HEALTH IT: GOALS, CONCERNS AND CHOICES

Health information technology, if properly implemented, can move us closer toward two fundamental goals of healthcare reform:

• Improved quality of care, through:
  * Making comprehensive patient information (clinical history, medications, test results, etc.) available at the point of care
  * Better decision support
  * Patient involvement
• Cost containment, through:
  * Prevention of errors; elimination of duplicate tests and treatment procedures
  * Faster dissemination of research results and best practices

From the provider standpoint, there are three logical levels of information aggregation. First, all pieces of medical data for the current encounter (complaint, diagnosis, tests, reports, notes, medications, treatment procedures) are combined with relatively static patient’s personal information (demographic, family history, social history), into a visit summary. At the next level, the entire visit history for that patient at this point of care is incorporated. Finally, all patient records from all source EHR systems are added together to form PHR.

In fact, the first and second levels of aggregation can be found in most EHR applications. There is still work ahead of us to simplify and automate communication between them and, for example, lab or bedside monitoring systems. Eventually, that will depend on the architecture of each EHR system, and is not going to be covered by interoperability standards. This means that the internal representation of patient data, the way it is stored, delivered and presented to the user, is up to the system vendor. Luckily, that is largely a technical task of establishing necessary protocols and data exchange formats.

It gets more complicated when we need to retrieve patient records created by another EHR system outside of our network. Basically, it does not matter if it is two blocks away or across the country, from a birds’-eye perspective, the process will look the same: to locate those records; send a request; get results. At a closer look, though, each of those steps has a number of actions involved, and architectural decisions have far-reaching implications.

For an EHR system, the capability to find external health records for a patient depends on access to a registry that links an identifier, which must be unique for each person, with all repositories where those records are stored. It either has to know that identifier, or should be able to get it based on the patient data it has. Basically, there are two choices: a nationwide patient number, which will be assigned at birth or on arrival to the U.S. with a proof of residence, or a Record Locator Service (RLS), that is to create a unique master index for every person and to tag all records for that person with it. The main objective against the nationwide identifier is that without proper identity verification process, it may be abused, much like SSN is, to gain access to somebody else’s medical records. As for RLS, it brings a few mostly technical issues. In general terms, it uses record matching techniques based on demographic information available in EHR. If certain fields are empty or contain incorrect values, they may return false positives or negatives.

The record retrieval process can also differ depending where the data is stored. If there is a centralized repository, containing copies of all medical records, it is relatively straightforward. The data management application

1. Authenticates the user (checks his credentials)
2. Authorizes him (grants access rights) based on his profile
3. Applies privacy protection rules (laws, regulations, patient consent instructions)
4. Formats results and sends them back to the requester
5. Creates audit records (who, what, when)

The most complex part of the workflow logic corresponds to steps 2 and 3. For example, an ED doctor requests health records on the out-of-state patient he currently cares for. If the state of residence has different disclosure rules than the one the patient is being treated in, which of them should apply? Should the doctor be allowed to see psychiatric records if the patient has apparent congestive heart failure?

Maintaining profiles of external users and implementing all that logic may prove too overwhelming for an individual EHR system in a pure P2P world. It makes a lot of sense to set up an intermediary that will handle most of that process. Each connected EHR system will only need to know a limited number of user categories, and what information has to be provided depending on which category the requesting user belongs to. In this framework, though, the big unknown is availability of source EHR systems, especially, in small hospitals and practices. Storing a copy of patient records at a local RHIO, much like in the centralized repository, will insulate the source EHR system from external requests, but the need for a record linking mechanism will still remain.

As far as clinical research and public health activities are concerned, where data mining and statistical analysis are applied against large volumes of data, a centralized repository of personal health records is the most efficient and, perhaps, secure option. Traditionally, researches receive anonymized, or de-identified, patient data directly from healthcare institutions. HIPAA allows for disclosure of de-identified records, but in a recently published paper, Paul Ohm of the University of Colorado Law School states that release of raw data does not guarantee necessary privacy protection, especially, if the data enters the public domain. In many cases, though, the end result of interest is computed statistics, bearing no links whatsoever with any personal information. By keeping data inside the repository, controlling and monitoring access to it, we have a better chance to avoid unintended consequences.

I tend to believe that there is no ideal architecture or technology that could perfectly meet all our needs, and personal health records are no exception. The law, policies and standards will continue developing, hopefully, with the goals, that I mentioned earlier, in sight.

HEALTHCARE REFORM: ARE WE LOOKING IN THE RIGHT DIRECTION?

There is an ongoing discussion whether our healthcare system is or is not the best in the world. Those, who say it is, refer to the fact that thousands of patients from around the world come to the U.S. for treatment. According to the Deloitte Center for Health Solutions, "In 2008, more than 400,000 non-U.S. residents will seek care in the United States and spend almost $5 billion for health services… Most come for a medical or surgical specialty program requiring hospital-based care." No doubt, our leading hospitals and clinics provide high-tech facilities and unmatched professional expertise. At the same time, compared to the other OECD countries on the basic health status indicators, such as life expectancy at birth, premature and infant mortality, as well as on healthcare expenditures per capita, we clearly overpay for mediocre results. Apparently, we are entering the stage of diminishing return in healthcare.

We all agree on the goals of healthcare reform:

• Covering the uninsured
  
• Improving quality of care
  
• Cost containment
  

According to the Economic Policy Institute,
in 2008, 58.5% of Americans were enrolled in an employer-sponsored health insurance plan, 8.9% purchased individual private insurance, 29% had public plan coverage, and 15.4% were uninsured.

In most cases, insurance plans, offered by employers, effectively insulate insureds from medical bills, except for co-pay and deductible, which are usually relatively low. So it comes at no surprise that 75% of policyholders are satisfied with the coverage they have. The problem is though, that rapidly rising costs of insurance for both companies and employees create a vicious cycle. On the one hand, in order to keep budget in check employers try to lower their contribution, cut benefits, or switch to high deductible plans. That makes employer-sponsored insurance even less attractive for younger and healthy employees, who normally pay higher percentage of their salary or wages in premiums than their older co-workers. If they opt-out of the plan the pool becomes smaller and riskier for the insurer and more expensive for the remaining participants. The same happens on a larger scale when some employers stop offering health insurance altogether. "Watered down" benefits increase the ranks of underinsured patients, who pay at least 10% of their income on medical bills, excluding premiums. It seems extremely unlikely that we will be able to extend coverage to the uninsured through individual mandate and subsidies for low-income Americans in the current environment without additional federal spending.

There is a popular perception that a large portion of healthcare expenses, especially, uncompensated for providers, is associated with the use of ED facilities by the uninsured Americans or illegal aliens. In June 2006, though, Health Affairs published an article that links higher use with age, health status and income, rather than with lack of insurance or legal resident status. If its conclusions are correct we can hardly expect any real savings on ED services by covering the uninsured.

What actually makes our healthcare so expensive?

In his testimony to the Senate Committee on Health, Education, Labor and Pensions, Dr. Dean Ornish, President of Preventive Medicine Research Institute, said that "…Heart disease, diabetes, prostate/breast cancer, and obesity account for 75% of health care costs, and yet these are largely preventable and even reversible by an integrative medicine program of comprehensive lifestyle changes." Most of us, unfortunately, find it too hard to change our habits, and instead rely on a "magic pill" that should fix problems our body develops over years of neglect. Actually, few use free or deeply discounted wellness programs and regular screening available through their insurance.

Some studies suggest that our healthcare system has become over-specialized, with primary care being marginalized, largely due to income disparity between specialists and primary care physicians. The Medicare fee schedule, often mimicked by private insurers, favors hi-tech diagnostic and treatment procedures, with little regard to their value or outcomes. The share of capitation payments is down even in primary care, whereas evidence-based payment systems, such as PROMETHEUS, do not seem to be quite ready yet for wide adoption.

The fee-for-service payment model, basically, shifts providers' focus from patient's health to selling more services and does little to promote care coordination and information sharing. The Dartmouth Atlas found no evidence that greater supply of resources and higher utilization improve access to care and its outcomes.

The pharmaceutical industry remains the most active lobbying force in Washington in its bid to prevent the government from obtaining the power to negotiate prescription drug prices under Medicare, maintain the existing inventor's protection regulations for "traditional" pharmaceutical products and make them more stringent for biologics. Despite slowing growth in spending on prescription drugs over the last eight years, which is mostly attributed to wider use of generics, the pharmaceutical sector is still exceptionally profitable. Besides, it may even benefit from the push to control healthcare spending, by replacing advanced surgical procedures with more conservative treatment.

Getting back to our first goal of covering the uninsured, any solution currently discussed requires additional funds, at least, to assist those who cannot afford it now. There is no way around that, but this is what has to be done anyway.

As far as two other goals are concerned, we should shift our focus from treating specific conditions to improving health status of patients. With this in mind, we may need to develop a "health score" or set of measures to gauge the overall physical health of an individual, and which will be based on more than just vital signs. The matrix of indicators could be populated at regular check-ups and hospital admissions and discharges. This would give both the patient and medical team an idea where the body needs attention the most and help work out a treatment plan and targeted wellness program. Measuring outcomes will be easier, but the trick is to get patients to follow the recommendations, especially, when we talk about prevention and chronic disease management in ambulatory settings. The "market way" is to encourage good and penalize bad behavior through cost sharing; with a single payer there could be different incentives. This may work for some of us; others may have to be policed. And, of course, a lot needs to be done to promote healthy living through education and mass media campaigns to make it "cool", at least, to our children.