HIE

CHIME Fall Forum Interview Series: Todd Rogow, CHCIO, Senior VP & CIO, Healthix

Todd M. Rogow, MPA, CHCIO

Todd M. Rogow, MPA, CHCIO Healthix

Healthix is the largest public health information exchange (HIE) in the nation, serving the most comprehensive range of organizations in New York, from the largest hospital systems to the smallest community health centers and physician practices. Healthix delivers data of more than 16 million patients to participant organizations that include hospitals and health systems, provider practices, behavioral health organizations, long-term and sub-acute care organizations, health plans, other public HIEs, and private HIEs. Todd Rogow, Senior VP & CIO, recently led the organization’s move from an outsourced resource model to an insourced technical team, including the implementation of a robust security program and SOC 2 Audit. In this interview, Todd elaborates on the benefits of building a mission-driven internal team to support the HIE, including improved scalability, nimbleness and responsiveness, but also cost effectiveness and innovation. Todd also shares his perspective on HIE funding models and sustainability, innovative approaches to patient identity and matching, leveraging predictive analytics to drive insight to the point of care, and the responsibility of the HIE in ensuring security and privacy.

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

When I joined Healthix two and a half years ago, I observed that we were losing ground because we were getting 11K new potential patient matches every day that required manual review.  With such a high volume, we couldn’t possibly keep up using a manual approach.

Having direct relationships with our vendors – whether they represent an application we leverage, hardware we run, or a service provider we work with – expedites the process of getting results by removing unnecessary overhead.

Insourcing the IT work has allowed us to become experts and facilitated a mission-driven, dedicated team that stays on top of our operations and growth. Being in this unique niche of healthcare IT and health information exchange really makes this approach advantageous.

Of key value to residents of New York is giving them access to their healthcare data. It’s something that we’ve taken steps to deliver through APIs made available to any of our participants that wish to tap into Healthix.  This enables them to make Healthix data available to patients through their own patient portals.

We believe that federal and state funding will continue to be a part of our sustainability model moving forward, although we can’t be sure of funding levels.  We are always exploring other revenue streams.

As a steward of PHI, Healthix understands that it is critically important to secure the data that we are entrusted to hold.  Technically, we do not own the data; it comes from a variety of participating organizations such as providers, payers, behavioral health, pharmacies, or in some cases Medicaid. It is therefore our obligation to protect it to the highest security standard we can offer.

Campbell: Tell me more about your bio, background, career trajectory, the organizations you’ve worked with, and the technologies they use.

Rogow: I’ve been involved in healthcare information technology for 15 years. I got my start working with electronic health record systems while as a contractor at Northrop Grumman, working for the Department of Defense. I helped to build their unique custom EHR, which was used by DoD, and spent several years enhancing that EHR product, from seeing its client-server application evolve, to helping create its first cloud hosted model. I then moved into the HIE space, spending over 5 years at HealthInfoNet, the statewide HIE for Maine. I was among the first five employees engaged there and saw the organization grow to a staff of 27. I led the redesign of the HIE from a technology perspective. One of the first things we did was to evaluate best-of-breed vendors to design an effective HIE solution for collecting data and providing real-time services to the participants, who are really the customer base.  The participants were comprised of clinicians in Maine’s healthcare community.

HealthInfoNet really shaped me and set me on a good path for what we’re doing here in New York. Going through that rebuilding experience and tackling scalability, having scaled the Maine HIE to be truly statewide, was impactful. In terms of the data we were collecting, the organizations we worked with ranged from behavioral health, with HIV sensitive data, to the common clinical data you would expect from reference labs or from hospitals or private practices.

When I joined Healthix, it was really to redesign the HIE, and begin a program to insource operations. For several years before I joined, the IT department was outsourced. One of the major tasks I was given was to build a team to handle the complexities of this business. We talk about Healthix as the largest public HIE in the nations. We really measure not just for the number of connections or data feeds we have built, but rather the size of the population we serve. At this point, we’re well over 16 million unique identities which contain clinical information. We have a lot of people who come in and out of New York City from all over the state, the country and even the world who may end up in our healthcare system.

On average there are 46 million messages coming into the Healthix system.  Over the last few years we’ve really focused on pushing data out. Like HealthInfoNet, Healthix is a real-time HIE, and that is where a lot of the value lies.  We have close to a half million real-time clinical alerts each month and push out over one hundred thousand continuity of care documents. In many cases, we build a tight integration into the EHR product, especially in those cases where the participants don’t have that capability, depending on the vendor they use.

Campbell: A well-rounded overview. I appreciate you reinforcing some of the high-level statistics you publish and highlighting some of the advanced work that’s occurring within the exchange today. If we could dive into one topic in particular, you mentioned managing more than 16MM lives. I want to touch on identity. You provided some detail around how a patient search is accomplished through demographics and MRN. Tell me a little bit about Healthix’s patient matching and identity management strategy, how exceptions might be handled, and what solutions you may leverage.

Rogow: I’ll provide you with another number. If you think of the variety of data sources that feed into Healthix – behavioral health, private practice, and hospitals – we get different medical record numbers from each of those organizations. As such, we have just over 58MM MRNs that we’ve brought in for the 7-8 years of data that we have. The challenge, as you pointed out, is really knowing that Todd Rogow is the same thing as T Rogow or just Todd Rogow who has gone to a different organization and has another unique identifier associated with him. We’ve been able to boil that down to close to 16MM unique identifiers and we have a couple of technologies in play that facilitate patient identity. We use IBM’s product, which was built by Initiate.

In addition, the velocity of matching associations wasn’t fast enough for us. We had a lot that fell into a gray area where we think they’re the same person, but they really need to be manually reviewed. As you can appreciate, this is extremely laborious. When I joined Healthix two and a half years ago, I observed that we were losing ground because we were getting 11K new potential patient matches every day that required manual review.  With such a high volume, we couldn’t possibly keep up using a manual approach. To automate the process, we contracted with Verato, a company that has a service that does something unique. They realized a while ago that there are a lot of public records for Todd Rogow. For example, I have an electricity bill, so there’s a public record of me and my address. There could be a credit agency that also has my name and my address and could include other things like a social security number, home phone number, or my date of birth. All of this is publicly available. They built an application that we reach out to as a service through an API, and we provide two identities for who we think may be the same person. We’re not certain, so we reach out to them and we ask them to query their public datasets from credit agencies, public utilities, etc., and come back with a recommendation on identity matching. Basically yes, maybe or no. It’s similar to what IBM is doing, but it’s another pass with more data that we don’t have access to.

With that, we have seen tremendous improvements. Not only have we dropped our manual approach of auditing these records individually, but we were able to go back and revisit our full backlog – anything which was a potential match. We were able to further collapse, by several million identities, and consolidate clinical records. From a clinician’s point of view, we’re now bringing extra clinical value around the proper identity of the patient and all of his/her records through that service. That’s been a really big improvement that we’ve made since I joined Healthix, and represents a new vendor that we’re working with very effectively.

Campbell: From sitting in on a New England HIMSS HIE advocacy panel event put on in early spring, outside security and privacy, identity is top of mind for HIEs. Thank you for elaborating on that. Shifting gears, you mentioned that you had out-sourced and then moved to an in-sourcing model. What challenges occurred with that, and what benefits did you realize as a result of moving to that model?

Rogow: I’d like to spend more time on the benefits, but let’s start with some of the challenges of moving from an outsourced to insourced resource model. A lot of companies go through the opposite – moving from insourced to an outsourced model. They think that outsourcing is better, only to swing the other way and insource. Just before I was hired, Healthix realized we needed more direct control over our destiny. What I mean is Healthix wanted to be very responsive to its customer base, and found that this was hard to do through 3rd party intermediaries. Having direct relationships with our vendors – whether they represent an application we leverage, hardware we run, or a service provider we work with – expedites the process of getting results by removing unnecessary overhead.

The other aspect is that Healthix didn’t feel that the growth we wanted to undertake could be accomplished without a change. Specifically, we didn’t feel that an outsourced vendor could keep pace with the scalability and amount of security required. Given the scope of the PHI stewardship responsibility of the organization, we felt that it was important to have that control.

As such, the organization engaged me to build a team and tasked me to insource our operations. Based on my prior experiences with HealthInfoNet in the state of Maine, I had familiarity with IBM Initiate for EMPI, and we leveraged Orion for the clinical data repository and clinical portal front end. However, Healthix implemented InterSystems HIE, so there was a little bit of a learning curve for me. The approach I took was to evaluate our system support needs and build a team that would address those needs. Certainly, there are some core roles you know you need to fill right out of the gate, but beyond that, there was examination of where resources were needed internally to be as responsive as possible to our customer base.

Once the core was in place, we directed focus on building new features and evaluating what resources we needed to tackle those initiatives. All-in-all, this approach offered tremendous benefits. We’ve witnessed enhanced scalability and quicker response times; a result of the direct relationship with our vendors. A major side benefit was the overall cost reduction we observed. We knew that if we were to try to scale to the same level where Healthix is today with an outsource arrangement, the costs would be too high. Insourcing the work allowed us to become experts and facilitated a mission-driven, dedicated team that stays on top of our operations and growth. Being in this unique niche of healthcare IT and health information exchange really makes this approach advantageous.

Campbell: I couldn’t agree with you more. It emphasizes the point that Ed Marx made at the NYSHIMSS meeting in that, it’s all about culture, and the ability to tap into that passion through a mission-driven team. The tough part is surely getting up to speed on a platform you aren’t necessarily familiar with, and identifying those roles you need to fill – whether its data governance and harmonization, or security and infrastructure. It’s great to hear that you were able to recognize some cost efficiencies as a result.

Rogow: Interestingly enough, we went through the same thing in Maine when I first joined HealthInfoNet. As I previously mentioned, when I first joined, I was among the first employees hired, and at that point, we had outsourced the IT portion as well. I brought that in-house. Being mission driven in this niche of healthcare really does attract the best people, and there is a lot of dedication that follows.  Ultimately, we are impacting patient care.

Campbell: I imagine you have countless stories of facilitating care coordination where key insights derived from the HIE are driven to the point of care as a result of the exchange.

Rogow: Absolutely. Both at HealthInfoNet and Healthix, I’ve heard stories where our staff goes out to visit with sites and they tell us how they are treating complex patients and how our service is being used to push insights out to them. It drives the point about mission home, and even though my staff are focused on keeping the system up and adding new capabilities and functionality to make it a more useful service, they believe, and I believe, that we are really saving lives. Not only saving lives, but also helping to improve healthcare for patients. That’s why we’re here and in this business. To have our staff get exposure to that is impactful when it comes to our mission.

Campbell: That covers the value proposition of HIEs quite well, but what about sustainability and solvency? Funding is an issue that comes up over and over again for both public and private HIEs. Whether it’s a subscription-based model that is used, or perhaps grants in play to prop up the HIE. What does sustainability look like for Healthix? You touched on having a series of clinical notifications planned, but how is that value funded?

Rogow: The state of New York is extremely supportive. The governor made a decision to support a statewide HIE through the use of federal funds that come in through CMS as well as state matching. Just before I joined, we entered into a period of 3 years where the state had allocated funding for us. 90% of our operational funds come from either federal or state funds. Before that, it was very similar to the model for Maine’s HealthInfoNet, where each participant, whether it be a hospital or private practice, would pay their portion of a service fee that would help fund the operation. We believe that federal and state funding will be a part of our sustainability model moving forward, although we can’t be sure of funding levels.  We are also exploring other revenue streams.

We’ve introduced new services, such as predictive analytics, focusing on the top 5-10% of the population that could be, or are the highest cost patients. We aim to get in front of the cost curve, and be proactively impactful, giving the care management teams of healthcare organizations an indications as to who the individuals are that we believe are likely to present in the ER or another inpatient setting, or have the potential of having a chronic condition. We highlight these patients so clinicians can effectively reach out to highest need patients. That is a Healthix service which customers are paying for today.

Other areas we’ve been exploring are customized real-time clinical event notifications. We offer a lot of the basic trigger events. For instance, if a patient presents in the ER, that will trigger an alert. However, if we’re able to provide a chief complaint, and other key data within that alert, that provides greater value to the provider or care manager.  Increasingly, we’re able to identify   services that our customers’ value and are willing to pay for. Healthix received funds for grants from various agencies, some at the New York City level, where we work on specific projects. As such, the grant money is really project-based and not a significant source of income.  Many feel that HIE shouldn’t rely on local city, state, or federal government picking up the entirety of the bill, but they do feel that there is a role for them to play in terms of funding. We’ve always thought of the three-legged stool in terms of funding – providers paying a service fee, the payers or insurance companies paying a fee, and the government contributing the remainder. The public services that we offer comprise the majority of our expenses, but we’re trying to make it a model where funding is more diversified across those we serve.

Campbell: It sounds like a very sound model. As you said, the point can’t be underscored enough in that it is truly a public service. What Healthix is doing is facilitating healthier New Yorkers, and healthier populations.

Rogow: We feel that there is a lot of untapped potential with delivery of services around predictive analytics and engaging providers or communities.  As they’re receiving a direct benefit from it, we can monetize those services. We certainly aim for a diversity of revenue stream, but having the backbone of government funding is critical. It’s helped us to mature as an organization, and to really show our value.

A critically important public value is giving the residents of New York access to their data. It’s something that we’ve taken multiple actions to deliver through APIs available to any of our participants that wish to tap into Healthix, so that they’re patient portals can make the data available for patients. Of course, all of this is contingent upon patients providing their consent, which is heavily controlled.

Campbell: That’s a great point. Being mission-driven, the most important entity in all of this is the patient. I myself use the MAHIway, and can appreciate the utility of having my chart available and being an active participant in my health. This is especially pronounced if you are managing many chronic conditions; having the HIE to lean on can be critical.

Rogow: It’s so important. We have a lot of HIEs across the country that are doing well overall and the service is getting more valuable as time goes by and technology improves. However, what’s really going to be a game-changer, is putting that control in the hands of the patient; when you’ve got a mobile device that provides you access to your records and allows for your records to be transportable. We are on the cusp of witnessing the patient really taking control of their records and leveraging that control to change healthcare. Not just the access to their clinical data, but providing awareness and contextual information around where to go for the best treatments, for instance.

Campbell: It certainly seems like there is a convergence taking place that will lead to data liberation. We know that the patients are clamoring for it given what’s at stake. Shifting gears a bit, at the NYSHIMSS meeting, the collaboration that occurs with other HIEs in New York through the SHIN-NY was highlighted. Can you touch on that and perhaps speak to other registries that you may integrate with?

Rogow: Starting at the highest level, we are connected to the Sequoia project, which is really the framework to exchange clinical information across the country. We’re also close to going live with the Veteran’s Administration for bi-directional exchange of clinical data with VA hospitals and ambulatory organizations. In terms of the SHIN-NY, it’s really a statewide clinical information exchange that’s comprised of each of the HIEs in the state. Right now, there are 8 of us serving the upstate and downstate regions. Since I’ve joined Healthix, we’ve witnessed a great deal of consolidation, which is a good thing. We know that people work, travel, reside and receive healthcare across geographic regions. Recognizing the size of the state’s population, and also the large geography, we have to collect data on behalf of the residents, regardless of the boundaries. This can be challenging, but there are services in place to identify that resident across the entirety of the state. This allows records to be exchanged within the state boundaries, and really offers a statewide support structure. Even though Healthix’s primary territory is New York City and Long Island, those boundaries go away when patients and providers retrieve data.

Going down to the next level, you mentioned attaching to different registries. We support several public registries. One in particular is the New York City Department of Health AIDS Institute. Their mission is to monitor the health and treatment of HIV+ individuals in our community and retain them in care. We identify HIV+ persons and the care they are receiving, so NYSDOH can focus public health surveillance efforts to ensure linkage to care, retention in care, antiretroviral therapy, and viral suppression.

Another registry we support that is kind of unique to New York State is what’s called eMOLST, around an end-of-life legal document. MOLST is a clinical process that emphasizes the discussion of patient’s goals for care, including shared medical decision-making between health care professionals and patients who are seriously ill or frail. The result is a standardized set of medical orders documented on the MOLST form that reflect the patient’s preferences for life-sustaining treatments. Our partnership with Excellus BCBS gives providers access, through the HIE, to the medical orders and wishes for an end of life patient.

We support a New York City Dept. of Health and Mental Hygiene service called NYCEPS – the New York Emergency Patient Search program. – After a mass casualty incident, a key concern is locating and assuring the safety of loved ones who may have been affected and cannot be easily reached or located. NYCEPs queries real-time patient data through Healthix, particularly information from encounters at acute care hospitals and nursing homes – all with the intention of facilitating family reunification. NYCEPS staff can help search for a missing person who may have been treated at a New York City hospital, thereby giving families’ one place to inquire about a family member. This potentially reduces the overwhelming number of phone calls to individual healthcare facilities which are already overburdened in times of crisis.

Campbell: Thank you for elaborating on those initiatives and advanced HIE use cases. It’s fascinating and compelling to see the many tentacles coming out of the HIE and the numerous entities that directly benefit. Any final thoughts you’d like to offer?

Rogow: I’m going to settle on security as the final thought, though it’s always at the very top of our minds. We will be undertaking the HITRUST certification by the end of next year. We’ve taken a lot of steps towards that third-party certification and have undertaken other measures, including going through a SOC 2 compliance and achieving that certification. These are critical when handling volumes of PHI.

As a steward of PHI, Healthix understands that it is critically important to secure the data that we are entrusted to hold.  Technically we do not own the data; it comes from a variety of participating organizations such as providers, payers, behavioral health, pharmacies, or in some cases Medicaid. It is however our obligation to protect it to the highest security standard we can offer.

With the recent press around ransomware attacks and digital security threats, Healthix takes this extremely seriously and dedicates a fair amount of resources and operating expense to implement the technology as well as secure the data. It’s an important message for people to understand: we consider this one of our highest priorities.

We talked about obtaining the patient’s consent in order for providers to access their record for treatment and quality improvement. The model we’ve implemented in New York State is consent to access (similar to an opt-in model).  This is what enables a clinician to look up a patient’s record. Typically, consent is obtained during the registration process. We have the proper technology in place so that we are able to control contextual access to the data, which could be sensitive, to ensure it is properly accessed by authorized and authenticated users.

Campbell: It’s reassuring to know that those safeguards are in place. It’s also refreshing to hear how serious Healthix takes their role as being a custodian of the data, especially in light of all of the other initiatives and operational functions. Considering the volume and velocity of the data, it must be top of mind, so it’s great to see that you folks are a leader in that area.

Rogow: When I came onboard, it was critical for me to bring on a Chief Information Security Officer. Our participant organizations and leadership continue to make this a priority.

Campbell: Thank you for taking time to speak with me. This has been extremely enlightening, and I am appreciative of you sharing your experiences, insight and wisdom.

About Todd Rogow

Todd M. Rogow, MPA, CHCIO joined Healthix in 2015 as the Senior Vice President and Chief Information Officer, where he is responsible for providing the vision, strategy and day-to-day operational leadership for all technical aspects of the company. Todd brings a wealth of knowledge and industry experience and has worked in the health information exchange space for over ten years.

Todd joined Healthix during a period of rapid growth and innovative change. He has fulfilled a critical role of building and leading Healthix’s Information Technology function, migrating its technology development and operations in-house through the implementation of next generation application software and completing the technical systems merger of several HIE organizations that now make up Healthix. He has driven a comprehensive security program at Healthix that includes the onboarding of a Chief Information Security Officer and achieving SOC2 security.

Before joining Healthix, Todd served as the Chief Technology Officer at HealthInfoNet, Maine’s State HIE. With 20+ years of experience, primarily in directing technical projects, he has provided business and consulting services to a range of Fortune 100 companies and many government agencies including the Department of Defense. Todd has served as a subject matter expert at conferences and on national and international panels and at conferences on the subject of healthcare technology. He has also authored a number of publications and case studies.

Todd has a Master’s in Public Administration and a BA from the University of Vermont. He is a certified Project Management Professional (PMP) and a 2012 graduate of the Hanley Center’s Health Leadership program. In 2016, he became one of only a few hundred Certified Healthcare CIOs in the nation.

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 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: 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.