The Denver-based Colorado Regional Health Information Organization (CORHIO) has proven itself as an example of a health information exchange (HIE) that is flourishing, at a time when many are floundering. Last week, in the first part of a two-part interview, CORHIO CEO Morgan Honea revealed how the state of Colorado has become a model for data exchange success, giving specific examples of how the HIE has led to better patient outcomes.
Part 1 of the interview also touched on the nationwide negative perception of HIEs, to which Honea said they aren’t unlike other things, in that there have been both successes and failures. “We don’t have the national studies that have quantified the value of HIE, and we don’t talk at all about the benefit to patients who have received services and better proof of care because of the HIE. It’s an exciting place to be, and also exhausting,” he said. To that end, Part 2 of the interview with Honea digs into the difficulties associated with successful heath information exchange, as well as the role the federal government has, and if vendors are keeping up with provider demands. Below are excerpts of that interview.
Do you think HIE has become too difficult?
It’s very hard, very challenging. There are a lot of different things that can increase or decrease the burden. Colorado is an opt-out state, meaning you have to take action as consumer to get out of it. That policy alone dramatically changes the challenge. As an HIE, you’re not only tasked with selling your services and creating the value proposition for a network of healthcare providers, but also trying to convince the public of value as well. That single thing alone changes the complexity of HIE.
Also, technology is changing. When CORHIO started, we relied mostly on HL7 message exchange. Then, the Office of the National Coordinator for Health Information Technology (ONC) backed Direct messaging with meaningful use and transitions of care, which changed the way we look at our own technology. Now we transition into continuity of care documents (CCDs) and consolidated-clinical document architecture (C-CDAs), as well as fast healthcare interoperability resources (FHIR). The change in technology alone is a challenge to make sure systems are operating and flexible enough to respond to the vendor and industry changes to technology.
Speaking of those technology changes, are vendors keeping up with provider demands?
I think to be objective, you must say yes and no. Some do better than others. Standards have changed since we started the conversation, and that’s a big challenge for them. The number of certified vendors has decreased dramatically as we have gone through meaningful use. Also, the market share is wildly lopsided in some areas. We have a very heavy Epic presence for our hospital systems, and we function fairly well with them. You can’t ignore that every one of these vendors is working tirelessly to keep up with meaningful use standards. From our perspective, we could put more focus on the interoperability of different systems and how they would work to exchange information. Direct and transitions of care methods maybe didn’t get us as far down that road as we could have gotten. It’s not solely anyone’s fault, but they all contribute to where we are now.
What has kept providers from getting more on board?
I am actually an ex-practice administrator who ran a rural frontier federally qualified health center (FQHC), so I understand the challenges of adopting different technology at the practice and provider level. It’s cost, bandwidth, infrastructure, and competing priorities. As you go down the spectrum from large hospital systems that have robust IT staffing and resources to single-doctor rural practices, you have to look at where the best bang for your buck will be as you look at your priorities. Meaningful use has gotten providers to adopt health IT, and we’re hopeful that the programs here in Colorado will do the same. At the end of the day, there’s only so much time and so many dollars.
How much do your participants pay?
We have varying levels of access. Providers wanting to use our community health record portal alone, which means not receiving anything into the electronic health record (EHR), but just seeing that community health record, pay a nominal monthly fee, less than $50 a month. Then you move up the spectrum from there. There is a cap on cost to large hospital systems based on size and geography. We work with our members on the payment system to make sure that we’re not costing them out of participation. With the model we have, we have tried to make the value proposition in participating in the HIE far outweigh the cost of joining.
What role should feds have in this and are you comfortable with the direction they are giving today?
ONC specifically, has been good with coming out with their goals and expectations. It’s great to set national priorities with guidelines and directions. One of the things that sets Colorado apart in most of these cases is doing a good job of taking federal direction and developing a local and statewide solution that fits the needs of our communities. Think about the differences that opt-in and opt-out make when you’re trying to implement these solutions in rural or urban geographies. Federal direction doesn’t always take these into account. ONC is on the right way in giving us direction and priorities, and my hope is that we continue to have flexibility at the state and local level to figure out how to take local solutions and get us towards those federal priorities. I would like to see a continuation of resources to support these efforts, but there doesn’t seem to be many in the future. I don’t want to be subjected to a bunch of unfounded mandates, but if the physicians in the system don’t have payment mechanisms that can support the cost of technology that we will all bear, then I would hope that the federal priorities are acutely aware of the challenge that creates—for HIEs, physicians, and even patients, who mostly assume this functionality exists already.
Your state is one that is moving quickly with HIE efforts. What’s your advice for those that aren’t?
If you look at where healthcare is headed and think about where it’s been for the past 20 years, I tell many people that I view where we’re going now as managed care 2.0. In the 1990s, we operated under a gatekeeper mechanism, where the system held the keys and decided where you can go as a patient. What you saw is the American public dramatically push back against that concept—we want to see the doctor and the specialist when we want to. Technology has given us a much greater ability to do a lot of what we used to rely on the system for. The system is going to have to come to terms with the fact that patients will access the services they want, but the risk will be put squarely on the system itself.
So as a provider, that means less control with where your patients go in the system, but an increased opportunity to take risk for managing outcomes, even with less control. You must understand what’s going with your patient population, down to specific patients within that population. It’s not only within your four walls necessarily, either. Unless you’re part of a large system, chances are good that your patients are accessing services outside your system. The more you can understand that utilization, the more you can look at and manage their costs, the better you can coordinate their care, and communicate with those patients. So at the end of day, you hopefully get a better coordinated system. If you think that’s where we’re headed, then I think it’s clear to see the value of HIE participation. The light is at the end of tunnel in that changes that are coming, and it would behoove most people to move towards the light. Adopting these technologies will give them the opportunity to be successful in payment reform.
