Using EHRs for Type 2 Diabetes Prevention and Management

good afternoon everyone and thank you for joining today's webinar the purpose of today's webinar is to provide an overview of how EHRs and supporting tools and systems are currently being used for type 2 diabetes prevention from raising awareness and education referral to lifestyle change programs to maintenance we will also provide an overview of current EHR challenges new and emerging technologies that may overcome these challenges and other EHR opportunities to prevent type 2 diabetes I will now turn it over to Robin solare senior behavioural scientist with CDC's division of diabetes translation to begin today's presentation thank you very much for joining us today this is the first in a three-part webinar series the series stems from work we've been doing with the Y USA American Medical Association CDC's chronic disease Center office for informatics and information resource management and an internal team of scientists Public Health analysts and contractors today I'll be joined by Sarah Murphy Sarah Murphy is a senior consultant with Deloitte Consulting federal strategy and analytics practice over the past few months a team of CDC scientists and public health analysts have been working closely with Sarah and her team to conduct a broad landscape analysis and literature review around the role of EHRs as they relate to diabetes prevention control highlighting key trends and issues related to the use of EHRs and chronic disease across the u.s. health system in addition as I noted earlier we've been working with y USA in the American Medical Association we'll be combining information from these three projects to inform this webinar that we're sharing with you today so today's webinar is an introduction for lifestyle change program providers using electronic health records for national diabetes prevention program referral and feedback today we're going to cover electronic health records just going through basic primer to make sure they were all in the same kind of level with regard to terminology we'll talk about why EHRs are valuable tools for type 2 diabetes prevention we're going to talk a little bit about what we know about current EHR used for diabetes type 2 diabetes prevention based on some review of your work that we've done do a brief deep dive into referral strategies that's about bi-directionally referrals in a demonstration project that we have been working on with the why then go through some current challenges and emerging technologies for improving the function of the EHR platforms finally we're going to talk about some future opportunities that we've been working on and then turn to our Q&A session next Thursday we'll be joined by our colleagues from the Y USA who's been who we've been working with for the past two years on a bi-directional referral project they will share lessons learned from this project with a focus on bi-directional communication with healthcare partners the target audience is National diabetes prevention program providers but registration is open to all who are interested the Y during this presentation will make the case for working with healthcare providers we'll talk about why this is important and how we can work to enhance clinics and community linkages they'll provide additional information to describe the landscape they work in and focus a little bit on some of the terminology we talked about today in addition they're going to provide an understanding of the capacities and kind of the needs by way of drivers for environment people processes and technologies that programs may need and provide some tips suggestions so that national diabetes prevention program providers can assess their own capacity for implementing bi-directional IVA thorough process our third presentation in this series will be facilitated by our colleagues from the American Medical Association AMA is work closely with Hawaii USA in evaluating the healthcare system side of a bi-directional referral process there would have been our targets health care systems and health care providers but again it is also open to national diabetes prevention program providers your partners and others who are interested AMA will describe the key components of pre-diabetes identification and the DPP bi-directional referral referral processes they'll review different approaches and examples of utilizing technology technological solutions to facilitate the identification and referral process and discuss key barriers that health systems may encounter and key considerations were implementing solutions to facilitate bi-directional bee referrals to CPT great Thank You Robin so this is Sarah Murphy I wanted to we wanted to start out today's presentation with a little bit of a level setting conversation since everyone on the phone today undoubtedly has varying levels of knowledge and experience here we just wanted to start out by defining some key terminology that will be used throughout the presentation so the two phrases that you see here electronic health record and electronic medical record often used interchangeably but in fact do refer to two different concepts so while electronic medical records or EMRs are restricted to a patient's medical information only electronic health records or EHRs include all of the medical information found in EMR as well as other relevant supplemental information to create a more comprehensive picture of a patient's overall health and well-being so in other words the hrs focus on the total health of the patient going beyond the standard clinical data that might be collected in the healthcare providers office EHRs are designed to facilitate the sharing of information with other providers as well so that a patient's record can reflect information from all clinicians that are involved in their care so during this presentation we will be using the term EHR some other helps other EHR related terms that we wanted to make sure to define here are health information exchange or hie and clinical decision support or CDF both of these phrases can refer to either a concept or action or a specific system so first starting with health information exchange that encompasses two related concepts so as a verb the appropriate and confidential electronic exchange of clinical information among authorized organizations and if you're using hie as a noun it would refer to an organization with agreed-upon operational and business rules that provide services the electronic and secure sharing of health-related information the electronic exchange of clinical information allows doctors nurses pharmacists and other health care providers and patients to access and securely share vital medical information electronically and this improves the speed quality safety coordination and cost of patient care looking at clinical decision support clinical decision support system use information that is housed in a patient's EHR to trigger actionable events or actionable provider alerts rather such as reminders to provide certain screenings according to best practices guidelines or flags for medication interactions duplicate testing alerts etc so this next visual that we have here this data we wanted to display this to highlight just how widespread the use of EHR systems is today across the United States both among hospitals and among office based physicians so the data that we're looking at here comes from the health IT supplement of the American Hospital Association's annual survey which is taken by hospital administrators as well as the national electronic health record survey which represents individual office based physicians and so what we're seeing here is between 2008 and 2015 both hospitals and office based physicians have steadily increased their use of EHR system and in hospital settings especially the use of certified EHR technology has become nearly the nearly ubiquitous so the key takeaway here being that EHRs are now really an integral part of the patient journey and understanding how they work will be beneficial for both current and future work with healthcare stakeholders and then looking at this data visualization here these graphics break down the specific information exchange and information use behaviors that are reported by hospitals and office base positions here we just wanted to highlight that most hospitals are in fact exchanging patient information electronically with outside sources which you can see on the left hand map which makes EHRs again a viable tool for us to be focusing on today however they are much less likely to report integrating the patient information that they receive electronically from outside sources into the EHRs which is where additional work will still be required in here we just show the same graphic broken down for physicians offices overall less less likely to report exchanging and integrating information but there is you know they're more likely to exchange information than integrate so same as the same trend as seen with hospitals Thank You Sara when we discuss and investigate each EHRs we often focus on EHRs is a tool for information or data collection storage and exchange indeed we actually pull information from electronic health records to do some of our surveillance work however there are many reasons for focusing on EHRs as a service tool it is this function we are most interested in in our mission to prevent diabetes we believe EHRs are important tools because EHRs can be used by community-based providers not just healthcare providers and systems community-based providers can be system owners or they can work with EHR users to facilitate the diabetes prevention process EHRs are searchable allowing for rapid identification of people with certain characteristics or risk factors and we'll talk about this through our presentation today in addition EHRs can help reduce clinicians workload chill providers treatment and service options and help manage referrals doctors make well over a hundred million referrals a year EHRs can help organize options alert providers and referrals are appropriate and can in some cases receive information from the refer provider we'll talk more about this as well EHR as can streamline communication between health care providers and service programs and EHRs provide HIPAA compliant methods for communication of health information large portions of the u.s. population as Sara just showed us our health data actually are stored in EHRs and again this makes a more valuable solution EHRs can help address type two diabetes prevention the American Medical Association and others have worked with the HR vendors like epic to create modules with special algorithms program information and referral options embedded algorithms can increase identification at the people with the of people who are at risk or who have prediabetes prompt health care providers to screen or test for pre-diabetes plans health care providers to refer patients to lifestyle change programs they may help providers become more familiar with the national diabetes prevention program and because many providers are unaware of the program increase awareness of the national diabetes prevention program if they are included in an EHR as a referral source in addition if it's listed as an evidence-based research referral option providers may learn from the EHR and become more aware of the program's effectiveness finally EHRs can create learning opportunities from lifestyle change program feedback is available great so as Robin just touched on we know that EHRs are in fact being utilized at many various points throughout the patient journey in different ways and so we have the patient journey mapped out here different steps include awareness and education risk assessment and diagnosis referral program enrollment and maintenance and at each of those stages EHRs are used in different in various different ways so just going through each one for awareness and education EHRs and their associated patient portals can be used to help deliver educational materials and increase awareness and engagement for patients with pre-diabetes or diabetes looking at risk assessment and diagnosis EHRs can be used to alert providers about abnormal values during routine screenings and the comprehensive data and an EHR can also be used to help identify new or undiagnosed sites diabetics so thinking about the alerts for abnormal values more specifically providers might receive pop-up notifications when patient's blood pressure hba1c BMI etc fall outside of the normal range and this allows providers to more closely monitor and follow up with patients who have abnormal readings to potentially refer them to a community-based program in risk assessment and diagnosis there's also EHR phenotype in so EHRs are a rich source of data for the development of prediction and screening algorithms as as Robin said EHR data can help to identify population characteristics that are associated with a certain condition or clinical profile and these phenotype algorithms can be used to screen for potential undiagnosed type 2 diabetes or to identify non-traditional risk factors associated with the development of diabetes also within risk assessment and diagnosis we have again clinical decision support systems which we touched on a little bit earlier so comprehensive set of tools like alerts smart forms protocols all available to providers via the EHR interface and these systems can be used to identify patients at risk as well and to provide guidance to clinicians regarding which tests need to be ordered during an upcoming visit and can also send reminders to patients who miss a test there are also computerised disease registries for risk assessment and diagnosis computerize disease registries or CDRs are a list of patients with a certain disease or condition within a given region or health system and that EHR data is continually uploaded to the CDR allowing providers again to identify patients with certain conditions even if they aren't the ones who ordered the specific tests or made the diagnosis themselves looking at the referral stage of the patient journey electronic referrals or ehre firls you know Robin will touch on those a little bit more in more detail later but currently most patients are referred to Community Program via email or fax but referral systems can be built directly into the EHR and into a provider's workflow eliminating the need to manually fax or scan a referral form and if the community program can send progress notes back to the provider through the EHR then it becomes a bi-directional you for all so and then also within the referral within the referral stage EHRs can facilitate referral by having embedded or pre-populated forms available to the provider within the interface that will automate the clinical workflow steps involved in the referral process and finally just looking at or not finally the program enrollment phase EHRs can be used with third-party apps which can be integrated with the platform to help facilitate enrollment in the community program so apps like purple binder and healthified allow health workers to provide patients with a tailored list of community resources and programs in their area EHRs can also be used to automatically populate again referral forms to more easily refer patients to community in lifestyle change programs like the national DPP providers are able to automatically populate a referral forms within the EHR workflow workflow that can then be sent to the community program which can improve program enrollment since the provider is no longer burdened with having to manually print and complete the referral for in themselves and community programs that are run within the same health system as the referring provider can potentially facilitate an easier enrollment process referrals from physicians can be electronically sent to program coordinators using EHRs eliminating the need for program coordinators to rely on paper or phone based referrals and then that way the program coordinator is able to reach out to patients from the EHRs queue to register them for a program so finally in the maintenance stage EHRs can be used with patient portals to allow patients to view their own health information connect with their provider and keep track of appointments providers may also be able to utilize feedback received from patients via the portal to make continuous adjustments to their care plan and also in the maintenance phase the idea of patient generated health data health data generated or recorded by a patient and integrated into the EHR system can be used to remotely monitor patience progress throughout the course of their treatment or whatever program they may be involved in in this data can be generated via devices like smart smart watches or Fitbit or it could be manually entered through apps like food food log apps such as My Fitness Pal and having access to this enhanced data can then help clinicians manage complex conditions such as type 2 diabetes in real time and so here again we have those different phases and just wanted to you know outline a few case examples to illustrate these concepts a little bit more concretely for you so in the awareness and education category for example we have the Blackstone Valley Community Health Care which introduced a patient portal that provides patient-specific education resources the EHR also has an integrated patient education tool that allows clinicians to sort through a repository of information that can be printed out and shared with patients so moving forward BBC HD has plans to target diabetes patients who use the portable portal to provide educational materials and will connect the patients with the diet and educator and then the next example that you'll see for risk assessment and diagnosis is a university hospital that was able to eat more easily detect abnormal results identify trends and identify the need for retesting of various biomarkers and thus patients are able to receive better care due to heightened awareness on about abnormal values and clearer trends through the use of the dashboard that they develop for referrals we've highlighted an example from Denver Health who utilized their EHR system to create a registry for patients who are eligible for the National DPP based on a set of various criteria and the Denver Health staff were able to filter the registry to identify eligible patients in order to request referrals from providers and then once the patient was enrolled in Denver Health in-house national Dyson DPP program their providers can track their progress through the EHR system where lifestyle coaches update the patient's progress throughout the program in terms of referrals we found an example Montefiore health system has created an e referral system that allows physicians to electronically refer patients to their in-house DPP and program coordinators receive the referrals through the EHRs central work queue which you know again eliminates the need to rely on paper or fax referrals and then finally in the maintenance category we have an example from the Massachusetts Department of Public Health which piloted a bi-directional referral program allowing providers to refer patients to resources at the YMCA for participation in the National VPP elder services or the states tobacco quit line and these community programs could then send information and treatment progress back to referring providers so these visualizations here we wanted to illustrate the current use of EHR technology in terms of the work that you all have been doing recently as well this data was generated after reviewing and qualitatively coding the 1422 and 1305 work plans to highlight EHR related work in a few different categories that you see listed there so overall the preliminary results of this analysis show that there's an overall increase in the number of grantees conducting EHR related work across each of the three categories from year 3 to year 4 with a particularly notable increase in the work related to clinical decision support and we've also just selected a few examples of grantee work that falls into each of those qualitative categories the texture pulled from the grantee work plan in the clinical decision support category we have New York as an example who worked on developing a measure for identifying and flagging patients with potentially undiscovered diabetes in the digital technologies category we have Tennessee who is working to develop and initiate electronic scheduling reminders using the software eye to eye tracks and then with establishing EHRs we have California as an example who collaborated with various stakeholders to promote increased adoption of EHRs and help IT in their states Thank You Sara so what we're gonna do now is we're gonna focus on the use of EHRs to include referrals to the National diabetes prevention program with the intention of building up to a description of what we did with the Y us a very briefly and then talking a little bit about the challenges lessons learned that we did there and then hopefully launching you into an interest in the next two webinars that we'll have with the Y USA and the National diabetes prevention program so as you know the referral process on the health care provider side as many steps than the order of workflows in very at the patient care or system level this figure adopted from a report issued by the Institute for Healthcare Improvement it takes a nine step referral process however even this well-thought-out depiction misses critical steps to the work we are doing in diabetes prevention for example a referral may be ordered but in many cases may just be recommended and not recorded in a system in some cases it may not even be given to the individual patient in any case the patient has to decide whether or not to schedule their service payment must be considered a range negotiated or just made directly and the patient must participate in the service once the patient participates in the service the initiating provider may or may not receive information about the experience from the patient or the provider so although we may want to lay out a referral process and understand it in this simple way it's much more complex and all that has to be understood when we begin to think about setting up bi-directional systems in electronic health records the technology can facilitate this process s-sarah mentioned we have patient portals and this can enable patients to check their records with communications from physicians they may get reminders of specific referral information and they can provide feedback to the providers in addition patients can generate their own health data of sharing information with providers in that way and the bidirectionally referrals can help to close the loop what programs are able to send updates via the electronic health records platform back to the provider who initially referred to the patient the patient to the program through the EHR platform so this is a kind of a depiction that one might see when they're thinking about be referrals so we want to remind people that bi-directional referrals can refer without the uses can occur without the use of EHR systems health care providers and lifestyle change program providers can develop relationships and communicate regarding referral programs and patient participation and success in a program indeed understanding this workflow may be critical to the successful process however bi-directional ehre Ferol roughly described in this graphic incorporates many of the things we discussed at this point to this point station our patients are identified either through algorithms or the direct screening or testing by a provider within the EHR the provider identifies the lifestyle change program and sends the lifestyle change program or referral the lifestyle change program connects with the patients and in a perfect world the patient participates in the program the lifestyle change program then sends information back to the provider for discussion with the patient this may be simple information that the person who enrolled actually participated or maybe information about the progress of participation is making through the program it's a patient is successful this may also encourage the provider to refer others to the lifestyle change program serving as a mechanism to increase enrollment so in 2016 we launched a demonstration project with the Y USA to test this process out we've been working with the OTT Y under a cooperative agreement mechanism just prior to the start of this project so Y purchased a cena net a cloud-based EHR to help manage a number of its programs including the y USA diabetes prevention program eight local y US x YMCAs were selected to support this project and each of those Y teamed up with local healthcare providers or provider systems to develop a bi-directional referral process the primary project goal the initial goals of this project included identifying pathways for e referrals that reduce time and burden for health care providers identify pathways for sharing participant progress with health care providers and integrating participant outcomes into the patient's electronic health records the Y USA has multiple referral pathways and a participating healthcare providers also have different referral pathways that they can with these include things like remote call forwarding clinical letters letters and direct messaging the direct messaging pathway is what we consider a truth bi-directionally referral where no manual faxing or printing and faxing referral is needed it's solely digital however the issue with the REC messaging is that you cannot pick and choose what information you want to send currently you have to send an entire patient care summary oftentimes health care providers do not want to send all of this information but they believe it's not necessary it also makes sense due to privacy and HIPAA issues and physicians also don't want to receive an entire patient care summary back from the Y or from the community-based program where it lists every single instance of each lifestyle change session so we'll discuss how we're kind of addressing some of this later at this point in our project the complexities of the various participating systems and their workflows became very apparent and system capable capabilities created challenges that then that result in a one-size-fits-all solution so Sarah was kind of sharing with us in a perfect world what it would feel like if we were able to do bi-directional referral but actually as we develop delve deeper under the hood of the world of EHRs and interoperability challenges our project goal shifted from creating that one five size fits all solution so focusing on sharing lessons learned and helping other lifestyle change programs and healthcare systems and healthcare providers think about processes and capacity so Y accomplished a great deal during the last two years and many of the local wives were able to successfully establish a referral process with their health care providers however they are still working on getting feedback back to the providers we have learned a great deal about this project with the Y team which the Y team will share in greater detail during the September 13th webinar but in brief we learned that it's really important to understand the capabilities of the electronic health record system you're working with and how it may affect interoperability second you have to consider the level of engagement with the EHR provider HAF provide EHR provider is willing to provide different levels of technical assistance to its clients in order to develop assistance needed understanding referral and feedback pathways that a national diabetes prevention program provider any childcare system or provider is critical as well and we actually learned that doing this on paper and just thinking about the human processes is as important as thinking about electronic processes the project requires two touch points thinking about changes in the system and changes in the human processes and because of this leveraging relationships with the healthcare providers is key and the Y was extremely successful at doing this which I think helps move forward the project forward to where it is now having a fully automated system a workflow is not easy so in some cases the bi-directional process through this Y program involved human faxing so although it was a digital tool and the information came from an EHR went to an EHR there was actually a human fax process and between it required transfer and entry of information we're going to close this webinar out talking about some technical challenges in solution so we've gathered from the review of our health plans things that we've learned from working with the Y and issues that we've learned from the literature going to turn it over to Sarah to talk about those challenges great thanks Robin so yeah as Robin said there there are several known challenges when it comes to managing patient information in the clinical process with EHR technologies spanning across a few different areas that we have outlined here so you know in the tech know in the technological arena the broad range of EHR platforms features and capabilities coupled with a gap and data reporting standards creates major challenges and exchanging patient data so as Robin said interoperability is an ongoing issue and just to you know interoperability refers to the ability to exchange and integrate health information electronically without any additional special user effort so as Robin was saying you know the intermediate faxing stuff is something that would you know we wouldn't ideally want to have to be involved so that's an ongoing barrier systems often have difficulty talking to each other if you will in a meaningful way so that data can be utilized easily and effectively um and then looking at the legal arena HIPAA and other laws and regulations governing health information exchange don't always keep pace with today's tech landscape and are varied and are also varied in application across different states which you know creates an additional barrier to the flow of information then in terms of clinical workflow the use of complex EHR software systems can become an administrative burden to providers and result in some unintended behavioral consequences the one that would come to mind would be alert fatigue where maybe a provider gets so many alerts in their in the interface that they start to ignore them because they're not prioritized so that's one unintended behavioral consequence they're looking at access there are some access disparities both in terms of you know patients who have access to providers that use EHR systems and also in terms of having access to tools for viewing your health data like patient portals even people who are offered access to patient portals don't always have the same ability to use them so some disparities there finally barriers to forming strong and enduring clinical community linkages may hinder implementation of bi-directional referral systems so as Robin said implementing referral systems requires human interaction and cooperation you stakeholder buy-in providers need to be aware that a program is available and be willing to refer to it and there needs to be standardization both in terms of the data elements used and in terms of the clinical workflow processes themselves so I think you know fortunately though our analysis has has highlighted a few pretty exciting new and emerging technologies that can help to sort of mitigate many of these challenges that we just outlined by enhancing the capabilities of EHR system so currently each of these various technologies listed here is being widely utilized expanded upon and discussed in the EHR and health IT space and so today we're just going to we have a few outlined here but for today's discussion we'll just be focusing on the customer relationship management platform integration and third-party app development we'll go a little bit deeper into each of those things so starting with customer relationship management platform integration just to define just to define this customer relationship management or CRM is a technology that's used for managing all of the various relationships and interactions that a company or organization has with its clients and/or potential clients you may be some of you may be familiar or know of CRM platforms like Salesforce for example and when integrated within an EHR system these CRM platforms can help to provide a more comprehensive view of the patient by capturing information that may not otherwise be found within the EHR so in the past you know doctors may have quickly jotted down the names of their patients and the names of their family members and their hobbies and other relevant personal information and the margins of their medical records as a way of managing patient relationships so one might view this is essentially an early analogue form of CRM CRM platforms complement EHR systems by helping to track and manage patient relationships and automatic tasks like scheduling and appointment reminders and facilitating increased patient engagement CRM platforms can be used to facilitate bi-directional communication between patients and providers via multiple communication channels like instant messaging or phone depending on the patient's communication preferences and they can also help to personalize the patient experience for example a patient may receive brochures or guidelines or other resources that are tailored to his or her individual needs and preferences and then looking at third-party app integration apps can be integrated or used as extensions of EHR system to provide tailor solutions tailored solutions to specific problems that providers may otherwise be unable to address just using the basic out-of-the-box EHR platform functionality so just to go over some terminology here because I think a lot of this is some text jargon so a third-party app just to be clear is an app that was developed by a person or company that's not directly affiliated with the platform that the app is used with so pretty clear example here just any apps that you might have on your iPhone for example that were not developed by Apple would be considered third-party apps and then API stands for application programming interface API SR specifications that detail how software components should interact so an API is essentially the glue that holds or that allows apps and systems to communicate to data stored in a separate location in this case EHR platform so EHR apps are becoming easier and easier to develop and integrate directly with EHR platforms using open API technology and we're using the word open here to describe these API because they're made available to third-party developers by the EHR platform vendors so that the developers have programmatic access to their systems to be able to design these apps so in closing thank you so much for all of it sir and closing we wanted to share what we think some of the current opportunities are in the EHR realm for our national diabetes prevention program providers particularly those that will enhance referrals and enrollments to the national diabetes prevention program itself so first obviously we believe there's great value in electronic systems managing and increasing referrals some of these may be non EHR systems for example we know many programs are using access based programs to manage their referrals but they also may think about using electronic health record systems either on their own and the wife and talked a little bit about their experience of that or by communicating with the systems of service of people who may provide the referral health care providers systems who may provide referrals to them of course the value may depend on your organization's capacity your capacity to purchase Technology and capacity use technology because it actually is quite complicated and you have to have a significant number of staff members to help to do that work the right kind of experience so the organizational capacity should be assessed in different areas including environments your environment for using it the people available the processes and whether or not they can be changed and modified to incorporate the technology and the actual technology itself for healthcare providers who believe there is value in raising awareness of prediabetes itself we know that that certainly is an issue we want to make sure that we can identify people who have pre-diabetes we want to raise awareness of the National diabetes prevention program and so these are something that you all can do when you're in even if you're not developing an electronic health record of your own you can work with referral with providers and other systems to incorporate information into their system in order to make it easier for them to refer to your program finally I'd like to end this program on promising notes first those engaged in conversations about EHR use are very familiar with the interoperability challenges EHRs were not originally developed to be able to communicate information across systems they're very competitive when they are able to communicate across systems often times its entire clinical care summaries containing large amounts of patient information as we discussed earlier healthcare providers may not be comfortable sharing full patient care summaries for things such as referral to the national diabetes prevention program lifestyle change services when much of that information is not needed to provide processor Earl however EHR vendors struggle with data segmentation in order for emerging technology and third-party apps to facilitate communication across the HR Plex EHR platforms to be successful common data elements are needed so CDC's chronic disease center is engaged in promoting EHR standards for pre diabetes and other conditions they are working on that actually this month with a ballot that is trying to get standards across EHR platform once these standards are developed third-party apps will be more easily be able to more easily be created so that direct messaging can be used where our only select data is sent while we are working on these standards we are also supporting the y USA through a new cooperative agreement to explore the use of a third-party application to facilitate bi-directional files between their EHR which is Athena net and healthcare systems and providers with whom they work during the next two webinars will be learn more about the experience in the Y USA if they develop various pieces of the bi-directional referral process they and our colleagues from the American Medical Association will discuss challenges and opportunities from the perspective of lifestyle change program and from the perspective of health care providers and systems have one question just asking us to elaborate a little bit more on what we mean when we say interoperability so I think we kind of we didn't discuss this in very concrete terms so we pulled up we have a definition here from the health information management system society or him so according to hims interoperability is defined as the ability of different information technology systems and software applications to communicate exchange data and use the information that's been exchanged data exchange schema and standards should permit data to be shared across clinicians labs hospitals pharmacies and patients regardless of the application or vendor so interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of health care for individuals and communities so I think it's also important to know that there are sort of different levels of interoperability that I just want to touch on quickly so we do have the foundational level which allows data to be exchanged from one IP system and then to be received by another without necessarily having the ability to interpret it but then the second level would be structural which is an intermediate level that defines the structure or format of the data exchange so in this level there's uniform movement of healthcare data from one system to another where the clinical or operational purpose and meaning of the data is preserved and unaltered so structural interoperability defines the syntax of the data exchange and then finally there is also semantic interoperability so that that is the highest level which takes advantage of both the structuring of data exchange and the way that the data are coded so that the receiving IT systems can actually interpret the data so semantics would mean you know you can exchange data but then it can also be interpreted without any additional effort so that level of interoperability supports exchange of patient summary information and other authorized among caregivers and other authorized parties via via EHR systems to improve to improve the care or to improve healthcare delivery thank you the second question is can you please elaborate on the work CDC is doing to advocate for standards to be in place across EHR systems are they specifically advocating for systems to be able to send and receive information outside of relying on CCD first we need to say that as a federal agency we cannot advocate assisting but we are our program VDP division as diabetes translation specifically doing this work we are supporting some efforts on behalf of our office of informatics which you mentioned earlier we can put you in direct communication with them if you'd like to send an email to our Sol er at CDC that subs I can put you in direct communication with our members of our office of informatics and information resource management so that you can ask them more specifically about the work that they'll be doing over the next few months and I think that's the best way to me that they answer that question you also been asked if the call is being recorded and will be available the call has been recorded we will have transcripts of the recording available I think perhaps within fourteen to twenty-one days we have to go through experiment process for that the next question is have any health systems or EHRs yet identified a way to modify the CCD specific to a referral so I'm gonna answer that question in part because I I can't I don't know the deep dives on all of this but I can say that epic has worked with the Henry Ford medical system to develop closed loop system so they have figured out a way to develop a module in epic that will allow them to refer and receive information back within the Henry Ford system we can provide you with a little bit more information on that that is a project that the American Medical Association has worked on with Henry Ford and there's an epic and they're trying to expand that work elsewhere I do not know if there is a specific system that actually works on on the community clinical in it I don't know exactly what you want to talk about there but again if you're interested in some of the other deep dive works as one of our partners are doing you can send me an email at our solar Sol ER at CDC that's us and we'll put you in contact with some of the other work that we're doing that Sarah's gonna oh it's so it looks like we have somebody asked about on our slide about third-party apps we had mentioned that API is help to drive app innovation or open app app innovation and the question is just to elaborate a little bit more on how api's might help to innovation so just to address that an open API you know basically allows developers to create innovative apps that are able to be adopted across health systems and EHR vendors so one example would be looking at the apps currently available to smartphone users where developers have used open api to create new apps that deliver products to consumers and create new opportunities for both the developers and the consumers so this can happen in the health IT industry too interoperability is a major challenge there and specifically with within the EHR space but in an open API can help improve interoperability issues and also create a more competitive market for developers to create innovative apps so in the the hl7 fhir fast health interoperability resources offers ways of standardizing and representing EHR data that are developer-friendly through its fire api so the next question is I think probably just an opinion question or why would independent EHR vendors with a clear business plan and profit motive want an environment that promotes interoperability I am NOT an EHR vendor we do know that more and more EHR vendors are actually participating in approaches to promote or increase interoperability and I think Sara's response to the last question may perhaps be part of this answer and that is that if the EHR vendors don't do it somebody else is going to create an app to solve a problem and so the solution is going to happen and the question is are the EHR vendors participating in a solution or the app developers creating a solution for them they think that stuff my opinion on that answer I think it's the best answer I can give I think that's about all the questions we have do you have anything else in the queue we don't have anything else in the queue we are going to let you all go and have lunch so we really want to thank you all for joining us today participating in this webinar again if you have questions about any of the deep dive work that our partners are doing we are happy to put you in connection with them please email me at our solar at and we will connect you with the right people and if you are yourself doing additional work in this arena that you'd like to share with us or share with your partners also please email me and we will see what we can do for future webinars we look forward to seeing or seeing your name and hearing your voices next week thank you

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