Category Archives: Trust

Innovation Series

This past year I had the opportunity to share my thoughts and insights as to where we need to go in healthcare.  I still firmly believe we need to meet the patients where they want care while maintaining a complete and comprehensive accounting of their medical history and interactions with the health system as well as in their daily lives.  In this short interview I try to offer insights into interoperability, how technology impacts to our movement from volume to value, and efforts to developing a unified consortium of trust partners to safely and securely share medical information.



Interoperability- The sub-theme of this years UGM

I had the opportunity this week to attend the Epic user group meeting.  I must tell you that the feel of collaboration around the patient care experience is nothing else I have experienced. One thing many of  the attendees may not have been aware of is the increased focused on interoperability in the next couple of years.  I have  the unique opportunity to serve as chair of the CareEverywhere Council, a group of individuals passionate about the seamless transmission of information.  Additionally I was most recently appointed to chair the CareQuality Trust Framework subgroup.  It is within these two groups I will try to drive toward the three factors that will ultimately facilitate this information transfer so patients can feel just as safe in the healthcare system as they do in their own homes. I have included the The Interoperability Report 2014 Care Everywhere Network here.  In short we must commit to:

  1. The use of industry standards
  2. A nationwide directory of exchange-ready providers
  3. Simple Rules of the Road

These rules establish a universal trust framework that outline the rights and obligations of network participants.  They would give each organization confidence that it can participate in exchange activities while upholding its legal and ethical obligations to maintain the security and privacy of patient records.

Unfortunately that single set of Rules of the Road does not exist across industry, so trust must be established individually.  In order to move beyond the one-to-one connections a framework of mutual trust agreements and standards needs to be in place.

With this in mind I have recently been appointed to chair the CareQuality Trust Framework WorkGroup.  It is here that I will continue to work with all vendors to create a framework that expedites point-to-point patient record exchange basedon mutual trust agreements and national standards

Over the past 2+ years we haven’t done everything right.  In the attached report we detail some of the touching stories of successful information transfer but also some of the issues we have uncovered.  As of August Epic has exchanged over 550,000 patient records with other non-epic vendors per month!!  That is a staggering number and one that is not accounted for in the many news stories on the perceived lack of interoperability.

Presently the CareEverywhere Network includes over 950 hospitals and over 21,000 clinics representing community hospitals. academic medical centers, children’s organizations, FQHC’s, safety net providers and multi-hospital systems all sharing critical patient information with individuals both on Epic and not.


Some of our lessons learned

  1. Patients overwhelmingly want to share their data in a secure way
  2. Strict adherence to fewer standards + succinct Rules of the Road + simple patient consent model = SUCCESS
  3. Providers attribute exchange success to integration with clinical workflows
  4. Nationwide exchange is practical even without a national patient identifier, and can be further improved
  5. Successful exchange does not have to be expensive and results in lower cost of care


  1. Simplify consent because the majority of patients want to securely share their data
  2. Simplify exchange: one standard per purpose with a single national phone book of exchange ready organizations and providers
  3. Continue to formally adopt nationally-defined reference terminologies to enhance utility of data incorporated into the local chart.
  4. Standardize how identifying information is captured to further improve patient matching between providers.
  5. Require public health and immunization registries to exchange directly with providers free of charge when using a single, national standard.


I look forward to my continued participation on both the CareEverywhere Governing Council as well as the new CareQuality Trust Framework Work Group.


A MegaTrend in HealthIT

I was reading this fascinating article written by Robert Pearl, MD the CEO of The Permanente Medical Group on the 5 Megatrends that could Transform U.S Health Care. I completely agree with the major trends Cisco chairman and CEO John Chamber sees:

  1. The Formation of Accountable Care Organizations (ACO)
  2. Moving away from Fee-For-Service Payment Models
  3. Rewarding Better Health Outcomes and Quality
  4. Health Information technology (HealthIT) Incentives
  5. A New Generation Of Physicians

I agree that we are at the cusp of a tipping point.  I was rather intrigued regarding the fourth megatrend, Health Information Technology Incentives.  While I agree with the premise there is some inconsistencies within the details.  It is truly unfortunate that healthcare is behind the technology wave that other sectors have adopted decades ago.  I feel that there is good reason for that which goes back to the reason physicians choose to dedicate their lives to treating people.  While that is easily another blog topic the fact is that we need to change and start to change quickly.  Not because of the meaningful use incentives but because it is the right thing to do for our patients.  Our patients are more mobile than before and want to access the healthcare system on their own time.  We are living is a physician centric system evolving to a patient centered system.  That change is going to take a lot of time when the current system has been in existence for almost 50 years. As  Mr. Chambers articulates lack of connectivity is the issue.  This is where the topic goes awry.  There is assumption that every hospital and physician office is on the same system.  That is far from the case. Even if they happen to be on the same system that still doesn’t mean that the two systems will connect.  They could be on 2 different versions of the same system.  Perhaps these two organizations don’t equally value the exchange of clinical information, or are fierce competitors.  Please don’t assume I am a proponent of this as an excuse but just current reality.  And those scenarios are for organizations that have the same system.  The issue compounds when the systems are from  different vendors and you may need a HISP for connectivity not to mention developing Query and Trust Frameworks.  As you can quickly see that the technology is the minor component and the People and Process areas are what make this successful.  While I agree that Meaningful Use Stage 2 will provide the incentives for interoperability I feel that this is just the beginning.  I honestly don’t think that the federal incentives will even cover a fraction of the cost required to connect these systems as we need to develop the appropriate trust framework necessary for complete interoperability.  What I truly feel is that it is in the best interest of the patient and the communities we serve.  A patient should feel safe and well taken care of within the healthcare system whether seeking care in California or New York.  As stated before, this is going to transform the health system and we need to understand that meaningful change takes time.

Seamless Transfer of Information

As I stated in my last post I have been deeply involved with establishing a “Rules of the Road” for the interoperability of patients health information.  I truly believe that in order to aspire toward the triple aim of better health, better care at a lower cost we must provide the most accurate, most timely information for the clinician to make a well informed decision. Only then will be truly understand the cost of care and drive to prevent redundant testing and render care in the most appropriate venue. With that in mind I had the pleasure of sitting down for an interview with Roya Camp of St. Luke’s Health System to discuss my involvement in this national initiative of improving the access of timely health information- interoperability.


Early in my medical career I was already thinking about interoperability and I have devoted much of my career to the seamless transmission of patient data to where it is needed most.  Fortunately there is a national effort to achieving this.  However, the current state of interoperability has been under some scrutiny as of late.  Over the past 2 years I have had the pleasure of serving as the Chair of the CareEverywhere council as well as a board member of the Idaho Health Data Exchange (IHDE).  It is here that I have truly seen the potential for true interoperability as well as where we need to go to make it a reality. Let me rewind the clock for you about 20 years.  I had just been getting ready for college and my parents took me to open a joint bank account.  I was excited as I just received my first ATM card.  The caveat here was that it only ran on the PLUS network of bank machines not the ones with the Cirrus icon on them.  There was no interoperability between networks.  Now 20+ years later both networks are still present but they decided that the convenience of the customer benefitted the industry as a whole so they were able to integrate their directories.  Now we can have the convenience of using any ATM machine we please.  Now, this transformation took more than 20 years.  I wonder why this same type of transformation is it expected for healthcare  in less than 4 years when it took 20 years for the banking industry to reach this type of integration.  Healthcare is very complex.  While we have made significant strides there is still a long road to travel and I know my colleagues and I work on this daily.  I came across an interesting article really criticizing  the current state of healthcare interoperability.

For those of you that work with me know I think of issues in the framework of people, process, and technology.  From my perspective this issue is mostly a people and process issue.  While I agree that there are some technological limitation the crux of this matter revolves around our ability to adopt a standard that will facilitate the transfer of information to any EHR.  Many HIT shops are very complex and have multiple initiative they focus on throughout the year all with the ultimate goal of improving patient care.  So from my perspective there are more issues at play than the blanket statement  “we can’t talk to one another”.

  1. Different versions of the same EHR
  2. Lack of Trust Agreements (Rules of the Road)
  3. Multiple different standards– which means there is essentially no standard
  4. competition between health systems in the same geographic location
  5. competition between vendors
  6. Different strategic focus of the organization (some organizations don’t feel that exchange is high on their list therefore they don’t build out the functionality- this will prohibit the ability to exchange information)
  7. HIE functionality (does the HIE view themselves as a repository or a broker of information exchange)
  8. I know there are others

I guess I feel I have a more positive outlook on the industry.  However, I will make one call to the industry– Please define a single standard that will allow all EHR’s to have the ability to communicate with one another.  I am happy to participate in anyway I can.  I feel that we have made enormous strides this space.  While there is a lot of work to do there are very smart people at the table and I am confident that we will see true interoperability in the near future where patients can feel just as safe in the hospital or doctors office as they do at home.