From the Health Plan Perspective, a Skeptical View of HIE Progress

Sept. 10, 2014
How quickly is health information exchange really moving , when it comes to connecting physicians in practice with health plans? The answer is, not as quickly as anyone would like, says Mary Franz, executive director, HIT, for L.A. Care Health Plan.

How quickly is health information exchange (HIE) really moving these days, when it comes to connecting physicians in practice with health plans? The answer is, not as quickly as anyone would like, as Mary Franz sees it. Franz is executive director, health information technology, for L.A. Care Health Plan (Local Initiative Health Authority of Los Angeles County), a public entity and community-accountable health plan serving residents of Los Angeles County, California, through a variety of available plans, and covering more than 1.5 million covered lives in L.A. County.

Franz will be participating as a panelist on a panel entitled “Enabling Data Exchange with New Models for Interoperability,” during the Health IT Summit in San Francisco, sponsored by the Institute for Health Technology Transformation (iHT2), and taking place March 25-26. The Institute became a part of Vendome Group, LLC, Healthcare Informatics’ parent company, in December 2013.

L.A. Care has been the recipient of a regional extension center (REC) grant for $16 million, and has functioned as a REC since it was awarded the grant in April 2010. Like most of the 62 RECs nationwide, L.A. Care is expecting an extension of that status through to April 2015, after its status expires this April. In that capacity, L.A. Care has worked very extensively with area physicians, supporting more than 5,000 doctors in implementing electronic health records (EHRs) and connecting with fellow clinicians.

Franz spoke recently with HCI Editor-in-Chief Mark Hagland regarding her perspectives on HIE and healthcare IT in the current policy and operating environment. Below are excerpts from that interview.

What will be the benefit of having the REC designation extended to L.A. Care for another year?

The benefit will be that we get to continue to provide service to the providers; and most of the 62 RECs will be getting extensions, from what we’ve heard from the ONC [Office of the National Coordinator for Health IT]. We’ve already worked with 5,000 physicians, and we will probably be able to work with an additional 500, if we’re extended through to April 2015.

What have been your organization’s most important learnings to date, from having served in this function?

The most important learning for me so far is this: that it’s going to be a long process [towards optimization of the use of healthcare IT, and robust data exchange], and it’s going to be iterative. And this is not new to the information technology adoption curve in any other industry; but in healthcare, the IT adoption curve is not a very well understood model. The healthcare industry somehow expects that you sort of use technology, and then you’re done forever. But in every other industry that exists, everyone knows that you have to constantly modify software and upgrade functionality, and that that is a long-term proposition.

Physicians have been off the grid in terms of understanding what happens in other industries, right?

Yes, they have. And their expectations are very high, perhaps partly because their adoption of tablets, smartphones, and apps, has been very high. But that adoption doesn’t translate into core information systems adoption or readiness. But the biggest learning is that we don’t have coordinated care in this country, and our payment models aren’t set up for that, so there’s a huge pushback around that. And so to get someone to share and exchange data, as with doctors, is a monumental effort.

In fact, I’m not sure that the HIE framework, as it exists right now, is viable; it’s a very, very difficult topology to have to navigate, with hundreds and hundreds of different interfaces. And it’s not simple, like the ATM model in banking. And no one has simplified the data transfer models. And I see it happening over and over again that when someone is trying to connect with another, unless they are owned by another, it’s extremely difficult, not just from the technological standpoint, but also from the contracting standpoint. And I’ve been in technology all my life, and have been in healthcare since 1989, and I just continue to be blown away by how difficult this is. And I’ve been involved with a lot of different HIEs; and you hear lots of great stories, but when you dig deeper, you find that a lot of these entities have been around for a while, and yet they’re still not breaking even.

So I think there’s a different way to think about this: California isn’t that consolidated a market. But the more you have integrated delivery systems that are owned by an entity, the better chance you have to successfully exchange data. And that just begs for national, single-payer healthcare. When I look at the health systems here, the one model that seems to apply here is the Kaiser model, where they own the hospitals and doctors.

So, in the end, the sets of issues around connectivity is just a conundrum in my mind. What I believe is that health information exchange has got to become as easy as an applet; a doctor’s got to be able to download an app and immediately exchange data. With ATMs, you can download anywhere and start processing transactions, but then again, it’s transactional, and it’s tiny bits of data.

Then again, when you look at the longitudinal medical record, you have to ask what’s really relevant. And I think that’s where it’s sort of got to get; what do you need in real time? But we’re exchanging years of history or transporting something in its complete form, and it’s deep but not wide. And I see a lot of HIEs transporting lab results, and that’s one thing, but it’s not enough. And you only need labs from the last few days. And I think the HIEs right now are much more technology-centric right now than they are information-driven.

From the standpoint of trust and care management, do you think physicians are more ready to exchange data now than in the past?

I don’t think so, yet. Here in California, most physicians practice within IPA [independent practice association] structures, so that if you’re in a very small practice with just a few people in it, your IPA is managing relations with the health plans. The IPAs are engaged in some data exchange, but it’s very limited in terms of how they really engage with the health plans. It’s a contractual relationship, but still not yet a true care management relationship.

And now if you look at what CMS [the federal Centers for Medicare & Medicaid Services] is requiring in terms of dual-eligibles management, or even Medicare itself, they’re starting to require that the payers do some form of care management. But that demand is only creating more multi-point relationships. And most accountable care organizations are very small in terms of the numbers of members involved. So when you think about an L.A. Care, with a million and a half members, or a WellPoint, those are bigger organizations. And care management is sort of being changed as we speak, by healthcare reform. And it looks to me as though more responsibility is being put on the payers. So from our perspective at L.A. Care, still, the IPAs are submitting encounters and claims, and have to achieve HEDIS measures and star ratings; but it’s not in real-time, as we care for the patient; it’s transactional, still.

What would you hope would happen in the next few years?

I’d love to see an HIE that really seems to work, that’s got a real business management point of view, and isn’t subsidized by the state or by departments of the state. I’d like to see how one that’s private and has legs, really works, and I’d love to see how it moves information. I’d also like to see the majority of providers adopt technology. To me, it’s like, just start using technology to help care for patients. Right now, we’re dealing with survey after survey in which doctors have expressed dissatisfaction [with the use of IT in their practices]; and I understand that to a point, because EHR technology really is not that good; it’s very basic. And I’d love to see the world of applets start to emerge in terms of the basic technology. Id’ love to see that come in so that you can use stuff on mobile devices and exchange data.

I think we’ll see some kind of breakthrough in this area in the next few years.

Yes. And also in my mind is the need for continued investment in infrastructure. And you see the meaningful use dollars getting smaller, and so some are just dropping out of the program, while the bigger providers continue forward. And somebody—maybe payers, providers—somebody needs to continue to invest in the infrastructure, to make this happen. And overall in healthcare, I don’t see the intense investment yet. And the other thing I’d like to see is for the provider market to understand why exchanging information for coordinated care is important for the patient. The physicians really don’t get it. There’s still largely a fee-for-service mentality among physicians, who see the patients when they’re sick, and that’s it. I’ll concede, though, that I don’t have as much experience within the large medical groups, and I’m aware that the largest medical groups are moving forward in terms of this.

Do you have anything else to add?

I would say there is progress taking place on care coordination and health information exchange, but it’s first-generation-type progress. This is the beginning. But I really think that the government investment program that was made, the incentive program [the Health Information technology for Economic and Clinical Health, or HITECH, Act], paid off, if the objective was to get first-generational usage. But there is clearly a need for exchanging data, and for the collection of data within practices, to do better care management and transition management. And I hope that the providers begin to see why collecting this healthcare data at the patient level can help them manage patients better. And then I’m hoping that the providers can be more willing to exchange information to help coordinate care; those two things would be gigantic. And I know some are doing that now.

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