“HIE is Hard, HIE Sustainability is Really Hard”

April 22, 2015
By giving up as executive director of Inland Empire HIE, Richard Swafford, Ph.D. is the latest example that those aiming to create regional and statewide health information exchanges (HIE) are doing yeoman’s work. As Swafford said, “HIE is hard.”

Richard Swafford, Ph.D. is the latest example that those aiming to create regional and statewide health information exchanges (HIE) are doing yeoman’s work.

The proof is in the fact that Dr. Swafford is the former executive director of the Inland Empire HIE (IEHIE), a Southern California collaborative that covers hospitals in the very large Riverside and San Bernardino counties as well as nine other counties.  IEHIE has approximately 160 participating agencies, 60-plus hospitals, 2200 doctors, and three payers and covers an area that is combined bigger than the 10 smallest states.

“Those of you in HIE know, it’s hard, it’s hard work.  People ask me why I left the Inland Empire HIE sustainable environment. I was ready to throw myself off the tallest building I could find. At some point, it’s time to turn it over to someone fresh. Sustainability is even harder than running the HIE as an organization,” Swafford said at the 2015 Healthcare Information and Management Systems Society (HIMSS) Conference, held at McCormick Place in Chicago.

Swafford, who is now a consultant with HIE vendor Orion Health, presented his education session, “A Hybrid Model HIE: Path to Sustainability,” which talked about strategies HIEs can use to build a sustainable model. It’s no secret, as Swafford pointed out in his session, HIEs are struggling to stay operational in the face of dried up funds from the federal and state government as well as other sources. Some are surviving, others are perishing.

In his session, Swafford put the words, “HIE Sustainability is Really Hard” in bold red letters. His message was clear, this isn’t easy. He noted how there were no models for HIEs to replicate since it was a new concept. He added that many HIEs were impeded in their business planning by those state and federal grants and focusing on a build-first come mentality. Also, he said many focused on technology and not marketable solutions; and overall lacked a focus on value. HIE failure, he said, is more about a business modeling than technology.

Value was a central point of his session. “What’s the purpose of business? It’s not to make money, it’s to create value for your customers,” he said. HIEs must figure out what value their participants and other stakeholders are getting out of the service. This is difficult, he said, because every stakeholder and participant is different and will need to be engaged differently.  At IEHIE, leaders implemented through a three-pronged strategy, focused on increasing value, service, and driving growth.

Growth was all about volume. IEHIE decided to grow beyond its region because Swafford said that there was no way it would get to sustainability if it stayed locked in. The organization rolled out a partnership strategy, where it offered its services to other HIEs in the state and across the country. “We drove volume by bringing in additional folks, they had their own governance and boards, but we’d be their service provider for HIE,” he said. In the same vein, IEHIE approached a number of mid-sized organizations and offered to be their enterprise-wide HIE.

 Service strategy was about creating specific products that could be used with the data, some of which were revenue-enhancing and some of which were not. The ones that cost participants a fee were around population health and business intelligence. However, Swafford noted that it was the free services, including a patient portal and public health reporting capabilities, that drove up membership. “The services above and beyond the data itself really kept people around,” he said. “I’m not saying be all things to all people. You can’t do that. Find those pain points in the practice and hospital environment, and create services around that.”

The service strategy tied into the value strategy, which was to help members be able to attest to various meaningful use and other government-based reporting requirements. Many of those aforementioned “pain points,” Swafford talked about were around reporting.

For HIEs to continue down this path, Swafford recommend a number of short-term and long-term goals. He said in the short-term, HIEs need to continue to expand services, expand meaningful use offerings, expand marketing and outreach, and continue to manage its reputation and perception. In the long-term, he said HIEs need to help participants move into a full-blown population health environment, look for opportunities in partner markets, recognize and advance on new markets, and continue to manage its reputation and perception.

It isn’t easy, Swafford reiterated. On top of a lack of experienced models and consultants, he noted how the industry was always changing, making it hard for others to focus in on a long-term plan.

“We still have a little uncertainty around the market. From a regulation perspective, from an ONC perspective, HHS and the state level, we’re still not entirely sure where we’re going to end up. They’re doing a fantastic job but I’m not certain we have a locked-in direction. The lesson is that you have to be agile to figure out how the direction is changing. It’s changing constantly. We never know day-to-day what's coming next [with] new meaningful use requirements, the new HIPAA release, state regulations, and the general feel of the market and how it shifts and flexes. The market from an economic perspective, how it shifts and flexes. It’s difficult to build any kind of long-term strategic plan around a [industry] that changes every 2-3 months,” Swafford said.

 Swafford advised HIE leaders to be flexible, try new things, and of course, listen to customers. He also told them not to give up. “Even though I did give up,” he admitted.

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