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How Not to Create an HIE

by John Moore | August 10, 2011

Sometimes, the job of an analyst can be so frustrating.

A core part of the Chilmark Research charter is to educate healthcare stakeholders on critical trends in the marketplace that will lead to better, more successful adoption of IT and subsequently improve the health of the nation (if not the world).  There are a couple of things we have learned along the way:

1) Little if anything gets adopted at scale in the healthcare sector (and for that matter virtually any other market) if it does not provide value to the end user that exceeds risk. That risk could be privacy, it could be a productivity hit, it may be liability; plenty of risk in healthcare, both perceived and real to trip up an IT initiative.

2) Provider engagement is crucial but if we really want to improve the health of the nation while concurrently lowering total healthcare spend (or at least slowing its growth) consumers/patients must also be engaged.

With those two points in mind, I was sadden and to some extent shocked at the press release announcing the formation of the New Hampshire Health Information Organization (NH-HIO). As I read this PR all I could think of was OMG, are they serious, is this their vision? If that is a vision, the NH-HIO leadership is wearing a blindfold.

So what brought on such a visceral response? Going back to those two points above:

1) Pushing summaries, referrals and orders electronically is the most basic function of any HIE and any quasi-government HIE, of which the NH-HIO is one, that has stated this as their core function has struggled to survive without some form of continual government subsidy. This isn’t a vision, this is just the same old, same old – your grandpapa’s HIE and will likely meet the same fate as that of Carespark and a host of others. Such an HIE provides very little, if any value to providers. And don’t even get us started on talking about the Fed’s Direct which frankly will do what NH-HIO envisions and doesn’t even need any overhead infrastructure, just a provider directory.

2) Nowhere in this fairly long and verbose PR is there any mention of what the citizen of New Hampshire gets out of the NH-HIO. Will they have equal access to their records? Will they be cc’d when summaries are sent so those files can get dropped into their personal, self-controlled folders, be it on their hard drive, their cloud service email account or even HealthVault? Nothing, absolutely nothing is said in this PR that relates to the consumer/patient. Talk about lack of vision. Geez, he says as he slaps his palm against his forehead.

Just to be fair, New Hampshire is not alone in lacking vision. This scenario has played out before and will likely be seen again but in this time of enormous government investments being made to facilitate the delivery of healthcare services via IT to ultimately reign in healthcare spending, examples such as this are the exact opposite as they will not lower costs and are a colossal waste of precious tax payer dollars.

Please, someone stop this madness.

13 responses to “How Not to Create an HIE”

  1. Jonathan Smolowe says:

    Bring on the consumer! It’s amazing to me that so many HIEs and RHIOs forget that small little detail. And they will fail for their lack of understanding …

  2. Jeff Donnell says:

    As usual, a provocative and on-point post. Allow me to point out that in Indiana, we have five HIEs (each with a different operating model) and a dozen pilot sites including practices, health systems, safety net clinics and employer clinics who are actively working on populating a portable PHR with HIE data. We will equip a mix of urban and rural, insured and uninsured patients with a PHR that can bring in a CCD from the HIE. Thanks to ONC Challenge Grant funding, we are working through the policy and technical issues with the aim of developing a scalable model that can be deployed elsewhere. As you might imagine, the hard work and heavy lifting is less on the technology side and more on the policy side. However, we have commitment and collaboration and work is well under way. IHIT (Indiana’s state designated entity) and NoMoreClipboard are knee-deep in this endeavor, and we will keep Chilmark posted. We are fortunate to be in a state where the HIEs are ready and willing to innovate and to INCLUDE the patient in healthcare data exchange.

    • John says:

      Hello Jeff,
      Thanks for chiming in on the conversation and would definitely like to hear more about what you are doing there in Indiana.

  3. Great post John! As always right on the money!
    Truly bizarre that we feel the need to replicate the SAME work over & over (at least 50 times…) to get to the same place… where is the leverage & best practice sharing when it comes to policy & HIT Development?!
    Other countries must be wondering why we continue to insist on wasting time & money to get the Healthcare digitized. But of course one person’s COST is someone else’s PROFIT!!!

  4. Celebrate the successes--study why no patient engagement. says:

    If the regional providers want to form an HIE which provides secure ,reliable and digital record communication from physicians and other clinicians to hospitals, labs, imaging centers and other Provider Service Organizations as as a core service they should be able to do that on their own without government subsidies as many have. Would you say that HealthBridge and IHIE are failures? If the HIE wants to provide a community wide healthcare information data base(s) to provide authorized care givers access to the patients history to provide better care they should be able to do that, shouldnt they? Are MHIN, MedVirginia, INPC, Rhochester, Delaware-DHIN or Inland Health failures?

    Consider the complexity of an HIE establishing a contractual relationship with each person/patient in a regional service area with all the legal requirements and documentation and risks. The relationship in most situations is between the provider or the physician and the patient not the HIE. Some HIEs are trying to provide portals for patients or PHRs. Has the sustainability model been presented and proven yet? What is the consideration that the patient provides to the HIE for this service? How much does each patient or family pay the HIE for this service?

    What happened to the Google consumer system? They have all the money any one would need. The consumer needs to be engaged and involved,true!
    The organizations who have a direct contractual relationship with the patient and a financial incentive might be good candidates for support as well.Where are they in this equation? We have a few examples of their involvement, a very few.

    In another post why not try to explore which HIEs have enough data flowing through their systems to provide a comprehensive enough set of patient data to meet the patients needs? All the labs?All the Meds?All the data from their physicians practices? Complete the list when you can. It is very thin in most markets.Even insurance companies dont have all the patients data and there is a financial incentive for its collection.

    • John says:

      Thanks for your thoughtful comments and many questions, all of which are valid, so I’ll give a try at answering them.

      Those regional providers that do create private, enterprise HIEs that can also be multi-stakeholder based are oftentimes excellent examples of what can be done in a given community and you list some good examples. See no fault with these and certainly was not inferring such in this post nor do I have a problem with physicians sharing records to help improve healthcare delivery. Actually, if you read other posts written on this topic, Chilmark Research is actually very bullish on the concept of health information exchange, the verb, but we often question the execution of such, as in the case of the NH-HIO which was the whole point of this post.

      Yes, HIEs can be difficult to stand-up and data governance issues are a chief culprit (it is rarely a technology issue, though it is time consuming to set-up the interfaces to the multitudes of EHRs that exist today) but I’m not sure I follow you as to how this relates to the issue of taking into consideration the patient, the consumer, the citizen taw payer hat frankly is footing the bill for these quasi-public HIEs of which NH-HIO is an example. So when you ask should the consumer be paying an additional fee to access the PHR that is hosted on the HIE? Hell no, they are paid for this HIE with their tax dollars.

      As to Google Health, have written in depth on that topic but do agree with you if you are inferring that possibly large corporations in a given community may also want to contribute, in addition to payers who in some instances, eg VITL are already footing the bill.

      As to your suggestion for a post to list those HIEs that can provide a complete longitudinal record for the patient and the care they receive in a given community… hmmm, can’t think of a one right now as I’m not sure even those that have been in existence for some time can make that claim.

  5. Leah Ridge says:

    Bravo for your insightful comments. Recently as a neurologist, I have been receiving “several inches” of 8 1/2 by 11 inch papers for every new patient. I have on average an hour to see them. It takes over a half hour to review these meaningless pages. There is very little pertinent patient clinical data in most EMR transmissions. I find this wasteful and disheartening.

    I may be a simpleton but I believe that there are way too many people involved in the patient doctor relationship. I see that most EMR transmissions that I receive are full of errors and devoid of content. I find this frightening considering the wonderful place that I came from ten years ago when we could give great care. I believe that the HIEs will simply add to this chaos in their current form.

  6. […] Article John Moore, Chilmark Research, 10 August 2011 […]

  7. So, John, I live there and would be happy to try to talk to someone and see how it goes. My default approach is always that the people involved have not noticed something yet, and to try to point it out. Where would that start?

    Forgive me if I’ve missed it in your posts, but is there another state’s approach to point them to?

    (I’m no expert on HIE… I’m sure it’s not massively complex but it’s not where I’ve been putting my time.)

    • John says:

      Hi Dave,
      Best bet is to go back and read the press release as several NH folks are quoted and go from there.

      • Ha ha ha – I wasn’t asking how to find someone to talk to, I was wondering what to point out to them. 🙂 I can go in blind but if there’s a pre-packaged focus, e.g. a list of “Here’s what Chilmark says an HIE should be, and I agree,” it’ll save time and improve accuracy…

  8. Gerald Theis says:

    “Innovate and INCLUDE the patient in healthcare data exchange” is the key to success. Actually, the patient must be in a central and meaningful role as the navigate through our daunting healthcare system in the USA. Maybe that is why, as an innovator of distruptive technology I have become so frustrated with the US and ” this madness” that I have turned to Africa to implement a patient-centric model of mhealth technology. Only when the consumer is empowered with consumer-friendly providers will rapid change occur in this exciting mohealth movement in healthcare.

  9. […] as is too often the case, patients and other stakeholders get left out of the decision calculus. Pittsburgh residents will hardly benefit from the competitive business […]

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