Halamka on the Most Important Interoperability Story of 2016

John D. Halamka, MDYou may have missed or not understood the implications of this press release.  Here's a guest post from Micky Tripathi, the CEO of the Massachusetts eHealth Collaborative that explains everything you need to know:

"This summary provides some additional information on the recently announced interoperability agreement between CommonWell and The Sequoia Project (Carequality).  For full disclosure, I am on the Board of Directors of The Sequoia Project, a contractor to CommonWell, and participated in the discussions leading to the agreement.  The description below does not necessarily reflect the views of either of these organizations or any of the named vendors.  It is based on my understanding and analysis of the implications, does not reveal any confidential information, and has not been pre-vetted by either CommonWell or The Sequoia Project or any EHR vendor.  It was originally developed in response to questions from provider organizations whom I work with and who, after reading it, felt that it would be valuable to others.

Current situation:

CommonWell is a network that provides a record locator service (RLS) and query/retrieve capability among participating vendors/providers. 

• Exchange concept.  The network architecture is patient-centric in the sense that one searches for a patient first, and then executes a query to retrieve a CCDA record from any of the returned locations that are connected and for which the patient has authorized being listed in the RLS. 
• Architecture.  The network -- which brokers all transactions, manages patient identity-matching, and hosts the RLS -- is a central infrastructure owned by CommonWell (a non-profit organization) and developed & operated under contract by RelayHealth.
• Participation.  The main vendors in CommonWell today are athenahealth, Allscripts, Cerner, eClinicalWorks, Greenway, and Meditech.  More are listed here:  http://www.commonwellalliance.org/members/
• Pricing.  CommonWell members by agreement don’t charge each other for transactions.  Each member charges its own customers according to their own policies.  So far, the bigger participating vendors such as athenahealth, Allscripts, Cerner, eClinicalWorks, Greenway, and Meditech are not charging their customers separately for access to CommonWell services as far as I know.

Carequality is a framework that provides a governance structure, legal foundation, and technical standards for network-to-network exchange. 

• Exchange concept.  The architecture of exchange is provider-centric in the sense that one searches a provider directory for a care delivery organization, and then executes a query to retrieve a CCDA from that individual provider organization (a directed query).  In terms of architecture, it is very similar to how Epic CareEverywhere works today, except now extended to the entire Carequality membership.  Carequality currently supports 2 interoperability functions.  Directed query is the core function.  There is also an RLS function that is optional, meaning that it isn’t subject to some of the same policy constraints (namely pricing) as directed query.  Surescripts is currently the only RLS service available through the Carequality framework.
• Architecture.  Carequality does not have any central infrastructure to broker transactions, however, it does maintain an XCA endpoint provider directory and it acts as an RA/CA for certificate management to enforce its rules.  Each node implements IHE XCA/XDS specifications and executes point-to-point transactions with other nodes, leveraging XCA endpoints from the provider directory and the certs issued by Carequality.
• Participation.  The main vendors in Carequality today are athenahealth, eClinicalWorks, Epic, GE, NextGen, and Surescripts (RLS).  More are listed here:  http://sequoiaproject.org/carequality/members-and-supporters/
• Pricing.  Carequality does not allow members to charge each other for directed query transactions for treatment purposes.  Each member is allowed to charge their own customers according to their own policies.  From what we’ve seen in the market so far, the major vendors such as athenahealth, eClinicalWorks, and Epic are not charging their customers separately for access to Carequality.  

The future:

CommonWell and Carequality will “connect” in the following way:

• CommonWell will join the Carequality framework for directed query and RLS.
• CommonWell will create a single gateway that will allow any non-CommonWell Carequality participant to query any CommonWell Carequality participant at the provider/site level (a directed query).  CommonWell member organizations will be listed in the Carequality provider directory at the individual site level, even though they will be connected via a single CommonWell gateway.
• CommonWell will offer its RLS as a separate subscription service that can be purchased by a Carequality participant; since it’s based on open standards, it will be integrated into the workflow of a Carequality-compliant EHR.

The implication for a Cerner (or any other) CommonWell user is:

• Once you agree to be a Carequality participant, you can search the provider directory from within your EHR’s CommonWell function and request a record from any other provider listed in the provider directory.  This will include any existing CommonWell members who agree to become Carequality participants, as well as current Carequality members (such as Epic, GE, and NextGen sites who have already signed on).
• The CommonWell RLS will now also include patient listings from any Carequality member who purchases the CommonWell RLS service.

The implication for an Epic (or any other) Carequality user is:

• Once you agree to be a Carequality participant, you will be able to search the provider directory and request a record from any other provider listed in the provider directory.  This will now include CommonWell members (such as Cerner, Allscripts, Meditech).
• In addition to your current ability to subscribe to the Surescripts RLS service integrated into the Epic workflow, you will now also be able to subscribe to the CommonWell RLS service integrated into the Epic workflow.  Both are fee-based services.

What’s the difference between the CommonWell and Surescripts RLS services?

• Each is founded on a different principle for determining record location, so each has its own peculiarities and gaps.
• CommonWell receives ADTs from all participating sites, so provider-patient relationships are based on encounter information.  Every listing in the RLS is an active query/retrieve link to a record; no patient is listed without at least one active link to a record.  The biggest gap is that some vendors – such as Epic, GE, NextGen – do not belong to CommonWell.  In this sense, one might say that it is currently deeper than it is broad.  This is not a criticism – just an observation on where it is today.
• Surescripts determines provider-patient relationships based on prescription information.  After a query it provides back a document listing the providers (and contact information) who have prescribed to the patient through the Surescripts network.  They enable active links to live Carequality endpoints to allow smoother transition from record location to query/retrieve.  The biggest gap is that not all provider-patient relationships can be found in the Surescripts network (for example, hospitals or ambulatory providers who do not use the Surescripts network for any or all of their patients), and not all returned relationships have electronic query/retrieve capability.  In this sense, one might say it is currently broader than it is deep.  This is not a criticism – just an observation on where it is today.
• Both Surescripts and CommonWell RLS services are fee-based.  Surescripts has announced that they will not charge EHR vendors for access to their RLS until at least 2019; EHR vendors can of course charge their customers, but I am not aware of any vendors doing so to date.  CommonWell is currently developing its pricing model.
• In the future we might imagine interoperability among RLS systems, so that a CommonWell member could benefit from the additional information that a Surescripts RLS provides, or a non-CommonWell Carequality member wouldn’t have to subscribe to both CommonWell and Surescripts RLS services to cover as much as ground as possible.  One step at a time……

The implication for providers in general:

• This agreement is a significant step toward basic nationwide interoperability – for most of the major EHR vendors, you will be able to electronically request and retrieve a medical record from any other provider in the country from within your EHR.
• The agreement is constrained right now to a single type of transaction – query for an individual CCDA patient record for treatment purposes.  It does not cover high volume aggregation of multiple patient records for analytics or population health or research, for example.  And it doesn’t cover other types of data such as images, or genetic information.
• The agreement does not do anything explicit to normalize or improve the quality of CCDAs.  The CCDAs delivered are the same ones that are now being pushed via Direct Messaging; it just provides another avenue for getting them.
• This doesn’t replace Direct Messaging – it is an additional interoperability option that enhances certain clinical use cases, such as when a patient shows up and records have not been sent in advance.
• This also does not replace state and regional HIEs.  Any HIE can join either CommonWell or Carequality (or both), allowing them to offer nationwide service to their customers (kind of like FTD does for florists).  It does mean that some HIEs will have to refine their business models if they rely on basic query/retrieve.  With basic query/retrieve now effectively commoditized, these HIEs may need to focus more on higher value services such as payload normalization/improvement and population health.
• Any organization that is investing in HIE capabilities should pause and evaluate before investing any more time and money.  This agreement doesn’t “solve” interoperability, not by a long-shot, but it does solve a lot of the daily headaches that plague CIOs and providers today, and it’s worth taking a hard pause to reevaluate your strategy before proceeding."