The leaders of health information exchange (HIE) organizations are developing a wide variety of strategies, at a moment redolent with both challenge and opportunity. With the shift towards value-based healthcare delivery and payment accelerating, the need for effective data exchange between and among all the stakeholder groups—physicians, physician groups, hospitals, health systems, health plans, public health agencies, and state health departments—is growing by the day.
In that context, the need for interoperability is accelerating apace as well. Yet creating true interoperability is far more difficult in practice than in theory, particularly given that there is no “magic bullet” or easy approach that can fast-track a path to near-universal interoperability and data exchange. So what are the leaders of some of the most successful statewide HIEs doing to create successful strategies, and to help support their colleagues in moving forward?
One HIE leader who has been thoughtfully pondering these questions is John Kansky, president and CEO of the Indianapolis-based Indiana Health Information Exchange (IHIE). IHIE was founded in 2004; Kansky has been its CEO for nearly 11 years. IHIE’s network connects 117 hospitals, representing 38 health systems; 14,592 physician practices, representing 42, 215 providers; and 13,221,125 patients, and 10, 916,592,344 data elements, according to information on its website. Kansky spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his perspectives on the current moment in health information exchange, and the potential for breakthroughs in interoperability in the next few years. Below are excerpts from their interview.
What are your organization’s top goals in the coming months?
We’ve got a strategic plan that we’re in the middle of executing, that has three basic tenets to it. One is integrating our data within the EHR [electronic health record]. I’m sure you’re familiar with the general theme that many have expressed, that having a physician have to leave the general medical record is suboptimal. In that regard, we’re one of the nation-leading HIEs willing to do the heavy lifting around that. Number two, in the context of the patient-centered data home, we have to share data beyond state lines and in different markets. We have to figure out how to increase interstate health information exchange. And the third theme is helping our participants in terms of supporting them around population health.
You’re the statewide HIE, of course. Are there also local HIEs operating in Indiana?
Yes, there are; there is one in Bloomington, and there is one in South Bend, called Michiana Health Information Network, with South Bend being near the Indiana-Michigan border. And that relates to another theme: we’re very collaborative and cooperative in our approach. And both of those HIEs are connected with us and are exchanging data, in the context of our patient-centered data home. It’s important for HIEs to take the perspective that if your state needs data in another HIE, you need to help get the data for them. My joke is, if you can’t make a long-distance call from South Bend to Indianapolis, something’s wrong with the phone system; and the data shouldn’t be any different [in terms of its connectivity].
So what would you say about the state of interoperability right now across U.S. healthcare, in this context?
I was on an ONC [Office of the National Coordinator for Health IT] panel last week Tuesday in Washington, and it was interesting discussion. Right now, most healthcare IT professionals have a very superficial understanding of the different interoperability approaches; and because their understanding is still rather superficial, there’s this idea that there’s a single best approach. And the federal government wants to know who’s got this interoperability thing figured out, and what’s best for the country? And obviously, healthcare IT professionals want an answer that’s no more complicated than it needs to be. But it’s wrong to try to simplify it down to one interoperability approach, because the various approaches do different things, focus on different things. And we often say here at IHIE that interoperability is not one “thing.”
There’s massive confusion around that in the field, right?
Yes, there is absolutely massive confusion around that in the field. And unfortunately, humans always try to go to the simplest solution to any problem. And at the DC panel, we were talking about what it’s like to move things around within any organization—physical logistics. It ends up being a rather complex effort involving trucks, cars, and planes, for example. And at times, we need to focus on making sure those different modalities work well together. And that’s a good way of thinking about data—why should moving data around be less complicated than moving stuff? And how HIEs, and Carequality, and the eHealth Exchange might collaborate together. There’s a tendency—whether you’re SHIEC or CommonWell or The Sequoia Project—there’s a tendency to think that your solution will solve everything. And so my stump speech is basically that you shouldn’t believe that, or want that for your organization, because that’s like saying, we’re going to move everything via train, so no trucks, cars, or planes, and then you’ll twist yourself into a pretzel trying to achieve that [limited vision].
What needs to happen, in the next two years, then, to achieve true interoperability across data exchange efforts?
Let’s talk nationwide, because Genevieve Morris [the Principal Deputy National Coordinator for Health Information Technology, at ONC], who was moderating the panel, challenged us to come up with solutions. And it sounds rudimentary, but we really need HIT professionals to understand the interoperability approaches more deeply than they do; there’s no way around that. So whether that means calling on HIMSS [the Chicago-based Health Information and Management Systems Society], or the ONC, or The Sequoia Project, which is about to hold its annual conference—there’s no way to change the behavior of an HIT director or a CMIO, but it’s going to be impossible for them to make solid decisions and design the interrogability approach for their organization, if they don’t understand what’s out there.
Now, in Indiana—we’ve talked about the three things that IHIE is focused on. We’re going to do those three things. And that is at the core of our strategic plan. But as you peel that onion, there are a lot of interesting things under the surface. For example, when I said we work hard to interoperate with the EHRs, to get our data integrated into the electronic health record, not surprisingly customer organizations have different EHR vendors, which support different interoperability platforms. So we’re doing some educating. We’ve worked very, very hard to learn the nuances of the different interoperability approaches, at a deep enough level that we can help our customers understand, and get involved in their interoperability planning. We have lots of participants that are individual hospitals or systems. So we challenge them on what their interoperability plans are, where they’re at, and how we can help them, even as their EHRs’ capabilities are advancing. And use us as a consultant, because we have much more time and capability to help you address that interoperability challenge.
What has the response been from HIT leaders at patient care organizations?
It’s been well-received. Some are further along on this than others. But you have to demonstrate your knowledge of the area. A story that exemplifies where we are as an industry. I was in a conversation recently with a hospital CIO who was using Carequality, but actually meant eHealthExchange—in a conversation. Both are run by The Sequoia Project, but in some ways, their approaches are very different. So if we don’t even know the differences between different initiatives at the national level, we can’t get past that. And we’ve had members who’ve said, we want to participate in health information exchange or some other initiative, and can you get on a call with us? And we’re thrilled when they call us, because obviously, the HIE involved has to be involved. And it’s important, on a national level, to understand that HIEs can’t stand still and whine about one interoperability approach intruding on their territory; they need to find out what their territory is, and work accordingly.
Where are key officials at ONC, CMS, and HHS, on this?
TEFCA is the Trusted Exchange Framework and Common Agreement, which is an element in the 21st-Century Cures Act; ONC was required to come up with the TEFCA. That’s their focus right now, from what I can see, and it is that, of necessity. What encourages me is that, in educating themselves, and as a result, the nation, on different approaches, and on what the framework of governance should be—you have to look at what they defense as a trusted exchange framework, and a common agreement. Their report came out fa few weeks ago, where they look at Carequality, Commonwell, SHIEC’s patient-centered data home, etc., and they matrix across those approaches. Because while they’re not going to legislate that all health information exchange in the country work within a specific format, they are going to try to define a broadly common framework, and a legal agreement. The common agreement will be a DURSA [Data Use and Reciprocal Support Agreement] of the current federal incarnation. And when you look at the eHealth Exchange, for example, they’re operating under the DURSA; it’s one of the models they’re going to look at.
Reaching a fairly common consensus vision of HIE in the next few years, is that going to happen? I often refer to the ancient Indian parable of the six blind advisers to the king, with each one touching a different part of the elephant and describing the whole elephant differently.
On the one hand, I agree with the elephant parable, with regard to the different EHR approaches, because if one of the advisers grabs the tusk, they’ll tell you about the tusk, and the tail, etc. But you need to understand the whole elephant. So there’s a prerequisite there that lots more people need to talk to more than one advisor at the time, to figure out what the elephant is. That said, I’m more optimistic, after the ONC panel—look at how much more implementation of EHRs we have in this country, and how the expectation of being more interoperable, has compelled the EHR vendors to focus on things like frameworks and legal agreements; none of that existed even three to five years ago.
So I would say that we’ve made tremendous progress in making the mess we have; without the mess, though—this is how we do things in America; we try a whole bunch of stuff, we let markets try things, and then in the end, we end up with something that works pretty well, even though it’s complex. So we have to get to this intermediate state of messy confusion, to have the opportunity to move forward.
How fast do you think we’ll get towards that level of advancement in the next few years?
Not fast; maybe at medium speed. I sent our marketing director a video of some individuals testifying at a Senate Committee in 2008, and it was surprising to her how much the discussion was like now. The point being that tremendous things have happened; we weren’t using the word interoperability in 2008, but nonetheless, it’s going to take a while; we’ll still be talking about this in ten years from now.
What should the CIOs, CMIOs, and other senior healthcare IT leaders reading this interview, be thinking and doing right now, then, based on everything we’ve discussed here?
They should be educating themselves more deeply about the different interoperability approaches available to them, and they should be challenging their HIEs and vendors about potential plans. Per the Indian parable, if their EHR vendor is only offering you a tusk, you need to ask why they can’t send you the tail as well.