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IHE USA Case Study:
Impact of IHE Profiles on Patient Care
(Interoperability Accelerating Release of Information)
Herman Oosterwijk, IHE USA Implementation Committee Chair and OTech Inc
Russell Leftwich, IHE USA Implementation Committee Chair and InterSystems
Seonho Kim – VP of Information Exchange, CIOX Health
Interoperability Accelerating Release of Information Business
Advancing the wayhealth information is managed
March 1st 2016
Seonho Kim, VP of Information Exchange, CIOX Health
George Abatjoglou, President, Provider Solutions, CIOX Health
Stephen Mallinak, VP of Customer Solutions, CIOX Health
IHE USA Case Study
3
Release of Information (ROI)
Request
• Patients
• Attorneys
• Providers
• Commercial Payers
• Government Payers (SSA/CMS)
• HEDIS/MRA Vendors
Retrieval
• Capture medical records
• Abstracting
• Indexing
• Logging and Tracking the lifecycle of requests
Release
• Packaging
• Delivery: mailing/ faxing/ SFTP/ Web Portal
• Invoicing/Billing
1. Logging, Tracking and Verifying the Request
2. Retrieving Patient Information
3. Release Only Authorized Information
4. Safeguarding Sensitive Information
5. Monitoring, Completing and Invoicing Request
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• A facility can get up 400 requests a day depending on their size
• During peak audit season, that number can easily triple
• To remove this laborious burden from their facilities so they can focus on patient care
• To ensure
– Requests are authorized
– Patient authorized records/information ONLY
– No sensitive records unless the patient expressly indicates
– Compliant with all the federal/state regulations
– The information is securely transmitted in an encrypted format when it is processed for electronic distribution
Why Providers uses an ROI Service?
5
• ROI business has been Transitioning from a pure service oriented business to a technology combined business
• The three case studies show How IHE profiles and other interoperability standards accelerated Release of Informationby achieving the following: – Ensuring Accurate Accounting of Disclosures by tracking PHI requests
electronically from the point of release to the acquisition by the requestor, with non-repudiation
– Reducing Administrative Overhead and increasing referring physician satisfaction by streamlining provider status requests
– Maximizing staff productivity by reducing data entry errors and error corrections
– Reducing Administrative Costs by eliminating paper, as well as Improving Care Coordination by enabling timely response to requests, proper assignment of patient data, and increased data accuracy and security
Interoperability Accelerating Release of Information
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Case Study 1: Automated Social Security Administration Disability Determination Workflow
CIOX Health
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• SSA mails/faxes patient authorization documents (Form 827) to providers. Provider normally scans the form and stores into an archive
• Legacy workflow requires high level of human intervention and manual process before release of medical records to SSA
• No interoperable interfaces exposed to query/retrieve medical documents (Manual record retrieval)
• No module existed to generate CCD documents from EHR systems
Case Study 1: Automated SSA Disability Determination
Service (DDS) workflow
File Disability Claim Request Records
Claim Determination Release Medical Records
Patient
Authorization
Form 827
DDS ProvidersClaimants
Phone, Web,
In-Person
Form 827
Fax,
Fax,
SSA ERE,
Bulk File Transfer
Scanning/
Capturing/QA
records
8
• Adopted IHE profiles to define/implement interfaces for patient matching (patient discovery) and query/retrieve documents
• Integrated systems between the provider’s EHR and the SSA for cross-community information exchange via the eHealth Exchange (formerly Nationwide Health Information Network)
Solution
Legacy DDS Workflow Automated DDS Workflow
Request for Documents
Mail or Fax (SSA Provider)Programmatic/Electronic Query: Patient Discovery Query
PatientAuthorization Letter
Mail or Fax (SSA Provider)Programmatic Query/Retrieval of Form 827 from SSA
Medical Records Retrieval
Manual capture of medical records (Field reps) Programmatic query/retrieval of
medical records (CCD format)Submission of Medical records
• Submission via Portal (SSA ERE)• Secure bulk upload
9
eHealth Exchange Gateway
PRISMExchange Gateway
Virtual EDGE Server
EHR System
Provider Facility
Automated request to
providers for Patient
medical records
Trusted Network
EDGE Server (Virtual
Machine) deployed &
integrated with the
provider’s EHR
PRISM Exchange
Platform
: eHealth Exchange
Certified Product
eHealth Exchange PD, QD & RDIHE XCA (ITI-38, ITI-39)IHE XCPD (ITI-55)
eHealth Exchange QD & RDIHE XCA (ITI-38, ITI-39)IHE XDS-SDIHE BPPC (HITSP TP30)
IHE XCAIHE XCPDIHE XDS-MSIHE XDS-SD
IHE XCA/XCPDREST Web Services
Query/Retrieve
Form 827
Fully Integrated/Automated SSA DDS Workflow
These integrations enabled fully automated end-to-end disability determination response process
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• Reduced costs and faster reimbursement for SSA disability claims
• From $11,400 per month net expenses to $6,000 per month net gain
• Increased revenues with reduced uncompensated care and administrative expenses
• Average turn-around time from seven days to less than five minutes for electronic requests (record delivery)
• Faster decision time – from up to a month or more to just few days
• Streamlined process
Outcomes & Benefits
11
Case Study 2: Semi-Automated CMS Medicare Audit Submission
CIOX Health
12
• Background
– Each year, the Medicare Fee-For-Service (FFS) Program makes billions of dollars in estimated improper payments
– CMS employs several types of Review Contractors to measure, prevent, identify, and correct these improper payments
– Review Contractors request medical documentation by sending a paper letter (Additional Documentation Request) to the providers.
– In the past, these providers had only two options for submitting the requested records
• Mailing
• Faxing
Case Study 2: Automating CMS Medicare Audit
Submission
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• Used to fulfill Medicare audit requests by
– Processing request letters (ADR)
– Capturing/Retrieving medical contents in PDF/TIFF from EMR or Paper charts
– Indexing contents
– Quality assurance (remove inappropriate contents)
– Delivery: Packaging in CD/DVD or Paper and Mailing/Faxing
Legacy Workflow
ROI VendorReview
Contractor
Providers
ADR LetterOutsource
Capture/Retrieval
Mail/Fax
Indexing, QA,
Pricing/Billing,
Packaging
14
• All Medicare Audit related medical documentation
requests were fully paper-based and manually handled –
labor costs
• Medical documentation delivered in mail (paper or
CD/DVD) or FAX – hard costs
• Manual Communication or Follow-Up to deal with any
issues with submissions/delivery/pickup of records
• Missing medical documentation submission deadlines
• High cost of guaranteed delivery of medical
documentations to Medicare review contractors
Challenges
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• Connected providers directly to CMS/Medicare to automate medical documentation submission, tracking and logging of each audit case.
• We adopted IHE XDR profiles to interface internal/external systems with an esMD gateway (eHealth Exchange) which communicates to the CMS esMD gateway
– Electronic Submission + Asynchronous Status Updates (IHE XDR)
– Scanned Medical Documents packaging (IHE XDS-SD)
Solution
ROI Vendor
Review
Contractor
Providers
ADR LetterOutsource
Records
Capture/Retrieval
Electronic Documentation
Submission esMD HIH
Gateway
CMS esMD
Gateway
Virtual EDGE Server
Indexing,
QA,
Pricing/
Billing,
Packaging
IHE XDS-SD
(HITSP C62)
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• Delivering medical documentations in hours vs. days
• Quicker turnaround: Payment turn-around time from 3 weeks to 6 days
• Reduced labor costs: Removing unnecessary labor costs such as printing, mailing, faxing, rescanning or burning CD/DVDs
• Reduced hard costs: such as shipping/handling expenses
Outcomes & Benefits
17
Case Study 3: Directed Exchange for Release of Information
CIOX Health
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• Background – Continuity of Care & Care Coordination within healthcare
communities (Acute care and clinic setting)
• HealthPoint Community Health Center, Seattle Area, WA– Manually manage hundreds or thousands of records requests for
information, monthly, from a variety of sources with small staff– Manually track and check status information via phone call or faxes
• Business Needs– Receive tracking and status information and not have to call or send
more faxes– Must be very secure– Solution must leverage MU2 investment and be in line with MU
objectives
Case Study 3: Direct Exchange for Release of
Information
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• Challenges– Largely driven by faxing
– Manual paper-based process of requests for patient information
– Onerous, Time consuming– Inefficient: heavily reliant upon manual content processing – Error prone– Extensive tracking and follow up to get records
• Goals– Improve request turn around time (TAT)
– Reduce processing overhead
– Reduce cost for all participants
– Improve tracking for AoD (accounting of disclosures)
– Provide real-time status of ROI request processing
Challenges & Goals
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• The solution is a simple secure way for providers to efficiently and securely access patient healthcare information without a fax machine
– No installation / Easy to use / Secure
• We adopted the Direct Secure Messaging as well as IHE XDR/XDM/XDS-SD profiles
– Adopted IHE XDR to replace Fax/Mail delivery mechanism (PUSH model)
– Leveraged EHNAC DTAAP HISP/CA/RA Accreditation
– Leveraged DirectTrust Federated Trust Framework
– eMail like Web Application for ease to use
• Interoperability Technology adopted
– IHE XDR is used as an EDGE protocol to integrate CIOX Health Direct/HISP infrastructure with an internal ROI platform
– IHE XDS-SD is used for content packaging (HITSP/C62 flavor)
– Direct Project: SMTP + S/MIME for requests capture and records delivery
Solution
21
ROI solution with Direct Secure Messaging
Clinic Physician
Request for Medical Records
Fulfill Request
Delivery of Fulfilled Request
Direct Secure Messaging
Provider Portal
IHE XDS-SD
(HITSP C62)
IHE XDRSMTP+S/MIME
Acute CareSetting
22
• Increased administrative efficiencies – reduced error rates (stemming from paper based process such as mishandling of fax requests)
• Improved continuity of care and care coordination by reducing average turn-around time (TAT) from 3.5 days (before implementation) to over few hours (after implementation)
• Early Results from HealthPoint– Moving away from an onerous manual process
– Very efficient tracking of the 400-600 ROI requests per month
– More focus on their 78,000 patients and not administrative overhead
– Reduced administrative costs
– Reduced turn-around time for requests so preparation for care delivery is more effective
– Streamlined communication with other medical records departments
Outcomes & Benefits
23
New/On-going Challenges &
Future Works
CIOX Health
24
Contents are still the biggest barrier
• SSA DDS Compliant CCD generation
• Significant amount of records still exist as unstructured formats
Adoption of interoperability technology is still low
• Lack of technical resources and expertise
• HL7 FHIR & IHE DAF are still evolving and under development
• A lot of providers are under transitioning
Electronic Records Retrieval is a big barrier
• Various legacy systems to be interfaced
• Proprietary interfaces
Partially automated workflows
Challenges to address
25
A provider @ Happy Community Clinic
Cloud-based Patient Health
Information Exchange Solution
PRISM Interoperability Platform/Gateway
PRISM Connect [email protected]
Direct/HISPGateway
Provider
(Hospital)
EHR
IHE XCPD/XCA/DAF
To-Be Fully Automated Interoperability ROI Platform
Responding Gateway
Initiating GatewayResponding
Gateway
Payers
③ Submit medical documentations for audit
① Submit a ROI request via Direct secure messaging
② Query and Retrieve CCDA documents about a patient from a EHR system
IHE XDR
Direct Protocol
③ Deliver medical records to the requester for continuity of care
IHE PIX/PDQ
XDS.bDAF
② Query and Retrieve CCDA documents about a patient from a EHR system
Community HIE
Infrastructure
26
CIOX Interoperability Platform at the heart of information exchange
27
Questions?
Seonho Kim, VP of Information Exchange,
CIOX Health
28
About CIOX Health
29
Using technology to connect over 18,000 providers
across all 50 states.
Legacy IOD sites Legacy HP sites
30
Using technology to connect over 18,000 providers across
all 50 states.
31
Building the Healthcare internet
CIOX by the numbers…today
> 3,000 embedded hospitals
> 15,000 embedded clinics
> 75,000 connected facilities
> 1 Million unique requestors
> 50 Million requests annually
> 7,500 employees
32
More than just ROI services to our customers
Full Suite of Services
• Release of Information (ROI):
timely, secure, seamless – a
solution to meet every need
• Transparency and automation
to improve outcomes
• Seamless interoperability
across systems
• Minimal internal HIM staff
involvement
• Payer audits for Providers and
Payers
• Accelerated SSA decisions:
provide CCDs in minutes
• Secure and efficient direct
messaging
• Analytics & Decision Support
• Inpatient & Outpatient Coding
• Full Coding Outsourcing
• Flexible yet stable staffing &
offshore coding
• Coder Skill Assessments
• lCD-10 Training & Education
• Performance Benchmarking &
Analytics
• EMR Pre-load Abstraction
Services
• Audit Denial Management
• HIM Scanning
• Point of Care Scanning
• Back File Conversion
• Secure Storage
• Seamless continuity across
episodes of care
• Designed, not adapted for
Healthcare
• environments
• Analytics & Decision Support
Information exchange Revenue Solutions Document Management
As the industry leader, we are partnering with healthcare organizations to meet
all their health information needs and drive outcomes
Interoperability is Key to Health IT
U.S. Government Focused on Interoperability
• Interoperability is a core component to healthcare
delivery systems
• Private and public sector called to work collaboratively
IHE Provides the Foundation for Interoperability
• Partnered with key industry stakeholders including:
o The Office of the National Coordinator (ONC)
o Government health agencies
o Health Information Exchanges (HIEs)
o Standard Development Organizations (SDOs)
U.S. Government Focused on Interoperability
• Interoperability is a core component to healthcare delivery systems
• Private and public sector called to work collaboratively
IHE Provides the Foundation for Interoperability
• Partnered with key industry stakeholders including:
o The Office of the National Coordinator (ONC)
o Government health agencies
o Health Information Exchanges (HIEs)
o Standard Development Organizations (SDOs)
Interoperability is Key to Health IT
Today the industry is finally ready to embrace interoperability
and implement IHE’s work to advance health IT.
HIMSS definition of Interoperability
• In healthcare, interoperability is the ability of different
information technology systems and software applications to
communicate, exchange data, and use the information that
has been exchanged. Data exchange schema and standards
should permit data to be shared across clinicians, lab,
hospital, pharmacy, and patient regardless of the application
or application vendor.
• Interoperability means the ability of health information
systems to work together within and across organizational
boundaries in order to advance the effective delivery of
healthcare for individuals and communities.
What is Interoperability anyway?
Three levels of Interoperability:
1 - Foundational: the receiving IT system does not interpret the data (e.g. a
pdf document with lab results).
2 - Structural: the structure or format of data exchange is maintained such that
the clinical or operational purpose and meaning of the data is preserved and
unaltered. It ensures that data exchanges between information technology
systems can be interpreted at the data field level. (e.g. the lab results directly
information stored in EMR database)
3 - Semantic: the ability of two or more systems or elements to exchange
information and to use it. This level of interoperability supports the electronic
exchange of patient summary information among caregivers and other
authorized parties via potentially disparate electronic health record (EHR)
systems and other systems to improve quality, safety, efficiency, and efficacy of
healthcare delivery. (e.g. take action on an out of bound lab value)
Different levels of Interoperability
1 - Foundational: exchange CAD results to a workstation.
2 - Structural: interpret CAD result: “micro-calcification at
left top corner”
3 - Semantic: display CAD mark on top of image with a visible marker:
The Image Display shall make available for display the following information about each CAD
finding, if encoded in the CAD object:
• Manufacturer (0008,0070)
• Algorithm as defined in (111001, DCM, “Algorithm Name”) and (111003, DCM, “Algorithm
Version”)
• Operating point as defined in (111071, DCM, “CAD Operating Point”)
• Content Date (0008,0023) and Content Time (0008,0033) of the CAD SR instance, if
more than one exists and applies to the displayed image
The Image Display shall indicate when CAD was not attempted or has failed, either entirely,
or if some algorithms have succeeded and others failed, as distinct from when CAD has
succeeded but there are no findings. This information shall be obtained from the status values
of (111064, 4495 DCM, “Summary of Detections”) and (11106 DCM, “Summary of Analyses”).
Radiology Example
HIMSS (www.himss.org)
• HIMSS is a health IT association and non-profit
• Focused on transforming healthcare through information technology
Key programs focused on Interoperability
• HIMSS Interoperability Showcase
(www.interoperabilityshowcase.org)
• HIMSS Innovation Center (www.himssinnovationcenter.org)
• HIMSS Annual Conference and Exhibition
(www.himssconference.org)
• TIGER - Technology Informatics Guiding Education Reform
(www.thetigerinitiative.org)
• ConCert by HIMSSTM Interoperability Testing and Certification
Program (www.himssinnovationcenter.org/concert)
• IHE (Integrating the Healthcare Enterprise)
o Mission critical to realize interoperability in health IT
o Established IHE International in 1999 in collaboration with
RSNA
o Established IHE USA in 2010
HIMSS Role in IHE
IHE International (www.ihe.net)
• Established in 1999 by HIMSS and RSNA
• Independent not-for-profit organization
• Develops interoperability solutions on an international level
• ISO recognized International Standards Profiling Organization
• Develops IHE Integration Profiles using industry consensus and
organized into guides called IHE Technical Frameworks
(www.ihe.net/IHE_Domains/)
IHE International’s Role
IHE USA (www.iheusa.org) • Independent not-for-profit organization
• Serves as a voice for US health IT interests and key
partners as a national deployment committee of IHE
International®
• Sponsor of the IHE North American (NA) Connectathon
• Published Interoperability for Dummies: IHE Edition.
Download your complimentary copy at
www.iheusa.org/ebook.aspx
IHE USA’s Role
IHE International
Development Committees
12 Domains
Deployment Committees
IHE USA
What is an IHE Connectathon?
Interoperability problem resolution
• Provides neutral environment for competing vendors to
collaborate to improve the quality and interoperability of their
health IT systems.
• Resolve bugs with test writers and standard experts on-site
• Utilize full logging details and common set of test scripts
High powered testing event!
• 4,000+ vendor-to-vendor connections;
9,000+ transactions
• $2.5 million worth of testing effort
5 Intense days of testing
• Discover each days achievements on
www.iheusa.org/learnmore.aspx
IHE NA Connectathon 2016550 engineers, 60 volunteers, and 15 countries
represented
IHE NA Connectathon 2016 Results
• 124 Health IT systems
• 142 Organizations, including government
and public sector
• More than 2500 tests validated on-site
• 9000 vendor transactions
IHE’s Global Connectathons provide a neutral environment
for competing vendors to collaborate to improve the quality
and interoperability of their health IT systems.
Learn more about IHE at HIMSS16
• Visit the HIMSS Interoperability ShowcaseTM
o IHE Profiles are the foundation to each use case and tour
o Ask the experts in the IHE Vignette
• Secure your complimentary eBook – Interoperability for Dummies:
IHE Edition online at www.iheusa.org/ebook.aspx
• Attend any of our education sessions at HIMSS16
Presentation Title Date/Time Location
IHE USA Case Study: Impact of IHE Profiles on Patient Care
Tues. March 1 at 11:15am - 12:15 pm PT
HIMSS SpotLevel 2, Lobby C
IHE USA Case Study: Impact of IHE Profiles on Patient Care
Tues. March 1 at 4:30 pm - 5:00 pm PT
HIMSS InteroperabilityShowcaseLevel 1, Exhibit Hall G, Booth #11954
Introducing the New Conformity Assessment Program from IHE International
Tues. March 1 at 3:00 pm- 3:30 pm PT
Decoding the Interoperability Testing and Certification Landscape featuring the IHE's Global Connectathons
Thurs. March 3 at 11:00 am - 11:30 am
