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

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