By David Sontag
When Jerry Tichner and I (co-editors of the Health Law Reporter) received the good word that John Halamka would be writing an article for this issue about the Massachusetts Health Information Exchange (“Mass HIway”), we thought readers would be interested in learning more about the person selected to serve as Director of the Massachusetts eHealth Institute (“MeHI”), the state entity responsible for helping providers and payers in the state connect to the Mass HIway. Luckily for us, Laurance Stuntz was gracious enough to grant us an interview, the results of which are reproduced below. But first, here is some background information about MeHI.
The Massachusetts eHealth Institute is a division of the Massachusetts Technology Collaborative and was established in Section 4D of Chapter 305 of the Acts of 2008, which is codified at M.G.L. ch. 40J, §§ 6D-6G. The Legislature tasked MeHI with generally “advanc[ing] the dissemination of health information technology across the commonwealth, including the deployment of electronic health records systems in all health care provider settings that are networked through a statewide health information exchange.” More specifically, the Legislature provided that MeHI:
shall advance the dissemination of health information technology by: (i) facilitating the implementation and use of electronic health records systems by health care providers in order to improve health care delivery and coordination, reduce unwarranted treatment variation, eliminate wasteful paper-based processes, help facilitate chronic disease management initiatives and establish transparency; (ii) facilitating the creation and maintenance of a statewide interoperable electronic health records network that allows individual health care providers in all health care settings to exchange patient health information with other providers; and (iii) identifying and promoting an accelerated dissemination in the commonwealth of emerging health care technologies that have been developed and employed and that are expected to improve health care quality and lower health care costs, but that have not been widely implemented in the commonwealth.
To accomplish this lofty goal, the Legislature directed the director of the Massachusetts Technology Collaborative to “appoint a qualified individual to serve as the director of the institute, who shall be an employee of the corporation, report to the executive director and manage the affairs of the institute.” Laurance Stuntz is that “qualified individual.”
Laurance is a graduate of Dartmouth College with a degree in history. Surprisingly, he didn’t take a single computer class, although he has done a lot of programming over the years (the “real coders” do not let him code anymore). His Dartmouth education taught him how to speak and write eloquently, which he has to do everyday in his new position. Prior to taking the reins at MeHI in May of 2012, Laurance worked at NaviNet for a year as the Senior Vice President, Product Development. Before NaviNet, Laurance worked at Computer Sciences Corporation (“CSC”) for almost 20 years. CSC is a very large, multi-national system integrator. Laurance was a partner in the commercial healthcare division. For the last 12 years he was there, he concentrated exclusively on healthcare information technology (“IT”) consulting. By the time he left CSC, Laurance was in charge of the national collaborative communities effort, which was the CSC practice that concentrated on the exchange of health information and helping organizations (e.g., payors and providers) talk to each other. Also at CSC, Laurance was the technical architect for the New England Health Exchange Network (“NEHEN”) in Massachusetts from 2000 until 2011, when he left CSC.
Soon after Pamela Goldberg became the CEO for the Massachusetts Technology Collaborative (“Collaborative”) in June of 2011, she began a search for a new Director of MeHI. Based on all his work with CSC and NEHEN, Laurance was highly recommended to become the Director at MeHI. And the rest, so they say, is history. But there is so much more to know about Laurance – why he is so interested in health information exchanges, why does he think healthcare IT is so important, and how he is working through (with his colleagues and advisors) some of the tricky issues posed by health information exchange, to name a few. Reading Laurance’s own explanations on these issues provides so much more depth than I could provide when interpreting.
What made you interested in Health Exchange or did you fall into it?
Originally at CSC I did a lot of work for retail and financial services clients. I was at a point in my career where I was wondering whether I should leave CSC because those industries didn’t particularly interest me. We had this new project at NEHEN, one of the early health information exchanges and it seemed very interesting. It was an industry that I found interesting from a career perspective, as well as from a socially good perspective. I’m not a doctor so I’m not going to deliver medical care directly, but the work we do in healthcare IT has a real effect on the way all of us experience the health care system. I purposely moved within CSC to the NEHEN project and over the 11 years I worked on that project I helped grow that organization from its original five founding members to about forty members when I left, as well over one hundred and fifty small practices using the portal application. I intentionally got into health IT and CSC allowed us, though the NEHEN project, to create something brand new. It was a totally unique project because we effectively had the Massachusetts health care system as a client.
Can you explain a little more your concept of healthcare IT as a “social benefit”?
From my perspective, in healthcare right now, there is a tremendous opportunity to improve efficiency in the way all of us experience health care. I really think that IT is one of the key ways we are going to get that. For instance, the Health Information Exchange that we just launched on October 16 (2012), is going to transform the way all of us interact with a system when we move care from one provider to another. In the past year, two of my children had injuries. One had to go from the ER to his PCP and the other went from his PCP to a specialist. All of these providers were in different networks. We had to carry records with us from one system to another. The health IT work that we are doing affects all of us. On NEHEN, when we were working on eligibility verifications, claims status inquiry and claims submission, all that work made it easier and less of a pain-in-the-neck for patients and providers to deal with the administration in the health care system. Another example that I’ve heard a lot about recently is that systems are emerging that provide a good, convenient way to schedule an appointment online.
I wanted to work in an area where I felt like we could affect the lives of lots of people, even if I wasn’t delivering medical care. There is so much opportunity within healthcare to improve the customer service and over time, to improve the quality of care. I did a lot of projects at CSC around e-prescribing and there are significant safety benefits to getting prescription history; making sure there are no interactions between current medications and what the doctor is going to prescribe. IT, in those cases, really has the potential to save lives.
Can you tell our readers what a health information exchange is and does, and what the Mass HIway is aimed at doing and how it is improving health care?
We launched Mass HIway on October 16, 2012. We demonstrated from Massachusetts General Hospital, Governor Patrick clicking the button that sent his medical records to BayState Medical Center in Springfield. We demonstrated, in an initial, high level way, the fact that over the next few years we are going to connect every provider in the state so they can communicate electronically from within their electronic health records (“EHRs”). We will make it easy to send records to the next setting of care. For instance, when your kid goes into the ER for a broken arm and the doctor sets it and sends info about that to the PCP for a follow-up visit or to the orthopedic surgeon for a follow-up visit, the record of that visit can be sent electronically, and seamlessly, and securely from one provider to another. Our goal over the next 2 years is to connect the majority of providers in the state all together over this one single statewide health information exchange.
I think of this as laying the gravel under the interstate highway system – we are really creating the foundation for lots of really interesting work that really will totally transform healthcare. For instance, one of the things that we have planned for Phase 2 of the health information exchange, which we are planning for now and will be implementing in 2013 and 2014, is patient access to their own data. So we will be developing the policies and procedures that are necessary to allow a physician to send patient data to them or to their app of choice. For instance, a patient could sign up with Microsoft Health Vault as a personal health record and the statewide health info exchange will allow a provider to send that patient’s data to their personal health record account. We are also going to be working on ways that patients can designate that their data goes to other tools, like a wellness app. There are all sorts of tracking applications that are out there on people’s phones. If we could include real clinical data with the user input data in these applications, I think there is really powerful potential for helping patients to manage their own health data. On the whole patient engagement front, the health information exchange is a big piece of that.
The other thing the health information exchange is going to give us is the opportunity to have a lot better understanding of population health as a whole. We are doing some demonstration projects now that allow us to distribute population health queries to participants on the network and allow those individual participants, maybe large EHRs like Beth Israel Deaconess Medical Center or Atrius or the Mass League of Community Health Centers, to receive the query, run the query against their own datasets, and send back a de-identified dataset to an organization like the Department of Public Health so they can understand in real time what is going on with the health of our community, which we’ve never been able to do before. So, initially we are going to connect everybody with the health information exchange, but then there is a whole layer of public health and personal health on top of that – that is how the health information exchange is going to transform how we all get care.
One word stuck out to me in your last response – de-identified. As a health lawyer, I recognize obvious issues around privacy with relation to the health information exchange and the accessibility to data by large numbers of people. Some of it will be identifiable data and some will be de-identified data or non-identifiable data. On behalf of the Health Law Section of the Boston Bar Association, do you call lawyers to help you with those issues?
There is a whole legal and policy workgroup of the health information exchange that has been helping to guide the policy. So there are a couple of things that are built into the legislation that governs the health information exchange, as well as the policies and procedures, which largely stem from the state legislation as well as the federal HIPAA legislation. One of the key features of the Mass HIway is that we have a strict opt-in policy to the health information exchange. In order to share a patient’s information over the health information exchange, each patient must explicitly give consent for their provider to share the patient’s health information. So in Phase 1 of the Mass HIway (the statewide health information exchange), we are starting with pushing out data. We are replacing all the faxes and paper that move around today with electronic transmission and there is a whole bunch of benefits we see to that: a) it’s more efficient; b) it’s auditable. A patient can now go to a provider and inquire, “Who have you disclosed my data to?”
Our experience is that the vast majority of patients will opt in to use of the health information exchange under these conditions because they understand they will get better care, because the provider they are going to will have a better picture of their health. The HIE is more secure than using a fax. Although a user of the HIE can select the wrong recipient of that HIE transmission, human error, every participant of the exchange is going to be an authorized user. So, there is no chance of sending a record to Joe’s Pizza Shop or a newspaper because non-participants in health care would never have an account at the HIE. Phase 1, with the strict opt-in policy and just pushing out data, is a giant leap forward. And the next phase, a lot of work on which will be in 2013, is working on the policies and the infrastructure we need to have a centralized and robust consent management process for patients to be able to register how they want their health information to be used and available for query. For instance, if a patient at BIDMC wants authorized providers to have access to any of his/her information, that patient can sign a consent that would be registered with the statewide exchange that says “any of my data that came from my visit at BI or my PCP, I am fine with sharing.” However, if you happen to be admitted to McLean Hospital, a psychiatric hospital, you may not want to share any of that data with other providers unless you explicitly allow it, so you might have a default opt-out of sharing that data and a specific opt-in for your behavioral health specialist. All of that consent management will be registered at the core health information exchange. There is going to be a lot of work from a policy perspective to understand whether this is sufficient. To the Health Law Section at the BBA, we are trying to reach out as much as possible to the community to understand where everybody’s concerns are. The health information exchange has a legal policy workgroup and folks should absolutely volunteer to participate in that. We need all the volunteers we can get.
How do people volunteer to get involved?
The Health Information Technology Council creates these work groups as needed. People interested in learning more about getting involved should contact Mark Belanger at [email protected]
So you are actively engaging lawyers in conversations about health IT?
They are invited to the work groups, in general. We have a few lawyers represented, particularly on the legal and policy work group.
Is your position now focused more on how the HIE works or do you also effect some of the policies the HIE will create?
It’s a combination. MeHI is not just the HIE. MeHI has a whole set of increasing responsibilities under Chapter 224. So we have three current programmatic responsibilities: (1) Connect every provider in the state to the health info exchange; (2) Run the regional extension center, which is helping abut 2,500 primary care providers install and use electronic health records meaningfully; and (3) We administer the Medicaid Meaningful Use incentive payment program. Under the Federal Meaningful Use Program, they delegate to the states the responsibilities to run payment administration for the program. We have supported more than 3,000 Medicaid providers getting paid for Meaningful Use incentives and more than fifty hospitals. Overall, we have helped pay out more than $120 million in Meaningful Use incentives to Massachusetts providers as part of that program.
Those are the three current programmatic areas, and in addition, over the next four years we’ve been asked by the legislature as part of Chapter 224, to help every other provider in the state get and use electronic health records and connect them to the HIE, with a specific focus on the underserved communities who didn’t qualify for the Federal Meaningful Use – communities like long-term care, home health and behavioral health. Our group will be helping all those organizations start to use EHRs and at the same time helping to connect each of them to the HIE, so they can exchange data electronically. In that role, there is policymaking we need to do. For example, there is an annual report to the legislature about the state of health IT adoption, key areas of need that the legislature might help us address, the accomplishments – all of that – sort of an annual report that feeds statewide policymaking regarding health IT adoption. So there is a combination of programmatic, as well as policymaking jobs within MeHI that I am responsible for. The third area of key responsibility comes out of our legacy with the Mass Tech Collaborative. Mass Tech is an economic development agency for the state, a quasi-agency. In health IT, we have a similar role that comes from our heritage at Mass Tech to help encourage and develop the health IT community in Massachusetts. So, we have programs around internships and workforce development that are designed to help grow the health IT industry in Massachusetts, create jobs and bring them here.
What has the reception been from providers – both physicians and hospitals – to the policies and outreach to try to get people involved?
It has been very positive. On the HIE, we have had very rapid interest. On our programs around helping to get EHRs up and running, what we find is that providers generally (but not universally) feel this wave of EHRs is coming and it’s something they are going to need to figure out how to adopt, so they welcome the support we are able to give to help ease their transition to EHR. So what we find is that providers are very welcoming of our role and they find the education and the infrastructure-development things that we do as a quasi-agency to be very helpful. Frankly, it’s why I was interested in taking this job; you rarely get a chance to help change the way 6 ½ million people experience the healthcare system. We have the opportunity to help every provider connect and make their lives more efficient. We got enough capital support from the federal and state government to make it relatively – not relatively – quite inexpensive for the providers to connect and support the operations of the exchange. I really think it’s a perfect storm of opportunity here to – going back to what we first started talking about – use health IT to really change the way that care is delivered.
Any advice to providers or counsel to providers who are behind the curve about what they should start doing (other than dedicating more money to EHRs) or thinking about, so they can get up to speed and get to where other people already are?
Education and training. I have to research and see whether we are doing a particularly effective job at providing those resources. One of the things that we expect to help provide is a series of training materials and educational materials for providers to help them understand what it is really going to take to start to adopt EHRs and what they can start doing now is just educating themselves on ways that other providers have effectively adopted technology. Because it doesn’t have to be a big bang, all-at-one proposition; it could be a gradual sort of thing. Providers have been very successful at this over the years, so they can educate themselves on what has worked well for other providers. Go to http://mehi.masstech.org/useful-resources for more information.
Anything that has surprised you since coming into your new position?
I had no public service background; I didn’t work for the government or anything like that before coming to this. Frankly, I have been very pleasantly surprised by how dedicated the folks in government are to helping, to furthering the public good, making sure the system works better. Sometimes sitting on the outside you can feel like there is bureaucracy or there is unnecessary sort of slowness in government and that has not been my experience. I have been very encouraged by how committed folks in public service, in general, are towards the public good.
In light of the timing of this conversation and the events of November 6th, do you see health IT as a political issue or do you see it as something people have adopted and understand, obviously funding aside?
I think it’s a non-political issue. The federal Office of the National Coordinator was started under President Bush, then it was continued under President Obama. My expectation is that it will continue on under President Obama. On the Massachusetts side, I’ve found that in my conversations with different legislators is that health IT is broadly supported on both sides. So, I don’t think it’s political. There may be methodology differences and potential funding differences, but I think that it is generally a both sides of the aisle thing. One of the more vocal promoters of health IT over the past 10 years was Newt Gingrich, who did a lot of work with Hilary Clinton on this before she took the Secretary of State job. I think that’s just symptomatic of how broad-based the recognition is that this is a good thing and is not a politicized thing.
Any parting thoughts in terms of any issues you think people should be aware of – specifically, the health lawyers out there – anything they should be focusing on or thinking about or legislating about?
I think the big question for us over the next year is how to effectively manage and implement the consent process so we protect patients’ privacy, but we don’t create a system that is so onerous that providers can’t get the data they need to treat patients with the full picture of the patient’s health. I think from a health law perspective, what I would ask the lawyers out there to think about is how do we make this an efficient, fair and open process so we can properly and fully inform the public, so that they can make an informed decision how to/what consent to give, but that we do that in as efficient a way as possible so health care can be delivered very cleanly and with all the information a provider needs to deliver safe care. That is a broad charge, but I think there will be a lot of conversation about this consent question over the next year and I think particularly the legal profession can help a lot in making sure it’s done efficiently and it doesn’t create a barrier to care.
David Sontag is Associate General Counsel at Beth Israel Deaconess Medical Center, and formerly practiced as an associate at Choate, Hall & Stewart LLP. His current practice focuses on negotiating and drafting contracts, and advising and resolving legal and compliance issues related to mergers and acquisitions and other business relationships with the medical center. David also advises medical center clinicians regarding guardianships, health care proxies and related informed consent issues, and oversees the process for obtaining guardianships for medical center patients. He is a graduate of Washington University and the University of Pennsylvania, where he received degrees in both law and bioethics.