For years, Massachusetts has stayed ahead of the curve in terms of IT adoption. But when it comes to data exchange, even the Bay State has had its share of challenges — both with the sustainability piece, and with what Joel Vengco considers to be a bigger obstacle: politics. In this interview, the first-year CIO talks about the work his organization is doing with the Massachusetts HIE Highway and the Pioneer Valley Information Exchange, how Baystate is positioning itself for ACOs using elements already in place, why transparency and trust are critical to HIE success, and why sometimes it’s better to bite off a small piece of a project than to try to boil the ocean. He also discusses being a Cerner customer in an Epic world, the steep costs of a rip-and-replace, and the key role end-users play in clinical IT success.
- About Baystate
- ACOs & HIEs — “By far, the larger issues are political”
- Mass HIWay & the Pioneer Valley Information Exchange
- “It’s not about just having the data, it’s what you do with it”
- Cracking the sustainability code
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The components of what makes up Baystate today — the medical practices, the academic medical center, the community hospitals, the health plan — those are certainly the right elements to making an Accountable Care Organization.
I think the past RHIOs that had failed were trying to boil a larger part of the ocean than what the Mass HIWay has intelligently tried to do, which is to take the basic secure protocol for direct exchange and use that as the initial feature and function for a state HIE, and bite that piece off first.
Overall, I think the larger hurdle is the political landscape — how do you get people to trust each other and to coordinate and to agree that this is the right thing to do for the patient.
Clinicians are scratching their heads saying, ‘okay, now I’ve got EMRs that I may be able to log into, plus I’ve got three or four or five HIEs to have to choose from or log into.’ This is not becoming more unified. It’s becoming more siloed.
It’s not the data that’s going to make a competitive advantage, especially if you gave it to everybody. It’s really what you do with it and how you deal with it. I think that’s really the core piece of it.
Guerra: Good morning, Joel. Looking forward to talking with you about your work at Baystate Health.
Vengco: Good morning, Anthony. Thank you for having me.
Guerra: All right, let’s talk a little bit about Baystate — four hospitals, the 60 medical practices, and a whole bunch of other stuff. Tell us about it.
Vengco: That’s actually one of the things that really attracted me to Baystate when I was considering the position, which by the way I’ve just taken about 10 months ago. I’m relatively new here at Baystate. It is the largest employer in Western Massachusetts; it’s a four-hospital system with basically a broad range of scope across four counties of Western Massachusetts. It also has a health plan, probably the largest in Western Massachusetts at this point. It’s a five-star health plan, so we’re very proud of that.
We’ve got an ACO organization called BayCare Health. That’s really an aggregation of Baystate medical practices, plus community partners and medical group partners across the region. So really a very large scope and a very nice community service to the region. Baystate, I think, is in a great position for what’s to come in healthcare in the future.
Guerra: Is that to a large extent because there’s a health plan element already in the organization?
Vengco: I think it’s partly that. There is the health plan piece. It’s also an academic medical center, so there’s a real focus on research and innovation on the clinical side. We’ve got a VNA, and that helps us get more toward the ambulatory piece of it. Again, we’ve got a broad range of partners across the community, including hospitals who aren’t necessarily affiliated with us, and that really makes for a very nice landscape for Accountable Care, because our patients do migrate. There’s no question about that. And some of the hospitals are so close in proximity that the migration is just a natural one. Yet we do have to make sure that somehow we connect each physician to all other physicians so that they can have access to patients’ records and make sure that they can care for that patient with comprehensive information.
I think the whole landscape is really setting it up, but to your point, I think the components of what makes up Baystate today — the medical practices, the academic medical center, the community hospitals, the health plan — those are certainly the right elements to making an Accountable Care Organization.
Guerra: We all know Massachusetts is extremely active. There are a lot of what we call industry luminaries in Massachusetts — John Halamka being one of them — involved in state initiatives. How do you see it setting up in your mind when we think about the ACO that you’re working on — how does that link up with the larger state initiatives around HIE?
Vengco: Actually, we’re one of the members of the Golden Spike initiative launched back in October that really marked the Mass Highway, which is the Massachusetts Health Information Exchange Highway. That initiative in October was really a demonstration that was led by our governor, Deval Patrick, to show that Mass General could send his record to Baystate Medical Center, which was a successful demonstration.
As we know, the Mass Highway is using direct protocols at the moment. That’s its first phase to really create information exchange across the state, which I think is really smart because that’s in many ways the basic entry point for basic information exchange. I think the past RHIOs that had failed were trying to boil a larger part of the ocean than what the Mass Highway has intelligently tried to do, which is to take the basic secure protocol for direct exchange and use that as the initial feature and function for a state HIE, and bite that piece off first. So there’s that part of the state initiative I think that’s really critical.
For us, we’re really looking at it from a local or a regional perspective in Western Mass, and we’ve actually kicked off our own health information exchange along with our community partners here. We’re calling it the Pioneer Valley Information Exchange (PVIX), and really the difference there between PVIX and the Mass HIWay is that we’re looking to have much more granular exchange out of the gate with our partners — the continuity of care document or the CDA in its granular form with meds, problems, allergies, lab results that are codified so that we can actually drive it into the EMR of any recipient or member of the PVIX HIE, so that they can actually have it in their workflow. We’ll still actually use PVIX as the on-ramp for the Mass HIWay so that we can connect to Mass General or Brigham or Beth Israel should our patients who go out there, or vice versa, and we’ll use that as the pipe or the network to get us from that exchange. But in terms of granular exchange, that’s much more specific for our region and for our patients that we share here across the community, and we’re going to look to be building our own regional Pioneer Valley Information Exchange HIE.
Guerra: Are there challenges with the concept you’ve discussed, which is a deeper level of exchange within a certain network and then a more shallow level of exchange with the wider network? Are there data challenges with that kind of dual setup?
Vengco: I don’t foresee any immediate challenges. I think the biggest challenges, and they’ve always been the bigger ones, are the political issues. Technology just continues to improve and the policies around these technologies like, for example, patient consent and do we opt-in or do we make it an opt-out — those discussions continue and they’ve continued to evolve. We’ve got TIGER teams at the federal level that have begun to help solve that and even local exchanges and initiatives like ours are continuously testing those policies. I think we’re seeing the policies around the technology really come to fruition.
I think the politics in terms of sharing — should I share and would it be a competitive disadvantage for me or an advantage for someone else if I shared my data — that’s really the bigger hurdle. We could go into the technology issues in terms of granular sharing and that’s, of course, the codification and standardization of the data that you get out of our stale source systems today which are getting better with certification and the push by the feds to standardize. But I’d say that’s probably the larger technical hurdle.
Overall, I think the larger hurdle, or the more grandiose hurdle, is the political landscape — how do you get people to trust each other and to coordinate and to agree that this is the right thing to do for the patient. The fact we’ve done that here in the Western Mass region, I’m just so pleased to see that happen, because there’s a lot of reason for us to feel like there is a competitive landscape that we need to be aware of. But I think to do the right thing for the patient, we have to create something like PVIX so that we can share patient data between physicians who are not affiliated.
Let me just add that part of the reason why I think PVIX is existing is because there are actually a lot of HIEs that are already cropping up here in Western Mass, believe it or not. There are at least three if not four. North Adams, which is northwest from here, is one of the first HIEs instituted by state funds back in the early 2000s. Now we’ve got some other players in the space who are also considering or have already implemented HIEs here in Western Mass. Now clinicians are scratching their heads saying, ‘okay, now I’ve got EMRs that I may be able to log into, plus I’ve got three or four or five HIEs to have to choose from or log into.’ This is not becoming more unified. It’s becoming more siloed. It’s that kind of thing that we’re now grappling with — who becomes the hub and how do we make people feel it’s not a political stance; it’s really a stance for us to do the right thing for patients.
Guerra: You mentioned opt-in/opt-out being one of the issues. Actually, you mentioned two issues — the competitive issue moving data between health systems that may be competitors, and then the privacy issue. Would those be equal in terms of the challenge they offer?
Vengco: I think that opt-in/opt-out is actually becoming more fluid and more tangible. Some states, as you know, have decided they’re going to be one or the other, and others like Massachusetts haven’t really determined for organizations within the state which way to go. The Mass Highway is an opt-in, but that didn’t mandate an opt-in for the rest of the HIEs that were cropping up in Massachusetts.
But, like I said, the patient consent piece is a lot more tangible now. Policies are being created and there’s a lot more experience out there across the nation, with the consent as well as how the systems handle consent. I think that’s becoming better and better; certainly better than when I had started at Boston Medical Center several years ago. We had started an HIE out there; the consent policies were still pretty nascent at the time. I think the exchange between organizations is a bigger hurdle, and often, I think is, what will either create inertia in an HIE initiative or actually make it fail.
Guerra: Very interesting. That level of sharing is going to be defined by the CEO and the board in terms, of what are our objectives, how much are we willing to share, how much are we focused on business issues in terms of staying solvent and making money; even if we’re non-profit we have to pay our bills versus ‘for the good of the patient.’ There’s a balance there, right?
Vengco: Yeah, there is. Often times we just have to step back and think about what it really means to have information or data — let’s call it raw data — about a patient or even a panel or a population of patients. I would submit that it’s not the data that’s going to make a competitive advantage, especially if you gave it to everybody. It’s really what you do with it and how you deal with it. I think that’s really the core piece of it. I think to hold it up or lock it up is really more of a disadvantage to the patient than to anybody else. I think we do have to think about that.
To your question about who makes the decision, with PVIX, what we’ve attempted to do, and I think we’ve achieved, is really put together a governance structure that really involves the players who are participating in the Pioneer Valley Information Exchange. With the help of Micky Tripathi and the Mass eHealth Collaborative, we’ve really formulated what I would consider a very inclusive governance structure that enables each member to have a voice in deciding really two things about the information exchange. One is how is the data going to be utilized — social security, privacy, and of course, the use of it in different ways. Second is how do we sustain the HIE. Those are the real big charges for the governance body; to really manage those two big pillars. I think that’s going to serve us very well going forward.
Guerra: Do you think we’ve made any progress on the sustainability issue?
Vengco: That’s a great question. I think there are certainly great examples out there that have provided good use cases and value-added services on top of HIEs that could show sustainability. I think there are different strokes for different HIEs. It doesn’t rhyme, but you know what I mean. It depends on the community, I suppose. At Boston Medical Center, for example, when we put together an HIE, it was Boston Medical Center, which is the academic medical facility and tertiary care center, and then basically a dozen community health centers around the greater Boston area — not affiliated with Boston Medical Center directly, but they’re partners with BMC. The sustainability actually came from creating this referral management solution that enabled the community health centers to more seamlessly refer the patients that they were referring anyway to Boston Medical Center, and then getting information back from that visit.
The reason why that became a sustainability play was because when I was at Boston Medical Center, we were actually losing referrals because of patients not remembering that they had an appointment, or the folks at BMC not getting information in time from the folks on the provider side who were referring to BMC, because it was sitting on a fax machine or it was in a voicemail. So there were lots of no-shows and also just basically dropped referrals.
When we put that service on top of the HIE, it actually took it from basically a 30 to 50 percent achievement rate of referrals or fulfillment rate of referral orders, to roughly 70 percent. And so even that 20 to 30 percent uplift is several million dollars, if not more. That, in it of itself, sustained the annual license fees that Boston Medical Center had doled out for the HIE. I don’t know if they’re still using it today, but that certainly was the business case there. Of course, there are other successful stories out there like IHIE and even some of the exchanges in New York where they’re starting to show sustainability, either with commoditizing some patient features and functions or really creating services for those members that are out there. We’re looking to do the same, and I think there are a lot of use cases from the ACO landscape that are going to help push some new use cases and some new features and functions or value-added services, as I like to call them, for us to be able to initiate subscription fees that will sustain the HIE. That’s the hope.
Guerra: If we get to the heart of the matter, I think it gets a lot more simple to come up with a sustainability model and that’s the fact that whoever is being able to asked to pay for it has to have an upside of revenue greater than the cost of what they’re paying. I mean, let’s just break it down here. We’re talking about money. Patient satisfaction and increased care is all fantastic, but when push comes to shove, if you want uptick on one of the investments that you’re asking an organization to make, there has to be a financial upside. It can be indirect, but it’s got to be there.
Vengco: It’s got to be there. I think there is a core issue that needs to be addressed in that statement alone that you made which I think is absolutely right, which is to say whichever organization it is, they’re making an investment and they need to have a return. And the way it needs to be seen by the community that hopefully is being serviced by it is that it’s not an investment for profit. It’s an investment to sustain the platform so that all in the community or all members of that HIE can actually continue to have that service.
I think often times what’s seen is that it may be a political play and it may be one in which the granting organization, whomever that may be, is really looking at it as yet another for-profit venture. And I think if you look at it from that perspective, of course it will fail, and folks won’t trust.
I go back to the whole trust of politics piece. Somebody’s got to fund it, whether it’s the state or the feds or an organization like Baystate that has the opportunity to fund at least the initial investment or capital investment of it. But that trust has to be there to see it as, it’s not Baystate trying to take over the region; it’s really, we’ve got an opportunity to connect to each other and do it for our patients. That’s really what needs to happen and we’ve got to build trust to get to that point. That’s important.