Breaking Down Data Walls: TEFCA and the Work of the CommonWell Health Alliance

Moving towards clean, efficient data exchange has long been a thorn in the side of healthcare organizations across the globe. How do large entities dealing with thousands of transactions every day maintain easy-to-use, accessible databases while ensuring that patient data is safe and secure? Is the iron hand of government regulation the only way that providers and tech organizations will get it together?

With the release of ONC’s TEFCA earlier this year (see our coverage here), these are questions that are on everyone’s mind. Will enough organizations participate as QHINs (Qualified Health Information Network) to make it worthwhile? Although complying with federal guidelines will be a big lift for many organizations, the pieces seem to be in place more so than ever in the search for a more connected future in healthcare.

What can organizations do now to be ready for the shift to greater connectivity that is sure to be coming? Can it be done without forceful government intervention? We sat down with Paul Wilder, Executive Director of the CommonWell Health Alliance, to discuss these issues and find out which way the wind really is blowing.

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AI-generated transcript below:

John Moore III: [00:00:00] All right. So, Paul, tell me what you do as the executive director of the CommonWell Health Alliance.

Paul Wilder: [00:00:04] Well, it’s a large job. We have a very small amount of staff. It’s just three of us that do all this work. We get a lot of volunteers from the member organizations. They’re in our clinical works, Athena. We set standards for ourselves to adopt, to proliferate throughout the industry, to allow interrupt to work across the country. And right now we have say about 20 some odd active members leading to about 26,000 practice sites connected and exchanging about 30 million documents a week. So a lot of stuff going on.

John Moore III: [00:00:36] That’s great. That’s good adoption. So thinking about the CommonWell Health Alliance, is this a way in some regards for the industry to self regulate itself around the interoperability needs of health care?

Paul Wilder: [00:00:48] It’s a great question in some respects. Yes, right. Because it started if you go back, it was founded in 2013 and that was around the time where Meaningful Use stage two and three was being developed and two was going out. It was kind of a way to get ahead of the regulation, right? We don’t need to regulate it. We just do this right anyway. And so it was altruistic in some respects of, “hey, our customers need access to data, they’d like to exchange with each other. We’d like to make it easier, we’d like to make it embedded. We’d like the workflows to work. Oh, and by the way, we also have less regulatory risk if we do this the right way.” So in some respects it is, right? The more we do, the less things have to be regulated. But right now there are things coming out to and others that are saying, yes, there’s a couple of things you could do a little better and we’d like to see you get better at it as fast as possible. We’re here to help do that. Okay.

John Moore III: [00:01:34] So we were talking about this a little bit before we started filming, but can you explain how TEFCA fits into the big picture of what you guys are trying to accomplish?

Paul Wilder: [00:01:41] The TEFCA question… So we’ve been talking TEFCA a lot here at HIMSS. So we did last HIMSS as well, but now it’s very, very focused. So TEFCA was pretty much designed for Commonwell and it takes what we did, which is how have these, these entities connected together to allow data to seamlessly flow across the country and push it up a notch. Right. If you don’t connect us to other things that are like us, it’s like having an AT&T phone with your iPhone and not being able to call your mother who’s on Verizon. Right. You have to connect this stuff, you need a bridge to do that. And so the QHIN is the qualified health information networks, which would be the backbone of TEFCA, is what we expect to be. We expect to be able on those top level nodes to bring all of our members to attach the other things. We do that today through the care quality. The way care quality works, the way it works is one little really important nuance difference that we enjoy more with TEFCA, and that’s why I want to get there as quickly as possible.

John Moore III: [00:02:41] Okay. So tell us about that nuance.

Paul Wilder: [00:02:42] I knew you’d ask that question. Well, so in care quality, the entities are all across the country, just like ours are. We’re not a regional exchange, or not a statewide exchange. The idea is if you’re fully national, if you have every doc connected, there’s no such thing as regional or national. It’s everything, right? So Paul Wilder’s data can be found everywhere, click a button and get it all. And care quality they don’t have a centralized infrastructure. There’s not a hub in the middle that knows where the records are. Right? So right now we have Cerner connected via Athena. Their sites are uploading demographics about patients all day long. And we at the center are saying are keeping track and saying, oh, Paul Wilder popped up again. If someone asks for Paul Wilder, remember to go ask this site, too, because that’s a new site that he just popped up at. And you have to guess, right? I think he’s been here and you would do some good guessing. We do it as well because we participate in care quality, we guess based upon where the patient lives and where they get care. If you went to a hospital in New York City, it’s likely that your ambulatory practice, your primary care physician is in New York City, too, so you kind of walk around there. What TPA does is add our kind of centralized hub philosophy that you need to know where it is before it starts and force it into a national framework. Right. And I say by force, it’s a voluntary framework. Anybody who wants to enter has to have that capability. It’s not a regulation by like information blocking or whatever. It’s still a voluntary framework. And we’re excited to get there because it kind of brings our philosophy to the forefront.

John Moore III: [00:04:10] So how do you actually reconcile different records if there is no national patient identifier? This is one of the big issues that we’ve talked to a couple of other people about. I was talking to Jonathan Bush from Zus yesterday, and that’s what he’s trying to do, is this has created a patient layer where people can tap into and provide apps that hits the patient wherever they’re receiving treatment, not just the one site. So everyone’s trying to solve this issue, but we don’t have a national plan yet. So how do you guys do.

Paul Wilder: [00:04:34] It, huh? Well, first of all, Zus is a member of Commonwealth, so they’re they’re a node connected to us. We’re not just EHR vendors attached to us. Right. It really is HIT in general, which is applications for consumers for EHRs and all their smaller applications that do stuff including connectors like like Zus, you can do a fair amount of good matching with demographics either. Today, we would embrace a national identifier in a split second. If they wouldn’t have existed, we would replace all the way. We do matching today and use that as our primary method, no doubt about it. But you can do a lot with a person’s name, address, phone number, email, gender. Like if you take all that stuff together, we do a pretty good job of matching across country. We currently have 164 million, might be 167. I’m like, It’s a lot. Let’s have the identified patients across the country.

John Moore III: [00:05:26] That’s half our population roughly correct.

Paul Wilder: [00:05:27] And it’s it’s actually a little higher if you consider that pediatric doesn’t go through this stuff much because pediatric matching is harder. You don’t have a verified address as a 12 year old, right. Your verified address comes from having utility, having a gas electric or home phone who has a home phone. But those other things you have, those are your verified addresses. All the rest is noise. So it’s harder to match pediatrics. I think if we were to improve something, that’s something we’d probably work on next. But you can do a pretty good job with that stuff.

John Moore III: [00:05:56] Okay. So you’ve been talking about the demographics. One of the other kind of buzzwords or popular topics that we’ve been talking about and hearing a lot about it this year as well as last year, is this shift toward maybe not a shift, but the initiative to start trying to address social determinants of health outside of the care setting, but in a care context. So are you doing anything to enable that? Do you have any partnerships already in place that are doing, you know, addressing SDH and incorporating that back into this hub?

Paul Wilder: [00:06:21] I wish I could say yes, right? Because it is social determinants. There’s multiple things. We actually mix up this conversation often with where care is delivered and where people have access to. There’s like the social determinants of your socioeconomic status and kind of what you are. And I think that’s kind of starting to creep into the EHR, which naturally flows across our network. Because I didn’t say this, the payload, the thing that goes across isn’t defined by us. It’s defined by what they want to exchange with each other. We’re really just there to locate the drives, correct. So once it’s added to the record, it’s there, right. But the other social determinants is like the care quasi provider. As you see, it’s the soup kitchen, it’s, you know, the homeless shelter where they need to engage the community resources. Community resource side and that we don’t have in place yet. I mean it’s a matter of trust. And we’ll, we’ll crack that. Not eventually, but we still have a little bit more work to finish the current grid, the current utility we’re building to get all the providers connected and then we can figure out how to extend that trust to the next layer.

John Moore III: [00:07:19] Well, I mean, healthcare IT has been so poorly adopted by this industry to begin with for a number of years. It’s only worse at these community resources because they tend not to have the budgets either to implement new and new innovative things.

Paul Wilder: [00:07:30] You also got to be really careful of abuse, right? These are, you know, the lower you go down in socioeconomic status, the more people prey on them. And so you’ve got to you’ve got to think twice. You know, this is what they say when you’re building a house, you know, measure twice, cut once. You know, think, think before you cut here, because it’s you could do some harm while thinking you’re doing something great. Yeah.

John Moore III: [00:07:54] So is there anything that you’ve learned that’s unique or really cool that you’d like to share from your work with the Commonwealth Health Alliance? From what you’ve seen working with all these different health IT vendors and bringing that data together.

Paul Wilder: [00:08:07] What’s really fun and is cool to learn is how much everyone cares, right? You know, so we talked about you started out, is this a defensive play against regulation and the altruism of trying hard to make this work? Right. It really is a strong community trying to do the right thing. You know, Cerner talked this morning and talked about how, yes, you know, margin and revenue matters to our company and our shareholders. But solving the problem, helping people live better lives is clearly at the forefront. Right. And if I do that well, the rest will come. Right. And I think that’s the philosophy. The the social networks inside of the membership really do believe that I actually had a member today I was talking to who said, you know, of course, I want to make sure I’m getting something out of my membership. I’m paying to be here. But I also want to make sure I’m giving something to you. What can I help with? I said, Well, thanks for asking that. I made a list.

John Moore III: [00:09:08] Okay. So something that like asking everybody to interview is what is your health care story that got you to enter this market and try to tackle the many problems that are plaguing this?

Paul Wilder: [00:09:17] And you want the 45 second version or the half hour one?

John Moore III: [00:09:20] Let’s go for a minute.

Paul Wilder: [00:09:21] Okay. Fair enough. Well, I was doing I did radiology informatics for the early part of my career. So I’ve been in health care for 25 years. Like it’s been most of my career, most of my living life, actually. And I was I moved out. I left health care and I was doing air conditioning stuff, train, commercial, don’t ask how on the health care vertical. It turns out that hospitals use a lot of air conditioning and it’s very unique system. So okay, fine.

Paul Wilder: [00:09:47] And then this thing started up, our start up and HIE was beginning and my daughter got born and she was fine, perfectly healthy, early, early born child. So she was about five weeks early, which is kind of early. All tests are fine and we bring her home. And on the third day of life, she develops jaundice. And she had jaundice in the hospital, too, but it went down. And when they said, like, problem, I was like, Why? It’s like, well, if you get jaundice when you’re born, we put you in the sunlight and maybe once it goes down, it doesn’t go back up again. Something’s wrong. And so on the third day, you know, we take her down. This is, by the way, at the primary care office, her pediatrician, that he observes this and goes, “You have a problem. You have to go to the hospital now.”

Paul Wilder: [00:10:32] So in the stroller, walk down the street, eight blocks to the hospital. That’s near us. She wasn’t born there. She’s born at a different hospital. And that other hospital’s in the city in New York City, I lived in Hoboken about three miles away. The records might have been might as well have been buried in the Sahara. We could not get to them. Right. Because it was a third day. And the answer I got when I called because the provider couldn’t get them, I said, can I get them? And they said, Well, they’re between floors, so what the heck does that mean? They were literally on a cart between the, you know, the birthing floor to where I am is going to file them and they haven’t filed them yet. So they’re actually in nether region. They’re nowhere. And so my daughter now had a meningitis spinal tap in which… I heard that scream from the other room and blue light for four days and you’re like and all these extra tests because they could not get the data to find it, the tests they’d already done. So when I got the lab bill and it was about ten pages right and I didn’t pay for that, so I wasn’t sure. But I’m like, This is ridiculous. All because the record couldn’t get from three miles away to where I was sitting at that moment in time. 90% of the tests were unnecessary because they’re already done. While she’s at the hospital, they did them again. I said, Someone’s got to fix this and now I’m here.

John Moore III: [00:11:39] Okay, that’s really cool. That’s a very good story to share. Yeah, there’s always a personal element to these things.

Paul Wilder: [00:11:44] I tell our stories to my staff that work with me, know that there’s always an analogy, there’s always a story.

John Moore III: [00:11:51] That makes sense. So anything else I should ask? I feel like that was pretty good, right?

Paul Wilder: [00:11:59] I often tell it and nearly start crying because there’s there’s sometimes I go at a different level. I was like, this is ridiculous. But today I’m good. I’m good. It was horrible. It was horrible. I was so mad.

John Moore III: [00:12:11] One more question. So what do you think the future of interoperability looks like in health care when you envision a perfect, seamless system?

Paul Wilder: [00:12:22] Well, that’s that’s two questions, actually. What’s the perfect system? And what do I think is actually going to happen?

John Moore III: [00:12:26] What do you think the outcomes will be like? What is what are you excited about when we solve this issue?

Paul Wilder: [00:12:31] When I’m excited about right now, we already have scale. Volume is growing. I could probably sit and almost do nothing and it’s going to continue to grow. That’s not good enough. The main thing that’s being added and TEFCA is trying to push us in and this is why part of the reason why I want the Alliance moved as quickly as possible is getting patients access to their data. So a story; you asked me to tell a story. If I enter this, why do I keep doing it? A lot of mistakes are made in health care and you just don’t know about it. And I believe that the human, the patient, the consumer is the ultimate arbiter of their data and the person that cares the most about it. And we’ve had years of portals and low adoption of them because they don’t work well. We need to plug patients into the networks of the providers already plugged into. If I have 50,000 entities connected and I can get all these records, why can’t I as a human get that right? And, you know, very simple story. About three weeks ago, I went to my primary care provider. High blood pressure control. Hopefully my life insurance company isn’t listening right now.

Paul Wilder: [00:13:33] I’m fine. I’m under control again. Don’t worry, I’m not going to die. And I got home. I looked at the portal because I’m a geek. I have access to every single portal I have. And it showed that I had a full blood workup or a test for it. I got a blood draw, which didn’t happen. And then I had HPV vaccine that day. I said, I’m not aware of many 40 some odd year old men that get HPV vaccinations. Something’s wrong, right? And if I didn’t catch that, you’re like, Oh, who cares? Every other provider ever sees that is going to realize it’s a mistake and not care. But let’s say go forward 20 years: I’m diagnosed with some rare cancer that is easily solved by some new therapeutic, and that therapeutic is contraindicated against someone that has HPV vaccination. I’m out there. All the a guy in the world is going to say, this would be great, except you did that, and it’s never going to suggest it because the data knocked it out before the provider even made a choice. I need that data to know that that’s wrong, to say it needs to be corrected and we’ve got to make that easier.

John Moore III: [00:14:26] Yeah, I know plenty of people that have had to correct the records. My mom included. I grew up with that. She was always on the phone with the insurance companies and the health care providers trying to make sure things were accurate.

Paul Wilder: [00:14:35] Do you know, as a nuance of that is they’re not required to accept the correction. It’s actually by law, they’re required. You’re you are you are fully authorized as a human patient consumer to request a change to your record. They do not have to accept the request. They have to adjudicate it and say why they didn’t accept it. It’s for good reason. They don’t want people to erase saying things that are important, clinical.

John Moore III: [00:14:55] To adjudicate the reason why to deny it. That makes sense. It was just they can deny then why would they ever do it?

Paul Wilder: [00:15:01] There are some perverse, you know, weird things that can happen because of that, some that are biased and political in nature. But it’s a weird thing. You have the right to ask for it. They don’t have the right to accept it. So I’ve sent in my request. I’m hoping they fix it.

John Moore III: [00:15:12] Okay, fair enough. All right. Well, thanks a lot for joining us today. Before we break, is there anything that you’d like to share with our audience about what you’re doing and also how to contact you if they want to reach out?

Paul Wilder: [00:15:22] Sure. First of all, our website is CommonwellAlliance dot org. All one word and I’m just Paul at that. So Paul at CommonWellAlliance dot org. Feel free to send me a note. I do have a lot of things. My inbox, if I don’t get to it, just send it two more times. I will see it eventually and I will get to it. As for things we’re kind of working on this TEFCA thing’s a big deal for us, right? It’s a big move. The problem with TEFCA and the reason why we’re out there saying that we’re going to be there is others have to show up or it doesn’t work. It’s a fax machine without something–okay, I’m sorry–We’re in HIT. We’re not allowed to talk about fax machines. It’s a phone without someone else having a phone. Right. You don’t want to be there with your friends and go, where is everybody else? So, you know, we’re coming. We’re going there. We’re we’re waiting for final documentation that we can sign the agreement that puts us as the super node or one of the super nodes. And with that comes patient access. So we’re expected to do a lot of moving in the next couple of years.

John Moore III: [00:16:17] That’s exciting. I mean, patient access is a really important thing and finding ways to actually engage the patient in the methods and the modes that they want to engage is one of the biggest problems. Like you said, portals they’ve been a waste of time for in a lot of cases. Like they’re good for getting a message to your doctor. Exactly. And little else.

Paul Wilder: [00:16:33] And someone asked that the other day. I said, Well, we already have all these portals and they’re not using it. I said, Well, some people are, but they’re using it for less for clinical things, using for administrative tasks. I need to ask a question. I need a refill or I need to make an appointment. I think in the future you’ll still do that. I don’t think my network is going to have appointment scheduling on it. I don’t. That’s very unlikely. And by then, probably not my network. It’s someone else’s network because everybody’s network, I don’t own this, I just work there. But the the portal is what I engage all the administrative things to the provider I have today. Yes. Well, the network does is remember the data that you used to have. You maintain the relationship with your data by having the network there to support that. And I think that’s important just because your primary care provider has changed and using their portal. Doesn’t mean the data from five years ago doesn’t matter today.

John Moore III: [00:17:18] Of course.