[Ed. This is the second of a two part series. Check out part one here]
In October, the Journal of the American Medical Informatics Association (JAMIA) published a study by led by Mark Frisse, MD demonstrating significant cost savings when emergency departments (ED) have access to patients’ data via health information exchange (HIE).
The study showed a total net savings after costs over $1.07 million over a 13 month period and was associated with a decrease in hospital admissions and statistically significant decreases in head CT use, body CT use, and laboratory test ordering.
This was an important milestone in the ongoing national effort to build health data “highways” and helped to validate the presumption that health information technology can reduce unnecessary testing and costs.
Dr. Frisse is a physician and professor of bioinformatics at Vanderbilt University. He also directs the executive-level Masters of Management in Health Care program at the Vanderbilt Owen Graduate School of Management. I had a chance to speak with Dr Frisse about his experiences with the alliance that manages a network of HIEs in Tennessee. He shared several insights that I found to be especially interesting and worth highlighting. These included the important role of political leadership, patients’ willingness to allow their data to be shared digitally and differences innovating in affluent versus less affluent regions.
BTE: So it sounds to me like you think the political element was very important, and an indispensable element of being able to accomplish what you guys have?
Mark Frisse: Governor Bredeson is a private business man now but he still believes there are a lot of ways for him to influence public policy. He actually wrote a great book that is worth a read called ‘Fair Medicine’ in which he basically goes through Obamacare and analyzes what he does and does not like. Phil Bredeson is really a fascinating visionary, he does a lot of work with Jeb Bush now, and he is still very much a national leader behind the scenes. Our success was really due to his influence, the low cost technology developed by Vanderbilt, and our method of keeping it cheap and simple, and showing the hospital executives that if they work together they will actually get results.
BTE: So is ICA replicating this model around the country and building other health information exchanges using the model you guys developed in Memphis?
Mark Frisse: Oh yes, they are definitely out there trying to grow, but they are a smaller player in the market and have had a difficult time finding their niche. They are still running our system in Memphis and have tried to expand but it’s not easy when every consultant in America is chasing HITECH dollars.
BTE: So what do you think will be the big disruptor that will bring all of these information exchanges together? How is your exchange in Memphis going to connect to exchanges in Columbus or Chicago for instance?
Mark Frisse: Well, first of all I am very skeptical of state-level HIE programs. State government has a really strong position with Medicare, but why should broke state governments be in the health information business? To me it makes no more sense than the administration trying to pick winners in industries like solar energy like they did with Solyndra. State government plays an important role, but this notion that we are going to have a hub and spoke model where doctors can talk to other doctors across their region, or talk to the state hub, that is like AOL fifteen years ago, its not going to happen.
Instead, what is going to happen is two things; 1) integrated delivery networks will start moving toward accountable care, because they are going to begin to understand that they need to know what is going on because basically, if I am a hospital and I am doing coronary bypass surgery inside one hospital it is easy, but if I am trying to coordinate care across six hospitals and physician groups it is like having an assembly line with each participant coming from a different company and there is nobody setting the rules. In order to be competitive and create accountable care organizations we are either going to be creating employment relationships by buying up physician practices or creating formal ACO-type relationships and exchange, the verb form of the word, is going to be a vital component of that.
So you are not going to see a Chicago health information exchange, you are going to see a dozen different exchanges, that are maybe not even called exchanges, doing the same exact thing just to coordinate care among their own buds. This may in fact, at least for a while, effect cross-institutional relationships, but then everyone is going to wake up and realize that no matter how hard they try they aren’t Kaiser Permanente and patients go all over the place and soon they are going to get dinged for readmission so eventually they are going to need to start exchanging data and come back to a model like Memphis. Instead of spending tons of money on a Ferrari version of the exchange model, they are going to insist that the connection between hospitals is as simple as possible, it only does a few things really well like quality reporting or readmission reporting.
How are we going to get to the point where you are at Vanderbilt, for example, and we need to access a bunch of your information in Chicago is going to be a whole different effort pushed by ONC under the direction of Guy Fridsma. It’s creating enough standards so that I can go out to a neutral trusted broker who knows me and knows that if I send certain credentials to them, like a secured email to prove that I am who I say I am, then that broker can forward that message to you. Under federal laws we can exert certain communications with, lets say University of Chicago hospital and Vanderbilt in the form of a secure email. So rather than try to pump everything you need into the network, we will find it is actually point to point, just like it is on the internet. I just want to know, ‘are the data used in ways that are agreeable’.
We are going to see a dozen different models evolving here which are going to follow the internet trend and for anyone to say ‘this is the only way to do it’, is absolutely foolish and it’s not what the public needs. I would argue in fact, that we have created sufficient momentum with Meaningful Use Stage One that if Meaningful Use rewards and penalties were stopped the horse is already out of the barn, everybody is going to be adopting this stuff, and it would be a lot better if we had a rational market with a little bit of leadership from government to foster collaboration, and we allowed the market to pull out useful information rather than dictating what a problem list is, for instance, based on the findings of some conference calls and committees.
I am a supporter of what the Obama Administration is trying to do, but a lot of it does run counter to my free market entrepreneurial instincts. Sometimes I wish we would just stop and let the creativity of individual physicians and health systems use this technology to pull us along and we should then follow their guidance rather than some government policy.
BTE: It sounds like you see a business opportunity in that secured broker role behind the ever growing federated architecture of these massive information exchange systems?
Mark Frisse: There are a number of companies who have already found opportunities in the trusted information exchange business. One great example is SureScipts, where I was a board member for awhile before they merged with the PPMs, who has figured out they can send secure communications between every clinician and pharmacy in the US and have since applied that technology to direct clinician-to-clinician messaging.
These services already exist. Peter Drucker said in 1959 ‘I don’t need to predict the future, but I don’t have to because if I look around the future is right there in front of me, I am just not yet connecting the dots’. A lot of the things we are discussing to be the future trends are already there, it’s just a matter of how the market matures them.
BTE: How do you envision the Federal government transitioning their role in this area away from subsidized direct involvement to more of a passive hands-off role?
Mark Frisse: I have been involved in a few working groups and committees that have participated in helping to shape Federal information exchange policy and I would say the current administration has had a fairly balanced portfolio to date. I would further submit that 80 percent of the current administration’s plan is on exactly the same trajectory as the Bush administration’s plan. As is the case with almost everything in politics today, we can either get wrapped up in the polar opposites that exist between the parties and rest on the rhetoric, or we can recognize the reality that leaders on both sides of the aisle have been very supportive of the same policy trends.
So if you ask me, I would say we are suffering from ‘high tech fatigue’. By and large, we have a portfolio of policies the administration has been supporting, such as accountable care organizations and the implementation of stage one and stage two Meaningful Use. One great example of a program I think is fabulous and very much pro-entrepreneur is the Blue Button Initiative, which offers simple tools to developers and challenges them to find the value in the data by building products and services around the data. Other great initiatives that the federal government has been wise to support are the X-Prize competitions.
I think the next big, huge, heroic thing will be done in the area of standards. How do we actually build out these secure directories so they can talk to each other? How do we create uniformity? How do we create a list of standard features that developers can reference when building products so they know in advance what types of systems and devices their software will be capable of interacting with without driving up costs.
It’s only when you get too far ahead of yourself prescribing how a system can be used or restricting its use early in the game that can have negative consequences. I would submit to you that if Meaningful Use stopped at Stage One we may not have as many implementations in ambulatory care practices in the next 3-4 years, but you will have just as many good ones.