Healthcare Innovation recently interviewed one of the report’s authors, Jonah Frohlich, managing director of professional services firm Manatt Health and former deputy secretary for health information technology for the California Health & Human Services Agency, as well as Melissa Buckley, director of the CHCF Health Innovation Fund, which invests in technology and service companies with the potential to significantly lower the cost of care or improve access to care for Californians with low incomes.
Jonah, you led the state’s health information exchange efforts in California over 10 years ago. Now there’s another push for statewide information exchange. Are the issues similar now or have things fundamentally changed?
Frohlich: Fundamentally, many of the issues are the same. There are some important differences to note. Twelve years ago, we were at the beginning of a journey to build electronic health record systems and implement them. Three percent of hospitals had a comprehensive EHR when the HITECH Act was initiated, and now it’s approximately 90 percent. We didn’t even have the onramps, let alone the highways. That’s an important change. We also did not have robust, tested, established exchange standards, and we now have much more robust standards, so there are rules of the road. That makes a big difference when you’re trying to build infrastructure for exchange.
Which things are still problematic? Business or cultural issues?
Frohlich: I would say they’re largely business issues. The imperatives for organizations that need to share data haven’t changed that much. We haven’t significantly advanced value-based payment arrangements. The benefits of HIE don’t necessarily accrue to those who have to pay for it. So that kind of externality has not been resolved.
Buckley: Absolutely. Just think back to the Affordable Care Act. It moved many, many people into managed care and the whole system toward value-based payment. Those things got people focusing on integrated care, whole-person care, and population health management, and data exchange underlies all of that. All our lives touch so many systems, whether they’re medical systems or social service systems. There’s no way to get a handle on where and how people are being seen. We haven’t historically focused as much on the technology piece, but it is absolutely foundational to being able to understand and deliver appropriate care.
If you look at states that have made more progress in having a statewide HIE utility model, do you see some crucial use cases where they’ve already made progress and where you’d like to see California make progress in a couple of years?
Frohlich: Some states have implemented mandates and requirements for data sharing—Maryland, North Carolina, and others—and that has been helpful for the participants to have access to more complete and timely data. They then marry those requirements with business and financing policies—for instance, having contractual requirements with managed care plans that their networks have to participate in health information exchange activities. Use cases such as emergency department and hospital alerts when somebody is admitted or discharged can really help with care coordination and care management. The regional and state HIEs are starting to build applications on top of the national networks’ data. They are compiling data, synthesizing it, and distilling all that information, making it really useful and actionable.
Are there some examples from the pandemic and public health reporting that a stronger HIE infrastructure could have helped with in California?
Buckley: Yes. People show up in different parts of the delivery system for different needs and their data lives in all sorts of different places. In a pandemic situation like COVID medical and social service providers may or may not know someone’s COVID test status, and without good information they can’t reach out to help or manage your care in the best ways. Some states had the ability to move a person’s COVID test status from the mobile testing site to the primary care provider’s office, and make it available to local emergency room providers to take extra precautions in case the person visited the ED. Also, at the public policy level, unless state-level decision makers who are thinking through vaccine allocation have an idea of where people are most vulnerable and where the current supply of vaccine is sufficient and insufficient, they can’t direct the vaccine distribution in an equitable or efficient way.
California Advancing and Innovating Medi-Cal (CalAIM) is an ambitious multi-year Medicaid transformation initiative that includes connecting behavioral health and community-based organizations to traditional healthcare providers. What kind of interoperability investments make the most sense to foster that system?
Frohlich: With CalAIM, the first programs out of the gate are enhanced care management services targeting individuals enrolled in Medicaid with complex needs who are being served by health plans, providers and state and county agencies. Local food pantries and housing agencies generally don’t have information systems that can share data with other providers. The Whole Person Care initiative that preceded CalAIM created infrastructure that in some counties resulted in successful data sharing. That’s the kind of infrastructure that’s going to be necessary to link up a behavioral health specialist to treat substance use disorder with a diabetes provider so they can communicate about what the patient needs and what they’re being prescribed. And they also can help coordinate a patient’s care and referrals to things like housing support specialists. What’s needed is the infrastructure to bring all these various segments together to share data, to actually use it, to understand all the person’s needs, and to have a coordinating entity or organization helping to manage that patients care.
What kind of action are we seeing so far this year in either the governor’s budget or in the Legislature on these issues?
Buckley: There’s a lot of interest this year. The governor’s January proposed budget included language indicating that he is interested in driving more data exchange across California. There are currently three bills in the legislature holding hearings on the topic. So we’ll see if we can, as a state, find elements of common interest. I don’t think anyone believes that we can afford to do nothing in this day and age. The question is, is there enough political resolve to find a pathway forward. And we’re optimistic.
