Mark Dunnagan – Interoperability: Creating Value

Today we are here with Mark Dunnagan, CHESS Vice President of Health Informatics to talk about Interoperability, what it means, why it matters in health care, and how better access to patient data for the entire care team will lead to improved outcomes for patients at a lower cost.

Mark Dunnagan, welcome to the Move to Value podcast.

Thanks, Thomas. Glad to be here.

So, Mark, today I want to talk a little bit about interoperability with you. So, can you first off explain what interoperability is?

Well, in the in the simplest terms, interoperability at least in in my travels is a is a metaphor for a conversation. Think of it like provider A wants to talk to provider B about patient Mark and it’s a means of making that happen.

And why is interoperability important for healthcare?

Well, I think in line with the metaphor of the conversation, you know, I think fifty, seventy-five, a hundred years ago when you only had one physician and they knew everything about you. You know, maybe it made sense, but in modern times with you know the various ways of receiving care, you know it, physicians don’t know everything about you and there’s no way for those forms that you fill out, you know, annoyingly so, when you go to the physician’s office can express everything that has happened to you. Interoperability is, is the key to that. Again, to know where Mark’s been and what happened to Mark and why it may have happened.

Well Mark, can you share a real world example of how interoperability provides value to healthcare?

So, I can and it’s part and parcel of that what we do on the value side literally every day. We receive what we call ADT feeds. It’s basically a notification that you know one of the patients under our care has recently checked into a hospital or has recently depending on the depth of the ADT Feed perhaps been seen out of network or gone to specialty services or whatnot. But that ADT Feed that notification that that one of the lives that we care about has been touched in some way by healthcare entities around us gives us information that we need to know to intervene appropriately. That if someone has been discharged home that we can you know abide by our contractual obligations to check in on them. That if someone has been seen out of network perhaps you know seeking high cost, high value services that we can make sure we understand what and why. And again provided you know the appropriate care management or interventions to help them with that. So again you know that is part and parcel what my teams deal with every day in a in a huge part of of the services that we provide. Without that form of interoperability we would struggle to provide the value that we do.

That’s fascinating. So, so we’ve established that the need for patient data exchange between providers is very important. How can we, how can we continue to close this information gap, how can we make this a better exchange?

There’s a million answers to this. I think I think that the foundational elements to make interoperability real or are there and to be honest with you have been there for some time Now, granted, what becomes interoperable meaning the data that we need to share continues to expand. You know of late; you know care plans and then the ingestion or the sharing of perhaps behavioral health information, you know the breadth of the data continues to expand. But the notions of interoperability have always been there as far as the structure, you know, the, the shape if you will, of the data and how it’s exchanged and then kind of the language, the nomenclature, the codified values there, there are at least examples and standard terminologies that can be used for most everything. I think you know, for me the struggles, if you will, continue to be around, you know, adoption and certainly EMR technologies take certain liberties with how they interpret those standards. You know, certain, certain entities, you know, I won’t point fingers at payers. But let’s just say if it were a payer, perhaps they don’t necessarily communicate things in a timely fashion or in a structure that’s, you know, so easily recognized. So, I think there’s, the technology has existed for some time. I would say that, you know there’s a need if you will to expand upon adoption of those technologies and for everyone to kind of agree to agree on certain interpretations.

So as technology advances and we begin to see real time interoperability, how can that improve outcomes?

Well, I think you know again the example of the transitional care that that ADT Feed I referred to is is probably you know one of the better examples of you know if we if we are to intercede and prevent a costly event or know that someone’s condition has degraded to the point where they might be at risk for a fall or for an emergency room visit or an extended stay in a hospital. You know that’s where a value based care where care management, some of the services that we provide can intervene and prevent you know you know further degradation of healthcare or bind together these disparate healthcare teams where you know primary care provider and a specialty maybe even a skilled nursing facility all need to kind of coordinate together to make certain things happen to the betterment of the patient. Knowing that information as quickly as possible is, is completely vital to what we do. I would say there’s also a very reasonable example where the timely access to data is important to us as well with respect to, you know, big part of value based care is quality measures and quality measures basically says you know, you are judged by your ability to conduct cancer screenings let’s say. And in order for us to know that that a payer has recognized that that gap has been closed, we need timely access to claims files. And if we can’t get that timely access, although we can say all day long that look, we can see that data in the EMR, we know that gap has been closed. If that payer doesn’t necessarily recognize that if we don’t get that file back and they say, hey, we recognize that that this has been closed, we suffer. You know it may mean that we don’t get paid in time which means we aren’t able to pay our payers in time or that we spend time trying to close the gap where we might have spent that time somewhere else to the betterment of another patient.

So you touched on this a little bit earlier and I was hoping that you could elaborate a bit more on some of the barriers that you’ve seen to interoperability in healthcare.

Before I speak to the barriers, I think I would just reemphasize the fact that it’s my impression that that the technology to support you know what I would say is, is, is true interoperability, true bi directional conversations about the health of a patient exist and arguably have existed for some time. I mean they have evolved and they will evolve, but I would say that the, the, the baseline technologies exist. I would say that the barriers are in interpretations of the standards and maybe the implementations of certain technologies where you know certain vendors let’s say take some liberty like for those of us that know The Dirty word of CCDAs and what those are, you know those are those are XML constructs that are kind of the envelopes or the trains that carry the data, the train cards that carry the data between systems. They have both a human readable and a machine-readable section and you know, it’s completely legitimate. It’s a well-formed document if a lot of the valuable information we’re looking for is buried in textual evidence in the human readable portion of it, but that’s not necessarily machine readable. So, you know, it comes down to context and interpretation of some of these standards. That I think is is a continued barrier. I would say that there are some creative forms of information blocking. Again, I won’t necessarily point fingers at any particular vendors or or any other entities other than to say that you know even in our world the dragging of feet, the less than timely response to requests for additional information or let’s say less than cooperative integrations with onsite systems where you know it’s a kind of a could versus should or would we. Where politics, where you know the lack of willingness to share information based on, you know, certain entities may be fighting for or footprints in certain geographical areas gets in the way of an altruistic exchange of information to the betterment of the patient. Again, forgive my political correctness, but you know, politics and revenue do come into play in this world, and I think they are barriers to true interoperability.

So, the next question was about standardization but although you touched on that with your previous reply, what else can you add about the need for standardization.

I would just affirm the need for standardization and standardization and flexibility or maybe the better word is extensibility meaning you have a set of standards but you agree that they must move and evolve and extend themselves as kind of the data that we that we take in. You know as we’re moving towards whole person care you know treating the whole person and expanding to care teams not just providers but maybe expanding a definition of providers beyond the traditional it’s a it’s a doctor or a nurse that that the standards must expand. But standardization itself is absolutely necessary and even after all this time and I could I could say that I’ve been an interoperability since it since it started. You know, I don’t want to give away my age, but it’s substantial that, you know, diagnosis and procedure codes I think are finally where we need them to be. But you know, we run into challenges every day with, you know, labs, with medication, with textual evidence that we know is indicative of some other diagnosis that are probably hidden somewhere in there. And there’s a number of technologies that can assist with that. But nonetheless, it’s not readily apparent. There’s other hoops you have to go through to get that. So you know the more standardization that is that is that is put in place the more the marketplace itself agrees that you know this is the way we must communicate that about Mark the better for all.

And do you see value based care demanding a greater push for open data exchange?

I do. I mean again you know it probably comes down to the definition of value. But I would say that that value based care is well on the continuum or certainly a lever to be pulled in what I would call whole person care. And when you start to think about taking care of the whole person you know mind and body and maybe even spirit if you will, that brings about the need to talk openly and where some of these barriers are talked about before whether to be geographic or business related. Hopefully not political but it’s sometimes that comes into it too, that that those barriers you know are removed, And you know it’s interesting you know we start to talk about barriers and this is going to be maybe a partial answer to some of your other questions but I can remember I was chief architect of one of the larger statewide HIEs and you know it’s mandate was only for state paid services. But when the COVID the COVID pandemic hit., you know, there was a there was an urgency to those that were only sending a piece of their health records. You know, and again, but think about all the hospitals in the state, you know, sending like only certain portions of the record, that everyone opened the doors, opened the floodgates and sent everything in response to what was perceived to be the greater good. And that was monumental. And I, you know, I would hope that it would take another disaster of that proportion for us to say, hey, it’s the right thing to do.

Agreed. So, Mark, I appreciate your time and this conversation today. But I do think that there’s more to this discussion. Would you be willing to stick around for a bit longer to answer a few more questions?

Yeah, I’d be glad to.