As it has in so many other areas of the U.S. healthcare system, the coronavirus crisis has highlighted some fundamental challenges with regard to interoperability, data exchange, and public health surveillance and reporting.

But there have been some bright spots too, as health information exchange organizations have pivoted to meet the unique needs of this moment – and have often seen a marked uptick in participating organizations, according to a recent HIMSS20 Digital presentation.

The discussion, Striving Toward an Open Ecosystem: Expanding Interoperability Across Care Settings, offers a broader overview of how stakeholder groups are enabling broad, use case-driven data exchange, and how they're working to help address gaps and shortfalls in different areas of the healthcare ecosystem. But during the chat, leaders from CommonWell Health Alliance, DirectTrust and Quality Health Network also offered some insights into how COVID-19 has changed their offerings in recent months.

During the presentation, moderator Ben Moscovitch, manager of health IT at the Pew Charitable Trusts, asked the panelists how the pandemic has affected them – which opportunities for partnerships it has opened up, and which challenges it has exposed.

"A ton of new activity and a ton of new endpoints"

"In particular, relative to public health, we've seen a ton of interest in using Direct for communicating public health transactions," explained Scott Stuewe, president and CEO of DirectTrust. "A bunch of American hospitals are utilizing Direct today already for indicating hospital acquired infections to the National Health Care Safety Network, which is a CDC capability.

"But there's also a bunch of things that are happening in regional settings," he added. "Direct is being pushed to the limit in places like Chicago, where there is ending up ... large scale transactions, volumes out of all the hospitals in Chicago, and actually funneling those through an academic medical center, Rush, in Chicago. That exercise has been very interesting and has utilized Direct messaging in a kind of unique way."

Likewise, said Stuewe, "we've been focused on trying to improve our approach to how we interact with the Association of Public Health Laboratories and their AIMS platform, which forms a sort of a routing capability and is actually sort of still in its early days. I'm actually really excited about some pilots that are being done in that space to enable many of the large vendors to have a ton of impact in terms of being able to move initial case reporting from kind of a pilot project to a production capability. That is extremely exciting.

"Another thing I would note is that it's just interesting to see what's happening as we look in our directory. We see that there's a growing number of addresses that are obviously tailored to COVID-19 purposes," he added. "Some of them are public health addresses that are being set for the purpose of receiving messages. But others are direct addresses that are used to receiving information about inbound patients that have COVID-19."

Stuewe explained that the pandemic had led to an "interesting set of new opportunities and challenges we're seeing in our environment and seeing a ton of transactions volume. One of our HISPs was able to identify that 3% of their transactions volume was actually related to COVID-19-related transactions. So a ton of new activity and a ton of new endpoints also set up for the purposes of making these exchanges happen."

"The ability to be nimble becomes really important"

For his part, Richard Thompson, CEO of Quality Health Network, made the point that the coronavirus crisis has "really taught us how little we really know, and that we're learning about this disease as we move along. And the ability to be nimble becomes really important. But at the same time, it's reinforcing some basic things about health information exchange that are vital."

A key imperative, he said, is that "we've got to be able to tie data specifically to an individual – so the master person index and the master provider indexes that are part of every health information exchange become priceless. Because we need to understand who may have symptoms of the disease, how we may tie those symptoms back to an individual (and) how that individual might be contacted."

The pandemic has also highlighted the value of "standards in the data itself," Thompson explained. "Because as you may be aware, there has been a remarkable shortage of testing, and the tests themselves have not had the efficacy we'd all like. So we begin to discover that coding correctly, whether it's for lab using LOINC or whether it's for diagnosis codes, using CDC kinds of standards, that it becomes really important when we're starting to do syndromic surveillance or symptom surveillance, because the testing isn't adequate. So we have to start to look for people who may have symptoms of COVID-19 who haven't been tested yet."

The other thing this public health emergency has done, he said, "is opened up the eyes of many folks, including public health, that not only can health information exchange be used for the collection and distribution of data, but there's real value in being able to analyze that data and look for trends to help us with capacity planning, to help us look at whether the incidence or frequency of COVID-19-like symptoms [is] on the upswing or on the downswing. All of that helps public health make policy that's unique to given areas.

"So those things have been kind of a revelation to our community. We've learned that one size doesn't fit all," Thompson added. "There's a great deal of variation both in our region and in our country as to how COVID-19 presents itself. So I think it's shown more and more that the standards matter, and being nimble matters. And we try to do all those things every day. But the movement is more towards the value of the data itself rather than just moving it."

"The mix has changed for sure"

Paul Wilder, executive director of CommonWell Health Alliance, also offered his perspective about how COVID-19 has changed things for the interoperability collaborative: "In some respects it hasn't – and in some respects it has a lot."

At a fundamental level, said Wilder, "if you look at the numbers and what we see going through our systems, actually it looks like nothing has changed."

Despite the fact that primary care practices have been closed and elective surgeries rescheduled, "we aren't really seeing our volume decrease," he said. "What we see now is that COVID-19 has put people into health settings they've not been before," he explained.

"There's still a lot of registrations going on. There's still a lot of events happening – just in different settings. It's inpatient, it's ED and it's pop-up facilities. So, from the perspective of a network, from a macro view looking down you see there were 2.4 million records exchanged before COVID-19. And there was 2.5 million a month later. So it looks like not much has changed. But when you look inside, you see that the mix has changed for sure."

Another thing that's really changed, he said, "we're seeing from our partners and our members in the alliance, an increase in people trying to get their own records. Why? That is a great question. One of our thoughts as people are looking for disability and healthcare related claims. They're trying to get a hold of their data. And when your primary care doctor is closed, as well as your specialists, and your local hospital doesn't want you unless you're sick. You have to start looking digital to acquire these records. And it's not as easy as you want it to be."

CommonWell is also noting an increase in public health and research use cases, said Wilder, noting: "There's a lot of workflow holes in COVID-19 that have almost no relation to interoperability on the surface. But when you dig in and look a little bit closer, you start to see there are some serious operational barriers to getting really fast lab exchange results for public health with accurate patient identification. It's a non-trivial problem. It's not that hard to solve. It's just going to take a kind of working together that we didn't expect to."