HIStalk Advisory Panel: When to Join an HIE 7/16/12

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This report involves a question submitted by a health system’s VP of physician systems. When is the right time for a provider to participate in a new HIE initiative: when it first launches, when it reaches financial stability, or when physicians and/or patients demand participation?

At Launch

• Probably upon launch or shortly thereafter. It could easily become chicken-and-egg and never reach the latter two without significant participation at the onset. If there’s never critical mass, financial stability and public awareness will likely never happen.
• If everyone waits until the HIE reaches financial stability, very few will get off the ground. It is important to support these as soon as they are available IF they can show a reasonable path to sustainability (if they can’t they shouldn’t be supported.) Limited term funding guarantees, a fair sharing of costs among providers, hospitals, and insurers (the major beneficiaries) should all be considered.
• Our hospitals is an HIE founding member, but our providers derive almost zero benefit from it. There are a number of reasons for this, but workflow is probably the most important. So, any advice I have about when to engage providers in an HIE must be taken with a very large grain of salt—it could reasonably be argued that I don’t know what I’m talking about. That said, I would say when it is first launched. If you wait until it is financially stable, it may fail because you are waiting.
• Excellent question, and one that we’re wrestling with as a nascent HIE is forming on our doorstep. Our health system has chosen to be a charter member (long before financial stability or patient and physician demand) in order to ensure this thing evolves in a way that matches our business interests. However, having previously been involved with a failed statewide HIE, I know all this effort may come to nothing.
• When it first launches, especially if vendor has a significant share of the market.
• Having been involved back in the early 2000s when we called them RHIOs and everyone loved  the idea but didn’t participate, I would say that getting in early and driving the direction and focus is better than jumping in late and playing catch-up. I think an early aggressive stance is better than sitting on the sidelines. I understand that there are cost issues to play in an HIE, but I would rather try and make the rules than have to follow the rules built by others.
• I believe that getting in at the ground level, when it first launches, is important. The provider will have some voice in necessary changes, will probably get in for a lower cost, and will not have to wait in line down the road when everyone jumps on the bandwagon.
• The right time is at the beginning so they can be involved in functionality and governance. But the more pragmatic time is when there is a definite need and business model to support it.

When Other Providers are Jumping On

• You definitely don’t want to be in early. Too many bugs and no real benefit because there are no other providers to collaborate with within the system. You also don’t want to be last in. There is too much risk of losing patients to providers who offer the service from an HIE with a patient portal. As an MD, I would start publicizing that I will be joining and when patient demand reaches a level that ensures interest and benefit start the process.
• For most providers, the right time is when the local hospitals start using the HIE. The real benefit for the independent providers is to exchange data with hospitals. Unless there are hospitals signed up, it does not make much sense to invest time and money into this fairly resource-intensive process. Alternatively, there are several incentives (state or federal outside of MU) that help the providers sign up to HIE. Independent providers should seriously consider joining the HIE if one of the financial incentives is strong enough.
• When the health system the provider affiliates or partners with is actively engaged – makes the individual provider’s efforts more worthwhile and helps to ensure that patient information useful to the provider is going to be available via the HIE.                          

When the HIE Achieves Financial Stability

• When it reaches financial stability. We have three that we could hitch our wagon to, but two of them probably cannot sustain their current financial model. I’m glad that we waited a year before making a decision. Our physicians and patients are still not demanding it, but it’s the right thing to do. If we wait for them, it might not happen for another three years.
• We have providers who fall into each of these categories. However, in the spirit of what is best for the patient regarding continuity of care and cost reduction, I would argue that once an HIE is established (assuming early adopters have technically proved it out) and sustainable, that would be the best time. Once patients start demanding, you are already behind the curve and have suffered from a customer service perspective.
• After it reaches financial stability, but before physicians and patients demand participation. In that window, you should move when you are almost but not completely comfortable that it will be *the* platform.

When Benefits Are Compelling

• Only when the benefit outweighs the risk. Only when the information offered by the HIE is worth something to your clinicians. We have yet to reach that point.
• When the participant (physician, nurse, care coordinator, etc.) feels that there is something useful being offered by the HIE, they will join. There must be utility in the service or potential participants won’t be bothered. What is utility? The answer depends on the person offering and receiving the information. Some physicians may want a simple hospital discharge or something as detailed as a complete CCD. Some may find a PDF that can be attached to the patient record useful; others may find utility only in data being stored in fields within their EHR. I just sat in a think tank meeting yesterday (my friends would find irony in that statement!) where a similar topic was discussed for hours among various stakeholders with no clear consensus. All that being said, sustainability is also a concern. Maybe some participants will operate under the “I’ll take what I can get while I can get it” mode, but many others will be more cautious and wait to see if this new service will be around for the long haul. In a pay-to-play model, I would imagine that participants would become hyper-sensitive to both of these points.
• I’m not sure there’s a magic answer here. The right time should be when any benefit can be realized for providers and/or patients. Ideally, you want a guarantee that an HIE will be financially stable and provide some benefit to the community. However, if someone doesn’t take risks to be the first, then you don’t make progress.  My experience to date is as follows:  our state HIE has wonderful presentations on their technology architecture, but no answer to how they will sustain the solution once the grant dollars dry up. It’s hard to create executive support for any initiative if you can’t tell them how much it’s going to cost. Creating a regional HIE would be an alternative solution, but the competitive environment between the practices and hospitals in the area may make this a pipe dream. Instead we have one-off integration attempts between select hospitals and practices. I think it’s a shame for the patient – most families will end up having their data compartmentalized throughout the community, and if MU Stage 2 continues with the proposed rule, patients will have to utilize multiple portals to gain access to their information. This is not progress.

When Physicians or Patients Express Interest

• I would say when physicians and/or patients are interested. HIEs are fee based, so value needs to be identified before committing. Stage 2 MU has some specific criteria regarding electronic exchange, so timing could be a moot point.
• Generally I would say when others demand your participation, but that is not what we are doing. We got involved right at the beginning, assisted with vendor selection etc. It is more expensive to be involved at the beginning, but you can impact the direction more that way. If you miss the beginning and have no input, then wait until physicians demand it. All of these are being funded on the backs of hospitals, so spend only when you need to.
• This question sounds like it comes from someone at a large organization. From the small practice perspective, not many providers really think about this. Most providers in private practice probably don’t know what HIE stands for. We have 10 providers (doctors and physician assistants). Of them, I know of one who might know what an HIE is. If the demand comes from providers, it will start at large organizations like Kaiser and hospital systems and then spread to communities. 

Depends on the Organization or Area

• There is no right answer here:  much like any other “bleeding edge” vs. mainstream vs. laggard discussion, jumping in too early can have more pain (growing pains, financial pains, failure) it also can be a marketing tool for patient engagement and connectivity. What is the value of that? Clearly, it depends on the locale, competition, etc. Understanding the dynamics of the local market and needs is more important, and having realistic expectations for all is a necessity.
• I think this depends on the size of your organization. Larger institutions are typically the earlier adopters and have the resources to get the HIE launched. Smaller institutions will join as it becomes more stable.
• The timing decision to participate in a new HIE depends on the culture of the provider organization. There are the early adopter benefits of participating at the beginning. You may be viewed as a thought leader and innovator. Additionally, your organization may shift faster to leverage and benefit from the exchange. There may also be early adopter risks of sharing without clear guidelines for exchange participants. Organizational support tends to be key regarding timing along the HIE maturity curve.
• It depends upon your broader competitive and clinical integration strategy. The more strategic, get in early. The less strategic, fit it in when you can, if it makes sense at all to do.
• This is really a chicken and egg question. If a provider does not start early, then the chance of the HIE being sustainable — and more importantly, set up in the best interest of all stakeholders — is greatly reduced. However, if the ante to be at the table early is too risky for an organization, then they should stay on the sidelines until the HIE is proven functional and sustainable. The issue across the country, of course, is one of sustainability… and politics.  In our state, an insurer/provider conglomerate tried to convince the state to run on their infrastructure. It took great effort to derail that thought (imagine you are a provider and the insurer side of this company has a deep dive or this kind of data to potentially use against you in contract negotiations) AND as soon as a new direction was set, the state then pushed the provider consortium aside for another politically-driven organization. At that point, the providers exited.
• HIE participation depends on multiple aspects, and requires frank assessment of both the HIE and the participating provider. If the HIE is inadequately funded, its leadership does not have a proven track record, and questions arise about its stability, then a provider organization should not devote resources to what may turn out to be a failing proposition. The converse is also true: if the participating provider is inadequately funded and dealing with its own internal problems (either staffing or trying to meet government and more pressing internal organizational goals,) then it should not try to devote scarce resources even if the HIE is a stellar player. The character and experience of the participating provider also should determine time of enrollment: if the provider is tech-savvy, at the forefront of the implementation curve, and has both time and resources to deal with startup issues, then they should be a first-launch participant. However, if the provider expects smooth sailing or a plug-and-play experience, then waiting for maturity of the HIE is in order. Looking back on historical ease of implementation and rollout of EMR to individual physicians may provide a template for which providers should go up first on an HIE and which should wait.
• Depends upon (a) the provider’s tolerance for ambiguity and willingness to shape the HIE. If high, get involved when it first launches and be among the first to participate. You can always use it as a marketing tool with your patients to show how advanced you are. If low, wait until there is demand. If you wait until it reaches financial stability, you’ll grow old and die first in most cases. (b) the cost of participation. There will be limited value at first, sort of like those who had the first telephones when their neighbors didn’t , but there may be discounts (temporary or permanent) that could be negotiated for early participation.