Nashville Post

A discussion of key health care players’ efforts to define, build data-sharing standards

In what seems like very short order, interoperability — the concept of getting health care IT systems to efficiently communicate and share data with each other — has become one of the hotter topics in the sector. Last spring, local power players HCA Holdings, Community Health Systems, LifePoint Health, Saint Thomas Health and Vanderbilt University Medical Center launched the Center for Medical Interoperability to be a provider-side advocate for such efforts and to look to line up with CommonWell, a coalition of vendors.

The Nashville Health Care Council recently hosted a panel discussion on the challenges with and opportunities arising from bringing together so much data housed at the nation’s health care providers. The conversation was hosted by CMI Executive Director Ed Cantwell and also featured Zane Burke, president of IT giant Cerner, and Mike Schatzlein, senior vice president and group ministry operating executive for Ascension Health, the parent of Saint Thomas. Here are some excerpts from their chat.

Driving change, surrendering a competitive advantage or two

Cantwell: What’s the return on investment of interoperability, which as an ex-CEO just scares me, right? It’s like asking what’s the return on investment for electricity because, believe it or not, that’s a pretty good analogy of what we’re doing. Electricity has enabled innovation on both the device side and the system side. So let’s talk about the barriers. Dr. Schatzlein, what do you see as the key barriers to achieving this goal?

Schatzlein: If we could come together and create a lab that would certify standards while working with the various vendors and acknowledging and using the work that they’ve done, we are in a position then to go ahead and implement that technology and, frankly, sort of enforce that technology. Because folks that can’t get to those standards are going to be less appealing to us for cost and safety and other reasons.

So I think the main barrier of calling providers together and then getting commitments from the crucial providers — [HCA Chairman and CEO] Milton Johnson’s sitting right in front of me but also on the board are [CHS Chairman and CEO] Wayne Smith, [LifePoint Chairman and CEO] Bill Carpenter, Jeff Balser from Vanderbilt. Of the board, five of us are Nashville people. We represent the biggest of the health care companies and so, by coming together and funding this on a membership model and setting up the labs here in Nashville to do the testing, I think that opens up the possibility. It’s been very heartening to see that folks like Cerner are bringing the technology, the intellectual property that they’ve developed in this space to the table. We will develop standards that are much better because of the participation of the vendors who are actually making the devices.

Cantwell: Just a fine point — not a commercial for the Center — but the disciplined process of using procurement power to drive transformation, but not in a draconian way, in a way where vendors know what to bill to and where the R&D risk is reduced. Almost every other industry does this very well so that there’s predictability on what to invest in. There’s an acknowledgement: Don’t invest in the plumbing. Appropriately commoditize the plumbing, invest in the innovation.

So from a solutions provider point of view, what do you see as the key barriers? Hopefully, we will have removed one of them.

Burke: Interoperability means a lot of different things depending on your vantage point, and for us as it relates to the device world … If there’s a standard, we can go innovate on that standard in a very robust way and even partner with third parties and venture capitalists to go do some of that work as well because there’s some amazing work to be done.

We actually direct a project, which some of you may be familiar with, around meaningful use, which was around secure email for physicians. We actually came up with that idea and donated the 150,000 lines of code to do that project, so that was kind of one of our first donations into the public domain.

From a broad-scale EMR perspective, one of the things we’re very passionate about is the lack of a national patient identifier. Just politically speaking … the legislation gets deferred every single year to actually have a national patient identification, and the lack of that means that it is incredibly challenging to match who the person is that’s receiving the care. We are part of a consortium called CommonWell along with about 40-plus other companies, really driving standards around the national patient identifier. We’re part of the Argonaut team, which is working around how do you create open standards for development on EMRs.

It’s in the infancy level. There are barriers on the provider side in that true interoperability business model-wise is not good, historically speaking, for the providers. So I’ll just say that. The connectivity in their own network has been one of the competitive advantages. “How do I get physicians closer to my hospitals? How do I connect them and make my referral network stronger?”

Those are real challenges in my own business model. We’ve gotten paid for interface for a long time. We all are going to have to say that this is about a greater good for the clinicians so there’ll be an experience around that at the clinician level, for the patient and we’re headed toward an at-risk world. And the closer we get to that at-risk world, the more we’re going to have to have interoperability because we’re going to have to have access to the data. I look at it and it says, “He or she who has the data will win.”

‘Industry has solved these problems in every other space’

Cantwell: What should the government do? What do we want out of the legislative side of the government and what do we expect of the regulatory side?

Schatzlein: [Sen. Lamar Alexander] has been in communication with President Obama over the precision medicine initiative and is tying this all in with that. They would all rather that there be a private-sector solution. It gets very Big Brotherish when government gets into this area so whether you’re liberal or conservative, you probably don’t want the government in this area. I am less familiar with the patient identifier initiatives than maybe some others here, so I’m going to steer us back to interoperability, but that’s sort of an area where we can establish standards as providers.

We can establish labs here in Nashville to test against those standards […] But I don’t think we need the government to help us with any of that. Now moving over to the regulatory agencies, they have had their toe in these waters here and there, and lab equipment is a perfect example of where they’ve been involved. The FDA has been involved, the FTC, some others have been involved in creating some standards. And I think that we would hope that they would recognize that, if we can stand up a strong private-sector, provider-based entity that can develop these standards, that they’ll sign on with them rather than competing with us in the standards development area.

We’re trying to make things not only safer for the patient, but easier for the innovators. I sat next to a young innovator at a similar function — I think Ed was there — maybe six or eight months ago. He’s got a company building something he can’t get it by the FDA. He and his venture capital funders are going to take a bath because he’s got a great idea that ought to be able to work. But the cost of getting by that regulatory barrier for him were too great.

Burke: We have to really move past the government engagement in this space. Industry has solved these problems in every other space. You look at Bluetooth: You get in a rental car at Avis and it pops up on the screen “Would you like to connect your phone?” This should not be any different than that and it’s up to the collective we to get our stuff together, so to speak, and really agree on those standards.

I look at government […] as a supportive role. So support the standards, help facilitate the standards. But this is a problem that should best be solved by us and the collective us is the providers and the vendor community. I think that, particularly in this case, this one is solvable. When you look at some of the other interoperability pieces, there’s some really big challenges in there. This one is very solvable and if we can get everybody just to stay on the same page around the standards piece of that, I think the innovation will be amazing. […] We can really begin to unleash some of the power of that core plumbing if we can get the innovation lined up next to it.

Aiming for a lasting moonshot

Cantwell: Should this be a moonshot? The patient safety movement is a movement focused on preventable deaths. I recently spoke at their conference; their goal is zero preventable deaths by 2020. Lofty, right? But admirable.

So one of the things we have in front of us — and really, it will be our boards and our members’ decisions — if we get enough concinnity to […] say, “By 2020, by 2018, we will start to build to an open platform.” So I’ll put one of my vice chairmen of the center on the spot: Should it be a moonshot or should it be a marathon?

Schatzlein: Well, I’m impatient when it comes to patient safety and you know I used to be a surgeon and it’s open, fix, close. It’s not a big, complicated, long process. On the other hand, it has to be sustainable. So it kind of needs to be both. If you look at the moonshot, we got a lot out of the moonshot and then we never went back to space in the next two decades or three decades.

I think we need to set goals for the 2018-2020 period to get the standards out there, to get the lab up and be testing to the standards. But we’ll never be done. The mission will never be over. So I’d like to see lots of resources put to it a quickly as we can, recognizing that it’s going to have to be both. We’re going to have to run the first 200 yards real fast and then go the rest of the 26 miles at a more sustainable pace.