3 Use Cases for Health Data Interoperability in Patient-Centered Care

Advance Care Planning Interoperability

Adoption of Health Level 7 International (HL7) data standards could help move healthcare away from a world of primarily paper-based advance directives to support advance care planning interoperability, according to Maria Moen, senior vice president of innovation and external affairs at ADVault Inc.

Advance directive documents outline decisions a patient and her loved ones may make at the end of her life. These documents include living wills, healthcare power of attorney forms, and pre-hospital medical care directives, often referred to as Do Not Resuscitate orders (DNRs).

Provider access to accurate, up-to-date advance directive documents is critical in ensuring they meet patients' end-of-life care wishes. However, these documents can sometimes get lost in translation due to industry data silos, leaving providers without crucial information to guide clinical decision-making.

That's because these directives aren't easily stored in the EHR, so it's hard for providers to access them.

Moen noted that paper-based advance directive forms lead to numerous barriers, burdens, and adverse patient outcomes during care transitions, as providers may not have immediate access to patients' end-of-life wishes at the bedside.

"Urgent treatment decisions are made at times, making immediate access to advance directives and advance care plan information essential to providing personalized, high-value care in the aging population," Moen said in an interview with EHRIntelligence.

Moen has been a member of the HL7 patient empowerment workgroup since 2019 and serves as the HL7 project lead for the Advance Directive Interoperability with FHIR project (ADI with FHIR), which began in the fall of 2020.

The ADI with FHIR project focuses on creating implementation guides for the exchange of advance care plan information through standards-based application programming interfaces (APIs).

"Our project began with the creation, exchange, and verification of information authored by a patient," Moen said. "We are moving into practitioner-authored data now to include portable medical orders for life-sustaining treatment and patient instructions such as DNR orders related to a procedure."

The project focused on converting existing documents stored in clinical systems into a standardized format, as well as new documents written by an individual or a provider, Moen explained.

"Then, we focused on sharing that information outside the originating organization, whether with family and friends or with other providers during the transition of care," she said. "We also paid specific attention to the verification of who created, authenticated, and signed the document."

Moen said that the HL7 community completed an environmental scan to derive a comprehensive library of advance directives and personal advance care plan documents. Standardized vocabulary codes existed for some documents, while the workgroup needed to create codes to support data exchange in other instances.

Moen said that health IT systems must have a patient-directed process so that individuals can communicate information about their advance care goals to inform provider-generated care plans.

"Interoperable exchange of advance directive information enables practitioners to create person-centered treatment plans that align with the patient's values and their quality-of-life priorities," Moen said.

Dentist Participation in Health Information Exchange (HIE)

A partnership between Colorado Dental Association (CDA) and CORHIO (a Contexture organization) will explore how data sharing between dentists and healthcare providers could advance patient-centered care delivery.

Greg Hill, executive director and CEO of CDA, noted that historically, dentistry has been entirely separate from primary care, similar to optometry. 

"Dentistry has got to be brought into that system," Hill said. "The mouth is a large portal into the body and a way in which disease gets into the body. It's been a relatively recent realization that the two systems are much more integrated and need to be thought of in a coalesced environment, so the policies and payments and things like that are catching up to that realization."

Due to a lack of data sharing between healthcare and dental providers, it is often up to patients to share personal health information with their dentist.

However, Hill noted that patients may not always remember, or even know, to tell their dental providers details about their health, which can lead to significant patient safety risks. Patients may not know the significance of certain conditions they have, or they may not understand the impact of the medications they are on.

Morgan Honea, CEO of CORHIO, the value of interoperability between healthcare and dental settings revealed itself during his earlier career running federally qualified health centers (FQHCs).

"I've spent most of my career integrating primary, oral, and behavioral healthcare in a service delivery setting," Honea told EHRIntelligence in an interview. "There are so many medical conditions that impact oral health and vice versa that creating better interoperability and insight into a whole patient's health is critical."

For example, Honea said an elderly patient came into an FQHC for a tooth extraction one day. Once the procedure began, the patient started having severe blood loss because the staff did not know he was on blood thinners. The patient had to be transported from the clinic to the Denver metro area to get the bleeding under control.

"That's where HIE is a perfect use case for connecting oral health and medical health," Honea said.
"Quite frankly, a lot of times, if you have to rely on just the patient to identify those important risk factors, you may not get everything you need, which can lead to some really unfortunate outcomes."

Hill pointed out that it doesn't have to be an extreme example for health information exchange to be of value. For instance, dentists should be aware of conditions that impact gum disease and healing, such as diabetes.  

Transitions of Care Interoperability

Health IT stakeholders are also working to advance interoperability between primary care providers (PCPs) and specialists.

Just as a circle has 360 degrees, Holly Miller, MD, MBA, FHIMSS, chief medical officer of MedAllies, says data exchange needs to be a closed-loop process to enable care coordination.

That's what she's trying to accomplish with 360X, an ONC-backed effort looking to build data standards to enable coordinated and streamlined care between PCPs and specialists.

"360X specifications were created because the process of patient transitions of care, both transfers and referrals, continue to be fraught with risk of adverse events for the patient," Miller, who is a part of the 360X work group, told EHRIntelligence in an interview.

For instance, when PCPs refer a patient to a specialty provider, they send along relevant health information to help the specialist manage the patient's needs. However, the PCP usually does not get information back from the specialist related to the patient, leaving the PCP to manually track their patient's treatment.

"Referrals can be difficult to track and require excessive manpower for providers and staff if they want to ensure that their patients receive their necessary care and don't fall through the cracks," Miller told EHRIntelligence in an interview. "Rather than manual tracking processes that may be missed or delayed, with 360X, every step is automated, so we always know what's going on with the patient."

The 360X process for a specialty referral begins with a PCP specifying the physician or the group whom they want the patient to see. That information is sent to the specialist along with the reason why the PCP is sending the patient, the urgency of the visit, and pertinent patient health data.  

The specialty staff will review the request and accept or decline the notification based on whether the provider can see the patient in the timeframe that the PCP requested.

Miller noted that 360X specifications leverage FHIR scheduling, so that scheduling can be done immediately and the patient can leave the office with a specialist appointment. This limits the clinician burden of having to manually call the specialist office to set up an appointment.

Then, ideally the patient would present at the specialist appointment. This is what Miller referred to as "the happy path."

"Clinical medicine is a push. When I'm sending a patient to another clinician, I want to send the information that I think is important for my colleague to be able to next manage the patient," Miller said.

However, Miller noted that being able to pull data from sources is equally important.

"Say that the specialist doesn't have every piece of information they felt they need," she explained. "For example, the PCP may not have known the patient had a given test of interest to the specialist, the specialist may be able to pull that from somewhere else."

This allows providers to streamline care coordination for more efficient care delivery.

"If a provider has recently done tests on the patient, there's no need to redo the test, so you're also reducing cost," she said. "Most importantly, the patient doesn't have to go through the inconvenience or discomfort of another test."

As healthcare organizations look to advance value-based care delivery, ensuring health data interoperability will be paramount for patient-centered care.