HealthIT

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.

CHIME Fall Forum Interview Series: Dr. R. Hal Baker, Sr. VP Clinical Improvement & CIO, WellSpan Health

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Dr. R. Hal Baker, M.D. FACP, WellSpan Health

Dr. Hal Baker is in a unique situation as a CIO who is also still a practicing physician at WellSpan. As his organization finalizes their Epic transition plans, he recognizes the importance of having an integrated patient record across the system and creating new workflows to accommodate the 5 hospitals and over 100 practice locations that are all coming together. In this interview, he talks about his organization’s community-focused, health data retention practice, his plans for legacy application support, and the value of attention units in the healthcare industry.

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 quickly experienced the value of an integrated patient record across offices, which highlighted the previous disconnect between maintaining two separate records in an inpatient and outpatient setting.

We’re bringing over seven years of laboratory and clinical information for our patients. We recognize that’s more than typical, but we think there’s value in having that depth in the record for our community.

I’ve been through enough of these to know that everything looks good in a demo and you need to get through the first couple of weeks before you figure out what have been the great wins and what have been the great challenges you didn’t appreciate until you got there.

The reality is that the most significant innovations arise out of smaller startups who then become large. However, a majority of small startups aren’t successful, and most legacy systems persevere.

The currency of the business of healthcare is dollars, but healthcare is applied in a currency of minutes and each minute a doctor or nurse spends doing one thing is a minute they’re not spent doing another.

Campbell: What has your focus these days?

Baker: To provide some background, we’ve had a couple of mergers or acquisitions into WellSpan, that we are trying to consolidate. We have McKesson, MEDITECH, Cerner, Allscripts systems that we’re migrating to Epic.

Campbell: That’s a good launching point. I presume that decision was made to simplify the portfolio and to move forward with an enterprise standard for an EHR. Can you elaborate on your decision to consolidate applications, and maybe also elaborate on how your organization manages applications within the portfolio today? Do you have further consolidation plans in the future?

Baker: From an electronic health record perspective, we went live in ambulatory and inpatient in a best of breed approach for legacy WellSpan. At the time, it was hard to appreciate the value of an integrated medical record, when you had disintegrated paper records at each office. We very quickly started to see the value of an integrated patient record across offices, which highlighted the disconnect that occurs between the two separate records in an inpatient and outpatient setting. As we had other communities join WellSpan we recognized the need to consolidate around a corporate-wide solution. It didn’t make sense to further propagate our non-integrated solution—a different billing system vendor, and a different EHR vendor on the inpatient and outpatient side. That’s how we came to our ‘Project One”, of coming together with one record for all of WellSpan.

Campbell: Related to the topic of consolidating data, what are your thoughts on health data retention? I talked to some of your peers at CHIME and they had concerns over ‘hey I have to store this data for the patient but I may not care about a lab result for a patient that’s 8 years old, but I also have no way of purging that data.’ Is that something that you have an opinion on or you could perhaps go in a different direction with that topic in regard to the eDiscovery inquiries you get and how your organization manages that?

Baker: We are converting seven years of clinical data in our migration – we’re bringing over seven years of laboratory and clinical information for our patients. We recognize that that’s more than normal but we think there’s value in having that depth in the record for our community. We have an archival strategy put in place to retire our legacy applications.  With the absence of a rigorous purging strategy, the entire database record needs to be maintained for the longest patient whom you have a record retention requirement for. In our state that, would be last baby born on the old record plus 21 years plus 7 – so 28 years. Our statute of limitations is age of majority plus 7.

Campbell: That makes sense. In talking with another one of your peers, who’s migrating over to Epic as well, he discussed the considerations and challenges with migrating data from a legacy application over to Epic.

Baker: Right. There are three buckets to my mind: there’s the data you need to import into the database; there’s perhaps a subset of that, which is data that you don’t want to import in bulk, but you want the ability to import selectively as needed later on; then there’s the data that you need to have access to for when you need it. For example, I need to go back and look at the past reports from 15 years ago, but I don’t necessarily need to move every pathology report from 15 years ago into the record— rather I need to have access to it from your archive system. Then there’s the metadata that you either may need for population health or business purposes in the future that you haven’t recognized you need. This could be due to requirements from a legal medical auditing perspective or for quality or for billing purpose under statute of limitations for regulations.

Campbell: I imagine the legacy systems are going to have to have some sort of application support, how are you approaching that? Are you going to dedicate all your existing staff to the new application and seek outside back-fill to support the back-end, or are you taking the approach of have some people support the legacy application while others in their departments learn Epic?

Baker: We staffed up for Epic with a combination of experienced IS staff, experienced operational staff, and a few outside people. We got everybody trained and certified. For the staff who continue to support the legacy application who did not move into the Epic team, we generally supplemented vacancies there with contracted staff from some of our contract partners. A critical element was implementing a very tight change control for the legacy systems and limiting any nonessential changes.

Campbell: Very good. What’s been the sentiment around Epic? Being a provider and talking to the other providers, I’m sure you have a keen awareness. Is there a lot of excitement of moving to the application, given the seamless nature with which you’re likely to be able to access data across care settings in the new environment? Are there any apprehensions they may have?

Baker: I think any move of this magnitude is both exciting and challenging. Our providers are looking at this thoughtfully and are actively involved in it, but we’ll know more when we get into training and go-live. I’ve been through enough of these to know that everything looks good in a demo and you need to get through the first couple of weeks before you figure out what have been the great wins and what have been the challenges that you didn’t appreciate until you got there.

Campbell: Let’s discuss data governance as it relates to the migration. There are different departments and specialties that will have different nomenclatures and dictionaries that they need to manage. How is WellSpan Health going about managing those dictionaries and deciding on potential adjustments to workflows to accommodate the new system?

Baker: We’re designing new workflows in the Epic process because we’re bringing together 5 hospitals and over 100 practice locations, many that were on different electronic records.  We’ve had a conjoined effort to find new workflows that everyone will be moving towards, and it has been around data governance principles, having single points of truth, and standardizing nomenclature. The expectation is that all traditional behaviors are going to need to be worked into the new workflows and those traditions will need to change to accommodate the workflows.

Campbell: Very good. Let’s shift gears to CHIME a little bit. Tell me about your impressions this year. Was there a particular session you attended that resonated with you? I know that CHIME is valuable from a networking perspective but what were the themes you witnessed this year, and in talking with your peers, what were the common topics?

Baker: The most interesting parts of CHIME are hearing people figure out how to creatively leverage the data. I went to a talk with a doctor from Mercy Health, who shared their approach to leverage data topography to understand correlations occurring in their system that are clinically meaningful, but would otherwise not be recognized. For instance, they discovered that a diabetes nerve medicine use seemed to correlate with an earlier discharge for a knee replacement. That was a hypothesis that arose from the data that’s being validated rather than one that was thought of and queried. I think it’s going to get very interesting when we look at how can we leverage these databases to generate information, opportunities for improvement, and for when the data becomes the source of hypothesis versus it all being contemplated.

Campbell: For the startup audience that follows the Health IT & mHealth, what catches your eye when it comes to smaller organizations or vendors? CIOs tend to be risk adverse and they’re attracted to something that solves a problem for them and a vendor organization that’s sustainable. Tell me why you might consider a smaller startup and/or what are the areas that you see as an opportunity for them to address the market incrementally?

Baker: I think it’s honestly a calculated gamble on whether to strategically bet on a small innovator or a major vendor. The reality is that the most significant innovations arise out of smaller startups who then become large. However, a majority of small startups aren’t successful, and most legacy vendor systems persevere, but get caught in some degree of inertia that makes innovation harder.

Campbell: While at CHIME, Blain Newton, Executive Vice President, HIMSS Analytics, shared with me that one of the more profound discussions he had with you was on the topic of currency for healthcare information technology leaders. Can you share that story with us?

Baker: The currency of the business of healthcare is dollars but healthcare is applied in a currency of minutes and each minute a doctor or nurse spends doing one thing is a minute they’re not spent doing another. We’re worrying about the percentage of the time available in day that is spent at the keyboard versus the bedside; the amount of time holding a mouse compared to the amount of time holding a hand. We want to be judicious with how we spend the currency of minutes of our staff so that it balances the needs of the business – the information systems, and the communications that the records provide – with the needs that the human beings who need our care and attention receive.

As a leader, the currency of my work as a manger and executive is attention. I have to decide where to spend my attention units and be judicious with that because there’s the same opportunity cost.  That’s why I have great sympathy for startups because it’s very hard for me to give up attention units to them that I could devote to my organization – to listen to a cold call pitch on a product solution. It’s also very difficult to try to dissect through the presentation to understand what the true opportunities of the product might bring – how it compares to its competitors, and what are the risks and unintended consequences that it might have. There’s a real challenge there because most of us don’t have enough time to spend with all the people who need our attention inside our organizations. So those who are outside, who are not currently our partners, and asking for 15 minutes are challenged because we all have to be very judicious in how we give up that time. One thing I will add is that it’s my opinion that the most persuasive approaches for a vendor is to have a credible client who has an enviable success that they’re willing to talk about with their colleague.

Campbell: Sound, candid, and sage advice & insight. Thanks again Dr. Baker.

This interview has been edited and condensed.

About Dr. R. Hal Baker
R. Hal Baker, M.D. FACP, serves as senior vice president for clinical improvement and chief information officer for WellSpan Health, a regional integrated health system that serves four counties in central Pennsylvania and northern Maryland. In this capacity, Dr. Baker leads quality and safety initiatives as well as the use of information technology as a means to create a reliable patient experience across the health system’s hospitals, physician practices and ambulatory facilities.

Dr. Baker joined WellSpan York Hospital in June 1995 as associate program director of the WellSpan York Hospital Internal Medicine Residency Program. He has also served as the lead physician at Apple Hill Internal Medicine, which is part of the WellSpan Medical Group. Dr. Baker came to York after completing a general internal medicine fellowship at Johns Hopkins Hospital and a residency at the Hospital of the University of Pennsylvania. He holds a bachelor’s degree in biology and a medical degree from Cornell University.

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 and 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.