Are we making progress when it comes to interoperability?
It may seem like a simple question, but in reality, it’s anything but, because, depending on who you ask, the answer can vary quite a bit. For example, patients and caregivers trying to access records might say the industry has made zero progress. On the other hand, those who have been working tirelessly to make interoperability a reality — who have seen firsthand the evolution of data exchange in healthcare, have a different perspective entirely.
As a 20-year veteran of health IT – and CEO of Sequoia Project – Mariann Yeager falls into the latter category. In fact, she’s optimistic about the future, and it’s because of the progress she has seen since the organization was launched in 2012. Recently, healthsystemCIO.com spoke with Yeager about how Sequoia Project acts as a “facilitator” among health systems, vendors, and government agencies; its key initiatives, including supporting disaster response efforts and interoperability testing; and what she believes are the most challenging and rewarding aspects of her role.
- Soliciting input – “We’re really sensitive to making sure we get feedback from clinicians & patients.”
- Ability to test & verify vendor systems “almost out of the box.”
- Her “incredible journey” as Sequoia’s first CEO
- The “human-facing side” of health IT: “A record is a life.”
- Interoperability w/ health system M&A
- “Getting the rest of the community connected is still a challenge.”
- Optimism for the future
- “If there’s a detour, we go around it.”
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Nothing is more of a proof point of interoperability than making sure a real-world system that’s being used in practice is actually meeting those requirements in a consistent and standardized way. That’s where we come in.
eHealth Exchange and Carequality are operating under their own corporate structures, and we’re broadening our focus. It was very fortuitous to have that type of foresight, but I don’t think we ever envisioned it would grow to this degree.
It’s realizing the human-facing side of this. We work on so many wonky technical policy issues. And maybe interoperability isn’t ubiquitous, but a record is a life. Ten records are 10 lives. A hundred records are 100 lives. That matters deeply to us.
I’ll know were starting to find success when providers start complaining about the data, because that means they’re starting to look at it and rely on it. We’ll know that we’re making progress when it’s actually used.
If there had not been any substantial progress for the last six years, I’d say maybe we’re going down the wrong path, but that’s not the case. We are seeing unprecedented growth and uptake of the connectivity that’s supported by health information networks.
Gamble: Are there specific formats for getting feedback from users?
Yeager: We plan to really facilitate this work in the most open and transparent way possible. We’ll have public calls so that individuals can provide feedback during the public comment sessions, and we’ll have informational webinars. When we seek input, it’s going to be on specific questions where we’re trying to get a sense of whether there’s commonality, or understand perspectives and the implications of a particular issue.
And of course, whatever draft works have come out, whether it’s a use case document, an implementation guide, or just a recommended implementation plan for new versions that are deployed around a particular specification, or as I mentioned, the consolidated CDA. We’ll put those documents out for input. And so we’re able to seek input through many means. Some of it will be done real-time through webinars, and some by submitting feedback online or through email.
Gamble: Can it be challenging to get input?
Yeager: Yes. There are challenges either way. If you get no input, that’s one challenge. And the other is if you get a lot of comments — how do we try to analyze those. But I think it’s going to be very doable because these are going to be very specific issues. We’re really sensitive to making sure we get feedback from clinician users and patients. For instance, we anticipate we’ll probably have to enlist input from specific groups if we don’t hear from them, just to make sure the work is calibrated to the real world and what’s going to really be beneficial.
Gamble: What about interoperability testing — how is that being done?
Yeager: We have a set of automated tools. We worked in partnership with NIST and IHE (Integrating the Healthcare Enterprise) to develop test utilities that have been used for years, more during development lifecycles. Since those tools are supported by the standards body and NIST, which is an expert in these activities, we were able to leverage that work and tailor it to the deep interoperability testing that is very much needed to mature the implementations and interfaces used for health information exchange.
Today, standards and accompanying specifications are great guides for developers of health IT systems, but there is room for interpretation. These tools represent the authoritative interpretation so that there’s consistency. And when a system is implemented in the real world, that’s when this testing comes into play, because you do it during the development lifecycle. But nothing is more of a proof point of interoperability than making sure a real-world system that’s being used in practice is actually meeting those requirements in a consistent and standardized way. That’s where we come in.
We have seen testing really mature in health IT systems and its implementations over the years. There was a time when we had to test every single connection to the health information network. Now, the testing is so rigorous that we’re able to test and verify that the vendor system itself is interoperable, almost out of the box. That negates the need for subsequent testing, and really gets us closer to the seamlessness we’re all striving for.
Gamble: Right. Now, for a little bit of background, you’ve been with Sequoia for about six years?
Yeager: Since its inception, yes.
Gamble: What made you interested in coming to the organization?
Yeager: Before the company was formed, I was doing contract work with ONC. I was working in that capacity to support the nationwide Health Information Network Initiative, which evolved into the eHealth Exchange as we know it today. At that time, the federal and private sector partners and ONC were very much focused on implementing its charge under HITECH, and this activity had predated it.
I had facilitated some discussions with private sector participants and federal partners, and they really felt there was a benefit in continuing to grow the network and the private sector, and it was very important to all that the company operate with the same will and level of integrity, transparency, and public good as the federal government. And so Sequoia was chartered to serve that role, and we realized when we were forming the company that there could be other things we might need to do over time.
When we chartered the Sequoia project, it was designed as a public-private organization, and the idea was that the eHealth Exchange would govern itself. We would provide support services, but we’d also have the ability to support other activities; six years later, we had formed Carequality.
Now, eHealth Exchange and Carequality are operating under their own corporate structures and we’re broadening our focus. It was very fortuitous to have that type of foresight, but I don’t think we ever envisioned it would grow to this degree. It was such an honor to have been appointed and hired to serve as the inaugural CEO of the company, and it’s just been an incredible journey since.
Gamble: Looking at your role, what have you found to be the most rewarding aspects of it?
Yeager: It’s incredibly humbling to see the real-world progress that’s been made. So much of the time, we focus on what’s not fixed yet. It’s rewarding to know we’re making health information available to better treat veterans as well as all patients. We’re starting to see that more in real life as we get other providers connected, particularly on the ambulatory side. It’s that sense of duty that this is helping people, including those who were impacted by the devastating fires in California.
We recently met with the program director for PULSE in California, who gave a talk about this at the ONC conference. She told a story about how she was in a shelter and the volunteers were trying to treat as many people as they could, but some people were so distraught that they couldn’t even really communicate, particularly one person. They asked him for his address, because they needed that information to search for this person’s records, but they couldn’t even voice it because their home had been destroyed. The entire town had been destroyed.
It’s realizing the human-facing side of this. We work on so many wonky technical policy issues. And maybe interoperability isn’t ubiquitous, but a record is a life. Ten records are 10 lives. A hundred records are 100 lives. That matters deeply to us, and that’s very fulfilling for me professionally and personally.
Gamble: On the flip side of that, what have you found to be some of the more difficult aspects of your role?
Yeager: There’s so much movement and change. To me, that means we have to be nimble, and that makes it exciting. I would say the biggest challenge historically has been getting momentum, but I think we finally have momentum. I think the first couple years for Sequoia Project were about trying to get enough momentum so that the interoperability was seen as a substantive, tangible progress. We’re finally seeing that, and so the next challenge is, how do we make those capabilities ubiquitous? It’s just going to take our continued focus, energy, and ability to bring stakeholders together to continue growing and expanding. That’ll be our uniform focus, until interoperability is just baked in and nobody’s talking about it anymore. It’s that constant desire to get to the next level. That’s what we’re focused on right now.
Gamble: Right. As a CIO-focused publication, a lot of the challenges we hear about involved mergers and acquisitions. There’s so much movement in that space. What are your thoughts on the challenges health systems face with interoperability, particularly as it relates to mergers and acquisitions?
Yeager: We’re seeing a lot of progress. Initially, the first adaptors were health systems, and so it’s usually migrating to what the authoritative system is using. I don’t know that it’s as big a challenge as it once was, unless one network is more or less mature than another.
The biggest challenge is getting the rest of the provider community connected so that they can exchange data with partners. Where Carequality steps in is getting ambulatory vendors on the same page in terms of how to get their systems interoperable, and we’re starting to see that. But most of the exchange that’s occurred over the past several years has been between and among health systems, HIEs and governmental agencies, and their affiliated practices. Getting the rest of the healthcare community connected is still a challenge, and I would wager a guess that they’re still not seeing the full benefit of that.
The other is there are a significant number of long-term post-acute care and skilled nursing facilities that aren’t fully digitized and they may not be able to share data with them at all. A large number of referrals are to long-term post-acute care rehab centers, and if they’re not digitized or connected to a health information network, there are going to be some inefficiencies. So we still have a ways to go.
I would guess there are challenges around the data they’re receiving. I always say, I’ll know were starting to find success when providers start complaining about the data, because that means they’re starting to look at it and rely on it. We’ll know that we’re making progress when it’s actually used.
That’s another big area is we’ve got to get the data better, in terms of data quality and completeness. That’s why we’ve spent a lot of our energy around testing — to get the systems matured to improve the quality of the data so that it’s valuable to clinicians and users.
Gamble: Right. Looking at the landscape, are you optimistic about where things are headed? It sounds like you’re optimistic, but also aware that there are roadblocks.
Yeager: I don’t look at them as roadblocks. If there are roadblocks, we’ll find a detour. That’s just the name of the game. We have to be tireless in our pursuit of making this work in the real world, and I’m eternally optimistic, because we are seeing progress. Now, if there had not been any substantial progress for the last six years, I’d say maybe we’re going down the wrong path, but that’s not the case. We are seeing unprecedented growth and uptake of the connectivity that’s supported by health information networks, and now across networks of Carequality, and we’re starting to see other uses of this connectivity to serve disaster response. To me, that’s galvanizing. There’s so much within our reach, and so if there’s a hurdle, we jump it. If there’s a roadblock, we go around it. That’s just the way it’s got to work.
Gamble: Right. And I would imagine that when looking back at the past six years, it’s been encouraging to see the progress that has been made.
Gamble: Okay, well that definitely covers what I wanted to discuss. Thank you so much for your time. I really appreciate it, and I think this has been really interesting.
Yeager: Thank you so much for your interest, and please don’t hesitate to reach out.
Gamble: Great. I look forward to catching up with you down the road.