Dr. David Brailer was appointed by President George W. Bush as the nation’s first head of the Office of the National Coordinator for Health Information Technology after developing one of the country’s first-ever HIEs in Santa Barbara, Calif. Today, Brailer serves as executive chairman of the consultancy Health Evolution and is paying close attention to health information exchange. Modern Healthcare insurance reporter Nona Tepper spoke with Brailer about the past, present and future for HIEs. The interview has been edited for length and clarity.
When you first started the Santa Barbara exchange, did you dream of it becoming a national infrastructure for HIEs?
We proposed under the Bush administration the Nationwide Health Information Network, and it was actually a network of networks. So the idea is that regions would tie all their health information producers together. Then we would tie them all together nationally in a kind of medical internet, if you will.
There are lots of general and specific networks, but they’re not really tied together. They’re tied into the endpoints, but they aren’t integrated in a way that they’re a cohesive whole. It’s just a lot of bottom-up efforts that are unintegrated.
Can you talk about the different types of business models these health information exchanges operate under?
Every business model imaginable has been tried. There’s been grant funding, there’s been government funding, there has been so-called subscription funding, where every participant chips in money. There has been private financing, treating it as a for-profit business. There have been health plans, or population holders, that have tried, for example, what’s going on in California.
So I think every financing mechanism has been tried. But there’s not one that I think has been proven superior.
There are some that have proved inferior—those are the grant funding models. No surprise, grant funders don’t want to become perpetually invested. They want to see something start. The other one is government funding models. You just need to look no further than the underfunding of our public health information infrastructure, which is itself data-sharing for specialized public health. Government has a short memory. They can’t withstand regular funding of things. They tend to get cut over time. That’s not a reliable model.
But I think the important question isn’t whether it’s funded by investors or by not-for-profit subscriptions. I think the question is, “Is it funded separately from the care process or part of it?”
A health information exchange is not an end unto itself. It is no different than a diagnostic test that a doctor runs for information that guides care, or that helps them refine therapy, or determines therapeutic endpoints. What is it that the lab test has that a health information exchange doesn’t? It’s part of the care process. So to me, the issue is health information exchange shouldn’t be funded as a utility that is separate from what’s going on in a hospital, or a clinic or a pharmacy. It should be funded within the context of what they’re trying to do.
How would the financing for that work?
You need to separate the two things as, “What is the cost that has to be invested in capital to get the network up and running?” versus “What’s the cost of operating it after that?” I think hospitals, tech companies, health plans, investors, grant-makers, any of those, could invest in infrastructure to get it up and running. But the operations of it, so it’s running at a defined level, should be financed through the benefit of being in a public or private health plan. And if the public health plans start, all the commercial health plans will follow.
Medicare, Medicaid and Medicare Advantage do not do this, and they should be leaders. Medicare leadership under the new administration is a very thoughtful group of people. They understand health information exchange. They’re in a perfect position to lead the market. Because once Medicare acts, everyone else will follow.
Are commercial insurers just waiting for public insurers to take this up? Are there any reasons why a commercial insurer wouldn’t want to be part of a health information exchange?
Whenever any organization acts, they have a first-mover disadvantage because they’re the ones bearing the costs, and then others will come along behind it and get the benefits. So this is where we should have organizations acting in unison. I think the truth is, if you want commercial payers to take this on, and really move the markets, and this becomes the standard of care, the only club big enough to really give them confidence that the market’s going to flip is Medicare.
Why does it need to be part of the care process then?
When you finance it outside of the care process, then what’s going to happen? Someone invests, public or private, it doesn’t matter. They invest in the infrastructure to do this, and then someone tries to pull the data, and they say, “Well, that’s $195 for data, right?” That is exactly what we don’t want.
We don’t want this being available to the highest bidder. That’s going to ensure that every local population, every underserved population, or Medicaid population is going to have inferior care.
I think a lot of organizations would be quite willing (to share data), but they’re just concerned about legal risk or, again, because it’s not just about sharing data, it’s about changing the care delivery process using better data. So it’s like, “OK, I can get this data, but what are my doctors supposed to do with results that came from someplace else down the street? Am I supposed to act on them? Are they acting on them?” It creates all kinds of care model problems. That’s why it has to be embedded in the care model. One of the big value propositions for health information exchange is simply reducing the duplicative tests.
So you have to have something that is ubiquitous, and equitable, and fair across everyone. And the only way to deal with that is to make sure the costs are widely allocated across the population.
Do you think that’s realistic for the healthcare system in the U.S.?
Making health information exchange equitable won’t solve the deep racist and other health equity issues that we have, which are deeply embedded. But we don’t want this compounding it, and being just another example of where you’re poor, or if you’re Black, or if you’re quite sick, it’s inequitable to them. People who are really sick aren’t able to navigate care the way someone who is healthy can. That’s the irony of healthcare. So we can at least make it not more piling on, if not a good example of how to do this in a broad-based way.
What trends should we be watching for in 2021 among health information exchanges? What does the future look like?
The most positive factor this year with health information exchange is my successor, Micky Tripathi. He’s a very credible, very thoughtful, very experienced guy, and that makes me feel good because now is the time.
Why is this particularly timely right now?
One is because ONC has released the API rules around information sharing and that now creates a huge disadvantage for covered entities like hospitals. Now an app can go and get a hospital’s data on behalf of the patient.
There are no more digital moats once that rule is in place.
I don’t think provider leaders understand the profoundness of the disruption that those API rules are going to cause to their data strategy. I think once they figure it out, they’re going to see health information exchange as one of a couple of key responses to keep them relevant in the healthcare digital wars that are coming.
Two, the pandemic has shown us, (through) our information-sharing apparatus—the ability to get lab tests and lab results where they need to go, who’s vaccinated and who’s not, the ability to understand what physicians have what skills available to see people—how important health information exchange really is.
Three, the new stimulus bill that was recently passed included significant funding for the expansion of the Affordable Care Act. It’s kind of taken access to care off the table as an upfront issue. Information sharing would be the natural extension of that like, “OK, now we’re getting people enrolled in insurance. How do we make sure they have a seamless healthcare experience?” Well, health information exchange is one of the core pillars of that.