In today’s healthcare IT world, there’s a whole lot of talk about interoperability — and unfortunately, there’s also a whole lot of misunderstanding, says Chuck Christian, VP of Technology and Engagement with the Indiana Health Information Exchange. He believes that if the industry wants to make real strides in achieving this Holy Grail, it’s time to start clearing the air.
Recently we spoke with Christian, who has more than 20 years of CIO experience under his belt, about the difference between what’s being reported about interoperability and what’s really happening in the trenches. We also discuss the most common requests IHIE receives from providers (and how they’re working to fulfill them); how his organization is leverage the knowledge of students to de-identify data; the discussions he believes CIOs need to have with vendors; and why, all things considered, he’s still optimistic about the future of healthcare IT.
- The critical role of care navigators
- Incentivizing interoperability – “We need to have some conversations.”
- Misconceptions about cost
- “It’s not going to happen in a vacuum, and it’s not going to happen naturally.”
- Taking control with vendors
- Workflow issues with pharmacy databases
- Reflecting on his days as an X-ray technician: “We’ve come a long, long way.”
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Even though the EHR vendors are not charging for CommonWell, Carequality and those type of things, there is a cost associated with it. Because they have the opportunity to bundle that cost in with something else, it can appear to cost nothing.
I think once we come to the understanding that there is value in having that data available within the workflows of the physicians, we can start seeing some additional outcomes.
If you don’t have an interoperability plan, go home and put one together, because it’s just not going to happen in a vacuum and it’s not going to happen naturally. It’s going to take some work to figure that out.
We have to make it easier for clinicians to get and use the information within their workflows. And the easier we can make it, the more often they’re going to use it.
They’re getting better at measuring things like: is the information available, did you use it in the decision-making about the patient’s outcome, and did it have a positive or negative impact upon the patient’s outcome? That’s really the hardest part to measure, but it’s also the most important.
Christian: With the automation that we’ve been able to put in place over the last eight or nine years, we’ve created quite a bit of siloed information that is very important for that continuum of care that the patient should be getting. Who is going to have the responsibility of pulling that all together, if the data is available in a fashion that makes sense? And if you have an oncology event, the care navigators that are in some of the oncology units are absolutely wonderful resources because they help navigate the whole thing. I’m not sure that, particularly for our chronic patients and people that have several comorbidities that require a higher level of coordination, we’re not going to see some level of that care coordinator or care navigator. I think that’s one of the things CMS was trying to get in the incentive programs for primary care physicians, where they were get a bump in their reimbursement if they follow up on the patient after discharge. That, I think, is going to be really important for the future.
Gamble: When you hear people talk about whether or not it’s realistic or would even be helpful to try to incentivize interoperability, what are your thoughts? Do you think we’re just not there yet as far as the steps that need to be in place first?
Christian: I think that we need to have some conversation about it. One of the things that gets my goat a little bit is when people think interoperability is free. It’s not. Even though the EHR vendors are not charging for CommonWell, Carequality and those type of things, there is a cost associated with it. Because they have the opportunity to bundle that cost in with something else, it can appear to cost nothing. But I can tell you; I know how much it costs to run a health information exchange like the one we have. It’s not an exorbitant amount of money in comparison to some of the healthcare organizations, but it’s more than you would think. Because it’s a fixed cost business, there’s a significant amount of cost and overhead that has to take place in order to store the data and house the data.
I had the privilege of managing one of the costliest resources — our data center — and making sure the security on top of that is as excellent as it possibly can be. We work at it every day. It’s kind of like a never-ending story because the threats change and we have to change with them. But I think once we come to the understanding that there is value in having that data available within the workflows of the physicians, we can start seeing some additional outcomes.
There have been a few studies done, and there are a few others that I’m aware of, that are under way that will help shine a light on where the value lies. And I’m going to use health information exchange as a verb and a noun in this sentence, which sometimes drives me a little crazy, but the value of health information exchange is in making sure that data is available, and you can do that in a variety of ways. I think that’s the other point about interoperability — there’s just not one way to do it.
At the CHIME Fall Forum, I was tried to educate folks a little bit on the variety of frameworks of interoperability. At the end of the presentation, I was encouraging my friends and peers by saying, ‘If you don’t have an interoperability plan, go home and put one together, because it’s just not going to happen in a vacuum and it’s not going to happen naturally. It’s going to take some work to figure that out.’
The other thing is just because a vendor tells you to do it this way, it doesn’t mean that they have your best interests at heart. You have to be in control of that, no different than you’re in control when they make recommendations on standard implementation approaches. At the end of the day, you’re going to implement the software which will fit within the culture and processes of your organization. It may not vary a great deal, but it’s going to vary a little bit, and it’s the same way with interoperability. Depending where you are in the country and what resources you have to bear, there are options depending upon what’s going to work best and what’s not going to work at all, and you need to understand what those options are and educate yourself or avail yourself of resources that can help with that expertise.
Gamble: Really good point. These are discussions that need to happen. It’s really important to challenge the vendors and talk about all these factors when it comes to interoperability.
Christian: The thing about it is, it’s not just about moving the data. It’s what you’re going to do with it. Is the data going to be used to inform a clinical decision process? If you take a patient that goes into the emergency room because they’ve broken a bone, there may not be a reason that physician needs to know a deep clinical history about the patient, because they’re there for an episode of care around that. Now, managing that break may be dependent upon how well it heals. Does the patient have osteoporosis? Do they have diabetes? Do they have a compromised blood flow and all those type of things? Absolutely, but there are reasons that the data should be limited, and depending upon what the use case is going to be, what you’re going to do with the data once it’s sent.
The idea of the CCDA as a form of coordinated care is a really great idea for moving information. However, there was such a volume of information in many cases and the EMRs were not able to put that into their systems in a meaningful way and present it to the clinician in a way that made sense. And so a lot of the data just goes unused because the physician doesn’t have time to go hunt for it, and it’s not within their own workflow.
If you at the PDMPs, the pharmacy databases of Class C narcotics that, in most states, require physicians to look in them to see if you have someone that’s already on an opioid therapy, it requires them to get out of their workflow, in many cases, unless they’ve got an integration with the PDMP at the state level, where it’s right there. In most cases, they can’t keep the data. They can only look at it unless they want to do a screen print. We have to make it easier for clinicians to get and use the information within their workflows. And the easier we can make it, the more often they’re going to use it.
Gamble: That’s what it all comes down to.
Christian: Absolutely and I think that’s what defines the value of the information — not just having it, but being able to use it and impact outcomes. The IMAT group within KLAS has been working for three years trying to figure out how do we measure this thing called interoperability, and they’re getting better at measuring things like: is the information available, did you use it in the decision-making about the patient’s outcome, and did it have a positive or negative impact upon the patient’s outcome? That’s really the hardest part to measure, but it’s also the most important.
We had a friend of the exchange call over the weekend. He was transferred from one facility to another and because of a request that he had made years ago about not sharing his information, the new facility couldn’t see it. He asked us to take that off and we did, so the new facility was able to see his information, and he said because of that, it saved his life. Now, I don’t know if it’s actually true that it saved his life, but I know that it had a very positive impact om his course of treatment and his course of care, because now this other facility could see the data from the facility that he was transferred from, which prevented them from repeating a bunch of diagnostic tests and sped up his care.
I’m an X-ray tech by training, many decades ago. One of the placed where I worked in Southern Indiana was not a trauma center, so we had to transfer patients to the trauma center in Evansville or they would go to St. Louis or Louisville, depending upon how many we had to send. And one of the things that always bugged me was you’ve got a patient who’s going out to get on a helicopter, and their x-rays are laying on the gurney with them.
Gamble: That’s not good.
Christian: What happens is the physician, the orthopedic surgeon, or the trauma surgeon doesn’t have the benefit — other than a conversation — of seeing those films until the patient arrives, and so it delays the treatment. Because if you’ve got someone with a crushed pelvis or badly broken bone, that orthopedic surgeon is going to have to do some studying about what pins and plates and things they’ll need to put the geometry of that bone or that pelvis back together again.
At that point in time, everyone was getting PACS. So one of the things I started working on is, let’s figure out a way of sharing those images so they can arrive a long time before the patient did. That way, when the patient arrived, they could take them right to surgery. Rather than having to wait for the films, and look at the templates, and figure all this stuff out, let’s use the technology. We were successful in some cases, but not always.
We could do the same thing now with data where the patient can be transferred and the information can be waiting on the patient, or be in the hands of the care team before the patient even arrives, which will have a great impact upon the patient if they’re having a heart attack or they’re having a stroke or any of those things where you’ve got a golden amount of time that is required. Those are some outcomes we need to think about. For me, this thing of data and interoperability can be used for a variety of things around the actual care of the patient, but it’s also looking at how care is provided across a population or a community.
Gamble: When you think back to those days of having films sitting there by the patient and how far we’ve come, it’s amazing. I think it’s all of our instinct to focus on what we still need to do, but it’s important also to look at how far the industry has come.
Christian: I’ll tell you, I go back to where I actually had developed x-ray film in chemicals, by hand. So we truly have come a very, very long way in the 46 years I’ve been in healthcare. It’s amazing what we’ve been able to accomplish. And so if you look at this thing called interoperability and compare it to things like banking, railroads, telephone systems, cell phone networks, and ATMs, we’ve only been working at this for a very, very short period of time, and it’s probably one of the most complex things of all those things that I mentioned. We just haven’t aligned the incentives correctly in order to get things moving in the right direction. And that’s not to say they’re not moving — they are, but we’re trying to legislate the ‘how’ rather than the ‘what.’
And so I think that rather than telling everybody how to build a bridge, they just need to say, ‘here’s a bridge. If it’s in Indiana, you build it in the way that works best for the folks in Indiana. If you’re in Wyoming, let’s build a bridge that works best for the people in Wyoming, and then we’re going to run cars across both of them.’ That’s where the standards come in.
Gamble: Right. It makes sense. We wouldn’t be doing our jobs if we weren’t always trying to do better and then push things forward, but at the same time, the amount of progress that’s gone on in the last five to 10 years is really amazing.
Christian: Absolutely, and it’s just going to get better because the technology is going to get better and the people are going to get smarter about how to use it.
Gamble: Here’s hoping. Well, I can always talk to you longer, but that this has really been great. We’ve covered a lot, and as always, really appreciate your time and your perspective on these really important issues.
Christian: Great. I appreciate the opportunity to pontificate and bend your ear a little bit, and hopefully some of the information I had to share is worthwhile.
Gamble: Definitely. Thank you so much, and I’ll see you in March.
Christian: Absolutely, sounds good.