CRISP Shared Services, the nonprofit technology infrastructure entity of Maryland’s designated statewide health information exchange, has grown to four regions outside of Maryland. In a recent interview, Brandon Neiswender, acting chief executive officer at CRISP, described how HIE innovations are being tested and then rolled out across member organizations.
In February 2022, David Horrocks, who had been president and CEO of CRISP since its creation in 2009, left to become CEO of the New York eHealth Collaborative (NYeC), which oversees the Statewide Health Information Network for New York (SHIN-NY).
Neiswender, who had worked with Horrocks even before CRISP’s creation, has stepped in as acting CEO. In a wide-ranging interview with Healthcare Innovation, he discussed what makes a statewide health data utility different from “HIE 1.0” and some of the activities under way in the shared services group.
If CRISP is seen as one of the models for what an HIE can accomplish, it did have something of an advantage because the State of Maryland has been involved in an ambitious total cost of care model with a waiver from CMS. CRISP partners with the Health Services Cost Review Commission (HSCRC) to provide monthly reports to all Maryland hospitals. The CRISP Reporting Service team can provide an updated analysis of inter-hospital trends and utilization by linking hospital all-payer Case Mix data with unique patient identifiers. Healthcare organizations leverage these reports to drive quality improvement, strategic planning, financial modeling, and other activities.
“That created the beginnings of a statewide ACO type of collaborative mindset,” Neiswender said, “and when you have that type of a mentality, specifically driven out of some of the HSCRC programs and metrics, it does change the collaborative model, specifically around data sharing.”
"That is what framed David Horrocks’ mindset around a health data utility,” Neiswender explained. “I think some HIEs are still thinking about HIE 1.0 — moving a clinical data set from one provider to another. Those things have become commoditized. I believe that our national networks and our EHR vendor communities are doing a great job on those things.”
Neiswender said bringing together EHR data, imaging, claims, etc., in Maryland allowed for the observation of statewide metrics around cost of care for certain cohorts of patients with different disease sets. “It is almost like a research community: how do you know if these programs are moving the bar? What are the variables in this statistical model?” he said. “CRISP was able to bring together a lot of those variables. CRISP can help organizations look at total cost of care around a cohort of patients before a program and after a program. What are the successes? What are the types of services they need? Did we reduce costs by X percent, and were the outcomes better? Once you are producing quality reporting on those types of metrics, it's almost an obvious next step for the state Department of Health or the hospital association or other interested stakeholders to ask if there is an opportunity to do public health reporting or hot-spotting.”
Neiswender said that CRISP has always been driven by particular use cases. “We are not believers in sending large massive datasets to providers and hoping that they struggle through them to find the information,” he said. “We look for use cases where we need specific small datasets, and where we are going to get the most bang for the buck.”
One example from working with the West Virginia Health Information Network is a Neonatal Abstinence Syndrome (NAS) alert. It worked with community partners to provide an alert on the patient’s record when an infant is born with Neo-Natal Abstinence Syndrome. This allows providers to make appropriate adjustments to treatment course throughout childhood. The West Virginia HIE also integrated with the West Virginia End of Life Registry, which allows a patient’s end of life choices to be shared broadly to all participating providers. Patients only need to submit one document to one place – eliminating duplication and confusion.
“Everything we do is built around use cases. We have lots of data and we can talk about interoperability and technology stuff, but I don't even like to think about HIE like that,” Neiswender said. “I like to think about HIE and valuable use cases. What are the data that can absolutely change providers behavior to create better outcomes for patients? That is what a health data utility does. It takes data, combines it and creates insights that may not have been there or easily accessible before.”
CRISP Shared Services has spread the technology infrastructure from Maryland to West Virginia; Washington, D.C.; Connecticut; and Alaska. I asked Neiswender to explain the advantage.
“We created some of these valuable use cases, and it became very evident that we could leverage our technology infrastructure for pennies on the dollar to extend it to West Virginia or the District of Columbia or Alaska and use that same infrastructure and not have to rebuild and rebuy all of that stuff, for instance, for the West Virginia Health Information Network,” he explained. “We want to leverage economies of scale, but we also want and need the local jurisdiction to have a say in what their priorities are. West Virginia's governance model mimics CRISP’s but it's unique in the priorities that they go after are West Virginia priorities when it comes to those use cases we talked about.
“CRISP Shared Services allows for that local statewide ownership of an asset in West Virginia, even though they're riding on infrastructure that can be more cost-effective for us to roll out. In our shared services model, we like to pool innovation. When we have five states all thinking about what's the next big thing that we need to do from an interoperability perspective, Washington, D.C., may be leading the charge on some social determinants work and maybe getting grants. Maybe Connecticut is doing medication adherence innovation. By each one of those states managing those innovations, as soon as they're in our infrastructure, they automatically scale and are copied out to multiple regions. That pooling of innovation is key.”
I asked Neiswender what CRISP’s approach is to aggregating and sharing social determinants of health data.
“Our approach has been to listen to the industry and stay in our lane,” he said. “We're an interoperability infrastructure organization. There are good private companies out there that are doing this well, such as Unite Us. We have taken an approach that says we just need to be collaborative with those organizations in the same way we are collaborative with EHR organizations.”
He said the HIE’s role in the SDOH space is to try to eliminate data silos in private networks that may exist within a region. If a referral is made in one of those systems, CRISP just wants to make sure that people know that that referral is out there. “We just need to make sure that that information is available if people are looking for it,” he said. The SDOH data says who's at risk and who needs services; the other part is how do I refer people for the care and the services that they need? "Not everybody is going to be part of those private networks, so we can be a system of last resort that also integrates back in. If a referral is made in a lighter-weight referral service, we're able to then push that referral out into those private networks as well so that they can collaborate.”
He said CRISP is trying to be agnostic about how SDOH data is gathered and referrals are sent. “If there is a referral that is created out of Epic, for instance, we have a way to receive that and show it, and it's then also available to the other networks that are out there. We're not a competitor. We are a facilitator and a collaborative partner where there's white space to fill.”
I asked Neiswender whether the TEFCA framework could eventually help CRISP with some of its use case development.
He said TEFCA further opens up opportunities for clinical data, where new and innovative use cases could come about. “I think that making the data more available for more purposes will only lead to innovation,” he added. “I think the governance models that have been developed will be very helpful and for states that aren't as far along in some of these activities, it might be an accelerator.”
Would it make sense for an organization like CRISP to seek to become a QHIN under TEFCA?
“In my opinion, it's not an effective use of our operational resources to try to put in another layer of governance,” Neiswender said. “It is not going to really change what we do or how we grow. At this point, I do not believe it's in CRISP Shared Services’ best interest to go and do that.”
Is CRISP Shared Services looking to expand to other states or regions?
“We are always in talks about expanding to other regions,” Neiswender responded.” We are in discussions with a lot of different states and as the industry consolidates, there are opportunities, especially if there's lower-cost, high-value opportunities. We think that there's some white space out there that we could fill.”