HIE ROAD TO CONNECTED CARE

With all the hype surrounding the ARRA incentives for implementation of EHR systems (which, by the way, will not be available until 2011), $2 billion already appropriated for discretionary spending starting this year, including an "HIE Grant program for states or state-designated entities", have been relatively unnoticed so far. In part, this can be explained by a low level of adoption of health information technology in general. Besides, most of regional and state HIE initiatives came out of government offices, were largely funded by federal and state grants, whereas actual participants were not entirely convinced on benefits of those exchanges. They may get a little more exited now, since the definition of "meaningful use" of EHR will almost certainly contain exchanging patient information as well as reporting on quality measures. In addition to that, the need for cost containment seems to gain more publicity, which may result in phasing down the "fee-for-service" payment model and replacing it with an outcome based one. This will provide a powerful incentive for wider use of patient data collected by other providers.

I have no doubt that there is a lot to be gained from consolidated patient information being accessible to providers, delivering care. It can minimize risk of errors, adverse reactions and side effects, and help avoid duplicate and unnecessary diagnostic and treatment procedures. But this is not all. In one of my previous blogs, I mentioned a few other benefits on a larger scale, which assume data mining and statistical analysis. My only reservation is emphasis on regional and state-level HIE, which potentially limits the completeness of patient information, available through each of them. Every year millions of Americans graduate from high school, college, university, relocate to pursue their career, or retire to a warmer climate. Quite a few of them move out of state. Unless there is a way to access patient records from outside of state HIO's, their full potential will never be realized. Frankly speaking, I would rather prefer a nationwide HIO (NHIO), which would store patient data in a unified fashion. Sure, there are differences in state laws and regulations regarding privacy protection, but they could be applied when the data is retrieved, not when it is stored. At the same time, I understand the rationale to utilize already existing and emerging state-level HIO. In 2006, HHS contracted AHIMA Foundation of Research and Education to run the State-level Health Information Exchange Consensus Project, "… to ensure all health information exchange activities throughout the Unites States align".

In order to account for likely heterogeneous systems of participating entities, the Nationwide Health Information Network (NHIN) was architecturally designed, basically, to provide capabilities to locate and link patient records residing within those systems, to ensure interoperability, and to implement authentication and authorization services on the inter-system level. This project is in its early stage yet, most of these functional areas need further drilldown, but the complexity of the structure is already obvious. I believe we can expect some clarity on whether more uniformity will be required from participats, or NHIN will become a very intricate formation with complicated overhead. Stranglely enough, the NHIN project was not even mentioned in the presentation of the HIE workgroup in today's meeting of the Health IT Policy Committee, which, apparently, demonstrates a certain disconnect between different branches within ONC…

HEALTHCARE REFORM: A BALANCING ACT

There are clear signals from Capitol Hill, which suggest that the idea of public healthcare is unlikely to gain traction in either chamber of Congress. Proposals in the works are aimed at preserving the existing market framework, while making health insurance more affordable, covering patients with pre-existing conditions and curbing healthcare spending. Whether the reform is going to work basically depends on how well individual and group interests will be aligned towards maximum efficiency in applying care.

The first, and arguably, most important aspect of any solution is to change the economic environment on the supply side, by drastically reducing use of “fee-for-service” compensation, which generally encourages waste and marginalizes preventive care, and replacing it with value-based reimbursement system. This is supposed to re-focus providers’ attention from selling more services within their domain, to achieving best possible outcomes with fewer resources, in coordination with everyone else involved.

On the supply side, cost sharing is proposed, in the form of higher out-of-pocket expenses and/or deductible. In theory, this should make consumers inclined to take more responsibility of their own health and chose higher-value care when they need it. At the same time, some patients tend to cut back even on necessary services with little regard to their actual value. To mitigate this side effect, patients need to have access to information about their health status and ways to improve it, as well as to be offered incentives for taking good care of themselves. Perhaps, something like a “health score” would help with setting goals and creating a program to achieve them.

In order to be successful in the long run, healthcare reform has to be comprehensive, but to be adopted, it must:
· have support of the most influential stakeholders, not just public at large
· be deficit-neutral during implementation
· have immediate tangible positive effects on a majority of Americans

There is a lot of explaining required from the Administration and Congress, especially on the last two bullet points, to prove that we will have the right treatment for our healthcare.

HOW MEANINGFUL CAN BE “MEANINGFUL USE”?

There are a few major categories of electronic record systems used in modern healthcare:

• Admission-Discharge-Transfer (ADT)
• Scheduling
• Diagnostic and analysis (laboratory, DI, radiology, pathology, etc.)
• Procedure
• Pharmacy/Rx
• Billing
• EHR

As it is with any other information system, their main goal is storing data, simplifying its retrieval and automating its processing to deliver information in the way that makes sense to each user. In most cases, they do a good job increasing efficiency of respective business processes. But their combined effect can be even greater if EHR systems are able to communicate with the others and one another electronically. In my previous post, I mentioned that the capability of an EHR system to interact with Rx applications would decrease the risk of drug allergies and incompatibilities, especially, when the information from available problem and medication lists could be utilized. Another benefit is the ability to use consistent terminology and codes (e.g., SNOMED CT, LOINC, ICD-10) throughout the entire care environment, which would enable much more efficient search and reporting options, especially, at the RHIO and NHIN level. This is what I would expect the Health IT Policy and Standards Committees to concentrate on, when considering definitions of meaningful use of EHR.

WHAT EHR IS ABOUT

Currently, a number of discussions are going on, regarding various aspects of the Electronic Health Record (EHR), including its definition, contents, structure, uses, availability and access control. According to the Health Information Technology American Recovery and Reinvestment Act (Recovery Act) Implementation Plan, published by the Office of the National Coordinator for Health Information Technology, there are two major goals set forth by the Federal Health IT Strategic Plan:

1. Inform Health Care Professionals: Provide critical information to health care professionals to improve the quality of care delivery, reduce errors, and decrease costs.
2. Improve Population Health: Simplify collection, aggregation, and analysis of anonymized health information for use to improve public health and safety.

From my point of view, they translate into:

• Paperless medical offices, including:
  - Computerized Physician Order Entry (CPOE)
  - e-Prescribing
• Continuity of care, meaning:
  - Prevention of duplicate tests and diagnostic procedures
  - Comprehensive medical, family and social history
  - Awareness of allergies and avoidance of adverse drug interactions
• Collection of diagnoses, treatment plans and outcomes, which would enable:
  - Discovery of environmental causes of disproportionally high or low probability of certain diseases among populations
  - Learning about effects of age, race, gender, etc., on the probability to develop a specific condition
  - Biosurveillance; early detection of epidemic outbreaks
  - Evidence-based decision support

Apparently, the items in the second list have little to do with and do not need much of personal information, so patient records can and should be de-identified. This is relatively easy to do as long as EHR data is well structured, and all sections and elements are distinctly separate. HIMSS defines the EHR as “… a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.” The Continuity of Care Record (CCR) schema adds advanced directives, family and social history. It provides a format for exchanging patient information between EHR systems and could become one of Health Information Exchange (HIE) interoperability standards. But this is a big topic, which I would like to touch a bit later in a separate post.

The complexity and features of an EHR system definitely depend on the environment it is used in, and will be different for a specialist office, family practice or hospital. But the system has to be able to communicate with other applications that deal with patient data, using standard exchange formats and protocols. This would be the first and most important step towards connected care.

Unfortunately, according to Wikipedia, adoption of EHR systems in the U.S. remains low. Among major reasons, the article mentions high start up and software maintenance costs, reduced productivity during the implementation phase, and, in most cases, lack of measurable gains, especially, for smaller hospitals and clinics. There is an apparent disconnect between potential benefits on the national scale and those for an individual provider or healthcare organization. Market has failed to create incentives for implementation of EHR systems, so the Government had to step in with the HITECH Act. I believe there is a good chance for an open source EHR system, such as OpenVistA, in an ASP model, which may remove most of perceived and real barriers to wider adoption of EHR.

ARE WE READY FOR HEALTHCARE TO GO PUBLIC?

The key difference between supporters and opponents of a universal healthcare system is whether guaranteed equal access to medical, dental and mental health services is a right or personal responsibility. Frankly speaking, looking at the statistics that demonstrates how “responsible” many of us are with respect to consumer credit, I understand why medical bills bring tens of thousands of un- and under-insured, even by conservative estimates (http://papers.ssrn.com/sol3/papers.cfm?abstract_id=587901), to bankruptcy each year. But, unlike our spending and saving habits that only affect our financial health, missing out on necessary care can leave a person temporarily or permanently disabled, or even lead to death. There is an article (http://www.msnbc.msn.com/id/30628634) describing how people are forced to ignore medical advice and to forgo recommended treatment because they just do not have money to pay for it. Basically, this is about us, as a society, being ready to provide healthcare to every legal resident, regardless of his or her ability to pay, and to make contributions to the appropriate fund(s) mandatory, just like Social Security Tax.

The Wikipedia article “Health care reform in the United States” (http://en.wikipedia.org/wiki/Health_care_reform_in_the_United_States) cites a number of publications and contains lots of information on the subject. One of the findings is that there is absolutely no evidence that public healthcare in all other developed nations, in which everybody has equal access to services, is more expensive, creates more waste and has worse outcome statistics than the system we currently have. That does not mean that it is ideal. But it is definitely better if we are serious about not leaving millions of Americans out due to financial reasons or pre-existing conditions. Patients can be less concerned about their health records being available to all providers they get care from, since there will be no reason to hide anything there out of fear that their insurance premiums will go up. Free market is not always THE solution. Let us address the issues that we know exist in public healthcare, but not reject it because of them.

TAMING HEALTHCARE COSTS

Looking for information on the breakdown of healthcare costs in the U.S., I came across a recent publication by the McKinsey Global Institute (MGI), titled “Accounting for the cost of U.S. health care: A new look at why Americans spend more”. The report contains some statistics and predictions, based on the current trends, which I personally found very alarming. For example, healthcare costs grow at a faster rate than GDP. In 2006, they accounted for 16 percent of GDP, and, according to the Department of Health and Human Services, will post “annual average growth of 6.7 percent over the next decade”. The Congress Budget Office projects that the share of healthcare spending will increase to 25 percent of GDP by 2025.

MGI analyzed healthcare spending patterns in 13 OECD countries and came up with a measure they call “Estimated Spending According to Wealth” (ESAW), which reflects the fact that countries with higher GDP per capita tend to spend larger portion of their GDP on healthcare. But even adjusted for wealth, in 2006, our combined healthcare expenses were $2.1 trillion, or $643 billion above ESAW.

MGI did not find any proof that we get a better value for the extra money we spend. Among the reasons why the current system keeps driving healthcare costs up well above their fair share of GDP, they mention several economic factors, which I interpret as follows:
· Relatively low and flat out-of-pocket expenses for insured patients
· Large number of uninsured Americans (16%). I believe that creates an incentive for providers to pass on un-compensated costs to those, who pay, in the form of higher prices
· Diagnostic procedures and treatment strategy are often chosen on the basis of maximum profitability for the provider
· Lack of statistical data from healthcare institutions, in part, due to patient privacy protection, keeps payers in the dark as to available treatment options for different conditions. They basically pay the asking price, and pass on the buck to their customers, raising premiums later on

It comes at no surprise that ambulatory surgery (ASC) and diagnostic imaging centers (DIC) are two fastest growing areas of healthcare, being extremely profitable. Sometimes, providers may seem obsessed with MRI or CT scan for almost every single encounter, but it also has obvious economic grounds. One of the solutions we could consider is to adopt the law that would require healthcare providers to switch to a CCHIT certified electronic medical record (EMR) system within, say, 3 years. The government should provide grants to public and community clinics and hospitals, delivering care to Medicaid and Medicare recipients, as well as to uninsured or under-insured patients, to assist them with the implementation of such a system. The patient must have the right to get all his or her medical information, collected or created during the encounter, in the electronic form on portable media, free of charge. EMR systems should be able to display that information, regardless of which of them was its origin. Insurance companies, if we keep our multi-payer system intact, or a single payer, whoever it may be, should create incentives for patients to request and share their medical records, by giving discounts or credits/rebates, respectively. The technology to support this already exists in the form of interoperability standards. It just needs to be utilized to stop the medical inflation from getting out of control.