Chuck Christian, VP/Technology & Engagement, Indiana Health Information Exchange
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 3
- Straight talk on FHIR — “It’s not the end-all, be-all.”
- Meeting with Cerner & Epic developers
- 2 components of interoperability: clinical and technical
- How FHIR can work
- Leaving the CIO post — “I need to learn new things.”
- “Passion” for patient care
- The problem with MU: “Tell us where we need to be.”
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Bold Statements
The people that believe FHIR is the next best thing since sliced bread are the people that don’t know too much about it; they only know what they’ve been told. But the people that have been working with it and doing development work and are deep in the weeds on the standards — they’re not so adamant that it’s going to be the be-all, end-all.
Clinical interoperability is very, very difficult because you can’t get anybody to agree on what is the content that we need to share. I run into that every day in talking with physicians and meeting with our members. There are differences of opinions about what information they need and want, and how they want to display, present it and where they can find it.
I’m very passionate the patient care side of things. I can see through a variety of ways of what this technology could do and how it could be brought to bear to improve the health of the people — how it could help prevent duplication of studies and how it could decrease the total cost of healthcare.
I can ask a question from the viewpoint of the healthcare CIO and translate that from an interoperability standpoint, knowing what I know about the variety of health information exchanges and where we’re trying to go.
I think from an industry standpoint, we’re just now starting to hit our stride about what we could do.
Gamble: I want to get your thoughts on FHIR. This is something where there seems to be two schools of thought. There are people who think this is the next big thing, and there are others who aren’t really quite so sure to rush there yet. I’m going to guess where you stand.
Christian: I’ll tell you what I know. I’ve listened to both folks, and I boil it down to this. What I’m going to say may sound a little crass, but the people that believe FHIR is the next best thing since sliced bread are the people that don’t know too much about it; they only know what they’ve been told. But the people that have been working with it and doing development work and are deep in the weeds on the standards — they’re not so adamant that it’s going to be the be-all, end-all.
We actually earlier this year had a connectathon sponsored by the Indiana HIMSS and Eskenazi, the Regenstrief Institute, and Indiana School of Medicine. We had a bunch developers show up and Cerner and Epic both made their sandboxes available to them. We had a portion of the IMPC research database and the folks at Regenstrief FHIR-enabled certain resources on it, and they actually wrote code to do development work on it.
The issue is even Graham Grieve, the father of FHIR, said there are two different kinds of interoperability. There’s the technical component of inoperability, and then there’s the clinical component of inoperability. The technical part is really easy to do because you can write the standards to move the data. Clinical interoperability is very, very difficult because you can’t get anybody to agree on what is the content that we need to share. I run into that every day in talking with physicians and meeting with our members. There are differences of opinions depending upon the specialty of practice and the kind of hospital about what information they need and want, and how they want to display, present it and where they can find it. Those are the different parts of this.
I’ll give you one of the forward thoughts that we’ve had about how we can use FHIR. We’ve got members that are both Epic and Cerner, large healthcare facilities that use both of those applications very, very well. And so one of the things that we talked about is because we have this thing called the IMPC sitting back here, if we know the patient had services in one of our member sites, we know what they had. So if you have a patient that’s in the emergency room at IU Methodist and that physician in the ER is about to order an echo, wouldn’t it be great if in the background you had a FHIR-enabled application that knows the physician position is about to order an echo and it goes and looks at the IMPC and immediately brings back to the physician, ‘doctor, this patient had this study done at Community Hospital two weeks ago, would like to see it?’ And it brings back the report for them and then he says, ‘Okay, I’m going to use this rather than repeat the study, but I want to include that in the medical record.’ And they would be able to pull that down and put that in the patient’s medical record so you can have that as part of the medical record.
I think that is one of the ways in which FHIR is going to be used. But I’m not certain. The school is still out, and I’m still learning if this is going to be this magical glue that’s going to make all the data just flow in a mysterious manner. I just don’t know. The thing about it is, Marc Probst is a good friend of mine out at Intermountain, and Dr. Stan Huff is right in the middle of all this. He’s in several different projects. He’s actually the previous past chair of HL7 board, and I’m watching and learning about what they’re doing and how the folks in the FHIR group are going to do this. And some of things I’ve looked at and noticed, particularly about the applications that the Smart on FHIR group, Intermountain, and Geisinger are doing is that they are more-application specific and using the Cerner and Epic and other databases as a store for where to get the data and where to store the data rather than the EHR vendor being able to write every bit of the specialty code.
I think we’re still learning. I think it’s a great, great standard, but I’ve also heard some people say it’s a strict standard. But again, if you talk to the folks that are going development work and they say, ‘no, not really.’ It’s not as cowboys and Indians as HL7 and those transaction standards, but there is still some extensibility that you can have with it — as long as you write to the base standard, you can extend it if you want to. There are going to be other flavors, and that’s where the creativity and innovation comes in.
Gamble: Really interesting stuff. I think in a way you’ve answered this, but what made you want to leave the CIO role and get into this full time? I’m sure that was an interesting thought process for you.
Christian: A couple of things. I’m originally from Alabama, but spent 24 years in Indiana. My children and my grandchildren are here. And thing is, one thing I’ve learned about myself is I need to learn new things. I kind of look at the role of healthcare CIO and there’s something around this interoperability stuff that I got involved in when I was here in Indiana and took that with me to Georgia. And then I had this opportunity to come to work with folks that I’ve known for 20 years who shared a similar passion and were kind on that leading/bleeding edge of the technology.
And there’s the fact that I’m a clinician. I was an x-ray tech for 14 years before I lost mind and went into informatics, and I’m married to a nurse too. So I’m very passionate the patient care side of things. I can see through a variety of ways of what this technology could do and how it could be brought to bear to improve the health of the people — how it could help prevent duplication of studies and how it could decrease the total cost of healthcare.
The other thing too is I’ve got a lot of friends in the CIO world — I truly am still a CIO at the health information exchange, but my title is just different — and they need somebody to help translate this stuff for them into a language that they can understand. Since I’m from Alabama, I’m not going to be able to translate too many things. The only language I know is southern. But I can speak their language, and I’ve had a lot of those conversations in the year since I’ve been back in Indiana with friends of mine that I’ve known for very, very long period of time about some of the business challenges that they experience in trying to take care and implement these federal regulations and also address some of the business qualities. That’s one of the reasons that I came back.
The other thing is from the health information exchange side, I can provide the CIO’s point of view. The other interesting thing is that two others on this leadership have also been healthcare CIOs — not as recent as I have, but we all have that view of what it takes to swim in those waters. And so I was able to come back and you kind of translate in both directions for the industry, for interoperability.
The other thing is that I have this real propensity for asking questions. My mom always said I was a curious kid. I say it’s just because I’m stupid, and so the only way I’m going to learn anything is to ask questions. And so I think that in the different settings I’m able to be in now — if I’m working on policy issue at the state level or the national level — I can ask a question from the viewpoint of the healthcare CIO and translate that from an interoperability standpoint, knowing what I know about the variety of health information exchanges and where we’re trying to go.
I think for me, one of the things with Meaningful is they’re telling us what to do. I’ve watched this industry for a long time, we’ll get there. Tell me where you want to go. It’s like when my wife and I get in the car to go to Wal-Mart. She’ll say, ‘why are you going that way?’ I’ll say, ‘you said go to Wal-Mart.’ She’ll say, ‘yeah, but you’re supposed to turn down and go this way.’ And I’ll say, ‘no, I can get to Wal-Mart this way.’ So rather than telling us how to go and what to do; tell us where we need to be.
If you take the example of interoperability, healthcare organizations were struggling with the idea that other than from a clinical standpoint, from a business standpoint, why did I need to know where that patient has services? It wasn’t this thing called ACOs and clinically integrated networks and other forms of reimbursement modification that came about and this bundled payments (like the one we’re doing for cardiac care) that the organization is going to be responsible or at risk for taking of that patient. So they need to know where that patient is getting care. In the not too far distant future, Medicare is not going to pay for duplicate testing. For a lot of physicians, it’s just easier to repeat the study than it is to go look up the result. Well, in the world that we’re trying to build with interoperability, that result should be at his fingertips, depending upon where he is, and eventually at everybody’s fingertips.
And so I wanted to come of back to Indiana where my children and grandchildren are, and also have a chance to work with the folks that I’ve known for a long time that are my friends. How many times do you get to do that in your lifetime where you actually work with people that you enjoy working with and that you share a passion with in that space? The fact is, we’re a non-profit supporting organization. The pressure is on us to do good things and make enough money to keep the lights on and to build on the future a little bit but not to build massive amounts of capital because we’re funding something else.
Gamble: Right. And it seems that you’re still able to be pretty involved in CHIME and HIMSS too and I guess that that’s really part of the role for you too is really getting out there, having the voice and speaking to and educating CIOs and other leaders.
Christian: Sure. This is my last year on the CHIME board. I’m the chair of the foundation, and I had the pleasure of being the chair of the board last year. I’ve rolled into some additional activities inside of HIMSS — I’m on their interoperability and EHR task force. I’m the chair of the advocacy committee for SHIEC. I’m the chair of the policy steering committee for CHIME. I’m helping the folks at eHealth Initiative do some things; I’m on a couple of committees with them. There’s plenty of work to do and I absolutely enjoy it. Everybody thinks I’m kind of this mega volunteer — I’m not; I’m just curious. I had the pleasure of serving those roles and I can learn a great deal from some really smart people and try to see how we can piece the stuff together. So it’s a selfish role for me. I get far more out it, I’m certain, than what I give.
Gamble: That may be true, but I think others would disagree with it.
Christian: Well, thank you very much. I appreciate that. I’m having more fun than I can stand.
Gamble: That’s great. You really are so passionate about this, and so it seems like you definitely made the right move in taking on that role a couple of years ago.
Christian: I hope so, as long John [Kansky] hasn’t fired me yet. He has to put up with me. I passed my initial 90 days and I looked at him and said, ‘now you have to keep me.’ And he said, ‘yes, it’s a little harder to fire you.’
Gamble: Good for you.
Christian: It’s fun. We have a good time, and the fact of the matter is that I’m bringing some of the skills and expertise and team building to this organization and we’re growing the customer relationship management team. I’m looking for other technologies we can bring to bear to make the organization more efficient from an operational standpoint. So it’s a new and different exciting role. It’s like the old saying, the more things change, the more they stay the same. We’ll see how it turns out.
Gamble: Alright, great. Thanks so much for giving your time to talk about not just what the organization is doing, but really the state of the industry. I’m pretty sure I’ll be hitting you up again for more. So, thank you so much.
Christian: Absolutely, anytime. I think from an industry standpoint, we’re just now starting to hit our stride about what we could do. I want to make sure that the folks and the press and the people that are writing about this stuff are getting as much appropriate and correct information as they possibly can. One of the things I’ve learned about the folks in Washington, DC is that they do their best to be neutral, and sometimes they’re neutrality is only good as the information they’ve gotten. I’ve had a lot of conversations with staffers of congressmen and senators who truly don’t understand what the industry is doing, or what we could be doing. They only know from the last lobbyist that walked in the door. But I also know that having made many, many trips to the hill over the course of time trying to do this kind of education, is that they’re actually very interested now in listening and learning. And as I go back, I’m talking to the same people over and over again rather than being shuttled off to the different, newer staffers who are younger than my children.
Gamble: That’s a good sign.
Christian: Yeah, a very good sign.
Gamble: Alright. It’s really interesting work you’re doing and thanks again. I will definitely want to speak more about this.
Christian: That’ll be great. Just give me a holler anytime. Thanks very much for the opportunity.
Gamble: I will. Thanks again, and I hope to see you soon.
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