HIT Perspectives: Five Predictions on How the COVID-19 Crisis Will Transform Health IT

The health care system is under siege in addressing the crisis surrounding the novel coronavirus disease 2019 (COVID-19) and its impacts. New information about the virus’ severity, life cycle, transmission mechanisms and spread come to light every day. We know our response to the COVID-19 crisis will forever change health care and health information technology (health IT), but that response has shone light on the importance of health IT to the health care system, particularly exposed risks and gaps requiring attention. Here are some early predictions on what — and how — health IT will change, even though the pandemic is far from over.

Prediction: Telehealth is here to stay. Response to the virus is built on a growing telehealth platform. There is wind to our backs and patients, providers and payers will not want to backslide.

• Where we are today: Telehealth was on a growth trajectory before the COVID-19 crisis, which then expanded its use exponentially. According to the American Medical Association, physician use of telehealth and virtual visits doubled during the 3-year period ending 2019. Kaiser Permanente already employed virtual visits for 90% of its routine care before the pandemic. Medical centers across the country are rolling out telehealth services to mitigate the risk of spreading the virus by reviewing patients’ symptoms remotely and replacing in-person, non‒COVID-19 visits with telehealth. A recent survey of consumers found two-thirds more willing to use telehealth due to fear of infection as a result of going to a doctor’s office. This will likely be the tipping point toward broader adoption of telehealth by patients, payers and providers.

Several factors came into play. Telehealth instantly became an easy-to-use, reliable method to connect patients and providers that eliminated risk of exposure to the virus and curtailed its spread. Restrictions were temporarily relaxed, including multistate physician licensure requirements, payments for telephonic and other types of telehealth visits, and prescribing via virtual consultations by the Drug Enforcement Administration.

• What needs to happen: Virtual (video and telephonic) visits should become part of agreed-upon standard, reimbursable services covered by all government and commercial payers. Reimbursement models require refinement to reflect differences in the level of intensity of a telehealth visit compared with an in-office exam. Restrictions on conditions treated and appropriate use should be evidence based. Oversight of telehealth use is needed at the local, state and federal levels. Other restrictions will need to be lifted at the federal and state levels, including multistate licensure of physicians, pharmacists and other health professionals and the ability to prescribe across state lines. Expansion of broadband coverage must be accelerated. The digital divide should be acknowledged so vulnerable populations can avail themselves of virtual visits. Electronic health records (EHRs) and telehealth applications must become seamlessly and fully integrated, enabling providers to stay within their clinical workflow, have direct access to a patient’s medical history, and be able to order medications and services while virtually consulting with a patient. New virtual workflows will be created. The myriad telehealth applications proliferating today — some not much more than a Zoom session — will consolidate to a market of robust, reliable and scalable systems. As the value of telehealth in the primary care and specialty settings becomes more evident, innovative uses in other areas will emerge, including behavioral health and population health management. Regulators and telehealth providers must be diligent in ensuring applications protect patients’ privacy and security. For example, some Zoom sessions have been hacked, while Microsoft warned of ransomware attacks on hospitals whose staff are working remotely.

Prediction: COVID-19 will further drive data exchange among payers and providers.

• Where we are today: Payers are sitting on a mountain of patient data. The complete view of that information is key to diagnosis and treatment, not just every day but in times of crisis. The COVID-19 response highlights the need for more complete access to patient information, which also will be needed if another round of the virus appears in the fall and certainly as other public health crises arise. The COVID-19 pandemic is an untenable use case for widespread exchange of health information among payers, providers and their patients/members. However, payers are still in the early phases of adapting their internally focused data streams to share information with providers and other organizations that are not closely held trading partners. Defined data endpoints are not in place. Providers — even those who are connected to a health information exchange — are unable to share essential patient health information across the continuum of care, particularly subacute care providers, home health and social service agencies. Connectivity with public health agencies is limited.
• What needs to happen: Evolving health information exchange — particularly bringing payers into existing and emerging data exchange infrastructure with providers — will need to leverage ongoing federal and stakeholder initiatives. The first is adoption of standards required for uniform data exchange under new rules from the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS). They are: 1) the US Core Data for Interoperability ​ standard, which will support the exchange of codified data elements; and 2) the Health Level 7(HL7) Fast Healthcare Interoperability Resource (FHIR) standard, version 4, which is being adopted as the foundational standard to support data exchange via secure application programming interfaces.

Stakeholder initiatives also will be key to transforming payer data exchange. An example is the stakeholder-led HL7 Da Vinci Project, which focuses on using the FHIR standard to share data necessary for value-based care. Several use cases could be applied to the COVID-19 response. For example, risk-based member identification use cases flesh out a standard for ways partners can agree for which patients they will exchange data. The Payer Data Exchange  set of use cases focuses on the ability for payers to tell partners — whether they be providers, other payers or health information exchanges — everything they know about a patient. Payers, providers, public health entities and health information exchanges (HIEs) need to become involved. 

Prediction: Unique patient and provider identifiers will be created.

• Where we are today: The response to the virus has highlighted the fact that there is no single way to identify patients and providers. Legislation instituting a ban on creation of a national patient identifier standard by the government was enacted in 1999. As a result, there is no single way to identify patients. Stakeholders have created one-off proxies, which remain imprecise. 

The problem has come to a head again with COVID-19. Patients receive care from disparate health care organizations (urgent care facilities, field hospitals, pharmacies, labs, payers and various types of providers) in different venues and even different states. Many of these sites are outside of patients’ normal health care channels, so their records (and advance directives) aren’t available to their care team. Epidemiologists need precise patient information to track the spread and severity of the virus. Providers need to accurately and quickly identify patients to determine their risk from comorbidities when being treated for COVID-19, manage treatments and document outcomes. Uniquely identified (and accurate) patient information is crucial to clinical trials for treatments and vaccines.

Similarly, there is no unique provider identification (ID), which makes it difficult to identify providers in the fluid environment of COVID-19 response. Physicians and health professionals are being called out of retirement, brought in from various geographic areas and moved in and around states. Some 40,000 health professionals from inside New York and out of state have volunteered to fight the virus there. They are practicing in novel sites of care, such as field hospitals. A unique provider ID is crucial for vetting licensure, knowing who provided care and where, and tracking quality and outcomes. A national provider identifier would help payers sort out billing at the back end of the crisis.

• What needs to happen: There finally will be an appetite to take politics out of the creation of a patient identifier, which is no longer a “third rail.” Congress will be pushed to remove the ban on government development of a standard. This should leverage the considerable stakeholder efforts already in place for patient ID algorithms. In terms of a provider ID, the Medicare National Provider Identifier (NPI) could be adapted. It is a unique 10-digit identification number issued to providers billing Medicare; that is, nearly all primary care physicians and a significant number of specialists. However, the number isn’t issued to all providers and lacks some useful data, such as the state of residence or specialty. The NPI could easily be expanded and used to jump-start the creation of a national provider ID, which may require legislation.

Prediction: HIEs will emerge stronger and more interoperable than ever.

• Where we are today: In the early days of the push for interoperability, about a decade ago, HIEs emerged as a promising way to exchange patient information. However, there were technological issues and questions about sustainability. Although many HIEs failed, a strong core have thrived and the HIE model has evolved with many state, regional and private-sector HIEs now in place. Nonetheless, there are still gaps in connectivity and data systems. COVID-19 has exposed these issues. HIEs often are not connected with one another, much less with providers across regions and government agencies. Such connectivity and data exchange aid in early identification and even prediction of the centers of epidemics. Patient consent across HIE platforms is not uniform, although some HIEs have temporarily relaxed such restrictions in response to COVID-19. 

Recognizing the value of HIEs, the Centers for Disease Control and Prevention (CDC), the Sequoia Project and Audacious Inquiry have introduced a new, but one-off way to identify patients and associate them with their records called PULSE-COVID, which is a health IT disaster platform modeled after one created during Hurricane Katrina. It allows verified providers to find and view electronic patient health and medication histories across national HIE networks. It is now connected to the eHealth Exchange, which includes more than 60 regional and state HIEs and 75% of all hospitals in the United States. However, this kind of capability is only rolled out when disaster strikes.

HIEs generally do not transmit nonmedical information. This includes information related to social determinants of health, which is essential for population health management and disaster response.

• What needs to happen: The need for a nationwide information superhighway is crucial, not only for everyday health care information exchange but for the inevitable future epidemics and natural disasters. HIEs have a huge role to play. Their roles and some of their interoperability could be addressed through the implementation of ONC’s Trusted Exchange Framework and Common Agreement (TEFCA). This creates a codified set of principles, terms and conditions to support the nationwide exchange of electronic health information across disparate qualified health information networks (QHINs). A successful rollout of TEFCA would go a long way toward ensuring that a health care consumer’s data are available in a standard format anywhere they are needed via a nationwide health information network.

What if TEFCA required QHINs to connect with and report to public health entities? This would tie together all QHINs into one national network that includes HIEs, health systems, and public health.  

In the meantime, policymakers should work on a standards-based, scalable and interoperable platform for HIEs that would dovetail with TEFCA and other federal interoperability efforts. The need for uniform patient consent and other privacy issues need to be reviewed and normalized.

Prediction: Public health data systems will become more interoperable with the rest of health care.

• Where we are today: Local public health data systems are a patchwork. Traditionally, public health agencies and health care providers (including those in federal qualified health centers) have not used the same information systems, data formats or even data standards. While there is a National Syndromic Surveillance Program, it isn’t as seamless as it could be. This has prevented the timely and complete exchange of information, which has been exacerbated with the COVID-19 crisis.
• What needs to happen: A limited number of public health agencies are currently connected with HIEs to receive lab results and reportable diseases. Just imagine if every public health agency was connected with a national health information network to receive test results before the COVID-19 pandemic arrived. Public health funding for interoperability tools needs to be on par with that of other agencies. Data silos need to be eliminated. In addition, the CDC should continue to update its platforms using the FHIR standard. This will standardize data exchange and reduce the time and resources needed to collect and analyze data. CDC should continue to work with burgeoning implementation guides under development at HL7, like the Da Vinci Project, to identify additional use cases and standards that may be extended to meet public health’s unique needs. Additional funding should be provided to the CDC for these efforts. The CDC should ensure interoperable access to immunization registries, which will be important once a COVID-19 vaccine is approved and deployed. Finally, the PULSE system should be merged or made interoperable with EHRs and HIEs on a nonemergency basis — perhaps as part of the QHIN model but with facets that could be employed during disaster response when other networks are down.

Looking ahead. There are many health IT innovations springing up in response to the COVID-19 crisis.  Point-of-Care Partners is keeping on top of these developments. Want to know more? Reach out to us at michael.solomon@pocp.com and jocelyn.keegan@pocp.com.

In this Issue:

1. The Critical Role of Health IT in Fighting COVID-19
2. Five Predictions on How the COVID-19 Crisis Will Transform Health IT
3. Take Note of the Health IT Opportunities Emerging From the Final Interoperability Rules of ONC and CMS