Projects required crucial coordination between three HL7 Da Vinci Project members – Cedars-Sinai, Anthem and CareEvolution
Two challenging problems in improving care coordination and quality are the focus of efforts between a prominent Los Angeles-area care delivery system, a large healthcare payer and a technology vendor.
The HL7 Fast Healthcare Interoperability Resource (FHIR®) is playing a role in aiding the effort, but those involved say the FHIR standard, while important, is only a part of the components of their successful project.
Cedars-Sinai, Anthem and CareEvolution detailed the lessons they have learned in the data exchange project during the HL7 Da Vinci Project’s Community Roundtable in October. While FHIR has played an important role in exchanging information, it is only one piece of the puzzle – all participants had several technical and planning tasks to accomplish to ensure the projects succeed and reduce users’ workloads.
Da Vinci’s use cases and implementation guides are “a great starting point, but they only define one stage in that pipeline,” said Brandon Raab, engineer lead for enterprise data and analytics solutions for Anthem. “The end-to-end actualization of the use case will likely involve the integration of upstream and downstream systems.” Achieving the desired results “was a substantially heavier lift than we anticipated.”
Cedars-Sinai, Anthem and CareEvolution – all members of the Da Vinci Project – began discussions about how they could work together to put FHIR into practical use, said Ray Duncan, MD, executive director for technology research and development in enterprise information services for Cedars-Sinai. The partners chose notifications and data exchange for quality measures (DEQM) use cases because those use cases were “pretty far along in the balloting process” and because the organizations “wanted to focus on use cases where we could try them without a lot of changes to clinician workflow.”
The notifications initiative builds off of CareEvolution’s repository of patient information from Cedars-Sinai and other providers in Southern California. Under the project, automated queries to CareEvolution identify Cedars-Sinai patients covered by Anthem who get services from other providers. FHIR enables these notifications to be sent to patients’ physicians via their inbox in its Epic electronic health records system and also push them into Cedars-Sinai’s Epic electronic health record using an Epic web service.
A lot of pre-production work was required, said Vik Kheterpal, MD, principal at CareEvolution. It was important to set up a process that filtered notifications so that physicians would not be overwhelmed by a huge new influx of communication about their patients, which could include information other than clinical results.
“FHIR is crucial for this to work, but it’s not sufficient in itself,” Raab emphasized. “You need a variety of skills and technologies to do the end-to-end transaction.”
Clinicians like the new notifications approach because they can use their in-box, Kheterpal reported. “What makes this an absolute runaway success was that, for primary care physicians and others across Cedars-Sinai, this was a non-event – they didn’t have to learn a darn thing new. They just got to do their jobs easier, and it just happened to be mediated by FHIR. They just know more about the patient, and they’re better armed to deliver better care, and that’s when technology is best.”
In implementing the DEQM use case, Anthem was looking to replace a process that uses HL7 messaging standards (a real-time ADT feed) as well as clinical summaries in the form of a continuity of care document (CCD®).
Like other payers, Anthem collects quality measures for members to identify gaps in care and notify members’ care teams. Its current approach requires both manual and technology processes. Anthem extracts information, maps codes to patient data, and eventually pushes results to a rules engine for downstream reporting.
Now, with the FHIR-based approach that took collaboration between the partners, Cedars-Sinai has created a driver table in their enterprise data warehouse that contains a listing of the patients who are Anthem members. The provider uses queries that are scheduled to run automatically to extract any new data for Anthem members relevant to quality measures. That data is then transformed into FHIR-based profiles and are sent to Anthem endpoints hosted by CareEvolution. The vendor parses it to ensure that code sets, terminology mapping and the enterprise master patient index is correct before it’s pushed downstream to Anthem’s quality systems.
The partners agreed to focus on about 15 particularly important measures, which represent a wide range of care quality initiatives that they deem important, Raab said.
“It’s important to note that the small part that FHIR plays in the scheme of things,” he said. “If you look all the way upstream, we’re dealing with Epic and its transactional database, which is moving data into the recording environment, from which Cedars-Sinai’s warehouse pulls data. You can see there’s a lot of technology involved.”
Shifting to a FHIR-based solution requires validation of use cases against legacy solutions, which may be labor-intensive and complex, Raab noted. An implementation team for this type of effort needs a diverse set of skills and knowledge of the local environment, systems, clinical data and standards. Additionally, downstream end users, specifically quality measure team members, should be involved early in the transition process to ensure that the data being received through the new process is adequate to verify compliance with quality measures, the project participants advised.
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About the Community Roundtable
The goal of the Da Vinci Project’s community roundtables is to increase public awareness among payers, providers and vendors of the resources and progress coming out of Da Vinci’s efforts. These 90-minute virtual sessions are open to Da Vinci members and the public and highlight how members leverage the Da Vinci use cases and implementation guides (IGs) in action in workflow.
Typically, two or three organizations showcase their work and answer audience questions, allowing for a vibrant discussion and fostering industry understanding of the Da Vinci work products and resulting market solutions. Sessions are recorded and available online after the event.
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