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.
- Responding to Chilmark’s report: “Not all HIEs are the same.”
- Decreasing in numbers, increasing in strength
- “We’re just now starting to scratch the surface.”
- Data access & public health initiatives
- “We have more data we can use appropriately & securely.”
- Impact of food deserts
- Cyberattacks: “You have to be forever vigilant.”
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The other thing that everybody should understand is not all HIEs are the same. Some persist data like we do, others do not, and so the data services we’re able to offer are different. We have to be very careful about painting all the HIEs with the same color and the same brush.
I’m going to violently disagree that HIEs have maxed out. I think that we’re just now starting to scratch the surface on what the capabilities may be.
You need to know where that patient is getting services, and if the only view you have is the data you have in your own EMR, you’re going to have a very narrow band of view.
The large majority of care from an individual standpoint is happening at the physician practices. Now that the large majority the physician practices that are automated, you have a whole lot more data that you can use appropriately and securely to do things around public health.
When you think you have all the doors bolted, somebody is going to crawl through a crack, and so you have to be forever vigilant.
Gamble: One thing I had to bring up especially knowing you for a couple years was the recent Chilmark report that talked about HIEs and saying that they’ve reached their limits of effectiveness and I know that kind of thing makes your blood boil.
Christian: The thing about it is, there’s a researcher at University of Michigan, Julia Adler-Milstein who published a piece which said that for Medicare patients in areas that are covered by an HIE, there is an annual savings of about a $139 a year. Well, that doesn’t seem like a whole lot of money, until you multiply that by all the Medicare lives that HIEs can cover — it’s millions, if not billions of dollars. There are competing viewpoints about health information exchanges.
The other thing that everybody should understand is not all HIEs are the same. Some persist data like we do, others do not, and so the data services we’re able to offer are different. We have to be very careful about painting all the HIEs with the same color and the same brush. Have you ever heard of the parable of the five blind priests that went to see the elephant?
Gamble: No, but it sounds pretty good.
Christian: How does a blind person see? They see with their hands. If you picture an elephant in your head, depending upon which part of the elephant you grab, you’re going to describe it differently. Depending upon what type of HIE you may be looking at, there may be some in the country that have reached their limit of capability and will either do need to do one or two things. They’ll either need to change — and many of them are changing their technology stacks in order to be able to offer different services — or they’ll just fade away. I’m hoping we’ve reached the point now that all the ones that were going to fade away will team up with others. If you look around, particularly out east, you’ll see consolidation taking place.
Actually, Julia did a piece of research that said the number of HIEs were decreasing. Well, that’s absolutely true, but the number of lives or population that was being covered by health information exchange was increasing, because they’re consolidating. You have smaller ones that are walled in a geographic area; they’re connecting and becoming part of the larger organization. So rather than being absorbed, they’re being merged into larger HIEs, which is fine. That’s exactly what’s happening in healthcare systems. The smaller hospitals that cannot survive by themselves because of a variety of market pressures have a tendency to join larger health systems or be acquired by larger health systems.
One of the things we battled with when I was at Good Samaritan was the depth and breadth of services that a community hospital should be offering? Does every one of them need to do open heart surgery? No. The old adage was who do you want to do your open heart surgery: a physician who does 300 a year or one that does 18 a year? I’ll tell you what my preference is. I want somebody that’s honed their skills about 300 plus a year. In smaller community hospitals, you may or may not have that kind of volume in order to be able to offer that service. So you have to kind of right-size it that a little bit.
I’m going to violently disagree that HIEs have maxed out. I think that we’re just now starting to scratch the surface on what the capabilities may be, because most of the HIEs have grown up regionally and they have a tendency to serve the people that are paying the bills, that are buying their services, and so it’s kind of like, this is what people are willing to pay for, so this is what I’m going to do.
The other thing is the rules continue to change. If you look at some of the advanced payment models that are coming out of Washington D.C., every one of those is going to require some level of data that doesn’t exist in your healthcare system, particularly if you’re getting into risk-based sharing type approaches around ACOs and some of the other programs. You need to know where that patient is getting services, and if the only view you have is the data you have in your own EMR, you’re going to have a very narrow band of view of where that patient is having services. You won’t know that patient has been admitted somewhere else.
It’s kind of like readmission studies. Readmissions are not just being readmitted to your facility; it’s being readmitted anywhere. Well, you need to know. Up until recently, you had to wait for the government to tell you what your readmission rate was, because it took a mathematical genius and a really good crystal ball to know if your patients were being readmitted somewhere else. With an HIE like ours, I can tell you today when a patient gets admitted in another facility that it’s also connected to us. I think that we’re just learning how to have an impact upon healthcare from a population standpoint, and from a community and public health standpoint as well.
Gamble: That tie in with population health is going to be interesting to see, and I can see why you say that HIEs have not yet maxed out because that’s a whole new – not new, but that’s a whole function that really could start to take some interesting shape going forward.
Christian: If you go back in the very beginning of Meaningful Use and some of the early PCAST reports, it’s about the data. Part of the issue was, if you think about it for a moment, where does the large majority of healthcare take place in this country? It is not in hospitals. But hospitals are the ones that had the financial wherewithal in order to put in the technology to get to the data to streamline their operations. But the large majority of care in the country from an individual standpoint is happening at the physician practices. Now that the large majority the physician practices that are automated, you have a whole lot more data that you can use appropriately and securely to do things around public health.
One of the things that our public health folks are looking at is childhood obesity — where are you going to get that data? Are you going to go to the schools and roll out a pair of scales and weigh every kid? Most of the kids are seeing either the family physician or pediatrician or they’re in some clinic and they get weighed. That’s the first thing they do when they call me back; they weigh my fat behind and then say, ‘you’ve gained a few pounds.’ I’m still waiting for them to say, ‘you’ve lost a few pounds, that’s great.’ But they do the same thing to children, and they measure how tall they are, and if you have their height and the weight, you can do their BMI.
Wouldn’t it be great if the public health system looked at that and then you could take that data set and bump it up against some of the other social determinate factors of health — where do they live, what their socioeconomic state is, and a few other things that you could take a look at? You’d start doing a better job of moving the services from a public health standpoint to the areas that they need.
Indianapolis is a pretty good size place; it’s pretty densely populated, and we have places that qualify as a food desert. I look at that and I say, ‘I’m not buying it.’ But the problem is a lot of the people are in the lower economic ranges; they use public transportation because there’s no place to park your car. They use public transportation because that’s all they need, so they have to walk to the grocery store. If there’s not a grocery store within a mile, people like elderly folks can’t get to the grocery store and back, so they’re in a food desert. The same thing goes for pharmacies. I said, how is that possible? On every street corner that I can see, you’ve got competing CVS’s and Walgreens, with a sprinkling in of Rite Aid and a few other ones out there. But once again, it’s within how far away from those population centers are those services. It was really kind of an eye-opening and an epiphany for me that we really need to take a look at how those services are offered and where they are.
I don’t know if you have Marsh grocery stores in your area, but Marsh has filed bankruptcy. There are a lot of Marsh stores in my area; there’s a big one not too far from the office that I go to maybe once or twice a week, and they have a great hot lunch bar. When that closes, they’re going to shutter all their stores. Well, that’s going to have a significant impact, because for a lot of younger adults that live and work downtown, that’s where they shop and it’s where they can go get a hot meal, so they don’t have to cook.
I think it comes down to how we use that data to identify those areas appropriately. I’m not saying that because we have this massive amount of data, we have free access to it; we do not. We are the curators of this information. We have a governance committee that defines who accesses the data, how they access it, and what data they get to access. Just because I want to, doesn’t mean I can. It’s no different than working in a hospital and having all the keys to the kingdom. I can look into the medical record, but I best not, because then I’d have to fire myself.
Gamble: Absolutely. Well, we’ve definitely covered a lot of ground. I know that there’s so much going on, so it’s hard to fit everything in.
Christian: The only other thing I’d say is I’m watching very carefully about what’s been taking place in ONC and CMS. I lay awake at night thinking about the recent cyberattacks. This latest one was quite disconcerting, and so we’re staying diligent. But it just kind of raises the whole specter of the fact that when you think you have all the doors bolted, somebody is going to crawl through a crack, and so you have to be forever vigilant. So now that ONC and CMS both are getting their staffing in place, we’ll see where everything is going to go from there, from an interoperability standpoint and from a standpoint of just moving forward. So we’ll continue to look at those public policies to see what comes out of DC.
Gamble: I think the next time we speak, we’ll have a little bit more information. We know these things take time for new administrations to really set up and get into gear. There will be more to talk about in terms of how this is going to affect everyone.
Christian: I think with the American Healthcare Act and some of the other things, we don’t know what’s going to come out of the Senate. I’m almost certain that what was passed in the House will not be what comes out of the Senate, because there are competing viewpoints about the expansion of the Medicaid populations. We’ve done it twice here in Indiana; it seems to have worked okay. Seema Verma was the consultant that helped both Mitch Daniels and Mike Pence with those revisions of Medicare and Medicaid in Indiana. I have no idea what she’s going to do from a national level, but that’s going to be interesting to see what policies come out from that. So yes, that would be a great topic of the next time we get together to talk about that and see how it’s panning out and what’s going on.
Gamble: Absolutely. These are very interesting times we live in.
Christian: Absolutely, and that is a blessing and a curse.
Gamble: I agree. Well, thank you so much for your time. I really enjoyed it.
Christian: You’re very welcome. I’m glad to do it.