CHIME Interview Series

CHIME Fall Forum Interview Series: Doug Dietzman, Executive Director, Great Lakes Health Connect – Part 2

This is the 2nd part in a two-part interview. Read part 1 here.

Brian Sterud, CHCIO, FACHE

Doug Dietzman, Executive Director, Great Lakes Health Connect

There are two parts to the health information exchange value equation: how do you add to it, and how do you demonstrate that value? Doug Dietzman, Executive Director at Great Lakes Health Connect, knows this all too well. Leading Michigan’s largest HIE means listening to what providers and organizations need, and creating solutions they can easily integrate to create more connected communities. In this interview, Dietzman discusses how being a nonprofit has made GLHC more in tune with their consumers; why he welcomes the scrutiny that’s put on HIEs; and the unique approach GLHC takes to demonstrate the value of their services. Dietzman also touches on top of mind topics such as the recent hurricane disasters and how HIEs are a vital part of our emergency preparedness.

The establishment of patient identity needs to originate at registration within the provider organization, where care is being delivered.  It will always be more difficult and messy to fix it on the backend.

We need industry consensus around a single security certification process that will satisfy all healthcare participants. 

As a neutral community-focused organization, HIEs sit in the middle of the health plans, hospitals, primary care offices, public health, and all the other physical, behavioral and social service organizations involved in healthcare.  There are compelling reasons why and simple ways how these industry stakeholders can all work together to do the right thing for the people we all serve.

Campbell: I’m going to shift gears, to a topic that’s of interest to a large audience, and certainly has a lot of differing opinions and confusion around it: Patient Identification. What I’d like to get at is how that’s managed within the HIE today, what tools you might leverage, what ideas you have. Mike Gagnon, from Nevada HIE, spoke about some of the vendors he’s talked to about facial recognition, as that’s become more ubiquitous, and whether it’s on private industry to solve, or the responsibility of government. Keeping politics aside, I’m more interested in how it’s technically facilitated at Great Lakes Health Connect and some of the advanced things you’re doing in that regard. Could you touch on any patient matching issues that you may have, and how those are automatically or manually resolved?

Dietzman: I don’t know that we’re doing much that’s different from everyone else.  Medicity remains our virtual health record platform; the MPI that we’re using is through them as well. We don’t have resources dedicated to maintaining or fixing patient identity issues, as we don’t encounter a great deal of those issues on a daily basis. As such, from an administrative and use standpoint, what we’re hearing from our customers is it’s not a huge problem that’s getting in the way of what they need to do. There’s a lot of work we can do in the HIE that doesn’t even require an MPI to be involved in the first place. We do have an analytics environment where we’re doing some patient matching for those purposes, but overall, not a huge issue for us.

It’s interesting that some are trying to solve the problem on the backend. It seems to me that when we talk about patient identity, it needs to originate and start at the registration within the provider organization because that’s where the care is being delivered. If we’re trying to fix it on the backend, it’s always going to be more difficult and messy. In my mind, we’re giving the wrong people the wrong care, potentially, if the patient is misidentified. Palm scanners, facial recognition, and other biometric devices would be the easiest way to solve this. From a social standpoint, there may be some problems with that. We need to make sure we’re treating the right person at the point of care. If we’ve accurately captured it at that point, the backend reconciliation should be much more straightforward. As such, I don’t see this necessarily as an HIE problem.

Campbell: That’s a great perspective. Thank you for sharing. Switching topics again, SHIEC held an annual conference at the end of August, and I was curious of insights gleaned and takeaways from the event.

Dietzman: I’m on the board of SHIEC (Strategic Health Information Exchange Collaborative), and was recently re-elected to a second term, so I’ve been involved with the organization for a while. The conference itself was great. The conference was bigger than the year before. I was encouraged by the energy and the sharing of ideas. It wasn’t just about us getting together and drinking our own Kool-Aid. The ONC was there for all three days, and a number of vendors came to show their support, and have meaningful conversations with the group, which was great. I heard a lot of positive feedback on the quality of the content and conversations. I thought it was another good step forward for the organization. We’ll have some big expectations to fill next year down in Atlanta.

Campbell: That’s fantastic. What were the themes that dominated the event and what problems were tackled at this year’s conference?

Dietzman: Patient Centered Data Home (PCDH) was a big topic; specifically how PCDH can serve as a mechanism for how we can connect SHIEC Member HIE networks on a national level. This was important conversation for helping people understand how SHIEC Member organizations are demonstrating success within our regions. Another was a series of updates on how various organizations are doing things. For instance, Dan Chavez of San Diego Health Connect led a session on how his group is supporting emergency medical services, and how other HIEs can replicate their program. In the breakouts, there were a lot of topical presentations that gave provided ideas and helped us understand behavioral health use cases. Some of the folks from the Nebraska Health Information Initiative (NeHII) shared what they’re doing around prescription drug monitoring programs (PDMPs) with controlled substances and medication databases. Exchanging ideas, collaborating, and being able to have meaningful conversations with industry peers is always helpful.

Campbell: Thank you for elaborating on that. Sounds like it was an invaluable event. I look forward to next year’s conference. That said, I always like to weave in practical stories of use cases where they’ve been impactful. I know you probably share those among staff to develop an understanding of the true impact of the HIE. If there’s one that comes to mind that you could share with us about how Great Lakes has made a difference in the lives of patients that would be great.

Dietzman: Let me give you two quick ones. We’ve been working with a community mental health organization here in Michigan, over towards Ann Arbor, and their use of our Virtual Integrated Patient Record (VIPR). We’ve been challenged with the consent laws and other legal frameworks to accept behavioral health data into our virtual health record. What we did in this case was to make sure their behavioral health care workers were provided with physical health information on their patients. There is no regulatory restriction there, and having access to that information informed their ability to care for the folks they were seeing in the CMH. The Director, Mike Harding, talked about one particular lab test that they would order on a regular basis for their patients. Once they gained access to the community health record, they could see the results of past testing, eliminating the need to run an additional panel. He estimated that their organization was able to eliminate about 200 tests a month because the necessary results were already in the record. This translated to a savings of $72,000 a year for them!

The other example is a center in Grand Rapids that works with a complex population; folks that have physical, behavioral, substance abuse, or other issues that drive frequent visits to the emergency room. We implemented the community health record with them as well. Their workflow and process was for the entire staff to meet as a team first thing in the morning, before patients started arriving. They could then review the records of everyone scheduled for that day to get a sense for each patient’s status and needs. On one occasion, a woman was scheduled for an appointment, and had requested a referral for a CT scan to help identify the cause of some head and neck pain she was experiencing. When they looked in her record, they realized that the previous week she had presented to all three emergency rooms in town on successive days, and had received CT scans during each visit! On one hand, this is not a great story. It highlights the work we have yet to do to inform different care settings and avoid unnecessary, redundant, and potentially dangerous treatments. But also, in this case it empowered those providers with the information they needed to intervene and quickly identify that there was something more going on with this patient. They were able to bring behavioral and social resources to bear on her behalf, and address the root cause of her complaint, rather than continuing to blindly treat the symptoms of her complaint.

These are just a couple of examples of how tools provided by the Health Information Exchange are being used to help people do things differently.

Campbell: Great, thank you for sharing those. Wrapping things up, I know earlier in the year you received a HITRUST distinction for security and privacy and that’s a topic that you take very seriously as an HIE. Could you touch on that topic, maybe conversations at SHIEC to that regard or any insights or points you want to make, regarding security and how that’s managed, and how you continue to evolve, as cyber threats manifest?

Dietzman: GLHC has a responsibility to be just as diligent about data security [if not more-so] as any of the large health systems that we work with. Gaining the HITRUST designation provided us with the assurance that we’re doing the right things where security is concerned. More importantly, this demonstrates to our participants that we can pass that highest level of scrutiny from an independent third party organization, considered the gold standard in this area. It doesn’t guarantee anything. As you said, the threat changes on a continual basis. But HITRUST shows we’re doing all we can to stay in front of those threats. One of the challenges, and some of the conversation that we’ve had within SHIEC and elsewhere, is the lack of a standard industry-wide security certification. There are some health plans, for example, that require HITRUST while others say HITRUST isn’t sufficient and require a different certification. HIEs are in a position, depending on their participants, to have to “check all the boxes” in order to be compliant. This is very expensive, and frankly not realistically possible. So, from an industry standpoint, I’d love to see some kind of coalescence around a particular security standard that we could all align behind. It’s not the security requirement that’s hard, they’re all essentially the same. Going through the process multiple times is a challenge. Having to do it six to eight times to get through all the different varieties is exhaustive.

Campbell: Certainly, there’s a lot of effort that’s involved in penetration testing, just to ensure you’re whole and don’t have any paths to exploitations. One topic that we didn’t touch on that I’d like to conclude with, is a little bit of bio about yourself, how you came to Great Lakes, your background, and how you got into healthcare IT.

Dietzman: Well, I got into it by happenstance. When I graduated, my dad was in retail and I went to work for a retailer for about a year, then I moved to another part of the country and got linked up with Anderson Consulting. When I showed up, I was a green rookie, and they said, ‘you know what, we need people that can breathe down at Aetna in their employee benefits division,’ and I qualified. I started working on some projects there, doing PowerPoint presentations as a young guy, and at some point the partner came up, after a little bit, and said, ‘you know what Aetna’s buying these things called HMOs down in Texas, we’re not sure what this managed care thing is, so go down, spend 30 days in the library and learn everything you can about managed care and all these terms that they’re throwing around and come educate the rest of the team so we can provide better service.’ And I did, and once I spent 30 days pouring through the details of the industry it kind of became my thing. I was hooked.

I spent most of my career, from that point, in managed care, mostly in health plans. I worked for a couple different health systems serving in different capacities: Project Management; IT; Management Consulting. I then worked with Spectrum Health, in Grand Rapids, MI, helping them develop connections to the providers in the community, delivering results and doing other things that they needed. A conversation started with other hospitals in town who were using the same technology about how we could do things better and collaborate around this clinical data exchange. They asked me to facilitate the conversation and then, once we decided to become a real entity and incorporate in 2010, they asked me to lead the effort and see if there was a business model and how the organization would go forward from there. It was just me, and so from 2010 forward it’s just been growing one person at a time, to try and solve problems, and figure out how we can build a model that will sustain itself. For me it was cool, I’d been in health plans, I’d been in hospitals, I’d been in primary care offices. It seemed to me that there was a way for all three legs of that stool to work together in a way that could advance healthcare outcomes. As an exchange, we get to sit in the middle and work with all the legs of the stool to figure out how we can share data and do the right thing for patients. It’s a great way to bring all of that experience together.

Campbell: That is so profound. Thank you for sharing. It’s always fascinating to learn of the turns and twists in someones career, and how that shapes, not only who they are, but the organizations that they lead.

CHIME Fall Forum Interview Series: Doug Dietzman, Executive Director, Great Lakes Health Connect

Brian Sterud, CHCIO, FACHE

Doug Dietzman, Executive Director, Great Lakes Health Connect

There are two parts to the health information exchange value equation: how do you add to it, and how do you demonstrate that value? Doug Dietzman, Executive Director at Great Lakes Health Connect, knows this all too well. Leading Michigan’s largest HIE means listening to what providers and organizations need, and creating solutions they can easily integrate to create more connected communities. In this interview, Dietzman discusses how being a nonprofit has made GLHC more in tune with their consumers; why he welcomes the scrutiny that’s put on HIEs; and the unique approach GLHC takes to demonstrate the value of their services. Dietzman also touches on top of mind topics such as the recent hurricane disasters and how HIEs are a vital part of our emergency preparedness.

Key Insights

There’s nothing about HIEs that have a right to exist just because we’re HIEs. We should only exist if we are indeed adding value, like any other business or organization would have to do.

CommonWell, Care Quality, and other networks connect EMRs and there is a strong role there but what’s the plan during a disaster when a good Samaritan clinician from Missouri is now in Houston and they want to look up a person’s record who has walked into a shelter with thousands of other people? Do we have to give them access to all the EMRs in town? As a practical matter, an HIE is really the right solution.

One of the things that makes us unique from many is we have not developed ourselves, or built, our operations, even to this day, and going back to the beginning, from any state or federal dollars. We had the mindset coming into it that if we can’t develop solutions and services that the stakeholder community is willing to pay for, that actually solves a problem, then we’re going to go out of business someday when the grant money dries up.

When we get into the community health record, this is probably true for a lot of my peers as well, nobody argues that a longitudinal record is a bad thing, everyone thinks it’s great, but if a hospital is going to pay increasingly scarce dollars for access to this longitudinal health record, how do we measure the value of that to them?

Campbell: I am flattered and humbled to interview you as part of this HIE series that we’ve been running, there’s no better example of the value of an HIE than Great Lakes Health Connect. Certainly, there’s been some scrutiny put on HIEs, there’s been some sentiment that HIEs don’t show the value for the effort or money put into it. Broadly, what is your perspective on the current state of HIE?

Dietzman: A couple of initial thoughts. To your point on scrutiny, my perspective would be, it’s very appropriate, there’s nothing about HIEs that have a right to exist just because we’re HIEs. We should only exist if we are indeed adding value, like any other business or organization would have to do. I think what we will continue to see is those that haven’t figured out how to do that well will be challenged. There may still be some consolidation, or HIEs that cease to exist, if they haven’t put a sustainability model together. That shouldn’t mean that the whole concept is wrong, just that, like in any business, some work and some don’t.  For example, there are some that know how to run a book store and some that don’t, and the bad book stores go away and the good ones continue to exist. So, I welcome that scrutiny and what it will mean for what we’re doing to enhance care coordination and facilitate cost optimization.

Campbell: That’s a great point. Tell me about some of the initiatives currently taking place within GLHC that contribute to sustainability.

Dietzman: There are a couple things percolating or that are of interest. One would be the recent hurricanes. There’s been press reporting on how HIEs uniquely helped there in the midst of the immediate aftermath. We are focused on how an HIE like Great Lakes Health Connect provides a unique value beyond some of the other national networks or other ways EMR vendors are talking about connecting with each other. You would not be able to deal with 1,000 people in a shelter, all coming from a wide variety of different places and have a uniform record for those nurses or care workers who are coming in from all over the country to help in the disaster, absent having the HIE there to provide that visibility. It’s a perfect use case for me, and when those crises come up, the HIE plays a vital role.

Campbell: That point can’t be underscored enough, and that’s just one of the value propositions for an HIE, but it’s a profound one because what alternatives do you really have? Can you expect someone to bring their record on a device? They probably don’t have it in those circumstances. Depending on the practice, you may not have access to that information, and otherwise, to transfer those records, so, the HIE is critically important in those scenarios.

Dietzman: CommonWell, Care Quality, and other networks connect EMRs and there is a strong role for that but what’s the plan during a disaster when a good Samaritan clinician from Missouri is now in Houston and they want to look up a person’s record who has walked into a shelter with thousands of other people? Do we have to give them access to all the EMRs in town? As a practical matter, an HIE is really the right solution. From an emergency preparedness standpoint, we stock pile beds, we stock pile supplies, we stock pile all sorts of things. Should a facility need to be evacuated or there’s a crisis across the country, what’s rarely thought about is: how do we prepare the clinical data and the records in a way that we can actually care for the people when those things happen? I’m hoping the continued push on this will put more of a spotlight on the need for seamless information sharing as part of how we prepare for these sorts of events, rather than always being caught off guard and then wishing we had.

Campbell: Right, a business continuity and disaster recovery plan is vitally important.

Dietzman: So that’s one, another is the patient centered data home activities we’re heavily involved with in SHIEC (Strategic Health Information Exchange Collaborative) and the Heartland Project, which is connecting seven HIEs here in the Midwest and working with the other regions to connect those together into a national network as well. It’s all activity that’s currently live. We’re actually exchanging ADT (admissions, discharge and transfer, data) with those other states today, and are working on adding the query capabilities. That’s pretty exciting for us and something that people have been requesting for a long time.

The last point I’ll mention is, we have added another non-profit organization under our corporate umbrella. Making Choices Michigan is specifically focused on advance care planning. We have partnered with them regionally for a while as the electronic repository making documents available once the conversation had occurred. But we recognized we could have greater impact if  our organizations were aligned to expand our collective capacity across the state. This would give us a consistent process, consistent tools, and a consistent state-wide delivery mechanism for those documents to really try and make difference in advance care planning and culture conversation. That’s another initiative that’s new for us and that I’m pretty excited about.

Campbell: Great, thank you for sharing that. That’s something that I actually talked to Todd Rogow about at Healthix in New York. He talked about their use of advance directives and defining the different value areas, maybe it’s in disaster prevention preparedness, or in the wake of those disasters, you’re providing access. Advance Directives is another area where HIEs can provide value, beyond just exchange of CCD (continuity of care) documents, results, or other clinical information.

Dietzman: Yeah, I was thinking about the concept of patient data a little bit more broadly. I mean, we’ve been focused, since our inception, on making sure a patient’s data gets where it needs to go to support care, and patient wishes are a portion of that. To that extent, as I see a lot of very small, pocketed, fragmented efforts all trying to create this culture, and through that fragmentation it’s losing some of the gravitas it could have. I’m hoping Great Lakes Health Connect, with our state-wide network, and the capabilities and trust we’ve created to this point, can help elevate that conversation and make it something that folks across Michigan start to tune in to. If most healthcare expenses are incurred late in life, it seems to me that increasing the percentage of the population who have advance care documents in place, and readily accessible can’t do anything but honor their wishes better and care for them according to what they really want. This can significantly lower the cost of healthcare for things people don’t want, and also save families from significant disagreements and heartache when those wishes are unknown.

Campbell: Certainly. So, if I may, I’ll present you with a loaded question, something that I’m interested in. I’ve asked a few of the other folks who I’ve interviewed as part of this series, what’s been the biggest differentiator for Great Lakes Health Connect? I know you folks are very advanced in terms of both the public and private HIEs, but whether it’s strategy, culture, technology, time. We’ve spoken with Maine HealthInfoNet, and for them, they’ve been around for so long, started early, and now they’re really advanced in their use of predicative analytics, where others may still be grappling with onboarding and participants. I know that GLHC is very deeply penetrated in the participant market, with those people who you provide value to, it’s not just hospitals and clinics but also community and mental health, public health, behavioral health, so I know you’ve really expanded that footprint. If you could provide a few points about what’s been the key differences in terms of how you manage your money, how you provide governance, I would be appreciative.

Dietzman: One of the things that makes us unique from other HIEs, is we have not developed ourselves, or built, our operations, even to this day (and going back to the beginning) from any state or federal dollars. We had the mindset coming into it that if we can’t develop solutions and services that the stakeholder community is willing to pay for, that actually solves a problem, then we’re going to go out of business someday when the grant money dries up. While I would’ve loved having $15 million dollars to play with, not having it focused us pretty intensely on the things that we needed to do to  be of value to our stakeholders. The point that I keep bringing up is, there’s a lot of basic blocking and tackling, exchange work, that is still a pain in the neck. Hospitals and other providers need to have those tasks taken care of for them. For all the standards that have been developed, and all the talk about interoperability, nobody is talking about how we make it so that a result message from a lab can automatically go into any EMR without having to do any sort of integration work. We still do a lot of that, and our participants are willing to pay us for it because they don’t want to have to deal with it themselves. That’s one of the key points for us, being very in tune with our customers, what are the tangible problems and needs that they have? How do we position ourselves to meet those needs and scale in a way that allows us to be sustainable?

Campbell: Right, that’s a great point and it’s hard to wean yourself off of grant money too. I’d spoken with Todd Rogow of Healthix, who are supported with a lot of government money. Once you’ve incorporated that into your business model, it’s awfully tough to substitute it, once you’ve gone down that path.

Dietzman: The tricky thing is, once a customer has gotten something for free, it’s hard to get them to pay for it later. So, it’s not so much the problem with the HIE, and one type of fund or another, but once you’ve given something away, to come back after a couple of years and say ‘well now you’re going to have to pay for it,’ when the mindset for those folks probably is ‘hey this stuff should be coming down in cost,’ or, ‘this is something I’ve never had to pay for before,’ that’s a hard conversation to have.

Campbell: That’s a great point, I’m glad you revised that for me, the point I was trying to make, but taking it from the angle of the participants. That’s so true. Speaking of subscriptions or pay-for-service from your participants, how do you report value to them? How do you show them the value that you’re providing for the funds they’re paying? I’m talking about just from a reporting perspective, and maybe saying, ‘hey these are the number of transactions, these are the ways we’ve intervened, this is how we’ve impacted your patient population from a public health perspective, or these things on the roadmap.’

Dietzman: It’s a good point, and on some level, a challenging one for us. The reason that we built our model in a menu set is we wanted those menu items that the providers are paying for to tie more directly to the value that they are receiving so that it would be clearly visible. If there is just one big fee to join an HIE and you get all this stuff associated with it, it’s harder for me to articulate exactly what they’re getting for their investment. If they only want 25% of the solutions, but they have to pay for 75%, then it makes the whole value-dollar dynamic really squishy. We established a core participation fee when you join, just to encourage further participation and active use of the exchange, but then additional solutions are broken out separately. So, results delivery would be an example item, and you pay for that. It’s easy to go to them and say, here are the number of offices for which we have built interfaces, or are getting your results through inbox, that sort of thing.

Translating that into how much that saves the organization from doing it themselves, or the exact value proposition, is where it gets  hard. Most  provider organizations haven’t developed a baseline, or know what it was costing them before. We are performing tasks that are outside of their core business, and that frees up there internal resources. From one perspective, the associated costs our participants are willing to pay is a reflection of the value that we’re delivering to them.

When we get into the community health record, this is probably true for a lot of my peers as well, nobody argues that a longitudinal record is a bad thing, everyone thinks it’s great, but if a hospital is going to pay increasingly scarce dollars for access to this longitudinal health record, how do we measure the value of that to them? The value depends on how much it’s actually used within the workflow and what it means inside the organization. We don’t control the relationship with the patient. That’s where it gets even more squishy with  ROI. That’s why we highlight use case examples  like emergency preparedness, and ask “what would you do in that situation?”. It’s happened in New York, when they had the ransom-ware attack and were able to use the HIE data to continue serving patients; otherwise their clinical data would’ve been locked up inside their EMR. Those are more subjective illustrations that  demonstrate value, rather than through an objective ROI. But it is very clear in a rapidly evolving value-based reimbursement model environment that those at risk MUST know what is happening to their assigned population when outside the 4-walls of their enterprise.  The longitudinal health record is going to be a core success platform in the coming years.