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OP-ED | Health IT In Connecticut - Learning From Mistakes

by | Dec 18, 2014 5:57pm () Comments | Commenting has expired | Share
Posted to: Health Care, Opinion, Health Care Opinion, Quasi-Public, Transparency

A wise advocate once told me that if I have a problem with wasting money, I should find a different profession. The latest example of that truth is HITE-CT, a quasi-public entity created in statute to develop a system of health information exchange (HIE) for our state. HITE-CT was dissolved by the legislature this year after wasting $4.3 million in federal grants and four years without accomplishing anything.

Accurate, timely information is key to effective health care. Patients with even modest health problems can have medical records in dozens of different systems that don’t talk to each other. An effective HIE can solve this problem, allowing providers access to the all information they need, but only what they need, to best treat the person in front of them.

With a functional HIE, no one would have to carry X-Rays between providers or remember medications and doses. If you ended up in an ER, the provider caring for you would know your health history, allergies, past surgeries, and anything else they need to keep you safe and make you well. A functional HIE can reduce medical errors, avoid duplication of services, help patients keep ourselves well, and allow policymakers to maximize scarce resources.

But HITE-CT failed. A new report by the state auditors cites some of the reasons for the failure, but as a HITE-CT board member I can offer more. The auditors found deficiencies in financial controls, legal problems, and a “need for improvement in management practices and procedures.” That is an understatement.

The report points out that HITE-CT developed an overly ambitious, unrealistic plan. HITE-CT leadership blamed the changing market, a lack of legislative support, and changing requirements from the federal agency that oversees HIE, but the real problem was mismanagement. The board fell apart and attendance at the monthly meetings waned as major decisions were made in small committees between meetings, and just submitted to the board as a done deal. Most meetings included long executive sessions, held out of public view, to discuss the continuing legal, personnel, and management problems.

As the consumer advocate on the board, I was particularly concerned about safeguarding privacy and security.  While it is critical that your doctor sees your sensitive health information — your neighbor, your employer, or a marketing firm should never see it. Strong privacy protections are essential to the integrity of an HIE.

Unfortunately, with scant consideration, HITE-CT’s board voted against a sensible opt-in privacy policy that would have given consumers control over their sensitive information. All of our surrounding states’ HIEs have adopted opt-in privacy policies and a survey found that most Connecticut residents prefer an opt-in policy. The federal health information technology strategic plan strongly supports “patients’ rights to access, amend, and make choices for the disclosure of their electronic health information.”

But HITE-CT Board leaders even testified against a bill to let people decide how their information is used. Bad privacy policy undermines public trust and that lack of trust contributed to HITE-CT’s failure.

When they dissolved HITE-CT, the legislature moved responsibility for developing a sensible health information technology and exchange strategy to the Department of Social Services. While details are still forming, the draft plan is incremental and based upon the reality and the needs of Connecticut’s health system. The plan emphasizes integration and engaging people in their own care.

Unfortunately SIM’s new HIT committee, charged with advising DSS on the plan, includes many of the same HITE-CT leaders. Hopefully, they’ve learned from their failure and won’t repeat the same mistakes this time. Connecticut deserves better.

Ellen Andrews, PhD, is the executive director of the CT Health Policy Project. Follow her on Twitter @CTHealthNotes.

DISCLAIMER: The views, opinions, positions, or strategies expressed by the author are theirs alone, and do not necessarily reflect the views, opinions, or positions of CTNewsJunkie.com.

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(5) Archived Comments

posted by: GBear423 | December 19, 2014  9:07am


business as usual in Corrupticut.  TY Ms. Andrews for this important insight.
Will be hard for the new plan to succeed when you have the same defective players.

posted by: Anonymous 1 | December 23, 2014  9:07am

The minutes of the HITE-CT meetings have always been available online. Reading them one does not find Ms Andrews voicing the objections she now claims.  In fact, as a member of the HITE-CT Board, she shares responsibility for what happened.  The question of opt-in/opt-out has been resolved in many states counter to the way she prefers.  This article reveals the unfortunate level of dissention within Connecticut’s leaders which results in a lack of progress overall.  We should wish the DSS project well while actively monitoring its progress.

posted by: Michael Woods, MD, MMM | January 17, 2015  8:33am

p 7: “HITE-CT was unable to meet its strategic and operational schedule primarily due to it’s inability to adapt quickly to changing market conditions.” Whether this is a result of poor planning, poor leadership, or poor vendor technical abilities is not clear from the article or the Auditors’ Report, but it seems most likely due to a combination. Any organization, whether service or product, must adapt to the same market conditions every other business is facing – or they cease to exist.

p 7, same paragraph, the auditors’ note: “The exchange’s board of directors recognized that the terms in the original contract with its vendor required significant modification to reflect the evolving market place for an integrated statewide electronic health information infrastructure. A lengthy renegotiation period with its primary vendor reduced the exchange’s options for achieving sustainability. The resulting amended contract with the vendor had a reduced scope for deliverables. It no longer included the establishment of an operational statewide health information exchange that could provide desired revenue producing services to stakeholders through fees
and other assessments.” I find it amazing that “market changes” occurred so soon after implementation of the project and were so profound that it required a new contract negotiation. (The most important piece in a project like this, it seems to me, is the backend functionality, which should have been to create an interoperable (technically, semantically, and process) platform, to which front end functionality could be added across time.) The agreement was signed with Axway, Inc. in September 2011, and by May 2012 new negotiations were underway. Market conditions changed so profoundly, so dramatically and unexpectedly in eight months – and after, coincidentally, Axway was paid $2.7 million? It seems incomprehensible that an experienced organization e.g. Axway, would be so profoundly caught off-guard by “changing market conditions.” The real question seems to be: If the amended Axway contract reduced scope so dramatically that it no longer included “an operational statewide” HIE, why wasn’t the project killed, as it could no longer deliver on the defined goals? (Axway has seemed to have had some troubles with pricing in the past.) The residual (likely significant) funds could have been used to explore more effective options.

Also on p 7 is the statement, “Market forces, such as the emergence of local health exchanges and negligible adoption of HITE-CT service, have caused us to reevaluate our initial strategy.” I can only wonder why a local health exchange would trump a (functional) state-wide health exchange, especially in a state as small as CT? And as far as the lack of adoption, what was there to adopt? I’m unclear as to if there was any functional component of the system. Did the customer have to financially commit in order to use the HITE-CT?

posted by: Michael Woods, MD, MMM | January 17, 2015  8:33am

If so, what would the motivation be to pay for a system that is either undeveloped or poorly functioning? None…which is, of course, consistent with a lack of revenue. A start-up software company would never think of selling a piece of software before it had created a functional, useful generally-available tool. Why on earth would there be an expectation that HITE-CT would be different from other market models?

At Sociotechnologix, LLC, we never see technology being successful in healthcare as an isolated solution. If you buy it and flip the switch on… they won’t necessarily, and generally don’t just show up because there is a new technology! No… technology is only successful when one understands what is going on in the culture of frontline users, the kinds of processes that exist in their environment, and, critically, the software is both easy to use and useful (i.e. provides useful information).

I offer a series of questions – from a sociotechnical perspective, as recommended by the Institute of Medicine related to HIT – that I would ask my Connecticut colleagues who are trying to pick up the pieces of this and create something usable. They are offered in the sociotechnical categories of culture, process, and technology. Here’s a short list:

Questions about the Culture where it is intended to be used
What type of on-the-ground, pre-build user experience (UX) research will be done to ensure HITE-CT will meet the needs of the frontline employees and patients actually using it?
What kind of leadership at the hospital level will be involved in supporting the project?
What kind of clinical leadership (MD, RN) from the user population will be involved in supporting the project?
What kind of patient involvement (including individuals of varying socioeconomic backgrounds, ethnicities, etc.) will be involved in supporting the project?
What will the governance structure look like? How will CT avoid the kind of Board non-participation failure it experienced in round 1?

Questions about Processes where it is intended to be used
What does the software development roadmap look like?
Should there be external oversight of the vendor by a skilled software engineer?
What milestones will be put into place for monitoring the vendor’s development performance to ensure it doesn’t get off track?
What is the implementation strategy for the software (the physical installation)?
Will a select “early adopter” be given the software for free in exchange for their participation in development and testing?
What is the adoption strategy for the software? (Implementation and adoption are very different endpoints.) Adoption involves education and training to ensure proficiency. What is the plan for that?
What is the plan for ongoing support of the software and users? Locally in the hospitals? Over all program?

posted by: Michael Woods, MD, MMM | January 17, 2015  8:33am

Questions about the Technology required
What can be learned from other states related to building, implementing, adopting, and sustaining HITE (e.g. Maine)?
What is the plan for HITE-CT semantic, technical, and process interoperability?
Will it be built to the new FIHR standards?
What is evolving in the “market” that may change the scope of technology development? (I ask this only because of the Audit report. Changes always evolve, but it seems they should rarely take a company by such surprise as to stall a project.)

Finally, it’s always easy to find the missed opportunities in a retrospective evaluation of a failed project. It’s much harder when you are in the throes of the actual project. My thoughts could be completely off base due to a lack of accurate information around the project. No doubt those involved with HITE-CT are good people who went into the project with good intentions. That’s almost always true, and every project has missed opportunties. We can learn from the project. The real failure would be if we didn’t.

Good luck, Connecticut.

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