Ep. 7: Laura McCrary, Ed.D., President and CEO, KONZA. Topic: Data Sharing During COVID-19
Kathy: Hi everyone, and welcome to Episode 7 of the Smarter Healthcare Podcast. So glad you could join us for this episode in which we hear from Laura McCrary, president and CEO of KONZA. KONZA runs health interoperability exchanges in several states across the country, and Laura is here to talk to us about how easier access to data and sharing information is helping hospitals, physicians, and public health officials better respond to the COVID-19 pandemic. Here’s our conversation.
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Kathy: Hi Laura, welcome to the podcast.
Laura: Thank you very much.
Kathy: Could you start off by talking about KONZA and its role in interoperability?
Laura: Sure. I think interoperability is a large word and for people oftentimes it has different meanings. But I think probably the most important thing to keep in mind is that interoperability at its core is really moving data from one place to another. And when that data is actually moved, for it to be usable in the format that it’s received in. So let me give you probably the most common example is that as a patient in our healthcare system today, you probably see four or five different doctors in different locations. All of those different practices may have different electronic medical record systems. So for example when you go to your primary care doctor’s office, they may be using a product called eClinicalWorks, and then you go to your specialty care doctor’s office and they’re using GE Centricity, and then unfortunately you might have to go to the hospital and they’re using Epic. So none of them are on the same technology platform. And really what interoperability means is that those technology platforms can share your medical records with each other in a way that can be usable and actionable for the doctor or the clinicians who are providing care to you. So that that data actually comes from your primary care doctor’s office to the hospital in near-real time, and can be incorporated in your chart at the hospital. And that’s truly what interoperability is. So KONZA’s role is to really make those connections happen between those electronic medical records systems and to do it so that every time that a patient moves from one setting of care to another, that the doctor at the point of care in front of the patient has a longitudinal medical record for that patient so the doctor, he or she, knows everything that they need to know about that patient. What’s the patient’s medications? Because a lot of times, particularly if a patient’s been in an accident or has been under a lot of stress, they may not be able to remember all of their medications. What’s the patient’s allergies and how severe are the allergies? What are recent lab tests that the patient has had? We don’t want to duplicate lab work if we can possibly avoid it. What is the patient’s diagnosis? Sometimes patients may be – again – it may be difficult to remember if you have a lot of chronic disease conditions and you’re in an emergency. So what we want is to be able to give the doctor or the health care provider as much information as possible about the patient at the point of care, because it keeps the patient safe and it helps the doctor provide the best care for the patient. And that’s what KONZA does. We build those connections between primary care doctors and behavioral health providers and hospitals, we build a network, kind of like, you know, your cellphone network, it allows you to be able to call someone anywhere and talk to them, that’s the network that we’re building to be able to connect electronic medical records systems together to really foster this idea of interoperability.
Kathy: Now I think the COVID-19 pandemic has brought to light some of the challenges with data sharing. Where have some of the bottlenecks been in sharing data between different stakeholders in healthcare?
Laura: You know, interestingly enough, we have found a number of bottlenecks that we didn’t even realize before COVID that there were bottlenecks there. So I’ll give you two specific examples that have created problems. One is that generally when a lab test is ordered on a patient there is a lab order number, and so the lab will be sent off to a facility like Lab Corp or Quest or some other facility to process the lab, and then the results have that order number attached to them and they’re sent back to the hospital or to the doctor’s office. So that works as long as that lab test is going from the doctor that ordered it to the lab company and then back to the doctor that ordered it. Well unfortunately what’s happened with COVID is that many times patients are being transferred. And so the COVID lab test would follow that route, it would go to the lab company then it would come back to the doctor but now the patient’s not there any longer. The patient’s now at the hospital, or the patient was at a hospital and been transferred to another hospital, or the patient’s now transferred to a different unit at the hospital. And because there wasn’t specific demographic data associated with that lab test like the patient’s name, patient’s date of birth, patient’s gender, oftentimes it’s almost impossible to associate that lab information with the patient. Because the demographic information isn’t part of that order. So just recently we saw a new ruling come forward that says moving forward, from now on, when you do a lab test, you must also include the patient’s first name, last name, date of birth, and gender, so that we can actually match that lab test with the patient. So that was something that we didn’t even realize was a problem because most of the time patients aren’t transferred that often. The second thing we found out is that oftentimes it takes a while for the diagnosis code to actually be entered into the medical record. Sometimes it could be two or three or four days after the patient’s had the diagnosis before that is entered into the patient’s medical record. Well, if that’s the case, and the patient has COVID-19, then we don’t know that that patient has had a positive diagnosis until that information is entered into the medical record. So consequently what we realized was that people were following the same process they always did, which is they got that diagnosis in probably within 48 to – two to three days, anyway – so we had to start sending out notices to people which was, ‘Please code your COVID diagnosis as quickly as possible so that we know that we’ve got a positive COVID patient there.’ So those are just two examples of things that we’ve always done exactly the same way for many many years that finally when we had a pandemic we realized the importance of complete information coded as quickly as possible. So if you don’t have patient name it’s going to be very hard to figure out who that lab test is associated with. And if you don’t actually enter the diagnosis of a positive COVID result into your electronic health record system, it’s going to be very hard for us to be able to tell other individuals who need to know that the patient has a diagnosis of COVID. So I think we will continue to find other situations like this that will become apparent as we move forward dealing with this pandemic, but those were the first two problems that we encountered with, “Oh my gosh, what we’ve always done in the past doesn’t work anymore.”
Kathy: What is KONZA doing to help facilitate information sharing during the pandemic?
Laura: You know we’ve done a couple of things that we think are really important. So we receive real-time data feeds from hospitals and from physician practices and from other healthcare providers and that data then is available in our health information exchange, not just in Kansas but in many states all across the nation, so that data is available at the point of care. So if a patient shows up at the hospital, the doctor at the hospital will be able to see the fact that that patient does have a positive diagnosis of COVID or has at least a suspicion of a diagnosis of COVID, so that’s what we call basic health information exchange. But in addition to that we created a unique dashboard for our state Department of Public Health that allows them to receive real-time updates of any patient that’s been admitted into a hospital, or discharged from a hospital, and any patient that has a positive diagnosis of COVID or a suspected diagnosis of COVID. So the Public Health Department can actually see who the patient is, where does the patient live, what was the hospital that the patient was admitted into, what was the unit, are they in intensive care, are they in the emergency room, do they actually have a positive diagnosis of COVID or is it just suspicion? So the state department can then follow up with the hospital to make sure that all of those patients are being tracked. Not just to be able to make sure that we have enough resources at the hospital, whether it’s enough bed capacity in the intensive care unit, or whether or not we’ve got enough staff, but also to be able to ensure that there’s the adequate information for contact tracing so that the state department of health and environment, who has the responsibility to reach out to those patients, knows how to reach out to them as quickly as possible. The other thing that we’ve done is we’re providing alerts out to hospitals and practices that say your patient has a positive diagnosis of COVID. So if that patient calls in for an appointment, or the patient calls in and needs additional support or resources to manage, after they’ve been discharged from the hospital, that the doctor and his or her staff know everything about the patient including their positive diagnosis and what kind of treatment they received at the hospital. So we’ve taken very seriously our responsibility as a data steward to make sure that we ensure that data gets into the hands of the doctors and the public health officials so that we can try to do our best to take the very best care of our patients and to manage the spread of the virus.
Kathy: You talked earlier about some of the challenges in terms of sharing information during the pandemic. What are some of the other big challenges in interoperability that we still have to solve?
Laura: The biggest challenge is the fact that the electronic medical records systems, and there’s about three hundred of them still currently in use across the nation, each are built on their own unique technology platform. And each one of those electronic medical current systems has created its own interoperability strategy. So for example, some electronic medical records systems create hubs for their practices, and their practices all dock into a hub, so an organization like KONZA would just connect to the hub and then they would have access to the practices that are docking into that hub. A number of vendors do that. A number of vendors require point to point interfaces, meaning that you have to buy four or five different interfaces in order to share a complete set of data. So a practice might have to buy a lab interface, a medication interface, a notes interface, an ADT interface, which is called ‘Admit, Discharge, and Transfer.’ Maybe abstracts, which has diagnosis and procedures, maybe immunizations. So in that case a practice is building multiple interfaces to KONZA to be able to share a complete set of data with us. Other electronic medical records systems create what’s called a CCD, a continuity of care document. And that document actually has all of the information in a structured format, in one document, about what happened with that patient at their visit at the hospital or at the physician practice, and that document is sent to us. Other EHR vendors use an API call. And we’re just starting to see that more and more in the market where we’ve had our first interfaces now where we actually are building APIs to allow information to move between the electronic medical records system and the health information exchange. Other EHRs can’t do any of those things that we talked about, and they can just provide us with a daily batch of information each night. So my point here is that without standardization and a requirement that the electronic medical record vendors all use a standardized way to transport data, we have a hodgepodge of different interoperability solutions, and an organization like KONZA has to be prepared to deal with any of those. So when we sit down with an electronic health record vendor that we’ve never worked with before, we start out with what’s called technical discovery, and we talk to the vendor and say, “What is your interoperability solution to move data out of this electronic medical records system to any other place where patients may receive care at?” And we sit down and we work with each one of them individually. And we’re nimble and flexible as a company but I will say that’s probably the biggest interoperability challenge that we have here in the nation is being able to actually incorporate all of the different types of strategies the vendors have and create a distinct network that works for everyone.
Kathy: And when we think about addressing that big challenge, where does the change need to be made? Is it government regulatory level? Is it that the vendors just need to commit to working with each other?
Laura: Yes, I think it’s both of those. I think that’s absolutely essential that both of those happen that you mention. We need to have a commitment from the vendors that they will share information, and we need to have a commitment from providers to share information. We’ve had some health systems that have blocked data in the past because they felt like it gave them a competitive advantage. Now both of those situations have been resolved by recent legislation that really stops information blocking. As a matter of fact, within the next two years, there will be significant penalties if an EMR vendor or if a health system or a health information exchange like KONZA blocks data, meaning that they don’t share that data for purposes of treatment. It appears that the penalties could be as much as a million dollars per incident of information blocking. Because truly, you think about this, the information that needs to be shared could mean the difference between a patient receiving proper and safe care and a patient not getting that. For example, if a patient is allergic to a medication and the information form the health care facility that indicates that isn’t available to the emergency room doctor, where the patient is at and the patient has a very bad reaction say to penicillin, I mean, that could be life-threatening. So information blocking really has gotten to the point where it is no longer going to be tolerated. The data belongs to the patient, it’s the patient’s own medical record information, the data belongs to the patient and it should be moved to the point of care where that patient’s receiving care at. So I think we’ll get past that in the next couple of years. I will say that there is a continued barrier of the cost of these interfaces. So we talked about all of the different kinds of ways that electronic medical records vendors can share data, but what I would say is that on average, for a physician practice, you’re probably looking at a one-time cost of somewhere between fifteen and twenty thousand dollars to get that connection built. And for many of our practices, particularly during COVID, they’ve got some significant cash flow challenges. And asking them to come up with fifteen or twenty thousand dollars to cover this one-time cost of an interface, is quite a significant investment for them. And for hospitals the same is true. Oftentimes the costs of the interfaces can easily be 50 to 60, even above 100 thousand dollars for these hospitals. So the cost of the interfaces is always a significant barrier. But I would say that all of these barriers are slowly coming down as people understand the importance of sharing data, and that really without the sharing of medical record data you are putting patients’ lives at risk. And so I think that we’re getting to the point where people understand that the barriers have to be reduced and I think, I’m very optimistic that over the next couple of years we’re going to see broad interoperability and it’ll be similar to the way cellphone coverage took place over time. Not everybody had cellphone coverage or had a cellphone, and it’ll be a slow growth for interoperability over the next ten years, but I think looking back ten years from now, we’ll think that this was the beginning of the time that changed interoperability. That COVID, as bad as it’s been for our country and our population, it has been good for really promoting the fact that data needs to be shared. Patient medical record data needs to be shared between the patient’s medical providers.
Kathy: What technologies or developments do you think will have the greatest positive impact on data sharing?
Laura: You know, one of the things that has I think been quite informative and is newly emerging is alerting providers on critical health incidents of their patients. So, for example, health information exchanges have been providing alerts around when patients are admitted into a hospital, or if they’re transferred in a hospital, say from the emergency department to inpatient, or if they’ve been discharged from the hospital. That’s been going on for, probably, the last three to four years. And really that product has reached I’d say pretty good maturity. And in fact, starting on May 1st of 2021, hospitals will begin having to provide alerts to a patient’s primary care providers, or if the patient’s in a nursing home or another post-acute care facility, hospitals will be required as a condition of their participation in Medicare and Medicaid to provide alerts to primary care doctors and post-acute care facilities. So I think this will become commonplace, where your primary care doctor is going to receive an e-mail alert, via secure e-mail, that you’ve been admitted into the hospital. So you shouldn’t be a bit surprised that when your primary care doctor calls and wants to talk to you when you’ve been discharged to see if you need any help in managing your medications or if you need to come in and actually have a visit to talk through any new procedures that were done in the hospital and the like. So that is becoming commonplace. And I would say within the next two years that new technology will be pretty mature and pretty widespread. I will say the thing though that’s interesting about it is that with the, with COVID, what we realized is that alerting technology could also be used to provide alerts on things other than the fact that the patient has been admitted into the hospital. So for example, I shared earlier we’re now providing alerts to doctors that their patient has a positive diagnosis of COVID. We’re providing alerts to the state department of health and environment on all the patients that have suspected exposure or have a positive diagnosis. So we’ve moved beyond just alerting that your patient has showed up at the hospital to say now we’re alerting on important critical health events. So for example, you could begin providing alerts if you, for example, if a patient gets a new medication prescribed. The primary care doctor could be alerted. “Your patient has a new medication.” Well the primary care doctor is the one that’s most likely going to be able to see that that medication might be contra-indicated with another medication that you’re on. That maybe those are not two good medications to be on at the same time. And they have the ability now to see that and to call you up and say I just see that your cardiologist has prescribed a medication for you that is probably not going to be best based upon the other medications that you already have. So all of the sudden we have the ability to look across all of the places that you’re receiving care and see your list of medications and alert your doctor that you’ve got a new prescription. Or let’s say that you’ve gotten a lab test that indicates that your - and you have diabetes - that your A1C level has risen to be an over 9 or 10, something that puts you in a critical juncture for your healthcare and your primary care doctor gets an alert on that. So these are the kinds of things that can now be done with alerting, is that we can be watching for important health events that occur in a patient’s life and we can alert their doctor that there may be something dangerous that’s going on here for that patient, for their patient, so that the doctor can get in touch with the patient right away to try to help them avert what could be a catastrophe.
Kathy: Well Laura thank you very much, this was a great conversation, thanks for joining me.
Laura: Thank you very much, I appreciate it.
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Kathy: I hope you enjoyed my discussion with Laura.
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