR) Percentage of external data elements viewed (numerator that measures perceived value of the external data) Percentage of external data elements incorporated/reconciled with internal records (represents meaningful data) Percentage of times viewing of external data changed current activity (e.g., appeared in clinical decision support, led to change in order being written), which demonstrates impact of external data 11

Accelerate Payment Incentives for Interoperability (1) Recommendation: Set specific HIE-sensitive payment incentives – that incorporate performance measure criteria – and timeline for implementation that establish clear objectives of what must be accomplished under alternative payment models While high-value interoperability measures targeting both providers and vendors can help motivate progress towards interoperability, progress will be dramatically accelerated if such measures are directly tied to reimbursement. Moving interoperability up the priority list will likely take financial incentives that are more targeted than a broad shift from fee-for- service to pay-for-value. 12

Accelerate Payment Incentives for Interoperability (2) Payers have existing mechanisms through which to incentivize providers to meet HIE-sensitive outcome measures, and Medicare is the logical payer to lead such efforts (particularly as they operationalize new payment requirements under MACRA). These measures do not require defining interoperability as a new domain of performance incentives; they could easily be incorporated into incentive programs that target dimensions of provider performance that are HIE-sensitive, such as coordinated, high-quality, safe care and coordinated across health and social services continuum. Recognizing that health information exchange, by definition, requires multiple parties to engage in collective, synchronous actions to complete the electronic exchange successfully, actions that constitute “information blocking” would preclude both parties from achieving interoperability. As CMS defines new payment incentives to reward value-based purchasing using HIE-sensitive outcome measures, it should incorporate mechanisms that identify and discourage information blocking activities that interfere with providers who rely on information exchange to deliver high quality, coordinated care. 13

Initiate Sustained Multi-Stakeholder Action (1) Convene a major-stakeholder initiative co-led by federal government (e.g., ONC, CMS) and private sector to act on ONC Roadmap to accelerate pace of change toward interoperability Successfully achieving the recommendations described above requires coordinated actions on a wide range of complex issues by multiple stakeholder groups. The Interoperability Roadmap provides a blueprint for tackling these issues and so it could serve as the framework for guiding such efforts. In addition, as described above, without coordinated action to agree on focal HIE-sensitive measures, it is unlikely that measures will be widely adopted and, as a result, will have little ability to strengthen market forces driving interoperability. 14

Initiate Sustained Multi-Stakeholder Action (2) Although there have been calls for action related to interoperability in the past, most have been limited to specific stakeholders (e.g., vendors, standards organizations). A number of things have changed in the environment that make the timing more ripe for change. First, as a result of the success of Meaningful Use, the majority of health information on individuals reside in electronic health record systems. Second, the Secretary has established clear milestones for delivery system reform, and the accompanying payment model reforms. Third, we believe that in order to achieve meaningful interoperability, collective, synchronous action must be undertaken by multiple stakeholders across the whole continuum, from professional education and training programs to healthcare organizations and payers, both public and private. In order to engage, educate, and create a shared action plan to achieve meaningful interoperability, we recommend convening a public-private, high-level, multi-stakeholder Summit to kickoff deliberate activities in response to the ONC- led Interoperability Roadmap. 15

Initiate Sustained Multi-Stakeholder Action (3) Today, these powerful stakeholders do not have a forum in which to coordinate their actions or a framework in which to do so. When combined with incentives to coordinate (driven by prior recommendations), rapid progress can occur. Convening a high-level working Summit leading to industry commitment requires the convening power of federal government to spur collective action, and the enduring private-sector business interests to sustain the effort. The output of the Summit would be an action plan with milestones and assigned accountabilities for achieving the milestones. We expect the compelling call-to-action would engage the stakeholders to continue their activities after the Summit as a way of meeting the payer-driven incentives that reward HIE-sensitive measures of coordinated care. Without these coordinated efforts, it is unlikely that the collective action to enable interoperability called for in the Roadmap will occur fast enough. 16

Barrier Categories Misaligned incentives Low availability and adoption of functional, standards-based EHR systems Change in clinical processes among providers Complexity of privacy and security Difficulty of establishing collective action to create collaborative solutions to barriers

Member Feedback Discussion (1)

Member Feedback Discussion (2) Need to clarify between “health information exchange” and “Interoperability” Need more attention to patient matching Need to change the culture of health care to advance information sharing and team-based care, with patients at the center. Fee for service model still exists

Discussion 20