Chuck Christian, the longtime CIO at Good Samaritan Hospital, believes that health information exchanges have been getting a bad rap. Christian has been involved in HIE work for more than a decade — long before Meaningful Use was even on the radar, and he wants CIOs to realize that getting connected with data exchange can yield benefits that go beyond just qualifying for funds. In this interview, Christian talks about the state of HIE in Indiana, how his organization is leveraging HIEs to improve patient care, and the optimal role for CIOs when it comes to HIE initiatives. He also discusses negotiation points, the importance of knowing the costs involved, and why he thinks the industry is just beginning to scratch the surface on how information can be most effectively used.
- The state of HIE in Indiana
- The Meaningful Use effect
- Sharing images
- Use cases for NHIN Direct
- Working with insurers
- Balancing costs/benefits
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We’ve been in the business of health information exchange since its inception. So we’ve had an opportunity to mature the relationships and we’ve gone through all the legal issues. The attorneys are finally finished with how we’re going to make sure that it’s very tight, very secure, and the information is not going to be used inappropriately.
If we don’t have access to that information about what took place, then we can’t really provide good follow-up care for that patient, particularly in our emergency room, where the ER physician may not know, other than the fact that when they examine the patient, they’ll see that their chest has been cracked open.
What we want to be able to do is proactively contact those folks and make sure that their visit to the ER was appropriate. If they’re using the emergency room as their primary caregiver, let’s see if we can get them connected with a physician or a physician extender in a rural clinic.
It’s a win-win — both for the intermediary, Medicaid, and for the state. And so, I’m thinking, ‘Well, we in our region provide care to these folks — why can’t we do the same thing?’ We can do the care management and interventions no different than Indiana Medicaid could or Anthem, and we could share in that savings.
We’re really siloed at how we provide care. If you’re at home, your care is provided by a home care agency. If you get sick, you go to the hospital. Well, we need to talk. All of us need to work together and coordinate that patient’s care, and we need to move that patient into the middle of the care continuum.
Guerra: Good morning, Chuck. Thanks for taking some time to talk with me today about what’s going on with health information exchange in Indiana.
Christian: Hi, Anthony. Thanks very much. I appreciate the opportunity. It’s been a while since we had a conversation.
Guerra: It’s always too long, my friend.
Christian: Thank you.
Guerra: So, tell me what’s going on in Indiana. I know you have some different things going on.
Christian: Well, from a health information exchange standpoint, Indiana is kind of blessed and kind of cursed. We’ve got five different health information exchanges. Most of them were formed regionally. The largest one, which is Indiana Health Information Exchange, was formed in Indianapolis. And it seems to have the farthest reach of all the exchanges. Now keep in mind, one of the exchanges that services part of Indiana is also HealthBridge out of Cincinnati, which is also a pretty large exchange and uses Axolotl technology. But we’ve been connected to the Indiana Health Information Exchange, or IHIE as we call it, for a couple of years and have been exchanging data on a daily basis. Actually, every time we register a patient, we exchange data.
We’ve looked at how to leverage that, and we have a couple of things that we’re using. One is called the INPC, the Indiana Network for Patient Care. And if you’d like, I can tell you a little bit about that. They have their docs for docs program, which is basically clinical messaging as far as results and a report delivery service they have with a 24-hour help desk. We’re also using that exchange of data to meet some of the requirements of the Indiana State Department of Health related to syndromic surveillance, bed availability in the case of either disaster or attack, and then also the reportable diseases that we had to track for the State Department of Health. We send all that data to IHIE and they move that over to the State Department of Health.
Guerra: Is Meaningful Use dictating the direction of HIE or the requirements in Stage 1? And I’m not sure what’s in Stage 2, but are they minor enough that what’s happening on the ground in Indiana is far beyond that?
Christian: Well, I think that one of the nice things about Indiana is that we’ve been in the business of health information exchange since its inception about 12 years ago. So we’ve had an opportunity to mature the relationships and we’ve gone through all the legal issues. The attorneys are finally finished with how we’re going to make sure that it’s very tight, very secure, and the information is not going to be used inappropriately.
But really and truly, I got involved with health information exchange way before Meaningful Use was on the radar. And we started looking at how we can leverage that from a healthcare efficiency standpoint. One of the things that we’ve done recently, which is health information exchange but really not on the definition of Meaningful Use, is related to studies around moving radiographic images. Typically, everybody has got PACS systems now. So if you need to take images to see a physician or if we’re transferring a patient out with trauma, you have to burn a CD and send it to the patient. We wanted to have a little bit different impact on that patient experience to get the images and the studies there before the patient arrives so that the trauma surgeon or whoever could start treatment planning before the patient arrives. So we came up with an approach related to using a very secure cloud of moving those whole DICOM stacks. And we’re kind of doing that originally with a couple of smaller hospitals around us and some of the larger hospitals to the south.
We’ve been looking at health information exchange as how do we augment and leverage it to improve healthcare for our patients. I’ve had some conversations with some folks about the direct technologies. And I don’t disagree that it is a really good way of moving information from one care setting to the next, but it assumes that you know where that next setting of care is going to be. And one of the things, particularly from our facility, is we will transfer someone to Indianapolis, which is 150 miles away, for open heart surgery if we can’t do it here. That patient comes back home post-discharge. And if they get into trouble, they wind up in our emergency room. And if we don’t have access to that information about what took place, then we can’t really provide good follow-up care for that patient, particularly in our emergency room, where the ER physician may not know, other than the fact that when they examine the patient, they’ll see that their chest has been cracked open. But who is the surgeon and who do they need to contact? Rather than letting the family be that historian and purveyor of information, we’re trying to create a little bit better approach. And so you would assume that through using direct technology, the next place of care that that patient is going to have follow-up is at the physician office. Well, that may not be the next place of care — maybe it will be the ER when they return home.
So I think that what we’ll see in the future is there’s going to be a place for both. One of the things you can’t do with direct is that some of the direct technology has basically very secure email. You have to call them and say, ‘I need this information,’ and they have to e-mail it to you, rather than having ready access with that information, like we have in the INPC.
Guerra: I know we’ve talked before about realizing value from HIEs, and there are a billion things to do for CIOs in hospitals and there are always more things to do than there are resources and money. So I would imagine there’s a temptation with many things, including HIE, to do the minimum that’s required for Meaningful Use and whatever other regulations that are out there. But it sounds like you want people to think a bit beyond that and try to think about capturing value from HIE in other ways besides, perhaps, direct reimbursement from different government programs. Tell me more about your thoughts around how health information exchange can turn into value for the organization.
Christian: I think we’ve just begun to scratch the surface on how we can use the information appropriately. I’m not suggesting that we turn the dogs out and give away the keys to the kingdom. One of the programs we have in Indiana that particularly benefits the physician practices is a program that Anthem put together with IHIE called Quality Health First. It’s a pay-for-performance program in which Anthem will pay a percentage premium if physicians meet certain quality metrics. A lot of that’s done through the health information exchange; it’s moving the data back and forth between the physician practices and the labs, those type of things.
I had a conversation with the regional Anthem folks down in Evansville, which is about 60 miles from here. And what they were asking us for is a list of all the patients that hit your emergency room in the last 24 hours that are Indiana Medicaid. What we want to be able to do is proactively contact those folks and make sure that their visit to the ER was appropriate. If it was emergent, that’s fine. But if they’re using the emergency room as their primary caregiver, let’s see if we can get them connected with a physician or a physician extender in a rural clinic.
They’re going to find out if that patient was in the emergency room anyway, because we’re going to process a claim for Medicaid to Anthem, but it may take us 30 days to process that claim. It may not take us that long, but it might. And so within that 30 days, if the patient has some kind of chronic process going on, then they could be in our emergency room three or four times, and so what they want to do is to intervene with care management.
I had a conversation with a young lady and when I started talking to her about health information exchange, she had no idea what I was talking about. I said, ‘How many different regions in Indiana or for Anthem are going to do this?’ She said, ‘Well, eventually, all of them but we’re running a pilot.’ I said, ‘well, what if you were able to do that for the entire state?’ And we’ll be able to do the analysis at a statewide level from a Medicaid perspective from the clinical data. They already have the claims data. It’s a very retrospective review, if we could do this in real time. And the other question I asked her is why does Anthem need to do that? Because what Anthem is going to do is they’re going to go to Medicaid and say, ‘Hey, through this program that we’re going to be doing, we can save Medicaid x number of millions of dollars. If we do that, will you share that savings with us?’ And so it’s a win-win — both for the intermediary, Medicaid, and for the state. And so, I’m thinking, ‘Well, we in our region provide care to these folks — why can’t we do the same thing?’ We can do the care management and interventions no different than Indiana Medicaid could or Anthem, and we could share in that savings. There are savings to us by not having that Medicaid patient hit the emergency room because we’re going to write off most of the cost of that visit anyway.
Guerra: But there are costs. Do you think that the costs are justified by possible benefits and also because it’s the right thing to do?
Christian: Well, if you look at the numbers in the hospitals in Indianapolis, there was one CEO, and I think it was a community hospital in Indianapolis, who said that by being connected to the health information exchange and allowing them to do the clinical messaging or report delivery for them, they saved about $2.2 million a year. And I think that depends on what your processes are and how big the facility is. We’re stepping off of that process as well, allowing the exchange through their docs for docs program to do that clinical messaging delivery for us. The value that it brings is that it gives our physician practices the advantage of not only the information that we are providing to them because of the diagnostic testing, but if we send the patient to Indianapolis or Evansville — if we refer them to a specialty that we don’t have — then that information, if the facility is connected to the exchange, comes back to us and back to their practice. So they can get that information in real time.
Yesterday one of our older physicians that has relationships with the area nursing homes and home care agencies, he and I went out riding through the countryside in about a 40-mile radius. And we spent some time talking with those folks. One of the things that we’re required to do as a healthcare facility is put programs together to decrease our readmission rates. Well, as our patient population continues to age, a lot of those readmissions may come from nursing homes because if our mom and dad or grandma and grandpa are in the nursing home because of a chronic disease process, and they’re very quick sometimes just to send them to the hospital, because in the middle of the night, they might have an issue or a problem. Send them to the hospital and get them checked. My mother-in-law was in a long-term care facility here in town and I can’t tell you how many trips she made to the hospital. I really didn’t think it was required; that if we have a little bit different skill mix at the facility, they could have taken care of her issue there, because they were trying to see if there was something more sinister going on. She had scratched inside of her ear and she had blood in her ear. They transported her by an ambulance to the emergency room to get that checked. Well it didn’t really require. My wife is a nurse and Betty was a nurse, and it didn’t really require that.
So what we’re doing is going out and talking to them and saying, ‘Okay, how can we better communicate?’ And one of the things I want you to do was kind of inquire, ‘what kind of automated systems do you have in place?’ Well, most of them don’t have anything in place. But they’re ready to make that purchase because they see the value of automating their operation as well — to have a full blown EMR at long-term care, just like I have in the hospital.
The whole thing of sending a CCD record to them and getting one from them as that patient comes in makes great sense because there is a ton of paperwork that has to be created by the nursing home for them to transfer a patient to be admitted to the hospital or come to the emergency room, same way as when we transfer that resident back to their facility. They’re handing off that care. And so we need to coordinate that care with social services, the community’s services, and the facility’s services. And so we’ve got to get more connected on how we move that data around, because we’re taking care of the same people. We’re really siloed at how we provide care. If you’re at home, your care is provided by a home care agency. If you get sick, you go to the hospital. Well, we need to talk. All of us need to work together and coordinate that patient’s care, and we need to move that patient into the middle of the care continuum, rather than them being on a roller coaster. They need to be the center of the universe and all this stuff needs to revolve around them.