Blog from March, 2020

Mike Miliard 

The CIO of Arizona's Health Current describes the health information exchange's efforts to serve its participants during the COVID-19 crisis – and discusses its ongoing efforts to boost data quality and consistency across the state.

Phoenix-based Health Current, Arizona's statewide health information exchange, serves more than 500 organizations: ACOs, behavioral health and community providers, emergency medical services, rural health clinics, hospitals and health systems, payers, labs, LTPAC organizations, and state and local health agencies.

For some time now, the HIE has been engaged with a major initiative focused on data governance and data-quality improvement, working to integrate more clinical and behavioral data across its network. Having seen 700% growth over the past three years, with its participants becoming ever more diverse, Health Current has been grappling with big challenges related to the sprawl and diversity of coding terminologies and data content across its stakeholders.

Since 2017, it has worked across its community of data suppliers and end users to work toward more commonality and uniformity in how data is relayed. That approach has been helpful in recent weeks as Health Current has had to pivot to focus on marshalling healthcare-data resources across Arizona in response to the COVID-19 crisis.

The HIE is working to ensure its data centers and IT infrastructure are solid and backed by multiple redundancies, even as its team members are observing social distancing by working remotely. The aim is to ensure all participants have easy access to critical data without any drop in service levels.

Health Current is enabling widespread access to longitudinal patient medical histories and data from patient encounters during the pandemic via its secure online portal, and with tens of thousands of alerts sent to clinicians and other healthcare staff. It's also offering expanded services for members to help monitor vulnerable populations, and prioritizing recruitment of new participants to expand its range of customers.

Healthcare IT News spoke recently with Keith Parker, Chief Information Officer at Health Current, to see how the HIE is serving as a critical public health infrastructure.

Q. How has Health Current pivoted in recent weeks, in light of the COVID-19 pandemic, to better serve the healthcare organizations across Arizona that rely on the HIE?

A. We're reaching out to our stakeholders and communicating with them about how best to use our data and the infrastructure we've put in place here in Arizona: everything from data-mining our database for our state or other authorized individuals to use for hot-spotting, to using our alert mechanisms, so when different labs or different high-risk patients come across, we can make sure that their care teams and their providers are aware of it as well.

Q. What is the size and scope of Health Current?

A. We don't really frame it in the context of the number of providers, but instead look at it through market-segment penetration. So we have about 98% of our acute care facilities connected and sending information bidirectionally – sending and receiving information.

Q. So the HIE is serving as a pretty critical information backbone to kind of help coordinate response to this crisis statewide.

A. We do have an infrastructure that is a pretty critical backbone for the state, as far as alerting and getting data to distribute across our healthcare community. And we send out, from a broad message perspective, well north of 20 million messages a month. But from a raw perspective, one encounter could equal several different message types that are going back and forth.

Q. That's just on a typical day?

A. That's typical.

Q. So you expect this to ramp up as the crisis continues to unfold.

A. Yes, and we've got the infrastructure in place. We've been doing north of 10 million alerts for the past almost year now.

Q. Talk about the importance of data quality.

A. We're on a journey to improving the data quality here in Arizona from a systems approach: How do we actually put in place mechanisms that engage our stakeholders, as well as the infrastructure that we have currently, to ensure that we have quality across the data continuum.

And what I mean by that is the data has to be input directly from the data source to us: The connection has to be built correctly – and to be built correctly as far as the types of data – and from a validation perspective: Is it actually syntactically correct, coming across? Is it complete and is correct?

We started down this path a little over a year ago, and I've got to tell you, it still feels like we're just at the beginning of that journey. There's just so much work to do to be able to clean up the data, make sure it's accurate, make sure that it's coming across on a regular basis.

Q. How do you approach that work?

A. We take an approach that's more collaborative. We have a data governance council. A lot of our ideas go to them. We put in place standards that go through our data governance council that we then take to our board, which is a representation of Arizona's market: payers, hospitals, providers, behavioral health, physical health. And then we move forward with it.

So from a data-governance perspective, that collaborative approach that promotes getting in the weeds, we actually have started running data-quality reports back on a subset of our facilities to say, "In these segments, this is what we're seeing." We've identified that we're missing specific maps, because not everything meets national terminology. And some of the areas that we've had to do this in his round of facility naming conventions, because what they name their facilities is not going to be in any national terminology book.

Q. And what about in a situation like the pandemic, which is so fast-evolving, with new CPT codes, new ICD-10 codes, new terminologies in general?

A. That's where having the foundation in place is valuable. We already know what those codes are, so we're just going in and validating that we're receiving those codes that we can data-mine against those codes. So when you take a look at it, it's the CPT codes, it's the LOINC codes for the labs, it's the CDC guidelines for symptoms or other areas that they're looking at.

So we've pretty quickly developed what that compendium looks like, and then we could go in and validate. But part of what we've done is, when we bring in our large data sources right now, those 98% of our hospitals, our acute care facilities that are sending us information includes labs. We've already got the foundation in place to be able to move that information back and forth. So it's just a matter of us going in and validating: This is the appropriate coding that we're looking for.

And then we can connect with the data sources and say, yes, that's how they're settling in as well. When it comes down to the national coding elements, it actually makes it a little easier because from a LOINC perspective, they follow those guidelines.

And if they don't, we can identify it. Then we can talk to them as far as how they actually code it. And then we have the appropriate data maps in place to be able to bring the data across as usable data. So the foundation really lends itself to us being able to stand up pretty quickly, to be able to say, as the testing is being distributed, we can then already have mechanisms that we're wrapping up or putting in place to be able to alert on those tests.

Having the right pipes in place is key – having those pipes support national standards, and having the appropriate mapping in place so we can make that data usable, and then doing spot checks (Is it actually working?), and validating against it. So from that perspective, it makes it a lot easier when something like this does arise to be able to work with our stakeholder and say, "How can we support you better?"

Q. Do you get the sense that the stakeholders, generally speaking, are appreciative of the role you're playing here and are using you to the fullest potential?

A. I would say here in Arizona, yes. So, we've got a pretty collaborative state when it comes to working together and sharing the information. We try to hit 90% or better on the data quality coming across. But the different data types is going to lead to natural variation that's going to be in the data coming across.

And our data sources work hand in hand with us to make sure the data quality is there. And then the end users: how is the data actually going to be used? A lot of our data goes out to those care teams, those care navigators that are supporting the rest of the care teams, the providers, the hospitals, the outpatient facilities on how to better manage those patients. The 10 million alerts that we send out are because most of our complex patients are on multiple provider panels.

Q. In recent years, as interoperability and data exchange imperatives have evolved, many HIEs have similarly innovated the services they provide. Talk a bit about how Health Current has changed its own business model in recent years.

A. Like evidence-based medicine, we pursue an evidence-based strategy. When we started sending out alerts we were at maybe 10,000, we thought we're doing pretty good. But when we reached out to our stakeholders and actually had deep conversations as part of what they really needed with the individuals who are using the alerts, we went from less than 100,000 to over 10 million a month.

We saw individuals starting to update their panels, stay more in touch, so it's really listening to our stakeholders. We do that. We take that same approach when it comes to data use from, say, pop health or analytic platforms. So we've spent a lot of time and efforts on developing different queries that we hit against our system to be able to support specific measures.

So if Organization A is using a given analytics platform, instead of just giving them CCDs, we give them the specific national codesets that they're looking for for those. Along with specified demographics, it's a lot cleaner. It goes into their system a lot easier. We do the normalization on our end, so it just feeds right into their environment.

We also work on it probably hitting their system in a few cases where we can support them with the alerts, to where it can support a care pathway. So they're using IP or solutions out there to be able to say, "I've got a diabetic; he presents in this way; this is the recommended pathway for the care team," they need that information to hit the system.

And we provide a mechanism when it's done to be able to hit their system like that. And we try to do it from a real-time perspective, so that information comes across. We immediately set it off to their system. The coding is then in place for them to be able to run whatever algorithm is downstream with their partners, with their care teams, as well.

So it's really listening to our stakeholders and understanding the direction they're going. It's also looking at it from an integrative perspective. We've the approach to where we're not shying away from 42 CFR information, if we bring in substance abuse information and make it available in accordance with SAMHSA, with national direction on that as well.

So it's really listening. As our environment's going to integrated facilities, integrated care, it's making sure that we have a data infrastructure or a direction that we're moving in that can support that as well. So it really goes from HIE to data management. So from the exchange to how do we actually manage data across market segments, and aligning both state and federal guidelines.

Q. We've seen often how in times of natural disaster, whether it's wildfires or hurricanes, HIEs really serve as key infrastructure: a "public utility … as critical as having roads, as having fire hydrants, as having an electricity backbone," as another HIE director once told me. Is that how Health Current sees itself as the COVID-19 crisis unfolds?

A. We see ourselves as a partner here in Arizona to make sure that we're providing the best care possible. So we see ourselves definitely as a piece of that puzzle. But only a piece of the puzzle. In hurricanes, when records were lost, well, you've got at least the start of a longitudinal record inside the HIE that you can begin using. And as the data elements become more complete and the quality improves, that only gets better over time. But yes, we definitely see ourselves as an integral part of the healthcare system and providing better care.

Heather Landi

Health IT leaders at hospitals and health systems are fast-tracking major technology projects—some in a matter of days.

As coronavirus cases rapidly increase in the U.S., healthcare chief information officers (CIOs) and IT executives are facing an unprecedented situation with a demand to ramp up technology tools on multiple fronts.

Hospital CIOs are quickly putting up telehealth infrastructure and telecommuting capabilities for thousands of employees and also developing screening chatbots and tracking tools to help frontline healthcare workers respond to the coronavirus pandemic.

"The leaders out in the field, at clinics, nursing homes, and hospitals, they are working at a pace that is heroic at best. What they are doing is right now is pretty amazing," said Russell Branzell, president and CEO of the College of Healthcare Information Management Executives (CHIME).

"We’ve never experienced anything like this," Geisinger Health System CIO John Kravtiz told FierceHealthcare, noting that IT teams are working at "lightning speed" to support clinicians. "You get things done, you plan on the fly. We're providing resources to solve problems. We have a fabulous IT team here at Geisinger. I can’t believe what we’re doing."

One of the key ways that technology can help in the response to COVID-19 is to reduce exposure from person-to-person contact and to prevent hospitals from being overrun.

Geisinger has developed a chatbot to help triage and screen patients remotely and is setting up video chat capabilities for patients admitted to the hospital to connect with their families at home. The health system also is using existing tools such as e-ICU to manage patients across its campuses.

Across its service area, Geisinger also has set up 13 screening tents outside of its facilities to screen and test patients. "The screening tents are like a MASH unit, there are computers and printers out there and they are fiber-optic connected. It's amazing how fast we were able to turn those things around," Kravitz said.

Branzell, a former healthcare CIO, said IT leaders are quickly shifting from focusing on the day-to-day IT needs inside the hospitals to enabling community-wide integration, including home wireless and internet connectivity. 

"What I'm hearing across the board is that organizations are making this stuff happen in days that could have taken years," he said. 

Virtual visits and telecommute

As Pennsylvania has joined California, New York, and Illinois with putting restrictions in place to curb the spread, health systems in that state are rapidly setting up telecommute capabilities and enabling physicians to do virtual visits from their homes.

The University of Pittsburgh Medical Center (UPMC), which operates 40 hospitals, has pivoted its patient-facing telehealth services to focus on onboarding primary care physicians to address the flood of patients with potential COVID-19 symptoms.

"We're also recognizing that many of our healthcare providers may be potentially quarantined or may be COVID-19 positive and this enables them to deliver telehealth care from their homes. We have been focused on making sure they have appropriate technology at home," Robert Bart, M.D., chief medical information officer at UPMC, told FierceHealthcare.

The health system's IT network is currently supporting 30,000 concurrent connections, with about 18,000 to 20,000 of those remote users, Bart said.

UPMC's urgent care telehealth platform, AnywhereCare, has seen a six-fold increase in visits, from an average of 80 visits a day to 500 visits a day. The health system's ambulatory care telehealth platform saw visit volume in one 48-hour period equal to the telemedicine visits performed in all of 2019, according to Bart.

"On our peak day, we saw about 1,500 visits. That number is climbing and we expect it to go higher," he said.

The health system also is working to deliver telemedicine functionality to all its inpatient units and ICUs.

Bart said UPMC's IT infrastructure is robust and has the capacity to scale up to meet ongoing demand. "We're less concerned with infrastructure and hardware than the durability of the people to deliver the care," he said.

Geisinger is working to onboard 1,000 physicians for virtual care visits by providing devices, cameras and headsets to physicians at their homes, according to Kravitz.

Danville, Pennsylvania-based Geisinger Health System services over 3 million patients in 45 counties in areas of Pennsylvania and southern New Jersey.

The IT department also is working to support radiologists working from home who need significant technology resources including high internet bandwidth, high-resolution monitors, and voice-to-text capabilities to transcribe documentation and get it back into the health systems' electronic health record (EHR), Kravitz said.

The number of Geisinger staff members and physicians working from home has doubled compared to a weather-related emergency such as a snowstorm, from about 6,000 concurrent users to 13,000 users, he said.

Crisis driving innovation

As health systems respond to the pandemic, IT leaders are pushing forward innovative technology solutions. Developers are working on tools using Fast Healthcare Interoperability Resources (FHIR) APIs to share public health data, Branzell noted.

Geisinger has worked with its local health information exchange, Keystone HIE, to develop a "heat map" dashboard that pulls in data from the Department of Health and laboratories and provides real-time data on people reporting symptoms and coronavirus cases by county. Hospital emergency departments find that information valuable to better prepare for potential patients coming in, Kravitz said.

IT leaders are setting up these capabilities while also ensuring that systems are running at peak performance and maintaining strong cyber defenses. "Cybersecurity criminals will look for vulnerabilities and take advantage. The cyber-surveillance cannot stop or we run the risk of being attacked and having major problems on our hands in our crisis situation," Kravitz noted.

UPMC is taking steps to implement telemedicine capabilities on EMS ambulances. "If there is a potentially affected patient, we can bring the physician to the patient to decide whether a patient needs to come into the ED or not. That will be helpful to triage patients in near real-time and potentially allow patients to stay in isolation without the risk of exposure to other individuals," Bart said.

Branzell predicts that the technology advances occurring now won't reverse once the pandemic ends.

"With telemedicine and remote monitoring, this is the new norm and how we provide care going forward is going to fundamentally change," he said.

Joanne Finnegan

It may be time to add a fifth “vital sign” when physicians and other clinicians evaluate patients: their travel history.

Asking about travel history when evaluating patients could help to prevent the spread of novel coronavirus and manage any future pandemics, two infectious disease doctors wrote in a commentary in the Annals of Internal Medicine.

Typically, clinicians assess patients’ vital signs when evaluating their health—temperature, heart rate, respiratory rate, and blood pressure.

“Given the increasing frequency of emerging infectious diseases that are geographically linked, is it time to add a ‘fifth vital sign’?” wrote the authors, Trish M. Perl, M.D., chief of the division of infectious diseases and geographic medicine at the University of Texas Southwestern Medical Center, and Connie Savor Price, M.D., chief medical officer at Denver Health and a professor in the division of infectious diseases at the University of Colorado School of Medicine.

That fifth vital sign could help to prevent the spread of geographically linked emerging infectious diseases such as coronavirus, which has been officially named COVID-19.

“The current outbreak is an opportune time to consider adding travel history to the routine. The COVID outbreak is clearly moving at a tremendous pace, with new clusters appearing daily,” said Perl, in a university announcement. “This pace is a signal to us that it is a matter of time before we will see more of these infections in the U.S. What is different with this outbreak is that this virus is more fit and transmissible and hence there has been much more transmission.”

While the numbers are changing daily, in the U.S., there are now more than 100 confirmed cases of coronavirus in 15 states and six deaths linked to the virus.

The infectious disease doctors said a simple, targeted travel history can help put infectious symptoms in context for physicians and caregiver teams, and then trigger a more detailed history, further testing and rapid implementation of protective measures. The added vital sign could signal a lurking communicable infection and flag potential risks to healthcare personnel and other patients.

Shared electronic health records also can integrate travel history with computerized decision-making support to suggest specific diagnoses in recent travelers, the authors said.

“We have the infrastructure to do this easily with the electronic medical record, we just need to implement it in a way to make it useful to the care teams,” said Perl. “Once the infrastructure is built, we’ll also need to communicate what is called ‘situational awareness’ to ensure that providers know what geographic areas have infections so that they can act accordingly.”

COVID-19 began in China and has continued to spread to more countries. Epidemics in Iran, Italy, and South Korea have shown no signs of slowing.

In fact, when the early coronavirus outbreak was concentrated in China, Anthony Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, urged clinicians faced with a patient with respiratory symptoms and a fever—the signs of coronavirus—to ask them if they have traveled to China.

The emergence of other diseases in the past two decades—including SARS, MERS and Ebola—demonstrates the need for action, the authors said.

Adding travel history as a vital sign would require training for all members of the healthcare team on how to integrate key epidemiologic information into their risk assessments in much the same way clinicians are trained to ask about tobacco use to assess a patient’s risks for cancer and heart disease.

“We believe that the urgent threat of communicable diseases makes the collection of travel history necessary,” the authors wrote.

Both MERS and SARS were associated with specific travel. MERS was associated with travel to the Arabian Peninsula and SARS was associated with travel primarily to Hong Kong, Singapore and Beijing, the authors noted. “Currently COVID is similar in that there are geographic clusters, but those lines may be blurring as the outbreak expands,” Perl said.

Perl and Price said ascertaining travel history is critical to protect both patients and those caring from them. They noted that in 2014, a patient presented to a Dallas emergency department after returning from Liberia with low-grade fever, abdominal pain, dizziness, nausea and headache. The patient had Ebola, but clinicians did not include travel history in the patient’s vitals and the diagnosis was initially missed, compromising the well-being of the patient and caregivers.