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Thoughts, comments, news, and reflections about healthcare IT from Microsoft's worldwide health senior director Bill Crounse, MD, on how information technology can improve healthcare delivery and services around the world.

Cracking the code on Health Information Exchange. Is it time to wipe the slate clean and start anew?

Cracking the code on Health Information Exchange. Is it time to wipe the slate clean and start anew?

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Three related columns in HealthcareITNews caught my attention this morning. The headlines pretty much say it all:

1. Satisfaction with HIE solutions drops.

2.  Vendors missing boat on HIE needs.

3.  CommonWell names 3 biggest HIE hurdles.

imageOver the years, I’ve written more than a few HealthBlog posts on the topic of health information exchange (HIE) and why I feel so strongly that most of the initiatives currently underway are missing their mark. As I’ve stated before, during my worldwide travels I haven’t yet come across a country that has accomplished a truly national, interoperable, bi-directional, fully functional HIE. Those few countries that come close are more like a large American city or small state in size, perhaps mirroring some of the moderately successful regional or state-wide exchanges currently operating in America. Over the years I’ve also watched implosions of national HIE attempts in several countries that have failed miserably despite billions of dollars being spent on the efforts.

Reading each of the articles referenced above, I once again reach the conclusion that what I have been evangelizing as a better model for HIEs still rings true. Stated simplistically, contrary to a model that attempts to bi-directionally connect everything to everything in the complex ecosystem we call healthcare (i.e. every doctor’s office, clinic, hospital, health system, lab, imaging center, pharmacy, insurance company, etc.) we should instead build systems that connect everything to the patient and aggregate information around the patient as a life-long, longitudinal continuity of care record that is for and about the patient. Every citizen should have access to a highly secure cloud account, hosted by a trusted provider, that holds this information on the patient’s behalf and gives the consumer/patient the exclusive right to share their information with whomever needs to see it; be that a family member, caregiver, nurse, doctor, insurer or anyone else who is involved in that person’s personal health and well being. A citizen would simply notify and authorize any person or entity that generates health information about them how to access and deposit such information into their “account”. As the citizen or patient moves through the ecosystem of care, their record and access to it would move with them. Since ideally a citizen should have choice about the trusted entity that stores health information on their behalf, there must be standards in place so that all data in the citizen’s account can be easily transferred, with permission and when desired, to another trusted cloud service provider be that a commercial enterprise, financial institution, government agency, or other kind of organization.

imageIf the model I’m proposing sounds a bit familiar, it should. I’m basically describing a service that is architected much like Microsoft HealthVault. In fact, there are several progressive countries around the world who, after watching the colossal failures of many national HIE initiatives, are now proposing models for HIE that look very much like what I have described above. Some of those countries may even use HealthVault as their service provider. Each citizen gets an account. Every vendor must be able to connect with and deposit structured information into the account. Wherever the patient goes, the information goes too—not just regionally or nationally, but virtually anywhere in the world.

I know that I am oversimplifying the case. However, you would be amazed how well this model resonates every time I sit down with a healthcare executive, clinician, health minister, or anyone else who is struggling with how to provide HIE services for the populations they serve. Is it time to wipe the slate clean and start talking about an entirely new model for HIE? Read each of the articles at the top of my post. What do you think?

See also prior HealthBlog posts on this topic:  

Microsoft HealthVault opens to the world……. or at least a lot more of it

Would you pay 50 cents a year to have your health information available on-line?

Bill Crounse, MD          Senior Director, Worldwide Health             Microsoft

  • Bill - I am shocked that after all these years in the industry, you still have the temerity to talk common sense and simpler solutions!!

    Of course, this entire Health records stuff needs to be centered around patients, be provided to patients by default and should be a patient's property, in their control. Like everything else about our healthcare ecosystem, we have created a labyrinth of gross inefficiencies in patient data exchange due to narrow self interest driven entities. Wish we could wipe the slate clean and truly start over.

  • Aditya,

    Thanks for your comment. We are obviously on the same page. And you'd be surprised how many others our perspective. It will happen. There is simply not enough money or time to continue on a path that is doomed to failure.

  • Personally, I believe HealthVault is one of the industries best kept secrets.  Helping the industry make the Copernican shift to placing the patient at the center, and making them the primary custodian of their own information is simple and elegant.

  • The real shift will happen when we all realize that patients are not only "part of" their own care team or their family members but in many cases the "primary care giver"

    Not only are they the only part of the health care eco-system not paid to be there but they are increasingly asked to pay larger and larger dollar amounts but tasked with increasingly complex care with very little support.

    HealthVault could be an amazing part of the people/process/technology solution. It could not only bring the data from their clinical encounters into one place but serve as the locus for collaborative care that most of us have only ever seen in pieces.. What if you could go there for  your latest labs but watch best in class videos for patient education and even schedule a quick tele-health consult with a specialist?

  • How does this model get a lab result back to the ordering doctor in their core office EMR system?  How does this model get information relevant to a specific transition of care to the other provider to whom the patient is being sent?  How does this model get an electronic order from the office to the lab so that it can be processed appropriately?  How does this model get an event notification to someone who otherwise would have no idea something occurred to even go look for it?  Etc.  Etc.  HIE is not a clinical database in the sky that everyone accesses, centered around the patient or otherwise.  Healthcare is a business and it needs to transact its business electronically as other industries do rather than the heavy reliance on paper it has historically had.  That makes up the complexity of the HIE effort throughout the US and the world.  Is it hard?  You bet.  Has the hype from the vendors been far more than the reality of what they could do?  Certainly and you see it in the articles expressing disappointment that "HIE" hasn't solved all the worlds problems in healthcare.  Do those things mean we're focused on the wrong thing.  No.  The solution you pine for doesn't exist because it doesn't solve the core business problems being experienced.  There are probably good reasons why HealthVault and Google Health didn't have the success some thought they would.  But we ignore those reasons and think it will happen anyway.  Its a good idea and will probably have a place in certain areas, but it is not the single answer to automating the complete business of healthcare which is what HIE is attempting to solve.  But it is these sorts of simple answers that confuse the industry in the complexity of what HIE needs to accomplish to truly make sure the healthcare industry operates efficiently and electronically on behalf of its patients.

  • Doug, I've posted some thoughts on your comment over at my blog here: http://bit.ly/1ilpdMA ... I believe the patient-centric model can do more than you've given it credit for. Would love to hear what you think!

  • I could not agree more with this timely post.  Patient/consumers are moving through the system transactionally and longitudinally.

    -  Allow the patient/consumers to assist in brokering the HIE deal.  We now have the technology that has moved beyond "smartcards" - the personal health record, BlueButton, and mobile devices can function in that capacity hand in hand with Direct.

    -  Allow me to get my trapped data out of multiple "tethered patient portals" in an automated fashion to where I want it to go- primary care, specialty, research, and globally as I travel or re-locate.

    -  Allow common sense to prevail-- wipe the slate clean.  From a clinician perspective this will reduce the manual care coordination process, and most importantly to never solely place the HIE burden on the sick patient.

  • Should Health Information Exchanges go back to facilitating individual "Personal Health Records" solutions for patients.  This solution, where the patient uses something like Microsoft's HealthVault, had some traction a few years ago.  The basic idea was that the patient creates their network of providers by "walking around" and visiting labs, hospitals, PCPs, Specialists, etc.

    It lost traction for a number of reasons, not least of which was the seeming inability for insurers and others to easily aggregate the information for their own purposes, beyond coordination of care for the patient.

    But is it time to step back?  In a sense, wasn't the federal government's suggestion that HIE's adopt a "Direct Secure" model of information sharing a "step back" from an HIE, whether that was a federated or a central data depository model?  And does anyone else remember that, 2 years ago, Direct Secure was supposed to be an interim step or way station to a more robust form of information-on-demand HIE structure?  Dr. Crounse's approach may be an appropriate strategic retreat for state HIEs.

  • I too believe that patient centric HIE (HIE of ONE) is the future. I feel that a model that we are delivering in our metro area will be the model that will gain the most traction and last the long haul because like a bank, it has a business model.  

    1.Consumers will have an account in their Regional Health Information Bank. The bank will collect and store patient health data. Healthcare providers auto-deposit information into the patient's account. Patients may or may not want to view the assets deposited into the account. This allows the patient that will never use a PHR to participate at the local level.

    2. With patient consent provided (or opt out depending on state), providers may auto-withdraw assets from the Health Information Bank. The patient is provided (like security settings on Facebook) what information is shared with who.

    3. IF a patient wants to leverage their assets in the bank, they can optionally use HealthVault to be their "online bank" interface to their account. As well, they can leverage the APIs of HealthVault to "deposit" additional information from any HealthVault source to their account.

    4. Just like a bank lives off the assets deposited, the Regional Health Information Bank is sustainable (even profitable) by leveraging de-identified assets.

    I implore your intelligent thoughts on this!

  • I teach Healthcare Information Systems in the Health Informatics and Management graduate program at UMass Lowell.  This is what I've been telling my classes for five or more years.  We can get to health information exchange quickly and inexpensively if we only work with the patient and use the existing CCD/CCR standards to capture and share information.  Epic is already doing this with its Lucy PHR (see www.epic.com/software-interoperability.php).  A great product opportunity for Microsoft, and one that could transform the HIT industry.

  • Micah, you are describing the Shared Care Plan application (www.sharedcareplan.org) that my company (Congral, LLC) developed for Whatcom County, WA some 5 years ago. It is still running serving many thousands of patients and just recently we added the prototype of the transition of care module, which allows group of Care Managers (aka Health Coaches) to assists the patients in home recovery after surgery to be as compliant with the prescribed regimen as possible.

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