Realizing the Promise of HIEHow to Maximize Health Information Exchange Investments
The HITECH Act provided funding for statewide HIE as a way to improve access to potentially life-saving information. Organizers of these statewide networks, as well as those forming regional HIEs, are looking for ways to win the support of healthcare provider organizations and consumers alike.
Two HIE pioneers offer insights on how to:
- Make the business case for HIEs;
- Position the use of HIEs as a natural next step for physicians implementing electronic health records systems;
- Address concerns, including consumer worries about maintaining the privacy of their information;
- Take advantage of best practices, including using an incremental approach, such as starting with the exchange of lab test results or immunization records.
Leslie, a San Francisco-based vice president with Booz Allen Hamilton, has more that 18 years of experience assisting healthcare payers and providers with technology strategies and other issues. She has served as an adviser to state and regional health information exchange projects.
Martin Anderson is a senior vice president at Booz Allen Hamilton, leading the firm's health information technology practice. She has advised the HHS Office of the National Coordinator for Health Information Technology. Earlier, she was involved in launching the nation's first health information exchange.
TOM FIELD: Now what is interesting is the two of you have worked on HIE at another organization since 1997, and actually launched the nation's first health information exchange, am I right?
KRISTINE MARTIN ANDERSON: That's right.
FIELD: Well. then we've got great knowledge here and expertise to talk about the topic today. Kristine, I want to lead off with you. We talked about the promise of HIE. What is the real promise of HIE for healthcare organizations?
ANDERSON: That's a great question. At this point in time, we have near universal agreement in this country that a patient-centered healthcare system would result in better coordinated and high quality care. And it's not hard for anyone to imagine the benefits of that, particularly for patients of chronic or even multiple chronic diseases. where having their physicians have another channel to efficiently communicate about their care that they are both treating makes a lot of sense. What we really need health information exchange for is to enable that patient-centered view of a patient's healthcare. and it really lets us achieve the aim or our health reform effort.
So without health information exchange -- and I'm using that as a verb in this case not as a noun -- we don't have an integrated longitudinal view of a patient's experience, then we can't evaluate the effectiveness or the efficiency of their care, and we certainly don't have the information required to manage that care in a holistic way.
Lastly, but equally important, is the opportunity of health information exchange to improve the patient's experience. We need to be honest about the current state today; each patient is their own health information exchange. They carry their information from physician to physician, they coordinate the care between the care givers imperfectly, and I would personally be elated to go, to let go the experience of just having been born the moment you walk into your doctor's or specialist's office. Health information exchange really underpins all of the health reform efforts that we hear about today.
The Promise of HIEFIELD: Well, Timathie, let me turn to you now. From your perspective, what is the real promise of HIE?
TIMATHIE LESLIE: Well, Tom as we move forward with health reform efforts, we will not be successful in bending the health cost curve without transforming our health system into the information age. I know we talk a lot about the need for us to be able to digitize our clinical information, but as we do that, as we move from paper to digital format, we also must make sure that our detail is not lost in priority silos that they tend to get locked into. It really prohibits us from being able to have both a patient-centered view that Kristine just relayed to us, but in addition to that a very important population view.
I'm not so sure that our question needs to be about the promise of health information exchange, but rather will we even be able to achieve our vision and the promise of our future state of the US health system without health information exchange?
Making the CaseFIELD: Well, Timathie, as we said up front, you and Kristine both were involved in a nation's very first HIE, so it is very appropriate to ask you: How does an organization go about building and selling the business case for HIE?
LESLIE: If you look back 13 years ago, when we first started the Santa Barbara Health Information Exchange, it was funded by a grant. Many of the health information organizations, using the noun not the verb, had also been funded by grants. It gives the organization a little bit of a breathing room in the first few years to be able to bring the planning expertise to the table to be able to cultivate the collaboration that is required at a community level. But what we've learned is that in the very, very immediate start of any of these health information organizations, sustainability and the value that they bring to their stakeholders must be discussed. Also, to have that commitment up front from the key stakeholders that are there at the very beginning it is essential. There is clearly value that stakeholders are going to be able to do to be able to obtain from health information exchange, but quantifying that value and then being able to deliver that value at a cost that is sustainable is really the equation that we are all seeking.
ANDERSON: Part of a business case is definitely the need to alter the competitive landscape in healthcare, to shift from competition per volume to competition for a higher quality, lower cost care. This requires payment reform. So each community that undertakes health information exchange needs to be focused on how the incentives operate in their community, and keep the payers, those who control payment, at the table. There are activities certainly at the federal level and at the state level, but there also needs to be activity at a community and regional level.
LESLIE: And if I can add to that, as we start looking at what type of sustainability models are out there, it really varies based on where your health information exchange is located. It varies on the demographics, it varies on the geography, it varies on your population base, and we've seen everything from organizations coming together and deciding that each of them will understand what their fair share it is. I think it is essential to have both the state and also the federal stakeholders at the table for that discussion.
I think that the discussion that we are having around how health reform will be implemented both at the state and local level is also very interesting to watch in that, for example, how the medical loss ratio will be calculated for payers could contribute to that public benefit of being able to have a shared infrastructure for health information exchange.
We also have examples of some very innovative pilots across the country that are paying based on a query transaction for that clinical summary. So, for example, having a payer look at a hospital to be able to bring back based on the query what that clinical summary is for a patient, instead of sending it electronically and paying electronically, so at a $3-to-$5 rate versus sending somebody out in their car to make that photocopy and bring it back to the home office. Just that as the simple transaction could serve as a way for us to think about how we're going to pay for exchange.
Top HIE BenefitsFIELD: Timathie, you used a key word a couple of minutes ago, and I'm going to ask both of you about this, and that was the word "benefits." Kristine, I would love for you to start with this and give us a sense of what you foresee as the top HIE benefits to organizations?
ANDERSON: You really have to tackle the question of benefits one stakeholder at a time, so I'll talk a little bit about providers, health professionals and hospitals. It is really just since the 1980's that medicine was corporatized in a sense that corporations did business in medical care for the large part, and that happened as regulation of the industry declined coming out of the 70's, and then market forces and market competition rose. Providers pursued management efficiency, and both the terms "market share" and "productivity" became the major drivers in healthcare, and it's really remained that way up until now.
So now fast-forward 30 years, and we're trying to take away part of the culture. We're asking large healthcare organizations, who have balance sheets, they have income statements to manage, to stop using the control of information about their customer as a way to create the stickiness in the customer base. And we now are telling them or messaging we want them now to compete on quality. They always cared about quality, but now we're asking them to compete on quality even though we are really at the very early stages of measuring quality, and in reality most studies have shown that their customer base doesn't really understand quality.
So we want them now to coordinate care, we want them to reduce readmissions if they are a hospital and a doctor that is involved in referring to hospitals. We want to reduce duplicate of tests ... asking them to increase their investment in the very technologies that will feed that revenue reduction. So in the short term, we are asking them to pay for revenue reduction. In the long run, they'll need to learn a new way to compete, but in the short run it requires a leader's sort of willingness to hold their nose and jump and trusting that it is a competitive landscape that will indeed shift to where the investment is good for them and good for their patients.
I see in the past year the government leadership is making good on the promise to change the incentive to increase, then, the faith of the healthcare providers in the shifting paradigm for payment, but we still have a long way to go to make the case to the full market, and we still have quite a bit of work to do to describe what that new payment methodology will look like that will be an incentive that reinforces what is good for the patient, which is the health information exchange.
LESLIE: In addition to the quality benefits that an organization achieves, there are also bottom-line cost efficiencies on the technology side. And as you start thinking about moving from a point-to-point infrastructure, where you need to be able to stand up and interface for every organization that you are going to start trading data, it really does make sense to start thinking about a common infrastructure that will then act as an intermediary much like our claim's system does today, to be able to route clinical data where it needs to be.
To give an example: When you think about a state infrastructure, where you have both Medicaid as well as public health and let's say also the immunization registry, to be able to bring all of those organizations together to think about how they are going to be interacting electronically with their data providers, which are going to be at the hospital level, academic institutions, and also large provider organizations, it really makes sense for them to think about a common infrastructure as well. And if you can then take that infrastructure and then share it at a commercial level, then I think you really have a homerun.
When you start thinking about what happens at the physician level, say they have electronic health records, so they have gone forward and made that initial investment and made the adoption to be a meaningful user of an electronic health record. What happens next when they are also asked to be able to share their information both at the state and at the federal level and then also within their community stakeholders and with the patient? That is where this common infrastructure really starts making a lot sense. So, that the individual physicians in the small clinician offices aren't taking the burden of inoperability upon themselves, and so there is a real value. and that benefit will go back to the stakeholders fairly quickly when we start thinking about doing things together versus individually.
Speedbumps to SuccessFIELD: To get to those benefits there typically are speedbumps. What are some of the common speedbumps that organizations are going to encounter?
LESLIE: Well, I think what we've really painted so far is this world where we all get together and it is easy to be able to make decisions about how we're going to be exchange information. But when you get down to brass tacks, of course, the devil is in the details. We have to really be very, very focused on what our incremental wins will be right out of the gate. I think in general that means starting pretty small. Whether or not it's at a pilot level that is in a very, very contained space that is a very small investment initially, you have to be able to show success. That seems to be one of those real best practices that can take hold and then grow the interest and be able to grow other stakeholders to meet together. So I think when you think about the speedbumps, it is imperative to not think really big, and to be able to bring together those really small wins.
There is also the balance of what types of policies might be in place versus where technology can go. And what we've seen over and over again is that it is not a technology problem to solve. It is at some level, but once you are able to show and demonstrate that technology can follow some of the very, very basic use cases, it then moves into the policy side. We run into policy barriers at state and the local levels, both at laws and regulation about how we can exchange very simple information. And to give you an example: Lab data, which is generally done at a laboratory. and then the results need to somehow make it both to the physician who ordered it as well as the patient. In some states, that is required to be done right now at a paper level, and in others -- Tennessee is a great example. They have gone through a complete review of their health information technology laws and regulations, and they made an amendment to their current statute around the ability to be able to share laboratory date not only to the ordering physician, but to the physician that requests it. And I think that it is the type of modernization to our current legal structure that needs to take place.
ANDERSON: We already talked about the challenges with the business case, and I think the other clear challenge for me is privacy. Convincing the public that health information exchange can be done in a secure way, where they still have control over who sees what element of their health data is quite a large [challenge]. It's been observed that financial data is about your assets, what you have, but medical data is about you. It is about who you are. This is another area where we have an accelerated culture change happening.
Before we had widespread insurance coverage with the passage of Medicare and Medicaid in 1965, medical information was closely-held, really, between the person providing care and the patient and or their family. And patients are wary when insurers came into the picture, even though they understood that insurers need to know a certain bit of information about their health and their healthcare in order to pay the bills, and that they have the right to some medical information. And patients were also wary when employers became insurers and had the same right. We know from recent surveys that patients don't particularly trust the government with their health data.
So in the situation where HIE occurs between parties other than the patients and their doctor or caregiver, so we have to navigate this privacy landscape carefully and help patients understand that the benefits that they gain individually and collectively will outweigh the privacy concerns. But they have to be convinced of that, and you have to do that at a community level and then at a national level. We are going to have to prove it by having a great track record of security of the data and the data transfer, and also a lot of hard work about trying to reconcile differences in privacy laws across the states in a way that still allows the technology solution to function and the patient still to believe that they have the control that they seek.
HIE ExamplesFIELD: Let's bring this down to a practical level now, Timathie. How do you see some of your communities tackling HIE?
LESLIE: Most communities today are past the planning phase. They have been able to secure upfront capital and they have a distinct plan, they have an implementation schedule, and they have a budget, and they are performing against that. We are seeing how communities are spread across the country, and you have those that have actually been in the trenches for many years that have made a lot of success and are now expanding that circle to make even more of an impact both in their community and also in the states.
Then you have those that are in the middle that I'll come back to, and then finally you have those that are just now getting to take advantage of some of the federal investments both in grants as well as state funds to bring stakeholders together to talk about how they are going to not only be able to react to and take advantage of some of the stimulus fund for HIE, but also how they are able to bring together the necessary resources to respond to reform.
Those in the middle are the ones that I started to talk about initially, where they have very, very distinct plans that they are implementing against. For those that are making some really rapid progress, they have a governance structure that has senior leadership from the required stakeholders in the community. Those that are seen as leaders and respected leaders, and then also that crosses the industry both representation from consumers, representation both from state and local government and representation from the care provider and physician market. They also have working committee structures, where they have a focus on their clinical aims and what they are going to evaluate themselves against in order to make that clinical intervention given their population. Then they have consumer outreach committees and they have technology committees that are wrestling with the details of how to exchange that information.
Those that we would look at as models of success, as I have mentioned earlier in our discussion, are those that are really not taking off too much initially and are being able to show real wins right out of the gate. I think that there is this tension of making sure that we have everyone singing to the same tune, that the collaboration is really strong, and that our policies are in place versus where technology can take us. And we need to be able to move quickly on both ends, because if we take our time on the policy side and the governance side, soon what we had planned for the technology will be out of date.
Best PracticesFIELD: Timathie, if you were to boil it down, what would you say are some of the best practices that you are seeing now from communities?
LESLIE: I can't emphasize enough being able to have a very incremental approach where you have achievable goals right out of the gate that are in probably about six months. That might be looking at just laboratory data, for example, and being able to start the exchange. Or it might be that you initially look at collaborating with state or at the county level around automating the immunization registry. I think once you are able to identify what your interventions are at the community level and at the clinical level, then the technology will follow, versus the opposite. So that is probably one of the best-case scenarios.
The other best practice would be working together with your state and local government to be able to bring them to the table upfront, so that they are a significant part of the population of looking at providing care for the underinsured and uninsured, and that they have a direct tie back to the state government that is going to require to have much of the oversight of the health information exchange. Being able to engage them in the dialog sooner than later is also something that I think really helps in the long run.
I would be interested in seeing what Kristine wants to add to that, as well.
ANDERSON: Definitely one of the most important elements is in keeping their executive leadership engaged. So, in all sort of large cultural changes, that executive leadership is the key, and the leadership needs to extend beyond the organization and exist at the community level and, as Timathie mentioned, in the public and the private sector. Those communities that are making progress on HIE are dedicating a large part of carefully chosen leaders' time to managing the change process and keeping the band together. They are managing those early wins that Timathie noted and are so critical. They are communicating their successes and their failures. Because remember: This is innovation, and innovation has failures that are worthy of learning from. They are keeping organizations honest about their common commitments. They are driving the business case and the sustainability plans, and really at the end of the day, this truly is a case where a few strong community leaders can make the difference between a success or a failure.
LESLIE: We also need to add there that having the physicians or clinicians at the table up front is also incredibly important. Because at the end of the day, it's their workload that is going to change. Keeping them informed, having that leadership as part of the discussion, is really important.
HIE AdviceFIELD: Final question for you. Kristine, I will send this to you first. Based on everything we've talked about realizing the promise of HIE, what tips would you offer to healthcare organizations to help them realize that full promise?
ANDERSON: Timathie made some really important points about starting small, and I don't think you can really overemphasize that. But if you think about it from the perspective of a classic use case, you say just from the beginning: Be very crisp about what do each of the parties get out of this individual piece of the equation that we've decided to take in the beginning, and very deliberate about how that ramps up to 'what's next?' I think it is the being deliberate part ... that is getting a lot of these organizations off the ground. It's really about being deliberate over the long run. Those organizations that have clear strategies and are able to execute on them and build momentum over time will be the organizations that are the leaders.
LESLIE: I would add that many of these organizations are clearly still in start-up mode. That is really important where you are looking at hiring the right staff and being able to then look at what your growth demands will be over time. That you have solid communication plans in place. That you have a business case that includes an exit strategy much like any start-ups. What is it that you are going to be when you grow up? Finally, that you really focus on that governance and being able to have the right voices at the table to help drive your success.