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.
Indeed, as HCI Senior Contributing Editor David Raths reported back in May 2012, “The turmoil surrounding the development of a statewide health information exchange in California has led to another significant change. The California Health and Human Services Agency (CHHS) announced last week that the Institute for Population Health Improvement at the University of California-Davis will take over HIE implementation from Cal eConnect, the Emeryville, Calif.-based non-profit, public benefit corporation created to develop California’s HIE.” Indeed, the considerable turmoil around Cal eConnect ultimately led to its complete shutdown.
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.
David A. Watson, who joined Cal INDEX as its president and CEO last autumn, participated in a panel on data interoperability at the World Health Care Congress, which was held March 22-25 at the Marriott Wardman Park Hotel in Washington, D.C. During that session, he noted that “Cal INDEX was formed last August, and our goal is to provide HIE for California; which is interesting, because there are currently 19 HIEs operating in California. And our funding entities did not want to talk to 19 HIEs; they wanted to have one, so they put up $80 million to found Cal INDEX.”
Watson told the audience of healthcare and healthcare IT leaders assembled for that panel discussion, “I view Cal INDEX as version 4. Version 1 was CHIN [community health information networks—a great aspiration, but nobody had any data to share, because it was all locked up in paper charts. And doing chart extracts to share was not very viable. Version 2, was RHIOs,” he said, referring to what were then called (and in a few places still are called) regional health information organizations. “I was involved in one of the organizations that funded CalRHIO. And we ran into a timing issue and a funding issue. Some organizations were implementing EHRs [electronic health records], and had no bandwidth to fund HIEs.”
The next phase, Watson told the audience, was “version 3, the Obamacare HIEs starting in 2009, where you got $20 million from the feds, and you got together a board of 23 directors, who were only concerned that you not [disadvantage] the consumers or other [stakeholders]. Most of those failed,” he noted. “Version 4 is Cal INDEX—HIEs bringing together payers and providers. The value there is immense. Prescriptions are an example: providers know what prescriptions were written, payers know what they’re paying for. And you can put those together and get medication adherence data. So there’s a business proposition there; in fact, payers say the investment in HIE is worth it just for that. And then there’s management of risk. That’s why Cal INDEX was formed,” he said. “We’ve loaded 10 million records already from among our two founding members. Prescription, lab, and radiology records from claims; and EMR-based provider data. And from that, they can share data.”
Shortly the panel concluded on March 23, Watson spoke with HCI Editor-in-Chief Mark Hagland, to add further comments to those he had shared in the data interoperability session at the World Health care Congress. Below are excerpts from that interview.
As you mentioned in the session a little while ago, HIE has really gone through a lot of ups and downs and ins and outs in California in recent years.
That’s right. There was CalRHIO and Cal eConnect, and they merged and then imploded. Cal eConnect was shut down in 2012. And then the state of California… Under HITECH, all states have to coordinate health information exchange, but don’t have to commission it, so California opened it up for county or regionally based exchanges, so they had 19 regional ones.
So the two Blues plans came together?
They were each building their own private exchanges to share clinical data with their ACO providers. So they agreed not to compete on a utility function. $80 from the two Blues over the next five years. 15 staff, to 26 by this summer.
And right now?
Right now, we’re doing outreach to the providers, and are in negotiations with 10 providers in both Northern and Southern California.
What are the biggest challenges and opportunities facing you and your colleagues right now?
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.
You mentioned in the panel discussion that you found you actually already have 3,000 individuals in the HIE with the name Maria Garcia.
Yes, that’s right, and 500 actually have the same birth date.
That’s rather mind-boggling.
Yes. And so 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.
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. But we have to put all those fragments of health history in one place to tap into and use. And beyond that, how else can we help to create that bonding influence to share data, including images and genomic data?
Is the policy landscape good for you at this time in the evolution of U.S. healthcare?
Yes, the fact that CMS [the federal Centers for Medicare & Medicaid Services] came out with more than 50 percent value-based payment as a target and a couple of years ago a payer trade group came out with the idea of trying to do require that more than 70 percent of their payments (the big payers) be value-based—that’s significant. And over 50 cents of every dollars coming from CMS, it makes political sense for the commercial payers to let CMS lead.
So it’s a good policy landscape for you, then.
It is, because of a lot of the old barriers to risk-sharing models are breaking down. I’ve had a lot of primary care doctors say, I’m happy to share claims-oriented data with payers, but why would I send them all my data? But if the payer gets all of my data, they’ll just screw me at contract time. And there’s still sentiment to overcome. But really for the first time, all these risk-sharing arrangements require payers and providers to share data more closely, or they cannot be successful. And that’s the biggest inflection point.
What are the biggest process challenges you’re facing?
HIEs have some unique elements to them like attribution, and who gets to see the record. We’re trying to optimize around learnings from others. But having a good, solid basis for relationship with the consumer is really important. We’re in California, and there are all kinds of consumer advocacy groups, so engaging with consumer advocates is important, as is giving people the ability to opt out. We can assuage concerns over who sees the data by giving them the ability opt out. We have challenges because of the California Medical Information Act (CMIA), which has a higher standard than HIPAA [the data privacy provisions embedded in the Health Insurance Portability and Accountability Act of 1996]. None of those regulations anticipated the sharing of clinical data; it was all about covered entities and business and associates. We’ll have relationships with hundreds, if not thousands of providers and covered entities. And liability, per cyber breaches. Security of the environment—it’s a full-time job.
And what are the biggest opportunities you face?
Our biggest opportunities are, one, to simply help solve the data issues around interoperability so that a person’s records can actually flow between and among the people giving them care; that’s no small thing. Second, once we bring together all the data fragments, we want you as a consumer to see your entire longitudinal record as a unified thing. That was the goal of Microsoft HealthVault and all those other things, which kind of died. I signed up for HealthVault, but it died because the responsibility was that of the consumer. So I logged on once, it was empty, and I never logged on again. So our goal is to give you as the consumer access to your record, as the PHRs were meant to do. That’s a reverse flow, and we’ll give you access to the record, and we’ll help you to manage it. When you went from paper charts to computed information with the EHR, what can you do now? We’re still exploring that. And if you then give access to consumers to that data, there’s real opportunity there. In the short term, it’s like trench warfare, right? But that’s the goal.