By Deborah Borfitz

May 14, 2019 | A nonprofit public-private collaboration has developed a successful and repeatable methodology to "mass produce data sharing by figuring out what not to do," says Tim Pletcher, DHA, executive director of Michigan Health Information Network Shared Services (MiHIN). The counterintuitive approach relies on multiple stakeholders agreeing to concrete, actionable types of data-sharing activity and "pay or penalty" incentives to adopt use cases as a priority in their organization.

The preferred tactic has traditionally been to "put all the data in a big pile… [and] just expect people to show up and do the right thing," Pletcher says, which has proven not to work. MiHIN has instead built a Use Case Factory where technology is subservient to whatever value creation activity is being tackled.

MiHIN, which Pletcher likens to an "HIE 2.0 or 3.0," is a state-designated entity originally funded under the Office of the National Coordinator for Health Information Technology's State Health Information Exchange Cooperative Agreement Program. It has been in the interoperability business since December 2010.

Currently, 35 use cases are in various stages of development in the categories of care coordination (10), public health reporting (10), consumer engagement (four), infrastructure (four), results delivery (four) and quality reporting (three). The most mature of these—for admission, discharge, transfer (ADT) notifications—is now being replicated in New Jersey and the Centers for Medicare & Medicaid Services (CMS) seems to favor the approach in a recent proposed rule that would require hospitals to start sending notifications to doctors when a patient is discharged, Pletcher says.

The Nitty-Gritty

"Right now, everyone wants to share everything all the time with everybody for every purpose, which in the abstract is awesome but at the level of the scale of the state is actually kind of an overwhelming quest," says Pletcher. With the Use Case Factory, great ideas efficiently move from the conceptual to the pilot phase because all the key players—including providers, payers, and government agencies—sit around the table to reach consensus about what's important and to hash out the "ugly, nitty-gritty" details such as how data will be transferred and protected and which standards and security mechanisms will be applied.

In lieu of individual data use agreements, statements of work, and purchase orders, MiHIN developed one master agreement for all data-sharing projects that gets tweaked for the nuances of specific use cases that range from populating an immunization registry to discharge medication reconciliation, says Pletcher.

Stakeholders then decide on the appropriate financial inducement to encourage adoption of the use case in a way that generates good data quality, Pletcher says. "We get payers to connect a portion of their existing incentive program to successful participation in a portfolio of use cases and each year they adjust that portfolio." The incentives are payer-agnostic and apply to all patients in the state, he adds. Policy levers may additionally be used to motivate providers to participate in use cases.

MiHIN issues report cards against all those use cases indicating which hospitals are consistently submitting the required data in the right format, so payers—potentially including the government—know to pay all or a portion of the incentive or withhold it entirely, says Pletcher. "This is sort of a precursor to the day when value-based care drives all of this... another way to create appropriate incentives to drive interoperability that works quickly and overcomes many of the issues we see with information blocking."

As the "neutral hand in the middle," MiHIN works with the differing agendas of payers serving commercial and Medicaid populations that can’t be expected to team up on a master data-sharing plan, Pletcher explains.

Many of the current use cases are in the implementation stage where providers are sending data, he says, but "to make a real change in healthcare we have to get all endpoints receiving that information."

Building a Use Case

ADT notifications is a common area of focus for provider and payer groups, so it was an obvious choice for a use case, says Pletcher. But getting competing hospitals and health systems to share their ADT messages would have been no easy task if Blue Cross Blue Shield of Michigan (BCBSM) had not agreed to flex its market power for the common good by tying 15% of its incentives to hospitals participating in this all-payers ADT use case.

In exchange, MiHIN sat with a use case working group to write an addendum to the master agreement covering permissible data uses and got everyone to abide by the consensus rules. It also created an unambiguous implementation guide that aligns with the formal specifications, and generated synthetic data to mock up a compelling persona story—complete with stock photo of mother and child—pointing to the big-picture benefits of care teams working and coordinating behind the scenes.

MiHIN has many examples of how HL7 messages work, and participating hospitals can practice sending ADT notifications prior to onboarding, says Pletcher. As the incentive payment deadline approaches, it also sends a conformance report to BCBSM so providers are appropriately credited.

Through a separate use case, Active Care Relationship Service (ACRS), physicians are financially incentivized to send their roster and enrollment files to MiHIN, notes Pletcher. "So when hospitals send their ADTs to us, we can then match up and route them to the appropriate doctors and specialists." ACRS give MiHIN the linkage between doctors and patients as well as how those doctors electronically receive information, which has resulted in a "robust" provider directory.

"Because everyone has signed our legal agreement for the ADT use case and the ACRS use case, no one is outside the legal chain of trust for how all of these pieces are interconnected, but the doctors did not need to sit down and negotiate a big agreement with the hospital for the whole thing to scale," explains Pletcher. MiHIN keeps the data for about 100 days since it is not trying to create a longitudinal care record but rather solve the communication gap during the most critical time period for care coordination.

Nearly 100% of all ADT notifications in Michigan are now transmitted through MiHIN, says Pletcher, with most of that traffic captured in less than one year.

More Than Technology

Death is a natural event but can take six weeks to be officially recognized. The Death Notifications use case seeks to capture early indications of death and to immediately spread the news to any healthcare organization with the need to know, says Pletcher. A classic example would be when people unexpectedly die in the emergency room and their unsuspecting family physician calls to make a routine appointment. But timely notifications of death are also useful for purposes of outcomes tracking and, if the deceased is a physician in good standing, might prevent someone from fraudulently writing prescriptions under his or her name.

The Centers for Disease Control and Prevention also has a death notification use case called Death on FHIR that is based on the popular Fast Healthcare Interoperability Resources (FHIR) standard, says Pletcher, but "it's yet another technology-only demonstration. We're trying to get our arms around a systematic scalable approach to deal with all of the issues around death notifications… inserting technology into context and advancing the old way and new way at the same time so we all arrive at the same point at the same time." The quality of the data, he adds, is as important as its creation and accessibility.

Many Sandboxes

During the recent Health Information and Management Systems conference in Orlando, Velatura—a subsidiary of MiHIN focused on providing products and services outside of Michigan—unveiled Interoperability Land, a cloud-hosted data visualization environment, to increase interoperability within healthcare. It's a place where developers can design, develop and test collaboratively within on-demand test environments, simulated application programming interfaces (APIs) and API sandboxes, says Pletcher.

Among the ecosystems inhabiting Interoperability Land is a FHIR-PIT, a pilot interoperability test bed for FHIR-based APIs, and a Ring of FHIR, which is amassing synthetic data that mimics realistic patient histories with clinically relevant patient encounters with hospitals, primary care practices, electronic health records, pharmacies and health plans. Interoperability Land also supports multiple open APIs, including those specific to blockchain.

"If all these notices of proposed rules [from CMS] move forward, and all the expectations around FHIR and open API is to really advance, organizations are going to need a safe place to practice and learn what works," says Pletcher. "We think Interoperability Land will play a critical role in onboarding the new standards." When it comes to managing the business of healthcare effectively, "the technology doesn't matter. But, in the past, it has been a stumbling block."

Given all the legacy data-sharing technology still in use, the growing number of open API options in healthcare and the expectation that artificial intelligence will soon be on his doorstep, Pletcher says, MiHIN and Velatura will be keeping a lot of sandboxes open for the foreseeable future.

To help move this forward, MiHIN and Velatura offer a Connectathon service, where teams of developers, vendors, and subject matter experts work together to create and test interoperable solutions in a safe environment. In April, Velatura facilitated a "hackathon" in the state of Connecticut and, at the end of May, will be hosting one as part of MiHIN’s annual Connecting Michigan for Health conference.

The idea is to work through all the interoperability hurdles in a synthetic, harmless space to figure out next moves and rapidly build prototypes, in part by taking down the legal barriers that can put projects in an 18-month holding pattern, says Pletcher. Perhaps more importantly, he adds, MiHIN and Velatura hope to play a role in bringing patients a more integrated care experience "where the world is bigger than the EHR."