- Of the growing number of private industry projects aimed at bringing health data interoperability to the masses, the CommonWell Health Alliance has always seemed like a leader of the pack. Founded in 2013 and able to announce pilot sites for its data sharing solution just nine months later, it has steadily added provider organizations and industry stakeholders to its growing roster of participants.
But the rise of CommonWell hasn’t been without its controversy. Its ongoing spat with Epic Systems has been widely discussed by observers concerned about the deepening rift between industry giants.
And even though its early expansion has been laudable, it retains a relatively small footprint in the massive health IT landscape, leading some stakeholders to question how far the collaboration can truly progress in an increasingly crowded environment.
“I support CommonWell's effort, particularly around the issues of patient identification and patient matching. But I’m not sure there's a whole lot of substance there at this point,” said Dr. David Kibbe, President and CEO of DirectTrust when discussing the industry’s various efforts to come together around data sharing, even though some of these initiatives appear to be driving vendors further apart.
“There could be,” he acknowledged. “They’re taking on some very tough problems, and collaborating at that level is very difficult. I hope they are successful, and I’m pleased to see they’re taking an open, standards-based approach to interoperability.”
DirectTrust has its own method of helping providers exchange critical health information – with an email-like secure messaging platform endorsed by the ONC, the organization has seen success with its vendor agnostic approach.
CommonWell also hopes to cross vendor lines and eliminate reliance on proprietary data standards, but it has not yet been able to escape perceptions that the Alliance, led in the beginning by Cerner, McKesson, Allscripts, athenahealth, Greenway, and RelayHealth, is pitting itself against its members biggest rival: Epic Systems.
Epic has repeatedly refused to join the collaboration, though it has invited CommonWell to become a part of its alternative “network to network” approach to health data interoperability. Along with The Sequoia Project, previously known as Healtheway, Epic has invested its time and effort into Carequality, preferring to chart a course towards data sharing on its own terms.
“I have no idea what Carequality is or why it exists, other than to be in opposition to CommonWell,” remarked Kibbe. “Epic has said they don't join organizations like DirectTrust, but then they started Carequality, and one of their former top people is now running it.”
CommonWell recently appointed a former athenahealth decision-maker as its executive director, but much of the muscle behind the collaboration also comes from Cerner Corporation, lending even more credence to the notion that interoperability in the United States has become a Cerner-Epic showdown.
“I try to stay out of this battle between the giant EHRs, because DirectTrust has to work with all the vendors, and we want all the vendors to be capable of using Direct to the extent that their customers want them to do so,” Kibbe said, “and I'm not into the body blows between the giants here.”
But Bob Robke, Chairman of the Board at CommonWell and Vice President of Interoperability at Cerner, has no such qualms about defending CommonWell from its detractors.
“I can attest to the fact that CommonWell is not vaporware,” Robke stated to HealthITAnalytics.com. “Standing up a nationwide infrastructure is not a simple thing. You need someone to drive the first spike into the railroad, as it were - someone has to be willing to start leading it.”
“The network is only as good as the amount of data that can flow across it, and the amount of good it can bring to the end users,” he addded. “So part of our initial challenge is to get to this critical mass to show that when data starts moving, it's a very valuable system to take part in.”
CommonWell recently added five Pacific Northwest organizations to the list of providers using their interoperability services, and hopes to reach more than 5000 sites by the end of 2015. Four new collaborative members, including ESO, Beyond Lucid Technologies, MYidealDoctor, and Varian Medical Systems, will help to bulk up representation in related markets such as telehealth, emergency services, and oncology.
While its membership numbers have quadrupled in the past year to thirty-three, Robke acknowledges that CommonWell has a long road to travel before its relatively limited impact is felt on a meaningful scale, but he also notes that the long and complicated journey has been made before, and very successfully.
“I recently listened Paul Uhrig to talk about the first days of the Surescripts Network, and how it really took them nearly seven years to get to 1 percent of the traffic in the US from an ePrescribing standpoint,” Robke pointed out. Surescripts now handles 6.5 billion transactions a year between 900,000 providers and 3300 hospitals.
“So you look at something that had to get started and had to provide value in order to grow to a national network…that's a pretty good story,” he said. “However, it does take a while to get to that first set of value propositions. We have been able to make that case pretty successfully in the Northwest so far.”
Private industry initiatives may be making progress on bringing providers together, but they are not getting all the support from federal regulators that they may desire. The ONC’s interoperability roadmap provides stakeholders with a notion of how rule makers hope to proceed over the next decade, but a lot of the work will need to be done at the local level – without the lavish funding of the EHR Incentive Programs.
“There’s a sense that the federal government is going to somehow make a lot of choices in this marketplace, but it seems to me that might not actually be the case,” Kibbe said. “The ONC is in the process of dropping the baton, and perhaps we're going to go through a period of even less regulation until maybe something from the next administration emerges. So really, Carequality and the HealtheWay, now the Sequoia Project, are organizations looking for something to do.”
CommonWell is not sitting idly by as administrators cast about for regulations that work. As CMS and the ONC juggles complaints about Stage 3 meaningful use and tries to chide stakeholders into reducing instances of information blocking, which have been anecdotally reported across the healthcare system.
While vendors often take the blame for preventing health data interoperability as a way to reduce competition and keep customers in line, neither Robke nor Kibbe necessarily believe that vendors are maliciously at the root of the problem.
“’Information blocking’ is a very negative term with a very negative connotation,” Robke said. “The problem is that interoperability efforts are happening locally, and there aren’t any truly meaningful ways to handle care and health information exchange on a national basis.”
“We begin to develop interoperability either on an organizational basis or a regional basis, and sometimes that actually defeats the purpose of what’s good for the patient. I think it’s good that we’re shining light on the issue of information blocking so we can get past some of these problems.”
Keeping patient-centered care at the heart of the health data interoperability debate will help the industry move towards more coordinated, data-driven services, Robke maintains.
“If you put the person in the center, usually those conversations about data blocking are very quickly thwarted, because patient-centered care requires data to follow the patient regardless of what organization they go to, or what state they’re in, or what HIE their provider is using,” he said. “That shouldn’t matter if you’re interested in keeping the focus on the patient. I think that's a pretty simple concept that we all understand, and ultimately, that’s the vision of CommonWell.”
“One of the main reasons why CommonWell exists today is that there really isn't anything else that can scale to all the places that the patient is going to go. And so without that kind of broad health data interoperability and exchange technology, you see a lot of organizations connecting the things that they feel are important, but that isn't always putting the patient in the center.”
In order to achieve a patient-centered continuum of care, many providers and payers are turning towards value-based reimbursement structures that financially reward organizations for ensuring that informed patient management becomes commonplace.
“Accountable care organizations and the move to value-based reimbursement have certainly brought attention to the need for data liquidity and sharing of information,” Robke observed. “Any time you're at risk for a patient's care, having a complete picture of their medical history is a big part of that.”
“In many ways, we’re still waiting for that business model to take hold – a lot of reimbursements are still based on the fee-for-service model, and that just doesn't present a real business incentive around sharing of information. Even though it’s a nice thing to have, it’s not necessarily a business driver when you’re more concerned about maintaining revenue through volume.”
As accountable care begins to make itself felt in a larger number of communities, the next question is how quickly health IT can close the gap between theory and reality.
“There are plenty of opportunities,” said Robke. “Technology today has matured enough so that data exchange can occur, for the most part. We still have a lot of unknowns around workflows and what is the best way to present the information to the end user, however. How do we bring it together to show only the relevant components versus just a big dump of data?”
“Vendors are starting to get their arms around that question now that data exchange can happen. It may happen only locally, it may happen only within the organization, but it is happening. There has to be a way for the end user clinician or physician to utilize that information without causing an immediate burden of time and complexity.”
EHR vendors have not yet cracked the secret of developing highly usable products with streamlined, intuitive workflows, and the imminent deluge of additional data sources from HIEs, wearable devices, home monitoring systems, and clinical decision support functionalities is sure to complicate the proposition even further.
However, organizations like CommonWell, DirectTrust, Carequality, and up-and-coming contenders including HSPC and The Argonaut Project are planning to bring standards-based approaches to EHRs, health information exchange, and the big data analytics that will eventually support large-scale population health management.
What role these private and public-private collaborations will play in the long-term health data interoperability landscape is still up for debate as each project pursues its chosen course, but with such a strong vision and growing industry support, CommonWell is poised to remain a major influence in the future of health information exchange and the wider goals of healthcare reform.