MobileMD Responds to GOHCR's Proposed Plan to Implement the Pennsylvania Health Information Exchange
By Todd J. Fisher, CEO, MobileMD
At the end of November, the Governor's Office of Health Care Reform ("GOHCR") submitted a proposed plan outlining a strategy to expedite and implement the Pennsylvania Health Information Exchange ("PHIX"). In my opinion, the plan is precariously perched on the precipice of disaster.
The only safe path away from disaster and toward success for the GOHCR is to step back, rethink its strategy to partner with the Delaware exchange, and consider what health information exchange technology and services truly means to the providers and patients of Pennsylvania. In short, the plan, as it is currently drafted, concerns me as an entrepreneur and Pennsylvania resident.
Perhaps most troublesome is a statement found on Page 54 of the plan: it states "In order to reduce implementation time and reduce costs, Pennsylvania should execute an intergovernmental agreement with Delaware to leverage their existing contract for HIE Services." The proposed plan, however, lacks an explanation as to why Pennsylvania should not create an HIE contract suited to Pennsylvania or why the Delaware contract is the most suitable HIE contract among myriad such contracts to "leverage." Although not mentioned in the Plan, HIMSS' Government Health IT publication has pointed out that the Delaware "...infrastructure includes the HIE application developed by Medicity and hosting services from ... Dell Services." The Plan’s recommendation, therefore, would result in the arbitrary selection of Medicity as the statewide health information exchange platform for Pennsylvania without any competitive bidding process or other reasonable objective vendor selection process. With due respect, the GOHCR's proposal seems wrong on many levels. I will make four points I feel are most important.
No-bid Contract
First, the very notion that the state would conduct a no-bid contract of such a scale with so much at stake for the well being, privacy and quality treatment of Pennsylvania citizens, is very disconcerting, and, frankly, jeopardizes the trust Pennsylvania providers and patients have in the GOHCR’s judgment - trust critical to ensuring the technology adoption and subsequent benefits GOHCR seeks.
State Health Information Exchanges
Second, I take issue with the manner in which many state-bounded health information exchange initiatives have unfolded.
If implemented properly, statewide health information exchange initiatives can serve to benefit providers and patients; however, all too often statewide initiatives such as the proposed GOHCR plan fail to appreciate the real-world regionalization of healthcare. While healthcare is clearly a regionally based market, health system boundaries regularly cross state lines, particularly in the crowded Mid Atlantic and Northeast regions.
The current state-based initiative in Tennessee, for example, is experiencing several challenges. Tennessee is bordered by eight states. Tennessee’s population exists largely along its state lines. As a result, many Tennessee-based health systems provide services to physicians and patients in bordering states. Due to its need to extend beyond state lines, the Tennessee initiative has experienced challenges such as varying privacy rules between bordering states, and funding constraints that stop the flow of capital at the state line. Increased expense, confusion, and poor technology adoption has been the result. In short, state boundaries are arbitrary in the context of health system referral regions.
Operational Issues
Third, the proposed plan fails to address specific operational considerations critically important to those who intend to participate. Essentially, two questions must be asked: is free really free? And, how can GOHCR possibly make an informed decision before such operational issues are more thoroughly understood?
Below represents a tiny fraction of the operational questions that must be addressed by GOHCR, the answers to which will most likely imply costs to the health systems, practices and other participating entities that will be very difficult for the GOHCR to quantify and will be entity specific.
- Who is going to actually work with the exchange vendor to support the individual subscribing entities?
- Who is going to work with the various physician communities when questions arise regarding status of anticipated results and reports?
- For example, who is going to take the call from the remote PCP when she is asking about Mrs. Jones' Discharge Summary?
- For example, who is going to communicate to the exchange vendor when subscriber interfaces have to change because internal systems have changed?
- Who is going to organize physician and community outreach programs to make potential subscribers aware of the offering?
- Who is going to manage the technology components that are deployed on site at the subscribing entities, whether the components are hardware devices, software or both?
- Who is going to handle integration mapping - whether it can be done by a user interface or programmatically?
- Who is going to support branding and private labeling to the local health system communities so a sense of brand recognition remains?
- Are the service levels for different healthcare organizations different? If so, who is going to manage that rather complicated matrix?
These and similar questions require significant thought, rigor, and entity-specific considerations. As a result, the time to work out operational considerations will take considerable time. If, for example, addressing such questions takes 10 - 12 months, is the GOHCR really saving time by circumventing the traditional bidding process? I respectfully submit the answer is no.
Freedom to Choose
Fourth and most important, my business experience in general and my experience in the healthcare industry in particular have convinced me that the best results are obtained when health systems are left free to choose how to solve their information technology needs, and do so in a manner that provides competitive advantage.
As a means of further making my point, allow me to quote Adam Smith, the founder of modern capitalism. "It is not from the benevolence of the butcher, the brewer, or the baker, that we can expect our dinner, but from their regard to their own interest." For our national drive to modernize healthcare's information technology infrastructure to succeed, we have to depend upon the "invisible hand" of competition to drive innovation and adoption. The mantra should be "competition first then cooperation".
Health systems should be provided the opportunity to compete for physicians and patients using information technology as a competitive advantage. Exchanges, more than any other type of information technology, provide health systems the opportunity to leverage technological innovation to establish and improve relationships with their physician and patient communities. The inter-system exchange of information will naturally follow, using national standards and freely available infrastructure such as the NHIN-CONNECT, as health systems reach a point at which their return on investment is improved by leveraging their technology to cooperate. Just look at the commercialization of the World Wide Web as the case study.
Summary
If the GOHCR wishes to use state and federal funds to improve the quality of health care by subsidizing Pennsylvania health systems such that adequate information technology is more attainable, I recommend GOHCR provide health systems with financial incentives for health information exchange adoption instead of using expediency as a reason to circumvent the competitive bidding processes. By offering Pennsylvania’s healthcare community a single technology choice with a single perspective and approach, the GOHCR fails to grasp an opportunity to encourage innovation. Rather, the default selection of a single vendor stifles innovation and jeopardizes health systems' ability to adhere to their mandate to provide the best possible care to their communities.
In my opinion, GOCHR's proposed plan represents an incomplete assessment of the key issues and potential solutions masquerading as a rational decision driven by a need to achieve speed to market.
As a postscript, the pool of several hundred or so connected physicians in the state of Delaware is hardly comparable to the needs of Pennsylvania’s legion physicians. Our health information exchange (www.MobileMD.com) has more than 1,000 physicians connected in the commonwealth of Pennsylvania, from Pittsburgh to Philadelphia, and we’ve just begun. By "hanging its hat" on the Delaware initiative as a proof of concept, the GOHCR appears to have failed to conduct appropriate due diligence and deliberation with respect to the challenges facing such an initiative.
The citizens of Pennsylvania deserve and expect better.
ED. NOTE: On Monday, December 21, 2009, MobileMD submitted a formal response to the Governor’s Office of Health Care Reform (GOHCR) for a Pennsylvania Health Information Exchange.
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