If there’s one word that could best describe Chuck Christian, it’s curious. Throughout his career — from the early days as an X-ray technician to more than 20 years as a health system CIO to now — he is constantly asking questions and trying to find ways to get the industry to a better place. It’s that drive that led him to his current role, where he is helping to lead one of the largest HIEs in the nation in its mission to leverage technology to improve patient care. In this interview, he talks about his passion for understanding policy and translating it to CIOs, his candid take on FHIR and how he believes it can work, how the Indiana HIE has been able to thrive (and what other HIEs can learn from its success), why clinical interoperability is so difficult, and why he believes the industry is just hitting its stride.
Chapter 1
- History of IHIE
- 20 years of sharing data — “We were doing HITECH before it was even thought of.”
- Writing their own code — “We don’t depend on anyone else’s software.”
- Partnership with Regenstrief Institute
- Dealing with customized service requests
- Data stored in Indiana Network for Patient Care — “We don’t own it; we’re stewards of the data.”
- Docs4Docs & electronic mailbox
- “I’m a policy wonk.”
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Bold Statements
In this metropolitan area, we’ve got a high concentration of large medical centers and people have a tendency to go to different ERs. And so those physicians were treating people based upon what information they had immediately available, but they needed more so they could do it well.
We can get together and make a decision and move very quickly, but we are a nonprofit supporting organization — we’re not in the business to make a lot of money. We’re in the business of making enough money to pay the bills, to add some services that our members would like to help improve their business.
When we joined the Exchange and sent our data, labs, and discharge summary, we could always see our data. But it wasn’t until that patient was registered in the ER or one of our outpatient clinics or in the hospital that all the data on that patient was made available, regardless of where that patient had care.
Most healthcare organizations want to do their own analytics. They don’t want somebody to do it for them and just give them the answer. With the depth and breadth of the data that we have in the Exchange, we can look across a variety of settings of care rather than just one setting of care.
It’s that kind of stuff that fuels the success of the organization, because we can see how the tools are getting used in the clinical setting and address some the needs of the data for clinical integrated networks, ACOs, bundled payments and quite a few other things.
Gamble: Hi Chuck, It’s always a pleasure to speak with you. Thank you for taking some time for us today.
Christian: Thanks for the opportunity.
Gamble: Great. Let’s get a little background information about Indiana Health Information Exchange. You’re VP of Technology and Engagement, correct?
Christian: That is correct. The IHIE is about 12 years old if you want to look at the incorporated entity. The exchange itself and the actual fact of sharing data has been going on in the Indianapolis area for over 20 years. The exchange actually grew out of some clinical needs from a variety of different sources in working with the folks at IU Medical School, the Regenstrief Institute, BioCrossroads and quite a few other folks. It was designed to share clinical data, particularly for those patients that may be seen in multiple emergency rooms, because in this metropolitan area, we’ve got a high concentration of large medical centers and people have a tendency to go to different ERs. And so those physicians were treating people based upon what information they had immediately available, but they needed more so they could do it well. So that’s kind of the birth of the exchange. The thing about it is, we were doing the exchange before hi-tech was even thought of. I was asked by Governor Mitch Daniels to be on a commission back in the mid-2000s to say, ‘we have this asset, how do we use it? (That’s when I was at Good Samaritan in Vincennes.)
Just to give you an idea of the size of it, we process millions of transactions a day and we service over between 27,000 and 33,000 physicians. We deliver clinical messages or results, which could be lab results, radiology results or anything else that our member facilities want us to deliver. We have about 109 hospitals in Indiana connected to this exchange. We have over 140 data sources in total, which would include imaging centers, physician practices, nursing homes, reference labs, etc., whoever wants to share with it. We put this data into the Indiana Network for Patient Care, which is basically a clinical data repository, but it’s not one great big data store. There’s some other architecture I could explain to you, but it would get far deeper than you probably want to go.
One of our architects looked at the data and wanted to see how deep our data goes, and we found that we have patient data from all 50 states and the six US territories, and we have delivered results to those physician practices. It’s very robust, very old exchange.
The other unique thing about this exchange is we don’t depend upon anybody else’s software. From the very beginning, we wrote our own code, and we maintain it every day.
Gamble: Has there been challenges with having your own code?
Christian: Absolutely, because as with anything else, with writing your own code, you’re dependent upon the talent you can find. We’ve been very fortunate since we’re in Indianapolis and we’ve had this great relationship with Regenstrief Institute, and the exchange has a pretty good reputation as a great place to work. We made the Modern Healthcare list last year, and again this year, of best places to work. It’s a small company; we’re very agile. There are four of the senior leaders, and I have the privilege of being one those. We can get together and make a decision and move very quickly, but we are a nonprofit supporting organization — we’re not in the business to make a lot of money. We’re in the business of making enough money to pay the bills, to add some services that our members would like to help improve their business, and we work cooperatively with them on a variety of things because this landscape of healthcare continues to change, and they need every tool they can get to help meet those daily challenges.
Gamble: How does that work — when they do have services that they want, what is the procedure for approaching it?
Christian: We’ve got a couple of different approaches. One is that we have a strategic planning process working with the larger health systems in Indianapolis just because they’re close by. Everybody’s problems are similar. We work with them thing on things that everybody could use because everybody has similar challenges. But if there is something that’s unique to just their organization, we’re more than happy to sit down with them and work out the requirements and put together a statement of work that they see value in, and that they’re willing to pay for whatever the programming time that is going to take to get that done. We’ve done that quite a bit. The great majority of the stuff we do is used by all the members and not just a few. And we do have some custom enhancements that are unique for that facility. We had one organization that was early in the ACO rounds and they came and said ‘hey, we need X, Y and Z.’ And so we sat down, we figured it out, and we delivered it for them in a very, very timely manner.
The other thing that’s unique about this organization is that the data store or the Indiana Network for Patient Care — we don’t own it. We’re the stewards of that data and we’re the caretakers of it. There is a management council where all members have a seat on the council. We’ve got several attorneys to sit on that and we actually have our own general counsel to make sure we’re allowing people access to the information appropriately and there is a clinical reason or operational reason for them to have access to that information.
Gamble: Just to make sure to keep everything covered in that respect.
Christian: Absolutely. Like I said, it’s not our data and we have worked very, very hard to make sure that the security is in place and that access to that data is going to be appropriate. I’ll give you an example, and I’ll use the hospital I worked at down in Vincennes. When we joined the Exchange and sent our data, labs, discharge summary, those types of things, we could always see our data that we put in the Exchange. But it wasn’t until that patient was registered in the emergency room or one of our outpatient clinics or in the hospital that all the data on that patient was made available regardless of where that patient had care. So if that patient had been in Evansville at St. Mary’s Hospital or at IU Health in Indianapolis, we would only see that data on that patient if we had an electronic relationship with that patient, and that’s true still today.
Gamble: So obviously when you were part of a good Samaritan, you were dealing with the Indiana HIE quite a bit?
Christian: Absolutely. John Kansky, who’s the president and CEO now, actually started out as staff here at the Exchange about nine years ago. John and I have known each other for about 20 years. We were two of the four people that reconstituted the Indiana chapter of HIMSS back in the late 90s, early 2000s, so I’ve known John a long time. Of course, when you’re the vice president of business development, it’s kind of like selling insurance — and he hates it when I use that analogy — you go talk to your friends that you know. I was a CIO of a hospital in Southern Indiana that was not connecting. And so John and I had a lot of conversation about and we had a lot of conversation about where’s the value to the organization for the money that we’re going to have to pay. And it wasn’t until we started wiring up or connecting the grand majority of the hospitals in Southern Indiana that the value became very real.
But the really interesting thing for me is when I was a healthcare CIO, you had to deliver the results of the diagnostic testing of the referring physicians, and you can do that a couple of ways. You can mail it to them, which is highly ineffective and they don’t like it. You can fax it to them, or do it some other way. We had fax servers running in the lab, we had fax servers running in medical records, we had them running in radiology, we had them running in several other departments, and it was just an arduous task of keeping up with everything.
One of the services that I thought was just absolutely outstanding is what we call Docs4Docs, which basically is a clinical message delivery of that result. I was able to turn on an interface to IHIE and they deliver it whatever way the physician practice wants it. If they want it integrated into their EMR, they get it that way. If they want it faxed to them, we’ll do that as well. I don’t like it as much as the EMR integration.
We also have what we call an electronic mailbox. It’s an online portal that physicians can go in and look what results they got today. It’s an also an archive of everything they’ve received and so if they need to go back and look something up years past, they can do that. That was one of the services that I found extremely important from an operational standpoint because it alleviated costs by making sure that we didn’t have to maintain fax service, or have the staff to do that or actually deal with them on a daily basis. There were delivery SLAs around when those results are going to be delivered, and then the helpdesk here at IHIE takes the calls from physician practices and helps them locate result or reports rather than phone calls back to the lab or to medical records. And so, it’s a really great service that we stood up and they still use that today, many, many years later.
Gamble: When you look at this HIE, it’s obviously really robust and has stood the test of time. What do you think has been the main reason for that? I know you’ve touched on some of this, but really what do you think has been the biggest factor in that sustainability?
Christian: The company that I came to work for last year is a little bit different than the one that I hooked up to several years ago when I was a CIO down at Good Samaritan. They were trying to come up with ways of utilizing our expertise and stand up for profit business called Thrive, which was going to be predicated upon analytics, because they had some really great data scientists around that data. But I think that they were like the Edsel. It was a car that was well before its time, and so it never took off because nobody knew what to do with all the bells and whistles and stuff. I think that’s the same thing that they found. As we know, analytics is a very, very important thing, but most healthcare organizations want to do their own analytics. They don’t want somebody to do it for them and just give them the answer. With the depth and breadth of the data that we have in the Exchange, we can look across a variety of settings of care rather than just one setting of care. But like I said, it was before its time. And I don’t think we’re there yet, but I think eventually we’ll get there. If you look at precision medicine, if you look at the Moon Shots program that the vice president is moving forward, it’s about how do we use that shared data to make better medical decisions over groups or similar patient populations. And so I think we’ll get there, but it was just too early.
I think one of the reasons that we’re successful is that, one, we write our own code. We’re extremely involved in what’s going on in healthcare in general. One of the reasons I joined is because I’m kind of policy wonk. I don’t mind reading federal regs and figuring out what it means to the organization — I did that when I was a Good Sam and when I was down in Georgia and even here. We look at the future to see what’s going to happen, and then work collaboratively with our members to say, how do we make sure that we don’t fall in this crevice that’s going to open up under healthcare because of a new regulatory change and that kind of stuff.
The other thing is I’m highly impressed as to how smart some of these people are who are writing this code, and how dedicated they are. Like I say, we’re not here to make money; we’re here to make a difference. We talk to our physicians a lot. Part of my engagement responsibility is I own the customer relationship management team — most of them are nurses, and they’re out talking to the physicians. We’ll get an email from a physician saying, ‘hey, this is how we use the tools and I found something out about my patient I didn’t know.’ We actually had one a couple of weeks ago where the ER physician told us he was able to immediately look at a test that was done at another location, diagnose the patient, and actually save their life. They had a brain issue that they had to address.
It’s that kind of stuff that fuels the success of the organization, because we can see how the tools are getting used in the clinical setting and address some the needs of the data for clinical integrated networks, ACOs, bundled payments and quite a few other things.
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