Erica Galvez is CEO of Manifest MedEx, the largest nonprofit health data network in California and one of nine Qualified Health Information Organizations under the state’s new Data Exchange Framework. She sat down with Healthcare Innovation last week to discuss the expanding role of her organization as the implementation phase of the framework begins.
Healthcare Innovation: During an online panel discussion you hosted recently, Krishna Ramachandran of Blue Shield of California used the Gartner Hype Cycle concept to say that we are somewhere between the trough of disillusionment and the slope of enlightenment when it comes to the state’s Data Exchange Framework. I'm wondering if you agreed with that, because I thought it seemed early in the process to be disillusioned yet.
Galvez: I actually thought it was an OK assessment, because there has been a lot of hype and expectations for massive data sharing as soon as the January 31, 2024, deadline hit, which came out of the effectuating legislation, AB 133. I don’t think we had that expectation, because we've been doing this for a very long time, and we know it takes time to implement and get all the cranks turned in the right direction, and get data flowing as it should. But we have had many stakeholders, who have not historically been part of national networks, who thought the deadline would hit and everybody would share data, and that did not happen, and it still has not happened.
Our assessment is very similar to that of Adam Davis, our physician colleague from Sutter Health on that panel, that much of the exchange that we are facilitating today is exchange that we were facilitating before the Data Exchange Framework, and has not really been augmented or disrupted by the Data Exchange Framework. I think we will see increases as a result of the Data Exchange Framework. I just don't know how long it will take for those to materialize.
HCI: When we look at payers like Blue Shield of California, what's the potential business improvement use case if the data does start flowing better?
Galvez: Well, I think they stand to get a lot out of it. The Data Exchange Framework requires data sharing for operations purposes, and that, I think, is part of what has created some of the hype and the energy, at least in the health plan space — that clinical data could give them real boosts on things like HEDIS measures. It could inform insights in their quality improvement efforts and risk adjustment, to the extent they run lines of business that rely on risk adjustment for payment.
HCI: Today, are they not getting that clinical data at all, or do they have to make arrangements to share data one by one with provider organizations?
Galvez: One by one. Or they partner with someone like Manifest MedEx where we aggregate data and send it to them, but it's still such a fragmented ecosystem.
If the state had decided to require not only data sharing, but take it a step further and say organizations have to use qualified health information organizations (QHIOs), that would actually mirror much more closely the TEFCA federal structure. You can't participate in TEFCA if you don't participate in a QHIN, right? California chose not to do that, but I will say, if they had chosen that path, I think they could have accelerated connectivity that reduces that data fragmentation more quickly.
HCI: During the panel session, you mentioned Manifest MedEx was disappointed that Assembly Bill 1331 didn't move forward out of the California Legislature's appropriations committee. Could you talk about what that bill would have done and why you thought it was important?
Galvez: There were two really critical pieces to the Data Exchange Framework in that bill. One is more clarity about the governing structure and the composition of the governing body. The second is enforcement. There's currently no explicit enforcement authority in the Data Exchange Framework. We have a mandate, we have a requirement to share data, and we have policies and procedures around that. The Data Exchange Framework in California is technology-agnostic. So there's no network, there's no spec, there's no requirement, for example, to participate in a qualified HIO or a national network. An enforcement mechanism would say we're going to make sure you're sharing data. We can't keep track of you through a specific network because there's no mandated network, but we have some enforcement mechanism to make sure you're sharing the data that you're supposed to share. AB 1331 would have put that in place. It would have given that authority to the administration.
HCI: Another thing you said during the panel was that Manifest MedEx hasn't traditionally shared data with the other eight QHIOS in the state, but now the infrastructure is there to make that happen, and data is starting to flow, but there are questions about data quality. Can you talk about that data quality issue?
Galvez: I would say we're very early in that process, but we have historically not queried and retrieved data from other qualified HIOS in the state. I mean, the concept didn't exist before, and several of them did not participate in national networks, so we didn't have any way to connect with them. Now, they participate in national networks. That's a requirement of the qualified HIO program, and we do query them when there's an acute episode for a patient at a provider's organization on our network, and pull their data back and and we have started to look at the data quality. We match that information, and then we consume that into our system, and we have very high standards for data quality, and we can control that. We have a whole quality control process when we're getting data directly from a data source. When we're getting it from an intermediary, like a qualified HIO, we don't have those quality assurance mechanisms in place yet, so before we ingest that data, we have really started to take a close look at it.
HCI: What would be a sign or an implication of poor data quality?
Galvez: It depends on what you want to use the data for. I would say, is it fit for purpose? I'll give you one example. Most use cases require provenance. In other words, I need to know where that procedure was performed, or I need to know who prescribed a medication. One starting place for us is just to evaluate, when we pull back information from these other aggregators, is data provenance consistent? It's looking like there are some gaps.
HCI: Let's talk about TEFCA. When I was talking to John Kansky of the Indiana HIE recently, he said the phone call he hates the most is a hospital CIO saying, ‘Do I work with you guys, or do I just go through TEFCA?’ Do you hear that kind of confusion from hospital CIOs? And because California is one of the few states that's created its own exchange framework, is it important that the two policy frameworks mesh well?
Galvez: Most hospital CIOs are not calling with that question, but it's because they're planning on their own around TEFCA. I think it's really important that the Data Exchange Framework in California is compatible with TEFCA and the national agenda. I think California has ambitions that far exceed where our national colleagues are on TEFCA. And in that respect, TEFCA is inadequate. It’s necessary, it's a good foundation. But I do think that having health data utilities that kind of wrap around TEFCA and meet those local ambitions and needs that extend far beyond what I think TEFCA will do anytime in the near future is important.
I think it's totally possible to stay in sync and not conflict. When I say, stay in sync, it doesn't mean we're doing exactly the same thing necessarily, but we're definitely complementary. We’re not doing something that conflicts with it. And frankly, because most of the organizations that will share data through TEFCA are also the organizations that will share data under the Data Exchange framework, you don't want to ask people to do duplicative work, right? You want to constantly be doing additive, value-added work.
HCI: It seems like one of the things California is doing that ONC is not really envisioning early on is figuring out ways for community-based organizations to participate. That may be an area where lessons learned in California can help the rest of the country.
Galvez: Absolutely. I think we are ahead of the curve on that. There are growing pains for us collectively around that. We're bridging a HIPAA universe with a HIPAA-plus universe. We’re trying to run fast and run at scale in California, and we have lots of lessons to share with our national colleagues on that.
HCI: California is so big and you have these nine qualified health information organizations. Indiana's John Kansky was also talking about how it's important to have one health data utility for each state. Does California need one health data utility? Do you see Manifest MedEx playing that role because you're the largest? Or potentially playing that role?
Galvez: Manifest MedEx could be that. Yeah. The state misses opportunities because they don't aggregate data across those regional organizations. And I understand it's difficult to do that. There are a lot of complex challenges in California. California has tried to do this in the past and it hasn't worked very well. We have to acknowledge there's a reason that California has regional solutions. The populations are different across the state; organizations are different across the state; the way we conduct public health activities varies across the state. You see this even in delegation through managed care in California, it's just very complex. Having said that and acknowledging that, state-level public health efforts, state level Medicaid efforts, state level cost-containment efforts — all of these would benefit from aggregation of data at the state level. I think it's a gap, honestly, for California. You know, California is not Indiana. It never will be. But there are benefits I think we can learn from Indiana and their experience in having one health data utility.
HCI: Is public health a good example of a health data utility’s role?
Galvez: I'm not sure how you are a health data utility if public health is not part of the core of what you do. We do a few different things on the public health front. One, we serve as the infrastructure for the California Department of Public Health for reportable labs. Any reportable lab result that gets processed in the state comes to Manifest MedEx. We match that at a personal level, de-duplicate it, consistently format it, and then we push that on to public health. And you would probably be shocked to know how much duplication there is in lab results that come to us.
We also report to public health on behalf of providers. So immunizations happen in a provider office. Those come to us on behalf of that provider, and we’ll report those to the state's immunization registry.
HCI: You mentioned during the webinar that more than 80% of the provider organizations in California that had signed the data-sharing agreement haven't yet populated the directory with the methods of how they're going to exchange data. Why is that? What needs to happen?
Galvez: I think it's a good question. The way the state has constructed their directory, Manifest MedEx, for example, cannot update anything in the directory on behalf of an organization. They have to go in and do it themselves, and it's not a high priority. And again, there's no enforcement. Nobody's coming behind them saying, ‘You didn't update your directory,’ so I think it falls to the bottom of the list. It’s just another administrative action that nobody has time to do. I’m not sure these providers fully understand that, given the technology-agnostic nature of the Data Exchange Framework in California, if you don't put an entry in that directory, no one else knows how to query you or connect with you for data sharing. So the directory takes on heightened importance, because that is the mechanism by which everyone knows how to reach everybody else.
HCI: Manifest MedEx launched its own California ADT [admit, discharge, transfer notification] network in January. Will other QHIOS participate in that? Or will they establish their own ADT services?
Galvez: Time will tell. I don't know. We have had quite a bit of interest in the free network that we launched, in particular from larger health systems, which is great. Organizations need a way to share ADTs, and they don't want to have to manage a bunch of panels, and they don't want to pay a bunch of different vendors or organizations to do that. We put it out as a free service in the interest of the public. We said, if cost is a barrier, let's get rid of it. If managing panels is a barrier, let's provide a solution that'll do that. If routing ADTs is a problem, let’s fold that in also. But I don't know what the other qualified HIOS will do.
HCI: Skilled nursing facilities were encouraged to send ADTs, even though they weren’t required to yet. Are any of them participating or interested in participating?
Galvez: We’ve definitely had interest from skilled nursing facilities in the network. We don’t have any of them on board yet. Part of that, I think, is a lack of mandate. They're encouraged to share ADTs, but they’re not required to share ADTs. They probably have a million other priorities that they're trying to solve before they figure out their solution for sharing ADTs.
