By Carladenise Armbrister Edwards, Ph.D., MS.Ed

This public commentary was written in response to the February 8, 2012 Brookings Institution Governance Studies report entitled “Health Information and Megachange” by Darrell West and Allan Friedman.  As referenced here http://www.ihealthbeat.org/articles/2012/2/9/report-finds-variability-in-effectiveness-of-state-health-data-exchanges.aspx

Compliments to the Authors

Before I share my thoughts on the article by West and Friedman titled “Health Information Exchange and Megachange”, I want to compliment the authors and the Brookings Institution.  I absolutely love the theme of this article and I truly support the authors’ attempt to bring clarity to a very complicated topic that has huge implications for the health information exchange movement that began even prior to President Bush’s executive order in 2004.  The authors have done a fine job of identifying key issues related to driving policy change and they have gathered insight from some of the most well-informed and influential HIE leaders, including my friends and dedicated soldiers in the movement – Marc Overhage, Janet Marchibroda, Jennifer Covich Bordenick, Mark Frisse, Micky Tripathi and others.  Each of them helped drive home the point made by the authors that megachange is complex and requires significant consensus building, financial support, and political will.

The distinctions made between each state on the megachange color wheels displayed throughout the article were very insightful and arguably accurate in that each of the states started in a different place and each state has landed in a different place.  Time will tell what the final outcome will be for each state when the 2014 alarm sounds, but based on this report it does not look good.

Finally, the authors hit the nail on the head by re-iterating the fact that dominant players, governance, and the degree of consensus are key drivers in implementing HIE at the state level.  I do not disagree with the conclusions made in this regard at all; however, I do contend that full implementation of HIE will continue to experience stagnation and failure, if we continue to focus on the micro-level issues such as the players or leadership’s capabilities, participatory governance, and agreement on issues like financing and privacy and security.  The major barrier to successfully achieving the megachange is the actual implementation strategy, and not the individuals or entities responsible for implementing the strategy and their willingness to agree on complex issues.

Observations

After leaving my post at Cal eConnect, I sat still for several months to reflect on my experience and the challenges of running a state level HIE.  I recently started documenting what I think are valuable lessons learned that may benefit my successor and peers in similar posts across the nation.  I shared my first commentary with JHIM earlier this week. It is entitled “Stop Ignoring the Consumer: Consumer Involvement in HIE Governance is Key to Transforming Health Care.”  The Brookings article did not speak to the need for consumer engagement, but I believe it is a key HIE governance issue that I would love to discuss further and to get insight and feedback on as it is central to successfully implementing sustainable HIE.

The second issue that needs to be addressed related to the challenges of HIE implementation is the nature or structure of the current governance models. The current models do not adhere to any of our basic tenets or principles of organizational development, business management, non-profit governance, performance management, or behavioral and environmental change as taught by the experts we all know and love like John Piescek, Jim Collins, John Kotter, Peter Drucker, Urie Bronfenbrenner, and so on. You all know these experts better than I do and you probably have even had dinner with many of my icons.  I simply know and love their work and believe their thoughts and methodology is important to these discussions.

So, within that context – please think about this. Each state has developed a governance structure for HIE that is based on the tenets outlined in ONC’s State Cooperative Agreements for HIE that require a governing board that is comprised of multiple competing entities who represent the existing health care delivery system and all of its problems.  These non-profit HIE Boards are then comprised of individuals who represent business ventures in health care that are NOT necessarily highly motivated to change the status quo, unless it has a positive impact on their business and bottom lines.  Many of them admittedly participate solely to ensure that the interest of their organizations and constituents are protected and not harmed by decisions made by the HIE. These boards are then given a non-profit socialist mission to make health care more affordable and accessible to all using health information technology that enables the sharing of the very information that the board members have been told to protect.   All of this is happening as part of a government mandate to be entrepreneurial and start a non-profit business with public funding that must be sustained with private dollars post implementation.  So, as my kids would say: “Seriously?”

So, here is the fundamental question: Is it really logical or possible for competing for-profit entities to start a non-profit business with government money and then agree to financially sustain the effort that adversely impacts their business when in all honesty, consumers who are the people we are trying to protect have no idea what the value of the entire endeavor is, and most of them
are probably unaware of how it ultimately impacts our mega-goals of (1) bending the unsustainable cost curve that governments and employers are experiencing and (2) improving the health and well-being of our nation so we can continue to compete in the global economy?

Proposed Solutions

Having many times been in the position of trying to herd cats, I am fairly certain that the above is not possible or logical. As stated so well on page 3 of the Brookings article, the war on poverty was torpedoed by the “win-lose nature of income redistribution as a policy goal, insufficient cooperation among the relevant federal agencies, lack of clarity in program vision, and the bureaucratic nature of federal management style.”  I believe that the war on unsustainable health care costs, suboptimal quality, and limited health care access is being torpedoed by the same perils.  So, what do we do?

1) MAKE A DECISION: Each state (or the federal government) has to make a decision – Do we want to radically transform our health care delivery and financing structure so that we can reduce government and employer spending and improve access to quality and affordable care for all?  Yes or No?  If Yes, then…..

2) COMMUNICATE BROADLY AND NONDISCRIMINATELY: Each state (or the federal government) needs to make the PUBLIC (especially consumers) aware that this is our Mega-goal and their support and cooperation is required to make it happen.
This is not an issue that simply impacts the health care industry or one that should be driven by the technology, health plan, and provider lobbyist.  Reforming the health care delivery system is an issue that impacts all Americans and everyone deserves the right to know the extent of the problem and how they can contribute to the solution.  We need a mass public awareness campaign that educates and informs ALL.

3) STAY IN YOUR LANE:  Each sector needs to design and develop their own HIE game plan and stay in their lane.  The current HIE governance model depends on the ability of individuals with limited knowledge or expertise in designing HIE solutions to make decisions on things that are often outside of their common understanding or experience.    This is not intended to insult or offend any of my friends who serve on HIE boards.  I respect them all for their contributions and willingness to participate in the collective game, but running a mission-driven, publicly funded non-profit is NOT the same or anywhere near the same as running a for-profit, publicly traded corporation or even a member-driven, well-funded association. Each entity at the HIE governance table, needs to step back and establish an HIE war room at their home base and focus on running that, so that their organization is contributing to forming a solution that is mutually beneficial as opposed to sitting at a table of adversaries where they are driving holes in the solutions that someone else comes up with.  Specifically,

1. The private sector needs to figure out how they will help the state or the nation achieve this Mega-goal while continuing to meet the expectations of their shareholders.  If they need to change their business models, then do it.  If they need to change the types of products and services they offer to the market place, then do it.  If they have to go out of one business and start an entirely new business, then do that.  The private sector can still make money, but just not at the nation’s expense.
2. The government needs to decide if health information exchange is going to be a private venture (and then let the private entities figure it out) or a public utility (and then create the policies, regulations, and funding vehicles necessary to implement and maintain). The money that has been distributed to the states for the development of 54 disparate HIE systems could be used to develop 54 co-existing and aligned public utilities that will ensure the private and secure exchange of health information is possible, economical, and regulated.
3. The consumers need to hold the private sector and the government accountable for achieving the Mega-goal by voting with their pocketbooks!  Don’t purchase products or services from vendors who are not committed to the goal. Consumers have done this to drive environmental change, why not drive change in health care? For example, if the pharmacy and the physician refuse to do e-prescribing – find one that will.  If the EMR vendor refuses to create an interface to the PHR that enables you, as a physician to effectively communicate with your patients, then don’t purchase that EMR.  I know we can drive this change if all parties are better informed and fully educated on the issue and understand the megachange we are seeking to achieve.
4. The HIEs or RHIOs (formerly known as CHINs) should re-think the focus on leadership and name changes and that they focus on administrative re-organization and replacing the governance model with one that is capable of managing to the performance outcomes that are directly aligned with the megachange we are ALL trying to achieve. They need to create short term goals and a longer term vision that stays focused on the War and the steps required to end the War!  I believe all public servants should be in the business of writing themselves out of business by focusing on solving the problem at hand and then moving on.

I believe these public-private partnerships called HIEs could become a formidable force that demonstrates to the world our capacity as Americans to identify a complex problem and solve it.  Americans have successfully driven change in the past and I am confident we can drive this change into the future!  As a nation, we have faced many institutional challenges and somehow we have managed to tackle them.  But it was not done out of context nor single handedly by the industry that created the problem in the first place. Megachange requires a behavioral, environmental, structural, and policy context (as alluded to by the authors on page 2) and a MEGA-GOAL. It is critically important to maintain that context and create a Mega-goal and empower and incent the leaders in each contextual situation to take positive and affirmative actions that will ensure the change will actually take place and
the goal is achieved!

I could go on, but will stop here, as this is already more than I wanted to write and more than any real important person has time to read. (SMILE!)  I started this commentary with the intentions of thanking the authors for their efforts to explain the challenges of HIE Implementation and Megachange (which really needs to be separated from how the HBEs are being implemented) and to offer my solutions, in the event others want to continue this dialogue.  I look forward to any opportunity to offer additional perspectives on HIE implementation, financing and sustainability, consumer engagement, politics, as well as the relationship
between HIE and the Health Benefit or Insurance Exchanges.   As someone who has been more than intimately involved in the advancement of electronic health information exchange and driving organizational change through strategic planning, business development, and the adoption of technological enhancements for over 15 years, I have gained “a little bit” of knowledge and I am always looking for the opportunity to share.

I welcome your feedback and an opportunity to work with other change agents on this very important issue.  I have been a solid follower of The Brookings Institution and have benefited greatly from the Institutes scholarly work and incredible social consciousness.  I am honored to have the opportunity to respond and participate in the dialogue.

Please contact me directly or share your comments on my blog:

Carladenise Armbrister Edwards

The BAE Company, LLC

carladenise@thebaecompany.com

510.285.9069 office

850.445.1561 mobile

http://www.thebaecompany.com/blog/

http://www.linkedin.com/pub/carladenise-edwards/4/3b2/957

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