Contributors

June 28: Today on TownHall Brett Oliver, CMIO at Baptist Health, has an intriguing conversation with Steven Lane, Practicing Primary Care Physician & Clinical Informaticist of Sutter Health concerning interoperability and his journey into the world of informatics and what started him on that path. How does he see TEFCA and Carequality working together in the future? What does he see as ways to solve data duplication and corrections to errors? How did his introduction to a world of informatics create a hunger for becoming a better physician? Finally, what we all want to know, what is his funny story about decorating his first office?

Transcript

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Today on This Week Health.

Our current methodology of interoperability, it's all about sending copies of data around. What I look forward to is a future state where the data just stays where it is. And instead of bringing the data in to whatever user and trying to make a copy and then work with it, that you bring the algorithm to the data.

Welcome to This Week Health Community. This is TownHall a show hosted by leaders on the front lines with interviews of people making things happen in healthcare with technology. My name is Bill Russell, the creator of This Week Health, a set of channels designed to amplify great thinking to propel healthcare forward. We want to thank our show sponsors Olive, Rubrik, Trellix, Medigate and F5 in partnership with Sirius Healthcare for investing in our mission to develop the next generation of health leaders. Now 📍 onto our show.

Well, welcome back again. I'm Brett Oliver, CMIO for Baptist south, and I'm pleased to have my friend and colleague today with me. Steven Layton. Steven is a family physician. Informaticists at Sutter health and I wanna make sure I get this right, Steven. He serves on the clinical informatics director for privacy information, security and interoperability, where I met Steven is on the federal high tech committee.

He has co-chaired its interoperability standards group and steering committee for the chair for care quality as well. Steve, you've got a laundry list of involvement in the interoperability world that would be the envy of any anybody's career. But I'm curious, number one, I wanna welcome you to the program, but I'm curious too. How did you get involved in all this? I've never asked you that.

Well, thank you, Brad. And it's really a pleasure to be here and to join you in this conversation. So I, as you can tell by my garb, I am indeed a practicing, a primary care doctor just had clinic this morning. And I really got into informatics because I wanted to be a better doctor.

Back when I was a resident many moons ago it became quickly clear to me that, we kind of needed all the help we could get. And when I became an academic faculty member I was at a big university hospital, UCSF in San Francisco. And I was attending on the wards in medicine and pediatrics.

I was delivering babies. I was doing all this stuff. And as a family doc, I, I really felt like it was hard to keep up with all of these. More focused specialists. But I, knew it was all there in the textbooks. We had all the information, I just needed it to come to me in real time at the point of care so that I could do the best thing I could for my patients.

So that's really what got me interested and it started me down a wonderful journey. You know, I was not intending to become an informaticist. There was no such thing as informatics back then. And I wasn't really much of a geek. I mean, I was sort of an early adopter of technology, beyond that, I trained in cognitive science, in undergrad and studied public health and did a lot of neuroscience, but wasn't planning on doing technology stuff at all.

. So, this is way back in the:

And they were very enthusiastic. And then I ended up leaving academia after a few years and coming to my current practice, 30 years ago here at Sutter health. And it was interesting cause I walked in the door and they said,what Color carpet. Do you want in your office and what, how do you want the furniture arranged?

And I said, none of that matters. I just need computer on my desktop. And they said, well, what would a doctor do with a computer? No way. Yeah. So that was like my welcome to my practice 30 years ago, what would a doctor do with a computer? So obviously a lot has changed since then. We quickly helped our organization figure out that doctors had a lot to do with computers.

We implemented the first electronic medical record in the ambulatory setting in California. I think it was like the third epic install in the country. And we managed to put up the first patient portal, the first MyChart instance now 21 years ago. And My first EMR use was actually when I was moonlighting in the emergency department at a Kaiser, in San Francisco.

And that was ages ago, and they had a homegrown Mac based system and it just made so much sense to me, that you'd write your notes in a computer where you could actually go back and find them, and you could actually analyze them and read them. Right, exactly. So, I got very involved in the electronic medical record, as we called it back then we didn't think.

As broadly as the electronic health record. And in fact, my Twitter handle is EMR doc one, because I was one of the first docs to use in EMR as we called them then, and then, you know, after, 15, 20 years of. Implementing and optimizing and rolling out and integrating electronic health records.

I got involved, in interoperability and that was, really the Dawn of interoperability when we were just starting to be able to share data between systems and got involved in that locally, trying to share data between my. Practice in Stanford hospital, which is literally right across the street.

That's where we used to admit all of our patients. And then got involved regionally as more and more folks were standing up EMRs and we could start to see what the value of that would be. And then at a statewide level. And then like you, I got myself appointed onto the health it advisory committee at the federal level, and I'd done a number of other.

Things along the way nationally, there was this thing called the certification commission for health. It, the CC H I T that I was involved in probably 15 plus, maybe 20 years ago now. And so I've really enjoyed over the years, being able to both be an end user, in my practice day to day using the tools and then also.

Working regionally and nationally to try to improve the situation. I think interoperability, when that started to become an opportunity for us, it was very exciting to me because in my practice, we don't have a hospital. Connected to my practice. So all of my patients go to other hospitals, be it Stanford or others in the surrounding area.

So interoperability is critical in terms of those transitions of care. But I also practice in a vibrant urban area I'm right in Silicon valley, where my patients come and go and they travel and they're very international. So there's a real need to be able to access. And utilize data from all sorts of different sources.

So interoperability really made sense to me as a focus area on top of the earlier work, just getting EMRs implemented in the first place. And now, as you and I both know, the opportunities are huge. I mean, we've moved into this era of big data and analytics and machine learning and all of the different sources of digital.

Data the there's so much more work to do. And I think, those who come behind us in the informatic space are gonna have lots of wonderful problems to solve. But for right now, I I'm happy trying to improve the access exchange and use of health data. My motto is get the right data in front of the right person at the right time and the right format and with the right supporting workflows.

And if we can do. We're gonna have a major positive impact on health.

I agree. Agree. Well said, well said we'll jump in kind of right into that interoperability piece. ONC has stated, I believe it's part of the cures act. A number of times that I've heard publicly, that TECA the trust exchange framework is to work in concert with privately the private sector, things that are already stood up using sort of care, quality. Cause I know you're familiar obviously with that organization and that structure. As an example, practically speaking, how do you see these two working together?

Moving forward? Are they each filling certain roles? Do you see them significant overlap? And then from a provider's perspective, what's the average non informaticists think about, well, am I supposed to connect here or there? Or how do I get the information that I need?

Well, that's a whole bundle of questions wrapped into one.

So let me go back and UN unwrap that, that present a little bit. So what is care, quality, first of all the idea, if we go back rewind to the beginning of interoperability, right? What we had was direct connections. Between organizations that wanted to exchange data, and those many of those took the form of just V2 interfaces.

HHL seven, the basic data exchange. And then we started leveraging the CCDA, the consolidated clinical document architecture and the exchange of documents. And we started to develop networks that, that allowed those documents to be exchanged between stakeholders. So most of those networks started out as.

Networks of opportunity. You either had people who were, trying to do a particular thing, like deal with pharmacy information or people who were using the same vendor, like the epic community or folks who needed to exchange amongst and with the federal partners, the VA DODs, the eHealth exchange.

So we saw grow up a number of these networks, the Commonwealth network that a lot of people are familiar with that Cerner started. Help facilitate their exchange with other vendors. So there was quite a number of years. We had all these networks, but there wasn't exchange between the networks.

It was kind of like back in the days when you had a cell phone and you could call other people who had the same cell phone vendor, but but you couldn't call other people or the banking, the ATM, where you had to go to an ATM that had the right logo on it , or your card wasn't gonna work.

So the idea. Of care quality was to create a framework much as the banking and the telecom industries did that would allow these networks to interoperate between them. So it's sort of a higher level interoperability and care quality was the first to, to that game. And it was a a. Private, it came out of private industry with the support of the feds.

But then when 21st century cures came along they, what it said in the law was that the ONC would either, identify and support or create. Framework to do this work. So the ONC had a critical choice to, to make, which was, are we going to sort of look to care quality as the established, evolving interoperability framework that allows networks to connect to one another, or were they gonna do something new?

And what they decided to do for better, for worse is to do something. So that's what Teka is. So Teka is basically meant to do what care quality is already doing, but with a heavy involvement of the feds to make sure that it's doing that in a way that. Satisfies, all of the identified needs.

So it's interesting. So as you're saying, there's now these two parallel processes, right? There's the private sector initiative, which was care, quality and it's blasting along, I mean, we're seeing increasing exchange. We're seeing increasing use cases. It's doing all the things that you would want to happen.

But we now also have TECA coming up, which is gonna do pretty much all the same things and perhaps more I mean it given the approach that we've been able to take to TECA, with, the various published versions and the public feedback, and then the iterations it it's clearly coming out a little different.

But now as you say, we're trying to figure out, well, how are these gonna coexist and for how. And how will a stakeholder, you mentioned providers, but I mean, any stakeholder payers, public health, et cetera, how do we figure out where the data's gonna go? And I think it's, frankly, it's gonna be a little awkward at first.

I think we're still trying to figure that out. And we're literally, in active dialogue between, care, quality and the Sequoia project. Thing as the RCE, the recognized coordinating entity, and then those same organizations are also acting to support the existing framework.

So, kind of trying to figure out how do you keep all the wheels moving in the right direction as we sort this out , as you well know, TECA participation is initially meant to be voluntary. So there has to be a reason for people to go there. And we're talking about people we're talking about sort of the end users, the connections, but also the QHINs, the, the folks who are gonna be QINs are already networks.

They're already connected to the existing framework. So how are they going to manage their traffic, and and it's tricky, there's a lot of. Subtle business decisions that need to be made because there's some cost involved in participation in either one of the frameworks, the costs to be involved in TECA are actually gonna probably be substantially higher than the costs to be involved in care quality because of some of the requirements that have been introduced along the way.

So, we're gonna see , the idea is that there are going to be QINs identified this year that they're gonna soon be opening the application process. There'll be an analysis that'll be done. And there are clearly a number of organizations who are very enthusiastic about being named, either the first or one of the first class of QINs.

So that's gonna take a little time, but, theoretically, if all goes, well, there will actually be QINs onboarded. This year, I, it seems pretty hopeful to me. Yeah. Given how things move. But I would say within the next year I'm pretty confident that there will be at least two QINs up and running and we'll have the opportunity to exchange data.

And there'll be folks who are already exchanging data via the care quality framework. So, what data, what stakeholders, what use cases are gonna move over is gonna be interesting. I mean, certainly one of the things we've learned in care quality. Is that we've stood up a lot of implementation guides and use cases.

And the private industry has not necessarily made a lot of use of those, we've got, patient queries, for example, clearly individual access services under TECA has been highlighted as a very important use case, but we don't have much. Use of that within care equality in part, because I think many of the participants already have, EHRs that have patient portals.

A lot of the, need for patient access to data is being satisfied today by other technology. But I think, I agree that, you sh you should be able to support patient access, and there's clearly a lot of patient data access needs that are not being well met by the current, community or.

Combination of services that are out there. So I think that's gonna be great, but that's a great example of something that we've, made available via care quality. There hasn't been a lot of uptake. TECA is very enthusiastic about it. So that would be a great thing for TECA to sort of pick up and run with.

And then there's the whole question of, how are we making this transition from clinical document architecture, CCDA exchange to. Based exchange clearly lots of incentives towards the use of fire for various, stakeholders, various use cases. Can we see some of that move more quickly on the TECA front or on the care quality front?

I mean, I don't think it's really clear, at this point, TECA is starting with CDA based exchange. But they have a roadmap to move towards fire and the care quality side we're about to come up, I think with our second version of the, fire implementation guide. So that could move, more quickly.

And of course, there's. There are a number of care, quality implementers who have really done a lot of work to support fire based exchange, especially the new CMS requirements of payers to make data available for query using fire based APIs. So it's a fascinating. World that we live in. There are a lot of really smart people.

There's a lot of investment that's been made to bring product to market. But then sort of how does, how does it fit into the framework as you say? I mean, I think if TECA is successful, I think it will be because at some point it's gonna go from voluntary to required. And I would predict that that's gonna be a move by CDC and or CMS to basically say, look, We've gone to all this trouble to stand up this TECA, we've got all this exchange that we need to do, be it quality measures and CMS, be it public health reporting, et cetera, so it seems like one of the feds or multiple fed, partners are going to say, look, just use TECA for this. And at first it'll be an option and then it'll be an incentivized option. And then eventually it'll be the requirement. But you and I both know that that, that could take years that transition.

So, what's gonna happen. Between now and then between the time that TECA is entirely voluntary to the time that it really is required. I think CMS and CDC both have great levers to pull. We all have to do reporting to CMS. We all have to interchange with them. It just makes sense to me that they would move in that direction, but we first we have to get Teka up and running and successful.

And get, a year or two of experience under its belt. I think before we can really say, we see the path forward with this.

Yeah. That makes a lot of sense. It's a bit of the build the plane while we're flying as we're with interoperability.

Mm-hmm

I wanted to shift gears a little bit in.

Still talking about interoperability, but with interoperability as you, and I see in the office, this increasing amount of data that's exchanged, some of it's incredibly helpful. Some of it's not some of it's duplicative it's of low value at least. To us as end users. And that's all I can, speak to.

Do you think technology might be the answer here or is it a from the standpoint of, for instance, maybe epic says, Hey, as an organization, you can deem these diagnoses as low value and we'll automatically delete those coming in, or is it a workflow issue? You know, What I see oftentimes is a busy clinician.

Doesn't have time that, and there's 10 outside problems, 10 outside medications that need to be reconciled. What happens? It either they're too busy, they ignore it and just builds up or accept all or delete all, there's not a careful curation. I mean, just to be transparent, there's not a careful curation oftentimes of that.

So that leads to what a bad problem list, a bad med list. That's not, and it sort of compounds itself. So while I definitely wholeheartedly agree with the importance of exchanging information, I'm wondering. Some of this hasn't been thought through yet. And I'm wondering what maybe what other things you see out there that are like that potentially happening, but do you think that technology has a role there, or is this a, we've gotta get some of the burden off the end user so they can look at these lists and take care of them are more appropriate.

Yeah. I mean, I really think it's both and you've really, hit the nail on the head. I remember the first time I, I put together a slide for a presentation that said drowning in data in the Whirlpool and the doctor in the middle with all this junk coming at them. And it's still kind of like that, as you say, I mean, we spent so many years.

Building the connections starting to get the data to flow, automating those processes. And now it's happening. But as you say, the catchers MIT has just gotten bigger and bigger. And the tools have not kept up. There to me, there's a number of obvious solutions that we need. To do one is we need to put the patient at the center.

We need to make sure that the patient can see their data and that they have the opportunity to curate their own list. Whether it be the problem list, the medication list, the allergy list, the care team list, the medical history, what you and I do in the office. Interviewing a patient and teasing all of this out over the course of, 30 to 60 minutes, the patient can do at home, at least some patients, right?

I mean, infants can't and people with dementia can't, but a lot of people, really certainly at what I've learned over 30 years in this practice is people care, people care about you having their story straight. So I think, engaging the patient in that process is key.

The other of course, Better tools, as you say, to do de-duplication to identify things that are either identical or nearly identical. And I think that they're the tool set that we're gonna need to draw on is really machine learning. I think that whether it's at the level of the individual clinician, sort of, how do I do that?

ey had a cholecystectomy, in.:

Of how much work it is. And, we all go into this work because we sort of have O C D and we care, and we believe in this. And especially those of us in informatics really believe in the value of accurate, complete data. Right. But, there's a huge cost as we were discussing earlier. I mean, I'm up till midnight every night, making sure my patient starts are accurate and complete.

And when I get a. A transition of care message. I actually look at it and I see what their diagnoses were and what their dates of admission were and what their discharge meds were. And that takes a huge amount of time. And it's really, I mean, even when you've got care teams and advanced practice nurses and people, it's just, it's really hard to do well.

So I think we need to figure out how to do that better. And, you mentioned epic, the large EHR vendor. I don't think that the large HR vendors can do this. I think that these are very specialized services that all of us are gonna need as patients, as providers, as healthcare organizations.

And I think that as we finally get there with fire and with interoperability I think. It, we're gonna see the development of these services as standalone. We're gonna do this really well. We're gonna do med rec or we're gonna do, whatever it is, keep track of the immunizations.

So that it's not on the backs of somebody who went to X number of years of medical school to do that kind of really clerical work, to sort that out. So I think some combination of IML, Built on broad access to information. Being able to sort of say, this is what you've got, this is what we found out in the universe.

This is what it looks like. The combination of those should be. What do you think? Yes, that looks good to me. Right. I can modify it as needed cuz you have to keep the patient safety question in your, you know, sometimes there's bad data out there. Right. So there still needs to be, I think for the most part, some human intervention, but if you have.

Machine learning, working in the background, it can see, it can learn what it is that you do again, as an individual or as a group and do that better and better. And then as I said, patient empowerment, let the patient see what all this is that said, and then they can catch errors too. Patients say, no, no, I didn't.

You know, It wasn't my. Left breast that was removed. It was my right breast. And, we all know about the challenges of inaccuracies that get into the record that then getting promulgated. So I think, it's gonna get better, is it gonna be on the backs of humans?

Yes. For a while. Is it gonna be technology that needs to be developed? Yes. Absolutely.

Let me just follow up that last piece, just for the final question, with some of the data not being good or being accurate or changes. I get a CBC on you and guess what? It turns out a week later there was something wrong with the machine.

It gets recalibrated and an updated CBC result happens. Well, maybe it's clinically important. Maybe it's not. What is my obligation for anyone that's accessed that data downstream, how do we prevent those errors from being propagated? That's a, that's one that I've seen in reality that really didn't have any clinical impact because it was, your MCV was off by, 0.2 and it didn't didn't change your outcome.

Right. But you know, some of it does, if it's a, a seizure medication that's listed on, in affect your insurability and things like that. And I see STR from the inside of the EHR companies, I see them struggle with this, just in terms of what's the process. Do you feel like organizations have those processes in place right now?

Does technology play a

role in that?

In any thoughts just to. Finish this up on the data quality piece that you mentioned, because I do think that that's obviously critical if you're gonna be exchanging.

Yeah. Well, I mean, we could talk data quality for days, but I think the specific issue of corrections to errors is really important.

And it's one that we don't have solved by a long shot. Often, users of, of the technology will see an error and may or may. not Take the time or have the means to, to report it or correct it. Right. Right. Exactly. So I think realistically more often than not, I mean, we see errors if you will, in problem lists and med lists, but I mean, mostly those are more tweaks.

I mean, it's rare to see something that's truly, wrong. It's more that it's been modified. It's been changed. It's been discontinued. Et cetera. So we fix those kinds of errors all the time, but some of those more subtle errors. I think it's really the patient who is in the best position to identify those.

And there's not a, yet a standardized way to deal with that. And I've heard from many patients and patient advocates about the frustration that they feel, where something will have been entered erroneously in one place. And now with interoperability that, as we said, that gets propagated across an expanse of users.

There is. Work being done on a fire based technology for patients to be able to at least request corrections. It wouldn't actually make the corrections, but it's a request. And this came up through our interoperability standards work group, and we're actually going to be making a specific recommendation next week, to the high tech and onto ONC for.

That particular use case to be supported and tracked in the interoperability standards advisory, and eventually, in the USCDI, if that were appropriate, but it's, really not a USCDI issue, but, it really is. It's a workflow issue and as you say, it can be very.

Complicated. Right. So it's not just the going to the source of the information, but who else has seen that information? Who else has had that information transmitted to them? What are the processes for chasing that down and trying to repair an error, in all of the relevant places where that data exists and that really gets you back to provenance, I mean, how are we going to.

Technologically keep track of the provenance of data. And I'm gonna turn this to another area that I'm really interested in, which is our current methodology of interoperability. It's all about sending copies of data around, and it's all about having a copy of the data, wherever it is that you're gonna apply your.

Your tools, whether it's your human thought, whether it's your algorithm, whatever it is, your decision support, it's all about looking at the data that I have in my system, which is, variably accurate, variably, complete variably up to date, right? Depending on all of this connectivity and, whatnot.

What I look forward to is a future state where the data just stays where it is. And instead of bringing the data in to whatever user and trying to make a copy and then work with it, that you bring the, as I say, bring the algorithm to the data, leave the data at the source, whether it's the laboratory, whether it's the clinician, whether it's the imaging, center whether it's the patient themselves, the payer, et cetera, and as much as possible stop making copies, stop trying to create this mythical longitudinal record.

That is going to, we're all gonna be the holy grail here. And all of the privacy and security problems that come up when we're shipping data around and the storage. Challenges that, that come up when, when I have to keep my DICOM image or my, or my genetic file, in multiple systems, it it's crazy.

Right. I mean, leave it where it is and then let's figure out a way. Using all this great interoperability to find this, the data that's needed in a, for a given decision instantaneously, do your processing, make your decision document, whatever you're gonna do, and then move on. And to me, Where we're getting with web three technologies with crypto, with blockchain.

Those are the tools that are gonna allow us to get there that are gonna allow us to get from where we are, which is incredible. Right. We put in EMRs, we put in interoperability, we can move, billions of, Documents and, and data bits around the system, but it's not really scalable.

I mean, when you think about all of that health data, when you think about wearable data, when you think about genomics proteomics, microbiomics you think about patient generated data and you think about all of the healthcare peripheral data, Patients activity, data, shopping data. I mean, sleep data.

I mean, it goes on and on. And if we're really going to be able to impact health, as we want to, right. We know the huge impact of social determinants of health. We know the huge impact of lifestyle. And, and all the climate don't even get me started. Right. I mean, you so, so there's so many types of data that we'll need to integrate and we're not gonna do it by downloading it all into our local EHR and expecting our EHR vendor to, to do through it and give us meaningful decision support.

So I think, this shifting paradigm. Leaving the data where it is and bringing it together to process in real time I think is going to be a huge change. And then as I said before, the idea that we can't expect any vendor, even a large international multi-billion dollar EHR vendor to be able to do everything.

So you're, we're gonna need to really see. A thousand flowers bloom across an app ecosystem where you've got, folks who are focused and able to deliver, reliable tools for, the specific needs, whether you're a subspecialty clinician, whether you're a social worker, whether you're an acupuncturist.

I mean, truly, there's so many people who need to interact with our health data and none of them really needs all of it. Right. That's just not except for the AI, the AI needs all of it.

that's right. That's right. Very well said. It's an exciting sort of feature that you paint. I think that makes so much more sense than continuing to push around copies.

And as we mentioned before, with the data quality worrying about where that copy ends up. Keep it here. If it gets adjusted, then you're gonna get the most up to date information when you query it. How we get there, I'll leave to the smarter people, but Hey, listen, Steven, it's been a pleasure. It's awesome.

Talking with you. I, I thank you for all the work you do for your patience, that the work that you've done, both state and nationally on interoperability and trying to improve things for patients, providers, everybody in our healthcare ecosystem, we'll have to have you back, cuz we're just feel like we're just getting, started here. So

there's lots to talk about. It's great to see you, Brett. Thanks a lot.

Thanks so much. All right. Take care.

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