In lockstep with the 2023 CIVITAS health information exchange (HIE) conference, a widely dispersed movement is taking root across the U.S., that seeks to effectively reduce competition—and sustainability risk—among HIEs by institutionalizing them using the framework of a health data utility, or HDU.
Proponents basically want to adopt the raiment of a digital version of an electric, water or cable company, giving HIEs—as HDUs—a permanent lifeline. There are reasons why this makes sense for the HIEs—and in theory, it could be great for Mobile Medical services. Or…it could be horrible for Mobile Medical services. Therein lies the rub: at present, it is difficult to see a middle ground. Caution is therefore warranted.
Utilities are “sticky” enterprises. You don’t hear about many of them going out of business. When they occasionally do, they tend to get folded into whatever takes over. A utility’s goal is to do its work, cash your check, and generally fade into the background of daily living. Recall the game “Monopoly” from childhood: “Water Works” was among the lowest-returning spaces on the board!
Utilities serve an important public function because they are available to everyone, and in exchange for limited competition, they face a bevy of rules and mandates, including low-income carve-outs. (In the health IT world, a low-income carve-out might mean ensuring that even rural health care providers can afford to join the HDU, and it is not limited to large hospitals, fire or ambulance services). It is unclear whether staying “off the grid” with respect to one’s healthcare information will be feasible in modern America.
However, all monopolies tend to become fat and happy without market pressures or incentives to innovative. It’s not as though the electric company can offer new products to boost profits, or the water utility can pipe in a different beverage. In short, if HDUs become the status quo, “What you see is what you get” at the time of designation as a utility could remain the case for a long, long while. Why change?
If the way things are becomes the way things will be (at least for a significant amount of time), it could be disastrous for the goal of Mobile Medicine—which comprises Fire, EMS, Non-Emergency and Interfacility Transport, Critical Care, and Community Paramedicine —to command the seat it deserves at Healthcare’s Table of the Future.
Many HIEs that are advocating to become HDUs are seeking for one utility to be “anointed” in each state. In some richly competitive jurisdictions, like New York, California and Texas, that goal may not come to fruition. But some states, like Colorado, are already moving in that direction: HIEs in Colorado and Arizona already merged, and in August 2023, Colorado’s two HIEs—Contexture and the Quality Health Network—announced a collaboration.
Several states that are advocating for HDUs are already shown themselves to be insular, ignoring or even rejecting calls to interoperate with Mobile Medical services operating within their coverage area but that are not presently sharing data with the HIE, either inbound or outbound. As a result, Mobile Medical Services might find themselves in a “separate and unequal” purgatory if HDUs become standard operating procedure for America’s health data ecosystem.
It helps to understand the purpose of the HDU model. In July 2023, David Raths, a Healthcare Innovation reporter, wrote: “…David Horrocks, who was then president and CEO of the Maryland-based Chesapeake Regional Information System for our Patients (CRISP), and John Kansky, president and CEO of the Indiana Health Information Exchange (IHIE), proposed the idea that every state should have a state-designated and regulated health data utility with a monopoly akin to an electric company. They noted that during the pandemic, states that already have such state-level organizations in place were able to leverage them for crucial public health needs.”
Horrocks and Kansky may be correct that healthcare services can better share data where there is one statewide HIE. But if homogenizing means leaving Mobile Medicine out, then communities will bear the brunt of missing details spanning from polychronic patients under managed care (i.e., community paramedicine), to patients with substance use disorder (because almost zero information about prehospital overdoses land in state prescription drug monitoring programs, or PDMPs).
We have seen the essentiality of Mobile Medical data, as roadway death counts have spiked to multi-decade highs, an increasing number of agencies are researching whole blood administration in the field, and Community Paramedicine services delivered vaccines and infusions during the pandemic. “Co-response” programs are all the rage, including efforts underway to align datasets for EMS, Fire, public safety, homelessness, substance use disorders, mental and behavioral health, home health, hospital-at-home, and SDOH.
At the 2023 National Association of State EMS Officials (NASEMSO) Conference, NHTSA’s Office of EMS said EMS’s inclusion in the National Roadway Safety Strategy was exemplified by its inclusion in the Safe Streets & Roads for All program.
Unfortunately, in 2016, I predicted a collision between health information systems based on HL7, and those based on a non-HL7 data construct. I have said before (and will likely say again) that my article for Becker’s Hospital Review is the only time I wrote something that I hoped would be proven wrong.
I wrote that “the interoperability train among EMS, EHRs and HIEs is sliding down a mountain thanks to ‘different colors of money’ being spent and departmental ‘siloes’ that don’t talk to one another…Even if hospital systems could access state EMS data repositories (which they don’t today in general, though they theoretically could if they wanted to), hospitals would find the data in those repositories is incompatible with their own health record and analysis systems… NEMSIS-structured patient care records capture transportation and incident stats (e.g., there are sections dedicated to identifying the vehicles involved in a crash) but nothing about past patient encounters or family history, or even a place to capture a license plate, which would help identify the cars involved in a collision but holds no statistical value.”
In the intervening years, I became a vocal NEMSIS supporter, so I was thrilled when USFA Administrator Moore-Merrell heralded the EMS data standard as a valued partner in the forthcoming National Emergency Response Information System (NERIS), which we covered earlier in this series. I wrote that “ONCHIT, NEMSIS, and NHTSA’s Office of EMS”— let’s now add FEMA’s U.S. Fire & EMS Administration to this list—”must incorporate technologists’ perspectives ASAP, to avoid the roadblocks that will persist and get worse if our industry keeps relying on ‘separate but equal’ data systems between prehospital and in-hospital care, when such systems are redundant, crazy expensive, and ultimately contradictory to the flow of patient information along a care continuum.”
HDUs that already consume Mobile Medical data will surely keep doing so. However, where the HDUs do not currently consume Mobile Medical data, the ambulance, fire and CP/MIH agencies will stay shut out until outsized pressure forces a change (say, an adverse encounter that could that have avoided if the crew had had real-time access to the more complete information in real-time).
If we are going to realize together the vision of a connected and proactive Mobile Medical ecosystem, then we also need to advocate that before they crystallize into HDUs, HIEs start ingesting discrete Mobile Medical data, to ensure that the insights and interventions of these professionals get incorporated into the patient’s broader health story.
More from the Author
Brave New Interoperable World: Part 1: The Black Swan Event of Fire RMS Data
Brave New Interoperable World: Part 2: The Liberation (At Last!) of Healthcare Data
The Economics of Co-Response: Designing a Sustainable Approach
The Powerful Potential for Artificial Intelligence in Mobile Medicine & Fire