Questions for California

On Tuesday the 21st the California Health and Human Services Agency introduced Jonah Frohlich, MPH, as the new Deputy Secretary for Health IT. Several people spoke during the hour-long conference call. In addition to introducing, Jonah two important planning documents were released: the roster of the newly appointed HIE Advisory Board and the HIE Work Plan. The new action from California DHHS is a welcome addition to the team effort towards HIE services throughout the state. However, what was said and what was left unsaid leave a lot of questions unanswered. Here are four questions that occur to me.

1. Why is Jonah the "Deputy Secretary for Health Information Technology" while the committee is the "Health Information Exchange Advisory Board"?   Why isn't Jonah the Deputy Secretary for HIE?   Or why is the committee not named the "Health Information Technology Advisory Board"? Is the state just being careless with the terms or do these variations mean something?
2. Five members of the newly appointed HIE Advisory Board are also listed as members of the CalRHIO Board of Directors. Now that they are appointed to the state board, do these five board members plan to resign from CalRHIO? And if not, will they recuse themselves in discussions which evaluate health IT issues in which CalRHIO "has a horse in the race"?
3. There are 10 HIEs in California that are planning a data service, and 8 additional HIEs in California that are already exchanging data, yet none of these projects are directly represented on the so-called "HIE Advisory Board". If none of the 8 experienced HIE projects are represented on the HIE Advisory Board, then how will the committee make informed decisions regarding the operating practices of HIEs?
4. If the state plan is to complete a careful baseline evaluation of HIE opportuties by the end of July, and to be prepared with a list of HIE projects to fund by October, then doesn't this mean that California is bypassing all FY 2009 HITECH funds in order to be positioned for FY 2010 HITECH funds? And what options are available to the 8 operating HIEs in California that are ready to expand their services now, during FY 2009?

There are other questions that can be asked, but this is a starting point. Full Disclosure -- I manage one of the 8 operating HIEs in California.

Process Over Product

I have a daughter who will graduate with an MA in English next month. Her thesis topic is the pedagogy of writing instruction.   This morning I marked up her manuscript in my parental role as a free editorial service (your basic punctuation, grammar and syntax nag). About half way through the manuscript I encountered a sentence about "...the pedagogical innovations of the process revolution in writing instruction, the decentering or sharing of authority, the recognition of students as sources of knowledge, a focus on writing processes over writing products..." I paused with a sense of deja vu and thought about "the process revolution in clinical care, the decentering or sharing of health care authority, the recognition of patients as sources of knowledge, and a focus on episodes of care over quantities of procedures." It's an inexact comparison, and the thought lasted for a moment, just long enough to make this blog post. Now I have to get back to editing her manuscript, because when I am done with hers I also have a son who will graduate with an MS in Math next month, and his manuscript is next. His thesis is on optimizing an energy model of the electricity distribution grid for Humboldt County, California, which he blogs about here.

California Regional HIE Meeting

The meeting was held two weeks ago in Los Angeles. As an event, it was a strange brew of scripted posturing from CalRHIO and abrupt intrusions of reality due to many inconvenient questions posed by attendees who represented operational HIEs. From my perspective there were no revelations at the meeting. CalRHIO continued their Quixotic quest to impose a misunderstanding of eHealth technology on the state, while the meeting held a room full of HIEs who knew too much to simply accept the self-serving inaccuracies that litter CalRHIO's common narrative in presentations, press releases and in meetings like this one. For example:

• The typical CalRHIO narrative claims that when they build an HIE service, at some future point, it will be a first for California. Over the past two months CAeHC has developed a definitive inventory of HIE efforts within California. When CAeHC launched in February, the inventory showed 4 operating HIEs. Now, two months later, the inventory shows 8 known operating HIEs in California, none of which are CalRHIO.
  


• The recent press release from CalRHIO about new HIE services in Orange County conveniently omits any mention that there already is an operating HIE service connecting the emergency rooms in Orange County. The press release says the planned launch by CalRHIO of a small portal in Orange County this summer will be the first county-wide HIE service, when in fact if it launches in July (as promised) the new service from CalRHIO will be the second county wide HIE service in Orange County, and it will join several other county wide HIE services already in operation in other counties in California. The Orange County press release is typical of inaccuracies in CalRHIO's narrative.


• CalRHIO continues to misunderstand the NHIN gateway architecture by asserting incorrectly that the CalRHIO web service from Medicity will be needed for all small HIEs in the state to connect to the NHIN. This assertion by CalRHIO is directly contradicted by the current federal architecture for the NHIN, in which any HIE in California that operates an NHIN gateway will connect directly to the NHIN without CalRHIO.


• CalRHIO said that if they cannot be the official statewide HIE, then they will close their doors, which is silly, because there is still a role for CalRHIO even if they don't yet understand the NHIN gateway architecture

So the short version of the meeting is that CalRHIO found itself in a room full of its peers, and instead of taking the opportunity to communicate openly, CalRHIO maintained its imperial, top down approach towards HIEs across the state that are already delivering clinical data (unlike CalRHIO). Here's the list:

1. Redwood MedNet
2. Virtual Clinical Network of Partnership HealthPlan
3. ACCEL
4. Santa Cruz
5. EKCITA
6. Long Beach Network for Health
7. Kaiser Permanente
8. Orange County MSI

In the end, the meeting was another missed opportunity for CalRHIO to harmonize their message with the eight HIE projects in the state that are already operational. Instead, rather than openly collaborate with other HIEs in the state, in this meeting CalRHIO described a clearly inaccurate version of events. When called on these inaccuracies by participants at the meeting, CalRHIO sought to talk them away. People I spoke with after the meeting were disappointed by the continued stonewalling from CalRHIO.

As the next phase in the NHIN unfolds this year, fueled by HITECH funds, and as the 8 operating HIEs in California are joined by the 10 planning HIEs, and as even more HIE projects in this huge state emerge, CalRHIO will find a robust community of peers available to collaborate on improving health care for all. This is not a question of if but rather is only a question of when CalRHIO will drop their mistaken assumptions that (1) they are in charge of the state or (2) are in any way essential to the NHIN, when in fact they are just one HIE among many.

Call To Action
In the next post I'll detail the Call to Action that was published earlier this week (on Monday) by the California eHealth Collaborative, which asks all communities in the state to articulate the actual, known, on-the-ground eHealth activities. Far more than the inconclusive regional meeting hosted by CalRHIO in Los Angeles, the CAeHC statewide survey will show how many communities are hard at work developing an eHealth infrastructure for California.