HIStalk Practice Interviews Laura Adams, President & CEO, Rhode Island Quality Institute

Laura Adams is president and CEO of Rhode Island Quality Institute, a nonprofit organization that provides a range of services to healthcare stakeholders across the state, including management of the CurrentCare HIE.

Tell me about yourself, Rhode Island Quality Institute, and its role in CurrentCare.
I became the founding CEO of the Rhode Island Quality Institute (RIQI) in 2001 after having experience in hospital administration, entrepreneurial startups, the system-wide application of quality improvement science, governance and leadership consulting, and bedside clinical care delivery.

CurrentCare, an independent nonprofit, came about through a strong partnership with the State of Rhode Island and the statewide collaboration of our hospital/IDN, provider, insurer, consumer, and employer partners. It was clear to us that if we were truly committed to the health and wellbeing of the people of our state, we needed to find a way for their healthcare data to be available anytime and anywhere it is needed, regardless of proprietary, geographic, and/or payer boundaries. As time passed and we observed others struggling with “data hoarding” challenges, we realized the power of keeping our eye on the “north star”— that is, what is best for the people we serve. To paraphrase Don Berwick, MD, the former head of CMS, the enemy was disease, error, and waste – not each other.

The RI Dept. of Health received HIE grant funding from AHRQ in 2004, which resulted in the development of CurrentCare’s governance structure, privacy and security framework, technology infrastructure design, branding and communication strategies, engagement of stakeholders, etc. RIQI then received grant funding from the HITECH Act in the 2009 federal stimulus bill that allowed us to stand up the HIE technology infrastructure and get data flowing within nine months of the grant award. We now have more than 200 unique data flows into CurrentCare.

All RI acute care hospitals are connected, with the exception of the VA (coming soon). Approximately 90 percent of all lab results and medication histories flow into CurrentCare, and data flows in from ambulatory care practices across the state. We also include such clinical information as data from CCDs, EKG reports, radiology reports, telemedicine alerts, etc. We are the only statewide HIE in the nation that has integrated substance abuse and alcohol treatment information from 42-CFR Part 2 providers. We have bi-directional data flow with the Epic platforms of our two largest IDNs/ACOs in the state; Athena, Cerner, and Meditech platforms will soon follow. This bi-directional flow means that providers do not have to leave their EHR to access and download/consume data from CurrentCare. The bi-directional achievement prompted the CEO of our largest IDN to report that one of his most seasoned ED physicians declared CurrentCare “indispensible” to providing emergency care now that it was accessible within his Epic system.

Our community is highly interested in leveraging the statewide HIE’s Provider Directory that we’re building. They support creating a statewide Provider Directory function in the center using multiple data feeds, creating a “single source of truth” for the provider information now critical to succeeding under new payment models. Healthcare stakeholders can purchase the data flow, allowing them to stop expending precious resources on duplicative provider directories that are expensive and very difficult to maintain. This is a very significant waste reduction opportunity for the RI healthcare community.

Since CurrentCare is the one place with the most comprehensive, longitudinal data from across many sites, irrespective of payment, we are committed to patient/consumer use of the database to manage their own health and that of their families. We are beta testing a consumer portal that will permit them to upload their own data from wearable technologies, and documents like Advance Directives/Powers of Attorney, etc. We are also building apps, such as the “My Meds” app, which allows a consumer to access their medication history data in CurrentCare from anywhere in the world. The portal also enables users to “view, download and transmit” their entire clinical record.

I haven’t even touched on the value to public health, quality reporting, shared analytics capability, etc., but you get the idea.

Why has the HIE faced such low numbers when it comes to physician adoption?
You may be referencing data quoted in a recent article in GoLocalProv, a RI publication. We were disappointed that neither RIQI nor any of our Board members were contacted for input into the article, as the usage representation was out of date and inaccurate. The survey referenced in the article is at least 15 months old, and it was conducted before we went live with bi-directional exchange with the Epic platforms of our two largest health systems in the state. Steve DeToy from the RI Medical Society — quoted in the GoLocalProv story — has been writing rebuttals/clarifications in several blogs and publications that picked up the story.

The measure of usage as reflected in the referenced survey from the State of RI is not only outdated, it includes a denominator of all licensed physicians in RI. RIQI focused the CurrentCare rollout effort on primary care and hasn’t even begun intensive roll out efforts beyond these providers. Therefore, the use of all licensed physicians as the denominator wasn’t accurate.

In addition, we don’t measure CurrentCare’s worth by just one measure of value. That would be as faulty as finding that a patient’s heart rate is in the normal range and concluding that they’re completely healthy on the basis of one metric. Health is more complicated than that and so is HIE. For example, the metric referenced doesn’t include use by other members of the care team, including PAs, NCM, quality improvement professionals, etc. It also doesn’t include our Hospital Alerts service usage. An analysis of the effect of CurrentCare Hospital Alerts over more than a year shows that they correlate with a 13-percent reduction in costly hospital readmissions within 30 days, and a 20-percent reduction in return visits to the emergency department within 30 days.

This metric also doesn’t regard the benefit to the research community. We are included in a number of research grant proposals because of the highly unique database of clinical information, including that from private practices. The research value to the RI community will grow exponentially over time.

The metric referenced doesn’t reflect the value of such services and tools as the NCM dashboard, which prompted the CEO of a very well respected and high-profile community health center to suggest that this was “a game-changer.” He quoted his staff’s reaction to it as, “The best data ever!”

So, in short, it is a disservice to the hundreds of people who are working hard on the community asset that is CurrentCare to characterize it as the article did. With all of the additional value cited above, we’ve just begun to leverage our community investment in CurrentCare. To disparage it now is like disparaging a nine-month old baby, expressing disappointment because this baby was expected to be able to run, jump, and play Little League, and all it’s doing at the moment is crawling around on all fours.

How is CurrentCare working to help physicians better leverage the HIE?
We are aware that physician adoption of health IT hasn’t been easy by anyone’s estimation. Despite their obvious value, CMS had to create a very robust incentive for physician adoption and use of EHRs. More than $100 million has been invested by CMS and RI Medicaid to incent RI physicians to adopt and meaningfully use EHRs. There have been virtually no incentives available to RI physicians to adopt and use CurrentCare. We also know that the value of an HIE is directly correlated with the evolution of the payment model. We knew when we began building CurrentCare that gaining adoption and use would be significantly hampered by RI’s nearly 100-percent fee-for-service model for many years into the future. The toxicity of the fee-for-service payment model meant that reducing duplication and better coordinating care resulted in financial penalties for providers. Now that we are finally seeing very encouraging movement of the prevailing payment model in RI toward payment for value, the benefit to ACOs/IDNs/hospitals/physician providers increases exponentially.

But we’re not relying exclusively on the payment system to increase adoption and use. We are executing a multi-pronged strategy to make CurrentCare indispensable. That strategy includes:

• Growing the data types and data sharing partners, which creates more value in the eyes of providers, public health officials, researchers, consumers, etc.
• Continually improving the design of the system in regard to ease of use.
• Working with our community partners to encourage CurrentCare usage through provider contracts and quality improvement incentives.
• Developing increasingly useful tools and services such as the NCM dashboards and the Provider Directory.
• Developing ROI metrics such as those for Hospital Alerts that offer evidence of the value of CurrentCare.
• Developing deeper data and analytics capacity, such as overlaying predictive analytics capabilities on top of our unique and much more comprehensive database, assisting providers to avoid preventable hospitalizations and ED visits.
• Creating innovative tools and services for consumers; for example, if we can alert a provider to an ED admit, then with a patient’s consent, we can certainly alert the family member(s) of his/her choosing, should an event of that type occur, regardless of where the family member(s) resides geographically.

As I mentioned before, we’re really just getting started in putting this asset to work. There is much more to come.

How do physician adoption numbers reflect overall physician adoption of EHRs in Rhode Island?
Physician adoption of HIE services is not necessarily related to overall adoption of EHRs. In fact, EHR adoption in Rhode Island has been very robust. Of the approximate 1,200 primary care providers who have worked with RIQI, most have adopted an EHR, 1,159 are able to produce e-prescribing and quality reports, and 876 (over 70 percent) have met Stage 1 Meaningful Use. And this accomplishment did not happen overnight but took more than five years of education, training, and direct technical assistance – not to mention nearly $100 million in federal incentives, as well!

The usability of EHRs has been the subject of much Congressional debate in recent weeks. What feedback have you heard regarding usability from the state’s physicians?
The feedback from our physicians does not differ substantially from that reported to Congress in the recent testimony in front of the Senate HELP committee. This includes the need for:

• Better usability for aggregating and viewing complete, accurate patient data at the point of care, including data from external sources, which will also improve the accuracy and lessen the burden of data collection;
• Smart approaches to structure free-form input (keyboard or voice) is essential to improve usability and to improve downstream data consumption and analytics;
• Ease of interoperability with HIEs and other external data sources— in other words, avoiding the charging of substantial fees for connecting and exchanging data, which we have seen happen in RI (this one is critical!);
• Built-in safety features that help avert errors and adverse events (auto checks for drug-drug, drug-allergy interactions, etc. with careful attention to having the RIGHT amount of reminders so they aren’t ignored);
• Clear training tools/assistance to ensure the above functionality is enabled, including an increase in training time since improving quality is often the responsibility of support staff (currently, on average there is only a one-week training period and any additional time comes at a cost. Increase to at least 2 weeks); have the EHRs clearly notify staff within the workflow when they aren’t meeting a quality measure (i.e., turn the field red or a notifications shows when a required procedure is missing, etc. Some EHRs do this, but many others do not).

How does CurrentCare plan to evolve over the next several years? Are there plans for self-sustainability?
CurrentCare does not now depend upon public funding for the majority of its revenue, but it is significant and could become the major source if anticipated grants/contracts come through in 2015. The plan is for CurrentCare to continue to expand its ability to serve as a “public utility” type of asset used by state government, consumers, researchers, providers, payers, policy makers, etc., as well as a provider of customized fee-for-service products and services to hospitals/ACOs/providers, payers, entrepreneurs/investors and other stakeholders. While RIQI doesn’t anticipate dependency on grants, it is definitely a center of innovation capable of attracting and effectively using grant funding to develop valuable and creative new products and services based on the needs of its stakeholders. With very broad stakeholder engagement, it can attract entrepreneurs with a need to test and evaluate innovative ideas that involve some type of assistance from health information technology.

Do you have any final thoughts?
I’ve always felt that my time at RIQI was the best work of my life and worth every life-moment that I invested in it. But its true worth hit me hard when I was diagnosed with breast cancer and began to see the need for initiatives like CurrentCare through the eyes of someone whose life literally depended upon the healthcare system. From the morning after my diagnosis, when I found that I’d cried myself awake yet had to scramble to assemble and transport my own health records, through the surgery when my last panicked thought before anesthesia was that my doctors and nurses didn’t have access to my advance directive, to the gaps in follow-up care that left me feeling frightened and alone … I knew I was being given the rare gift of understanding the true value of my own work. One can perhaps then understand why I’m a staunch defender of HIEs, regardless of where they are on their developmental trajectory.

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Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg, Lt. Dan

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