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The Tallest Kindergartener  

(Season 1Episode 1) 

This is The Tallest Kindergartener brought to you by IHIE, Indiana’s Health Information ExchangeIHIE enables healthcare providers to deliver services that make a real difference in health and healthcare. The Tallest Kindergarten, episode one.  

[Music] 

That’s ZDoggMD, a physician who parodies the complications and frustrations of the American Healthcare System. You can listen to this song in its entirety, as well as several others on his YouTube channel or website.  

And hey, we’re not nearly as talented or entertaining and ZDoggMD, but we do hope to foster some dialogue in this and future episodes of our podcast about interoperability, the impacts of federal regulations and many other topics related to health IT. 

John Kansky: Hey, everybody. I’m John Kansky. I’m the president and CEO of the Indiana Health Information Exchange. But that doesn’t matter. What you really need to know about me is I’m sort of a battle weary, experienced health information exchange curmudgeon. And hoping to start this podcast series to share some ideas that I think are relevant and hopefully useful to others in the health information exchange and interoperability business.  

So, I promise I’m going to explain the title of the series, The Tallest Kindergartener, but let me share a few thoughts first. So, thinking about what’s going — If you’re familiar at all with national interoperability and what’s going on, you know that this is a very fluid and uncertain time. And there’s plenty of threats and there’s plenty of questions and there’s plenty of opportunity, if you’re in the health information exchange business or you’re just an organization that is trying to figure out interoperability and meet its needs.  

So, let’s spend a few minutes talking about or thinking about the last 30 years of health information exchange. Because if you go back 30 years, we’d even call it health information exchange in those days, but there most definitely was health information exchange happening as early as the early 90s. I know that because in Indiana, we worked with Regenstrief Institute. If you don’t know who that is, Google it (R-E-G-E-N-S-T-R-I-E-F). Interesting story about a guy who invented the front-loading dishwasher. Trust me, it’s really fascinating.  

But the Regenstrief Institute did some informatics pioneering work in the 1990s that one could argue they invented health information exchange. And they’ve been a partner of the Indiana Health Information Exchange since our inception in 2004.  

So, if you go back, we really have something that was health information exchange happening in the 1990s. But then in the 2000s, really more pioneering work was being done, grants were being granted from federal agencies, organizations were proving that the technology could connect systems together into organizationally. We were doing electronic results, delivery. We were inventing, if you will, clinical data repositories. And there were what I would consider a lot of local grant funded experiments. And that’s what health information exchanges felt like.  

Maybe until about 2010 when we moved in to an era where health information exchange was more common in different markets. But people with sort the whole, Oh, is it sustainable? question and the government was giving us some hightech dollars to get a HIE started in the markets where it didn’t exist.  

So, this is sort of a period of building and scaling where we had singlemarket or singlestate HIE is and they were becoming common and they’re becoming sustainable.  

And then if you think about just the last five or six years, we have the emergence of Commonwell, we have the emergence of KAREY Quality, we have the evolution of the e-Health Exchange from the federal government to a sustainable and growing notforprofit. We have the emergence of SHIEC, the Strategic Health Information Exchange Collaborative. And all those things, in my view, represent progress in national interoperability.  

They don’t all work in concert with each other. Some of them view the other’s efforts as competitive. They are absolutely potentially complementary. And we’ll get into some of that in future episodes.  

But all that conspires to give us the current uncertain, fluid and opportunity situation that we have now. Kind of exciting stuff. Little scary. Keeps me up at night, but makes me love my job.  

So, in conclusion, why The Tallest Kindergartener? Two reasons. One, we were always kind of unusually large in size, like that one kid in the back row of the class picture, but also because we felt that health information exchanges in general were kind of in kindergarten, in terms of our progression towards what we really could ultimately be.  

And this Tallest Kindergartener reference or comparison that we use for our health information exchange, well, it’s several years old. It feels like we’re still in primary school. So, lots has changed, but we’re still feeling a little bit like the tallest kindergartner. So, that’s why the name of the podcast series.  

I hope this has been interesting. I hope you’ll come back and listen some more. And we’d love to hear from you at info@ihie.org. Thanks. 

The Tallest Kindergartener  

HIE Consolidation 

 (Season 1, Episode 2) 

This is The Tallest Kindergartener brought to you by IHIE, Indiana’s Health Information ExchangeIHIE enables health care providers to deliver services that make a real difference in health and healthcare. 

John Kansky: Hi, it’s John Kansky here for another episode of The Tallest Kindergartener. And what is today’s topic? Should HIEs consolidate? I mean, should they merge together? Should they acquire other HIEs? Should they group themselves together to become bigger?  

And my answer is yes. And I’m going to say yes. I usually caveat it by saying unless a particular HIE has a deliberate strategy to be small; maybe they have specific local programs they’re focused on, maybe they have some financial connection to their community. But I’m not sure I’ve ever seen one of those HIEs 

So, the simple answer, my opinion, is that most what most of us think of as health information exchanges, they should be looking for opportunity to consolidate. 

Okay, let’s pause here to give you an idea of the scale we’re talking about. There are more than 70 HIEs in the U.S. today. Think about that; 50 states and more than 70 HIEs 

And this idea consolidation, it’s not a new trend. In fact, over the past 10 years, we’ve seen more than 10 HIE mergers and consolidations. In the same period, we’ve also seen at least seven HIE closures.  

Now, back to John for his explanation of why consolidation is a good idea. 

John: Why? Well, let me get to the why in terms of economic reasons in a second. But I just want to say that I think for HIEs, being small is either, and(or) being inefficient, it means being incapable of certain largescale value propositions because of the scale of your HIE that’s required or the size of the investment that’s required.  

Or worst case, being an HIE and being small may mean being doomed in the long run. Controversial statement; I apologize to my colleagues that run small HIEs. Would be happy to split a pitcher of beer and debate this one.  

So, why? Why should HD consolidate? I’ve got four reasons; there’s probably more than that. But my first one is an important, but not very sexy reason, is good old economies of scale.  

I’ve had many conversations with HIE leaders around the country and everybody agrees it’s silly to be small organizations repeating the same costs. If we all have a data center bill and a software vendor bill and a help desk and a marketing department, et cetera, et cetera, we’re all repeating costs on a small scale and that’s expensive. And find any forprofit industry, they would probably clearly demonstrate that that kind of small-scale cost being repeated is just a recipe for being out of business. But we’ve gotten by with, inot forprofit HIEs, because of our circumstances in grants, support, et cetera. 

Second reason is sort of the cousin of the first reason; it’s to have the financial scale to make ever more sophisticated investments. That doesn’t sound very interesting, but actually this is probably my favorite reason, is because if you think about it, here’s a for example, to be an HIE in the future, you’re going to need to be capable of connecting via FHIR API and doing all kinds of cool things.  

don’t know if you guys have looked into what it costs to buy or build an API layer to your platform. But it takes a lot of resources, whether those are financial and or human. And not every HIE is going to be able to afford that investment, but it’s absolutely necessary investment for the future. 

Third reason is that it’s very important that HIEs are prepared to carry their water as a valuable component of national interoperability. It doesn’t make any sense to try and stitch together 150 small HIEs into a national quilt of interoperability. It makes a lot more sense to stitch together 20 HIEs of significant sophistication and capability. Don’t hold me to the numbers; I’m just trying to make a point.  

The last reason, and again I said there’s probably others, but this is important as well, is the national perception and relevance of HIE. Think of the HIE as a brand and how it’s perceived by the ONC, by your customers or participants, by large health systems, by insurance companies, by large national pharmacy chains.  

The brand of HIE right now is sort of associated with small, notforprofit, not necessarily strong, capable organizations. And that needs to evolve over time if we’re to be perceived on the national stage as I think HIEs need to be. 

Okay. But (there’s a big but with an exclamation point). In terms of, So, everybody should merge, Kansky; is that what you’re saying? No, not quite. I am encouraging all HIEs to think about and consider consolidations where it makes sense for them.  

But some HIE {indistinct 6:39} have argued to me that, Look, because of my politics or my corporate structure or my strategy or even geography, my market, it makes sense for me to maintain a degree of autonomy. I can’t merge or I can only merge with this far and then I can’t merge anymore. Well, suffice it to say that some HIEs need to retain autonomy. And in many cases, I think that’s absolutely right.  

So, then what? So, let’s see. We need a way for HIEs to maintain their autonomy, yet share costs, pull investment and sometimes act as a unit with other health information exchanges.  

Okay. So, open your mind. Maybe HIEs need to form something like a league. Did you know that the National Football League, the NFL, was a notforprofit until 2015? That was a way for a bunch of autonomous teams to be able to make their own decisions in their own markets, hire and fire as they needed, have their strategies, do their drafts. Yet the league was able to do national contracting and pool costs, and that made for an interesting and necessary governance layer that doesn’t exist in the HIE world.  

But just think about it; what if there were some kind of structure that looked or felt like a league of HIEs that allowed us to share costs, pull investment, sometimes act as a unit on the national stage.  

So, here’s a little teaser. In the next episode, I’ll talk a little bit about our consolidation with the Michiana Health Information Network in South Bend, Indiana, and to show you that we’re walking the talk. And we’ll share some of the experience, warts and all, with you in our next episode. 

Thanks. Thanks for listening. We’d love to hear from you. Send us any thoughts, our questions at info@ihie.org.  

The Tallest Kindergartener  

IHIE and MHIN Consolidation 

 (Season 1, Episode 3) 

This is The Tallest Kindergartner brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare. 

John: Hello and welcome to Episode 3 of The Tallest Kindergartener. This is John Kansky and I have a guest with me today. It’s Kelly Hahaj. And do you want to say hello, Kelly? 

Kelly Hahaj: Hi, everybody. This is Kelly. 

John: So, I’m going to explain why Kelly’s here. Kelly has two jobs at the same time. She is the CEO of the Michigan Health Information Network and she’s the Vice President of Consolidation for the Indiana Health Information Exchange.  

And if you listened to Episode 2, you know that that was my views on whether IHIEs should consolidate and why. And if you’re following along with IHIE and MHIand the goings on, our two organizations are consolidating to form one HIE serving the state of Indiana. 

Kelly: Let’s pause here for a little additional context. MHIN an HIE in South Bend, Indiana, has a long reputation as one of the oldest and most successful health information exchanges in the nation. IHIE, aHIE in Indianapolis, Indiana, also has a reputation as one of the oldest and most successful health information exchanges in the nation.  

Both organizations have been committed to providing secure, timely delivery of clinical data to improve quality of health care and reduce costs. The consolidation of these HIEs allows the state of Indiana to have just one HIE; a single source of health information exchange. 

John: And that’s why it seems super interesting to talk to Kelly today. So, if you remember from Episode 2, we had for reasons that I gave; economies of scale, leveraging expensive, but necessary investments. These are all reasons to be an organization of greater scale.  

Reason 3 being part of the national interoperability landscape; HIEs need to carry their water and have an answer to how they’re supporting national interoperability.  

And then finally, just elevating the relevance and perception of HIE, the brand, and being respected by ONC and EHR vendors and others that matter, in terms of figuring out how we fit.  

So, that’s how I came to invite Kelly to this conversation because we wanted to talk a little bit about what we’re doing, in terms of consolidating our organizations, and where we are now and a little bit of hitting some of the highlights how we got here. Does that sound okay?  

Kelly: Sounds great.  

John: So, let’s start with a little bit of the how we got here. Now, let’s start with where we are now. So, you’re tasked with, in terms of your role of the VP of Consolidation, of making this happen; making everything be okay. And it’s not easy; right? 

Kelly: No, it’s not. Well, it’s easy, but it’s not. We know the space very well. And as we were evaluating, Is it the right decision to consolidate or not? and considering all of the factors, some of the things that went through our thought process is, How would we be successful?  

And so, we had our boards that gave us a lot of good support with common goals and that made a lot of sense for us to take as a direction to look to see whether or not we could do this and be successful long term. 

John: Yeah, we’ve kind of got better together on our websites as a sort of catch phrase of why we did this. But it’s not just marketing. I mean, I think that was part of the calculus was figuring out with the people, the process, technology, all factors considered in being an HIE, would we be better together? 

Kelly: Exactly. And as we went through that, we found that there were a lot of similarities between our organizations. Probably more similar than we are different. And where we’re different, we sort of complemented each other. And we thought we could bring more value to our customers, bring more value to the state of Indiana and put a bigger brain trust together to do new things that we’ll have to face in the national landscape, as you were touching on, as the world is evolving and changing. Let’s do it together. 

John: So, the where we are now is we’re really only two months in changing at this point from the actual official consolidation that happened on January 1st, 2020. And we’re working through the people, process and technology combinations that this requires. 

Kelly: Yeah, and we’re early in it. We’ve put a lot of work in in the last few months, but I think it’s very early in the process still. So, our timeline is about 15 months and that’s a lot of work to get done. But so far, our teams have worked very well together and they’ve kind of have some really good relationships and we’ve learned a lot from each other that’s going to carry us a long way. 

John: Now, I think that’s an important point, is it’s going to take 15 months before we’re actually literally and completely one organization. And laying out that timeline, being realistic about it and making sure our boards understood that it’s going to take 15 months and all the contracts and all the processes and all the projects that are laid out. Everybody understood that’s a 15month project to make this happen. 

Kelly: Right. And it’s realistic, but it is kind of aggressive when you look at the whole body of work to do. 

John: And listening to you talk, I was reminded of some of the how we got here that I wanted to touch on because so much of the work was before January the 1st, 2020. And as a matter of fact, when people ask me how it’s going, what I usually comment on is how much more I was involved before there was a deal signed. And that Kelly and all the other leaders at IHIE really began carrying the real water, meaning that there was HR planning that had to be done.  

I mean, just think about the — I mean, that maybe it’s obvious, but the thing that was the main water that had to be carried before we signed the deal was governance stuff, making sure the boards were okay, jumping through all those hoops, having plans for HR down to payroll and 401(k) and org charts and managing any concerns and message and the sequence of messaging of all that along the way.  

And then all just a little bit of technology that we did before January, 1st where it’s like, Okay, everybody can have an e-mail account. How is this going to work? Who’s logging into what? How do the offices connect? 

Kelly: Yeah. So, if we were looking at a 15-month transition time, we really had to start that work at least three or four months before that. Because a lot of work has to go into the planning. You can’t just start January 1st and then say, Hey, you know what? What are we going to do? How are we going to do this?  

We have to have a roadmap somewhat laid out so that we’re successful the first day, so that we’re communicating well. It’s well-thought out and we have the right people at the table making the hard decisions on what’s impacted and what do we need to have in place by when to hit our goal. 

John: And we’ve gotten this far in the conversation without using the word customer. And there was a tremendous amount of work we needed to do (Well, not tremendous amount of work we needed to do) really important work we needed to do before January 1st, to make sure that key customers would be okay with this.  

And then now, what we’re really working hard on is explaining and bringing along all of our customers with the transition so that they know what’s happening and so that they hopefully, 100 percent, are willing to come along in the transition. 

Kelly: I’ve had several meetings personally with our customers explaining how this impacts you, how this impacts HIE. And it’s been met with great response. Everybody sees the value. Everybody sees how it can be helpful throughout the whole state and for new possibilities down the road. 

John: And I, for one, was not and am not taking that for granted because, I mean, anybody listening to this, we want to make sure that we’re being honest. I was quite concerned about all the customers coming along and they may not all come along.  

We’ve already encountered some things like MHIN services and IHIE services were maybe triggered differently or require different authentication and we’re working through those things. We’re not expecting everything to come out perfectly, but frankly, thus far, past the signing of the deal and two months in, I would say it’s fair to say we’ve been pleasantly surprised. 

Kelly: Exactly. I think it’s going very well, very smooth, met with great reaction. 

John: Okay. So, thanks for tuning in today. If anything else interesting happens, which is probably hundred percent chance. Anything interesting that happened to this consolidation, we’ll circle back and do another episode, telling you how it’s going or how it went.  

And as always, if any of you out there are thinking about consolidation or have questions, feel free to reach out to Kelly or me.  

Kelly: Thank you.  

John: Thanks. 

 

The Tallest Kindergartener

The Value of HIE in the Pandemic Response

(Season 1, Episode 4)

As many others are these days, IHIE staff is working remotely while the response to COVID-19 continues. Today’s episode was recorded via an online meeting platform. So, you might notice segments where the audio quality is a bit muffled. Thanks for your patience.

This is The Tallest Kindergartener brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: Hello and welcome to another episode of The Tallest Kindergartner. Today, I am talking with Dr. Shawn Grannis, who happens to be a personal friend of mine, but is also the Vice President of Data and Analytics at the world-famous Reagan Street Institute.

He’s also a professor at the IU School of Medicine, and he’s also the Chief Medical Information Officer at the Indiana Health Information Exchange. Shawn, did I miss anything?

Shawn Grannis: I think that’s enough.

John: Yeah, there’s more, but anyway, he’s a good guy to talk to about our topic for today. And something Shawn and I have talked about in the past, which is kind of the role of health information exchange in supporting public health. And specifically, what are the key success factors or an HIE to be sort of minimally relevant in the context of this pandemic?

In my view, and I’ll tell you what; I’ve had conversations with the CDC and the ONC and my peers at other health information exchanges, and the pandemic response has really, in ways that even surprised me, shined light on the relevance and the necessity (that’s really the word) of health information exchange.

So, one of the biggest learnings from the pandemic response for me has been that every state really needs to have a capable and relevant health information exchange to support public health.

Shawn: Absolutely. Yeah. I agree with you a great deal. Or do you want me to start waxing philosophical at this point or —

John: Yeah, because you and I have talked a little bit about, “Well, what does that mean?” So, what are the minimums that a health information exchange has to have to fulfill that role? But hey, I’ll listen to anything you’ve got to say.

Shawn: Okay. Well, to start with, I do think HIEs play an important role in public and population health for a variety of reasons. But I would start at the highest level; interoperability is important.

Health information exchanges are really the frontlines of interoperability, making connections happen, making data sharing happen. And you not only need interoperability, but you need to be a part of a community, a part of a trusted framework of organizations who are willing to exchange data for particular purposes.

Interoperability is the ingredients for the recipe, but people (the chefs) have to come together to decide what kind of cookie they’re going to bake. And HIEs, I think, help for communities or regions, like the state of Indiana that IHIE works with, comes together to say, “Hey, how are we going to do electronic laboratory reporting? How are we going to do syndrome mix surveillance? How are we going to support the needs of public health?”

And so, your question about what can or should HIEs do to support public health? I think, one of the first things they should do is develop a relationship with the public health stakeholders in their state to understand their needs.

Beyond that, I think that there are some common patterns across the country that we’ve seen clearly emerge over the last decade and more. And that is two common use cases that I think HIEs need to think about supporting our number one; electronic laboratory reporting.

So, every state in the nation is required to send notifiable conditions to public health authorities. We also know (and we’ve known this for over three decades) health systems, physicians, laboratories all do a poor job of reporting; over and over we’ve found that.

Why is that? Because these organizations and people have a lot of priorities, and sometimes things fall through the crack; they think somebody else should send the results or somebody else will send the results or they don’t even know.

So, I should say we’ve shown through IHIEs infrastructure that electronic laboratory reporting can report more than five times as many notifiable conditions as the traditional human-based processes. So, there’s electronic laboratory reporting; number one.

The number two common pattern is Syndromic Surveillance. So, after 9/11, there was an anthrax scare. That motivated the CDC to build and network at the state level of surveillance capabilities. And that can sound scary, but it’s usually de-identified information or aggregate information.

But what it’s looking at is any unusual trends that suggest there might be outbreaks of concerning diseases. Back in 2001, the concern was anthrax. In 2020, we are concerned about COVID. So, the same infrastructure that IHIE helped to build back in the early 2000s for anthrax and then H1N1 is now exactly positioned to support the corona virus.

So, electronic laboratory reporting, syndromic surveillance, which comes from typically emergency department visits; looking at trends over time to identify any unusual outbreaks. I’ll stop there.

John: So, good. To me, Shawn, what you’re reminding me of is that, I think, what an HIE needs to bring to the table to carry into water on public health can be separated into technical and, I guess, non-technical or trust relationship.

So, as you started with, both of those things are necessary, I’m sure we can find HIEs in the country that have great technological capability, but maybe you lack the established trusting relationship with its State health, Public health authority and vice versa. And just having a trusting relationship, but not being able to do these things or have the capabilities and infrastructure in place, you have to have both sides of that equation, right?

Shawn: Yeah. Yeah, exactly. I think both are necessary, but not sufficient on their own. No question.

John: Yeah. So, I’m trying to boil this down to, I mean, you gave a couple of excellent examples in electronic lab reporting and syndromic surveillance. But I’m trying to boil it down to if I was trying to make the case to another HIE leader or to Public health authorities at the Federal or State level. And they said, “So, boil it down for me, Kansky. What does a health information exchange need to have?”

I sort of feel like my list is; you’ve got to have a trusted relationship, but then you’ve got to have the existing data flows from a sort of minimum necessary amount of stakeholders. And I think you need to have a normalized repository of that data to do some of the things that are going to be asked of an HIE to support public health.

And then there’s this sort of miscellaneous category of you have to have capabilities, whether those be from relationships you have with vendors or your team that you have at the HIE, you’ve got to have the data flows in place, you’ve got to have a repository and you have to be capable and you have to have a relationship. Does that is sound right or what would you {indistinct 8:50}.

Shawn: Right. You’re covering the waterfront. I guess the way I would have said what you just said. Of course, you need the data flows; that’s sort of the lifeblood of the enterprise. Once you have those flows, standardization, making sense of the data, cleaning it up, improving its quality, getting it ready for consumers like public health to benefit from that is important.

But then you also need people within your organization that understand the capabilities of this data, that understand how to take the requirements, the expectations, the needs from your customers and transform that data into something that is useful.

So, for example, understanding that the registration mess — who knew that registration messages from health systems would actually be the foundation for surveillance systems? People didn’t imagine that originally, but it took creative people, who understand electronic data flows and their capabilities, to recognize how to connect the dots between what is available and what the need is. And that’s where, when you talk about capabilities, that’s what I think of in terms of being able to leverage your resources to meet the needs.

John: I’m sensing kind of an emerging concept or conversation, whether that’s emerging with the ONC, CDC, within HIE leaders of this idea of HIE as a sort of State-designated utility. And I’m not going to define those terms because we’re kind of working at defining what that means.

But I think the gist is that a state that’s well-prepared to serve its public health needs, whether those be during an emergency or on an ongoing basis, there needs to be this utility (that is, the HIE) carrying its water. And so, going forward, I’m really going to be trying to explore that and advocate for it.

I think there are states that have that and I think there are states where the HIE and their relationship with their state comes up a little short.

Shawn: John, I’ve always said if we want to make advancements in interoperability and HIE, you need something like an asteroid strike. Unfortunately, a calamity to bring people together. And Corona Virus has done an excellent job of exposing the cracks in the system and actually peeling back all of the subterfuge to underscore to actually expose, not only the cracks, but the value that HIE has to public health.

You know, we’ve eliminated a lot. So, COVID has been a powerful attractant, a powerful accelerator for data sharing. And with whom do people want to share data? The HIEs; those are the people who are sharing data today. And again, this powerful demand for COVID support; that use case has shown just what HIE can do for the world.

Unfortunately, I predicted an extra-terrestrial invader causing this to happen. And unfortunately, it was something terrestrial instead, with the virus. But I {crosstalk 12:34}

John: I guess we haven’t ruled that out as the cause of COVID-19.

Shawn: Sure.

John: Yeah. So, yeah, absolutely. So, in closing; from my perspective, even in ways that surprised me, this pandemic and the response has shined light on the need for health information exchange. So, I’m going to redouble my efforts to get that word out, especially in terms of HIE support for public health.

Hey, thanks so much for having a chat with me today. And we’ll talk more on the future.

Shawn: Great. Thank you.

And that concludes another episode of The Tallest Kindergartner. As always, feel free to e-mail us at info@ihie.org with questions or feedback.

The Tallest Kindergartener

HIE as the Public Health Infrastructure

(Season 1, Episode 5)

This is The Tallest Kindergartner brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: Hey, this is John Kansky and welcome to another episode of The Tallest Kindergartner. As I record this, we’re still in the middle of a pandemic response in this country. And I’ve been talking with a lot of my HIE peers from different states about their experience.

And one of the things that I’m thinking about today that’s really been a recurrent theme in these discussions is that HIE is a necessary part of public health infrastructure, period.

And so, what does that mean? Why is that interesting? So, it means that every state needs to have an HIE and that that HIE needs to be working in concert with its public health function, its public health authority, presumably the State Department of Health and probably local health departments.

And the HIE needs to be prepared to carry that water; meaning not just during a pandemic, but for the management of chronic disease and all the other things that public health focuses on, HIE needs to be there and needs to be part of the public health infrastructure, needs to be working actively in surveilling public health and responding to public health needs with information, with movement of information, with the stories and analysis of information, HIE needs to be part of the public health infrastructure. Okay, that’s important, but that’s not the only point.

Well, what’s been interesting about that in discussing with my peers from other states is that the Indiana Health Information Exchange, we have been working actively with our public health departments at a state and sometimes local level, for the larger population centers in our state.

We are probably the most privatized HIE state in the country, meaning IHIE has a model of we deliver value in exchange for fees and sustain ourselves that way and aren’t funded or officially part of our state. Versus some of my peers in other states, I mean, in the extreme case, the HIE is literally run by the State Government, within State Government, and if they’re not connected well to their state health department, I don’t know what’s going on. They hopefully are.

But there’s also a continuum of many states that are more actively funded by their State Governments and particularly through the Medicaid program. And again, that’s a different kind of relationship they have with their State Government than IHIE does.

So, the conclusion that I’m coming to and what I’m really rethinking about our business model is not that we don’t need to be privatized, deliver-value, earn-your-money kind of HIE, I think that I still firmly believe that that is the model of HIE. But the extent to which if we need to be part of the State Public Health infrastructure, what should our relationship with our state be?

And it needs to be, I think, a bit more official and a bit more formalized, even if it’s only part of what we do, meaning that I’m going to work with our state officials to formalize that relationship so that they can know that the health information exchange can be counted on to fulfill, of the informational part of ongoing public health infrastructure.

Again, ongoing every day, week-to-week month-to-month public health and being prepared for a pandemic. I need to make sure that we’re making a commitment to the State Government that will be there for them and hopefully in exchange, we can formalize some kind of financial and support relationship to compensate us for the water that we’d be carrying on behalf of the state.

So, it’s a bit of a public-private partnership model of public health involving the HIE and the state’s public health.

Anyway, that’s been a really super interesting conversation lately. And I wanted to pass that along. Thanks. Thanks for listening.

And that concludes another episode of the tallest kindergartner. As always, feel free to email us at info@ihie.org with questions or feedback. Thank you.

The Tallest Kindergartner

An Inside View: Serving on a Health Technology Committee

(Season 1, Episode 6)

This is The Tallest Kindergartner brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: Hey, everybody, it’s John Kansky, back for an episode of The Tallest Kindergartner. And our topic today is something that some of my friends, peers, colleagues have asked about and I thought people might find it interesting, is what is it like to be on the HIT Advisory Committee or the Health Information Technology Advisory Committee to the ONC? Or people call it HITAC.

So, I have the privilege, and it really is a privilege, of serving on that group. And it’s kind of interesting to know that it exists and what it does and how it works. But I also have kind of just some observations I wanted to share about the experience of being on HITAC.

So, first of all, it’s the one and only advisory committee to the ONC. It was created by the 21st Century Cures Act, and it replaced, if anybody remembers that there used to be an ONC Policy Committee and an ONC Standards Committee, it replaced those groups. And now there’s only one.

I was didn’t serve on either of those. I have some friends that did that gave me some guidance when I was appointed to HITAC. And I have to imagine it serves largely the same purpose for the ONC.

If you’re curious, HITAC is something called a FACA (I have to say that carefully). It’s a F-A-C-A, meaning it’s subject to the Federal Advisory Committee Act. If you’re an attorney, you might be aware of that or want to Google that one.

But what that means is that there’s a bunch of very specific rules that have to be followed. And as I’m going to observe a little bit later on, sometimes those rules just feel kind of anal retentive, but sometimes, they have a kind of important purpose to make sure that the kind of our democratic system of government is being followed. More on that in a second.

So, what is HITAC? It’s kind of a group of industry experts that serve loosely two purposes; one is to give the ONC a general sounding board, and two is to do deep dives on regulations or standards that the ONC is focused on. Or maybe they’re creating a regulation or a role and they want feedback.

Some of these deep dives, which are done by what’s called task forces, are amazingly intense. They’re intense in terms of the time commitment, and they’re intense in terms of the discussions of passionate people who have different perspectives on a given issue. But since there’s a lot at stake, you want that intensity and you want those different perspectives brought to bear.

The composition of HITAC is deliberately diverse. This is a little bit of an oversimplification, but I tend to think of it as kind of two groups. One is consumer or patient advocates; the people that have different perspectives on the need for patients to have access and control of their health care data. And then there’s a bunch of “HIT experts”; I would put myself in that category. There is EHR experts, there’s interoperability experts, there is standard experts.

And the I’ve learned a lot from listening to folks on the committee from different perspectives. Don’t always agree. They don’t always agree with me. But that’s entirely the point is we’re bringing our knowledge and experience to bear to give again, the ONC that sounding board or when necessary, to step up, serve on a task force and do the deep dive on questions that they want answered.

The process of getting on HITAC was kind of interesting. I’m not more qualified than five hundred other people in the country, but there’s a little bit of, “Are you interested?” “Are you willing?” “Are you lucky?” in terms of the timing. And there’s interviews and it’s kind of fun and interesting to see if you get on. And again, I was fortunate enough to be allowed to serve.

So, that gets to really the thing that made me want to talk about this the most, which is that the observation of sort of, you know, there’s the old joke about there’s two things you don’t want to watch being made; laws and sausage, is there’s a little bit of feeling like that you’re working in the sausage factory, in terms of interoperability regulations or things that the agency is working on. Because you feel like you really have a front row seat, but that front row seat comes with some responsibility.

So, my observations are that serving on HITAC is really kind of giving me a strange renewal of the faith in our system of government. That is to say, I’ve watched a lot of people working for the federal government trying so hard to listen to all the different constituencies and work so hard at ensuring that the public would (define the public any way you’d like) has the opportunity to be heard.

And there’s anal retentive rules that I referenced earlier that are designed to ensure that that never doesn’t happen. Sorry for the double negative. One example that I would give is that there are so many calls that if you were willing, interested and bored enough, that you could participate in on as a member of the general public. And there is always a public comment period and you do not skip it. And it’s just it’s kind of fun to watch the government have that degree of discipline and follow the rules that are written down.

The other thing is that I feel kind of an intimidating sense of responsibility and a surprising degree of influence that you’re given as a member of HITAC, if you don’t step up and serve on task forces and you don’t come prepared to the calls, having read rules that are going to get written and rewritten and if you don’t come prepared with your point of view, you feel like you’re shirking on your responsibility and that someone else could be there in that chair, who would be stepping up and fulfilling that responsibility. So, the degree of pressure that I think one feels.

And as far as the surprising access, there’s people that are influencing these important decisions that are very willing to listen to you. And I don’t think you have to be on HITAC to be listened to. And I guess that’s one of the morals of this story, is being on HITAC puts you in the front row, but being a member of the public, if you’re willing to engage and listen to calls and provide comment, you can be in the second row.

So, lots going on in terms of TEFCA and information blocking and the evolution of national interoperability that makes this stuff pretty important. So, welcoming anybody to get engaged and offer their thoughts and feedback on where we’re going as a nation.

So, with that, sorry, that was interesting. And I’d love to hear your comments. Feel free to reach out at info@ihie.org. Thanks.

The Tallest Kindergartener

TEFCA – The Jury is Out

(Season 1, Episode 7)

This is The Tallest Kindergartner brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: Hey, everybody, it’s John Kansky for an episode of The Tallest Kindergartener. And I wanted to reflect a little bit on TEFCA, something that if you’re not thinking about, you probably should be.

We know that the Sequoia Project, the recognized coordinating entity, is hard at work on a Draft Common Agreement, and that will be the next thing that we see, and have the opportunity to review and comment on. So, probably a good time to reload, TEFCA into our brains.

But I did a recent episode on what it was like to be on HITAC and referenced policymaking that’s going on now. And TEFCA is one of the most important thing that’s going to happen to international interoperability, possibly for the remainder of my career. So, I wanted to spend a little bit of time on that.

I’m going to try and avoid giving you an opinion on TEFCA good or TEFCA bad. Frankly, as things sit right now, we don’t we don’t know yet because there’s so much that remains to be hammered out between ONC, the RCE and the market itself.

But the other reason I’m going to avoid that, besides the fact that it’s just good judgment, is that this feels like one of those things that people are going to be proven wrong on one day, whatever side you come down on now.

What do I mean by that? Well, if you think about the possibilities of how TEFCA it is going to play out, we could have TEFCA come out and there could be rapid adoption that leads to undeniable value. And we could look back at this in three to five years and say, “Wow, whoever said that was a bad idea, it was clearly wrong.”

On the other hand, this could still land with a thud, meaning there could be little or no adoption. There could be pushback by major stakeholders in the interoperability equation that could make this essentially, I mean, it is not a not a mandatory regulation (What’s that word that means not mandatory?) Voluntary, thank you.

But we’ll know, in three to five years, if the market has accepted it and embraced it.

What else could happen? Well, it could feel a lot like what we have now, in terms of interoperability that sometimes sort of works, but that no one is entirely ready to declare victory on, except that we will have added a layer of good old federal government to it, which would not be perceived as a victory if we don’t have awesome interoperability as compared with what we have now.

But I really feel like the most likely thing that’s going to happen is that three to five years we’re going to look back at TEFCA and say, “Wow, that was harder than we thought. It took longer than we thought. We achieved a bit less than we thought, and maybe it will require more government levers to drive adoption than we thought, et cetera, et cetera.”

So, we’ll just have to wait and see. But that’s why I’m not going to be dumb enough to weigh in on whether this is a good thing or a bad thing for those two reasons.

But that leads me to one observation and one allegedly thoughtful question that I wanted to pass along.

So, my observation is that I’ve learned that policy is a blunt instrument. It’s hard to do surgery with a butter knife. What I mean by that is that I feel like I observe that when a policymaker wants a very specific outcome, they want to see interoperability, which means that they want patients to have access and control their own information and they want no organizations to not be sharing their information.

When they want very specific outcomes, they tend to make rules that are more prescriptive. They make rules that don’t just describe what they want to see, but how they want to see it. And my opinion is that that’s usually not a great direction for making policy. Too much specificity is usually a bad thing.

The question that I think about a lot or that I would encourage you to think about is I believe that Congress perceived a market failure in putting the requirement that there be a TEFCA in 21st Century Cures. And so, my question is was there or is there a market failure when you consider — I remember somebody walking up to me and saying, “Hey, there’s these electronic — we used to call them electronic medical records. It’s going to be great in health care that are going to be adopted rapidly and solve all kinds of problems.” That was 1986.

So, it’s taken a long time to get from 1986 to where we are now on electronic medical records or electronic health records. And it’s only been in the last six-ish years that we’ve had the creation and emergence of Commonwell of Cure Equality of the e-Health Exchange being spun out of the Federal Government. Remember the Nationwide Health Information Network and the NIN. We didn’t have {indistinct 6:39} and we didn’t have Patient-Centered Data Home.

All these things that have clearly been steps forward and maybe sometimes sideways or backwards, but always ever forward towards better operability, these have happened by the market in the last six years.

So, is there a market failure? No one would declare victory yet. No one would say that we have an interoperable health care system. But is it right to bring in the butter knife to do surgery at this stage?

So, I’d like to think that or my view is that TEFCA hopes to be a simple solution to a complex problem. And it’s not that there are never simple solutions to complex problems, but when there is, it’s because that simple solution is brilliant in its conception and elegant in its design. So, for TEFCA to ultimately be that solution, we’re going to need brilliance and elegance and we’ve got some work to do to hammer that out.

Okay. That was my thought for the day on TEFCA. We’d love to hear from you. Any feedback, feel free to contact us at info@ihie.org. Thanks.

And that concludes another episode of The Tallest Kindergartner. As always, feel free to email us at info@ihie.org with questions or feedback. Thank you.

The Tallest Kindergartner

Are we at the beginning of an HIE renaissance?

(Season 1, Episode 8)

This is The Tallest Kindergartner brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: Hi, this is John Kansky, CEO of the Indiana Health Information Exchange. Thanks for tuning in for this episode of The Tallest Kindergartener.

And today’s theme is a question. And the question is, are we at the beginning of an HIE renaissance? That question came up just this week, but I’m going to start explaining that going back to {indistinct 0:39} 19, meaning more than a year and half ago, at the beginning of 2019.

And our COO, Keith Kelly, and I did a talk. And the title of our talk was, “The reports of our death have been greatly exaggerated”, kind of based on the old Mark Twain quote. But that reference made a reference to the fact that despite the fact that HIEs were still chunking along, delivering valuable services, doing good things for health care, there seemed to be some tarnish on the brand of the term HIE or the market had sort of lost interest or faith in what we were doing.

Well, then last week, I was in a meeting and Dr. Shaun Grannis of the Regenstrief Institute, who also serves as our Chief Medical Information Officer, said, “You know what? I feel like we’re at the beginning of an HIE renaissance.”

And at the time, it immediately registered for me that I was feeling that, too; sensing that. And I didn’t immediately ask him where that was coming from, but I had the opportunity to ask him later. So, more on that.

Well, just let me suffice it to say, is that the story I’m telling here incorporates some of the thoughts I got from Dr. Grannis when I asked him about this.

So, when I say, “Are we at the beginning of an HIE renaissance?” (And posing that as a question), let me support that with changes that I have observed.

Change Number 1: Nobody wanted a pandemic. But one of the things the pandemic did was immediately shined light on many of the interoperability use cases and needs that HIE were fulfilling or able to immediately step up and fulfill.

Interoperability is not one thing. It isn’t query and receive data at the point of care; that’s an important use case. But there’s many other things that became immediately necessary in pandemic response; positive and negative tests pushed to the public health authority or pushed to the physician that ordered the test, or pushed to the physician who the primary care physician for a patient.

What about positive and negative tests trended at the population level with populations defined in terms of their geography, their race, ethnicity, their age, the HIEs, many by and large can do that.

Surveillance. We want to know every time someone with influenza-like illness shows up in an emergency department, we can do that.

What about comorbidities? You’ve got populations that have tested positive or had these outcomes in terms of hospitalizations or being ventilated. What are their comorbidities? HIEs have that data.

So, it all became suddenly very important. And my thought was actually it was always very important. But in the context of a pandemic, it suddenly became very, very important.

So, it’s not just me that’s seen this recognition. A lot of the state and federal level officials and various people I’ve talked to, many have said, “Wow, we see now the value of the HIEs in the context of the pandemic.

But to declare a renaissance, I have to have more than one thing that to pose that possibility. And I would point out to something that we’ve talked about before in this podcast series, which is Consolidations.

So, HIE consolidation is not a new thing, but the acceleration of consolidation is a new thing. And we’ve had consolidations in Michigan, Indiana, New York, California, Texas. I’ve got the data somewhere and I should have been able to give you a cold, hard fact. But look it up for yourself or drop me an email. The consolidation is expanding or accelerating.

And also, you observe organizations like Crisp in Maryland who are now providing other HIE services to support surrounding states in D.C. and West Virginia. You’ve got other HIEs launching ambitious initiatives. These are not things you saw from ages five years ago.

And this, to me, points that the community is understanding the need for scale. They’re acting in more mature and businesslike ways. And there’s an understanding of the national context in which they operate. It’s bigger than their city. It’s bigger than their state.

And then finally, and part of this comes from when I asked Dr. Grannis what he was saying that made him make that comment about an HIE renaissance, is this just vitality that one can sense in talking. He was able to just immediately send me three articles that were very pro-health information exchange, speaking to the vitality of what’s been happening lately.

Anybody that attended the recent virtual {indistinct 6:16} conference; virtual conferences are hard to pull off. There was absolute vitality there and a high level of attendance. Our communication with federal agencies; there’s a there’s a new vitality in those conversations.

So, none of that is cold, hard, conclusive evidence that I can put on a graph, but I guess I’m just pointing out — I feel it. There’s there is some degree of HIE renaissance now, but I think it’s on us, the HIE community, to be deterministic of that future. We can, if we squander this momentum or this opportunity, then in six months you guys can all tell me I was wrong. But if we can build on what’s happening now and keep working hard like we have done for years; I think we can help push that renaissance along.

All right. Thanks for listening.

And that concludes another episode of The Tallest Kindergartner. As always, feel free to email us at info@ihie.org with questions or feedback. Thank you.

The Tallest Kindergartener

The Story of the 3 Roadmaps

(Season 1, Episode 9)

This is The Tallest Kindergartener brought to you by IHIE, Indiana’s Health Information Exchange. IHIE enables health care providers to deliver services that make a real difference in health and healthcare.

John Kansky: It’s John Kansky here with another episode of The Tallest Kindergartner. Thanks for checking out the podcast. I think I have something really interesting to share. I have the story of the three roadmaps, but in order to tell that story, I have to start here.

So, the Indiana Health Information Exchange is a not-for-profit HIE and our mission and our not-for-profit status is absolutely part of our DNA. But we’re also famously and economically sustainable healthy not-for-profit business focused on business.

I wanted to share one of the things that we do that I think is a key part of how we keep that business going and continually add to the value proposition we offer to health care stakeholders in Indiana. And that is the story of IHIE’s three roadmaps.

So, a little bit of history. We were one of the first, if not the first, HIE in the country to have a product management function and a Director of Product Management. Product management is a science that’s been around in other fields for many, many years; books are written about it.

But we tried to implement it and did; it took us a number of years, but we implemented it in health information exchange. And when I say product, I mean HIE services; the kind that you would typically think of the few in a HIE, but everybody calls it product management. So, we do too.

And getting in the habit of having a product management function, building a product roadmap that described where you were going with your products, what were the next enhancement? What was the next product you were going to launch? When? Well, that habit to come time. And we were chunking along for a few years. And we, during that time, had to keep our technology infrastructure healthy.

We’re a little bit unusual, at the Indian Health Information Exchange, in that we have our own infrastructure. So, we found that we needed to keep making technology investments and improvements in that infrastructure.

And we had some growing pains in that we discovered we really do need to call those out at a high level. We needed to put them in in company level goals to make sure that we made those technology investments.

And then, not surprisingly, it seems obvious now, but it wasn’t at the time. Data is in everything that we do. Everything that we do that produces value is dependent on data; the right data, high-quality data, combinations of data, data that you don’t have that you need to get. You can’t be in HIE and produce value, you can’t have products producing value without data.

So, this is all happening over a number of years. And again, in hindsight I feel silly, but we backed into the interdependence of these three things; of the product and the technology and the data. All products that we had depended on having the right high-quality data and the right technology to deliver the data as a service.

And that interdependence was tripping us up. Teams were we’re kind of independently prioritizing data work that we needed to do, and other teams are prioritizing technology infrastructure that we needed to build on. And the product development team was chunking along, working on products.

So, whenever that the data wasn’t ready or the technology wasn’t ready or the product wasn’t ready, we were slowed down. And being slowed down means missing opportunities or disappointing customers, et cetera, et cetera. So, you see where this is going.

The answer that we came up with is we added to our roadmap, a data roadmap and a technology roadmap. But not only having those three roadmaps isn’t the key, it’s the painstaking linking of the three roadmaps together, so that when you know what product you’re planning to have in what quarter or what enhancement, you can link that with what data you’re going to have to have ready or what data sources you’re going to have to have connected by that time. And you connect that with the technology infrastructure that you need.

So, sorry if that seems super obvious, but it wasn’t obvious to us and it took us several years to come up with the three roadmaps; the product roadmap, the technology roadmap and the data roadmap. Thanks a lot.

And that concludes another episode of The Tallest Kindergartner. As always, feel free to email us at info@ihie.org with questions or feedback. Thank you.

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