Health Management
What is an interoperability issue in your organization? Who are the stakeholders? Why is this an opportunity? Read the case. Identify and discuss three lessons you might infer from The Oregon Clinic to your own organization. Document your response in a three to five page paper. Paper must be doubled-spaces with 12-point font. Proper APA formatting and referencing is required.
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HIMSS Interoperability Case Study – The Oregon Clinic, August 2018
Background
The Oregon Clinic is an independent specialty physician organization based in the
Pacific Northwest, which works with many hospital systems on patients with complex
stories. The practice consists of about 260 providers, 160 physician shareholders and
nearly 20 specialty practices. The physicians at The Oregon Clinic are affiliated with
multiple hospitals across the region where they use a variety of different electronic
health records (EHRs) as well as their own EHR at their respective private practices;
this has presented them with unique interoperability challenges.
Tim Fitzgerald, Director of Information Technology (IT) for The Oregon Clinic since
2010, was interviewed for this Case Study, which tells how The Oregon Clinic went
from little to no interoperability to sharing information bi-directionally, previewing
records and proactively surfacing pertinent information from inbound Consolidated
Clinical Document Architecture (C-CDA) documents.
In 2010, two major local hospitals started using a large EHR system and The Oregon
Clinic started to feel pressure from these hospitals to use the same system to simplify
their data exchange. However, due to a variety of factors, this was not a viable option.
They decided instead to look into alternate solutions to exchange information with
hospitals. The goal was to find a cost effective solution that would get the information
they needed into their patients’ charts in a timely, legible, accurate and relevant
manner while using multiple systems across the continuum of care.
Prior to beginning on their path to interoperability, The Oregon Clinic shared
information with hospitals by faxing referrals and other patient information between
facilities. This was time-consuming and often failed to produce patient information in
a timely manner. Their two local partners, Providence and Legacy Health Systems,
https://www.oregonclinic.com/
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were already involved in exchanging health information with other systems, which
proved instrumental in helping The Oregon Clinic with their interoperability needs.
First Discussions
The Oregon Clinic participated in Stages One and Two of Meaningful Use, and as with
many organizations, they believed that interoperability would “just happen” when they
met the requirements. When it became clear that this was not the case, The Oregon
Clinic knew they had to do something more to become interoperable on their own.
However, no one knew what interoperability should look like, so it was difficult to
understand how to begin. Under the leadership and advocacy of Dr. Fausel, The
Oregon Clinic decided on three interoperability goals that they felt were the most
impactful and attainable:
1. Referral Processing – To receive referrals as a C-CDA document using Direct
Messaging, and return a consult note as a C-CDA document to the referring
physician
2. Bi-directional Exchange – real-time C-CDA exchange with their local Epic-
based hospital systems
3. Asynchronous Provider-to-Provider (P2P) communication
In the fall of 2015, a fortuitous chain of events occurred which moved this
interoperability project forward: The President of The Oregon Clinic CEO, Dr. Craig
Fausel, went to a fundraiser for the U.S. Senator from Oregon, Ron Wyden. At that
event, Dr. Fausel expressed his discontent about the lack of interoperability. Soon
thereafter, Tim Fitzgerald and Dr. Fausel found themselves in a conference call with
leadership from the Department of Health and Human Services, Epic Systems and
local hospital systems. The conversation started with Epic explaining how they had
some external providers connected to the CareEverywhere® network.
Encouraged by this conversation, The Oregon Clinic started learning more about IHE
profiles, HL7 standards and C-CDAs, which led to the launch of their interoperability
pilot. First, they reached out to local healthcare systems to collaborate: Legacy and
Providence both agreed to be a part of this project as did Epic Systems.
The first phase of the project focused on developing the communication standard
between The Oregon Clinic and their local healthcare system partners; they used SSL
connections and implemented IHE standards to accomplish this. The Oregon Clinic
had used GE Centricity Practice Solution (CPS) for their EHR since 1998, so they also
engaged GE Healthcare and their interface partner Qvera to begin working on the C-
CDA exchange.
However, once they were able to start exchanging information, the data was not
readily accessible in the clinic and providers were not happy. They knew they needed
https://www.healthit.gov/topic/federal-incentive-programs/meaningful-use
http://www.epic.com/
http://www.hl7.org/index.cfm
http://www.legacyhealth.org/
https://oregon.providence.org/
http://www.epic.com/
http://www3.gehealthcare.com/en/products/categories/healthcare_it/electronic_medical_records/centricity_practice_solution2
https://www.gehealthcare.com/en
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to get the information into the clinician workflow and C-CDAs into patient charts in a
manageable way. Having multiple specialties meant that providers wanted to access
different information from the C-CDA documents. The Oregon Clinic worked with their
clinicians to try to figure out how to make this work best while still meeting regulatory
requirements.
Stakeholder Engagement
The driving forces to get interoperability rolling were the President and CEO of The
Oregon Clinic. They knew they wanted to engage the physicians in this projec t
because a common complaint from their doctors had been that they felt ignored. Even
if something is working on the technical side, it may not be useful clinically. As the
project took on more definition and the scope became clearer, The Oregon Clinic
expanded their stakeholder engagement and continued to engage providers in the
process. Each time they made improvements to the workflow, they would get informal
feedback from the physicians on the clinically relevant aspects . They did this until the
responses were mainly positive and indicated that the implementation of
interoperability solutions was useful in the clinical setting. This brought them to their
current workflow, which includes the ability to preview a C-CDA document in real time
and bring over only what information is relevant to the viewing physician.
Technical and Interoperability Approaches
Referral Processing
Their first project goal involved using C-CDA referrals by Direct Messaging. Since The
Oregon Clinic represents specialty providers and receives many external referrals ,
they wanted to use interoperable exchange to create a type of closed referral loop.
The process involved use of the C-CDA via Direct Messaging and a Surescripts®
service called Automated Clinical Messaging.
Example Clinical Workflow:
1. An external Primary Care Physician (PCP) sends a C-CDA referral to a
Specialty Provider at The Oregon Clinic.
2. Once The Oregon Clinic receives the referral, a referral receipt message is
sent back to the PCP. This not only alerts the PCP that the referral has been
received, but it also confirms the communication pathway between the PCP
and the specialist to confirm the Direct Messaging is working.
3. After the patient visits the specialist and the encounter is documented and
signed, the consult note is then sent back to the PCP via Direct Message.
There is an Automated Clinical Messaging (ACM) service on the back end
that queries the data in the EHR for an appointment type that matches the
referral. If it finds a match, it will initiate sending the consult note back to the
referring provider.
https://surescripts.com/ge-centricity/automated-clinical-messaging/
https://surescripts.com/ge-centricity/automated-clinical-messaging/
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Thus far, they have had a positive response from specialists and referring providers
as this process eliminates extra steps for collecting data and verifying that the patient
visited the specialist.
Bi-directional Exchange
The second goal was to implement bi-directional, real-time C-CDA exchange with their
local Epic-based hospital systems. This process was a little more extensive than the
first.
The Oregon Clinic had previously reached out to GE to improve interoperability. They
worked to use a federated network to register and store health documents and build
the infrastructure required for storage and exchange. Qvera, their interface vendor,
understood the interface connectivity pieces but needed access to patient records and
clinical documents from multiple EHRs to accomplish this task.
In September 2016, GE and Epic began to collaborate with Qvera in a pilot program
to publish clinical documents to a shared registry through which clinicians could query
and retrieve documents from their respective repositories. The last essential piece of
this project was Carequality, which allows its members access to a vast, trusted
network of clinical documents wherever they exist. The bi-directional sharing of clinical
documents is possible through the implementation of the IHE cross-gateway sharing
infrastructure Cross Community Access (XCA) profile.
This is the timeline of the bi-directional exchange with Epic to-date:
https://sequoiaproject.org/carequality/
https://wiki.ihe.net/index.php/Cross-Community_Access
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Asynchronous P2P Communication
The last goal that The Oregon Clinic had set out to achieve was to create
Asynchronous Provider-to-Provider (P2P) communication. The Oregon Clinic is still
looking for the best way to implement this functionality and is engaging with their
partners for the most viable solution. An example of a potential use cases could be:
1. A PCP wants to ask a specialist for advice on a particular patient regarding
whether they should refer them to the specialist or not. To do this, they would
send information on the patient’s history to the specialist for their opinion.
2. A PCP has a general question such as “What tests should I order for symptoms
of shortness of breath?”
In these scenarios, external systems exchange information in a real-time advice or
consult context.
Outcomes and Reporting
To measure success, The Oregon Clinic decided to use provider feedback as a
benchmark. They would know they were successful when the IT team could show the
providers how the interoperability features work and get agreement from physicians
that the result was an improvement in their clinical workflow. Because some
participants were wary of any IT project and any resulting modifications to patient
charts, The Oregon Clinic felt they had to close that credibility gap by listening and not
confusing purely technical achievements with progress to improve the clinical
workflow.
In addition to provider feedback, The Oregon Clinic uses message volume to measure
progress. They became members of Carequality in February 2018 and since that time,
the total number of messages sent has grown from 4,000 messages per month to
12,000. The expectation is continued growth of this metric as access to patient health
records increases. They also continue to monitor and get feedback on system
performance and issues, and communicate enhancement requests to GE.
Interoperability and the Clinical Workflow
Changing the clinical workflow has been the most challenging aspect of implementing
interoperability solutions. Even when The Oregon Clinic could demonstrate technical
improvement in the timeliness of the information, improved quality of the information,
patient benefits and physician buy-in, they still had to get individual clinic sites to
accept the change and it was not always an easy discussion. There was an initial
expectation of immediate acceptance by clinicians once they saw improvements in
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action. Instead, they had to go clinic-by-clinic and sometimes person-by-person to
implement change. With respect to the Referral C-CDA in particular, the specialists
initially rejected it because it contained too much information and the presentation was
unorganized. Once they worked with their specialists to make the most relevant
sections within the C-CDA document easier to find, broader adoption and use of C-
CDA began.
This work with physicians has led to an evolution of their workflow, which now allows
the clinician to decide what they want to see by enabling them to preview the
information first, then only import particular sections of the C-CDA document they want
based on the referral information. They work with their medical staff to assist in that
process by training them to import the items that the providers want.
Costs and Budget
As a private company, funding and budgets for these solutions come from the owners
themselves. The Oregon Clinic leadership had already approved the budget line item
for the software necessary for this project even though they were not fully clear on the
scope. However, they found the largest real cost was the staff time to develop the
systems. The Director of IT was able to assign resources as needed, but this required
a substantial resource investment of time and personnel over 18 months.
Challenges
The three biggest challenges that The Oregon Clinic faced for this pilot were:
1. Lack of existing implementation structure or roadmap: Because the term
“interoperability” was not clear, there was no existing structure or roadmap to
build upon. Everything they did felt as though it were breaking new ground.
2. Willing and motivated partners: Interoperability requires willing partners who
are motivated to operate together. The Oregon Clinic found that some of their
community partners struggled with resources and understanding of the
technical and operational reasons for working together. They found two
partners (Legacy Health & Providence Health) who were motivated to
participate with engagement from senior leadership. These partners were
instrumental for moving forward.
3. Clinical staff & existing workflow: There was an initial reluctance of clinical
staff to adopt changes into their existing workflow, even when those changes
were clearly beneficial to the organization.
Ongoing Challenges
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The Oregon Clinic continues to encounter community partners who do not understand
the benefits of interoperability. Because of their pilot work, they are better informed
and are able to help these partners engage. The interoperability landscape has
changed significantly since the start of this pilot and The Oregon Clinic now has
processes, templates, tools and infrastructure in place that they can leverage for
ongoing implementations. In addition, the interoperability dialogue with partners is
much easier as both sides gain experience through the pilot. The slow pace of
adoption is still a challenge, but continues to improve as internal users and partners
see the benefits of interoperability.
Change Management
Change management was a challenging aspect of this project. Realizing actual
benefits of interoperability required ongoing incremental testing and validation with
end-users throughout the process. The original expectation was that clinics would see
the benefits and immediately adopt the changes. Instead, they faced reluctance to
change well-established workflows; obtaining buy-in from physicians was paramount
to overcome this. Once the physicians were on board with the new changes, they
became drivers in change implementation and helped the rest of the staff see the
benefits and start using the new technology in their workflows. Each clinic had its own
project go-live plan, which they implemented by the end of June 2018.
Lessons Learned
1. Listen carefully to physicians and clinical staff and incorporate their feedbac k.
Work to build trust and do not implement a technical solution that they do not
perceive as an improvement.
2. Do not underestimate the power of physician champions to break through the
status quo. People often become “stuck in a groove” and will do things the way
they have always done them unless they can see a clear reason to change.
3. Develop close relationships with important community partners and figure out
who is ready and motivated to take on an interoperability project. It does not
work to implement change before a partner is ready and willing to collaborate.
4. The Oregon Clinic could have done a better job researching and learning about
the interoperability options that were already available, participating more in
interoperability communities and keeping up-to-date about the available
technical standards. This would have helped with project planning to decrease
the number of surprises and new discoveries.
Summary
The Oregon Clinic has attained two of the three interoperability goals they set out to
accomplish and those are exceeding expectations:
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● They process over 90% of referrals electronically via the automated referral
management system outlined above. Almost all of those referrals receive an
automated chart note (the patient encounter documentation) back from The
Oregon Clinic’s specialty physicians. The referring physicians are happy to get
their referrals handled quickly and to get detailed, consistent information back
from Oregon Clinic’s specialists.
● The Oregon Clinic is aggressively rolling out their Carequality initiative. They
have reached a tipping point with thousands of C-CDA documents now
exchanged every month. Clinics are clamoring to be included and physicians
are seeing improvements in how their charts are prepared.
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Acknowledgements
This resource was developed by the following volunteers from the Healthcare
Information and Management Systems Society (HIMSS):
Work Group Chair
Te ri Kato, PT
Program Manager
Therapeutic Associates
tkato@taipt.com
Inte rview and Editing
Alise Widme r, RN, CHDA
Product Manager
Lumeris
awidmer@lumeris.com
Noam Arzt, PhD, FHIM SS
President
HLN Consulting
arzt@hln.com
Amul Pate l
Director, Product Integration & Delivery
Blue Shield of California
Amul.Patel@blueshieldca.com
Te ri Kato, PT
Program Manager
Therapeutic Associates
tkato@taipt.com
HIM SS Staff
Audre y Garnatz, PhD, CAPM
Program Manager, Informatics
agarnatz@himss.org
Katie Crenshaw, MPPA
Manager, Informatics
kcrenshaw@himss.org
M ari Greenberger, M PPA
Director, Informatics
mgreenberger@himss.org
HIMSS is a global advisor and thought leader supporting the transformation of health through the application of information a nd
technology. The inclusion of an organization name, product or service in this publication should not be construed as
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service to be construed as disapproval. The views expressed in this paper are those of the authors and do not necessarily reflect the
views of HIMSS. www.himss.org
mailto:tkato@taipt.com
mailto:tkato@taipt.com
mailto:agarnatz@himss.org
mailto:kcrenshaw@himss.org
mailto:mgreenberger@himss.org
http://www.himss.org/