If you really want to get Chuck Christian’s goat, ask him why all banks are connected through ATMs, and yet healthcare still struggles with interoperability. The simple answer? It took quite a bit of time for banks to figure out a system. Oh, and accessing data is slightly more complex than withdrawing $10. In the latest of our Fireside Chat series, Christian talks about the progress Indiana Health Information Exchange has made in facilitating data exchange among organizations, why it’s not a lack of standards, but rather the lack of a single standard, that is hurting the industry, and what healthcare can learn from industries like banking and railroads. He also discusses the need to use data to help and not hinder clinicians, and why he strongly disagrees with reports suggesting that HIEs have maxed out.
- Discrediting the banking comparison – “Healthcare is far more complex.”
- Turning mistakes into experience
- Data sharing through SHIEC
- Community hospitals & the HIE value proposition
- Physicians’ plea: “Don’t tell me what I know; tell me what I don’t know.”
- Google searches with INPC
- “We’re dealing with human beings.”
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Healthcare is far more complex than trying to get out $10 or $20 out of your bank account, and so it depends — are you looking for a report? Are you looking for a lab value? Are you looking for a referral document? There’s so much, much more.
Do we have all the answers? Absolutely not. Can we learn from the other exchanges in the country? You bet, and that’s the one of the reasons that we were one of the founding members of SHIEC.
They’d say, ‘you’re giving me a bushel basket of data and you’re asking me to wade through it to find something that may or may not be important, and it’s just not worth my time to do that. There are other ways I can get the same information but make it a better use of the physician’s time.’ And I absolutely agree.
There are ways we can use the data to better inform and assist the physician, and not replace their knowledge, but add to their knowledge based upon what their habits are. Two physicians may have two entirely different approaches, and that’s fine. We don’t need to fence them in and say, ‘doc, you have to do it this way.’
We have to be careful because we’re actually dealing with human beings. We don’t have the privilege of going out and experimenting on will this work, did that work.
Christian: A lot of people talk about interoperability and say, it’s just like ATMs. Let’s look at the history of ATMs for a second. They’ve been around for a long time. There used to be hundreds of ATM networks that didn’t talk to each other. You could only get money out from your own bank’s ATM.
Eventually, the banking industry figured out that from a customer service standpoint, this is what people wanted. They also figured out a way of funding it with inter-bank transfers of funds like ATM fees, and figuring out the technology and the standards to make those networks talk to each other. I think there are still 20-plus ATM networks, but you and I don’t know it as an individual going to a bank, other than the fact is if it’s not your bank’s ATM, there’s going to be a $3.50 transaction fee.
The other thing is healthcare is far more complex than trying to get out $10 or $20 out of your bank account, and so it depends — are you looking for a report? Are you looking for a lab value? Are you looking for a referral document? There’s so much, much more. The other thing about the banking industry a lot of people don’t understand is they also have separate networks for wire transfers and a lot of the other transaction types that banks do. Those are not done on the ATM networks; those are done on a separate secure networks that may or may not be owned by the banking industry itself. We have a lot to learn from them.
Another example I’ve used many times is the railroad. Most of the railroads, depending upon where your train was, had a different gauge of width between the tracks. And they were all done regionally. It wasn’t until the financiers started buying up railroads to try to do interstate or intercontinental commerce that they realized they were having to unload trains and reload trains because one train can’t run on another’s track. And so there was an industry requirement from a commerce, profit, and loss standpoint for them to come up with what’s now called the standard gauge. Interestingly enough, the standard gauge is the same width as the wheels on a wagon. The way they came up with that is when you put two horses side by side, that’s about the width you’re going to get for a stable wagon. Those are some of the things that need to drive the standards to help us get to that point.
Gamble: We’ve see the banking example come up, but when we’re talking about different networks, I think people forget that it’s more complex than it seems from the outside.
Christian: The reason they think it’s so easy it’s because over the course of about 30 years — and that’s how long it’s taken us to get to where we are — it’s come to a point where I can go to just about any ATM in the world and get money out of my checking account or my savings account sitting in Indiana. But it wasn’t always that way. We’ve only been at this like 8 or 9 years in healthcare in terms of seriously wanting to do this.
The exchange I work for is one of the oldest in the country. It’s been around for a long time, and I think we’re fairly mature. But do we have all the answers? Absolutely not. Can we learn from the other exchanges in the country? You bet, and that’s the one of the reasons that we were one of the founding members of SHIEC, to create that collaboration of HIE so we can learn from each other. It’s like that saying — what do you call a mistake? It’s called experience if you learn from it. What we were trying to do is share our collective experiences so that everybody is not making the same mistakes over and over again, and hopefully, we can speed this process up a little bit.
And it seems to be going really well. I just came back from a planning leadership meeting in Dallas. It’s really great to have the brain power that’s sitting in that room trying to work together to figure things out and say, ‘here is what we’re doing in Indiana. What are you doing in Colorado? What are you doing in Arizona? What are you doing in Oklahoma and Michigan? That kind of stuff. Trying to get that collective gray matter together is extremely beneficial.
Gamble: One of the things you mentioned before was community hospitals. We’ve been seeing the trend for a while now of hospitals becoming part of bigger systems, but for those that don’t follow that route, I would think these HIEs and pilot programs can help them stay independent, if that’s what they want to do.
Christian: I was at a community hospital for a long time. When John Kansky — who’s now CEO of this organization and who has been a friend of mine for a long time — was in charge of business development, he came down to Southwest Indiana to talk to me about hooking up to the exchange. And I said, ‘John, most of your business right now is in Indianapolis. Our referral patterns take us south to Evansville, Louisville and St. Louis. And so there’s really not a great deal of value in us being able to exchange data with the Indianapolis hospitals.’ Well, it wasn’t until we were starting to wire up the Evansville hospitals and the ones in south that we decided that that was an important thing.
I think working with the HIEs to create that value around what those referrals are is important. This exchange is little different from some, because we can cover the grand majority of the state of Indiana. We still have a few hospitals that have not connected to anything because for variety of reasons. I’m not going to try to read their minds and figure out why they haven’t chosen to do that, but I think there’s going to be continue to be more compelling requirements to do that from a data sharing and clinically integrated network. I know the physicians I talk to are looking at ways to leverage the data to help inform themselves and their colleagues about the care of the patients.
When we’ve done some strategic planning and met with CMIOs, the physicians will say, ‘don’t tell me what I already know; tell me what I don’t know.’ They also say, ‘present the information to me without me having to go hunt it.’ I’ve had lot of conversations, particularly when I was working in Georgia, where physicians were complaining about the volume of information that was contained in a transition of care CCD. They’d say, ‘you’re giving me a bushel basket of data and you’re asking me to wade through it to find something that may or may not be important, and it’s just not worth my time to do that. There are other ways I can get the same information but make it a better use of the physician’s time.’ And I absolutely agree.
I’ll give you a few examples of some things that we’re thinking about doing. We’re very fortunate of having a great relationship with the Regenstrief Institute, which has really smart MD, PhDs, and researchers. Regenstrief and IU Health is where this exchange grew out of years ago. And then in 2004, we incorporated as an entity in its own and moved out from underneath the feathers of the mother hen that was sitting on the eggs. They hatched us.
So, if you’re an ER physician and the patient walks through the door with a chief complaint of chest pain, there are a handful of things that physician wants to know about that patient from their past medical record: have they been admitted recently anywhere else with that same chief complaint? Do they have a history of coronary artery disease, heart attack, and that kind of stuff? Have they had a cath lately? Have they had an echo lately? What did their last troponin levels look like? Where did they have their last EKG, and can I see it to do comparisons from a historical standpoint?
Well, wouldn’t it be great if we let the machine learn what that physician routinely looks at? We have this massive lake of data that goes back many years, and once we have that secure treatment relationship established with that physician, it can query the data lake and bring that information back to the physician and just present it to them. They don’t have to do anything. We’ve created an interim step because there are some hooks and things that need to be written inside the EMR systems to do that, or there has to be some layered software on top of it.
And so we’ve created a Google search-type of approach for what we call the INPC (Indiana Network for Patient Care), which is the clinical data repository that we have, and they can do safe searches by physician. A friend of mine who is an ER physician at Eskenazi Hospital has one that he calls ‘chest pain.’ He goes up to the Search bar at the top of the screen and types in ‘chest pain’ and it goes out and queries and searches the INPC for those type of things. For example, ‘give me the list of the recent admissions that patient has had,’ or ‘I need some labs’ — those types of things, and it lands him back on the Search page and list out that information form.
Now, he had to initiate a search, but he didn’t have to go look for each one of those things. He just went and looked for a group of those things predicated around a safe search. You can do the same thing for abdominal pain, or back pain. If you have a patient that comes in with just nondescript chronic back pain, wouldn’t it be great for you to know if that patient has a substance abuse problem and you need to get them some help, rather than not knowing that patient was in another hospital ER last night with the same chief complaint? There are ways we can use the data to better inform and assist the physician, and not replace their knowledge, but add to their knowledge based upon what their habits are. Two physicians may have two entirely different approaches, and that’s fine. We don’t need to fence them in and say, ‘doc, you have to do it this way.’ They need to be able to practice medicine the way they were trained to practice medicine.
Gamble: That’s a really good point, and one I’m sure that you’ve heard a lot from physicians in terms of the frustrations that they have.
Christian: Oh absolutely. Look at the cars we drive today. My wife’s van has so many features. It helps me to not do something stupid, like change the lanes when there’s a car beside me, or back up when there’s somebody walking behind the van. We’re going through these iterations, and some of these iterations may be painful because what we think may be the best thing may not really the best approach when we actually put it into practice. We’ve got to go through these iterations.
We have to be careful because we’re actually dealing with human beings. We don’t have the privilege of going out and experimenting on will this work, did that work. We’ve got to figure out ways of doing it through pilots and other things. It’s like clinical trials; you do it on a subgroup of people and see if it works. If it doesn’t work, then you don’t release the drug. It’s the same thing with what we’re doing with some of the pilots. Let’s see if it is beneficial. If it is, great, we’ll roll it out. And if it’s not, we’ll go back to drawing board and have more conversation with more physicians.
One of the things that the federal government is mandating these days is around the appropriate use of imaging and unnecessary radiation, requiring folks to make sure that if you’re going to do another cardiac scoring in this patient, you need to first look at when was the last one the patient had, where did they have it done, and what were the findings? Is this next cardiac score you’re going to do worth the amount of radiation the patient is going to receive? Being able to inform using that data is extremely important.
There was a conversation about somebody keeping up with the total body radiation for a patient over their lifetime. Well, my goodness. How many different places have you had an x-ray done? Unless we’ve got a way of gathering that data from all those sources, who’s going to track that? I don’t know. We need an opportunity to do that and provide that information to the physician when they’re about to order something.
I’ll give you an example of something recently happened with my son-in-law. He was supposed to go for a radiology study and they had it all set up and he’d taken off work and he was driving to it and then he had a phone call from somebody in the radiology department who said, ‘we just don’t really think that this test is warranted at this point in time and so we’re going to cancel it.’ Wouldn’t it have been better if he had known that before he’d taken a day off work or taken a half-day off work to go ahead the study done? So we saved him the ionizing radiation, but we created an inconvenience in his life. We can do better, and I think at some point in time we will do better.