For years, Massachusetts has stayed ahead of the curve in terms of IT adoption. But when it comes to data exchange, even the Bay State has had its share of challenges — both with the sustainability piece, and with what Joel Vengco considers to be a bigger obstacle: politics. In this interview, the first-year CIO talks about the work his organization is doing with the Massachusetts HIE Highway and the Pioneer Valley Information Exchange, how Baystate is positioning itself for ACOs using elements already in place, why transparency and trust are critical to HIE success, and why sometimes it’s better to bite off a small piece of a project than to try to boil the ocean. He also discusses being a Cerner customer in an Epic world, the steep costs of a rip-and-replace, and the key role end-users play in clinical IT success.
- Transparency + governance = trust
- Pioneer Valley Information Exchange Summit – “The idea was to begin the conversations”
- The patient poaching issue
- Population management and patient consent
- Gearing up for analytics
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The way that we formulated the summit and designed it was so that we can have conversations. Let’s educate and then let’s have a conversation and let’s just bring everything out on the table and be transparent about it.
One of the clinicians in the audience said that he’s been practicing in the valley for 20 years and he has never seen all these hospitals in the same room. I thought that was just an amazing comment, and it just made me feel like we definitely got the ball rolling in the right direction.
That’s an important core principle to this — while there may be a centralization of the data or the patient information because the exchange is architected that way, it doesn’t mean that it’s a large Google search or a free-for-all.
We need to have our partners weigh in and talk through how does that work, how does that feel, and what does it look like. I think those are going to be difficult conversations, but let’s start with the basics first and get this exchange going.
Everybody’s got to have access to it. If you give one organization the advantage of having data that somebody else doesn’t have in terms of an aggregate form, they just have that one more step to be able to do something more unique and more advantageous. So I say, open up the whole kimono.
Guerra: Does it make sense to say that the way you build trust is by transparency? For example, if you’re going to propose something like this to the entities that you want to be involved; if you’re the leader in this, lay it out, make it all clear — here’s what it’s going to cost. Here’s your upside. Here’s what it takes. There’s just a lot of transparency and you can’t dance around these issues because that creates mistrust.
Vengco: That’s exactly right. We, along with help from our HIE vendor, InterSystems, and the Mass eHealth Collaborative put together a summit for the region. The whole idea for what we call the Pioneer Valley Information Exchange Summit was to really begin that transparency and begin the conversations — what’s the intent of this, why should you participate in it, who are the folks who are really interested in it beyond Baystate, and why should it be seen as a community initiative? Having only been here for 10 months and seeing the opportunity to really bring this community together, the politics to me are something that we of course need to be sensitive about, but I know that in everybody’s hearts and minds, they want to do the right thing for the patients. And so the way that we formulated the summit and designed it was so that we can have conversations. Let’s educate and then let’s have a conversation and let’s just bring everything out on the table and be transparent about it.
We talked about the elephants in the room and those things about trust. What about the financial pieces of this, and what about our HIEs? How do we sustain it if this is going to be out there?’ And so I think those are really good conversations to have and they cannot be ignored, and to your point, should be a continuous, transparent conversation to the point where you’re really showing everything and making sure people understand that we’re doing this for the right reasons and you’re part of this process.
That’s really what the intention of that summit was — to say, ‘You’re part of this process we’re starting from the ground up here. Please join us.’ I’ve got to say, it was hugely successful because our partners across the community became involved and had great conversations. One of the clinicians in the audience said that he’s been practicing in the valley for 20 years and he has never seen all these hospitals in the same room. I thought that was just an amazing comment, and it just made me feel like we definitely got the ball rolling in the right direction.
Guerra: You mentioned referrals before when you were talking about Boston Medical Center — there’s a lot of money underlying the referral process. Is it fair to say that some of the logic behind some of these organizations and health systems is to take the approach of, ‘Hey, we’re okay with the idea of sharing patient information with your HIE.’ If we’re talking about an ACO, then there’s an economic reason behind it. It’s one entity and there’s sharing and all that. But if we’re talking about an HIE and we’re talking about competing hospitals, could you imagine a health system saying, we’re okay sharing information, but we want our patient back. We don’t want to lose patients. We want them back. So we’re willing to send you their file and information and it’s great if they wind up in your area, but how can you assure us or at least tell us you’re not going to try and steal them. Does that make any sense? Is there some logic that organizations have around that?
Vengco: That does make a lot of sense, and I think it’s certainly one of the elephants in the room that needs to be discussed. You can think of ways where that still can happen, even in the analog world where you’re still faxing or patients have their record in hand or their mobile device. I think it still can happen outside of the realm of HIE, but I think those are things that are part of the trust factor. When you submit a patient record in the HIE, it’s not necessarily there for everybody to see. It’s only there for folks who actually have an interaction with that patient. And actually that’s an important core principle to this — while there may be a centralization of the data or the patient information because the exchange is architected that way, it doesn’t mean that it’s a large Google search or a free-for-all. I think that’s the core principle.
Our first basic rule out of the gate is we’re not going to do things like aggregation, particularly on patients or panels of patients that you don’t have access to, because I think in terms of gaining trust and really getting an understanding of the use of data, that would be a show stopper. Right now, it’s about exchanging at a patient level, and the security and guard rails are such that you can’t fish for other patients. I think that’s an important piece of at least starting the governance to how the data is used.
Guerra: Yeah, no big data free-for-all.
Vengco: No big data free-for-all. But that is the concern. I think that’s something that really needs to continue to be discussed — how do you not create a marketing database or a poaching mechanism? That’s certainly something you just need to spell out in the governance and principles of the HIE; that this is just for exchange.
You do want to think about the use of it for population management and even registry development. And that requires, on some level, perhaps broader data beyond your own, as well as benchmarking. I think those are the things that we get to in the next phase of this project, and we need to have our partners weigh in and talk through how does that work, how does that feel, and what does it look like. I think those are going to be difficult conversations, but let’s start with the basics first and get this exchange going. And then we’ll have the intentions of really getting to the next level of the use of this data into what I consider information insight. Those are going to be the more interesting conversations, I’d say.
Guerra: It really is fascinating, because you establish it with one idea in mind and one set of guidelines, and then you say, okay, we’ve got all this data. Maybe there are some good things we can do. I don’t know if we can de-indentify the data or things like that, and then it’s a question of who gets to do it — does everyone get the results of whatever data mining was done? And you run into any issues of consent changing; whereas patients consented to one use of the data and now a secondary use has been approved by the governance of the HIE, do you have to go back and get new consent from a certain number of all these patients? How do you know who they are? Am I on the right track of how things might go?
Vengco: Oh, yeah. I think those are exactly the toll gates you’re going to have to go through. It could be an interesting set of discussions, no question about that. I think from an aggregation perspective, clearly those are things that we need to be able to really get into. I think de-identification is just a technology that can be imposed on the data and it’s certainly something that’s possible, obviously, and has been done already in other realms, of course.
But do you share it with everybody? I think the answer is absolutely. Everybody’s got to have access to it. I think if you give one organization the advantage of having data that somebody else doesn’t have in terms of an aggregate form, they just have that one more step to be able to do something more unique and more advantageous. So I say, open up the whole kimono. But people have to pay for it; I think that’s how we sustain it. Because there’s going to be work in aggregating and de-indentifying and all that stuff.
I think that’s when the value-added services really have to come into the picture and say ‘okay, governance body and membership, do you guys really want this? If you want it, it’s going to cost this.’ Some of us want it. Some of us probably don’t care, so let’s subsidize it. We’ve got to figure out the economic model behind that and all that stuff; but I think it’s going to be very important to have that kind of information in the future.
There are studies already. Frost & Sullivan and Forrester and Gartner and the like say there’s a 135 percent CAGR over the next five years in terms of growth of analytics and the use of information, and so I think it’s just an inevitability that people are going to want to have even portions of that data. So we have to have those conversations and I think the sequence of conversations that you had just laid out is exactly where we’re going to go. And ultimately, there’s going to be some inertia because there are some difficult discussions there.
Guerra: It sounds like it will make for no shortage of meetings.
Vengco: That, I don’t look forward to. Collaboration is good, but there are just so many meetings today, particularly in the health system.
Guerra: And you can imagine these are the kind of meetings where two hours go by and you haven’t gotten anywhere.
Vengco: Yeah, exactly. Maybe we should set up a governance body for how to create meetings and hold meetings, I think.
Guerra: Absolutely. Who gets to call them, how long they have to be and when people get to duck you out?
Vengco: That’s right, exactly. Maybe we should have a technology for that. Whoever invents that technology is going to make a lot of money.