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What’s the Best Foundation for a Health Information Exchange? How About a Practical One?

April 4, 2015
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My interview with David Watson of Cal INDEX last month spoke to some core sustainability issues for statewide HIES

It was both informative and enlightening to speak with David Watson on March 23 in Washington, D.C., just after he had participated in a panel on interoperability at the World Health Care Congress (held March 22-25 at the Marriott Wardman Park. As the CEO of the California Integrated Data Exchange, or Cal INDEX, Dave Watson has a very strong sense of both vision and mission, as he leads his health information exchange (HIE) forward.

As I wrote in my interview-report on March 27, “The development of statewide health information exchange (HIE) has proven to be a very long, twisty journey in California. The nation’s most populous state has seen both HIE expansion and HIE collapse, including not only a very early HIE in Santa Barbara, but also the first two statewide HIEs in the Golden State—CalRHIO and Cal eConnect (which merged and later collapsed)—even as a dozen and a half regional HIEs have been created and survived so far.”

I further wrote, “But perhaps the third time really will be the charm, when it comes to statewide HIE efforts in California: the Walnut Creek-based California Integrated Data Exchange, or Cal INDEX, was formally incorporated on July 31, 2014, and was publicly announced several days later on August 5. Initially created by the two biggest Blues plans operating in the state—Blue Shield of California and Anthem Blue Cross (formerly Blue Cross of California), which pledged $80 million in funding for the next five years.”

Importantly, as Watson noted in my interview with him, Blue Shield of California and Anthem Blue Cross (formerly Blue Cross of California) had already each been “building their own private exchanges to share clinical data with their ACO providers. So they agreed not to compete on a utility function,” he noted. And right now, he said, “We’re doing outreach to the providers, and are in negotiations with 10 providers in both Northern and Southern California.”

Meanwhile, Watson told me, “The biggest challenge is getting to critical mass. So having two payers contribute roughly 10 million records is a start; but we need to sign up the other big payers in the state, as well as providers.”

Here’s what was particularly heartening to me in all this, with regard to the winding journey that health information exchange has taken so far in California: Watson understands where things need to go, and is helping to lead the movement in the right direction. As he told me, “The challenge is not only getting to critical mass, but also making sure we have very high accuracy of patient matching. And then the quality of the data that comes in requires a lot of scrubbing, so you have to scrub the data, and do semantic mapping. And so whether the data came from a health system, primary care doctor, or payer, it’s mapped to a payer model so that when you consume it, you always see it the same way in the longitudinal patient record.” And so, he said, “Our value is that we acquire, curate and manage the data. And our goal is not just to create interoperable points; the question is, how do you join systems of care to appropriately share information? So our goal is to complete the system of care; and we’ll get at that in stages, and it will define itself as we do the work.”

And so what is great here is how practical the vision is that Watson and his colleagues at Cal INDEX have. After two failed experiments with statewide health information exchange in California, a third statewide HIE has been created, one that has been founded with strong seed funding from two of the state’s biggest health insurers; and the Cal INDEX folks are focusing on building practical HIE bridges, not trying to build castles in the sky or boil the ocean.

That strategic vision jibes very well with the strategies of several major statewide HIEs—in Maine, Michigan, Ohio, and Colorado—that have achieved sustainability in the past few years. As I noted in one of our Top Ten Tech Trends in the January/February issue of the magazine, the statewide HIEs that are surviving, and even thriving, long-term, have senior leaders who recognize that sustainability will require the ability to meet some kind of set of market needs, whether it be providing ED visit or hospitalization alerts, enable the participation in outcomes measurement, help support clinician-to-clinician messaging, facilitate the sharing of continuity of care documents (CCDs), or provide some other type of service that individuals or organizations are willing to pay for.

Of course, there are terrific justifications in principle for establishing statewide HIEs. But the reality of the history of health information exchange in California, a huge, complex state, is that abstract principles and broad ideals around data exchange have in the past not been able to sustain actual HIEs.

So the fact is, the reality of health information exchange at this point in the history of HIE, is that statewide HIEs will be sustained based on their practical usefulness to actual people and organizations, not on their fulfilling abstract ideals.