Revelations in Regional HIE Development
Dick Taylor, M.D., is CMIO of the Oregon Region of the Portland, Ore.-based Providence Health and Services, a regional integrated healthcare system that encompasses 28 hospitals located from Alaska to Southern California. The Oregon Region encompasses eight hospitals in the state of Oregon. Taylor spoke recently with HCI Editor-in-Chief Mark Hagland about his activities around health information exchange (HIE) within the Providence organization.
Healthcare Informatics: What parties are involved in your HIE?
Dick Taylor, M.D.: The experience at Providence with HIE started roughly two years ago, not with the question of interoperability, but over the issue of bringing the clinical benefit of providing clinicians with unified data without having to purchase a single electronic medical record. We have EMRs in all our hospitals, and we’re paperless in our clinics. But we have three major vendors in our environment—GE, McKesson, and Picis.
HCI: So the HIE is for your region?
Taylor: Yes. Essentially, we took a look at this, and we said, how can we achieve a unified record in a very disunified world? And one of the things we looked at and continued to keep as an option was to potentially go to a unified record. But we also have the problem that two-thirds of the people who refer to Providence don’t work for Providence, and never really will. And the Portland area, there are essentially no paper-based medical groups anymore. So Portland is extraordinarily electronic, and very diverse. Mark Leavitt wrote Medicalogic for Portland; and there are many vendors here. So we recognized that we had to do HIE to make things work. We also, four years ago, introduced something called a clinic tab for McKesson, via the physician portal. And that made the clinical record—a static image of problems, medications, etc., available whenever a patient referred from a clinic was admitted to the hospital.
HCI: So that information could be drawn into the hospital record that way?
Taylor: Yes. And that went live about four years ago. And we determined that usage of that tab was unexpectedly low. One of the issues we’ve had to face, and it’s keeping us honest, is that it’s not what you can exchange, it’s what you do actually exchange. And we found that if a patient comes into the emergency department or straight into the hospital, and they’re very sick, that’s the time when you’re least likely to use the portal tab. Why is that? First of all, it’s because it isn’t there for every patient (since sometimes they’re coming in from physicians not involved in that portal); and second, you had to copy the information down and reenter it into the system. As a result, it actually added work. People weren’t using it because it involved therapeutic non-compliance; in other words, it wasn’t readily actionable data. And the clinician, while retaining control of the record, has to have a choice about whether that data is usable. So we created something called connected charting, which is based on an xds.b registry and repository. And we standardized on HITPSE c32’s continuity of care document (CCD), their interoperability XML document. And the nice thing about those documents is that they’re nice documents, and contain the ability to have coded data within them. So we created the capability within this HIE to pass coded data among these systems. So GE, McKesson, and Picis are in various stages of being able to generate coded information. We use a vendor-neutral coding system called RxNorm, which is a medication standard maintained by the NIH (National Institutes of Health).
HCI: When did you go live on this?
Taylor: We brought the HIE live and began exchanging data between systems in February at our Seaside Hospital in Seaside, Oregon, a community on the Pacific Ocean just south of the Oregon-Washington border, and with three clinics in that area, one in Seaside, one in Warrenton, and one in Cannon Beach. And we chose that area because it was geographically isolated, so we could pilot this without having to involve the entire metropolitan Portland area.
HCI: It’s gone well?
Taylor: It’s been very informative. We’ve had as much trouble as success. Anytime you create transformative data, you face your own bad data and other issues. So we’re working our way through data coding and quality issues. And we have a strategy of progressive engagement. And the next phase of the pilot will start in late June. And so we expect to be live throughout the region by the end of the year. It’s about 40 clinics involved, along with the eight hospitals.
HCI: Is the biggest lesson learned so far confronting your own bad data and processes?
Taylor: Absolutely. And I’ll even add in the word ‘behavior.’ When you document care, you document it with the sense now that everyone who sees this data may act on it. We call it ‘church stewardship.’ You can’t be sloppy anymore. A real-world example. I’m a pediatrician by specialty. But if you’re taking care of a very old patient, and if the clinic physician doesn’t feel like entering the meds, and so enters them incorrectly or misses something, then the hospital is forced to deal with that. And if the clinic physician doesn’t enter clear or accurate instructions, then the hospital physician is going to have to deal with that, and perhaps a nurse will have to clean up the language in the record. And the physicians in the clinics are wonderful and are very devoted to patient care, but this is new for them.
HCI: Over the long term, though, this will lead to improved processes, correct?
Taylor: Yes, and I don’t think it will take until the long term, but it will involve some interesting interactions. And GE and McKesson have added the capability of showing the coded data to their products, within one view on one page. But we asked them to include in this not the system or institution that that information came from, but the actual person, the clinician who entered the data; and we list the person by name. So if you do a sloppy job, not only will the information be visible to them, but your name will be right next to the poor documentation. And that will be a subtle but powerful motivator. Because nobody wants to do a bad job, and nobody wants to be seen to do a bad job, and I’m utterly shameless in using that phenomenon for the benefit of the patients.
HCI: What would you tell CIOs about your experiences around regional HIE development?
Taylor: I think that the biggest thing that you need to do with the HIE, especially if you’re a health system CIO and especially if you don’t have a clinical background, is that you have to have a credible, believable, plain-language rationale and explanation for what you’ll do with this and why; because ultimately, if it doesn’t change the practice of medicine, you’ve failed. So if you aren’t comfortable at the bedside, find somebody who is, and if they’re not comfortable explaining this, keep looking and keep talking until you find your answers.
HCI: Are the clinicians getting the hang of this so far?
Taylor: I think the physicians at Seaside will eventually forgive me [laughs]. They’re very much in the throes of this. The senior physician leadership, those with the 10,000-foot view, they see this and they get it. The pilot is working as well as I’d expected it would, and frankly, the technology is working very well indeed.
