Health Information Exchanges
This week I am talking to Lisa Bari, Interim CEO for the Strategic Health Information Exchange Collaborative (SHIEC). Lisa started her career in the Bay area in digital marketing for Practice Fusion, and winding through CMS where she worked on the interoperability rules. Along the way discovering the incremental insight that for policy changes you need to find an open window for change
Once you do something people realize it can be done
In the case of Interoperability you need enough people to be successful and once you have critical mass policy change is easier.
The SHEIC organizations has demonstrated this, successfully connecting 81 different Health Information Exchanges (HIE) across 45 states overcoming the decentralized status in our healthcare system and helping a bottom up approach to demonstrate the multiple use cases for HIE’s beyond the traditional clinical data sharing to population health, SDoH and, health analytics. As we discuss HIE’s not only decrease waste but improve care by removing wasteful repetition and preventing harm.
Listen in to hear how the COVID19 pandemic amplified the value of HIE’s with communities and states that had invested heavily in the HIE infrastructure were able to stand up essential information resources quickly including bed and ventilator trackers, combining longitudinal records of patients with COVID19 and now moving into tracking immunization programs, and being able to fill the gaps of missing information relative to health inequity helping improve the distribution to match the need driven by the established priorities. You can also hear Lisa discuss where healthcare might go with a public option and what we can expect to see relative to patient identifiers.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Lisa Barrett. She is the interim CEO for the strategic health information exchange collaborative. Lisa, thanks for joining me today. Yeah, thanks, Nick. So, I always start off, because I think everybody has fascinating backgrounds. Yours equally. So tell us a little bit about your history and how you arrived at this role in this organization?
Lisa Bari
Yeah, absolutely. So I first joined healthcare. Back in the bay area where I’m from, I worked for many years in digital marketing and data driven marketing, and ended up as the executive Head of Marketing at Practice Fusion, the now infamous electronic health information exchange, or excuse me EHR, rather than exchange too soon for, for mostly primary care, independent primary care practices. And I left Practice Fusion, you know, very, very interested in health policy and less interested in staying in the sort of startup landscape of the Bay Area at the time. And then I went back to school as a, the oldest graduate student, and, and got a health policy degree from Harvard, and then realized that I really wanted to do more in the policy world. So ended up with the CMS Innovation Center, which runs all of the value based care models for CMS, where I ran health IT an interoperability policy for first the Comprehensive Primary Care plus model, which at the time was the largest test of primary care payment and delivery system reform in the country, and moved on to sort of advising the entire center and parts of CMS on health IT interoperability policy. And in that role, I co wrote the CMS patient access interoperability rule with many other talented folks and contributed from the CMMI perspective, and and then left to do my own thing. And through that ended up in this interim CEO role at cheek, which is the strategic health information exchange collaborative, the organization representing 81 different agencies across the country, to other folks to states, the federal government and other partners. And so in this role, I’ve been able to really work on expanding the visibility of the work that h eyes are doing across the country.
Nick van Terheyden
Fantastic. I mean, you know, there’s so many things within there. So first of all, you were in the Bay Area, and you left, there’s some people that would question that decision. So there must be somebody behind that.
Lisa Bari
Definite definitely, definitely working at CMS, you got to be here in Baltimore.
Nick van Terheyden
Interesting that that’s, and you’re still you’re still here, right? Yeah, yeah. Yeah, I
Lisa Bari
also had family ties to Baltimore into Maryland. So it wasn’t a huge stretch for me. But definitely, you know, if you want to be close to the work that’s happening around Medicare and Medicaid, it really is helpful to be in the broader DC area.
Nick van Terheyden
Good to know, I think, you know, for those people that are interested in those kind of areas, I think that’s an important thing to actually understand. And but then, you know, before we get into chicken, you know, some of the work there, I want to ask you about the interoperability rule if you were part of actual food. And, you know, I got us say, as an external person, you know, looking at this, my question really is, why is this just not being a mandate? From the very outset? Why is it It feels like this bolt on, it’s like security? Oh, we’ll deal with security. Why did it take so long? I know, you may not know fully, but I’m interested to understand why.
Lisa Bari
Well, beyond just that I am, you know, a scholar of health policy to some extent. And so I can tell you that with with government policies and public policies, it really is a question of creating, you know, the the right or finding the right policy landscape and finding sort of the open window. Once you do something, people realize that can be done. And that is really important in health policy in the US. When you look at something like the Affordable Care Act, which led to so many of these things, including the CMS Innovation Center, including obviously healthcare.gov you know, once it happens, then it expands people’s minds as to what is possible and I think With these interoperability rules, so many of us have been talking about, we just need to mandate we have to make it happen to make it happen. But you need enough people in states enough states enough health IT vendors enough HIE s, enough health care providers to start to get to the same place before you could really successfully mandate an air quotes mandate, something it has the time has to be right, the landscape has to be right. And so we got past that hurdle, we got to the place where enough people were saying, this has to happen, it’s time for this to happen. And that creates the opening for new policies, new laws, new regulations that actually get us, you know, closer towards interoperability. And now, just a couple years later, we’re looking back on the interoperability and patient access final rule and saying, it didn’t go far enough, do more, do more. And that’s, that’s great. That’s that’s actually how policy works. Right. And so I think it’s really about in the best case scenario, that’s how policy works. That’s really the best case scenario. So I think that, you know, I find, I think it’s really, I think it’s great, and a great sign that people are asking for more now, because that means we got it right, we didn’t go far enough. And there’s more to do. But that’s good. We’re moving down the path now.
Nick van Terheyden
So I think that’s really interesting. I, if I was to tease out of that the incremental steps of the inflection point is you have to have critical mass you deal to effects? A, A, let’s call it significant policy change, is that a fair sort of assessment? 100%.
Lisa Bari
I mean, I think in particular, in health care, particularly in the US, you know, I think you have, there’s so much decentralization, there’s so much that is left to the States, there’s so much that you know, the private sector has control of, so you really need to get to critical mass. I think this is a particular political ideology, to wait until the private sector has started to do something, or also started to create sort of standards and guidelines. But I think it’s actually pretty effective, right? You look at something like the Karen Alliance, who are trying to create these rules of the road for apps that needs to happen from that group. And it is going to be better if it feels like it’s coming from the bottom up versus from the top down. And so, you know, again, I’m not trying to get into the complexities of political ideologies of libertarianism or whatever. But ultimately, when you have, you know, this decentralized system that we have, it’s really important that things do come from the bottom up versus the top down to really, you know, get a foothold. And so I think that’s what you see with the interoperability of patient access final rule, and also with the Cures Act rule, and things that are coming after that. There is a little bit of mandating, but a lot of it points to things that were developed in the private sector.
Nick van Terheyden
Yeah, that’s really interesting. I think, you know, some great sort of insights there to help people sort of navigate this policy area, you know, certainly me as an external, non policy wall, you know, I’m frustrated watching from the outside, but I feel like that’s, you know, valuable insights in terms of how, you know, maybe individuals, companies and so forth can help push and change and move us towards this better infrastructure and goals. So, right, moving forward, you know, as you think about the health information exchange collaborative, obviously, you know, central tenants of that is interoperability, so that feeds in So, obviously, there’s got to be some positive impact for the regulations that are now rolling out. But you know, there’s some other things going on. Tell us a little bit about what’s going on. You talked about 81. That’s a lot of HIE seems to be sort of participating. Does that mean that we’ve got h 81 different groups that are truly sharing information that’s accessible and people can plug into that?
Lisa Bari
It really varies. So So sheiks coverage is 81 different HIE s across the country across 45 states. So almost all the states and HIE is really very, you know, it’s true, you can say when you’ve seen when he you see when he, however, you’re seeing HIV starting to really expand their work into all different kinds of use cases beyond just, you know, clinical information exchange. They are working in the public health space, they’re working in social determinants of health and community information exchange. They’re working on things that are more in the population health analytics area. So you’re really seeing HIE s that have good sustainability and good connections within their states. You know, really expanding what they do, but at this point, it really takes all kinds. I think the most important thing to think about here is that you know, HIE s are generally the result of an investment that state and a community of healthcare providers And payers and plans and other health care stakeholders have come together to create and work on for their community. And so just like we just talked about, it’s really tempting to come in from the top and say, we need a national solution. But that’s just not realistic on the ground, HIE s are different. And they’re important because they represent the needs and the preferences of their local and regional stakeholders who are generally multi stakeholder Coalition’s of people who were affected by this right, including patients, including providers, including payers and plans, including all other you know, community representatives. So so it’s just really important to recognize that health information exchange is local, as much as it is National. And so, you know, I think when folks think about like, what is what is the policy I can I can I can I can impose here to sort of make HIE happen, it’s really tempting to say, we’re going to make everybody do this national thing. But that’s not effective. What you want to do is make sure that information can be exchanged across jurisdictions and also to the federal government necessary, but still representing and reflecting and respecting that sort of local and regional HIE investment and effort. And so they’ll try to make it complicated, it’s not that complicated. The government should support the federal government should support state and local efforts, and also help build the national chassis and infrastructure and make sure that standards of technology are as standardized as possible, so that we can really enable nationwide interoperability.
Nick van Terheyden
So I think, you know, great progress, in terms of connecting many of the dots, you know, remains imperfect, but you know, for me, all of the lessons around incremental steps, you know, don’t let perfection stand in the way of progress delivering value. And then COVID-19 happens. Could we turn to that and say, ah, is potentially another possible silver lining outcome from the COVID-19 experience, do you think?
Lisa Bari
Yeah, I mean, I’m hesitant to say silver lining with anything involving COVID. But I do think that we are not a great would rather do without if I had a choice. But I think that in general, you know, what you saw is that communities, whether they’re, you know, states, and, and, and, and communities, regions, any place that has really invested heavily in their HIE infrastructure, they were able to turn to those HIE s and start getting information quickly. So many HIE started standing up things like bed trackers, ventilator trackers, you know, started doing things to enhance the information that states had about patients with COVID. Right? They one of the things that he can do really well is patient matching, and sort of combining those longitudinal patient records from many different places. A patient shows up on a hospital with COVID, and er with COVID. And you know, suddenly they’re able to access all of their records from various different places and understand their coexisting conditions. And I think that that is, you know, I’m really, really important in an area that they were able to step up quickly, and then it’s moved on from there, right? They’re assisting with things like immunization programs, they’re connecting the immunization Information Systems, they’re connecting and providing that missing information about health equity, you keep reading about how people who are getting the vaccines aren’t the people who are at the highest risk of dying from COVID. And so these are all places that HIE s are really playing that are really expanding. And, you know, making sure that you know, that programs have the right information at the right time. So I think we saw where communities had invested in HIE s in a serious way where there was real connectivity to the state and to public health to Medicaid, they’re able to collect on that and they’re able to get information in a faster and better way. And that’s just gonna grow. Like I said, there’s more and more connections coming out to immunization information systems that are being built up across the country. And you know, as that expands, I expect those HIE s to be more involved.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Lisa Berry, she is the interim CEO for the strategic health information exchange collaborative or chic for short. What a cool branding idea that is just going to say we were just talking about the the sort of value proposition This is really delivered to, you know, state regulators, you know, all of these regional groups that have been struggling with information and you know, data is the driver or at least it should be the driver of everything that we do, you know, in response to this pandemic, I think all the way back to sort of Early days from peds which, you know, shocking that we even had to sort of think about that, but that became a highly topical issue. Now moving into immunization programs, and, you know, trying to resolve some of the health equity issues that I think, oh, add significant value, as you think about this going forward, you know, we’ve got a new administration in they, they clearly have a different take on the world. And, you know, a different focus in healthcare. Tell us a little bit about where you see this going, and what the opportunity is for further development, expansion of some of these capabilities, and how you’re driving that?
Lisa Bari
Yeah, absolutely. So one of our big, you know, one of our big priorities that she can we primarily do work to make sure that lawmakers and regulators understand the role of HIE s, in all types of health reform issues and all types of improving quality initiatives, you know, advancing interoperability, all of those things are really important to us. So we do a lot of educating and trying to make sure that HIE s are not sort of left out of the discussion. Because we fundamentally believe that if you have invested, you know, millions and millions of dollars, through the high tech act into building out these AI use cases across the country and sort of state and federal partnership, you should not lose all that investment, you should make more of it, you should grow it, you should support it, you should make it just make sure it’s sustainable, so that it can actually further those objectives. Okay, so with that in mind, you know, we’re looking at all of this COVID, legislation, cares act, other, you know, other legislation to provide COVID relief, we want to make sure that some of those funds can go to further enhancing the HIE use cases are already in place. So that that’s a big priority for us. And I think that will continue to be a priority with the Biden ministration. One thing that I’m really interested in which we’ll see what they end up doing, previously, you know, the when when when, when President Biden was running for office, he talked a lot about the public option, the so called public option, which is an alternative to fully government provided health care, but rather just an option for people to purchase on the healthcare.gov exchanges that would be provided by CMS, let’s say, just like Medicare, and so you would just buy into the system, and they would compete against private commercial health insurers. And you know, this is a major policy lever, if it’s actually implemented, one of the things they could do is they could say, for the public option in quotes, you HIE, health information exchange is necessary. It’s a requirement. If you, if you are offering health care under this public option, we have to make sure that all of your health information is shared. So we don’t waste resources so that we make sure your information gets to the right people, for example, it could also, for example, require that any healthcare delivered under the public option has to be you have to make sure that everything is coded or inputted into an EHR in a certain way, they could require certain use of Standards and Technology they can’t require from other payers yet, there’s all types of things that could do with that sort of policy vehicle, including I think promoting health information sheets can be very, very interesting. So we don’t know what they’re going to do yet. They haven’t really given us a lot of signals. But I think if they go down that path, we would certainly encourage whether it’s working with an HIE as a member of Sheikh or not that that health information exchange, the verb is a key and core part of any type of health care that’s delivered by the federal government.
Nick van Terheyden
Yeah, it feels like, you know, if we stepped down that path, rather than adding it as an afterthought, which, you know, is the kind of things that we’ve done with some of the high tech act as an example where Yeah, that’s implemental this stuff, but Oh, they don’t need to talk to each other. Why would you need to sort of enforce anything? Even the architects of those programs, you know, lament the failure. So I think this is a great opportunity to sort of enable, you know, a more thoughtful approach. politics aside, I mean, I think to your original point of that critical mass, it feels like there’s a sense of critical mass and an urgency because so many people are sort of being displaced. And I think you’re seeing perhaps as a result of the HIE work that you’ve done, this inaccuracy that’s being shown through in the data that historically would have been unavailable, but not for all the work that you’ve done.
Lisa Bari
Yeah, that’s exactly right. And And going back to sort of the creating a critical mass you see in the CMS interoperability and patient access final rule, and the recent proposed rule on interoperability, and provider burden and prior authorization, which by the way, that the future of that rule, which was pushed through at the very end of the Trump administration, is in question because the administration has pulled back all of these rules that were finalized very recently. However, if you look at the provisions of that, they’re really just continuing to build on the previous interoperability rule. And those rules that rule and those rules, they really start to move us in that direction. They say, if you’re a payer, or a plan, who is regulated by CMS, you have to share information, right? That’s what these rules are asking for. They’re saying you have to share electronic health information by a standards based API. Great, that’s wonderful. So that’s, again, building the critical mass of saying, fundamentally, you have to share information on health care, and here’s how we’re going to get to it. This would be just another way of sort of continuing to build on that and saying, the underpinnings of everything, the basis for everything is health information must be shared, we must achieve interoperability. We believe HIE s can help sheep believes he can help with that, with that, with actually making that a reality. But fundamentally, the idea is, health information must be shared, stop using excuses, stop wasting money, stop wasting time, got to got to enable that exchange one way or another. And so that’s kind of what that’s where I would see this going.
Nick van Terheyden
Yeah, and, you know, not just wasting of resources, but better care, because an awful lot of those wasted resources are in fact, repetition of things that we didn’t need to do, we just didn’t have the available information. So I found a positive spin as a, in addition to the sort of, you know, saving of money, this is better can so.
Lisa Bari
And also, I should say also patient time, right, I think, you know, we talk a lot about provider burden, and certainly the most recent rule focused on provider burden. But you know, it really fundamentally harms patients, when they are unable to access their information, which is, again, sort of the underpinning of 21st Century Cures, and the thinking behind information, blocking, and regulating that and requiring people to not information block. And this all results in an incredible amount of time and effort on patient’s behalf that is is really, you know, often ignored by the healthcare community. But ultimately, we hope this results in patients being able to easier and easier to easily access their information in the form and format that they choose, especially if it’s in electronic form and format. So, you know, hopefully this also goes to leads us to a future where patients don’t struggle as much to get their full information.
Nick van Terheyden
So in the balance of the time left, I know this is a big question, but you intimated a little bit, you said the HIE isn’t good at patient matching. And one of the reasons that we have to do patient matching is that we have no national patient identifier, you know, social security number aside that, isn’t it? It’s never meant to be? Do you see a pathway where that either that’s necessary? And if it’s necessary, viable as a potential future? Yeah, I
Lisa Bari
mean, I’m not willing to sort of put my thumb on the scale either way from a sort of a universal patient identifier or not. But one thing I can tell you is that if there is a ban, on even researching better options, were in a dangerous place, right, just like the the fact that there was a band for a long time, and it still sort of is on on funding for gun violence mitigation. Same thing, there should never be a ban on researching better solutions at from Congress or anyone else. And so the only thing I can certainly say is that there should never be a ban on researching information about how to improve patient matching, I’m not willing to put my thumb on the scale yet on whether it needs to be a single patient identifier, or just better tools. But I do know that when there’s a ban, we have a problem. So we’ve got to find solutions. We got to find them faster. Ha you have great information in this space. And they should their their expertise and years of experience is certainly pulled upon by federal regulators and lawmakers to figure out the best solution.
Nick van Terheyden
I think that’s extraordinarily person. And, you know, the idea that we ban research. I mean, unless there’s research, I mean, I guess but you know, that principle, it just seems really strange to me. So I think that’s a great point to close with. Unfortunately, as usual, we’ve run out of time, I think, you know, fantastic conversation, I think tremendous opportunity for AGI as, you know, both as a sort of inflection point but also building on you know, capabilities. We’ve had just remains for me to thank you for joining me on the show Lisa. It’s been a pleasure.
Lisa Bari
Thanks so much. Likewise.
