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Aligning Incentives around Health Information Exchange

August 11, 2013
by Mark Hagland
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Jody Cervenak of Aspen Advisors offers her perspectives on HIE evolution
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Jody Cervenak, a Pittsburgh-based principal with the Denver-based Aspen Advisors consulting firm, has spent years in the healthcare IT space, including a long stint at the University of Pittsburgh Medical Center (UPMC) health system in Pittsburgh, Pa. She spoke recently with HCI Editor-in-Chief Mark Hagland about the topic of health information exchange, for his upcoming September cover story on HIE. Below are longer excerpts from that interview earlier this summer.

What do you see as the fundamental obstacles to HIE progress right now?

The reality is that I think that the major underlying obstacle comes down to aligning incentives, because if we align incentives among stakeholders, progress on standards and models will take place.

One of the metaphors that springs to mind for me is going into the grocery store and seeing a huge, long aisle of different brands and types of cereal. It just seems as though there are so many—perhaps too many—models of HIE infrastructure at the moment. Your thoughts?

I love your mentioning the choices in the cereal aisle at the grocery store as a metaphor. You’re right, there are so many types of cereal at the store, right? But they’ve all agreed to put standardized UPC [universal product code] codes on their cereal boxes, for improved efficiency of store management. And that standardization was created  because everyone in the food industry had aligned incentives, because they wanted to get the product to the consumer, faster, cheaper, better. What needs to happen in healthcare is to break down the silos of patient health information and data. And that would mean that my height, weight, age, problem list, allergies, etc., would be presented in some standardized fashion across all the different databases in healthcare. The problem is that we have technology vendors that may not yet have aligned incentives.

So there is some technical standard operating in the retail distribution area, correct?

Yes, and you know what? That UPC code is used by so many different stakeholders in manufacturing, delivery, and so on. I’ve actually started a diet, and I can scan that code from my phone, and I can actually get information on nutrition, etc. That’s a perfect example of efficient operations. That is a perfect example of how there’s been a standardization of those codes, and all the “vitals,” all the components of that product are known by that code. And it was created, because everyone in the food industry had aligned incentives, because they wanted to get the product to the consumer, faster, cheaper, better. So there was no confusion, because all the companies involved wanted to move the process along. And the grocery stores that got their scanners going first, survived; because the mom-and-pop grocery stores had trouble keeping up.

And, not that we want to barcode ourselves, right? But the point is that if we had a way in the healthcare ecosystem to align the incentives of everyone—the physicians, hospitals, payers, patients, families, government, etc.—we could track information much more efficiently. And if we could break down these silos, it would be more efficient and effective, and could speed the appropriate sharing of data among all the stakeholders. Everyone could know my height, weight, problem list, allergies, etc. But the problem is, we have technology vendors that may not have aligned incentives; and our payment system, our reimbursement system, is so confusing, and lacks aligned incentives. And it’s not always clear what components, what vitals, are important to have included in different venues, and how they should be presented.

Russ Branzell [CEO of the College of Health Information Management Executives, or CHIME] believes that the federal government should develop quite detailed federal standards for HIE. Do you agree?

Well, you have to start somewhere. And the CCD [consolidated care document] was a great start; the idea that you should have five pieces of information on the patient, that’s how you got the CCD. And I agree that the federal government should be involved, and there are definitely interoperability standards under meaningful use. Some people feel the requirements are coming too fast; others, that they are coming too slowly. But also, the healthcare system is too fragmented. You said there are too many models; but there are also too many organizations, to begin with. And any organization would have trouble developing things in this environment. If the top ten vendors and the top ten payers got together, they could create a consensus and drive things forward. And we all tend to forget that the most successful health information exchange we’ve seen so far in our industry is e-prescribing; e-prescribing is a form of health information exchange, among providers, payers, and pharmacies.

And SureScripts brought the big payers, big providers, and big pharmas together, and said, let’s work on this. And I’m shocked that more people don’t look to the model of SureScripts. And why can’t we do that with lab results, for example. Really, if you brought together LabCore and Quest, the two largest lab organizations across the U.S.—if you brought them together with an aggregator, or with a hub-and-spoke model like SureScripts, it should be very easy to order and to get my lab wherever it should go, just as e-prescribing has done.