We teamed up with Nikhil Krishnan of Out of Pocket Health to bring you a comprehensive course on Interoperability. Here's a compilation of frequently asked questions from our live event - answered by instructor, Troy Bannister.
EMRs will not respond to any query other than Treatment today, even with a patient’s signed HIPAA authorization request.
Most clinical data lives in EMRs. HIEs and other types of stakeholders are part of the networks and we do get data from them too, but the vast majority of the data comes from EMRs across the networks.
No, fax will always be an option but the cost is high to manage data exchange from fax. Organically, however, health systems will be moving away from paper to digital exchange of information.
Good question - different methods will yield different datasets. Fax gets everything, while HIEs will yield a CCD under the USCDI V3 requirement.
CCD requests yield a set of records, all mixed with different types of data. Converting those CCDs to a FHIR dataset allows for the parsed data to be categorized, making it easy to ‘grab’ just what you want.
Healthcare Operations is defined differently than Treatment. Quality falls under the Operations Purpose of Use (PoU). The best way to think of it: if you’re querying for a single ‘step’ — i.e. patient is coming in for an appointment — then it’s Treatment. If you’re querying for multiple ‘steps’ — i.e. pulling data on a cohort to decide who needs to come in for an encounter — then it’s Operations.
If the organization is not a covered entity or a BAA of a covered entity, it is not Treatment. It is possible for a home visit to be Treatment under this definition.
Networks are federated — not centralized. The data is returned from each endpoint independently, and when aggregated, may be thousands of CCDs for one patient. The data is not organized when retrieved. Particle can consolidate and parse CCDs into a single, unified record in FHIR. At this point, it is now organized.
It is possible for research to be considered Treatment, but only if the patient is receiving care and it ‘just so happens’ that they’re also enrolled in a trial/study.
CCD vs. FHIR is kind of like Crude Oil vs. Gasoline. Crude Oil contains all the energy required to run your car, but Gasoline is distilled and organized such that it’s ready to be used in a real-world setting. We actually have an article written about these different data formats – check it out here.
Sythesia is a great, free tool to generate synthetic data in multiple formats. While it doesn’t quite reflect the nuances of real-world HIN data, it’s close enough to get started.
ADT (Admission, Discharge, Transfer) notifications are meta-data rich, real-time pings that an event has occurred. These messages don’t contain meaningful information on ‘what’ happened, but rather ‘where’ and ‘when’.C-CDA, on the other hand, is clinical-rich data. It is not oriented towards ‘live notifications’ but contains the information on the ‘what’.
HIN data becomes available on an EMR by EMR basis. Some EMRs make it available very quickly (hours) while others can take up to a day.
It takes between 30 seconds and 1 minute to query, download, pull, and parse a patient's record on average. This can take more time if there’s more data. Some patients have 10,000+ documents.
HIN fees are different depending on which HIN you’re integrating with. Most have ‘set up fees’ and ‘testing fees’. HINs also have variable, yearly fees based on either (a) how many transactions you conduct or (b) how much total revenue you generate. Costs on a per HIN basis range from $20,000/yr to $500,000/yr.
Anything under the Treatment PoU is fair game. Interestingly, secondary use of the data is also fair game, so long as it fits under HIPAA. We see a lot of use cases fall under the “managing risk” theme; e.g. identifying unknown conditions, lab results, gaps in care, etc.
There is no official difference — however — the industry typically uses HIE for state exchange and HIN for national exchange.
Large HINs have standardized the BAA across all their participants. The BAAs are non-negotiable. This type of agreement is what TEFCA is formalizing into the “Common Agreement”.
Interestingly, cloud providers do not (and seemingly will not) build their own HINs, connect directly to HINs, etc.
The networks today are ‘pull’ based, in that you must query for a record. There exists technology today to offer ENS, or Event Notification Services, however, it is currently optional and the vast majority of the network participants don’t support it.
Each healthcare organization is liable and accountable for determining its use case and legitimacy. While HINs and Particle can provide guidance, we do not know the intricacies of your product, workflows, and use case, nor do we have control of what is really happening behind the scenes.
Value is created by making better, faster decisions. Interoperability allows for the seamless acquisition of net new data such that it can enable better, faster decisions. Most organizations in value-based care (VBC) settings need as much data as they can get to manage the risk of their population. Intervening with that one patient that otherwise will go to the ER next week can save tens of thousands of dollars.
Organizations that run Treatment, Payment, and Operations Use Cases can still connect and leverage network data. Their initial purpose of use must be Treatment, but subsequently, the data can be used secondarily for other Purposes of Use (PoUs).
The reason we call it “Purpose of Use” or “PoU” is to indicate the reason or intent as to why we are requesting PHI. If the purpose is for trial matching, then the PoU cannot be for Treatment. You can request data for trial matching, however, it will need to be under a different PoU — like Individual Access.
Direct Trust (or Direct Messaging) is an older, but still widely used, method of data transfer. It’s very similar to HIPAA-compliant email where you need the address to send the data. There hasn't been a lot of innovation with Direct Messaging in a while, but it’s not a bad option if you know the address of the recipient provider.
Generally speaking, fax is most complete, then networks followed by portals.
Most EHRs natively opt-in to a HIN under the Treatment PoU. It’s taken years for EHRs to all opt in, but we are now well past substantial coverage.
Yes! Either through an EHR, like App Orchard, or via OAuth/SMARTonFHIR Integrations like MyChart.
Interoperability should begin to impact more use cases outside of Treatment as TEFCA rolls out. Prior Auth is a good example where a diagnosis can be pulled via API granting authorization for a certain medication to be filled and covered by a payer.
This order is essentially correct. From most data to least: HL7 Integration > HIE/HIN > Portal.
See USCDI for info on what data is shared via networks.
Yes. They will all be essentially the same, in terms of functionality.
Sub-Participants would only need to choose one Participant. This is because all QHINs must be fully interoperable with each other, thus making no difference where a Sub-Particpant decides to connect — at least in terms of coverage. It is my belief that Participants will be very differentiated, however, in terms of value props.
Correct. Connecting with one QHIN gets you full access to all QHINs. QHINs share a directory, so organizations can only be represented one time.
Every country has a vastly different data interoperability landscape. Some are single-payer systems, some are government-run. The model is so different that Particle’s tech would likely need to change significantly to accommodate these nuances.
Health systems buy EMRs to manage their data. EMRs must also meet certain requirements to receive federal subsidies under CMS (See HITECH Act). One of these requirements is the ability to share medical data across different HCOs.
There will likely be a limit on how many QHINs the ONC permits. By having more QHINs in the beginning, we will get more competition and a faster race that should lower prices and promote the best QHINs to the top of the pack. We expect to see consolidation as QHINs compete, costs lower and QHINs become more of a utility than anything.
Developers must certify any Health IT Module that is part of a product that electronically stores EHI to the § 170.315(b)(10) EHI export criterion, and it must be available to their customers by December 31, 2023.
Yes, data from QHINs is identified. You must query for a patient’s records using identifying information (Name, DoB, Address, etc.).
Yes. The fundamental principle behind TEFCA is QHIN-to-QHIN interoperability. Connecting to one gets you full access to all QHINs.
That exists today through organizations like Particle!
The Treatment PoU is the only Use Case that requires reciprocity. Other PoUs, like Operations, which would cover the Payer use case, do not require reciprocity.
All HINs must respond to queries with a minimum dataset, a set called the USCDI.
While payers are connecting to HINs, their use case is often times Operations, not Treatment. As such, they are not leveraging the HINs currently.
The biggest reason for state discrepancies is the Opt-in vs. Opt-out state policy. Some states, like New York, require patients to Opt-in to share their data via HIEs/HINs while other states require patients to Opt-out. The states that are Opt-out have many more accessible records.
The DoD is connected to eHealth Exchange.
We look at 2 factors: (1) did we find a patient match, successfully? And (2) how many records did we find in that match?
You can create a free account in our Developer Portal to view synthetic sample data. Sign up today here.
HINs today are separate from the incoming QHINs. While they’re built on the same principles, they are different ecosystems. QHINs will have more functionality than HINs, but they are different and do not interoperate. Some of the major HINs today will be QHINs (eHealth Exchange and CommonWell).
We have guides around this question, but simply put the HINs ask to share as much of the USCDI as possible. The major question is: what data do you have that a provider somewhere else could use to better treat a patient?
Unfortunately, yes. It is costly to onboard a customer on Particle and so we must charge for production access.
Working directly with our customers for years has given us insight into how to deliver data products that target provider use cases. We get lots of feedback from our customers who oftentimes are providers themselves.
While technically possible, the network traffic would be cumbersome and obvious. Network participants would complain about being queried by Particle over and over again.
Ultimately, Particle can’t confirm the data returned is 100% the correct data. This falls on the EMRs to ensure patient matching is accurate.
Hard question to answer since it is gradually adopted across the ecosystem. Technically, organizations have ~6 months to comply with the new USCDI requirements as they roll out.
The biggest difference is the way we integrated with the three networks. Taking a look at our API docs vs. Health Gorilla’s API docs will show how Particle has consolidated the three networks into one API while Health Gorilla has three separate flows for each network. This has downstream implications about how to manage queries.
Payors can use these networks if they have a valid Treatment PoU use case. Many payors do this in the form of technology their providers use.
EMS typically falls under Treatment. Ultimately, you’ll need to reference HHS’ definition of Treatment and confer with legal counsel to be sure!
Anything to get Individual Access up and running I’m a huge fan of!
Here is a good starting place: https://chpl.healthit.gov/#/search
Small practices should look into HIN/QHIN connectivity via their EHR/EMR providers.
Unfortunately, there isn’t much ‘101’ material out there. I’d recommend checking out Carequality’s Implementation Guide and TEFCA’s TEF, QTF, and overview slides!
Please email us at email@example.com to request a copy of the course slides. You can also book an interoperability consultation for your organization by emailing us or submitting our contact form here.
Thanks for tuning into our course with Out-of-Pocket Health! Check out their site for more upcoming courses: www.outofpocket.health/course-library
Particle VP of Engineering Dave Hauenstein spoke with PodRocket about what happens when companies start relying on teams instead of individuals, and how developers can build meaningful careers.
QHINs, or Qualified Health Information Networks, will become a foundational part of the healthcare data ecosystem.