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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.

But these organizations can’t get over their competitive tendencies. I actually applaud SureScripts and RxHub for, in the 1990s, getting everyone together. But their incentives were aligned, because the pharmacies wanted a more efficient way to get prescriptions filled, and the payers wanted to push generics. So the barriers are aligning incentives, and then pulling large organizations with significant potential gain, to solve the problem together.

Epic’s CareEverywhere has been mentioned as a kind of pseudo-nationwide HIE, though obviously only for Epic customer organizations. What are your thoughts about the fact that one very large EHR vendor might be offering something akin to a private nationwide HIE?

With any technology, you’ll have some people say it works great, and others who say it doesn’t do what it should. But I think a lot of people have a lot of animosity towards Epic, saying they’re a closed system. I’ve never gotten that feeling. I think what they’ve put together is to say, we can talk really, really tightly to other systems. So the Epic system at UPMC and the Epic system at Kaiser and the Epic system at Cleveland Clinic, and the Epic system at Geisinger, yes, they’re all different, but the fundamental core is the same everywhere. It’s a bit like the language, Spanish, with different dialects. And Epic was smart in saying, we have to solve this first within our own family.

And I was one who was pushing them to go outside of Epic, because at UPMC, we had the whole Epic-Cerner thing going. And I don’t think it was because they were being dogmatic or closed or monopolistic—I personally believed that the reason they did that is that they really, truly cared about doing it right. And I think that they looked at it on such a detailed level, and that led to their wanting to do it right within their own systems, and then they would be willing to expand outside Epic customers. And I believe a lot of people going into the HIE market underestimated the complexities, and are having to eat their words now. And Epic looked at it as complicated from the start. So the good thing is that they’ve figured out how to do it within their own group. And the concern that the industry has… But you’re right, by de facto, they’ve created their own version of a national key… So I think Epic being a monopoly would be problematic, for all the reasons that a monopolistic environment is dangerous. And they have a great company, and stand by their word, and have created quality, but I don’t think it’s realistic to allow that.

Concerns are being expressed about the possibly monopolistic nature of having one vendor emerge with so much reach and power.

It reminds me of Microsoft… doesn’t it?

This whole thing is kind of a conundrum.

Yes, it is. Think of Microsoft—it was a great thing that we could all communicate with each other, via Word, etc. On the other hand, the cost—our budget for Microsoft was really, really expensive. First of all, there weren’t any options… but also, it was so expensive that you had no choice. So I would hope that we never get to that point with Epic, right? That’s the downside. But the point you’re making, around this decision to make choices per vendors in order for information to flow, that’s an important point, right? Because even if Epic owned the entire core EHR section, they’re not going to own the lab area, or own the payer space. And getting to standards of exchange is important.

What should CIOs and other healthcare IT leaders be thinking and doing right now?

They should obviously have a meaningful use plan underway, and meaningful use requires them to do interoperability outside their enterprise. And they need to set expectations in their provider community about what they can and cannot get through HIE, because the biggest mistake I’m seeing is inflated expectations. And clinicians don’t want another application, another log-in, another set of tasks to have to handle. And whether it’s eClinicalWorks or Allscripts, or Cerner, or McKesson, you have to figure out how to consume it. And the lack of standards and interoperability will most affect patients, because a patient is going to have a separate log-in and portal to go to; and that becomes very difficult for patients. It’s the reason a lot of people like to consolidate all their financial services under one bank. But there are times in healthcare where you have to go multiple places. I was just this morning talking with a provider system that has a different inpatient system from their outpatient system; and they’re really struggling with how this will look to the patient. And the other thing is, we need to develop our skill sets. Population health/data analytics is a whole missing skill set in healthcare right now. So I would encourage CIOs and CTOs to look at the skill sets on their teams, to be effective.

Do you have any predictions about the next few years?

UPC code! [laughs] But I do think we are going to find some way of creating some sort of code that gets us everywhere—something like a code that patients will have that will take them anywhere, either via a national health identifier or some other vehicle. And I think patients will own it, because at the end of the day, they are the ones most motivated to make sure that that key information about them is stored and current wherever they go. So I think the role of the patient will be very important in storing and keeping accurate their patient records.


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