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

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