In nearly every discussion about the state of health IT, the word ‘complex’ always seems to surface. But when it comes down to it, the ultimate goal is actually quite simple: to inform care though data. And to Chuck Christian, former CIO and current VP of technology and engagement with the Indiana HIE, that means presenting clinicians with the data they need — both inside and outside the EHR — in a matter of seconds.
In this interview, Christian offers his usual candid take on where the industry stands in terms of interoperability, and how HIE is working toward that goal by focusing on EHR integration, interstate and intrastate data exchange, and population health initiatives. He also gives his thoughts on the opioid epidemic, data blocking, and how CMS could be changing the game.
- IHIE’s 5-year strategic plan
- Same basic tenet: “Moving data to the clinicians”
- FHIR app w/ Regenstrief Institute
- Chest pain data in 12 seconds
- Incorporating outside data
- “If it works, let’s expand upon it. If it doesn’t, let’s do something different.”
- Direct connections with HIEs to “share data in real-time to help inform care”
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We’re basically the data fuel for that. It works really well. We’ve gotten some really great feedback from that organization — it’s helped them create an integrated network of partner physicians, not employed physicians.
Patients don’t just get care in one emergency room. They don’t get care in one hospital. They don’t get care in one physician practice. They get care in a lot of different places, and so being able to inform that care with information from outside of your organization is an area where we can actually have an impact.
The speed in which you can get that information in front of the physician’s eyes is going to be paramount, because they’re not going to wait four or five minutes for somebody to pick up the phone or look something up. It needs to be right there.
Now that we have the data, we can do things quicker. And with standards like FHIR and others that are being worked on, we can create those prototypes and see how they work and if they’re of benefit to the medical community or not.
The issue is about sharing the data where it’s appropriate, and letting the data follow the patient very simply. We’ve found it doesn’t require a lot of framework or a lot of additional effort to move that data.
Gamble: Hi Chuck, thank you, as always, for joining us.
Christian: Always a pleasure. I appreciate the opportunity and I always wondered if I had anything worthwhile to say.
Gamble: And yet we always find things to talk about, right?
Chuck: Yes, we do.
Gamble: I’d like to talk about some of the things you’re working on at the Indiana Health Information Exchange (IHIE). What are you focused on right now?
Christian: Sure. We spent some time back in 2015 actually doing strategic planning, which was new for us. I told [CEO John Kansky] it was because I joined the team, but that’s not really true. He had planned to do that — and in fact, they asked me to join the company early so I could be part of that planning process. We’ve been working on the five-year plan that we initiated with our board. We’re going to be refreshing that this year, but it’s still the same basic tenets of moving data to the clinicians; rather than having it outside their workflow, how do we get it inside their workflow. So we’re focused on EHR integration.
We have two pretty good success stories around that. The first is a health system we worked with in Northwest Indiana. They’re putting together a clinically integrated network and we’re feeding their integration with a lot of data. Basically, it’s a consolidated CCD in an XML format that they can consume into their platform. They’re running Epic and using that dbMotion as a way to integrate that information inside of the physician practices. We’re basically the data fuel for that. It works really well. We’ve gotten some really great feedback from that organization — it’s helped them create an integrated network of partner physicians, not employed physicians.
The other, which I think I told you about, is we’re working with the Regenstrief Institute at IU Health on a FHIR app that is predicated upon a chief complaint in the emergency room. We sat down with the informaticists at Regenstrief, including one of their informatics fellows, a young man from the Netherlands who is working with ER physicians at IU Health Methodist, and said, ‘let’s start with chest pain. When we have a person walk in the door with chest pain, here are five pieces of information that I need to know. But I don’t want to have to look it up — I want it right here.’
We came to a consensus among ER physicians about what those five pieces of information should be, and now by using FHIR, we’re able to present those data elements to the physician in a navigation window in Cerner. And since this is a FHIR app, it will work in Cerner or Epic. This started as a research project — now we’re now going back and doing SMART on FHIR and using OAuth to make this work in a standard way.
The really interesting thing is we actually have another informatics fellow, Dr. Jason Schaffer, doing research on this. And he asked, ‘What’s the impact upon the outcome of the physician having this information, and what’s the timing of it? How quickly can the physician get that information?’ While he was working a shift as an ER physician (at IU Health), he noticed that a patient showed up with a chief complaint of chest pain. All five elements were lit up — they were there. But he also noticed that all five elements came right out of his own Cerner application. So after they took care of the patient, he wanted to see how long it would take to look up those five elements within Cerner versus how quickly it would take using the FHIR app. It took him four and a half minutes to find all that data within the Cerner EHR, which was all native. It took him 12 seconds to find it in the app.
That’s one instance — he actually presented it during an ER conference here in Indianapolis. Is it going to be that way every time? I don’t know. One of the things we’re working on is speed. Even 12 seconds wasn’t fast enough for him. He wants the screen to change and information to be there, and there are things that we can do in order to make that happen.
The good news is that since we did it for chest pain, we can do it for abdomen pain. We can do it for a whole litany of other chief complaints; that’s where we’re going with this. But there are so many other ways of using that data — not just what’s in the EMR, but also from a patient centric view, because patients don’t just get care in one emergency room. They don’t get care in one hospital. They don’t get care in one physician practice. They get care in a lot of different places, and so being able to inform that care with information from outside of your organization is going to be one of the areas where we can actually have an impact upon helping the industry move from volume-based care to value-based care, particularly when we get into more risk-based situations. We’ve got ACOs out there, and there are other organizations doing similar work, and we’ll see how that goes.
At one point in time, Medicare was saying, ‘We’re not going to pay for X, Y and Z study if it was done in this timeframe. The physician practice is going to eat that cost.’ Now we’re talking about real dollars that hit the bottom line, because either you’re going to have to try to collect from the patient or they’re going to have to write it off. That’s not a rule yet, but I expect to see it in the not too far distant future, particularly when we can inform care with more data. I think that’s another place where we’re going to be able to have an impact on the total cost of care.
When I say ‘we,’ I’m talking about the industry. I’m not talking about HIEs in general, but being able to utilize that information. And the speed in which you can get that information in front of the physician’s eyes is going to be paramount, because they’re not going to wait. If they have a patient who may or may not be in distress, they’re not going to wait four or five minutes for somebody to pick up the phone or look something up. It needs to be right there It’s speed of information delivery that we need to think about and worry about. That’s what we’re working on in that realm.
Gamble: Okay. So in terms of the FHIR app, you mentioned the possibly of looking at beyond chest pain into other areas. But in terms of this specific app, is it going to become available on a wider scale? What are the plans with that?
Christian: That’s what we’d love to be able to see, because it truly can have a positive impact on the outcome of the patient. One thing that we’re waiting to do is look at the research. That’s one of the very reasons we’ve partnered with Regenstrief Institute and IU Health, so we can get the serendipitous results.
But there needs to be a discipline around how we gather the data and the information that’s reported out. Is it going to be of value or not? We’ve done a whole lot of things since Meaningful Use came out — can you definitely say it’s been positive? It depends on who you talk to. We want to take a researcher’s view of this to see what is the true impact to the patient, from an outcome standpoint and from an organizational standpoint? If it helps, great. If it doesn’t, let’s do something else. That’s one of the things we can do with data. We can try things very quickly. If it works, great, let’s expand upon it. That’s why we started this in a pilot project. If it doesn’t work, let’s abandon it and go do something different.
I think that’s one of those things where now that we have the data, we can do things quicker. And with standards like FHIR and others that are being worked on, we can create those prototypes and see how they work and if they’re of benefit to the medical community or not.
Gamble: Right. And what are some of your other priorities at IHIE?
Christian: We basically have three tenets of our strategic plan. The first is around EHR integration. I don’t care whose EHR it is. If it’s Epic, Cerner, Allscripts, or Meditech, we’ll work with any of them — and we have.
The other tenets are around population health and interstate and intrastate interoperability with other HIEs. That goes back to PCDH (patient-centered data homes) and some of the other issues we have, and I’ll tell you about that in a minute. But on the population health side, we’ve had some really good success stories with providing data to ACOs so they can have an impact upon how they manage their patient populations.
Some of that is around ADT alerting. Nobody has asked for real-time alerts yet because they haven’t worked out what that process would look like. They don’t have staff hanging around waiting to intervene. It’s having case managers know not just when a patient has an admission or an event, but also where they had it done, so they can move them back either into a more appropriate level of care, or back to the resources where they have control.
One thing we’ve been able to do is, with some of the measures that have to be reported, you’re allowed to use data about a patient from outside your organization. Since we have data about patient populations wherever they have care, we’ve been able to pool the data, which has a very positive impact upon the star rating. Some of the health systems have asked us to partner with them on that, which has not been an insignificant increase to their reimbursement around those quality measures. We continue to have conversations with payers about how we can work together to have an impact upon that, and how do we appropriately share data based upon our data governance structures.
We’re also working with the State Department of Health on what they need in order to manage health in the State of Indiana, and how can we provide data to allow them to do that. One of the initiatives they’re working on is infant mortality. I find it disturbing that we have an issue around infant mortality. There are ways in which we can inform that care through data. Goodwill and the State of Indiana are helping to fund a program called the Nurse-Family Partnership where care is provided free of charge prenatally and after the child arrives. We’re hoping to inform data in all those settings so it can be used in the provision of care, both from the nurse’s standpoint and the physician’s standpoint.
There are a lot of ways to look at data from a population standpoint. For example, do we have a child obesity problem, and where is that data? Where do we need to move our state level resources in order to have the largest impact? And so there are a lot of different things we can do.
The last tenet of our strategy is around intrastate and interstate data. Indiana has state borders, but people who seek care really don’t care. When I was down in Vincennes — a community that sits on the border of Indiana and Illinois — we had a lot of patients coming over to our facility from Illinois to seek care. But the physicians down there didn’t have the information of what happened in the referring hospital, so we’re trying to address that with some of our own initiatives. As you know, there are two other pretty good size exchanges: the Michiana network, which is in South Bend, and the Health Collaborative, which is in Cincinnati. And then you HealthLink, which services most of the Bloomington Orange County area. They’re an IU Health facility, so they’re already one of our members.
We have direct connections to those HIEs and we’re sharing data with them in real time to help inform that care. They share with us as well, but they’re also part of the PCDH initiative that we have with SHIEC in three different regions in the country. The issue is about sharing the data where it’s appropriate, and letting the data follow the patient very simply. We’ve found it doesn’t require a lot of framework or a lot of additional effort to move that data. We all have a governance structure that’s set up around how we share data and how we move data, and that governance structure is typically defined locally or in the state. So we’re doing that.