Reginald Coopwood, MD, has been intimately involved in the creation of multiple health information exchanges and, most recently, the closing of one HIE.
That would be Health Information Partnership for Tennessee (HIP TN), of which Coopwood was chairman of the board before the state decided to shutter the three-year-old exchange.
Government Health IT Editor Tom Sullivan spoke with Coopwood about what happened, lessons learned that others implementing statewide HIE would be wise to heed, and why there needs to be an appetite for health data and an iPad of HIE if health information exchange is to reach its potential.
Q: With the news that HIP TN is closing, what might be some lessons learned here?
A: Probably the most valuable lesson learned is the complexity of what our undertaking was. We decided to do this three years ago. At that time there were two HIEs across the state. Among the people at the table, our goal was to create a statewide HIE, a network of networks, therefore we were setting ourselves up to be the connector from the east part of Tennessee where there was an HIE, to the west part of Tennessee. So that was the early work of HIP TN to have activity of delivering full medical records and, ultimately, radiology images – so this wasn’t just CCDs. It was a bold vision at the time and during the course of this two other HIEs have been stood up, one folded. Now we have three HIEs, two of them are different than the originals. HIP TN was kind of slowly progressively trying to get the rules, to get the ability to exchange data, trust brokers, to make sure the technology would deliver on the requests. We didn’t fail in moving in that direction.
Q: It sounds as if HIP TN was progressing, so what happened?
A: We fell upon the criticality of time where states are being incentivized to exchange data in order for providers in the state to meet meaningful use, and what we were building delivered way more than the minimum data set and probably would not fit in the timeframe the state needed in order to be compliant with the requirements ONC was placing on them. So the decision by the state was not that HIP TN was a bad thing, it’s that we were investing in building more than is required today. As Direct became more mature, more available, and met the minimum requirements of at least Stage 2 [meaningful use] that was the direction the state felt was in their best interest in order to meet the obligations to the federal government.
Q: Would I be stretching to think that HIP TN was, perhaps, ahead of its time?
A: I think time will tell that. One of the reasons why I was involved is because I was part of the early stages when we stood up the Nashville HIE and when I moved here to Memphis it was the original HIE in the state and I’ve been intimately involved with the local HIE. Then I was involved with HIP TN since its inception and I believe that – and I’m not speaking for anyone but myself – I firmly believe that in order for HIE or data exchange to do what they’re intended to do, there need to be good and robust data that gets exchanged to help manage patient care better.
[See also: The biggest challenge for HIE is not technical.]
So we were building toward that, but I couldn’t tell you whether in five years there will be something that makes that completely obsolete and does the things that I think are more robust than Direct. I think the concept is maybe before its time but when that time hits, whether that will still be the right technology or not I couldn’t tell you. But I do feel that we are going to need to exchange more than CCDs at the end of the day.
Q: Based on your experience would you anticipate that Direct has a similar impact on other HIEs?
A: The other fundamental problem with HIE is sustainable funding. If you’re depending on significant government funds, as our HIEs have in their inception, and then some degree of support moving forward, without a sustainable model of revenue that keeps the HIE independently going, it will be difficult when the funding at all levels of government is toward a certain type. In our case, the funding was there to develop what we set out to and we were wholly dependent on that state funding, which was passed down from the federal government. So when the attention then turned to Direct at the federal level and the funding got diverted, if that HIE does not have a sustainable business plan to keep it going, then that HIE is at risk of closing, yes.
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Q: That’s interesting about Direct. At least the perception is that ONC has been very pragmatic in saying that HIE – the verb – doesn’t have to rely entirely on Direct. Health entities can also use, for instance, Web services standards…
A: Direct is fairly inexpensive. In the scheme of things it’s cheaper than a more robust data exchange. A lot of the technology has a Direct component but the cost for technology to perform more robust exchange, if there’s not a way to pay for that, you’ll default down to Direct if the amount of money that’s coming in is only enough to sustain a Direct solution. Until we find a model that sustains the exchange of this data, we’ll always be significantly dependent on governmental investment.
As I tell people, when we first had the ATM machine we were scared to even take our money out of it because all you could do was withdraw money. But at that point, had the banking industry described online banking and bill pay, no one would have signed up for it because it was before its time. We went from the basic ATM, to deposit, to banks that don’t have branches anymore – all of that started by these early ATMs. We created an appetite for online banking and availability of our funds, but that appetite has not yet been created for health information. Until we do that – whether it's the public, providers, employers – as long as it stands that the government thinks it's a good idea, then let’s let the government pay. Somewhere along the line we have to create an appetite for the data that’s available that people can carry around and not to haveto fill out form after form every time we go to a doctor.
Q: The ATM analogy is rather apt. And there's certainly been a lot of discussion lately about the evolving nature of HIE. Dr. Farzad Mostashari, for instance, has said "HIE is a verb. I refuse to talk about HIE as a noun." And former Vermont Gov. Jim Douglas, who is now part of the Bipartisan Policy Center, said at the recent Government Health IT conference that what's dubbed HIE today maybe not be the HIE of the future. What in your experience does the short-term future hold for HIE, both the verb and the noun?
A: I think it’s a verb because it’s ever-evolving and the investments made to date help us better understand an industry that didn’t exist before the federal government decided to start making investments in this space. So while I agree that it’s a verb I wish I could tell you I had an answer, that we’re building the answer right here. We’re not. We’re trying to get to it, trying to find a way to fund it. I fundamentally believe that somebody, some entity that owns a piece of people’s health will find the value and create the model of sustainability. Back to the original ATM analogy: Having access to my bank account is important to me because I need to make sure I have enough money to pay this or buy that, whatever it is, so I’m personally emotionally tied to it but I’m not personally emotionally tied to my health record. Whereas we may pay $2.50 to access $20 from an ATM, I’m not sure that we can create a sustainable model where the patient will pay to access their data in a similar fashion.
[See also: The 3 truths of health information exchange.]
The provider is in the loop now because the federal government has offered them incentives to buy electronic medical records and to have the ability to exchange data, but they’re not going to be willing to pay for something they can get by fax. So the question, then, is who can you create that appetite in? At the end of the day, it might be the employers. It might be the insurance companies who somehow will create that business model that says ‘This is valuable data to better manage your business, to more efficiently manage your healthcare costs’. Whatever the hook is, someone’s going to have to make it relevant.
Q: Now, ONC, CMS, HHS are currently embarking on patient engagement efforts on a fistful of fronts, the idea being to get patients more invested in their health and their health data. Patients are certainly important in all this, but it sounds as if it has to happen at a higher-level to really succeed…
A: Patients are a part of it. There’s no other industry where you to go to register and fill out the different paper forms. Everywhere else you can do it electronically and once – except at the doctor’s office. And no one’s complaining or demanding more, so I think the patient does play a role when they start demanding more. Until someone creates something where the patient says ‘Wow, that’s what I want and I can’t live without it,’ but right now they are not in an uprising, they’re not really aware of all that’s going on. I’d say 90 percent of the patients in our community aren’t even aware we have an HIE.
We didn’t need the iPad before somebody created it. And this is a sluggish industry to change. It’s really going to take somebody creating the iPad of HIE – and then no one can do without it.
