CalRHIO's Coda

First, a disclaimer. I am not on the CAeHC Board of Directors, I do not attend CAeHC Board of Director meetings, and I do not speak for the CAeHC Board of Directors. The following comments are solely my own personal opinions.

To the matter at hand: a rumor is circulating today that "CalRHIO and and CAeHC will be forming a new nonprofit to be the HIE Governance Entity for California." That comment was published today in an email broadcast by staff from CPCA. While the comment circulated by CPCA is not entirely untrue, it is also less than fully accurate. To flesh out this rumor, the following statements are also true.

1. CalRHIO applied to be the HIE Governance Entity, CalRHIO was turned down outright by the State, and CalRHIO is covering their failure by "agreeing not to compete with a new Governance Entity that is being formed by the State."
   
2. The State, appalled at the suboptimal HIE Governance Entity proposal from CalRHIO and unwilling to act decisively, used CAeHC as a proxy to simply negotiate CalRHIO to death.
3. CAeHC, formed to help stakeholders collaborate on health IT deployments, applied to be the HIE Governance Entity primarily to prevent CalRHIO from becoming the HIE Governance Entity, and now in the end everyone can see that CalRHIO will not be the HIE Governance Entity.
   
4. CAeHC is helping the State launch a new nonprofit HIE Governance Entity, but CAeHC is not going out of business like CalRHIO; that is, CAeHC is merely stepping aside so the State can operate an HIE Governance Entity, because CAeHC has other lines of business to attend to.
5. The new HIE Governance Entity is not a "merger" between CAeHC and CalRHIO, but is rather the final coda in the tragic tale of CalRHIO, while the new HIE Governance Entity is also merely an opening act in the emerging saga of CAeHC.
6. CalRHIO is no longer in business, the State is micromanaging the HIE Governance business, and CAeHC is still in business and still advocating for comprehensive eHealth collaboration.
7. CalRHIO needed an outright win to survive, but CAeHC only needed a draw to eliminate CalRHIO.
8. CalRHIO is no longer relevant and no longer in business, while CAeHC remains relevant and remains in business.

In other eHealth news, yesterday CAeHC submitted a $10 million preliminary proposal to ONC to operate a REC on behalf of 4,000 primary care providers in a five county urban region in California. Also, after a successful year of 38 weekly webinars on eHealth, CAeHC announced yesterday that it will launch a new eHealth Webinar Series for 2010 on January 12.

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.

No HIE Is Excluded and All Are Invited

The title of this post refers to the California eHealth Collaborative (CAeHC). As a point of full disclosure, I am on the CAeHC Steering Committee.

This post has three parts.

1. About the California eHealth Collaborative
2. Open Letter to CalRHIO
3. After the Letter & Before the Meeting

About the California eHealth Collaborative
The Collaborative was formed last month due to a confluence of factors. One factor (out of many) was the emergence during 2008 of a strong cohort of six operating HIEs in California. Our collective perspective was that the presence of so many local HIE projects with deep and credible experience in the emerging federal architecture for interoperable health IT signaled an opportunity to advance the eHealth conversation in California. In particular, other large infrastructure states, and especially New York, showed us a credible road map for a statewide collaborative process. In February the conversation finally moved a few of us into action. A website was launched for the California eHealth Collaborative and outreach was begun to initiate our vision of an open and level playing field for HIEs in California. Starting with the basic principles of openness, no HIE is excluded and all are invited to participate in the emerging community discussion. Recognizing the importance of thoroughly understanding the options, the first product added to the website was a series of weekly webinars featuring national subject matter experts. In the near future, the next step will be to unroll the collaborative process to all eHealth stakeholders in the state.

Concurrent with our community effort of HIEs seeking to launch a full and open collaboration across the state, CalRHIO announced a half day meeting in Los Angeles on Wednesday March 25th to discuss regional HIE efforts in California. On Friday March 20th, CalRHIO released an agenda for the meeting. At the top of the agenda, four goals were listed:

1. Define the HIE vision for California
2. Identify HIE assets and gaps at local and statewide level
3. Discuss roles of local HIE efforts and CalRHIO’s state-level role and opportunities for collaboration and leveraging to operationalize vision
4. Discuss opportunities for operationalizing a shared vision in light of the federal HIE stimulus
   

Clearly these goals were designed to lead HIEs through a process of rubber stamping a state-level role for CalRHIO. Accordingly, on Monday March 23rd I wrote an email reply to all 20 participants invited to the meeting.

- - - - - - - -

Open Letter to CalRHIO
March 23, 2009 8:30:24 AM PDT

Jennifer and all HIE meeting attendees,

I look forward to the HIE meeting in Los Angeles on Wednesday March 25th. Thank you for all the work you have done to coordinate this meeting. To be clear, I plan to introduce three ideas during the
meeting:

1. CalRHIO is in the planning stages of HIE while six other HIEs in California are already in operation

2. It does not seem rational for a planned HIE to speak on behalf of functioning HIEs at the state level

3. CalRHIO should join with all other HIEs as a peer by working with the California eHealth Collaborative to form a truly open and statewide public private partnership

I believe these are public issues that are best discussed in the open, so I am cross posting these comments to my health IT blog (www.minformatics.blogspot.com) and to the California eHealth Collaborative blog (www.caehc.org/blog).

Here is a brief discussion of my three ideas.

CalRHIO suggests that they have a statewide solution, but CalRHIO doesn't actually operate an HIE service, while six other HIE services are now in operation in California. I support giving CalRHIO a grant to implement a modest technology plan, but not a statewide plan. It is too risky to propose that CalRHIO's undemonstrated technology plan qualifies for statewide funding. The HIEs in California that qualify for aggressive expansion funding are the six operating HIEs: Santa Cruz, Redwood MedNet, Long Beach Network for Health, Kaiser Permanente, ACCEL, and EKCITA.

As a planned HIE, CalRHIO cannot fairly "represent" local HIEs at the state level because CalRHIO's business plan relies on providing services "statewide" -- including the areas that the other HIEs are already operating in. This isn't an inclusive statewide plan, it is competing with the local HIEs. California HIEs should plan and collaborate on a statewide basis as equal HIE peers.

I have personally invited CalRHIO to participate in the Collaborative, an invitation that will remain open, because the Collaborative is at root an open public process. If any organization is going to "represent" the HIEs, it is the California eHealth Collaborative, which was recently launched by four of the six operating HIEs. The Collaborative is by design an open networking process. It is neutral, it works on behalf of all HIEs, it does not advance one HIE over another, and it does not compete against individual HIEs. The Collaborative is the logical entity to build a public private partnership with the State of California. No HIE is excluded from the Collaborative, and all are invited.

On Wednesday most of the HIEs in California will meet in Los Angeles. The agenda that CalRHIO released for the meeting (attached) shows that the other HIEs are intended to rubber stamp a proposal to have CalRHIO be declared the lead HIE for the State. I have canvassed most of the HIEs who plan to attend the meeting. I have found that a large number intend to oppose the designation of CalRHIO as the "lead HIE." So, in the interest of having a productive meeting rather than a family feud, I suggest that the current agenda needs to be scrapped in favor of a truly open discussion.

Shortly I will post this to my blog, and I will call for a new public draft agenda for the meeting.

With best regards,

Will Ross
- - - - - - - -

After the Letter and Before the Regional HIE Meeting
Several people contacted me after the letter and expressed their support for the issues I raised. A common theme in these was concern that CalRHIO was not the appropriate entity to coordinate statewide collaboration among HIEs.

Arriving at the regional meeting on Wednesday March 25th, the final agenda for the meeting handed out to attendees replaced the four goals in the draft agenda with two entirely different goals.

1. Exchange information and answer questions
2. Emerge with ideas of where there is potential collaboration and mutual support and where there is remaining difference of opinions or approaches

These new goals represent a substantial change in tone and approach. I hope my open letter was helpful in moving the agenda. Now the meeting is underway. As the conversation unfolds, I'll post more details later.

Senate Health Committee Hearing

I testified at the California State Senate Health Committee hearing held in San Jose on March 13, 2009. Chaired by Sen. Alquist, there was a lot of high quality testimony at the hearing. For me the highlights were comments by Paul Tang, John Mattison, Sam Karp and Robert Miller. Speakers each had 8 minutes, and the Committee staff was efficient at promptly moving the process along.

I spoke on a panel of four HIE representatives.

• David Katz, former Executive Director of the Smart Valley Task Force


• Will Ross, Project Manager, Redwood MedNet


• Laura Landry, Executive Director, Long Beach Network for Health


• Molly Coye, MD, Chair, Board of Directors, CalRHIO

The main story I heard in the four HIE presentations was the gap between the first three presenters and CalRHIO. The first three presenters focused on their three HIE road maps, with narratives rooted in what worked (myself and Laura) and what didn't work (Dave). In contrast, Molly's presentation was a pitch for funding. To briefly compare and contrast the four presentations, I'll list an outline of the CalRHIO narrative, followed by observations drawn from the other three presentations.

Molly opened with the three important characteristics of CalRHIO.

1. It is sustainable


2. It is secure


3. It will be self-financing over time

Next, Molly presented five opportunities for the State of California.

1. Rapid deployment of HIE across the state


2. Providing the state with a plan to enable California to move to the front of the line for drawdown of federal funds


3. Offering the State the opportunity to recognize a broad public private partnership, designate an organization, and apply for federal funds


4. An additional opportunity to maximize federal stimulus funds based on meaningful use of HIE


5. Establish a public private partnership that provides a core technology for HIE

Briefly comparing these remarks to the other HIE presentation to the committee, the following contrasts are apparent.

• Smart Valley presented a detailed and practical analysis of the fiscal disincentives facing the launch and operation of an HIE service. The analysis did not spare state or federal health IT leadership with regard to incubating and enabling viable business models for HIE services. I find it hard to overstate the importance of Smart Valley's experience, which included a thorough and realistic vetting of hard boiled financial projections. In contrast, CalRHIO presented a financial model with massive HIE revenue generation, but I am unaware of any substantial public vetting of the CalRHIO revenue model.


• Redwood MedNet presented a methodical, chronological and incremental narrative showing steady progress through planning stages to the launch of an operating HIE, with practical details for integration of HIE services into the work flow of local clinical practices. In contrast, CalRHIO, an organization still in the HIE planning stage, presented a high level plan to rapidly deploy full HIE services statewide, with no recognition of the nuts and bolts of deployment or of actual integration with clinical practices.


• Long Beach Network for Health explained why they are creating HIE services, how they are building it, how far along they are as one of nine successful NHIE's funded by the federal government. Laura also emphasized shared community trust and a focus on supporting and collaborating with safety net and public health stakeholders, and how the Long Beach core infrastructure is installed and is scalable up to millions of lives. In contrast, CalRHIO asked the state to bypass any of the six HIEs that are already functioning in California by suggesting that the CalRHIO plan, which has never been tested, has the greatest likelihood of quickly deploying across the state.

In addition, both Laura and I announced the creation of the California eHealth Collaborative, an open and inclusive organization, where no HIE is excluded and all are invited. In the next post, I'll detail the Collaborative's call for a truly open statewide process to help all HIE efforts move forward in a public private partnership. And I'll explain why CalRHIO cannot fairly represent local HIEs at the state level.

Hello World.

Welcome to the Minformatics Blog. "Minformatics" is an amusing concatenation of the name of my technology consulting business, Mendocino Informatics. It is also a pun drawn from a personal focus on minimally invasive technology. My broad goal for starting this blog is to leverage this verbal venue to advocate for technology solutions that enhance our humanity, protect our privacy, conserve our resources, and accelerate our collective ability to create peaceful and productive communities for ourselves and for all inhabitants of the planet. The narrow focus of my comments will be the theory and practice of health informatics, with specific attention towards the ability of small rural communities to participate in the emerging eHealth agenda. Occasionally I will lapse into commentary on art exhibits, musical performances, sustainable technology, horticulture, raising children and other peripheral topics; however my primary discussion will consider how to make electronic health data agile across the community in an affordable way while maintaining appropriate privacy, security and access controls.

The next post will drill down into recent public claims made by CalRHIO, including their general barrage of press releases; CalRHIO doesn't actually operate a health information exchange (HIE), they merely issue press releases about planning to operate one. Specifically, I will analyze the public testimony by Dr. Molly Coye, Chair of the CalRHIO Board, at the California State Senate Health Committee hearing in San Jose on March 13, 2009. I will compare and contrast the assertions in her testimony to other testimony at the same hearing.