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.
- Smartphone capabilities – “Why can’t we do the same thing?”
- Potential of using Alexa in the ED
- “Technology has to be obtrusive at first”
- MyHealthEData & Blue Button
- His “misgivings” about patient data access
- VA’s challenges – “It will actually take an Act of Congress”
- Data blocking: “I don’t know of anyone who’s doing it on purpose.”
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Everything I need is in my phone. It’s a piece of technology, but I don’t think about it. It just works, and that’s the same thing we need to be able to do with our data systems and how we connect those.
I have some misgivings about patients sharing their data, because I’m not sure they truly understand what they’re sharing and what can occur with it afterwards.
That tells me that they’re taking this seriously and they’re having some good conversations, both within and outside the government, about what this should look like. Because I think what worries everybody is that this has the full weight of OCR and OIG behind it. There could be some serious rules made about data blocking.
We’re curators of the data. We don’t own it. We don’t decide who gets access to it. It’s done through a defined a governance structure that’s been in place for 15-plus years and works really well.
Gamble: You made the point earlier about having technology fade into the background. It’s not an easy thing to do obviously, but it speaks to your point about making sure it’s all about the patient and that interaction, and that it’s not centered on the technology.
Christian: That’s exactly what we need to do. When’s the last time you walked into a room and flicked the light switch, and thought about how it happens and who creates the electricity to fuel that light?
The other thing that’s amazing to me is I have an iPhone, and if you think about the number of devices and the amount of equipment that’s in that phone, it’s amazing. I remember the camcorder. I remember the iPod and all that, and all of that — everything I need — is in my phone. It’s a piece of technology, but I don’t think about it. It just works, and that’s the same thing we need to be able to do with our data systems and how we connect those. When I walk into my house in the evening, I tell Alexa to turn the lights on. I can also tell Alexa to set the temperature in my house. Why can’t we do the same thing around our healthcare data? We can, we just need to have really smart folks who can be thoughtful about it and decide what’s appropriate. Alexa’s listening all the time — so is Google and some of the other ones that are coming out.
I have a friend who is an ER physician, and when the Echo first came out, he said, how can we make this work for an internal resident in a medical facility? If you’re in an emergency room and you need a piece of information, ask Alexa to find it for you rather than having to go look it up yourself, because then you can be doing something else while you’re waiting for that information. That’s how we can use it.
One of the things we’ve talked about is, wouldn’t it be great if you could ask Alexa to look at the INPC (which is our clinical data repository) and see if this patient had a hemoglobin A1c in the last six months, and if they did, give me the result. Then you’d say, ‘Alexa, make sure that gets in the patient’s chart.’ This is kind of Star Trek-y, but can we get there? Absolutely. I truly believe that we can make the technology less obtrusive. But it’s like everything else, it has to be obtrusive at first. It’s like being a woodworker — I have some great tools, but I’m in awe of the people that know how to use all the hand tools. The furniture they build is sometimes more beautiful, and you can see the craftsmanship that’s put into it versus the stuff I built with all my power tools.
Gamble: We heard some of this talk at the CHIME-HIMSS Spring Forum, and it was interesting because they weren’t talking about technologies that are years out. There were some pretty good examples of the things that are happening now — maybe it’s on a smaller scale, but it’s encouraging to see that we’re moving closer to some of those realities.
Christian: I’m reminded of a short video Hewlett Packard put out several years ago. It started with an executive who was getting ready in the morning and having a conversation with his computer. The first meeting he had was about the financials of standing up and building a new hospital, and he wanted to make sure he had all the information he needed in the electronic folder. And he asked a couple of questions about the data, which the computer gave him, and then switched to other aspects of care, like how ambulances were dispatched and how information is provided to an ER physician about a young boy whose liver was shutting down. That was 15-plus years ago, but we’re just now starting to have the amount of information we need to make some of those things a reality.
Gamble: It’s very exciting. Looking back at this past HIMSS Conference, what were some of the themes that were of interest to you?
Christian: When I was at HIMSS, I had the pleasure of having some conversations with the folks at CMS as well as ONC. It seems like half of the federal government came from Indiana, and we have some good ideas. Do we have all the good ideas? No. But one thing CMS and ONC are focused on is making sure patients have access to their data, and I don’t disagree. CMS Administrator Seema Verma announced the MyHealthEData initiative, which will make data — basically claims data — available to the patient, and enable them to share that information appropriately with whomever they want. I have some misgivings about patients sharing their data, because I’m not sure they truly understand what they’re sharing and what can occur with it afterwards. But that’s really not the intent of MyHealthyEData or the Blue Button 2.0 initiative. I’ve worked with the CARIN Alliance, a public-private group that was stood up to look at patient access to data and how we can appropriately do that. I think we’re now getting to the point that we’re able to have those conversations.
One of the things that I’ve wondered in the back of my mind is, we have this epidemic of opioid abuse, but we have a very strict way that people can access that information. The rule — called 42 CFR Part 2 HIPAA — puts a whole other set of guidelines around drug treatment and therapy where the patient has control of who sees the data and who doesn’t, what data gets seen. Is that a stumbling block in being able to treat patients, particularly if the patient shows up in the emergency room and physicians don’t have the benefit of the that information easily? The same thing goes with veterans. We’re moving forward with community connect, where if veterans can’t get timely and appropriate care at a local VA facility, they’re now able to go out into the community and seek care. But the VA is constrained about sharing the data they have on that veteran, because of another federal law that requires the veteran to give consent to opt into sharing that data. Interestingly, I had a conversation with the [former] CIO of the Veterans Administration. He is a disabled veteran who has had care both in and outside of VA facilities, and said that no one has ever asked him to sign that consent.
I was on a panel where I mentioned to VA Secretary that we need to change that, and they’re working on it. Unfortunately, this will actually take an Act of Congress; it’s not something the VA can change themselves. They can modify the interpretation a little bit, but in order to change the way the data is shared to match the way in which everybody else shares data around the HIPAA requirements is going to take a change in federal law.
Gamble: Very interesting. The announcement about MyHealthEData was very exciting, but the initial reaction by some was, what exactly does this mean? How soon are we going to see it become a reality? Do you think CMS made the announcement to appease the public, or is this going to happen?
Christian: I don’t think that’s the case. I think they’re really doing it. I was on a recent phone call with the CHIME Policy Steering Committee and the CMS folks talking about Blue Button 2.0, and they’re serious about it. They’re trying to get the data out there. I had some questions about secondary use of the information and gave them a couple things to think about, but I think that they’re moving this forward. It’s not one of those things where they’re saying, ‘we’re thinking about this.’ They’re ready to go, and I think we’ll actually see it happen.
Gamble: That’s the benefits of being on the inside track.
Christian: Well, it’s not written in stone yet, but from the discussions I’ve had, they seem to be pretty far down the road. There’s actually a video about Blue Button 2.0. They set up a developer sandbox so that people can actually trial their code against it to see how it works.
Gamble: Interesting. We’ll have to keep an eye on that.
Christian: There’s one more thing I’d like to mention. We as an industry, particularly those of us who work in this mine called interoperability, are waiting on a few things from the 21st Century Cures Act. The first is putting together a trust framework — we don’t have time for me to talk to you about that. The other is to come up with the exceptions for data blocking; we haven’t seen that yet. They’ve basically signaled that it’s not coming until mid-summer (instead of April). That tells me that they’re taking this seriously and they’re having some good conversations, both within and outside the government, about what this should look like. Because I think what worries everybody — my friends who are hospital CIOs, and others in the HIE space — is that this has the full weight of OCR and OIG behind it. There could be some serious rules made about data blocking.
I don’t know of anybody that’s being a data blocker on purpose. One of the definitions I’ve heard is if you don’t hook up to the HIE, you’re a data blocker. I don’t believe that, because there are other ways of sharing data. You have to figure out what’s appropriate for your institution. The other thing I’ve heard is that vendors are charging us a lot of money in order to create interfaces, which means they don’t want to do it, so they could be misconstrued as a data blocker. I’m not sure that meets the definition either in my mind. Years ago when I was on the vendor side — this was back in the 80s — and a customer wanted customization, we thought it was a bad idea. They still wanted it and we said, ‘well, it’s going to cost you X dollars’ as a deterrent, because we could do it, but we knew that the way it was designed, it wasn’t going to do what they thought it was going to do. We knew it was going to be a waste of time and effort. So what do you do — do you outprice some of these things?
I do believe that early in the EHR space, were vendors looked at this as an opportunity to enhance revenue. I’m hoping that mindset is now changed, because I don’t know of any vendor we’ve worked with — and we’ve worked with hundreds of them — that right off the bat says, ‘nope, we’re not going to connect with you.’ Some do charge, but it’s not an exorbitant amount of money. They’re trying to cover their costs, just like we are. We charge for connections as well, but just to cover our costs. We’re not generating stockholder revenue or anything like that, because we’re a nonprofit supporting organization.
Gamble: To me, that certainly doesn’t sound like data blocking. But I can see this being a tricky area.
Christian: Think of it this way. If you have a large insurance company that comes to your exchange and says, ‘I want you to share your data with us,’ and we say, ‘no, our governance structure doesn’t allow for that kind of sharing,’ are we data blocking because the request they made was not within the confines of our governance process, and therefore we can’t share data with them? I don’t believe so. We’re curators of the data. We don’t own it. We don’t decide who gets access to it. It’s done through a defined a governance structure that’s been in place for 15-plus years and works really well. It meets all of the HIPAA standards around the treatment, payment, and operations; we have a lot of attorneys that sit on that committee that help us make those determinations.
Gamble: It’s a really interesting topic, and one that people feel really passionate about. It would be good to see more information come about those exceptions and clarify some of these misperceptions that are out there.
Christian: Yeah, but don’t ask ONC to give you any heads-up, because they won’t don’t do it. I ran into Don Rucker at HIMSS; we had met before, but we just stood in the crossroads for about 20 minutes and had a conversation. He said they’re not going to tell us anything yet because they’re in the middle of rulemaking. I have great respect for those folks. They get asked all the time and they’re consistent — they say, ‘no. You’ll know when everybody else knows,’ which is fine because they can’t give people advance knowledge to give them an advantage. I fully understand that and wouldn’t expect them to do it any other way. They earn what little money the federal government pays them to do their job every day.
Gamble: That’s exactly what you want, for them to keep things under wraps until they’re ready to give the definitive answers.
Gamble: And the media will try to get them.
Christian: The media tries all the time.
Gamble: That’s what we do. Well, we’ve certainly covered a lot. Thanks so much, again, for your time. It’s been really great. It’s always great to hear about what you guys are doing.
Christian: You’re very welcome. Always willing to share and happy to do it.
Gamble: Great. Thank you.