One Health System CIO's Perspective on the State of HIE

Aug. 27, 2013
Michael Restuccia, CIO of the University of Pennsylvania Health System, which has been participating in more than one HIE initiative, shares his perspectives on the challenges and opportunities inherent in health information exchange, with HCI's Mark Hagland.

As health information exchange (HIE) becomes more and more widely adopted, leaders of patient care organizations nationwide are sharing with each other and learning from each other, in terms of key lessons to be gleaned from pioneering efforts in that area. In that regard, Healthcare Informatics will be publishing its September cover story on the top challenges facing HIE innovators nationwide right now.

One of those interviewed for the cover story was Michael Restuccia, vice president and CIO of the University of Pennsylvania Health System, otherwise known as Penn Medicine. Penn Medicine has been participating in a regional HIE sponsored by the Delaware Valley Health Council, with member hospitals, as well as several payer organizations, in southeast Pennsylvania. At the same time, Penn Medicine is using the CareEverywhere data exchange capability built into the core electronic health record (EHR) solution from the Verona, Wis.-based Epic Systems Corporation.

Recently, Restuccia shared his perspectives in this important area with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Tell us about your broad general involvements in the health information exchange area.

We have two or three current courses of action around information exchanges. One is a regional HIE known as HealthShare Exchange. HealthShare Exchange will securely transmit healthcare data among hospitals, doctors, other healthcare providers and insurers to improve communications and the efficient delivery of care. HealthShare Exchange is being funded by more than 90 percent of the acute-care hospitals in the Philadelphia region; by the area’s largest health insurer, Independence Blue Cross (IBC); as well as by AmeriHealth Caritas, one of the nation’s leaders in healthcare solutions for the underserved; by Health Partners, a Philadelphia-based, not-for-profit health plan owned by a group of local hospitals; and by federal and state grants.

Michael Restuccia

When was HealthShare Exchange incorporated or created?

The specifics are on the website, but about a year ago. You can go to

Has any data been exchanged yet?

No, we have just finalized our vendor selection, and anticipate pilot activation in the fourth quarter of 2013. We have multiple committees, which have identified the initial use cases we’re going to address. One is an exchange of medication lists among providers and payers; a second would be a discharge summary release, in PDF format. The first two use cases are much more about direct messaging. Our plans after these two are to move towards more robust HIE capabilities.

Do you have a volume expectation?

I don’t think we do at this point.

Are you involved in any other HIEs?

The other one surrounds the use of our Epic ambulatory clinical system. We participate with what’s called CareEverywhere, the connective capability available to all Epic facilities. We very readily exchange data with other Epic users.

Are there other area hospitals exchanging data with you through CareEverywhere?

I’ll give you the hospitals and then tell you the story why. There are several facilities we have clinical alliances with. One is Lancaster General, about 75 miles west of us. And Geisinger Health System, as well, about 200 miles away. We sort of serve as a referral center, particularly for cardiac transplants and cardiac specialty services. So receiving the information on a patient prior to their arrival here at Penn, is of great value.

How much volume of data exchange is involved in that initiative? Would you say that information on dozens of patients or more is being exchanged?

Yes, data is being exchanged on multiple patients per month, is maybe a good way to put it. And the reciprocal of that is that when patients leave Penn, they go back to their homes, some distance away. And then the data we’ve gathered on them here travels back to their home facility.

Would you say that what is possible through Epic’s CareEverywhere is full HIE capability?

As an organization, you have to define what data you want to exchange. And first and foremost, I personally think we should focus on exchanging the clinical patient data. If you put the patient at the center of the universe, what do you want to be exchanging first? I think it becomes a fairly easy question to answer.

One West Coast CMIO I’ve spoken with has told me he is helping to lead his organization to replace their current electronic health record [EHR] with the Epic solution, primarily to participate in the CareEverywhere-based information exchange process, as all the neighboring hospitals and health systems in his community are already doing so, even though that exchange process is not as robust as what is taking place in some HIEs nationwide.

I would agree with that CMIO on the West Coast, that to locally to locally exchange data on the immediate care of the patient, is most important. If you put the patient at the center, getting to a platform that allows for ease of transfer of data, should be first and foremost. That was one of my observations about exchanging data via Epic’s CareEverywhere, versus trying to create a regional HIE. There’s a lot of infrastructure that has to be created in a regional HIE, there’s a governance structure that has to be established; you have to come up with a sequencing plan, priorities, and funding. The simplicity of the Epic situation is remarkable, no? You basically just have to set up a system of approvals, obtain consents, and then you go ahead. It’s remarkable.

So my point with all that is, we need to get to a standard. And if the standard is going to be designated by the Office of the National Coordinator [for Health IT] or CMS [the Centers for Medicare & Medicaid Services], we ought to define it and get there. But the idea of each state having multiple HIEs and platforms, is not the most efficient way to get there. It seems that, without a governmental mandate, the Epic approach seems to be winning the day in California and other states.

Some are questioning whether, as a policy issue, there might come a time when we as a society should question whether one EHR vendor should have so much market share that it might potentially be able to dictate healthcare IT policy.

I think in any industry when any one vendor becomes overly dominant—we saw that with AT&T, when they broke up the Baby Bells—I think you have to determine—and again, this is my personal perspective—what the implications are for policy. What has happened is this: Epic placed all its bets on the concept of the patient being in the center of the universe, and systems being integrated. One data model, no interfaces. Many of the other vendors placed their bets on interoperability, which is, we’ll be able to exchange data with multiple vendor systems with different data models, and different data standards, and different data vocabulary. And that bet hasn’t paid off, has it? So now, are you going to penalize Epic? Everybody made their bets. Epic placed its bet on integration; Meditech placed its bet on integration, at least in the inpatient world. The guys who didn’t place their bets on real integration placed their bets on interoperability. But without industry-wide data exchange standards, interoperability isn’t an optimal strategy.

So the federal government needs to set data exchange standards for HIE?

I don’t know that I would say the federal government, but the department responsible for this, such as ONC, needs to do that. In lieu of available alternatives, I would suggest that Epic is a way to go, because Epic is already covering half of the lives in the country. Use their data exchange format., since a large part of the country is using that; just make that the standard. But don’t penalize organizations that are already using data exchange successfully; don’t penalize us, and tell us we’re having to start from scratch.

What do you think will happen in the next couple of years in the HIE sphere generally?

I think what will happen is that there will be a continued deterioration of HIEs throughout the country as being unsustainable. Grant money will dry up; many of the business models won’t pan out. And generally speaking, clinician adoption will be varied; and it will be varied, because not every HIE will actually exchange the data and place that data into the resident EMR. If a physician has to go outside their own EMR and go to a portal and look up “Mark Hagland” and try to spell his name right and make sure it’s the right Mark, they don’t have the time. The data has to be embedded into their EMR in order for this to happen successfully. So for those three reasons, I think HIEs will will continue to struggle on a regional basis. And I think there’ll be one or two overarching or overriding HIEs that will start to dominate the landscape. That just follows what’s going on in the whole industry; it’s the capitalistic approach. That’s what’s happened in other industries such as with the airlines.

What would your advice be for other CIOs, CMIOs, and CTOs in hospitals, medical groups, and health systems right now?

Don’t underestimate the complexity of being involved in a regional HIE. It costs money, so there’s the funding issue; there are unnatural alliances, such as between providers and payers—that have to be managed. There’s a whole staffing issue involved. You have to hire people to run an HIE, but what’s the talent pool for people being involved in an HIE that may not be sustainable, right? So then you have to rely on the volunteerism of hospital and payer personnel. And we’ve got a full-time job! So it’s time-consuming. And what are your motivators? So if you’re a provider, your motivator is to make sure your patient is receiving the best care possible. Other organizations might be more financially oriented. Perhaps others have a financial interest ahead of the care interest; I don’t know. But you have to make sure your interests are aligned. And what you see is only the tip of the iceberg. There’s a large amount of work that’s below the water level. And a key part of that is, how ready is your organization to start accepting data and using it from another facility?

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