Leaning into the slide. Coopetition can fix U.S. healthcare infrastructure

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The past eighteen months has been evidence that, as a country, we have no connected health data infrastructure. 

 Collectively, because of misaligned incentives, we’ve instead have built disparate fiefdoms that have blocked the flow of data. The rationale for this data blocking centers around competition or intellectual property as a reason to not participate in interoperability. The result? A hammer of regulation requiring exhausted hospital and nursing home staff to complete manual data entry in a scrappy effort to get transparency for decision-making during a global pandemic. The data wasn’t and isn’t always accurate, nor is it delivered in a timely or actionable way. According to a recent article in POLITICO, states were more than five weeks behind in reporting mortality data to the CDC in January, 2021. 

As a result, we have erosion of public trust in healthcare—a dangerous condition during a global pandemic. 

Healthcare is complex. If it wasn’t, we’d fix it and stop writing articles about how the industry should be more like the banking sector. Incentives are misaligned. Patients don’t behave like consumers and the industry comes with complex regulations that some have exploited—as a result, we’ve accepted the worldview that records should follow the system, not the patient. Free market competition doesn’t always apply in healthcare. 

Certainly, health information exchanges (HIEs), when they function as a health data utility, can do an admirable job of addressing these issues, facilitating public health reporting and surveillance and moving data to improve healthcare delivery. Nevertheless, many HIEs struggle to sustain themselves in the face of the growing demand for, and complexity of, integrated physical, mental, and social care. And, for many years, HIEs fought against competition—which often took the form of innovative companies in the private tech sector. This competitive attitude has, in part, led the HIE industry to where it sits today—hyper fragmentation, lack of sustainable funding sources and bloody noses on both sides. 

There is a better way: Coopetition.

In 1997, Adam Brandenburger and Barry J. Nale wrote a book about the pioneering business strategy known as “Co-opetition.” It works. Today we now see Apple and Samsung collaborating and Space X meeting with Blue Origin.

Just as it sounds, coopetition is essentially collaboration between competitors. It is gaining traction among HIEs and healthcare vendors as an avenue for growth amid market shifts and changing funding and operating landscapes. To borrow from Steve Jobs, coopetition “just works” when it comes to the collection and sharing of patient healthcare data among stakeholders across the spectrum of healthcare: patients, providers and payers. 

In the case of health information exchange, coopetition takes performance and viability of HIEs to a higher level. Take CyncHealth, (the Nebraska and Iowa state designated health information exchange) and a non-profit serving as the health data utility for the Midwest, not unlike an electric service provider CyncHealth generates, packages and distributes healthcare data, much like electricity to users, across a defined geographic area and to defined healthcare providers

Historically, CyncHealth had fought against new market entrants claiming to do a better job at certain core HIE functions, like notification services and alerts, even if they could do this work at scale and cost effectively. 

Then CyncHealth met Collective Medical. A for-profit company, Collective is a best-in-class event notification services (ENS) and care coordination platform that had long been seen by HIEs as a major threat to their markets because HIEs believed that ENS was best offered via their own core services. Many HIEs had developed home grown ENS solutions with so-so adoption and at great expense using federal and state dollars. 

But by 2020, despite major resistance from HIEs in nearly every state, Collective had connected a multi-state network of more than 1,200 hospitals across 35 states on its platform. So, in what was considered a controversial move by our HIE peers, CyncHealth leadership asked Collective to partner in a coopetition framework. As an HIE and public health data utility, we are good at data, governance, state and local stakeholder relationships and boots-on-the-ground clinician and political navigation. Collective Medical’s technology solutions for care coordination are best-in-class, and the company saw the acceleration potential for both parties if we could combine our strengths and work together. 

We learned what motivates each organization. As a for-profit company operating in the wild, Collective Medical was more than willing to partner with CyncHealth and become a part of CyncHealth’s tech stack for the Central Plains region. A year later, Collective Medical’s care coordination and ENS platform is now a service of CyncHealth for providers in the Midwest. In addition to its platform, we benefit from Collective’s approach to clinician engagement and experience across markets. The company’s clinical team shares lessons learned from other states and helps the CyncHealth team avoid these same pitfalls. Likewise, our participants now receive alerts on their patients when they have encounters across Collective’s vast network, versus only within our region, adding value and scale we could not achieve alone.  

Similarly, with social determinants of health (SDOH) taking center stage in state and federal policymaking, there’s a host of innovative companies solely focused on delivering community data exchange solutions and social care referrals. CyncHealth similarly leaned on the coopetition approach to address SDOH for our participants, rather than invest millions in developing a state-specific solution. We evaluated several SDOH vendors and found that Unite Us, which has a social care network covering more than 40 states, offered the strongest platform for this work had a road map towards interoperability and data standards, where others fell short. Without interoperability and data standards we’d be back to where we were 20 years ago with EHRs—with microcosms of customized approaches with no ability to facilitate the data following the person. 

Our deep roots in data standards and interoperability informed our belief that addressing SDOH needed to be expansive and had to be considerate of the technology gaps of broadband while still providing services to frontier and highly rural counties of the Central Plains. We found that Unite Us was ready for the mission and excited about the opportunity to partner on this the infrastructure challenge. CyncHealth has now sponsored Unite Us to build out its social care network across our eight-state region, coupled with our core HIE services and approach to community engagement. 

Both Collective Medical and Unite Us could have been CyncHealth’s competitors. In other states, they are still perceived as threats. HIEs have spent significant state and federal funding resources building their own competitive solutions or marketing to defend their participant base against these players and others like them. But these HIEs are fighting leadingedge private sector solutions that had to become the best in order to survive—they can’t access federal funding on their own. 

This approach is not fully embraced across the healthcare continuum. In some cases, because of misaligned incentives and the fragmented systems, data moving across systems does not exist and is often resisted despite new CMS and ONC rulemaking to push interoperability between systems and stakeholders. CMS and ONC have detailed roadmaps, embedded FHIR APIs into incentives and provided funding but healthcare systems and providers must be able to provide patients and other stakeholders with secure and easier access to healthcare records. The experience of CyncHealth and other HIEs across the nation that have embraced coopetition shows that economies of scale and higher levels of healthcare delivery can be achieved. 

Ultimately, state, policymakers and healthcare systems CEOs and HIE executives must ask themselves whether they want to continue building fragmented systems that service their corner of health data needs—or whether they want to provide the highest level of service and value for the betterment of their communities, counties, and states through a utility model. 

It is not a failure of technology that we do not have ready access to healthcare information in some of the most technology-enabled areas of the country. It is a failure of people, process and policy.at needs to change.

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