“For HIEs To Succeed,
We Need To Start Small”
By Anish Mahajan MD – CMO of Harbor-UCLA Medical Center and Chair of the Los Angeles Network for Enhanced Services Board of Directors
We tend to think of healthcare as the relationship between care providers and patients. When I say the word, you probably picture a patient sitting in a paper robe on an elevated bed, their heartbeat assessed by a stethoscope-wielding doctor. For me, healthcare is also every single data point surrounding this interaction, and one reason we as a country are spending so much on it is because those data points aren’t speaking to each other very well. Let me illustrate this with a story.
Adrienne Chan, a Physician Assistant at Los Angeles Christian Health Center (LACHC), is treating a new primary care patient (we will call him Mr. S) who was complaining of headaches, as a result of a head injury sustained 3 months prior to the visit. Adrienne notes that “Mr. S said he had a fracture in his forehead and that he needs surgery.” Mr. S informs her that he has already had a bunch of tests at the emergency room and has seen a specialist at one of the local hospitals.
Wanting a thorough diagnosis, Adrienne considers how to fully work-up Mr. S’s head injury and residual headaches. She questions Mr. S about his previous care visits and then contacts those facilities to see what the patient’s records reveal. She reaches voicemail for several of her outreach efforts. All told, she and the clinic staff spend hours trying to retrieve information. Though the clinic receives some partial medical record information by fax, Adrienne knows she’s not gotten all of the previous work-up results she needs. So Adrienne proceeds to reorder the tests Mr. S has already received, wasting thousands of dollars, Mr. S’s time, and potentially exposing Mr. S to unnecessary radiation by repeating the CT Scan. All because our current idea of healthcare relies on this single data point rather than the collection of many.
Luckily for Adrienne, this actually wasn’t the case for this particular visit, because LACHC participates in a regional Health Information Exchange (HIE) called the Los Angeles Network for Enhanced Services (LANES). LANES is an independent and non-profit organization that seeks to make patients’ health information available when and where it’s needed to enable better clinical care and care coordination. This is a lot to unpack, so let’s go back to Adrienne.
By accessing LANES, Adrienne was able to view the radiology report of the CT scan from Mr. S’s previous hospital visit and concluded he had multiple skull fractures. Adrienne was also able to view the hospital discharge summary which indicated the name of the specialist that the patient had seen and the exact brain scans that needed to be done in follow-up. LACHC was able to avoid duplicate testing, provide consistency with the hospital discharge plan, and establish care coordination with the specialist.
The focus on HIE’s so far, if there has been at all, has been on the national level with the idea that your medical records from your doctor visits in Oakland can be viewed by a doctor in New York if you happen to end up in the emergency room there. There are hundreds, if not thousands of physicians, administrators and policymakers that are devoted to the idea that we can create a comprehensive national database and that the gravity of federal policy will make it happen. I love big ideas and grand solutions, but this approach will likely add to the billions already spent on low-value health information technology rather than address the real and everyday problems clinicians and patients face when they are going between hospitals and their outpatient providers.
The reason why LANES and other Regional Health Information Organizations (RHIOs) are different is because of the reality of patient care. Adrienne’s patient with the headaches went from the LAC+USC Medical Center to LACHC for his care coordination. As you can tell simply from the acronyms, these facilities are all in Los Angeles. He didn’t go to San Francisco for his headaches, let alone Boston. Despite the fact that LAC+USC and LACHC are 3 miles from each other, without a regional HIE, they might as well be in separate cities.
Let’s think about it from a research perspective. To pioneer a new pharmaceutical or to study a cellular phenomenon, a researcher will often start with a single-celled organism and work their way up to humans. You look at basic structures before moving up to complex ones. Regional HIEs and RHIO’s are based on the same principle. Medical professionals from the same areas are familiar with each other, more willing to band together for shared outcomes, more easily able to share those outcomes with those that are still on the fence.
This is an important point, because even at the regional level, there are obstacles. Healthcare costs have led all administrators to demand ROI from any new initiative, but by starting small, the savings are more evident. Two hospitals 3 miles down the road from each other were once worlds apart in terms of the data they accumulated, but now they can eliminate overlap. The Adriennes in this connected system have more time for more patients. Their labs run only the necessary tests instead of duplicates. 3 miles can feel more like 3 feet.
Maybe once we have more LANES successfully proving this case around the country can we turn towards creating super-regions, scaling our focus outwards for bigger outcomes. But we can only get there by making sure the smaller bricks are solid, that the strategy, technology and economics are viable. My point here is that we don’t have to give up on our big ideas. In fact, our big ideas are more possible than ever thanks to our commitment to starting small.