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

Beware of the Black Box

June 22, 2010

I’ve written numerous times that making HIE work takes more than technology.   Successful HIEs consist of predictable, reproducible processes, procedures, and technologies all supported by healthcare savvy engineering and operational personnel.  So, beware of the messenger that brings good news about a new “black box” or “agent” packaged as a patented plug and play component promising to deliver complete clinical data exchange, integration, and interoperability.  If such a package were unpacked, one would see either nothing, or a tangled mess unworthy of the moniker “product”.

Rational thought leads many to believe that if we are smart enough to put a probe on Mars, perform painless brain surgery while the patient is conscious, and broadcast movies on our cell phones we must be smart enough to produce a single black box capable of seamless, plug and play integration with every healthcare technology system and entity.  Such thought, unfortunately, is flawed.  Unlike inventing something self-contained and brand new, healthcare IT requires those of us providing solutions to simultaneously accommodate decades of disparate technologies and myriad computing environments, communication and formatting “standards” and methods of integration.  I must therefore break the news that there is no single “black box” or “agent” that can handle such diverse computing needs without significant human effort.  Those suggesting there are such things are selling shadows, the likes of which Plato wrote of in his Allegory of the Cave.  They simply aren’t real.

Making matters worse is what I like to refer to as the patent façade.  The patent façade represents a metaphorical set of blinking lights that lead the uninitiated to believe the patented component is special and uniquely able to comprehensively, almost magically, accomplish the goal for which it was created.   Keep in mind that there are currently approximately seven million U.S. patents and one million U.S. patent applications.  If one has an invention worth protecting, a patent is a very good way to protect that invention and the associated intellectual property.  But, make no mistake; a patent does not, by any stretch, ensure the invention is worth anything, provides a competitive advantage, or in some way promise that which is patented is special. 

Scalable, sustainable HIE works when solid technologies are combined with procedures and processes that are franchisable and in combination are designed to support mass customization – the ability to mass produce unique components in quantities of one and implement those components precisely when and where they are needed to accomplish the objective – HIE, integration, and interoperability.  This means outstanding people, service, and technology must be organized in a manner that embraces the diversity of healthcare IT while leveraging every possible similarity.  HIEs that work accept disparate technologies.  They live in a world of such data and system disparity every day.  Those purveyors of the shadows, the black box, on the other hand, pretend a magical solution has been developed that somehow inherently understands even that which it can’t know.  So, please beware of the black box.

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Posted by Todd Fisher

Are State-based HIEs Good for Healthcare?

June 9, 2010

In our attempt to offer the marketplace genuine value, HIEWorks aims to offer our readers a combination of information and experienced-based opinion.  It is therefore necessary for HIEWorks to occasionally stake out a position, popular or not, when it may be more convenient to sit on a fence.  HIEWorks, is genuinely concerned with issues related not only to making HIEs functional, but, more importantly, leveraging HIE services to accomplish the greater goal – improving healthcare.  So, let me get to my point very succinctly: monolithic, state-based HIEs are not the best vehicle for leveraging federal and state investment dollars intended to improve healthcare through information technology adoption and modernization. I’d like to address three specific reasons I believe this to be so. 

Accountability and responsibility:  Accountability for clinical and administrative data exchange is diluted by the introduction of numerous layers of bureaucracy, leaving no clear desk at which the buck stops. Consider healthcare reform: providers are incented and penalized (via reimbursement) based on measurements regarding the quality of care.  Several information technology initiatives are underway to support quality care improvement; critical among those are HIE initiatives.  How can providers’ reimbursement be based on quality care and outcomes when the systems designed and implemented to support improvement are governed by an organization outside the control of the health system being evaluated? 

When a state-based initiative charges for a solution, the problem is exacerbated.  In short, doing so creates the appearance that control is transitioned over to the “buyers”. But, in reality, a solution forced on a health system arms those that should be accountable and responsible with the argument that they did not choose the technology and service and therefore can’t be held responsible for its performance and errors. Making matters worse is the appeal, to some, of the potential to abdicate such important clinical information management and communications responsibility.    

Innovation: There’s no better way to douse the innovative spirit than to off-load technology assessment, selection, and implementation to government-sponsored entities without the support of the “invisible hand of self-interest”.  Time and again the drive for competitive advantage has led to rapid and beneficial innovation.  Loss of such a drive creates complacency, and stagnation. 

The perfect opportunity exists now to seize on the clinical data digital revolution.  Let us not squander this opportunity by putting crucial information technology decisions in the hands of those that are not “in the field” and empathetic with providers in desperate need of clinical information access when and where care is provided.

Regional Nature of Healthcare:  All too often state-based HIE initiatives fail to appreciate the real-world regionalization of healthcare and underestimate the communication standards that do exist and are being developed currently. While healthcare is clearly a regionally-based market, health system service areas regularly cross state lines.  As a result, there are numerous technical, operational, legal, and regulatory issues that require rigorous analysis and accommodation. In a state-based initiative, who is responsible for handling such diverse requirements that result from the need to cross state lines?  Are the needs of a community in the middle of a state that has no issue with state boundaries the same as those communities that sit along state lines with patient care crossing into many states, at times?  These are real issues of consideration that are hampered by abdicating HIE choices and implementations to the state.  In short, state boundaries are arbitrary in the context of a patient’s network of care.

Summary: If a state wishes to assist with health information exchange, great!  Provide financial incentives to health systems to acquire and implement solutions for which the health systems feel responsible and accountable – let choice serve as the basis for such responsibility and accountability. The state funding should come with the stipulation that these networks can interoperate, thus accomplishing ONC’s goal of interconnecting physicians across the state.  Health systems should be provided the opportunity to compete for physicians and patients using information technology as a competitive advantage.  If the same solution is used by all because the state selects that solution, the state is 1) enabling health systems to abdicate responsibility and accountability for critical information technology selection, implementation and adoption, 2) dissuading free market competition and thus muting innovation, 3) drawing arbitrary boundaries around care geography that have no real relationship to patient movement.

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Posted by Todd Fisher

Avoiding HIE Buyer’s Remorse

May 25, 2010

The HIE market is changing and evolving as fast as any technology in recent history.  Developing HIT strategies that properly integrate health information exchange is a truly challenging task made even trickier given HIE’s unique ability to bridge the digital gap between the acute and ambulatory environments, finally aligning HIT with the real-world care continuum.

As the HIE market’s velocity increases so too does the number of HIE vendors and disparate solutions.  It is therefore critical for those looking to the HIE market for a strategically sound solution to move with purpose while exercising discipline.  To avoid buyer’s remorse, I recommend purchasers incorporate the following basic elements into their HIE selection process.

  1. Research.  When researching HIE alternatives, use multiple sources – the typical HIT analysts are challenged to keep up with the rapidly changing and developing HIE marketplace and can represent an incomplete source of potential solutions when considered individually.
  2. Peer Assessment.  Talk with peers that have successfully implemented health information exchange – ensure you talk with organizations that represent more than one HIE vendor or HIE model (e.g., centralized, federated, hybrid, etc…). Get their perspective on the business impact of their project, as well as their vendor relationship.
  3. Consultative Selling.  Take advantage of HIE vendors’ desire to inform purchasers of the pros and cons of the various HIE models.  Seek to gain an appreciation of the different models in use and their value to your business challenges; do not tolerate mudslinging. 
  4. Value Proposition and Competitive Advantage.  With your list of candidate vendors narrowed to four or less, ensure the competing vendors can articulate their value proposition and competitive advantage in a single page.  Vendors that can’t clearly and concisely state their value proposition and competitive advantage may lack an understanding of your business challenges and the impact of their offering.
  5. Values.  Ask your candidate vendors what they believe to be the most important aspect to their offering.  Their answer should be consistent with your organization’s objectives, mission, and values; otherwise, your respective priorities will be misaligned.
  6. Market Understanding.  Challenge your candidate vendors to articulate their view of the HIE market’s direction and future role in HIT.  Serious HIE vendors that know the market and business will be well aware of market direction, tendencies, Federal agendas, and alternative directions of evolution.
  7. References.  A vendor’s ability to perform in the future is best determined by understanding that vendor’s past performance.  While checking vendor references, ask for the entire client list and contact clients without prior notice from the vendor.  If a vendor has to “set up” a reference call, I recommend caution.  Happy clients are generally more than willing to provide positive comments during a cold reference call.  If the reference is busy, an alternative time can be set up for a follow on call.  The vendor should not have to play intermediary during this process.
  8. Robustness and Agility. Implementing HIE establishes a foundation for your information flows that support your most important business relationships. In partnering with an HIE vendor, you want to be sure their offering is robust and demonstrably agile.  Such feature traits are critical to support the inevitable evolution of information exchange. Without this robustness and agility, today’s cutting edge gadget can become tomorrow’s stale, unmanageable clunker, jeopardizing your business.

Follow these eight simple steps and you will be able to efficiently select the right HIE vendor for your organization.  With a clear strategy, alignment of values, and an acquired knowledge base, successful implementation is a simple matter of execution.  As Nike says, “Just do it.”

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Posted by Todd Fisher

Out and About

May 20, 2010

Sorry for the long time between posts.  Travel and vacation have kept the blogging to a minimum over the past two weeks.  That will change next week.  Please be on the lookout for new postings including how to avoid HIE buyer’s remorse and HIE in the behavioral health environment.

I will chat with you again next week.

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Posted by Todd Fisher

What’s Your HIE’s IQ

May 6, 2010

As HIE becomes more popular, organizations benefiting from HIE are increasingly cognizant of the wonderful, value-added capabilities HIE can offer beyond the vanilla exchange of clinical information.  Just what makes HIE “intelligent”.  I can tell you: algorithms and computer-based logic are only part of the answer.

I’ve been giving the notion of an “intelligence” engine designed to manage data transformation, communications, and integration considerable thought.  After reading Outliers by Malcolm Gladwell, I’ve distilled down the “intelligence” needs of HIE into two basic categories.  If you’ve read Outliers, you are familiar with the chapters in the book entitled “The Trouble With Geniuses, Part 1” and “The Trouble With Geniuses, Part 2”.  Without providing a book report, allow me to address the two categories of “intelligence” that I believe are necessary to ensure HIE works – the same categories Gladwell discusses in “The Trouble With Geniuses, Part 1”. 

First, traditional IQ is a measure of only one type of intelligence – convergent intelligence.  HIE with convergent “intelligence” encapsulates such features as patient matching algorithms, alerts, auto-generated reports, and notifications – essentially any feature built on the premise that answers can be determined or inferred from the existence or lack of available data (i.e., the engine converges on the right answer and acts accordingly).

Gladwell, however, goes on to describe a second type of intelligence – divergent intelligence.  This type of intelligence is not measured by traditional IQ tests.  It focuses, rather, on the ability to be creative or facilitate creativity and ingenuity.  For example, just how many different uses or variations on the available universe of data can be gleaned such that ultimately value and quality is added to patient care?  There’s not one answer but multiple uses.  HIE with divergent “intelligence” is represented through HIE flexibility, such as configurable preferences and options used to enable flexible information routing and filtering.  Such features are representations of divergent intelligence in that HIE has access to a universe of data; flexible configurability provides the capability to allow every consumer of that data to utilize it however they want/deem appropriate, within the constraints of healthcare and privacy regulatory, legal, and ethical boundaries.  (e.g., How many uses are there for a Discharge Summary? Where should it go, where shouldn’t it go, clinical, administrative, financial, etc…).

Here’s the bottom line:  When folks discuss HIE in terms of algorithms, and “intelligence”, ask yourself if the discussion is inclusive of flexibility that enables creativity or is it strictly a manifestation of rules designed to provide a single answer.  To make HIE work, both forms of “intelligence” are necessary – convergent and divergent “intelligence”.

Footnote:  I’ve placed the word intelligence in quotes in most contexts during this posting, because true intelligence extends well beyond that which can be represented by systems.  Moreover, there are entire fields of study involving artificial intelligence that are not the subject of this brief posting nor is such a field currently part of the HIE vernacular – maybe someday.

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Posted by Todd Fisher

Keep in Tune with How HIE Works

May 3, 2010

Sorry we’ve been out for a bit.  We’ve been busy traveling, consulting, and presenting. But, we’re back at it working on our next blog entries.  This week you can look for discussions about “Intelligent HIEs” and “How to Avoid Buyer’s Remorse”.

So, please keep your eye out for our next posting, and we look forward to your feedback.

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Posted by Todd Fisher

All Roads Lead to HIE

April 27, 2010

While discussing where the HIE market is headed and how to convert healthcare providers from market observers to market participants – we find ourselves returning to three basic questions:

  • Did the ARRA legislation trigger HIE market activity?
  • Did healthcare reform expand the HIE market?
  • Are the payors’ latest games  “plans” apt to create demand for HIE?

Across the board, the answer is yes, yes, and yes – though ARRA  circumvented market dynamics a bit by throwing a $19B “gift” on the table.  Hey, whatever it takes.

Here’s the bottom line: ARRA, overall healthcare reform, and new payor models seek to achieve considerable change in healthcare.  To achieve such broad change effectively, those close to healthcare have come to realize the need to forcibly move healthcare information technology into the 21st century.  We therefore hear calls for the mass digitization of patient health information – in essence, a healthcare digital revolution.

Digitizing patient health information is important, but not the end game.  Once discrete information is available, it must be securely processed, communicated, exchanged, integrated, accessed, and analyzed to be truly useful.  HIE is the platform, the enabler, the catalyst that makes such processing possible. Without HIE, information silos continue to persist, limiting health information technology’s ability to deliver on of the promise of care improvement.

So providers are waking up, realizing they need to get on the HIE bandwagon. And, providers are not just looking around to join an HIE effort in their community - many are finding value in an HIE directly supportive of their own organizations, an Enterprise HIE.  They are recognizing such solutions help protect their market, position them for exchange with others, and establish an on-ramp to broader HIE initiatives. And, these organizations realize they need such HIE now, before their competitors eat their lunch, and long before the government rolls out their pieces and parts of meaningful HIE.

Healthcare visionaries have known this for a couple of years now; call it the “tip of the spear”, entrepreneurial organizations that have adopted HIE as a competitive advantage. Now, the center of the market is shopping – they see Enterprise HIE as an instrumental component of their success as we all live through this Healthcare Digital Revolution.

For years Enterprise HIEs were simply not discussed.  They were, by definition, not considered “true HIE”.  Broader perspectives have prevailed, however.  An Enterprise HIE can quickly generate depth and breadth of connectivity between ambulatory and acute providers, built upon a strong, sustainable economic case. From that point a community can weave together these Enterprise networks (say, using the NHIN specifications). Done properly, which requires all four dimensions of HIE, you can get to the community-wide, holistic solution faster than ”waiting for Godot” – poorly funded, loosely organized state and community initiatives that lack genuine economic incentive to innovate.

More and more I’m hearing HIE works: HIE helps and even solves today’s many challenges faced regularly in healthcare – clinical and business challenges.  The market is rapidly coming to understand the clinical and business issues of tomorrow cannot be solved without HIE. Yes, in fact, all roads do lead to HIE.

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Posted by Chris Voigt

HIE in 4D

April 15, 2010

Time and again, vendors deliver technology and indifferently move on while these “solutions” sit and collect dust. Purchasers, once rapt with the blinking lights of automation, rapidly devolve, suffering buyer’s remorse.  While technology is important, it’s just one dimension within which HIE operates.  To work, HIE must operate in four dimensions: Technology, Service, Care, and Economic.  As a way of creating a mnemonic, let’s compare HIE’s four dimensions to the space-time dimensions learned in school – width, depth, length, and time.

Without technological innovation, HIE would never move past fax, courier, and a myriad unsupportable point-to-point interfaces.  Consider the Technology dimension as width.  A broad set of proven capabilities are important to ensure relevance, usability, security, scalability, and regulatory compliance.  Without sound Technology, utilization is muted, stability is jeopardized and liability is increased.  The Technology dimension, therefore, is significant to ensure a working system is in place, built on a solid, scalable foundation, protecting all stakeholders from the risks inherent in communicating patient health information – legal and clinical.

To truly operate within the Service dimension, HIE must wrap Service around deployed technology. Community outreach support and strategic utilization consulting are vital components. Visualize the Service dimension as the depth – the extent to which and sophistication with which HIE permeates a community.  Without such depth, HIE languishes, left unused, neither deriving nor generating benefit.

The Care dimension is lost on most vendors, as it requires a true understanding of, appreciation for, and empathy with the criticality of the ultimate mission – providing quality patient care.  The Care dimension introduces the human element to provide what I equate with length.  Every patient, every piece of information, every clinician, and every episode of care is critical in its own right and must be treated with a keen sense of urgency and worth.  HIE can’t do this without a human element that expresses understanding, appreciation, and empathy.

The Economic dimension is best viewed as time.  I’ve previously written that an economic model based on self-interest’s “invisible hand” is important to ensure sustainability.  While some cooperative models have succeeded, they are, unfortunately, the exception:  those that have proven successful are directed by passionately committed strong leadership able to place benevolence above self-interest in a manner that provides sustainability. 

Generally, however, without competitive market pressures, HIE falters with inadequate funding, structure, and incentives.  While altruistic cooperative purpose is noble and achievable, our economic activity is predicated on the notion that such altruism is achieved through self-interest. Community good is realized when individuals (e.g., healthcare organizations) achieve what is good for themselves.  Competition, therefore, must precede cooperation.  As the market matures, however, cooperation inevitably evolves. Consumers lean heavily against healthcare’s regional nature, forcing providers to cooperate to ensure quality care.

There you have it; HIE in 4D.  If you want to know how HIE works, use 4D lenses.  Those dimensions missing will become apparent, and corrective action can be taken to adjust appropriately.

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Posted by Todd Fisher

Changing the Direction of HIE?

April 13, 2010

I’ve been talking with folks who do HIE on both the community and enterprise levels. Questions come up as to how NHIN Direct might impact HIEs and the secure messaging services they offer: does NHIN Direct erode the business value of a ‘proprietary’ (i.e. non-NHIN-Direct) secure messaging network? Can we wait for the NHIN Direct open source and just use that?

So let’s look at NHIN Direct in the context of both the current and future state of HIE. These Health IT folks are keenly aware of the economic viability and sustainability issues with respect to the HIE. And the promise of an open source solution can certainly have an impact on implementation cost and long term support for such a system.

So, can we wait? My short answer is no. But just ending the blog at “no” is no fun… I’ll expand on my answer in three parts:

  1. The ability to push information in support of an effective, secure clinical dialog between providers in different care settings (or between clinical systems and providers) has an immediate impact on patient outcomes. It therefore presents an opportunity to add immediate value to healthcare providers.
  2. Looking back on my experience with similar initiatives, one can safely assume it will take a while for NHIN Direct to formalize to the point of being production-ready, and even longer to have operational significance. We’re 5+ years down the NHIN road, and that production network is barely off the ground (officially called “limited production exchange” by ONC). I hope Direct moves faster, but the industry, the government, and the process are what they are – the best way to predict the future is to look at the past.
  3. No matter how or when NHIN Direct rolls out, we also know from experience that it will take years for the standard to be supported in the systems and tools of the healthcare community. Until 100% of the provider community uses tools that support Direct out-of-the-box, somebody will need to provide an alternative solution – said differently, an HIE’s “proprietary” solution will continue to deliver value. Compare this to the adoption of IHE’s interoperability profiles for information exchange: currently there are just a few 100% IHE-compliant exchange networks, and they have virtually no IHE-based connectivity to EMRs (through no fault of their own – it is just how the HIT ecosystem evolves).

There are many new pressures on providers to accelerate the need for provider-to-provider messaging: hospitals are concerned about bundled payments, and all providers are watched and measured with respect to readmissions, care transitions, and handoffs.

Secure messaging solutions facilitate the clinical integration and coordination that supports improvement in these areas, as well as supplying what we’ve come to expect in terms of delivery of lab results, consult reports, transcriptions, alerts, and such – all key elements of information exchange that increase efficiency and reduce errors.

So you can see where I’m leaning: NHIN Direct is going to take a while to become relevant, on the order of years, not months. The provider community cannot wait that long.

It still makes sense to invest in an extra-enterprise or community secure messaging solution now, get it operating ASAP, broadly deploy it across the region, and insist that the platform vendor stay 100% compliant with Direct.

The NHIN Direct work groups are striving to have a demonstration later this year. I’m a part of that effort, and I too would like to see something that soon.

In the mean time, let’s not allow the momentum of robust information exchange to slow.

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Posted by Chris Voigt