In nearly every discussion about the state of health IT, the word ‘complex’ always seems to surface. But when it comes down to it, the ultimate goal is actually quite simple: to inform care though data. And to Chuck Christian, former CIO and current VP of technology and engagement with the Indiana HIE, that means presenting clinicians with the data they need — both inside and outside the EHR — in a matter of seconds.
In this interview, Christian offers his usual candid take on where the industry stands in terms of interoperability, and how HIE is working toward that goal by focusing on EHR integration, interstate and intrastate data exchange, and population health initiatives. He also gives his thoughts on the opioid epidemic, data blocking, and how CMS could be changing the game.
- Using SDoH to identify food deserts
- Data’s role in the opioid epidemic – “We get smart by using data.”
- IHIE’s patient-centered data home initiative
- “We’ve created the governance around how those regions are going to connect.”
- 250K million ADT messages exchanged in 3 months
- “It has to happen automatically.”
- Working with MESH Coalition to coordinate EMS
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There’s not a national standard yet, and so what we create in Indiana might look a little bit different than what San Diego is doing, but we can inform ours with the work that they and others have done.
We have to be smart about how we do that, and we get smart by using the data. The more data we can use, the better off we’re going to be.
It shouldn’t be a burden on top of everything. In my opinion, the simpler we keep it, the more apt we are of getting people to use it. If it’s done in the background and if it’s done appropriately and securely with the patient needs in mind, it will be beneficial.
We’re getting to the point now where we can use the information that we’re gathering appropriately to have an impact upon how we take care of our community, and how we respond in case of crisis and emergency.
Gamble: We’re hearing a lot about social determinants in healthcare. It seems like we’ve been moving toward that direction of getting a complete picture of the patient by going outside of the traditional healthcare facilities. I imagine that comes through in a lot of the work that you do.
Christian: We have a lot of conversations about that. Part of the issue is this is still new. The folks in San Diego working with the health exchange and the 2-1-1 program have done a good job of creating data standards for social determinants of health. Unfortunately there’s not a national standard yet, and so what we create in Indiana might look a little bit different than what San Diego is doing, but we can inform ours with the work that they and others have done. I absolutely agree it’s critical to put all these data together to try to understand the patient’s socioeconomic standpoint.
I’ve been shocked to realize that within Indianapolis, there are food deserts. There are also pharmacy deserts. When I heard that, I thought, ‘That’s not possible.’ But depending upon a person’s socioeconomic status, it is. For example, you may not have a car, and so you’re dependent upon either your family or public transportation, or you walk to get to a grocery store or pharmacy. And if you’re elderly or infirmed, it better be within a mile or so of your house, or you’re not going to have access to those kinds of services. It’s distressing to realize we have those things in a town that’s as well-serviced as Indianapolis, but we do, and so we have to find those by using the social determinants of health.
Earlier this year, the Indiana Chapter had a Midwest HIMSS conference here in Indianapolis. As a precursor of that, the State of Indiana created a data repository — not a clinical data repository, but a repository — to gather data from different places, including Medicaid claims. They created 25 de-identified data sets and they had a data-thon where groups could look at the data. There was a group of students from IUPUI that took all the datasets and looked at the data around opioid consumption. They then overlaid that with another data set that was readily available around where the treatment facilities in Indiana were located. Lo and behold, it was very apparent where new resources were needed to help address services around treatment of opioid addiction.
Those are examples where we can truly have a positive impact using the data. The State of Indiana has opened up three or four additional markets for those kinds of services, which I think is absolutely what we need. Because we need to help prevent people becoming addicted, but once they are, we need to help them manage that addiction and live in a more productive way.
Gamble: The industry is starting to pay more attention to the opioid endemic and IT’s role in it. It’s interesting you brought up opening up new service markets because it’s not just about moving data around but having physical facilities that serve those areas.
Christian: Absolutely. The thing is, we have to be smart about how we do that, and we get smart by using the data. The more data we can use, the better off we’re going to be around those type of things. And so sometimes your gut tells you one thing but the data tell you something else, and so you shouldn’t always go with your gut. It’s like Ronald Reagan said, you have to trust but verify — trust your gut, but verify what you’re thinking.
Gamble: There’s a push to incentivize using things like clinical decision support and e-prescribing, which gives providers information at the point of care so they can be aware if someone has an addiction or is already taking medications.
Christian: I think that being able to use data to tell them a patient has a propensity is very valuable, because if they keep taking it, they could become addicted. But in talking to my wife, who is a retired critical care nurse, I believe we as an industry have to express some blame for this.
Years ago, one of the things we used to gauge care was pain control. We thought we were providing better care, because people had no pain. And as everyone started doing that, the drug companies came up with better and better pain control mechanisms, but unfortunately, they became more and more addictive. That’s just my take. I don’t have facts to back it up; those are just some thoughts we were having over a cup of coffee the other evening.
Gamble: Right. Now, as far as the patient-centered data home, which you mentioned earlier, where do things stand there?
Christian: We’re moving forward as fast as we possibly can. As I mentioned before, we have three regions of HIEs in the country that are working together on this, and we actually have 22 HIEs that are signed up for this agreement. It doesn’t sound a whole lot, but they cover a big swath of the country. We have the Heartland Project, which covers Indiana, Michigan, Kentucky, eastern Tennessee, and Ohio. We have a Midwest exchange that covers Oklahoma and Arkansas. We have another that just stood up in Missouri and Kansas, and then we have one out West that includes Utah, Arizona, and Colorado, and is now connecting into California and in Texas. Those regions are sharing information already, and now we’re connecting them. We’ve created the governance around how those regions are going to connect; those four gateways are operational, and we continue to work on that. We’ve got some areas that are exchanging data to the Heartland group, which we’re a part of, and we’re also the gateway for the Heartland group that’s exchanging information with the western group. So when folks from Colorado come to the Indianapolis 500, if they wind up in the emergency room in Indianapolis, we can notify their primary care physicians back in Colorado.
To give you an idea of the transaction volumes we’re talking about, just looking at ADTs alone — and this is in the Midwest region in the last three months — we’ve exchanged over a quarter of million ADT messages with the other six exchanges in the Heartland Region. That means we’re on a path to exchange more than a million ADT messages to help inform care, and we’re exchanging CCDs with several of those HIEs already. So that means if we get a patient in a region that we serve and we notify one of the other HIEs we’re exchanging data with, they in turn will send a clinical summary or a CCD back to us that we can present to the emergency room. That’s where the data follows the patient.
In my view, it needs to happen automatically. Somebody doesn’t need to initiate it by saying, ‘I see this patient has had care in X, Y, and Z facilities. Let me go see if they have anything I could use.’ If there’s something there, it needs to show up. And if there’s nothing there, they need to know that too. That’s one of the things I’ve learned in talking to physicians over the course of many years — if you can present information to them in a manner and a process that fits into their workflow, they’re more apt to use that as part of the care process and part of their clinical decision-making. If you’re going to make it like an Easter egg hunt, they may or may not be able to do that, unless it’s a tough case and they need to know more information.
We continue to add members to the patient-centered data home. We’re talking to many more HIEs, particularly in the Northeast, the Southeast, and the West, about setting things up. Kelly Thompson, the CEO of SHIEC, has made several trips to the Washington state area to have conversations with those folks and explain what we’re doing, so we can make it easy. It shouldn’t be a burden on top of everything. In my opinion, the simpler we keep it, the more apt we are of getting people to use it. If it’s done in the background and if it’s done appropriately and securely with the patient needs in mind, it will be beneficial. But we’ll see how it goes. We’re gathering numbers and trying to see if we can do some research and analysis on top of that as well.
Gamble: There’s been a lot of focus on setting the foundation for that, and now it seems like it’s time to start moving forward and building on that.
Christian: We’re just starting to get to a point — you can call it a tipping point, you can call it a tip of iceberg — where we can do that. There are some things happening around the country where HIEs have clinical data repositories and they’re helping to support some of the Medicaid programs. One example — and I’m doing this from memory so I may not get all the details correct — happened during the flood in Houston, where a Medicaid program used a database to could identify the most at-risk patients, because they had a respirator in the home. They were trying to provide emergency management services to the most vulnerable patients, and so they looked at the state database. HIEs have better, more up-to-date information on those patients because of the data they have in their clinical data repositories, and so they can have a higher impact.
How we work together as a community to have an impact, particularly on those who are most vulnerable, is really important. We’ve had some conversations with a local organization called the MESH Coalition. It’s a partnership among five health systems to better manage emergency services. Every organization has the same issues — beds, surge potentials, etc. — and so MESH works with state planning and state EMS to coordinate that. We’ve worked out a way of providing access to data in an emergency or a crisis situation. We’ve been invited to sit down with them for the EMS planning that’s going to take place in the not too far distant future to see what else we can do.
A while ago, we had a disaster at the State Fairgrounds when Sugarland was playing here. There were hurricane force winds, which caused the rigging to blow down; unfortunately, a few lost their lives and a lot of other people were injured. The difficulty the EMS had was to hook those families back together once the crisis was over — there wasn’t a good way of doing that. I think it should be pretty easy.
So we’re working with MESH to figure out a simple way and a secure way to do that, because it has to be controlled. You can’t have anybody walking up EMS and asking, ‘where did you take this patient?’ You have to ensure that this person needs to know that information or should know it. There needs to be some identity checking. We don’t want somebody from the newspaper asking questions and getting information inappropriately. Those are some of the policy and procedural things we’re working out. But like I said, we’re getting to the point now where we can use the information that we’re gathering appropriately to have an impact upon how we take care of our community, and how we respond in case of crisis and emergency.