Feuding HIEs Pit Cerner vs. Epic Loyalists in Missouri

A fight over whose health information exchange will prevail is roiling in the nation's heartland. Kansas City is Cerner's town, and St. Louis is dominated by Epic EHR installations. But something in this Missouri HIE controversy doesn't add up.

Joe Boyce is the only CMIO I know with an asteroid named after him.

A former NASA program scientist on fourteen flight programs, and a flight surgeon in Houston from 1986 to 1991, he was bestowed the honor of having asteroid 1978 VQ5 named after him.

Having conquered space, Boyce [the man, not the asteroid] moved on to applying his considerable knowledge of technology to running physician workflow designs at Cerner.

Then in 2009, he joined Heartland Regional Medical Center (now Mosaic Life Care), a St. Joseph, Missouri hospital with 350 licensed beds.

He was just in time to board the rocket ride/torture chamber of meaningful use.

As we talked last week at the HealthLeaders Media Population Health Exchange about the Centers for Medicare & Medicaid Services' proposed rule for MACRA, Boyce told me about a standoff in the state of Missouri, pitting the St. Louis area against the Kansas City area.

Related: CMS: Meaningful Use for Physicians Would End in 2017

There's more bad blood flowing between the two regions than during the 1985 World Series between the Cardinals and the Royals.

This time, the fight is over whose health information exchange will prevail.

Kansas City is Cerner's town, and St. Louis is dominated by Epic EHR installations. After meaningful use started, a race of sorts was on in each region to build an HIE.

According to Boyce, Kansas City, led by Mosaic Life Care (then Heartland), got there first.

First, Mosaic won a Malcolm Baldrige Award, for standardizing its workflows and quality metrics. That was no mean feat in an era when off-the-shelf population health tools were just a dream.

Since 2012, Mosaic has been in an ACO arrangement with Medicare's Shared Savings Program, and in another one with Blue Cross.

About five years ago, Mosaic spent $2 million to create its own HIE, called LACIE, which stands for Lewis and Clark Information Exchange.

But other Kansas City-area health systems and practices refused to join LACIE because Mosaic owned it.

A Generous Offer

In an effort to reach some understanding with his peers, Boyce started a periodic dinner for all the area CMIOs to get together; they represented a mix of Cerner, Epic and Meditech shops.

"One day, I said, 'if you're not going to join this thing, how about if we give it away?'"

In particular, Boyce approached Greg Ator, CMIO of KU Medical Center (part of the University of Kansas). "We send patients to them, but also they're big competition," Boyce says.

"I said, Greg, if you're not going to join it because we own it, how about you join it, and we'll run it as a collaborative. We'll have competing people on the board all the way through, and we'll rotate the chairmanship and all that. It will be a coopetition model."

Ator agreed, LACIE became a 501(c)3 nonprofit organization, and in short order, KU Medical Center joined LACIE, as did North Kansas City Hospital, Children's Mercy Kansas City, and Truman Medical Centers.

A number of area medical clinics also jumped on board, and the volume of data exchange jumped sixfold. "There's hundreds of thousands of hits per month now," Boyce says.

Giving up ownership of LACIE was like sending a gift basket down the Missouri River to the patients of Kansas City, delivering what Boyce describes as reasonably priced HIE services with enough value to drive HIE volume.

But on the other side of the state, in St. Louis, LACIE's offer to connect [Boyce says at no cost] to that region's developing HIE, Missouri Health Connect (MHC), was met with a counter offer: No thank you, and they wanted LACIE to pay substantial fees to join MHC instead, Boyce says.

Vetoed by the Governor

I put the LACIE conversation out of mind until an hour after Boyce and I talked, when I saw the news that Gov. Jay Nixon (D- Missouri) had just made a line-item veto of $500,000 from the state budget that would have funded connections between the state's Department of Social Services and MHC.

"The language added places conditions on health information exchange services that would unfairly exempt [some] providers from the requirement to pay for such services as called for under existing contracts," Nixon was quoted as saying by St. Louis Public Radio.

The veto was quickly followed by a statement of support from MHC with some eyebrow-raising language.

"The budget was inappropriately and unconstitutionally manipulated as a result of special interests that are working to hinder and fragment the adoption of health information exchange (HIE) in Missouri," MHC's statement says in part.

"The impact of the budget language would have compromised the free market system by eliminating hospitals' and providers' ability to choose the HIE that best suits their needs."

Since I was not able to get further clarification, or any comment at all out of MHC in time for this column, presumably one of those special interests is LACIE.

Monopoly Pricing?

Boyce suggested I call Mike Dittemore, executive director of LACIE, for more background on the governor's veto.

"We were live at least two years before Missouri Health Connection was even trading their first piece of data, and that was really in Direct messages, not in query-based exchange," Dittemore says.

LACIE even began exchanging data with another HIE in the state run by the Tiger Institute for Health Innovation out of the University of Missouri in Columbia, Missouri.

"MHC doesn't feel it's fair that we're able to provide services at less than half the cost that they can provide services at," Dittemore says. "They're trying to form a monopoly."

I was unable to determine how many messages MHC carries between its members.

But it's worth noting that many Epic-powered health systems, such as those which make up the bulk of MHC's member organizations, bypass regional HIEs entirely and instead use the Epic-provided CareEverywhere mechanism as an EHR vendor-powered HIE.

So it seems unlikely that Dittemore's monopoly fears will come true any time soon.

At this point, Boyce emailed me to add his thoughts to my conversation with Dittemore:

"The legislature passed a law stating HIEs couldn't charge each other to connect and share data, and established a separate panel to oversee the HIEs in Missouri. MHC, which has gotten over $14 million in federal dollars to provide a state coordinating body, flipped and tried to create a monopoly for Medicaid data they will charge others to connect with—exactly the opposite of the intent of the HIE funding. Then they get Nixon to veto when his buddies lose their monopoly."

"Cerner," he wrote, "has nothing to do with this. You have [St. Louis-based] Barnes Jewish Hospital with St. Luke's on MHC (haemorrhaging [sic] tax $ and blocking exchange) and two self-funded regional HIEs in LACIE and Tiger institute on the other. The only 'special interests' are federally-supported HIEs blocking data sharing."

It seems clear to me that something in this Missouri HIE controversy doesn't add up.

I hope this column brings a response from MHC and its defenders, and we can more fully understand why Missouri's two biggest HIEs cannot connect to each other.

If the matter cannot be sorted out in the public arena, I suspect that those policy makers in Washington trying to eliminate information blocking will take a more active interest in what's going on in Missouri.

How ironic would it be if information blocking were being facilitated with the help of federal funding?