Healthcare providers will be motivated to support, and HIEs will be economically successful, when the convenience of sharing my clinical data across organizations is worth me paying a transaction fee for it to occur. In the US healthcare system, continuing to seed HIEs with government fertilizer money in hopes that they will sprout and grow is a waste of time and tax payer money.
Health Information Exchanges are never going to be successful until there is economic incentive for healthcare providers to participate. “For the good of the patient” does not cut the economic mustard. The simple fact that government subsidies are required for adoption is reason enough to conclude a priori that the models are not sustainable. In a good ole’ capitalist society that exploits the poor and rewards the wealthy, you don’t need government funding to convince investors to join the club. They’ll fight, punch, and claw their way past each other to grab the business opportunity. Just ask Steve Jobs.
Many of us in healthcare love to throw the banking analogy around—“If banks can find a way to seamlessly share data for 35 years, we can!” and “I want a healthcare system that’s as easy as my ATM.” Ya, uh-huh. But… Are any of your banks willing to host your longitudinal financial record– across all of your banks, credit cards, retirement accounts, and investments? Nope. That’s left up to me and tools like www.mint.com. Banks are motivated for you to consolidate your financial record by conducting all your business with THEM. The ability to share transaction data between banks was not motivated by altruistic bankers trying to help their customers. It was motivated by business efficiency and risk management… for the banks. By the way, wire transfers between banks has a data model that could be described in probably 50 or 60 attributes. In contrast, take a look at the HL7 reference data model for healthcare. It’s not an apples-to-apples analogy in that regard, either. And never mind the cardinality of those attributes, which pours more water on the banking analogy for simple data transfer.
The ATM analogy pains me, too. In the early days, ATMs were a business differentiator. All of us wanted to do business with the banks who were early adopters—we wanted the convenience of after-hours cash withdrawals and at distributed locations. While that type of convenience might be handy for a Personal Health Record, it’s not compelling for most us…it’s definitely not a reason that I would seek medical care at particular facility. ATMs did not explode in number and thus inter-bank cash-movement-convenience until the economic model emerged that charged for every transaction outside the boundaries of your financial home…and customers were willing to pay for the convenience. That “and” is an important conjunction. The unfortunate reality in healthcare: The customer that cares most about the benefits of that inter-hospital data transfer is, for the most part, the insurance company or self-insured employer. Someday, they’ll only do business with providers who are willing to electronically exchange patient data… and that will change the economic model of HIEs towards success.
I see the need for a new socio-economic model that blends socialism and capitalism… I think it’s called China.
:-)
Anthony Guerra says
First off, this is an excellent post, and I couldn’t agree with it more. Find the economic incentive and watch things happen, keep relying on the finer points of human nature, for all of us to “come together” and you’ll be waiting a long time.
The policy wonks and true believers can keep banging their heads against the wall if they like, and we’ll just watch and wait for them to figure out the magic formula, which is, in general, everyone wants to work a little less and make a little more money.
This goes for putting in EMRs, creating HIEs. and everything in between. If what is being proposed doesn’t increase the cash in my pocket, or at least not decrease it, you can forget it.
We have to accept who we are as human beings — in general, again — and play on what drives us, namely, profit.
Brian Ahier says
If those who benefit most are the ones who should carry the freight, and the whole point is to benefit the patients, then the question becomes will consumers be willing to bear the costs of information exchange?
Dale Sanders says
Brian, I’m thinking the answer is largely, no, consumers are not yet willing to bear the costs of information exchange…at least not yet. I can envision a future with a data exchange fee in my healthcare bill that accompanies a referral or hospital discharge/transfer. But, as Anthony states so clearly, Darwin got it right. Our genes are programmed around self-preservation and in today’s voyage of the HMS Corporate Beagle, that translates into “less work and more money for me.” And that’s coming from someone who is regularly called a naive idealist. :)
Anthony Guerra says
Dale — I think you make an important distinction. What you suggest is a fee for a particular service at a particular time; but when Brian talks about consumers “bearing the cost,” that sounds like a tax on all for services used only by a few. I absolutely think consumers will not bear such a tax. I do think people would accept the fee model you talk about.
I think that’s an important distinction.
I was amused at a recent conference when someone from an HIE was talking about how some of their operating money would come from government grants and some might come from a direct tax. Who are we kidding? Where do we think those pools of grant money came from?
Talking taxes for HIE is a losing proposition.
Brian Ahier says
I was mainly making the point that it is ultimately the patient/taxpayer that pays for it all. Whether it is ARRA funds, hospital revenues, grant monies, Medicare/Medicaid payments, taxes or fees to providers the money comes from the people.
dmmorreale says
Dale I think the opportunity to streamline access to essential data at the point of care should have value to a clinician, also the ability to gather a comprehensive picture of your patient population and use that to fine tune treatment models is not something awful. Look at the exchange for what it will enable you to do, learn and treat your population. I even bet there is some money there!
Paul Roemer says
Part of the problem I have with HIEs is similar to the old Wendy’s commercial, “Where’s the beef.” Only in this case the question becomes, “Where’s the value add?”
There are hundreds of them, HIEs that is. Each one developed autonomously. Some are built within a hospital which has more than one EHR. Others are being built to serve among a hospital group, and others are geographical. Which of the HIEs is being built by a team of people who have ever built one? To my knowledge, none.
Hundreds of HIEs being built independently from one another by people who’ve never before built an HIE. Hundreds being built to transport the electronic medical records of providers using a few hundred different EHRs, each EHR operating with different standards, none of which benefits from interacting with another.
What is the purpose of the HIE? It reminds me of this children’s’ icebreaker game where the children sit in a circle. The first child starts by whispering a phrase into the ear of the person sitting next to her. She can only say the phrase once. The child she whispers it to must then whisper it to the child next to her. This continues until it goes all the way around the circle. Usually, by the time the phrase gets back around to the original person, it is completely different.
Like shuffling an EMR from one place to the next through a series of intermediaries. What does it look like when it comes out the back end?
After all, what is the purpose of the HIE? It should act like a handoff, like a mini N-HIN. It does not modify the data, at least not intentionally. If there is a more complex way to get a person’s health record from point A to point B, I have not seen it. HIEs are healthcare’s Rube Goldberg mechanism.
I think that when all is said and done, HIEs will have faded away. Until then providers should keep their focus on developing an EHR which actually serves their business model.
Dale Sanders says
Ultimately, HIE’s should save money and taxes by reducing redundant testing and improving outcomes. But our current US system does not return the money saved to the payer as a benefit, while the providers are highly encouraged by volume economics towards redundant testing and care. Patients are in no position of awareness, yet, to demand the exchange of their data as a condition of choosing a provider– that might come in time.
In the right environment, HIEs are economically valid, but under the current US system that encourages healthcare volume over quality, they are not. And of course, if implemented properly, they are definitely a benefit to the moral and just physician who serves the patient’s interest.
I love the analogy described by Paul…I’m going to reference him and reuse it! HIEs change the nature of the “truth” about the patient’s care. It’s another filter… another layer away from the firsthand truth…another ear in the child’s gossip circle. We should definitely be aware of that effect of HIEs. In my experience, most physicians are naturally inclined to be wary of critical data not personally collected, firsthand. I also totally agree that, at a time when very few organizations have an EHR and fewer yet have optimized their own EHR, we should focus on getting our own EHR house in-order before we rush to share our problems with others.
Great discussion… thanks everyone!
Chris Giancola says
At NEHEN we have an economically viable HIE that has been in operation for over 12 years, exchanging information between payers and providers across New England. It works when parties collaborate, cooperate, and share costs. They then reap shared rewards of interoperability and lower individual costs to improve care coordination and streamline administrative processes.
This isn’t a small operation either; our HIE members render and pay for over 90% of the care in Massachusetts.
Those of you who have posted have clearly had negative experiences in HIE, and they don’t negate our demonstrable successes here in New England.
To make it economically viable, providers and payers start their HIE with directly exchanging the administrative transactions (eligibility, claims, etc.) and use the cost savings from improving those processes and not paying transaction fees as offsets for clinical data exchanges (such as clinical discharge summaries) that have less clear-cut economic rewards but certainly benefit quality of care, care coordination, and overall cost of care across all of a patient’s care settings.
HIE can also simplify the compliance reporting that providers must do, such as quality measures and public health measures like syndromic surveillance and immunization rates. Hospitals likely have independent, one-off methods of exchanging this information with the appropriate counterparties (insurers, DPHs, etc.) and a good content-agnostic HIE can be leveraged to satisfy those reporting requirements and save a lot of money by consolidating operations.
Anyway, you can keep trying to figure out ways to make HIE work in your healthcare community for the betterment of your patients and your fellow providers and payers, or you can keep thinking that collaboration is doomed to fail and you’ll be guaranteed of that continued failing result.
Dale Sanders says
@ Chris,
I’m the most optimistic, determined, failure-tolerant person you’ll ever meet, so this has nothing to do with negative thinking, as suggested in your last paragraph. I’m very familiar with the success of your HIE, as well as those in Utah and Indiana. These represent the very rare minority of evidence that HIE’s can be successful– if the business model from the beginning is developed around sound economics, not everlasting federal grants and subsidies. I’m also a political liberal and recognize the value of federal money as an effective business stimulus in some environments, so this isn’t a veiled conservative attack on federal funding. I’m frustrated as a professional that we keep throwing money and time at an abysmal batting average for HIEs– there’s no denying that evidence– and trying to encourage our fellow CIO’s to think twice about their involvement in HIEs and stop following the poor batting average.
Maybe, in acknowledging your point and to take the higher road of solving problems vs. identifying problems, those of us on this thread should develop another blog, “Characteristics of a Sustainable Economic Model for HIEs” and borrow from the lessons in New England, Utah, and Indiana. I would love to do that, actually.
:-)
Steve Huffman says
As a participating member to one of the successful HIE’s in Indiana I would be willing to share information on how we got there.
Brian Ahier says
Steve please share! I am involved with planning and development for a regional exchange and also our state-wide HIE and we are searching for successful models.
Contact: brianahiergmailcom
Dale Sanders says
How about I start a new blog, “Successful Economic Models for Health Information Exchanges” and seed it with a few observations from Utah, and ask that Steve H., Chris G. and others to reply in contribution… then coalesce everyone’s thoughts into a single paper and make it widely available?
Brian Ahier says
Dale, that sounds like a fine idea and will be very helpful to efforts at creating successful HIE.
Anthony Guerra says
Dale – I would love if you made that paper widely available here on the site. I’m sure we can figure out a way to do that so people have easy access.