Health Information Exchange

CHIME Interview Series: Paul Brannan, Alabama Health Information Technology Coordinator, Alabama Medicaid Agency

Paul Brannan, Alabama HIT Coordinator

Paul Brannan, Alabama HIT Coordinator, Alabama Medicaid Agency

A champion in the Medicaid arena and now in health information exchange, Paul Brannan, Health Information Technology Coordinator and Director of Alabama’s HIE, One Health Record®, knows how to make quite the connection. His advice to those in the HIE startup/entrepreneurship space is the same he follows himself: create solutions that are easily usable in the provider’s workflow. One Health Record® is intentionally free to its providers and has gained flexibility with how they send records outbound, based on what the system is ready to consume. They are also willing to customize their interface with the provider’s EMR system. No EMR? No problem. One Health Record® provides a portal through a secure website where you can see the longitudinal record of care. Brannan’s future initiatives reflect this provider-centric way of thinking: from working to integrate with Public Health so One Health Record® can become a connection hub for their providers, to reestablishing their connection with Georgia’s HIE, One Health Record® has a robust value proposition and it shows.

CHIME Fall CIO Forum provides valuable education programming, tailored specifically to meet the needs of CIOs and other healthcare IT executives. Justin Campbell, of Galen Healthcare Solutions, had the opportunity to attend this year’s forum and interview CIOs from all over the country. Here is the next interview in the series:

Key Insights

We’re in the process of expanding into providing a patient portal for patient’s to be able to see consolidated views of their records from the providers who participate in our exchange.

In the state of Alabama, we find a lot of our provider community is rural in nature and may not have a high-profit margin, so we want to be as low cost to them as we possibly can.

The move to value-based purchasing in the healthcare arena is going to make the information that we have, and its ability to improve treatment, of greater value to our large-scale payers.

If providers don’t have an EMR or they’re not happy with how the information being sent is viewed from the EMR, we also provide a portal where providers can access a patient’s longitudinal record of care.

What we find with a lot of our smaller providers is that, without an extensive IT staff, the cost and difficulty of maintaining all the different connections they encounter is becoming prohibitive.

Most providers are still thinking in a fee for service mindset, where they’re looking at the volume of healthcare. If a HIE adds time and effort to the treatment of the patient, there’s going to be resistance even if the HIE adds value.

Campbell: Can you give me a little bit of background on yourself, your organization, and your current role within the organization.

Brannan: My historical background has been with the Medicaid Agency. I’ve been with the Alabama Medicaid Agency for 20 years. I first came on board in the tech support area. In the late 90s, when we were looking to implement a claim processing system, I was drafted to be a part of the team who developed the RFP and did the implementation.  As a result, I was promoted to Deputy MMIS Coordinator. After a couple of years, my boss moved on to another opportunity, I had the chance to take over our Medicaid Claims Processing System as MMIS Coordinator.  Our Commissioner later gave me the opportunity to direct our Project Management Office because of the project management rigor we were using in the MMIS area.  Two years ago I was asked to lead the State’s health information exchange and was named by our governor as the State HIT Coordinator.

Now our HIE’s background: Medicaid has been interested in the electronic health record market for many years. We started under transformation grants, establishing a free EMR for Medicaid providers, focused on monitoring certain chronic conditions. That morphed, when the Affordable Care Act was passed, taking advantage of the funding by helping providers purchase their own EMR system through Meaningful Use as well as establishing a statewide health information exchange. In Alabama,  One Health Record® is the only HIE in the state.  We offer services for all Alabama providers, not just Medicaid.

We’re in the process of expanding into providing a patient portal for patients to be able to see consolidated views of their records from the providers who participate in our exchange, as well as implementing ADT alerting.

Campbell: I appreciate the thorough background. I noted on your website that as of January 31st you’re at just over 2 million patients, 87 connected facilities, 13 connected hospitals, and over a million registered documents. That’s pretty impressive. Tell me a little about the sustainability and, quite frankly, the solvency model for the HIE. I know with public HIEs, some of them are funded through grants, others have a business model centered around the value proposition they’re offering. If you could elaborate on that, that would be helpful.

Brannan: We have intentionally been free to our providers, at least as far as what we charge, to drive adoption. In the state of Alabama, we find a lot of our provider community is rural in nature and doesn’t have a high-profit margin, so we want to be as low cost to them as we possibly can. This means we’ve been funded to date by a combination of: federal funding, state funding through the Medicaid agency, as well as grants from the Department of Public Health, and Blue Cross Blue Shield—which is Alabama’s major insurance provider. Long term, for sustainability, we’re looking at several different funding models.  We feel that sustainability will come from a combination of value to our large-scale providers and our major hospitals in the state providing a large part of the funding. Lesser amounts will likely come from our individual providers, our primary care doctors, and others, with some funding coming from our insurance community as well.  The move to value-based purchasing in the healthcare arena is going to make the information that we have available, and its ability to improve treatment, of greater value to our large-scale payers.  In Alabama, large scale payers make up a good portion of the population under Medicaid.  Therefore, we anticipate Medicaid funding being a part of the long-term solution, and we hope that our major insurers will see value in what we’re doing as well.

Campbell: In terms of the transactions that are taking place, you mentioned ADT’s for the patient portals, but what about for providers? What data do they have access to in the portals? What inbound transactions do you consume today?

Brannan: We can consume any of the ITI-based standards for incoming transactions, and as such we support patient registrations and queries for information.  We are fairly flexible in how we send things outbound based on what the target system is ready to consume. If they want a CCDA, we can do that. If they want a customized interface with their EMR system, as some of our large-scale providers do, we’re willing to work with their EMR vendor to implement that by breaking the CCDs into discrete data elements per standards. If all they’re ready for right now is purely a direct account, we are a HISP (Health Information Service Provider), so we can provide direct mailboxes for them as well. If they don’t have an EMR or they’re not happy with how the information we send is viewed from their EMR, we also provide a portal that they can go in to see the longitudinal record of care. That can be viewed through a secure website, and if their EMR system supports it, we can make that viewable as a window within their EMR system.

Campbell: Switching gears a bit, a lot of the HIEs are swimming in a deluge of data. Can you elaborate a bit on the governance process you use today to dictate data access? Is it federated at all?

Brannan: We are a hybrid. We have some providers who are very interested in having us store their data. For them, we have a data repository where we can store their records. However, we have several providers who feel strong ownership of their information and are not interested in it being stored in multiple locations. For those, we offer a more federated approach where we simply store the demographics along with the pointer information. That information then gets pulled on-demand, but it’s not stored, so it does not persist with us, it goes straight to the provider. We require everyone who is connected to our exchange to agree that they will only provide records for people that they’re actively treating and they will only pull those records for treatment purposes.

Campbell: Is there a particularly compelling use case that you can share, in terms of the HIE being used in the provider community, or more broadly, for public health purposes?

Brannan: The use cases that we support directly with a query-based exchange have a lot to do with emergency situations: someone’s away from their primary source of care, they’re on vacation or somewhere where their records are not easily accessible. We make it so that those records can be made accessible in an emergency.

We had an even more interesting use case recently where a provider referred to a specialist, and the specialist called to get the records. The people who had those records said ‘you need to get on One Health Record® so we can send them electronically, we’re trying to get out of the paper record business.’ Without us even having to contact that specialist, they were calling us saying ‘I’ve had a couple of people wanting us to get on One Health Record® so that we can quit this paper exchange.’ They were interested in what they needed to do to be a part of our exchange so they could remove the inefficiencies involved in sending paper records back and forth.

Campbell: That’s great. When people are coming to you, instead of you having to sell the value, that they’re being incentivized to do so, that’s when you know it’s working. I noted an article published in the Birmingham Medical News in December 2015, featuring Alabama One Health Record®, mentioned you were pursuing initiatives around immunizations and specifically alerting. Can you tell me about any progress or challenges you faced with that initiative?

Brannan: The only real drawback we’ve had in moving forward with those initiatives is getting approval from public health authorities to set it up. They want to make sure the information that is going to be shared is secure. We’re working with their leadership to hopefully make that happen soon because it is something we’ve had provider interest in. Once that occurs, what we envision happening, as part of our value-added service, is being a connection hub for all our providers. Right now, providers must maintain multiple connections. We want to simplify that for them by taking on the connection to Public Health so they can do immunizations reporting, cancer registry reporting, or any public health-related reporting, without having it as a separate connection. We’re even exploring, as a long-term possibility, establishing connections to insurers as well, to allow them to do eligibility inquiries and claim submissions.  What we find with a lot of our smaller providers is that, without an extensive IT staff, the cost and difficulty of maintaining all the different connections are becoming prohibitive. We’re trying to simplify that as part of our value-added proposition to our healthcare community.

Campbell: You hit the nail on the head there, as smaller groups just don’t have the resources. If you have an entity like the HIE it makes a lot of sense: the infrastructures is already there, let it do the heavy lifting and connect rather than having to make a major outlay and investment in IT.

Let’s talk about other initiatives that have your focus in this near term. There is seemingly a purchasing pause in the industry, at least in the provider community, where they’re trying to rationalize their existing infrastructure and investments. It’s not the days of money being thrown into the implementation of new technology via government incentives, but rather there’s a lot of rationalization occurring. That said, tell me what it’s like to operate as a HIE in this climate, and what initiatives that you might be facing in the next couple of months.

Brannan: We’re asking a provider to make an investment of time and for many a capital outlay. We are free but their EMR vendor will likely charge them for establishing the connection as well as charge an annual maintenance fee.  Before they make that kind of investment they want to know what’s in it for them. The obvious selling point for a HIE is having complete access to the record of the individual at the point of care. Part of what we’re marketing now, as more and more payers in the Alabama region are moving to some type of value-based reimbursement, is the importance of them being able to see what’s happening in the provider community and with other people who are treating the patients as well. Our value-add proposition is to provide any data they might need to help manage their population, as well as looking for opportunities to partner with them to improve healthcare practices in those hospitals.

Campbell: Absolutely, if you have access to the data, the power of analytics and machine learning applied to that data is very profound. Switching topics for a moment, has there been anything made aside from just the initial connection to GaHIN (Georgia Health Information Network) or is there active communication today? Was it merely a proof of concept or is it something used in practice to serve the two geographies?

Brannan: It has been used in practice and we’re looking to reestablish it. Unfortunately, one of the drawbacks of being a state entity is that as long as we’re under the state umbrella, we follow state procurement laws, which means we can’t purchase a system that other vendors use on a permanent basis. Instead, we have to periodically go out for bid.  Our HIE backend software had to go out for bid last year, and a new vendor won the bid, which meant we had to replace our HIE software. This required us to reestablish our Sequoia certification which was part of the underlying agreement we had with Georgia.  Because we are reestablishing that certification, we have had to temporarily cut off the connection with GaHIN. We are right on the brink of regaining that Sequoia certification – we expect that happening in the next few weeks – and Georgia has expressed interest in reestablishing the connection as soon as that happens.

It is a very important connection. We have people in the eastern part of the state, who see providers in Georgia. There are also populations who simply cross over to other states and have the need for medical care while they’re there and providers there need to see their records. So, that’s something we’re interested in reestablishing as soon as possible, but it’s not currently active today.

Campbell: I can appreciate that. It is a major forklift going from one major HIE platform to another

Brannan: We have providers actively using the new platform as it stands. We tried to make that cutover without causing any disruption to their current connections, making it as seamless as we can.

Campbell: And all the while you must be mindful to look at what’s in the queue in terms of integration that has yet to be developed. As such, I imagine there was some bifurcating of feeds that were occurring while you were working through that transition.

Brannan: Exactly. We had that going on for a good period of time making the transition as seamless as possible. Ultimately all our connected provider had to move to our new endpoint. It took them a little while to make that transition, depending on what their IT infrastructure looked like. We’ve been able to do it fairly painlessly. Most providers made the move with us, which is something that we’re very pleased with.

Campbell: Very good. Lastly, in closing, given your vast background on the Medicaid and HIE side, what have you learned over the years that you would like to impress on our audience of health IT entrepreneurs and startups. Has there been anyone, mentor or colleague, that’s impacted you? If there’s something you’ve learned in your career, or just based on your experience, and can share that story, that would be great.

Brannan: The key to working in the entrepreneur/startup space is making something that is usable in the provider’s workflow. That’s ultimately where the rubber is going to meet the road. As long as a HIE system is seen as an additional tax on the provider’s time, then it’s going to be difficult to get buy-in, no matter how much value it gives. Most providers are still thinking in a fee for service mindset, where they’re looking at maximizing the volume of patients treated. If what is being provided for them adds time and effort to the treatment of the patient, there’s going to be a resistance. Integrate what you’re doing into the workflow of the provider so that it works somewhat seamlessly or causes minimal disruption to what is already a busy workflow.  Most of the resistance we’ve seen comes from providers who say ‘well I see value in that, I just can’t afford to take an extra five minutes per patient. Because of the way my EMR looks at the records you provide, it requires me going to a whole other screen and making so many additional clicks.’  That’s part of the reason we’re willing to integrate into EMR systems for providers who have the wherewithal to support the cost and effort it takes for the EMR to integrate our records into their system.

About Paul Brannan
Paul serves as Alabama Health Information Technology Coordinator, where he is responsible for managing the $5 million HIT program for the state. He also serves as Director of One Health Record®, Alabama’s State Health Information Exchange.

Paul works with local, state, federal, and private partners to build collaboration with Alabama’s health providers, payers, and patients to improve health information exchange and promote better health outcomes. His vision is to see all Alabama stakeholders connected and securely exchanging data as appropriate to make Alabama a healthier state.

Paul is a graduate of Auburn University, holding a BS in Secondary Education.

About Justin Campbell
Justin is Vice President, Strategy, at Galen Healthcare Solutions. He is responsible for market intelligence, segmentation, business and market development and competitive strategy. Justin has been consulting in Health IT for over 10 years, guiding clients in the implementation, integration, and optimization of clinical systems. He has been on the front lines of system replacement and data migration is passionate about advancing interoperability in healthcare and harnessing analytical insights to realize improvements in patient care. Justin can be found on Twitter at @TJustinCampbell and LinkedIn.

CHIME Fall Forum Interview Series: Robert Napoli, SVP, CIO, Planned Parenthood of the Great Northwest and the Hawaiian Islands

Have you ever started a new job with a lengthy to-do list? Robert Napoli, Senior Vice President and CIO at Planned Parenthood Great Northwest and the Hawaiian Islands, can relate. When he first joined the organization three and a half years ago he began a rip and replace of their entire system, and in the end, the only thing that remained was the telecommunication system.  Once he was finished redesigning and replacing, he moved on to strategic initiatives including BI and analytics strategy, mobile health, patient engagement, and more. With experience on both the acute care and ambulatory side, Napoli offers up a unique perspective on the harmonization of clinical data. In this interview, he discusses his organization’s journey through data archival; why integrated solutions are the way to go; and the question on everyone’s mind: what’s happening with the potential defunding of Planned Parenthood? Napoli is a well-seasoned healthcare technologist who’s always aiming to innovate, and we discussed what he’s done and where he’s going.

CHIME Fall CIO Forum provides valuable education programming, tailored specifically to meet the needs of CIOs and other healthcare IT executives. Justin Campbell, of Galen Healthcare Solutions, had the opportunity to attend this year’s forum and interview CIOs from all over the country. Here is the next interview in the series:

Key Insights

In my experience, I have found that integrated solutions are typically easier to deploy and maintain, provide more predictable and lower TCO, and offer better support for overall organizational workflows.

So long as the data exists, we have a repository that is easily reference-able and accessible.

We ripped out the entire network, redesigned it, upgraded the equipment, installed wireless for the first time, replaced email and moved services to the Cloud.

Given the political landscape and the potential for defunding, we’re looking at ways coalesce those services, perform consolidation, and expand the expertise that some of the individual affiliates have to a broader, more national effort.

There’s hardly a CHIME event that I don’t come back with something that I can either implement or use in my organization.

We were recognized by CIO Magazine IDG for successfully launching the federation’s first mobile health app. This service virtually extends our medical expertise and allows patients either through a smartphone or computer, to have a real-time visit through a secure video consultation system.

Campbell: Thank you for taking the time to chat with me. Can you provide a little bit of background about yourself and about your organization?

Napoli: Sure. I’m the Senior Vice President and Chief Information Officer of Planned Parenthood of the Great Northwest and the Hawaiian Islands. We’re the affiliate that is based in Seattle and operate health centers in Alaska, the Hawaiian Islands, Idaho and Western Washington. We have ambulatory clinics in each of those states, providing both primary and reproductive care for men and women. I’ve been in this position for a little over three and a half years now. Prior to that, I was the IT Director at a mid-size hospital in Connecticut and before that, held CIO accountability at a similarly sized hospital just north of New York City. In that role, I reported to the CFO and oversaw the strategic and tactical direction of the department as well as the operational management of our technology and information systems.  I was in that position for nearly nine years. So, I have both acute care as well as ambulatory experience.

Campbell: Certainly valuable to be able to understand both of those perspectives, especially given the challenges surrounding the harmonization and coalescence of that data from the ambulatory side to the acute side. Thank you for that background. In terms of applications within the portfolio, can you provide an overview of that? Specifically, the applications that fall under your umbrella in your organization? Could you also elaborate on your enterprise portfolio approach – best of breed, integrated, etc. –  and whether you have plans to consolidate in the future?

Napoli: In my experience, I have found that integrated solutions are typically easier to deploy and maintain, provide more predictable and lower TCO, and offer better support for overall organizational workflows. Certainly, this isn’t the case with all information systems and there have been occasions, throughout the years, when we’ve gone with best of breed solutions – cybersecurity tools being one such example. Also, a slightly different question, although related, is what to do when native functionality in systems isn’t as robust or feature-rich as third-party options. Population health and analytics are good examples of this. In these cases, we have no problem implementing third-party solutions to provide additional functionality and capabilities. But as a rule, I tend to push for integrated technologies when possible.

The application portfolio that my group manages is pretty standard and includes all of our clinical and business systems including the EHR and practice management systems. Shortly after arriving, I initiated a business intelligence and analytics strategy, so we support and manage these systems as well. There are a couple of outliers. For example, there’s a Cloud-based learning management system that we provide some support for, but that is managed primarily by our education and training departments. Outside of that, nearly every other piece of technology or software used by the organization is supported by my group. We’re comprised of the technical folks that support our infrastructure, computers, and telecommunication systems as well as the clinical and business analysts and data management teams. As the organization’s Chief Security Officer, I am also responsible for ensuring our organization’s HIPAA and cybersecurity posture, which our technical team supports with assistance from external consultants.

Campbell: Very good. Let’s touch a bit on data archival strategy. Do you leverage a data archival solution today? I know you mentioned the data warehouse, and I’ve talked with some folks where they’ve used the data warehouse for archival purposes.

Napoli: We do, although we haven’t been able to reach a consensus on a specific archival period. Fortunately, we have the capacity to archive all of our data without limitation, so landing on this hasn’t been a priority.

When I arrived at the organization in July of 2013, we didn’t have a report writer or database administrator, let alone a cohesive data management or analytics strategy. I made the decision very early on that once I had addressed our operational issues by stabilizing systems and redirecting staff, that we would need to focus on being a modern, data-driven organization. One of the first strategic initiatives that I proposed to my executive team and board was a comprehensive business intelligence strategy – it was an easy sell. In hindsight, this project was a heavy lift, and our biggest challenge was transforming an organization that wasn’t accustomed to working with a lot of data to one that now had a ton of data available. To realize full value from our investment and effort, we needed to get our business leaders to a point where they understood the data and owned the business results of using the system. Architecting the system was relatively easy compared to the cultural shifts that needed to take place. My goal from the outset was to provide a self-service data platform – I didn’t want our end users dependent on Information Services to understand our business and to get access to the data that is most meaningful to them. Although this work was extremely difficult at first, it has been a huge success.

Our biggest consideration when architecting the system was whether to build a data warehouse (which is better for archiving) or go with an OLTP approach, which is more suited for real-time business operations and better met my objective of empowering our business leaders. We decided on a hybrid approach that includes a data warehouse precisely for its archival capabilities. Our warehouse includes historical and current data feeds from both internal and external data sources for all our business units. So long as the data exists, we have a repository that is easily referenceable and accessible.

Campbell: One of the things I talked about with several of your peers was requests to access legacy data. The archival whitepaper we published addressed some of the concerns and challenges when there are eDiscovery requests for data. Specifically, when you archive that data, the shape of the data is inherently changed. Another consideration is what the chart that the clinician was presented with at the exact time of inquiry. That could differ from the PDF of the chart that is produced from most archival applications. There’s certainly a lot of metadata considerations. If you could elaborate on how your organization approaches that today and any insights you may have, that would be helpful.

Napoli: Fortunately, we haven’t had many eDiscovery requests in the time that I’ve been at the organization. We implemented our first EHR in 2010, so there isn’t a lot of data that I would describe as “legacy.” Other information systems were minimal prior to this. Our EHR vendor provides an archiving module which helps make our underlying storage environment more efficient, but our most requested data is in our repository where our users can access what they need although It’s not uncommon for us to receive requests for ad-hoc reports or custom dashboards. The requests for eDiscovery information typically occurs between the business unit making the request and our data management team, and I don’t necessarily have a lot of visibility into the actual discussions themselves. My team does a great job ascertaining that the data we’re pulling is correct and appropriate for the need.

Campbell: Shifting gears a bit, tell me a little about what keeps you busy these days. Any major organizational initiatives? Perhaps you could touch on some items you went to CHIME looking to find out more about.

Napoli: Right now, things at my affiliate are extremely stable. As I mentioned earlier, when I first got to the organization there were a ton of operational challenges that we needed to address. We spent the first couple of years ripping out and replacing every piece of core technology in the organization, except for the telecommunications system, which was replaced the year before I got there. We replaced every endpoint, server, and storage device including the infrastructure that housed our EHR and PM systems. We ripped out the entire network, redesigned it, upgraded the equipment, installed wireless for the first time, replaced email and moved services to the Cloud. In the middle of all this, we acquired the Hawaii affiliate and had to merge their systems with ours and bring them up on our EHR, so operationally we had a ton going on. We’ve spent the past couple of years focusing on the more strategic stuff – getting the data warehouse and business intelligence environments up and running, releasing a mobile app, implementing population health and patient engagement platforms, expanding our telehealth services, among other things. We’re at a point now where, not only operationally, but tactically and strategically, we’re in a great spot.

Lately, I’ve been focusing more of my time on assisting Planned Parenthood Federation of America with some newer and broader initiatives, such as cybersecurity and a shared services model. Let me quickly explain our relationship to the federation as this can be confusing. The national office provides our branding and accreditation, but they do not operate any health centers directly, which is the responsibility of one of 56 affiliates. Each affiliate is an independent organization with its own executive team, board of directors, budgets, information systems, and internal decision-making process. Given the political landscape and the potential for defunding, we’re looking at ways to coalesce those services, perform consolidation, and expand the expertise that some of the individual affiliates have to a broader, more national effort. It’s exciting because one of my earliest observations was that affiliates could benefit from centralizing systems and services, but there were internal politics and personal interests that prevented these conversations from moving forward. Although I do not welcome the thought that we could lose a significant part of our revenue, the situation is forcing us to be more agile and lean, and this is a good thing.

Campbell: I imagine sustainability and solvency is top of mind for you, providing value added services to create revenue generation in creative ways, and as you mentioned, finding economies of scale, and getting more operationally efficient because you need to. Tell me a bit about data sharing that may occur from a regional level to a national level.

Napoli: That’s one of the areas we’re evaluating. We decided to build our own data warehouse because there weren’t any viable options available through the national office or another affiliate. During the requirements gathering phase of this work, we heard anecdotally from many of our business leaders who expressed a desire to benchmark our measures against other affiliates or even those of other organizations. We’ve recently partnered with OCHIN, Inc. located in Portland, for our EHR template customizations and they offer an extremely robust real-time healthcare-specific data aggregation tool called Acuere that would provide this benchmarking. We’re impressed with Acura’s capabilities and are moving forward with a subscription. However, its ultimate usefulness and value are dependent on our end user adoption and whether other affiliates see the value in a data aggregation tool and participate in the program.

Campbell: Do you leverage any health information exchange technology? Or have you evaluated that? I know with some groups, it makes it easier if there are other affiliates that need to connect, to move to that hub and spoke model. An alternative is asynchronous requests where you web services are leveraged to broadcast out to other affiliates, ‘hey do you have any data that I care about,’ and that request is fulfilled.

Napoli: We don’t. We do share data with OneHealthPort, which is the Washington State HIE, so the interfaces and configuration necessary to exchange that data are in place. However, this is a state requirement if you see Medicaid patients and there isn’t much of a business case for participating without this mandate. There is, however, a huge business need to share patient data across the federation since most patients don’t realize that our affiliates (even those that are near one another) are independent, stand-alone organizations with separate EHRs, unique patient identifiers and completely closed data systems. Our patients are often surprised that their medical record is not universally accessible in all our health centers since we present a unified brand.

The aforementioned OCHIN has a potential solution to this that, although not an overnight fix, provides what I believe is the best opportunity for coalescing our disparate EHRs into a truly portable patient record. I’ll be working closely with them over the next few months as we explore this further.

Campbell: I wanted to get your thoughts on CHIME. I talked to Chuck Christian, VP at  Indiana HIE –  one of the founding members of CHIME – and he just raved about how refreshing it is to be amongst your peers. There is a lot of noise at the HIMSS conference whereas the CHIME forum is much more focused. At CHIME, you’re talking about the things that are meaningful to you and given the multitude of issues and responsibilities that come with being a healthcare CIO, it’s seemingly invaluable. I’ll give you another perspective you may have read in one of our earlier interviews, that was extremely cogent advice, from Dr. R Hal Baker at Wellspan. He mentioned the currency of a healthcare leader is measured in attention units. You want ambitiously desire to accomplish a great deal of initiatives, but your primary job as a CIO is to ensure extraordinary care to the patient population you serve. There’s so many ways where you can get distracted or lose your focus. Without me rambling on too much I’d like to hear your perspective on what CHIME means to you and the value you get out of it?

Napoli: I would agree that there’s a lot of noise out there, especially at the HIMSS Conference, just because of the size and scope of it. In many respects, I find it overwhelming even though I’m a proud member of HIMSS, hold CPHIMS certification, and serve on the HIMSS Innovation Committee. CHIME is an association that I value, and the annual conference is one that I look forward to for a couple of reasons. For starters, there are so many people over the years that I’ve connected with and met through CHIME. Chuck Christian, for example, was one of my faculty at the CHIME CIO Bootcamp that I attended several years back. Having the opportunity to reconnect with people who you invariably meet over the years is vital. Additionally, the content of the program is extremely relevant, and it’s engaging and useful. There’s hardly a CHIME event that I don’t come back with something that I can either implement or use in my organization. I sit on the CHCIO Exam Review Panel and recently agreed to serve as a CHIME Ambassador – these are testaments to the value I place on my membership.

Campbell: That’s great. Certainly, when you get so much out of an organization it’s great to hear that you pay it forward and give back to it as well. Any closing thoughts that you may have? The readership for healthIT & mHealth is primarily health entrepreneurs or digital health startups and in past interviews I’ve tried to inquire to the interviewees about advice they may have for folks in that space or what’s on the mind of your organization.  You mentioned patient engagement, and it’s a crowded space with a lot of apps offered in that area, but who’s moving the needle in a meaningful way? Any parting insights you’d like to leave our audience with?

Napoli: Mobile health is a personal interest of mine. After all these years, I still consider myself a technologist at heart. I helped develop one of the first medical transcription and dictation systems in the early 90’s and still like architecting systems and solutions as time allows. In 2015, we were recognized by CIO Magazine IDG for successfully launching the federation’s first mobile health app. This service virtually extends our medical expertise and allows patients either through a smartphone or computer, to have a real-time visit through a secure video consultation system. I also recently designed a mobile health app that I’m hoping to deploy nationally to all affiliates. It’s an app that patients can use to find our health centers, book appointments, connect and communicate with us. I’ve provided our national office with the design documentation, so that’s something to look for in the future.

It’s an extremely exciting time to be in Health IT. The more progressive organizations understood long ago the value that technologies such as big data, mobility, social media and the Cloud brought to the business. Increasing numbers of CIOs are now viewed as business drivers as opposed to the business enablers or operators of old. In my opinion, the real innovation is happening around technologies such as artificial intelligence, augmented reality, autonomous systems among others, which have the potential to greatly improve patient outcomes. The work around cancer genomics is especially encouraging. We’re not quite there yet, but I believe that we are on the cusp of some significant breakthroughs.

Campbell: I appreciate your perspective. It sounds like a lot of innovation is occurring and that’s something our readers will certainly be interested in.

CHIME Fall Forum Interview Series: Charles Christian, VP, Technology & Engagement, Indiana Health Information Exchange

Charles-Christian-CIO

Charles Christian, FCHIME, LCHIME, FHIMSS, CHCIO Indiana Health Information Exchange

Innovation is high on the mind of Charles Christian, and rightly so. Christian is part of the largest health information exchange in the U.S. and is continually looking for ways to make connecting over 100 healthcare organizations simpler. His view? When all options are exhausted, the simplest solution is normally the best and most cost effective. It’s a unique perspective coming from someone who is doing the connecting rather than struggling for a connection. In this interview, Christian discusses the compelling work his organization is engaged in: From aiding the United Way in their quest to reduce infant mortality rates in particularly lower income areas, to analyzing data to target childhood obesity. Not only is Christian constantly looking for ways to improve healthcare’s information accessibility, but also healthcare’s leadership. Check out his 7 key takeaways from CHIME’s CIO Bootcamp.

CHIME Fall CIO Forum provides valuable education programming, tailored specifically to meet the needs of CIOs and other healthcare IT executives. Justin Campbell, of Galen Healthcare Solutions, had the opportunity to attend this year’s forum and interview CIOs from all over the country. Here is the next interview in the series:

Key Insights

One of the innovative capabilities we have is a smart search within our repository – likened to a google search.

In the end, we’re not willing to put the privacy and security of the data, for which we are custodians, at risk for the sake of giving someone access.

We have 3 pilots underway, where if a patient shows up in the ER at one of SHIEC’s members, information for that patient is queried to other member HIEs based upon zip code and in the case of a match, a clinical summary for that patient – often times CCD – is returned.

What we’re finding, is that the changing ambulatory landscape is making getting access to the data more challenging.

To me, the whole purpose of CHIME is to weave those networks of individuals regardless of size of organization, longevity in the business, and depth of expertise. It provides the education CIOs need to be highly successful.

Campbell: Let’s start with some background on you, your organization and your role.

Christian: I’m currently with the Indiana Health Information Exchange and have been here about 18 months. I spent 27 years as a healthcare CIO at a couple of different organizations and actually was a customer of the exchange when CIO at a southern Indiana healthcare organization.

We operate the largest health information exchange in the U.S., connecting over 100 hospitals, long-term care facilities, rehabilitation centers, community health clinics and other healthcare providers. All said, we have 140 total data sources, connecting to over 12,000 practices and serving over 22,000 physicians and 12MM patients.

We’ve only been incorporated since 2004. Years before that, the exchange was created out of clinical need in the Indianapolis area. It was actually created by the minds at the IU Health Methodist Research Institute, one of the big health systems in Indianapolis. There was a known need for the ability to share clinical information. We’ve been doing this for over 20 years, and the data in the HIE in some cases is over 30 years old. We currently have over 9B clinical data elements stored in the HIE.

Campbell: That is incredible and impressive. What types of exchange takes place today with the HIE?

Christian: One of our core services is results delivery. We provide the nation’s largest implementation of clinical results delivery and support the Indiana Network for Patient Care, a clinical data repository accessed via IHIE’s CareWeb application.

Results are delivered to participant EMRs in one of three ways – either to a secure inbox, through HL7 integration or through fax. A lot of physician workflows are built around receiving a fax. It’s examined, sorted, indexed and filed.

Campbell: You have quite a few endpoints, which is fantastic. Tell me a bit about the process for participant onboarding.

Christian: We’ve connected to over 250 EMRs. We recently established an HL7 connection to athenahealth. That enabled us to turn on HL7 delivery to over 2000 physicians at one time. Another health system we are working with is moving from fax to electronic delivery. My goal is to have electronic delivery and HL7 for every EMR. Part of the challenge is in resourcing – setting up the feed and building the integration with the EMR. It takes some specialized technical work to execute.

Campbell: Tell me a bit more about the payload of transactions that you receive.

Christian: We currently don’t receive CCD. Instead, we predominately get ADT transactions, results, transcribed documents, or HL7 embedded with PDF. We ingest it into the repository, normalize the data and send it along to subscribing entities. Through normalization, we organize the clinical elements to present to the end users via a portal. In this way, it makes it nice for physicians to use SSO from their EMR of record to the portal, and be able to see a lab result from Methodist hospital, let’s say, sitting alongside a lab result from St. Francis Health.

One of the innovative capabilities we have is a smart search within our repository – likened to a google search. Take one of our ER physicians at Eskenazi, for example. He’s got a search protocol called “chest pain,” which pulls any recent admissions with chest pain as the chief complaint. It also pulls troponin levels, any echocardiograms, or cast studies, and delivers to him instead of the physician having to hunt for them. We are actually working with an EMR vendor to embed this capability within the system of record. In this way, we can embed a search bar and the physician can access saved searches that retrieve information based upon criteria and filters they setup.

That is just one example of the extremely creative initiatives we are working on to minimize the workload for the physicians.

Campbell: With so many sources, I imagine there is a deluge of data you are swimming in. Can you elaborate a bit about the governance processes you employ today to dictate data access?

Christian: We have a seat on the management council for The Indiana Network for Patient Care. The exchange is also a curator of the data. It’s owned by its members and there is governance across that. A group of 20 voting members are elected by the members and use cases of HIE data access are presented to the voting group. The group determines the appropriateness of data access requests and whether they meet HIPAA guidelines. This approach is used for a variety of use cases. With approved requests, a window of access is provided. Participants can always see the data they provide, but the only way full access to the record is granted is if there is a treatment relationship with the patient. We’ve had some physicians present unique use cases where they are seeing a patient, for instance, a consult with an oncologist, and they don’t have a treatment relationship with that patient. Hence they cannot access the data. I get it. If it were my family member trying to consult, there would be frustration with the impediment. However, it’s one of those balancing acts to provide secure access to the data. Same goes for organ procurement, which has about a half a dozen use cases, but we still haven’t figured out how to create the appropriate access safely. In the end, we’re not willing to put the privacy and security of the data, for which we are custodians, at risk for the sake of giving someone access.

Campbell: Thank you for elaborating on the sound approach you are using for data governance, security and access. Do you have a unique compelling use case that comes to mind that you could share?

Christian: United Way has a program – fully funded by them – where they send nurses out into the community for areas that have high infant mortality rates, particularly in the lower income areas. The nurses provide help – whatever they may need. Perhaps get them to the pediatrician’s office, for instance. United Way approached us and said it would be marvelous if they could see the corresponding data – prenatal care, course of events, C-section, those types of things – that would be helpful as part of their outreach. The problem was that they are not a HIPAA covered entity. Our attorneys helped get them covered and we stood up the program. It’s great because of the difference made in those children’s lives, especially considering they are typically low income folks that don’t have the same access others are privileged to have. It’s truly an extraordinary effort to provide help to that population.

Campbell: It’s great to hear stories like this, where health information exchange truly makes a difference in the lives of patients who need it most. What other initiatives is IHIE working on or taking part in?

Christian: We are a member of the Strategic Health Information Exchange Collaborative (SHIEC), whose members are 50 of the sustainable HIEs in the country. Many of the members have different business models than we do. For instance, some are state entities, like Kentucky Health Information Exchange (KHIE), and others don’t persist data, they just transact, as with the Kansas Health Information Network (KHIN) model. Our first annual meeting was in 2015, where about a dozen of us got together to share ideas and have conversations about how we can work together, ways to share services, and how to lower operational costs.  Our country does not have an operational HIE that covers all of the market. SHIEC is the closest we have, and that covers about half of the population.

Take for instance, the Indianapolis area, where 500K people present downtown. They inevitably come to the ER. Unfortunately, the providers treat them based upon what is in the head of the patient or family members. We have 3 pilots underway, where if a patient shows up in the ER at one of SHIEC’s members, information for that patient is queried to other member HIEs. In the case of a match, a clinical summary for that patient – often times CCD – is returned. Once treatment for the patient is finished, it is bundled up with the clinical record and shipped back to the querying HIE. That is a model that can be replicated.

Campbell: That is truly an impactful initiative and I’m excited to hear where it will go – hopefully eventually providing connectivity for all of the population. Let’s shift gears a bit and discuss data persistence. With 9B clinical data elements, and metadata considerations, I imagine that creates a huge demand for storage. Do you purge any data today?

Christian: We persist data forever. We are acutely aware that it costs money to store the data, and costs money to back it up. We take our direction from our general council and we have terms and conditions built within the confines of state and federal laws for participants we receive data from. That said, we don’t have the primary record, rather we have pieces of it. In light of that, is it OK to purge or trim? It’s a good question, but it is not built into the software. We are socializing with members and asking the question “if you are going to delete data, what would it look like.” Our CMIO advisory group suggest that we don’t get rid of any of it. One of the use cases we came up with, is that if you are deceased for 5 years, and there is no new data after 5 years, then the data can be purged. All said, pursuit of purging data is a difficult boulder to push up the proverbial hill.

Campbell: It’s no secret that a lot of HIEs face solvency and sustainability issues. What does IHIE offer its members today as part of its value proposition?

Christian: Healthcare has long been very hospital centric. Hospitals were the ones who first moved to digital solutions and automated. Now we have a large number of physicians practices that are automated. We get data from them, parse that information and store it in our data repository. Consequently, the opportunity truly lies with the innovation occurring on the outpatient side. What we’re finding, is that the changing ambulatory landscape is making getting access to the data more challenging. You have urgent care offices popping up, telemedicine is gaining traction, and a lot of educational institutions use their own health clinic.

One of the initiatives we are working on is targeting childhood obesity. We are analyzing the data – such as height, weight, and age – to produce insights. Most of that data is located in the physician office record. Children have more access to physician care in a practice, particularly infants that are seeing the doc.

Campbell: Shifting gears again, let’s talk about CHIME. Tell me a bit about your experience attending this year. What did you get out of it? What were some of the things that drew you to the event?

Christian: I am actually one of the first charter members of CHIME. When I was with a small hospital in Southern Indiana, I received the call for an invitation, and thank God for it. A lot of my success in that small hospital was the result of having the privilege of standing on giants – John Glaser, Jim Turnbull, Bill Reed, Skip Hubbard. I got to know them and it was invaluable to call on them as a resource. Whenever I had a question and would send an email, they always answered it. The thing that differentiates CHIME from organizations like HIMSS, for instance, is that with HIMSS, I sit at a table with engineers, folks from telecom, people from different disciplines, whereas with CHIME, I sit down with all CIOs, and I know a lot of them very well. I only get to see my good friends once or twice a year, and it is vital to collaborate with them and gain their perspective and opinion.  It’s truly a privilege being on the faculty. In fact, it reminds me of a story. Buddy Hickman, a faculty member as well, and close personal friend of mine, is someone I know I can go to if I’m struggling with life or a work issue. We got together one Friday night as we were about to begin CHIME boot camp, and we got to talk about a personal issue. We huddled and shared each other’s stories. It’s really consultation group therapy. I left that critical conversation ready to rock and roll.

To me, the whole purpose of CHIME is to weave those networks of individuals regardless of size of organization, longevity in the business, and depth of expertise. It provides the education CIOs need to be highly successful. There is no fantasy that members take all the advice offered, however, if 1/10 of it sticks, they’ll be in great shape. As I mentioned previously, the beauty of it, is that I look at these people who work in prestigious organizations – some of the most noble men and women – and they are more than willing to give time they don’t have. CHIME has been accused of being a fraternity or sorority of sorts – an exclusive club – and my response is “And….?” To me, that is the draw and the beauty of CHIME. I remember being on the board for the first time in the early 2000s and I was in charge of membership where we were struggling to get to 900 members. We’re now up over 2000 members.

Campbell: You certainly have a wealth of experience and expertise surrounding pertinent healthcare information technology issues. Given the broadness of the field, is there a particular area of initiative you are working on to advance information technology in healthcare?

Christian: I’m working on a piece around predictions – many around interoperability. I have this feeling of the sirens calling me to a shipwreck. My view is that when all other options are exhausted, the simplest solution is the best and will cost the least. However, I have no delusions that I have a biased opinion, that’s to say, I have a view of the topic that is different. When you typically read about HIE – both the noun and the verb are used interchangeably, and that isn’t appropriate. A friend of mine, Dr. Josh Vest, Associate Professor of Health Policy & Management, IU, is conducting research on HIEs, classifying them: Are they private/enterprise? Are they a state entity or a community-based? He was originally shopping around the idea to fund it, but as happens all-to-frequently, there is not that much money when you are researching. He instead decided to take the research on pro-bono even though he has very well-funded research. I remain very interested in the results he finds.

About Chuck Christian
Charles Christian, serves as Vice President of Technology and Engagement Indiana Health Information Exchange, which provides the nation’s largest implementation of clinical results delivery in the country (DOCS4DOCS Service).  Christian has spent 40 years working in healthcare, including 26 years as CIO at Good Samaritan Hospital in Vincennes, Indiana, where he led the development and implementation of an EHR system and other IT initiatives. He also worked for Compucare and Baxter Travenol, in both management and implementation roles. Prior to his current appointment, Christian was vice president and CIO of St. Francis Hospital in Columbus, Ga.

Christian is a charter member and 2015 Board of Trustees Chair of the College of Healthcare Information Management Executives (CHIME), and served as Chairman of the Board of Healthcare Information and Management Systems Society (HIMSS) in 2008. In 2010, Christian was recognized by CHIME and HIMSS with the industry’s most prestigious honor: the John E. Gall Jr., CIO of the Year Award.  He was also honored by the Indiana Chapter of HIMSS with an award in his name: the Charles E. Christian Leadership Award. 

About Justin Campbell
Justin is Vice President, Strategy, at Galen Healthcare Solutions. He is responsible for market intelligence, segmentation, business and market development and competitive strategy. Justin has been consulting in Health IT for over 10 years, guiding clients in the implementation, integration and optimization of clinical systems. He has been on the front lines of system replacement and data migration, is passionate about advancing interoperability in healthcare and harnessing analytical insights to realize improvements in patient care. Justin can be found on Twitter at @TJustinCampbell and LinkedIn.