A couple networks are live, and the Office of the National Coordinator for Health IT hopes the first group — among 12 entities that submitted letters of intent — will be officially designated qualified health information networks (QHINs) in early 2023.

Part of the Department of Health and Human Services, ONC published a framework in January for exchanging health information nationwide: the Trusted Exchange Framework and Common Agreement (TEFCA). Required by the 21st Century Cures Act, the framework provides non-binding principles and the agreement technical terms, and now it falls to ONC’s recognized coordinating entity, The Sequoia Project, to approve interoperable QHINs.

“What we’ve heard informally from a number of the prospective QHINs is that they are building in anticipation of getting approved,” Tripathi said, during eHealth Exchange’s annual meeting on Dec. 15. “They think that they would have a pretty good opportunity to do this in the 12-month window and hopefully shorter than that with some of them.”

QHINs will be added on a rolling basis to include electronic health record (EHR) vendors, ambulatory practices, hospitals, health centers, federal and public health agencies, and payers. Epic Systems became the first EHR vendor to announce it would seek QHIN status in August and was later joined by the likes of the eHealth Exchange network and trade association CommonWell Health Alliance.

How TEFCA coexists with other exchanges when it comes to benefits determinations, health care operations, treatment, payment and individual access remains to be seen. But scaling TEFCA will be the “real challenge” and one for which incorporating the Health Level Seven (HL7) Fast Healthcare Interoperability Resource (FHIR) data standard will be key, Tripathi said.

FHIR application programming interfaces streamline health information exchange by eliminating the need for separate data use agreements, and eventually they’ll enable questionnaires, scheduling, links, Clinical Decision Support hooks and subscriptions. That’s why there are already federal deadlines in place for their steady adoption across the public health ecosystem, but QHIN-to-QHIN brokered exchange remains years away.

By the end of 2022, certified EHR vendors must make a FHIR API available to customers.

HL7’s Helious FHIR Accelerator aims to improve the exchange of situational awareness information on hospital and intensive care unit beds available, ventilator counts, personal protective equipment counts, and vaccinations. The HHS Protect system launched during the height of the COVID-19 pandemic provides a lot of that information right now.

“But it’s done via spreadsheets,” Tripathi told FedScoop in July. “A lot of manual work is still done to populate that now.”

The government has spent about $40 billion on EHR infrastructure since the passage of the Health IT for Economic and Clinical Health (HITECH) Act in 2009. Yet clinical operations and health payment systems remain largely rooted in paper because states — most of which still don’t require electronic case reporting — have health authority in the U.S.

Jurisdictional issues and scarce resources are some reasons why about 30% of U.S. hospitals still don’t connect to a health information network, Tripathi said Dec. 15.

Naturally issues with case reports, lab and testing results, and vital records arose early in the pandemic, when they were often being shared by phone or fax.

For all these reasons the Centers for Disease Control and Prevention launched its Data Modernization Initiative (DMI) in 2020 to streamline sharing of electronic health information between care providers and state, local, tribal and territorial (SLTT) health departments. 

The DMI’s first phase has involved getting data from electronic sources into a Microsoft Azure cloud environment, called the Enterprise Data Analytics and Visualization (EDAV) platform, while providing SLTT health departments with automated forecasting analytics tools.

Data standardization is key to improving information sharing between these systems, which is why ONC is working closely with the CDC on its North Star Architecture. The U.S. Core Data for Interoperability (USCDI) Version 4 (v4) that ONC has planned for 2023 will become the de facto minimum set of health data classes and elements for nationwide, interoperable information exchange.

At the same time ONC is developing USCDI+, a nationwide public health data model, for release beyond 2023. Discussions with the CDC and Centers for Medicare and Medicaid Services revealed more than 20 data elements that overlapped, allowing the agencies to agree on a common approach.

ONC is now speaking with the White House Office of Science and Technology Policy and the National Institutes of Health about tailoring a USCDI+ program for President Biden’s Cancer Moonshot program.

EHR vendors support TEFCA and the DMI because they’ll be able to maintain just one customer interface, rather than hundreds to meet the various jurisdictional requirements of SLTT health departments, Tripathi said in July.

Phase I of the DMI is also improving the CDC’s situational awareness, which is based on the Data Collation and Integration for Public Health Event Response (DCIPHER) platform — originally intended to track food-borne diseases. DCIPHER gave rise to HHS Protect and has since had hospital capacity, social vulnerability, mobility, race and ethnicity, social determinants of health, economic, two-on-one, and climate data layered atop it as part of the new Center for Forecasting and Outbreak Analytics’ work, Dr. Dan Jernigan, deputy director for public health science and surveillance, told FedScoop in August.

The center can already do weekly influenza and some Mpox forecasting and has visibility into emerging problems at about 70% of emergency departments.

“To see a fully formed prediction center, it’s going to be a couple years,” Jernigan said. “The numbers of staff that are in the Center for Forecasting right now are in the tens to thirties, but it is anticipated to be a much larger group.”

As part of DMI Phase I, 128 reportable diseases now automatically trigger EHR electronic case reporting, which is routed to the Association of Public Health Laboratories-APHL Informatics Messaging Services (APHL-AIMS) cloud platform and then SLTT health departments. Electronic case reporting increased from 187 facilities pre-pandemic to more than 14,000, more than 30 of which turned on Monkeypox reporting.

While the effort highlights the CDC’s move toward pathogen- and program-agnostic systems through its DMI, electronic case reporting continues to fall short.

“It’s not nearly the volume that we need it to be,” Tripathi said in July. “But at least we’re starting to set up those pathways.”

At the same time the DMI has seen “dramatic improvements” in COVID-19 reporting across immunization information systems (IISs), he added.

IISs were slow to take adult COVID-19 vaccination information, but now they accept line-listed records using privacy-preserving record linkage — even for Monkeypox.

The CDC recently revised its DMI implementation plan, and Phase 2 will focus on improving state health departments’ cloud infrastructure and update the National Electronic Disease Surveillance System (NEDSS) Base System (NBS) that 26 states use for case management.

Cloud migration allows doctors like Phil Huang, director of Dallas Health and Human Services, to match immunization, lab and death records to know if a patient who passed away tested positive for COVID-19 and was vaccinated. 

“That ability to put that data together and integrate it with other kinds of information, even down to the neighborhood level, helps him do his prevention work and his mitigation work in a much more targeted way,” Jernigan. 

CDC proposed the DMI receive about $200 million in fiscal 2023 to continue its “incremental” progress, but the Healthcare Information and Management Systems Society estimated the initiative needs $33 billion over the next 10 years to be successful, he added.

Meanwhile ONC, unable to enforce TEFCA, is working with federal partners to highlight the need for network-to-network interoperability and hoping its rollout leads outside providers to question why they’re still faxing records.

“We were given no dollars and no new authorities to do this,” Tripathi said.

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Running five years, the contract unites the Palantir-driven Health and Human Services (HHS) Protect, Administration for Strategic Preparedness and Response (ASPR) Engage, Tiberius and DCIPHER programs into what the CDC is calling its Common Operating Picture.

The CDC contracted Palantir to launch the public health infrastructure programs during the height of the pandemic, and the new Common Operating Picture approach will allow for long-term, interagency planning and operational consistency around outbreak and incident preparedness.

“There’s no way Palantir could do what we’re doing in this space without a really deep emphasis on partnership and interoperability, not only with our federal partners but with other technology systems and the other key players in the public health technology landscape,” Hirsh Jain, head of public health federal at Palantir, told FedScoop in an exclusive interview. “By definition a Common Operating Picture really requires that level of engagement with other systems and other entities.”

The Common Operating Picture allows Palantir to scale its modular technology beyond the specifics of COVID-19 for more generalized public health response to diseases like Monkeypox and respiratory syncytial virus (RSV).

Beneficiaries include federal agencies, jurisdictional health departments and industry partners, which rely on the Common Operating Picture for disease surveillance, outbreak preparedness and response, and supply chain visibility and management.

“Every platform is being used for use cases and mission areas beyond COVID,” Jain said. “The underlying modules were configured in a way that allows for pretty immediate expansion beyond COVID and reusability across that broader space of diseases.”

The National Wastewater Surveillance System uses Palantir software for wastewater genomics, while the Predict Division within the CDC’s new Center for Forecasting and Outbreak Analytics is embarking on an “ambitious” effort to deploy models and analytics addressing critical needs as they arise, Jain said.

Advances in such work are more likely given the length of the Common Operating Picture contract.

“We’re really excited about the 5-year commitment here, knowing what the last five years have been like,” Jain said. “Having long-term preparedness and public health response infrastructure in place is so critical, and this gives Palantir the place to support CDC and the broader public health ecosystem in delivering that.”

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Palantir will continue to modernize the Data Collation and Integration for Public Health Event Response (DCIPHER) environment, built on its Foundry platform, to ensure CDC has the infrastructure necessary to perform genomic sequencing of variants and track them and their outcomes.

DCIPHER is one of Palantir’s longest-running public health software partnerships, having run more than a decade, and influenced its COVID-19 pandemic response support — despite being a separate initiative encompassing food-borne outbreaks, Ebola, anthrax management and bacterial special pathogens.

“Beyond COVID, by incorporating innovative genomic workflows into traditional public health surveillance, CDC is building upon its foundational investments in a modernized technology infrastructure,” said Dr. William Kassler, chief medical officer for U.S. government at Palantir, in an April 15 announcement.

The CDC is increasingly investing in modular technology that can apply COVID-19 use cases to other diseases and incorporate granular demographic data from multiple sources to help improve health equity in underserved communities, according to a person with knowledge of the contract.

Palantir declined to disclose the length or value of the contract extension, but it builds on the tech company’s wastewater surveillance work with CDC, which provides a picture of diseases affecting particular communities.

DCIPHER is currently used by the System for Enteric Disease Response, Investigation and Coordination; National Center for Immunization and Respiratory Diseases; and National Wastewater Surveillance System within the CDC’s Division of Foodborne, Waterborne and Environmental Diseases. The Department of Health and Human Services, National Institutes of Health and Food and Drug Administration also use DCIPHER, as did several military branches to mitigate COVID-19’s impact.

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The one-year, $7.4 million contract renewal covers the modernization of the Data Collation and Integration for Public Health Event Response (DCIPHER) environment, based on the Palantir Foundry platform.

While the National Center for Emerging and Zoonotic Infectious Diseases has used DCIPHER to better manage food-borne outbreaks since 2010, the COVID-19 pandemic showed other CDC centers the benefits of using scalable, interoperable cloud solutions.

“We’ve learned from the pandemic just how important it is to modernize surveillance to have that situational awareness for any public health issue,” Dr. Bill Kassler, chief medical officer at Palantir, told FedScoop.

DCIPHER collects epidemiological, surveillance and laboratory data from various sources so CDC centers and their partners can make informed decisions around outbreaks.

Within NCEZID, both the System for Enteric Disease Response, Investigation, and Coordination (SEDRIC) and the National Wastewater Surveillance System use DCIPHER.

More recently other centers have requested similar cloud infrastructure to assist with surveilling the flu and HIV and the Center for Global Health.

The pandemic made CDC centers recognize the need for earlier situational awareness on social determinants of health, to plan a more equitable response, and supply chain instability, to get personal protective equipment and other resources where they’re needed, Kassler said.

Unfortunately many CDC systems are legacy systems that can’t be scaled for more compute or storage in a crisis to handle hundreds of necessary data sources. Systems like that can take contractors two to four months to recode for collection of new data fields pertaining to novel outbreaks.

DCIPHER’s usefulness extends beyond outbreaks though as new data sources on genomics, social needs, behavior from wearables, and clinical records help monitor conditions like heart disease and stroke.

“We think there are huge opportunities across the federal government to bring disparate, multimodal data together to help to visualize that data and to make it into a form that advanced analytics such as machine learning and predictive modeling [can use],” Kassler said.

The Department of Health and Human Services awarded Palantir several contracts early in the pandemic that were not competed citing the “unusual and compelling urgency” of the crisis. Those contracts supported the development of HHS Protect, which informs the White House on COVID-19’s spread and comprises most of Palantir’s work around the pandemic.

Palantir also supplies the analytics platform behind the National Institutes of Health‘s National COVID Cohort Collaborative (N3C) Data Enclave, used by researchers to better understand the coronavirus.

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