National Health IT Week preview: HIEs a challenge for next ONC head

CHIME fellow Charles Christian talks about National Health IT Week, HIE implementation and challenges Farzad Mostashari's successor will face.

SearchHealthIT and the College of Healthcare Information Management Executives have collaborated to bring you a series of interviews with CHIME fellows to preview National Health IT Week, Sept. 16-20, in Washington, D.C., as well as offer thoughts on the legacy of outgoing federal HIT coordinator Farzad Mostashari, M.D. This interview features Charles Christian, longtime contributor to Indiana's health information exchange (HIE) efforts and current VP and CIO at St. Francis Hospital in Columbus, Ga.

Charles ChristianCharles Christian

What do you see as Dr. Mostashari's biggest contribution to health IT during his tenure at ONC?

Charles Christian: One thing he did, particularly after he became coordinator, was surround himself with people extremely knowledgeable about the industry, David [Muntz] and Judy [Murphy, both deputy national health IT coordinators] and Jacob [Reider, chief medical officer]. Really good, bright folks who know healthcare operations and how HIT regulatory pieces are going to impact the delivery of healthcare.

The other thing Farzad did a really good job of [was that] he was a convener. He convened various groups, he made himself available, he listened quite carefully. I can't tell you how many conversations I had with Farzad about the application of the regulatory things. We also had a lot of conversation around the impact of certification issues. He did a really good job of listening to the industry and some of the struggles that we were having implementing meaningful use requirements. That should be his legacy, as far as I'm concerned.

What kind of person will ONC need to replace him?

Christian: There's been a precedent set: All the previous coordinators including Farzad were physicians. I think there's a credibility factor -- when you're having conversations with physicians, you've been there, done that. David Brailer [the first coordinator, 2004-2007] got it from the very beginning: If we do not bring the physicians along -- because that's where the majority of healthcare takes place -- and get their offices automated, anything else, such as [HIE] or acute care, [can't be automated either].

Personally, I'm not sure a physician is what's going to carry it forward. I don't think we need someone who has deep academic roots. I think we need somebody who understands operations, because now we're into deployment and operationalizing the automation. Meaningful use stage 1 was about deployment. Stages 2 and 3 are about incorporation, engagement and outcomes. You really, truly have to be process-oriented, taking that automation and making the practice of medicine more efficient and safer. I don't think that we should have a rate-limiting criteria that it has to be a physician. I think there are individuals already there who would do a really good job of moving the ball down the field.

It's painfully apparent -- as physicians join the St. Francis family and we incorporate their data into our larger EHR implementation -- that many EHRs are just reincarnations of the paper templates the physicians used before.

Charles Christian,
VP and CIO, St. Francis Hospital

What should be the new coordinator's first order of business?

Christian: Making sure the team is intact. The changing of the guard's going to take place, there's going to be some changing of staff, some people are going to go, some people are going to stay.

But we've got stage 3 standing out on the stage now, ready to walk out from behind the curtain. The recommendations are coming out from the advisory groups -- I'm scratching my head with those; I'm still trying to figure out how we're going to do some of the stuff in stage 2, and stage 3 carries it a little further.

It's kind of like getting the band together. I've lost the lead singer, I've got to get another one of those, we've got to make sure we can harmonize.

ONC is struggling to help create a nationwide HIE network. You were heavily involved in Indiana's statewide network. What's it going to take to get that done?

Christian: Everybody's realizing it's going to be much, much more difficult than we originally thought it was going to be. We keep getting in our own way. Here at St. Francis in Columbus, we serve people from Alabama, too. We have to not only worry about the rules and regulations in Georgia, but Alabama, too. Any kind of border facility is going to have that [issue].

How can we remove some of the friction of putting these HIEs up? These invisible things called state boundaries, they get in our way. We need to work a little bit harder to remove some of these barriers. There's been a lot of demonstration projects out there related to exchanging data all over the country. It can be done, but on a routine basis [there's] really no way of being able to call up your records that transcend multiple state borders.

In my own personal, humble opinion, [if they want] to do one thing to take the friction out of health information exchange, [then they should] create a patient identifier. A lot of people cringe when I say it. But if you stop to think about it for a moment, these regional exchanges spinning up now -- [that allow users] to exchange data even within their own enterprises -- that's how they're doing it. These things called enterprise master patient indexes. There's a number assigned to a patient, running in the background, as a translator key to all the other numbers assigned to that patient in all the other systems. Until are all using the same software platform that assigns the number in the same way, and there's a master out there, I'm not sure that we're going to be able to efficiently exchange information.

What's going to be tougher about ICD-10 going live next year: The technology piece or the workflows between hospitals and payers, which involves learning how different payers will handle different codes, etc.?

Christian: I have three different areas around ICD-10 where I have concerns. One, are all the vendors going to successfully write their code to do this? I think so, pretty much, but on some of the systems we have to implement, the ICD-10 piece isn't ready yet. That means we're going to have a lot of system upgrades and patching to do in order to get there.

Two, education and processes that we're going to have to get to. Some of the folks we're going to have to retrain are physicians; in their practices they know a lot of these codes by heart and so do their staff. There's going to be a period of time when they're going to relearn those codes. We have to be diligent that they use the appropriate and correct codes now that the codes are going to be very specific. You can't code just "a lower leg" in ICD-10; you have to code "the anterior surface of the left lower leg."

Three -- and it's the piece I'm more concerned about than the other two -- are the payers: Are their claims adjudication systems going to be ready to go? Depending on who you read or who you listen to, a lot of big payers say yes, they are; other ones say no, they're not. The biggest payers -- Medicare and Medicaid -- use those commercial payers as their third-party intermediaries. So, if they're not ready to do their own claims, are they going to be ready to do much bigger claims? It's one of those things right now that's on my radar, but it's not the first thing. Toward the end of the year I'm going to get really, really serious about having a more pointed conversation with our payer partners.

What are you hoping to get out of attending National Health IT Week?

Christian: More conversation [with peers and ONC leaders], figuring out what I need to be aware of in what's coming down the road. I think it's going to be two-way listening; I need to say, 'Here's what I'm seeing in Georgia, here's what I'm seeing in the industry,' but I need to listen for 'Here's where I need to go,' and then remark on that.

It's pretty apparent if you look at the stage 3 recommendations that came from the Health IT Policy Committee that they're trying to throw the ball pretty far down the field, from an outcomes standpoint. In 2014, we're going to have to start submitting information for the quality measures electronically. I was reading an article yesterday, and the four in the pilot program all used the same software, which I don't use. We've started that conversation with our vendor, 'tell me how you're going to get me there.' Our new director of quality is extremely interested in this because if we're able to extract that quality data electronically, we can also use that internally to have a very positive impact on some of the processes that create those quality measures.

What will EHRs look like in 10 years, and what will Dr. Mostashari's fingerprint be on them?

Christian: Hopefully they will look nothing like they do today. Our CEO likes to say we're a very large physician group that happens to have a hospital attached to it. I've spent most of my time since I've come to Georgia automating those physician practices. We have a variety of EHRs, and it's painfully apparent [that] many EHRs are just reincarnations of the paper templates the physicians used before.

The processes are changing, so we really need to look at the workflows. We're trying to make widgets out of things that really shouldn't really be widgets. We're putting checkboxes, and [it gets] real jumbled and real complex, very quickly. The physicians, particularly if they're used to dictating, they have a method and an order in which they do their critical thinking, depending on how and where they were trained. Some of the physicians are so regimented, [the EHR] gets in the way.

The work that Farzad and his predecessors have done is [they shone] a great big, bright spotlight on the physician's practice EHR space, and said, 'Hey, folks, this is some place we really need to take a look at -- there is huge opportunity for improvement in this area!' This is where we can truly have an impact on population health: If we can arm the physicians with appropriate information and appropriately aligned incentives, we can truly have an impact on the quality of healthcare and the cost of healthcare in this country.

Next: An interview with Randy McCleese, vice president of IS and CIO of St. Claire Regional Medical Center in Morehead, Ky. Previous: Series introduction

Let us know what you think about the story; email Don Fluckinger, news director, or contact @DonFluckinger on Twitter.

This was first published in September 2013

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