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

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

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

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

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

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