Innovation Ecosystem

Location, location, location

As R.I. EOHHS pursues efforts to implement a HIT Rhode Island Strategic Roadmap, questions remain about who should be responsible for managing the implementation and where the project should be located – within state government, housed at a quasi-public, or housed in a private health system

Image courtesy of RI EOHHS

The cover for the implementation plan for the Rhode Island Strategic Roadmap, published on July 24, 2020.

By Richard Asinof
Posted 10/12/20
While stakeholders expressed numerous concerns about the existing health IT systems, the voices of patients appeared to be missing from the analysis. And the larger fundamental questions about value of health IT were never addressed.
How will patients’ use of personal wearable devices change the equation when it comes to managing health care decisions? Is there an underlying problem with developing algorithms to predict consumer decisions in health care, with the decisions weighted by the desires of corporate marketing of products? Will cost controls of medical expenses ever involve a reduction in salaries and benefits that are paid to corporate health system executives? Why is there a data gap when it comes to integrating data around the diseases and deaths of despair – drugs, alcohol, suicide, and gun injuries sustained in domestic violence, tied to economic disruptions of the past 40 years? How does racial equity reflect systemic racial bias in housing?
Navigating the health care delivery system is always a difficult chore, no matter how skilled you are in advocacy for yourself and family members. What the coronavirus pandemic has demonstrated is how access to testing, to primary care, to even hospital admission, is largely governed by job status and wealth.
Being able to talk back to a doctor, to say no to a procedure, to challenge a diagnosis, to be willing to confront providers and insurers who create roadblocks to receiving care is a time-consuming, energy-draining process. The relative speed of health IT data does not influence or change the status quo when it comes to receiving treatment in a timely fashion.

PART Three

PROVIDENCE – The second report in the series of five documents, “Rhode Island Stakeholder Assessment,” provided a mixed bag when it came to an analysis of its content.

First, there were numerous “positive” references to the State Innovation Model, or SIM. Indeed, much of the work of the Rhode Island HIT Strategic Roadmap appears to have had its origins, according to the Stakeholder Assessment, the second of five documents, in the four-year SIM project, which ran from 2016 through 2019, funded with $20 million in federal funds in a grant from the now-defunct innovation division of the Centers for Medicare and Medicaid Services in 2015, under the Obama administration. The program ran out of money last year, with a number of SIM staff folded into positions at EOHHS.

“Many stakeholders spoke to the positive experience of Rhode Island’s State Innovation Model grant program, especially as a model for coordination and convening, shared decision-making, and transparency of efforts,” the Rhode Island Stakeholder Assessment document said, which amounted to systemic praise for a project that many stakeholders felt was limited in its accomplishments.

The Assessment document continued: “There was a strong desire to build upon that work, though also caution that SIM was successful, in part, because of the shared purpose and access to resources, and that it would be important to ensure both of those enablers were in place to support the statewide HIT Strategic Roadmap.”

The problem, however, that much of the work of SIM, despite its concerted efforts to bring everyone to the table, had some important innovation blind spots.

For instance, SIM never focused any discussion on Neighborhood Health Stations, such as the one developed by Blackstone Valley Community Health Care in Central Falls, as an example of innovation.

Another prominent issue missing from SIM discussions was the way in which an accountable entity, a prominent, integral feature of the Reinvention of Medicaid law, had never been developed for managed Medicaid programs for long-term supports and services, where some two-thirds of all Medicaid funding from state and federal sources is spent. Translated, it is difficult to control costs and improve outcomes if no accountable entity exists for the largest source of Medicaid expenditures.

A third problematic area in SIM’s work, identified, discussed but never remedied, were apparent deficiencies in the statewide survey conducted by the R.I. Department of Health of physicians, physician assistants, and nurse practitioners, which consistently left out the largest group of health care providers in Rhode Island – nurses.

As a result, the state lacks any reliable data source on the practice data on its nursing workforce.

Further, that lack of knowledge is compounded by recent budget cuts to Rhode Island College, coupled with the decision by Gov. Gina Raimondo to withhold federal money that had been apparently targeted for the college. The lack of funding has threatened the stability of one of state’s leading nursing schools, at a time when the demand for nurses promises to be increasing in response to the coronavirus pandemic. During several monthly SIM meetings attended by ConvergenceRI, questions were raised about changing the statewide survey to include nurses, to no avail. [See link below to ConergenceRI story, “The State Innovation Model winds down to zero.”]

Criticisms voiced
The statewide analysis of stakeholder interviews did a better job of capturing criticisms of the SIM project and how stakeholders voiced worries about how that might carry over to the work on the HIT strategic roadmap. Stakeholders, for instance, identified work financed by SIM to create a statewide online provider directory as a project that was never finished and how work on it was abandoned in 2017.

There were also questions about the efficacy of the Health Information Exchange, known as CurrentCare, voiced by stakeholders, and the need to change legislation around it becoming “opt-out” rather than “opt-in” in order to increase the rate of participation.

Further, there were concerns voiced by stakeholders about the lack of investment in health IT projects in order to make them sustainable enterprises.

“Some of the diverging views were connected with stakeholder perceptions about the State’s ability to successfully implement large-scale information technology initiatives,” the second document said.

The analysis continued: “Many stakeholders referenced the State’s eligibility and enrollment project, the Unified Health Infrastructure Project [UHIP], as an example of a problematic IT project, and shared examples of continued data quality problems with information received out of the system.” [Editor’s note: In the initial document, the report adopted the state branding of RI Bridges; in the stakeholder document, the report used the more commonly known name, UHIP.]

More stakeholder concerns
The analysis also documented concerns voiced by stakeholders about the need to emphasize that “patients are core to the work of their organizations and agencies,” and that the needs of patients should be kept at the center of thinking.

“Several stakeholders also wanted to ensure patients were included in the development of the roadmap process itself, though some shared concerns about making sure the engagement was meaningful,” the analysis said.

“Stakeholders also shared that provider burden should be a top concern of the HIT Strategic Roadmap,” the analysis continued. “Many stakeholders agreed that HIT has contributed to provider burden and burnout.”

Another stakeholder concern voiced was about the unevenness of data received from accountable care organizations and accountable entities, according to the analysis.

“Most provider stakeholders were receiving some claims based data from their contracted health plans, especially when [participating] in accountable care relationships such as the accountable entity program,” the analysis reported. “However, many [stakeholders] shared that information they received from plans varied in content, completeness, and format, making it difficult to use the data effectively. One organization shared that due to the non-standard nature of the data, and the associated resources required to make the data useable, they have decided to contract with only one [managed care organization for the accountable entity program.

Further, the analysis continued, “All health plan stakeholders commented on the multiple needs for claims information. They shared that data submissions to multiple government agencies and provider organizations were resource-intensive and inefficient and expressed a desire for a single [reporting vehicle].”

Calculating value
What was never addressed or discussed in either the initial assessment or the analysis of stakeholder interviews were questions about the fundamental assumptions about the value of health IT systems.

It is a big question: Do health IT systems promote better health outcomes for patients, or do they enable health systems to squeeze more money out of the billing system to support an unsustainable business model for health care delivery?

In March of 2013, seven years ago, the amount being spent by the government on EHR implementation was $1.6 trillion, according to Stephen Soumerai, professor of population medicine at Harvard Medical School. At the time, Soumerai said that the investment was being made without any research evidence to support the claims that change in delivery, outcomes, quality and cost savings could be achieved through EHR implementation.

Carl Dvorak, president of the Epic Systems Corporation, in a talk given on Jan. 29, 2018 at the Warren Alpert Medical School at Brown University, likened the investment in health IT to a major public works project undertaken by the federal government.

This was our [21st century] version of the Tennessee Valley Authority,” Dvorak said. “They [the government] didn’t care if it worked; it just had to have reasonable expectation that it would work,” in order to help keep the economy afloat in the aftermath of the Great Recession.” [See link below to ConvergenceRI story, “Is it all about the data, the data, the data.”]

Further, Dvorak added, as a kind of meaningful aside: “The puzzle is that when you take government money, it comes with strings attached. The money is temporary, but the strings are permanent.”

The need for health IT to calculate and to analyze the equations of outcomes for accountable care organizations, for Medicare and Medicaid, for meaningful use, is no longer optional, according to Dvorak.


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