Q&A: SHIEC’s Lisa Bari on ‘Critical Time for HIEs in This Country’

Oct. 23, 2020
Speaking about TEFCA, Bari says that ‘until it is written into requirements and given some teeth, it is going to be a little tough to see it moving forward quickly’

The nonprofit Strategic Health Information Exchange Collaborative (SHIEC) represents 81 health information exchanges (HIEs) and their strategic business and technology partners. On Oct. 9, SHIEC’s board announced the appointment of Lisa Bari as interim CEO, succeeding Kelly Hoover Thompson.

Bari, who previously served as the health IT and interoperability lead at the Centers for Medicare & Medicaid Services’ Innovation Center, took time on Oct. 22 to do a Zoom interview with Healthcare Innovation about her goals in the new position and the critical role of HIEs during the pandemic.

Because your appointment is interim, do you have to have more of a short-term focus or are you working from a strategic plan already in place?

Bari: We are definitely having those conversations with the board. The role of an interim CEO can be many different things. Generally people are of the opinion that it is a really critical time for HIEs in this country and for the healthcare system and public health overall. HIEs play a really big role in that, so there is no way we can sit back and not make decisions and plans right now because everything is happening at the same time. For instance, the CDC just released interim guidance on how they are planning on doing immunization tracking. We have to act now.

You spent several years working on interoperability issues at the CMS Innovation Center. Are there some things you learned from that experience that you can readily apply to this new position?

Bari: At the CMS Innovation Center I worked with HIEs as well. I designed health IT and interoperability policies for the Comprehensive Primary Care Plus model, which at the time was the largest test of primary care payment and delivery system innovation in the world. We intentionally wrote in policies to encourage primary care practices to use their regional HIEs. So I have been doing this work since then. I really believe in the value of health information exchange as a key underpinning and enabler of value-based care, which is what the Innovation Center is about.

One of the initiatives SHIEC is best known for is the Patient Centered Data Home [PCDH]. Is that something that you want to expand upon?

Bari: The Patient Centered Data Home is a project SHIEC members are focusing on. We are figuring out how it will fit in the overall landscape. There are a lot of opportunities right now around creating national connectivity and taking advantage of the CMS interoperability and patient access rule and the ADT notification requirements that are coming into effect really, really soon. They were extended until May 2021. We believe PCDH will likely play a role in the implementation of some of those new requirements as organizations look at how they comply with these new rules.

Do you have some strong feelings about the approach the RCE is taking with TEFCA? Do the SHIEC members have a clear idea of what their role is envisioned to be in that framework as the QHINs are defined?

Bari: We don’t have a strong perspective on what the RCE is doing, specifically. Certainly, different SHIEC members are going to become QHINs or not. They are looking at that right now. I think with TEFCA, I am just really concerned because of the approach CMS took in the final rule of not including TEFCA in a meaningful way. They didn’t give it the importance or support or didn’t make it required.

It’s like they were on separate tracks.

Bari: Exactly. That is really concerning. Fundamentally, if you ook at the idea and conception of TEFCA, that makes sense, right? We need a model agreement. We need standard rules of the road. So SHIEC may get more involved in that and the RCE may get more involved in that, but until it is written into requirements and given some teeth, it is going to be a little tough to see it moving forward quickly.

Are HIEs starting to understand that creating a repository of regional data for lookup may become commoditized and may not be a viable business model going forward?

Bari: One thing you can say about HIEs is that they all have different perspectives. I would say it is tempting for everybody to look at the environment and say a single tech vendor can do that. But that doesn’t work because the healthcare landscape is intensely local and political. State laws are critical for data sharing. HIEs generally are nonprofit, vendor-neutral and highly tied into their states and communities’ systems of governance. You need those HIEs connected to their communities to make health data sharing happen. That is how I see it.

But do most HIEs see that they have to provide more value-added services such as aggregating data for analytics and clinical quality measures, including merging clinical and claims data? Doing ADT feeds? Or building connections to post-acute care and behavioral health?

Bari: Absolutely. Just doing basic provider-to-provider health record sharing is absolutely not cutting it. HIEs are most successful when they are really community-level integrators — when they incorporate social determinants of health. In Nebraska, for instance, they are incorporating PDMP [prescription drug monitoring program]. They can incorporate lots of different services and really serve as that hub in their communities.

I wrote something recently about a presentation at the SHIEC conference by David Horrocks of Maryland’s CRISP HIE and John Kansky of the Indiana Health Information Exchange in which they argued that every state should have a state-designated and regulated health data utility with a monopoly akin to an electric company. Do you agree with them?

Bari: The public data utility model of HIE is one approach that people are talking about. In addition to Horrocks and Kansky, Claudia Williams of Manifest Medex in California also recently published a piece about the public data utility model. Personally and from a SHIEC perspective, we definitely think that is a great idea. It doesn’t solve all problems and may not be appropriate in every single circumstance, but it is a good idea. I will say that if you are going to be a utility, there is a whole new level of regulation that goes with that. For example, I live in Baltimore, and Baltimore Gas & Electric has to provide connections to everybody in a certain geographic region. If you are a utility you are subject to different rules around pricing and coverage, so there are two sides to it. From a public health perspective, it is an interesting idea.

Some states already have something akin to that, such as Maryland.

Bari: Yes, it is written into the state’s global budgeting and the agreement they have with CMS.

But some states have really struggled due to cultural, political and other reasons. Even a state like Minnesota, which has done a lot of good things in terms of health IT, doesn’t yet have a statewide HIE. And one reason they have had trouble getting large health system participation is that the hospital systems are all on Epic and so they can easily share information with each other privately and don’t feel a strong need to contribute to building a broader public infrastructure. Unfortunately, that leaves a lot of providers, especially small ones, out of the loop. How can states like that get from where they are to where Maryland and Indiana are?

Bari: It is so tied to the state government and what it prioritizes. One vendor is not going to solve health information exchange. Let’s say that all the hospitals in the region have one vendor, which I would argue might be a problem, you are still missing long-term care, post-acute care, social services, prisons, foster care. You are missing so much that is part of the healthcare landscape. That is the promise of these nonprofit, vendor-neutral community integrators that are part of the HIE landscape.

David Horrocks and John Kansky also argued that there needs to be more consolidation of HIEs both within states and across state lines to get greater purchasing power and more scale. Soon after they made their presentation we saw the HIEs in Colorado and Arizona announce plans to come together. Is there a role for SHIEC to help in sharing best practices for bringing organizations together?

Bari: Across healthcare broadly we see a lot of consolidation happening. That may also happen in the HIE world. I think what SHIEC can do is work to bring HIEs together to have a bigger voice as one entity, essentially, and also help SHIEC members work on standard transactions and quality initiatives and to align advocacy issues like patient matching or to align on issues around funding through HITECH, which is sunsetting soon, or Medicaid technology funding – just making those connections stronger. We are already doing that. I don’t think we want to have a role in either slowing down or speeding up any part of consolidation.

It is interesting that we are seeing two strong statewide HIEs in adjoining states come together. We haven’t seen that happen before.

Bari: Health Current and CORHIO are really great community integrators that have forward-thinking CEOs and boards, who are excited to see what can happen if they can be stronger together. CRISP is becoming regional, with Maryland, D.C., and part of Northern Virginia and West Virginia. We may see more of that. At the same time, some communities are really tied to the HIEs as they are today and they don’t have any intention to grow, but maybe they will partner more.

The pandemic has demonstrated the importance of data sharing, particularly with public health. What are some other ways that SHIEC can help advocate for investment in improving infrastructure that can last beyond the current emergency?

Bari: We just got done meeting with key congressional committees, and one of the asks we made was for a GAO report to be put in legislation to look at the historical investment in HIEs and the different methods of funding. It is esoteric and complex. Even though there are all these things available to states and HIEs, it is often such an asymmetry of information between what is technically allowed, what states understand, and what the guidance is. States and the federal government have invested a lot of money in HIEs for this technology build-out. It is really important to get their money’s worth and keep those investments going where it makes sense and figure out how to get the most out of it. We just saw the CDC saying here is a paper card to track vaccinations. My goodness, why? Build on the infrastructure you have already started building. Don’t re-invent that wheel.

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