Man in the Arena: Choose Your HIE Vendor Wisely

September 15, 2011

In 1910, President Theodore Roosevelt gave a rousing speech to an enthusiastic audience assembled at the Sorbonne in Paris; the speech has since been referred to as “The Man in the Arena”.  A slightly modifed version of its most famous passage is offered below:

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena… who strives valiantly… who does actually strive to do the deeds… who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

Why, one might ask, would this passage be offered in a blog post about Health Information Exchange (“HIE”).  As a provider of comprehensive HIE technologies and services, I’ve been very fortunate; I’ve witnessed, first-hand, improved patient care through enhanced care coordination within and between communities facilitated by real, useful, intelligent health information exchange.

I do, however, find myself regularly frustrated at the press releases and pronouncements outlining grandiose HIE initiatives that ultimately never leave the paper on which the plans were drawn.  Yet dollars are spent, consultants are engaged, and industry ratings from various third-parties are offered.

Where, amidst all this activity and all this buzz about HIE, has the provider and patient landed?  For some, real value (measured by adoption, participation, use, transaction volumes, and effective clinical communications) underwrites improved patient care; the “doer of deeds… realizes the triumph of high achievement”, not because money is made but rather because care is improved through tangible, “rubber meets the road” clinical data distribution and integration – in other words, by “…the man who is actually in the arena”.

It has been my experience that all too often “could, should, and might” hide behind the veil of slick marketing and stories of what might be, could be, and should be as substantial resources in terms of dollars and time are spent; yet, those that spin such a yarn never actually enter the arena.  For if these “timid souls” entered the arena, their performance would be measured; the performer(s) would be held accountable.

So, I come to my conclusion. When choosing an HIE vendor, be sure to choose wisely.  Choose from those that have strived to deliver, those that have leapt into the arena and learned from experience, those that have stumbled but continue because a relentless pursuit of improved care is the objective.  Avoid those “…cold and timid souls who neither know victory nor defeat.”  Let them continue to sit on the sidelines and pontificate about the struggles and realities only a few of us truly know.

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Posted by Todd Fisher

HIE and Co-opetition: The Cooperative Imperative

June 21, 2011

I’ve written often of the values of a bottom-up, private market approach to Health Information Exchange (“HIE”) deployment.  The implementation and successful, deep, broad deployment of HIE brings with it competitive advantages that include better care, improved physician alignment, enhanced referral flow, and higher patient affinity and satisfaction.  Such benefits occur directly from improved information flow and better information delivered to the right provider at the right time improves care and creates an environment in which care providers prefer to work and patients prefer to receive care.  The corresponding return on investment makes the bottom-up market-driven model self sustaining.

I’ve said and written numerously when considering HIE, a health system should think, “competition first, then cooperation.”  The purpose of this nifty quote is to re-direct those that would consider a top-down, publically funded program predicated solely on the values and virtues of inter-health system cooperation.  Such top-down approaches have failed abysmally.  At this point, I don’t believe I need to enumerate the litany of failed public HIE initiatives.  In fact, my recommendation to our federal and state governments is to reconsider such public funds and direct them to other initiatives more appropriately served by the government.  In my opinion, driving market activity with public funds is a precarious endeavor wrought with great danger and instability especially when considering public HIEs operate at the whim of an administration powered by political and fiscal priorities often unassociated with the provision of care.

A bottom-up, free market approach to HIE does not preclude cooperation.  In fact, private HIE is justified using a simple guide:  competition first, then cooperation.  Inter-health system cooperation is not simply empty words placed in a free-market thesis to appease those searching to serve the public good.  Rather, it is a necessary and inevitable aspect of the private HIE market, as benevolence ultimately results from the invisible hand of self-interest.  Let’s consider why.

1. Risk Mitigation.  Health systems wishing to enter into a quality-based, shared risk reimbursement model must assess how to maintain quality care while mitigating risk.  Generally, such reimbursement models are defined by a specific patient population, not a provider population.  As a result, absent a complete geographic monopoly, which is extremely rare, a health system that enters a risk sharing reimbursement model cannot positively control all aspects of care vis-à-vis the care of the covered patient population.  This is true because health systems and their affiliated physician population cannot ultimately control where a patient chooses to seek care.

The best way to combat this phenomenon is to ensure patient health information is liberated and flows freely to all those that may deliver care to a covered patient.  In areas where physicians split referrals across entities serving overlapping and tangential communities, leveraging the HIE asset as a means to share critical clinical information appropriately spreads (i.e., dilutes) risk and helps mitigate what is otherwise a complete loss of control over patients for whom the health system is financially responsible.  Better information flow equals less risk and better economics.

2. Consumerism.  It is well documented in books like How We Decide (Jonah Lehrer) and Blink (Malcolm Gladwell), for example, that consumers don’t necessarily like too many choices but do seek out some choice – even in a highly inelastic environment such as healthcare.  Without choice, consumers, which in this case are patients and physicians, feel squeezed and hobbled by those that limit choice.  It is important progressive healthcare organizations that have chosen to leverage HIE for competitive advantage ultimately allow other organizations to participate in established exchanges.  Doing so provides health systems and smaller community hospitals two important features:

- First, when such progressive organizations offer health information exchange to additional providers in and near their community, they appear at once benevolent and confident in their own services.  Simultaneously providing such service to those that may have been competitors in the past offers patients and physicians in the community care options with comparable HIE capabilities, which will inevitably keep the patients and physicians comfortable in the notion that choice is available.  Absent the perception of choice, patients and physicians will seek alternatives and potentially disregard the community entirely as one in which choice is so limited as to call into question quality.

- Second, smaller community hospitals have an opportunity to band together, tied by the string of efficient, secure, enhanced information flow, and appear larger and more cohesive to the consumer market without losing individual hospital and health system identities.  This is particularly important now as there is a tendency in the industry for consolidation to gain scale in an unfavorable economic environment.  Ironically, not only does this approach enable smaller organizations to remain independent and appear larger, it offers such organizations better information flow, which invariably leads to better care.  No one would argue the point that better care equals better economics.

So, there you have it.  I absolutely believe establishing a market-determined competitive advantage through HIE is critical and the only means by which a truly sustainable business model can be established for health information exchanges.  But, my strongly held belief that it’s about competition first, then cooperation necessitates both sides of the equation.  For the system to truly grow and thrive, cooperation will emanate from a functional market supporting and advocating health information exchange.

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Posted by Todd Fisher

HIE’s Real Missing Ingredient: Value

May 31, 2011

Most health information exchange networks continue to struggle with financial sustainability. Reports come out on nearly a daily basis highlighting the issue: fewer than 10% of the HIEs in eHealthInitiative’s 2010 HIE survey proclaimed financial viability. Harvard’s recent report found less than a third of the HIEs they spoke to had it.

I think I know why.

My colleagues and I were just talking about a regional HIE presentation we saw. It was like many others, presenting their nice architecture, their nice volumes (x hospitals, y patients, and z patient records), their nice support of standards, and nice plans to drive up adoption.

Towards the end they dedicated one slide to financials. The first bullet, right at the top, said they were still working on achieving financial sustainability. Then they had the usual nice ideas of charging the 3 P’s: providers, payors, and maybe even patients. Classic “build it and they will come.”

To me it is clear why they’re not sustainable. They can describe their nice technology, they touch on their nice service, but they cannot describe their value.

To me, especially given that many HIEs are funded with state and federal tax dollars, the lack of demonstrated value is an absolute crime in our industry.

How do providers use their service? How is care improved? How can real people/organizations save real money? How about some examples? …and please, don’t use the overused and generalized “unconscious patient presents in the ED and the ED doc is going to take a few minutes to look up records in the HIE.” That doesn’t work (and guess what, this presentation included that as their one and only scenario – very “HIE 101″)

Value begets money. Money begets financial sustainability. Follow the chain.

When Vince Offer pitches his Shamwow wonder towels he pitches value exclusively. He compares it to a wimpy paper towel. He shows how you can save your brand new white rug from your overindulgent friend’s gravitationally-challenged red wine. He makes it clear that not only is Shamwow better, faster, and stronger, but using it is faster, easier, and more effective than pretty much anything else you’ve laid your eyes on. Value, Value, Value.

He does not get into the exact measurement of the Shamwow. Or list the ISO certifications achieved by its manufacturer. Or tell you how many he has at his house. Those details might be intellectually interesting, but would never entice the mass market to part with their $19.99.

The HIE market needs a lesson from Shamwow: figure out how using HIE makes healthcare delivery faster, easier, and better… delivering measurable value.

I can pick on the sustainability of established HIEs, but that is water flowing under the bridge even as we speak. What about folks in the market for HIE today? Can they be saved with a nice dose of value?

We’ve responded to dozens of HIE RFPs. We chat with the industry analysts working to help buyers of HIE services. They all have checklist after checklist asking things like:

  • Is your HIE architecture hybrid?
  • Do you have a clinician portal?
  • Do you have a patient portal?
  • Do you support standards like IHE, NwHIN, Direct, HL7, XYZ?
  • Is your system secure?

I know many think of us as “evil vendors”, but really now, we’re not that dumb. We’ve done our homework. We’ve invested and built our products out. And we are prepared to answer “yes” to pretty much any of these questions. If we can’t say “yes”, we’ll say “yes, with a partner” for sure.

The problem is these questions don’t get into value, and the buyer/analyst cannot truly assess the value potential of one solution over the other. Value is more than technology widgets, it is how the technology widgets are deployed and used in the real world.

At first one might consider adding a few things that are less technical, like

  • What is your deployment model (site-installed, hosted, SaaS, all)
  • What is your support and training model (helpdesk for end users or just train-the-trainer)
  • What is a typical implementation timeline (how long to install connectivity between 1 hospital and 3-5 practices, for example)

These questions are points that HIE vendors still have different approaches on, and hopefully buyers understand the impact of each difference.

Ask vendors how their solutions are improving healthcare.

I’m not an expert at how to do this, but at least I have the excuse that I’m not an analyst.

If you were to ask me how my company, MobileMD, demonstrates HIE value, I would roll out a bunch of facts and figures (backed up with client phone numbers) that illustrate the impact with have in our client sites today.

  • Trim 15% off ALOS in California
  • Bring in $2.3M of lab business in Pennsylvania
  • Reduce ED utilization by uninsured frequent fliers by 20 visits per day, also out west
  • x thousand of page views per day (that’s pages individually requested by human end users, not pages sent by an automated computer system)
  • y physician users added to the system monthly (who have logged in more than 5 times – it is easy to add users to a system, a little more challenging to get them to logon at least once [maybe entice them during a training session], but 5 logons begins to differentiate)

We just lit up a connection between a hospital and a home health agency. We think this will have a real impact and set the stage for real ACO/P4P case management, though honestly it is too soon to measure quantitatively.

Much of the value I list is to the benefit of a single given provider. That’s fine… as you, our loyal HIEWorks blog reader knows by now, our approach is to fill the healthcare landscape with enterprise HIEs that are valuable and sustainable, reliable and secure. Then we weave the “private” enterprise HIEs together into a public exchange fabric with technologies like NwHIN and the Direct Project: fed by the rocket fuel of competition before the fruits of cooperation. I’ll avoid digressing by referring you to our other posts, including this one that contrasts public and private HIE viability.

This, to me, is the ultimate “secret sauce” in HIE – how do you use this sometimes vague, nebulous, and often misunderstood technology to improve healthcare, streamline operations, and improve patient and provider experiences? If we do that we can show value, and we can quickly solve sustainability.

Unfortunately it isn’t as easy as just applying the latest IHE standards profile!

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Posted by Chris Voigt

The Mission: Care Coordination

May 5, 2011

Health Information Exchange (”HIE”) means many things to many people.  Ask 10 people what they believe to be the definition of HIE and you might well get 10 different answers.  Some will define HIE as a noun, some will define HIE as a verb.  Some will define HIE as a public initiative, some will define HIE as a competitive advantage-adding technology, and some will simply suggest HIE is merely a way for large consulting firms to make money as they write and then evaluate massive RFPs.  All that said, make no mistake, the fundamental mission of HIE is to improve care coordination.

But, what do I mean by care coordination?  Coordinating care can involve coordinating the care of an entire population, a specific population with a given disease state, health surveillance for a geographic region, or coordination across the provider payor relationship.  All such care coordination efforts are critical and significantly impact the cost and quality of care; and, all these examples benefit from HIE.  At the foundation of all care coordination, however, is the physician patient relationship.  Specifically, the quality of care coordination is largely defined by the quality of information flow between care providers along a specific patient’s care continuum – care from provider to provider, provider to patient, facility to facility.

So, allow me to offer this: health information exchange is absolutely necessary to improve care coordination if for no other reason than HIEs, such as MobileMD’s offering, liberate clinical information from its source system silos and delivers all the right information to the right provider at the right time within the context of a care community.  Without HIE, clinical data remains highly compartmentalized; care coordination is thus significantly hampered due to lack of timely, context-based information flow.  The result is redundant procedures, unnecessarily long hospital stays, unnecessary ER visits and hospital readmissions, ill-informed clinical decisions, increased patient and physician risk, increased costs, and decreased care quality.

While there are several good examples, allow me to highlight a particularly obvious example. Psychiatric patients often visit numerous specialists as a result of their health condition.  As one might expect, each specialist makes care decisions based on the information available at the time of care.  If a psychiatric patient visits a psychiatrist, a neurologist, and a gastroenterologist, potentially multiple times over a three month period, due to symptoms from both the underlying condition and medication side-effects, how can each care provider possibly deliver quality, comprehensive care without requesting redundant procedures and without prescribing contra-indicated medications, for example, if each provider is not offered a complete care picture for that patient?  Traditionally, patient health information has been sourced by the patient and, if lucky, partial patient chart information sent via courier or fax. The result:  each provider must fly, so to speak, without proper instrumentation.

If, however, each provider along the continuum described above has real-time, ready access to complete patient health information, better informed procedures are  requested, accurate diagnoses are more easily derived, and medications are better aligned, to name just a fraction of the care considerations that lend to quality and cost and emanate from a coordinated care effort.

As the rapidly emerging primary medium for clinical information flow, Health Information Exchange serves as the cornerstone for care coordination.   Better care means less expensive care, thus rendering to the shadows those that would suggest care must be rationed to control costs.

With that, I request that you “tune in” to a future post for more about “right care at the right time” vs “care rationing”…

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Posted by Todd Fisher

HIE Frameworks, Generating Real Value and “Clobber-ation”

March 29, 2011

At this year’s HIMSS conference in Orlando, the University of Maryland’s Center for Health Information and Decision Systems released and presented a framework to assist folks in developing and assessing sustainable health information exchange networks, the “CHIDS Evaluation Framework for Sustainable Health Information Exchange”.

The framework is based on interviews, environmental scans, user surveys, and benchmarking. Interestingly, they benchmarked HealthBridge, Michiana Health Information Network (MHIN), and Delaware’s network, DHIN - these HIEs are supported by either participant subscription fees or “legislated contribution”, in DHIN’s case. I like a couple of success factors they pointed out about the benchmarked networks:

  • Look for quick wins
  • Align incentives with the community and avoid competing with it
  • Be flexible and offer access mechanisms for everyone, regardless of their technical prowess
  • “Push system has a clearer value proposition than a pull system”
  • No matter what folks think, don’t count on payors for operational funding
  • Assemble a broad stakeholder group

They go on to define what I would call a Golden Rule for HIE sustainability: a RHIO should work with stakeholders to identify valuable services, deliver those services, and charge a fair fee for those who use the services; sustainability is reached when folks receive value, pay for that value, and the fees cover HIE costs.

That seems really simple, but it is something missing from far too many public HIE efforts.

Whether you look at a region, a state, or even some of the nationwide exchanges as examples, the perceived value delivered does not add up to the cost to deliver those services. So where are things going wrong?

I’ll describe two issues that I think effect why public HIEs cannot generate enough demand for their service or their service doesn’t yield value,  and thus they care unable to generate the revenue to achieve sustainability: Collaboration and Generating Real Value.

Collaboration is hard. In healthcare we are all driven by elements of the Hippocratic oath, whether we are physicians or not. We need to do the right thing for patients, improve health and the delivery of healthcare, and help control healthcare spending for the health of our economy. Many folks get around the table as “RHIO Stakeholders” with these holistic thoughts in mind and devise ways to share data, share services, and setup structures for the common good. But then all too often people go back to their “day jobs”, where they run their healthcare businesses, compete in their local market, and make tough decisions. When these worlds collide and can lead to Clobber-ation, not collaboration. These undercurrents undermine progress at the community level, maybe deliberately or through indecision, absence, or some other indirect action, whether motivated by politics, competition, or plain old money.

Sounds evil and sinister, right? But as providers of all sizes jockey for their piece of the pie, these things do happen. “Should I share data with my competitor, when in my day job I’m figuring out how to set up an accountable care organization?” 

Generating Real Value is another problem. Real Value can’t be determined in a RHIO Board meeting. Real Value depends on things like end-user experience, service quality, data availability, and education. The DC RHIO report mentions the classic emergency department use case: the ED doc who expends precious moments during her work routine, logging into a RHIO application, looking for patient records, only to find that most of the time there are no records in the system – a catch-22 for HIEs that struggle with limited investment, limited participation, or who take the overly cautious path of phased implementations that choke the flow of useful data (clobber-ation in action!).

I encourage you to check out the framework. It was immediately put to work assessing our Capitol’s DC Regional Health Information Organization (RHIO).

DC’s RHIO started in 2007 and has been focused on hospitals and safety net providers. According to the report, after 3 years and $6M in public funds, only two hospitals and six clinics have gone live on their Microsoft Amalga platform. It faces staggering operational expense, with costs running between $3.4M and nearly $5M per year to run it.

What about Private HIEs?

The CHID HIE assessment framework is 100% oriented towards public HIEs. They focus on Governance, Community Engagement, Public Trust, and Technology.
 
Given MobileMD’s near-exclusive focus on the private/enterprise HIE market, I don’t believe Governance, Community Engagement or to a large degree Public Trust are relevant to our space. It is the fact that we have simplified, single-party Governance that makes our sustainability and adoption seemingly “natural” in our implementations. Public Trust in our world is driven by the discrete patient-provider relationship that we understand and manage to; again, not a factor that impacts adoption in an enterprise-focused network.
 
As for Technology, our cloud-based deployment, zero footprint, and “100% service” approach means nobody on the client side needs to know about or implement our technology. So again, we’ve removed the roadblocks and stumbling points.
 
So, I guess we validate that the framework correctly targets the key points that cause community HIEs to falter. We firmly agree that they bring to light the underlying issues impacting both adoption and sustainability of an HIE. MobileMD has built our 4D HIE solution, established our deployment approach, and selected our target market in such a way as to naturally mitigate most of these concerns.

What To Do?

Here’s our take: Rather that build public community HIEs in phases or baby steps that constrain data, limit participation, and suffer from clobber-ation, start the effort with privately focused enterprise HIEs. Deployed in alignment with health system or practice group business lines, these HIEs thrive given their close alignment with a business-oriented community of physicians, a natural patient flow, and in the spirit of competition. Connect these private HIEs by weaving an HIE fabric that spans an entire geography; use NwHIN CONNECT and Direct as the thread that pulls them together. This fabric accomplishes two things at once: it meets the internal business needs of an enterprise (think ACO, quality programs, and management of payment bundling and re-admit rates), and it provides information exchange across the community to improve outcomes and population health. Truly Competition Before Cooperation.

What do you think? Leave a comment!

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Posted by Chris Voigt

Evolving HIE: The Cornerstone for Healthcare’s Social Network

March 8, 2011

When I consider what direction to take HIE, I do what any entrepreneur would do… I look at the market, market trends, what is deemed valuable and worthless, what is used and what is not used.  I then extrapolate from that and determine how to move HIE in a direction that makes sense given not only current habits and patterns of technology use, but also what does history tell us about the path forward.  I then try and pick a point on that path forward and plant a flag, an objective to reach.  In small, bite sized chunks, I then move up the path, a path that never stops, but always delivers a scenic, valuable view.  For those of you reading this and thinking of the now famous (or infamous depending on your perspective) phrase, “bridge to nowhere”, the path I write of is not a path to nowhere; it is a path to the future.  A path to better health information delivery and by extension improved patient care.

In technology years, I need only go back a short while to evaluate innovations and glean direction.  As with any entrepreneurial endeavor, evolving HIE has risks.  But, risks can be mitigated.  So, let’s take a look at two unrivaled market leaders for some insight.  Over the past decade, give or take a few years, we’ve witnessed a clear path from silo-based systems to sophisticated search (i.e., pull) tools ala first generation Google to individual profile-based information delivery (i.e., push) ala Google Ads, new Google search algorithms and, of course, Facebook.

Google essentially started as a logical simplification of an increasingly difficult task – find information stored in a very diverse and geographically and technologically disparate, increasingly large network known as cyber-space.  Google developed innovative ways to aggregate content from any public website, regardless of format, organization, or corporate entity (sound familiar?). Google’s brilliance was in their simplicity; users could visit their single text box web site and ask simple questions of the entire Internet and get consolidated, meaningful responses in the form of usable, readily accessible information.  This should sound familiar, because in healthcare we have the same issue, diverse, geographically and technologically disparate systems, which all house critical information that when consolidated create a sum that is far greater than the parts.  Health Information Exchange has successfully begun to address this problem – the consolidation of and access to health information generated and natively stored in multiple facilities, disparate health IT systems, and various corporate entities.  That’s HIE Act I –query methods (i.e. pull metaphor) for information exchange.

HIE Act II gets very exciting and follows more closely to the Facebook paradigm, thus setting healthcare exchanges up for true collaborative computing in the social networking sense – a highly specialized social network.  By collecting end-user profile information, cloud-based applications intelligently deliver (i.e., push) mass-customized information to subscribers, which in the case of Facebook is a staggering 500 million plus unique users.

How does this manifest in health information exchange? Well, I’ve spent a good deal of time pondering this question.  And, the answer is that it manifests in many very useful ways.  Originally as a means to avoid information overload for physicians, HIE vendors, such as MobileMD, innovated and invented new ways to provide PHI consumers (i.e., providers, patients, and payors) the ability to create mass-customized subscription profiles to control the flow of information.  This added the intelligent push metaphor to providers, in particular.  The result is better information automatically delivered where it is needed and when it is needed.

So, as I consider an “intelligent push encore” for HIE, I have come to the realization that the profile-based push metaphor not only benefits physicians and payors through intelligent filtering, rapid delivery of pertinent information, and the elimination of unnecessary, and redundant PHI, the profile-enhanced push metaphor stands at the precipice of effectively and usefully bringing HIE to the patient population – a truly staggering opportunity, a tipping point.

This makes sense for a few reasons:

  1. Patients represent a logical extension of the HIE “network”, thus further contributing to the “Metcalfe Law” effect – the value of the network is proportionate to the square of the number of participants on the network.
  2. The patient market as beneficiary and consumer is massive.
  3. HIE’s networking roots, real time aggregation of meaningful clinical data, collaborative computing capability, coupled with a profile-based architecture contribute seamlessly to a health community social network.
  4. Extending on the profile-based architecture and availability of real clinical data – who better than a well-architected and deployed HIE is better positioned to intelligently push not only clinical results but also useful, mass-customized content to patients such as articles and medically vetted suggestions pertaining to issues of particular importance to the patient given the patient’s condition?  The alerts, content, and suggestions are enriched by information that arrives from and is delivered across the care continuum via the HIE.  The inherent shortcomings of partial information originating in technology silos is eliminated.

Centralized HIEs, in particular, sit on a mountain of valuable clinical, quality, and administrative data and are thus well-suited to deliver that data along with other relevant content based on profile.

As Einstein once said, “The secret to creativity is knowing how to hide your sources.”  In other words, it doesn’t matter how HIE gets to the right place, it simply matters that it does get to the right place.  The larger “digital information sharing” market, as represented by the likes of Google and Facebook, has pointed to a path and effectively said, “go that way”.

As you read this entry, it’s important to remember, “Rome wasn’t built in a day.”

 

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Posted by Todd Fisher

Thoughts on PCAST HealthIT Report

February 8, 2011

With many key words and tricky phrases, the PCAST report essentially proffers six tenets, which either state the obvious or introduce entropy by suggesting the solution to the problem is found in more technology and standards.  The Holy Grail

With that said, let’s review the six tenets and then come to a conclusion.

1. HHS’s vigorous efforts have laid a foundation for progress in the adoption of electronic health records, including through projects launched by ONC, and through the issuance of the 2011 “meaningful use” rules under HITECH.

This is certainly true.  HHS’s recent vigor surrounding EMRs has clearly kicked up a great deal of dust and arguably initiated an increased rate of adoption and some minor behavior modification surrounding the use of EMR technology.  It would be disingenuous of me in this blog to fail to point out that the lion’s share of activity has been spawned by the prospect of financial reward, or minimally financial subsidization.  Unfortunately, such top down financial incentive is provided at the sole discretion of the government – a government challenged with many things, most notably in this context deficit reduction.    Financial sustainability in a free market is therefore critical.

2. In analyzing the path forward, we conclude that achievement of the President’s goals requires significantly accelerated progress toward the robust exchange of health information.

This too is certainly true and in our humble opinion rather self-evident.  With the introduction of an information technology “digital revolution” designed to capture patient health information in a manner consistent with this century’s manner of processing data, the need certainly exists to exchange, aggregate, share and analyze the data.  Keeping the data locked up in silos renders its digitization quite valueless.  Health information exchange (as a verb, not a noun describing a network) is, in fact, the cornerstone for properly leveraging digitally captured and available patient health information (dare we throw in the semantically interoperable tricky phrase?).

3. National decisions can and should be made soon to establish a “universal exchange language” that enables health IT data to be shared across institutions; and also to create the infrastruc­ture that allows physicians and patients to assemble a patient’s data across institutional boundaries, subject to strong, persistent, privacy safeguards and consistent with applicable patient privacy preferences. Federal leadership is needed to create this infrastructure.

The notion that additional standards are needed is a bit odd given the number of standards developed over the past 20 years  - standards offered by numerous well-meaning technologists and clinicians.  In my humble opinion, this tenet introduces unnecessary entropy and suggests the problem we face in healthcare is largely one solved by technology.  That’s just wrong.  There’s plenty of standards and technology that can be brought to bear on the information challenges in healthcare.  Amidst the entropy such a suggestion creates, the real issues that must be addressed are overlooked; we must align incentives with behavior to encourage symbiotic information technology deployment to improve care and reduce costs.  The problem is one of behavioral economics, not technology. 

4. Creating the required capabilities is technically feasible, as demonstrated by technology frameworks with demonstrated success in other sectors of the economy.

While ruminating on the PCAST report, I thought about a famous Albert Einstein quote, “make everything as simply as possible, but not simpler” (emphasis added).  In other words, distilling this problem to some simple issue regarding technology frameworks that have been deployed to streamline information flow and improve service quality in other, different industries fails to recognize that healthcare, as an industry, is quite different from most industries guided by the free market.  Healthcare, certainly at the provider level, is inherently benevolent, for example.  Selling cars is not.  Investing money is most certainly not.  People don’t choose to get sick.  People choose to purchase cars, stocks, bonds, widgets, etc.  I strongly advise readers of this blog to be careful of superficial analogies.  A misinformed analogy applied to a problem has potentially dangerous implications. 

5. ONC should move rapidly to ensure the development of these capabilities; and ONC and CMS should focus meaningful use guidelines for 2013 and 2015 on the more comprehensive ability to exchange healthcare information.

As with tenet number two above, this is good and quite obvious. Dr. Blumenthal has been quoted for over six months suggesting the bar will be raised for HIE in Meaningful Use Stage 2 and Stage 3. Given the realities in which providers operate, long product development cycles, and complex installation and testing activities that are needed to deploy technology upgrades in their facilities, enhanced exchange of what is available digitally is appropriately suggested and well-timed – get the EMRs to some level of exchange capability (driven by ONC’s Standards and Certification rules), then give providers a year or two to meaningfully deploy the exchange capabilities proffered.

6. Finally, as CMS leadership already understands, CMS will require major modernization and restructuring of its IT platforms and staff expertise to be able to engage in sophisticated exchange of health information and to drive major progress in health IT.

What does this really mean? CMS already spends significant dollars on their IT modernization and maintenance. I believe the directive sets or should set CMS up to redirect behaviors within healthcare such that securely sharing digitally available healthcare data and turning such data to specific action is a goal worth pursuing.  The key, however, is behavior modification driven by aligning the incentives of a complicated environment that includes many players, some driven by self-interest and some by benevolence, all sitting on top of a consumer base that for the most part have little choice when it is time to “purchase” care.

At the end, the report makes certain recommendations, most of which we’ve heard before. Create, formalize and propagate standards, set up measures that will instrument and illuminate production-level utilization of information technology, health information exchange, and align Federal agencies and their IT systems to support such an industry infrastructure.  There are even a couple of holdovers from ARRA, like pushing forward comparative effectiveness, surveillance, research within FDA and CDC, and yet another nudge to get VA and DoD to step up their interoperability.

I like this recommendation in particular:

“Direct … efforts under the Patient Protection and Affordable Care Act toward the ability to receive and use data from multiple sources and formats.”

I don’t like that it is tied to the debacle that is PPACA, but the underlying advice is crucial. We need to establish incentives and economic devices that alter how business decisions are made in healthcare, reduce the self-service biases that exist, and empower our citizens to engage in and share more responsibility for their healthcare. Expect friction with socialistic norms and capitalistic principles. But today’s behaviors in healthcare are rarely rewarded for sharing information, and are not incented to use shared information.

My PCAST recommendation: regardless of the standards, technology, or implementation choices, move healthcare providers and our nation’s patients to weave themselves into our burgeoning healthcare information technology and exchange fabric, to participate, use, and benefit from the electronic flow of data. Focus on incenting this behavior, and we will have moved the dial on our nation’s healthby improving care quality while simultaneously reducing costs  – the quest for the healthcare industry’s holy grail will be complete.

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Posted by Chris Voigt

HIE: Healthcare Catalyst

January 27, 2011

My apologies for the delay since our last blog entry.  It is my intention to keep up the blog much more readily.  That said, surely the health information exchange market is moving and evolving very quickly with no signs of slowing down.  In fact, HIE is a more critical element to the HCIT landscape now than it has ever been – and its importance increases with each new provider, payer, and technology initiative.

I have good reason for my delay since the last post.  I’ve been fortunate to travel the country speaking with numerous providers, payers, and healthcare technology innovators about healthcare IT in general and HIE in particular.  During my travels it has become flagrantly obvious that HIE is not only a cornerstone of any health information technology initiative, HIE serves a second very important purpose – that of catalyst to all those innovative providers, payers, and technologists that have assembled leading edge, potentially valuable policies, technologies and services that have yet to find a following.   In short, the common refrain from all those I’ve spoken with has pointed to a glaring hole in their respective strategies.  Their creative, valuable ideas, products, and services all work optimally on a comprehensive data set, and may in fact lead to errors and dangerous outcomes without such a data set.

Let’s consider the following three examples: analytics, clinical decision support systems, and Accountable Care Organizations.

Analytics. Whether the goal is to analyze physician alignment, referral patterns, care quality, or risk, anyone in the analytics field will indicate that the more clean, “source of truth” data available, the more useful and accurate the analytics run on that data.  Analysis is critical.  It’s function is to turn raw data to understandable information upon which actions and decisions can be made.  Heretofore, the data available on which to conduct analytics has been locked in silos defined by the boundaries of the systems generating that data.  HIE eliminates the oft-arbitrary boundaries and provides an aggregated set of data representing all clinical and administrative information associated with patient care, including importantly the ubiquitous transition points associated with care.  Analytics run on anything less than a complete data set either limits the type of analytics that can be run, or worse, renders inaccurate or misleading information that by extrapolation results in misinformed decisions and actions.

The introduction of HIE provides a tremendous amount of opportunity to those that have been in the healthcare analytics business.  No longer is analysis limited by individual system boundaries or the limited data found on a claim. Said differently, analytics without HIE is of limited value.  Analytics with HIE is considerably more valuable measured both tangibly and intangibly.

Clinical Decision Support Systems. I think of CDSS as the next logical step up from the analytics I spoke of above.  If actionable information can be generated from raw data, some actions can be supported with automation, whether those actions are alerts, chronic disease surveillance, or communication of care protocols, CDSS is only as good as the information on which it relies.  There are a number of innovative clinical decision support systems built internally by providers and payers as well as offered by technology vendors.  But, their market value is muted.  Libraries replete with tens of thousands of rules stand ready to operate on data and information.  But, where does that data and information originate?  Where is it stored?  When a CDSS makes a determination, is that determination made with the best data and information available?  Or, is the CDSS constrained by the lack and type of data?

The aggregation function of a solid, scalable HIE provides a set of data prepared and ready to populate the myriad variables and algorithms that comprise a CDSS.  Without such a comprehensive set of data, once again the CDSS is only partially useful.  And, if deployed in an environment lacking data with the assumption data is complete and accurate, CDSS will render sub-optimal results often out of context or lacking key elements locked away in a different system (or heaven forbid on paper).

Accountable Care Organizations (ACO). ACOs represent a new means by which providers are compensated for the patient care they provide.  Emanating from the Affordable Care Act, ACOs and associated initiatives are relatively new.  They are predicated on the notion that providers should be paid on the quality of the care delivered not the quantity.   In my humble opinion, this is critically important as it much more effectively aligns the inherently benevolent nature of healthcare with the profit-seeking goals of the free market.  Do we wish to pay for more healthcare or better healthcare.  Since more healthcare can often lead to more complications and more cost, the obvious answer is to align incentives such that a team of providers is compensated on how well they care for their patient population – not how many services they provide.

On the surface, this sounds great.  Here’s the rub.  Without access to a comprehensive set of clinical information, a holistic view of a patient, how can care providers that constitute an ACO possibly know what services are necessary and what are not?  How can redundant, unnecessary tests be avoided?  How can providers implement meaningful preventative care programs?  Wouldn’t it be better and much more effective to care for a patient before that patient falls into the abyss?  Simply put, access to all the necessary and applicable information is absolutely critical to enable such a program.  And, I’m glad to report HIE stands ready to provide such access.  Analytics run on data efficiently aggregated by an HIE offers providers actionable information based on comprehensive data, thus mitigating risk and supporting better decisions.  Clinical Decision Support Systems operating on that same quality and quantity of data can provide real-time surveillance across terabytes of data and millions of patients, offer standard protocols for chronic disease management, and provider and patient early warning signals, via alerts of various types, so that patients can be carefully guided away from the abyss.

HIEWorks exists to discuss the dos and don’ts of health information exchange.  After my recent travels, I felt it necessary to point out just how critical HIE is to the entire industry.  To use a phrase I heard in San Francisco recently, HIE “liberates data” and in liberating data an entire set of innovative providers, payers, and technologists are given what they need to leverage their various and often brilliant initiatives – moving such initiatives from concept to reality.

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Posted by Todd Fisher

Health Information Exchange: A Network of Networks

October 12, 2010

Welcome back to the HIEWorks blog.   We took a bit of a hiatus during the summer months.  We’re back and ready to comment on the state and direction of health information exchange.

For some months leading up to the summer, we learned of numerous stalled and failing publicly funded health information exchange (HIE) initiatives.  After speaking with numerous organizations and personnel in the HIE market, including the ONC, it became clear that large, publicly funded HIE initiatives financed with government subsidies and constructed around the delivery of a single technology option for HIE is rapidly falling out of favor.  As we’ve written before, lack of sustainability is the primary issue facing publicly funded HIE initiatives. Moreover, such initiatives often follow geographic boundaries dictated by the public funding sources such as those specific to a particular state, and not the needs of care communities. As a result, public initiatives have been weighed down by considerable challenges and unfortunate entropy.  State patient privacy and regulatory compliance, patient consent laws and regulations, financial and regulatory considerations for inter-state healthcare systems, and Medicaid reporting disparities between states are among the myriad issues that arise from bounding HIEs using arbitrary geographic determinants.

Here’s the good news. A clear change is underway in the HIE marketplace.  Current and planned standards emanating from the ONC and other widely accepted standards committees indicate a strong preference for interoperable exchanges designed to serve individual enterprises, Accountable Care Organizations (ACO), medical referral regions and local care communities – i.e., those communities that serve a logical and well understood population of physicians and patients.  And, through established and evolving standards such as NHIN CONNECT and NHIN DIRECT, the HIE market direction is to support a network of networks (or exchanges) linked together through a common, open source architecture, promulgated by the ONC and other recognized standards bodies.

The sustainability and practicality of monolithic, publicly funded HIEs that do not provide for “on-ramp” connectivity from established and planned exchanges is precarious at best.  The ONC has made it clear that all HIE initiatives should, at a minimum, make provisions to support connectivity between disparate exchanges.   That is the very purpose of the standards, and that is the only way to encourage innovation while leveraging past and planned investments.

It is no secret the healthcare landscape is littered with failed public HIE initiatives designed to deliver a single-source solution to an arbitrarily determined collection of care providers and patient populations.  Simply put, such initiatives are not guided by the free market.  Rather, they are subject to the whims of annual government budget cycles, grants and misguided governance.  So, what do we do? I believe publicly funded initiatives must facilitate and encourage interoperability between HIEs built on sustainable models that support logical healthcare communities – communities built around natural provider-patient relationships, referral patterns, and accountable care organizations.  In doing so, these initiatives (i.e., public initiatives) have an opportunity to add value, properly leverage public funds, and help lay down the necessary infrastructure required to facilitate the network of networks that will someday be known as the Nationwide Health Information Network (NHIN).

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Posted by Todd Fisher

Regional Extension Centers vs. the Competition

July 6, 2010

The HITECH Act created the Health Information Technology Extension Program, an effort to drive HIT adoption among primary care clinicians. The program creates Regional Extension Centers (RECs) across the country, each working to assist providers learn about health IT, find EHR solutions, procure and implement those solutions, and become meaningful users. HHS defines the REC’s mission as:

The Regional Extension Centers will focus their most intensive technical assistance on clinicians (physicians, physician assistants, and nurse practitioners) furnishing primary-care services, with a particular emphasis on individual and small group practices (fewer than 10 clinicians with prescriptive privileges). Clinicians in such practices deliver the majority of primary care services, but have the lowest rates of adoption of EHR systems, and the least access to resources to help them implement, use and maintain such systems. Regional Extension Centers will also focus intensive technical assistance on clinicians providing primary care in public and critical access hospitals, community health centers, and in other settings that predominantly serve uninsured, underinsured, and medically underserved populations.

During the first two years of the program, the REC receives funds from HHS for each provider that they assist in attaining Meaningful Use. Funds continue in the third and fourth year of the program but at a vastly reduced rate, with a goal of weaning off of federal dollars and ongoing sustainable independence.

The REC concept is a promising one. It brings localized support to providers looking to swim in the EHR pool, with the watchful eye of an “EHR lifeguard” nearby. The model fills a potential gap between the software and services provided by an EHR vendor and the actual amount of work it takes to get a small practice to be a meaningful user.

I believe one of the issues we’ll see play out is how RECs compete with EHR vendors themselves. Providers can buy from a REC or an EHR vendor – the choice is theirs. Frankly, the RECs are in many ways offering the same solution as the vendors: they resell EHR software and services, they provide consulting services, and they push providers to the Meaningful Use level.

Of course most of the providers’ purchase decisions will come down to value per dollar… RECs need to keep costs down and consider value-added services. I offer some ideas of value-adds:

  • Stay Local – The hands-on support of local service suppliers who have EHR expertise is critical. This might be a tough to offer across a broad or rural geography, but RECs should look to small boutique partners to fill this role. Large EHR vendors cannot provide this same level of intimate support, and it is essential to truly meaningful use (note lowercase!)
  • Bundle HIE – This is a great opportunity to connect EHRs to local resources right from the get-go. RECs can require that EHRs include connectivity to nearby HIEs, local labs, local service providers, and others critical to the patient care continuum in the community. The “local” nature of this service cannot be beat by national vendors, and RECs can bring value with their regional expertise.
  • Drive Volume – Probably a no-brainer, but RECs bring the ability for a small provider to benefit from a leveraged, large group purchase. Volume pricing will bring costs down considerably for small physician practices.
  • Centralize Operations – Providers can benefit from a centralized hosting and support offering, so they all can expect the same service level, same helpdesk phone number, same folks with local knowledge of the products, services, and healthcare providers within the REC community. A local operations approach also brings economic development within the REC community, a nice side effect. I believe many large EHR vendors would struggle to offer local personalized support like this.
  • Offer Portability –
    Having been in this industry for a while, we know that relationships between a healthcare provider and an HIT vendor looks more like a high school sweetheart fling than a committed marriage; they last for a while, going through high highs and low lows, but frequently end up with the provider looking for another partner. The REC could be a long term partner, offering a variety of EHR vendor solutions, and giving providers an outlet to switch technology and a “painless” method to move records from one vendor platform to another.

Regional Extension Centers play a key role in covering the difficult “last mile” of provider HIT adoption by targeting their support at primary care practices with ten docs or less. RECs should consider the list above when amassing their teams of suppliers and vendors to go to market (not just EHR vendors, but also consultancies, HIE vendors, hosting facilities, and operational support groups). I hope RECs can sustain their important service by putting together these pieces in a high value, low cost way, and help us all improve healthcare.

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Posted by Chris Voigt

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