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Greg Franklin is the deputy director of health information technology for the California Technology Agency. Healthcare IT Connect had a chance to sit down at the 2012 NASCIO Conference in San Diego, following his panel discussion entitled Batten Down the Hatches on Health Data Exchange.

Zach Urbina: As the deputy director for Health IT, for the California Technology Agency, what are your main roles and responsibilities for this position?

Greg Franklin:  My main responsibility is to monitor and be a consultant to all California departments in the area of health information technology. What I try to do is have visibility into all state departments, to create an environment of information sharing, technology sharing, I look at architecture, to make sure to at least be able to say that there are commonalities in the architecture, and therefore this department, the department of health services should be talking to the department of insurance, because you both are trying to build the same thing. So that’s my primary role. Secondary to that, obviously, I try to participate in those committees with a work group and lend my expertise in that regard.

ZU:  More technologically progressive states are beginning to recognize this opportunity to align their health information exchanges and the implementation thereof with MMIS, (Medicaid Management Information System) Medicaid management information system, modernization. What are some of CTA’s efforts in this area and are you seeing opportunities to share data with other state agencies to better coordinate care?

GF: One of the things I think we do extremely well in CTA, and that is we have an office full of what I would call experts. Experts in project management, experts in enterprise architecture, experts in IT policy. And we certainly know state law fairly well. We certainly are connected to other control agencies like ours. So what we try to do is to be a consultant to those organizations that are looking to do integration or looking to have a system that’s interoperable and looking at an enterprise architecture that lends itself to the kind of building of a system that encompasses more than one function, more than one priority within a department. To that end, though, we’re also an early warning device to those departments that may be going down the wrong road or may not understand the landscape and maybe we help them by identifying expertise in the community. Maybe we help them by identifying expertise in other states. So what we try to do with our partners and our departments is be that critical eye, because of our expertise, and two, be that helper, because of what we know and who we know, and who we’ve seen perform in California.

ZU:  States across the country are implementing different sustainability models. California recently transitioned a statewide HIE from Cal eConnect to the Institute of Population and Health Improvement (IPHI) at UC Davis. HIE from Cal eConnect to California E health quality program overseen by the Institute of Population and Health Improvement. Could you tell us a little bit more about this transition and how you envision further development of California’s statewide HIE infrastructure?

GF:   It’s run by a Dr. Ken Kizer who was a director at DHS, actually when I first came into health services so many years ago here in California. And Dr. Kizer, I can’t say enough about him. Tremendous individual I’ve known for a long time, and I know that one of the things he’s interested in are health outcomes. And how does HIE lend itself to improved health outcomes? He’s also interested in impacting, what I call impacted programs, and the example I gave was the many of the dual eligibles. That’s an individual who’s eligible for Medicare and eligible for Medicaid. And one of the initiatives going on in the country and certainly in California, where we’re trying to see if the dual eligible folks would do well in what we call organized systems of care, where there’s managed care, where there’s an ACO, a medical home, but whether they would do well in the system. So how can HIE help with that effort? Because you have two systems. You have the Medicare system and you have the Medicaid system. So there needs to be some sharing of information. The other thing is, I truly believe that Dr. Kizer and his folks will be working on, will be the funding and support for some of the local initiatives that are going on. Some of the RIO’s or RIO look-alikes that are going to be going on. So I think that where we are now, we’re still moving forward and I have to believe we’re in a better place, so that’s sort of one thing. And keep in mind, that they just got this function probably about two or three months ago.

ZU:  So we’ll see what develops.

GF:  Well, I think a lot has developed. When you put a mission statement out, that you’re interested in health outcomes, it’s a different method from the original state designated policy.  They had more of a business model-type approach because they were building toward sustainability. Dr. Kizer’s first priority is not necessarily sustainability, but is improved health outcomes. Because with that, they’re not putting products out there so Cal-E would want to put a product out there, then you have a health plan, you sign up, you get this information, I charge you $15 or $10 in transaction. Dr. Kizer is putting something out there that makes you think about health outcomes first. And then sustainability and profitability.

ZU:  Is sustainability the eventual plan? What sort of timeframe do you see emerging?

GF:  They’re just getting started, they’re staffing up and they’re putting together a advisory committee that should happen soon. I would think after the advisory committee is in place. It takes time.

ZU:  Speaking of recent news, the New York eHealth collaborative and the partnership for the New York City Health fund, announced the launch of the New York Digital Health Accelerator. It’s a program aimed at supporting health IT innovation, job creation. Does the CTA have similar efforts in place to engage technology innovators and entrepreneurs in developing cutting-edge solutions for health systems reform and Medicaid modernization efforts? 

GF:  Let me explain CTA’s role first. So we’re a control agency. And as I said before, and what we do, when departments and agencies have initiatives, we run them by our experts and say, it doesn’t work if this happened, if that happened. To that extent, we’re a consultant. Do we advance or promote innovation? Yeah, we do. But not certainly like if we were in a department or an agency. So one of the thing we’ve been very interested in is sort of mobile devices, mobile applications and trying to make that part of government services so that we now know that x amount of the population, a percentage of the population, has a mobile device, and they would probably like to interact with the government from a mobile standpoint. So we try to do as much as we can in that area. We have a data center. Our office of technology is called OTECH. And they’re looking at potentially file-based services and how that’s going to help our customers. So what can we do with cloud-based services? Well there’s a lot we can do with cloud-based services in terms of creating an environment certainly of efficiency. And hopefully an environment that’s even more cost effective. So to that end, we practice and try to preach and be innovative, but to a certain extent, what we want to do, what our role is, we want to help departments and agencies realize their vision, their innovative vision. Because really, they’re the business, they know the business, they know what they need to do to be successful. And we try to fill in the gap in the era of innovation.

ZU:  What do you see as the biggest security and privacy challenges for healthcare data? From a state perspective?  

GF:  The legal aspects of data transmission, data sharing, and data availability. As you know, as we talked about, there are going to be various users that require data. And certainly, what are the legal situation requirements to deal with and to share that data. To allow anyone to be able to share that data. And if I’m doing privacy and security, let’s just say that I’m an ACO and I’m doing privacy and security but I would really like to have access to a person’s in depth data. Because I believe some of the people who are coming here have assumed the identities of folks who are dead. I want to do that myself because part of my, if I’m an ACO, I want to do that myself because as part of my agreement or contract with whomever, I need to keep my costs down. But if I’m providing services to individuals that I’m not going to be reimbursed for, and I feel like the plan or the purchaser is not doing a good job at screening, then I might want to do that at my level. But can I have access to that information? That becomes, legally, can I have access to that information? So that becomes a question. Legally, can I capture and retain information and transmit it to other folks? Legally, can I capture and retain security numbers? So I think the legal aspect surrounding data capture, data transmission, data storage, data sharing, becomes a huge issue as we start to move through how we’re going to treat data and use data, not only for outcome purposes, also for cost containment purposes.

ZU: During the NASCIO panel discussion you talked in regards to the opportunity to share data with other agencies. For example some of the common investments in HIX and MMIS modernization.

GF:  It’s a common investment, but it’s a federal investment. So this is what the federal government’s paying for 100% and that’s that they want states to have, one, to have the ability, two, to do enrollment, and three, retention, because what happens, and this is again what I was talking earlier, this is really insurance reform. This thing, right, right, this, to be honest with you, I’m not too sure where we are in the continuum of health, in the first five or six years, because everyone has their learning curve. So it’s really insurance reform, so what’s going to happen here is, and why the retention piece is so important, what if I miss a premium payment? Do you kick me out of the plan in that month? Well, I don’t know. That policy hasn’t been discovered yet. Do I have a grace period to pay my premium? Fourteen days, fifteen days? So eventually, I mean, I’m a customer. I’m a paying customer. I missed a payment. But I need that money, that might be part of my sustainability model. I need a certain level of enrollment. So retention is going to figure big, along with eligibility and enrollment. I don’t want my system kicking folks out after they miss one payment. I’m going to send you a bill next month for two payments. And then maybe three payments if you miss the third one. and then, if I don’t get all three payments, then maybe I exit you from the system. But I have to have a retention policy.

ZU:  At our 2012 Accountable Care and Health IT Strategies Summit in Chicago, the CIO of Cook County Health and Hospital System presented his work onIllinois’ insurance waiver demonstration project, so they’re taking on a Medicaid population, and I was wondering if California has any plans to do anything similar.

GF:  We’ve already done our waivers.  So it’s a federal waiver, it’s called an 11-15 waiver. And I’m sure that’s what they’re doing. 11-15 waiver. And these waivers, these 11-15 waivers, just to give you guys some background, these 11-15 waivers used to be the federal government’s way of letting the states do their own mini-version of health reform. So what you’re asking for is being able to waive little pieces of the eligibility standards for Medicaid. So for example, if I wanted to waive asset testing, back in the day, if I wanted to waive asset testing, I’d use the 11-15 waiver. So we did our 11-15 waiver and our 11-15 waiver, you can Google it, it’s titled the Bridge to Reform. And this waiver was approved in, this is 2012, this waiver was approved in October 2010. And in this waiver there were several initiatives, but I’m going to highlight a couple that are relevant for health reform. So in this waiver, and the reason we called it a bridge to reform, there is a population of folks who we assume are going to be eligible for health reform at the county level. So in this waiver we created, we asked for the approval to pre-load or pre-prepare this population, roughly about 500,000 folks, and it’s called the low-income health program. That’s what it’s called. And what we’ve done is we’ve pre-prepared these folks on, on day one, they go right into the expanded Medicaid program. In other words, single adult, childless couples who have not historically been eligible for Medical. So we asked the feds, had asked the feds, to pre-prepare them, let counties provide services to these folks now, we’ll reimburse them. The feds are partners, they will reimburse them as well. And on day one they go right into Medicaid. And that was one significant piece that’s in that waiver.

The other significant piece that’s in the 11-15 waiver is what we call the DSRIP; theDelivery System Reform Incentive Project.

Its for the public hospitals. It allows them to use certain initiatives, if we gave them a certain amount of money, to be able to treat a certain population but they have to advance a certain initiative, like medical homes. And so if you’re doing medical homes, we’re going to give you this much money. And there’s others in there, I just can’t remember. So we’ve already done our waiver, it’s called the Bridge to Reform, and I think that’s what Illinois might be embarking on.

ZU:  Do you have data from it?

GF:  They probably have data now, the Department of Healthcare Services, it is a five-year waiver. Something’s going to get published soon, though, cause what generally happens is the California Healthcare Foundation, they’ll come back and they’ll publish, like there’s a publication out from the local health programs, that the California Health Foundation did, they’re the publication, there should be a publication out on this next year.

More information of Illinois’ Waiver Demonstration Project is available in online video from Dr. Bala Hota, CMIO of Cook County Health and Hospital Systems.