If there’s one word that could best describe Chuck Christian, it’s curious. Throughout his career — from the early days as an X-ray technician to more than 20 years as a health system CIO to now — he is constantly asking questions and trying to find ways to get the industry to a better place. It’s that drive that led him to his current role, where he is helping to lead one of the largest HIEs in the nation in its mission to leverage technology to improve patient care. In this interview, he talks about his passion for understanding policy and translating it to CIOs, his candid take on FHIR and how he believes it can work, how the Indiana HIE has been able to thrive (and what other HIEs can learn from its success), why clinical interoperability is so difficult, and why he believes the industry is just hitting its stride.
- Health Affairs study
- “There’s not just one flavor of health information exchange.”
- HIE as a noun vs verb
- Patient-centered data homes
- A one-stop shop for data: “That’s the functionality we have.”
- Problem with CCDs — “Physicians don’t want to have to weed through data.”
- Thoughts on MU/HITECH
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There weren’t a lot of people out in the industry that knew how to do health information exchange. It’s not an easy thing to do, and a lot of people were saying, ‘we can do this. We can stand this up,’ and they’d burn through the cash.
There are many different flavors of health information exchange. There are many, like the one I work for, where we persist data and we normalize the data and it can be displayed side by side. It’s coded and it’s a really good clinical tool. But then you have those exchanges that are basically just moving transactional data around. They don’t really persist data.
If you look at some of the definitions that ONC and CMS use, they’re very EHR-centric, and there are thoughts out there that the data can be shared seamlessly from one EHR to the other. I have a lot of questions about how that happens.
If you talk to the clinicians, to the physicians, they don’t want a basket of data that they have to weed through and hunt for the nuggets. They want succinct information presented to them that’s based upon what happened to the patient and what the care plan is.
I think it’s kind of hamstrung part of the industry related to innovation, because we had to work so hard to meet those standards, and then rather than us setting those standards as the floor or the threshold, that’s became the ceiling.
Gamble: There was a recent study from the Health Affairs that said the number of HIEs has dropped. What are some of your thoughts on why that’s happening and what HIEs need to do to survive?
Christian: You have to go back and remember that a lot of this thing called health information exchange was mandated out of the HITECH Act because we need to share data and so we need some way to do. Oh, and by the way, we’re going to drop billions of dollars into the states with the HIE State Cooperative Agreement Program grants to stand these things up. Well, they’re not easy to do. And a lot states were going about it as a way to help create some modernization of their organizations internally. There weren’t a lot of people out in the industry that knew how to do health information exchange. It’s not an easy thing to do, and a lot of people were saying, ‘we can do this. We can stand this up,’ and they’d burn through the cash. After the grant money was gone, they hadn’t thought about how are we going to sustain this from a value proposition, so some of them failed.
One thing I couldn’t ferry out of the article is a component of that decline was the consolidation of HIEs. If you look in Michigan, California, Colorado, and a few other places, including Texas, several smaller exchanges have merged together to create one. And so it’s no different than in healthcare or any other market. If you look at the physician practice EMRs, we see that every day. If you look at the EHR market for the inpatient and acute care side, it’s the same thing.
I don’t disagree that the value proposition for a health information exchange is not an easy thing. One of the fallacies that drives me crazy a little bit is when you look in the press and they talk about health information exchange — when you read that, you think it’s one thing. But there are many different flavors of health information exchange. There are many, like the one I work for, where we persist data and we normalize the data and it can be displayed side by side. It’s coded and it’s a really good clinical tool. But then you have those exchanges that are basically just moving transactional data around. They don’t really persist data. And you have a variety of other ones in between that are standing up services; some do a lot of hands-on work and other don’t. There’s just not one flavor of health information exchange.
The other thing that’s really interesting is that the health information exchange is both a noun and verb. If you look at something that just came out from the ONC about why health information exchange is important for EMS and the emergency rooms, they’re not talking about the noun of health information exchange. They’re talking about the verb of actually moving data from one place to the next. I’m not really sure that the organizations have helped ourselves by having a name that’s both a noun and a verb.
The other thing that’s recently occurred that the health information exchanges last year got together and formed a group called SHIEC (Strategic Health Information Exchange Collaborative). We have about 39-40 members throughout the US and we’re doing things together. We do policy work from the advocacy side. We’re looking at initiatives, one of which is the patient-centered data home, where the patient’s data will actually follow them when they go from one region to another. For me, most of my care is going to happen in Indianapolis, but if I have to be travelling down Alabama to see my family, the only medical record I’d take with me is what I have in my head or what my wife has in her head, and if I’m in distress, that’s no good.
In Indianapolis, we have this thing called the Indianapolis 500, where about 430,000 of our closest friends show up for that race. So if you have a patient from Michigan that’s in Indianapolis for the race who has an issue and winds up in one of our emergency rooms, we will get that transaction. We’ll be able to look at that patient’s zip code and say, ‘this person is from Michigan. Let me ping the Michigan HIE to see if they know anything about this patient.’ And so they’ll get that request and say, ‘yeah, we know that patient.’ They’ll send back a clinical summary, and we’ll deliver that to the clinician at the emergency room, and so now they have a clinical summary of what that HIE knows about that patient. And at the end of that treatment, we’ll bundle up clinical summary and send that back up to the home HIE so when the patient goes back home, their primary care physician will have the benefit of that information about what occurred — what diagnostic tests were done and what the treatment plan was.
That’s some of the extra added value that we’re able to bring if we’re persisting data. Some of the exchanges won’t be able to do it quite at that depth but they have some services where they can also participate. So, a very long answer to your short question.
Gamble: No, that’s alright. That’s the vision people saw when all this started to get stood up; that ability to treat patients who are several states away.
Christian: Correct. One of the questions I have to ask myself, and I’m sure you’ve heard about CommonWell and Care Everywhere and Carequality, and if you look at some of the definitions that ONC and CMS use, they’re very EHR-centric, and there are thoughts out there that the data can be shared seamlessly from one EHR to the other. I have a lot of questions about how that happens. The fact is, if you have a patient in Indianapolis and they’ve had care in four different hospitals and three different physician practices, the quickest thing, in my mind — and my opinion may be very well be biased, and I realize that — is looking for one data the source has all that information rather than having to go to and figure out what all those multiple data sources are, because then those data sources are all going to have some nuances around the data. If you have one place to go that the data has been normalized, you can get everything you need in a one-stop shop. But like I said, I’m biased, because that’s functionality that we have and what we’re able to do today. So I think we have a ways to go. When people ask me, ‘what’s your answer to data sharing?’ I don’t think there’s one answer. I think there are multiple answers.
I had the pleasure of working in Georgia for two and a half years, and there is no State wide exchange. Denise Hines is the executive director of the Georgia Health Information Network, and they want to be a network of networks, because before Georgia got their strategy together, some regional exchanges started to form in various referral regions within Georgia. And those were quite successful, so they didn’t want to say, ‘okay, that’s great. Thank you for taking care of it, but we’re going to do it now.’ So they decided to let there be a network of networks.
When I got to Columbus, we didn’t have regional exchanges, and so I went to work trying to stand one up between the other health system and Martin Army Hospital at Fort Benning. Like I said, it’s not an easy thing to do. It’s more like herding cats than anything else I’ve ever done.
Gamble: As soon as you bring up the word interoperability, I think it makes a lot of people cringe. Like you said before, the seamless exchange doesn’t really seem to be happening. And it seems that there are organizations that are put at a disadvantage — ones that don’t have one EHR across the board.
Christian: This exchange participated in several years ago when ONC did their demonstration projects about can exchanges exchange data. We were one of the demonstration sites between the HIE in Cincinnati called Health Bridge, and MHIN, which is the Michiana Network located in South Bend, Indiana. We were able to send all kinds of data back and forth, but the issue was, what’s the use case? We can send it, but what use is it? How’s it going to be used?
Even today, the conversations I had down in Georgia and the conversations I had up here about the content of the CCD are that it’s not very useful. The fact is that most of the data in it that can readily be brought into an EHR has to be self-reconciled — allergies, medications, and immunizations, because those are discrete data and they have some very strict coding standards. Lab results is another animal. That’s a whole other interview that we could do where I could get way deep in the weeds on why it’s so difficult to do.
The fact of the matter is if you talk to the clinicians, to the physicians, they don’t want a basket of data that they have to weed through and hunt for the nuggets. They want succinct information presented to them that’s based upon what happened to the patient and what the care plan is, that kind of stuff. And so that’s kind of an interesting progression with this thing called Health Information Exchange or interoperability; in the beginning, if the physicians had extra data other than what they had right at hand, that was great. They didn’t mind going and looking it up. Now, because they have access to the data, the question is, what’s the next generation? Well, the next generation is making it readily available within their EMR so they don’t have to go somewhere else.
And so, in order to meet some of the requirements of Meaningful Use, we’ve come up with these things called the CCD for direct and those types of things. In my humble opinion, I think it’s kind of hamstrung part of the industry related to innovation, because we had to work so hard to meet those standards, and then rather than us setting those standards as the floor or the threshold, that’s became the ceiling. I only have to do this to check it off, so that’s all I’m going to do. And the vendors were spending their scant resources on coding to meet not only the interoperability standard that was in Meaningful Use, but all the other ones as well. And at the rate of change, they were scrambling, trying to get that out and get it implemented in all the thousands of hospitals and physician practices to get that implemented. So in some cases, the high tech act and Meaningful Use has been very good and other cases I think it has hampered us a little bit in allowing some of the creative and innovative juices to flow, but that’s just me and that’s my opinion. That and a buck and a half or two bucks will get you a cup of coffee at most Starbucks in Indiana.