ONC Holds A Key To the Structural Deficit

It’s called Blue Button+ and it works by giving physicians and patients the power to drive change.

The US deficit is driven primarily by healthcare pricing and unwarranted care. Social Security and Medicare cuts contemplated by the Obama administration will hurt the most vulnerable while doing little to address the fundamental issue of excessive institutional pricing and utilization leverage. Bending the cost curve requires both changing physicians incentives and providing them with the tools. This post is about technology that can actually bend the cost curve by letting the doctor refer, and the patient seek care, anywhere.

The bedrock of institutional pricing leverage is institutional control of information technology. Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing. Pricing leverage comes from vendor and institutional lock-in. Region by region, decades of institutional consolidation, tax-advantaged, employer-paid insurance and political sophistication have made the costliest providers the most powerful.

The most powerful providers use information technology strategically to lock in both physicians and patients. HHS promotes this lock-in through Stark law safe harbors for EHR subsidy and $12 Billion of Stage 1 Meaningful Use subsidy. The EHR vendors have gladly evolved overpriced and non-interoperable technology to serve their institutional customers. Neither physicians nor patients purchase health IT. Our lack of market clout is frustratingly obvious in both my state medical society and the online patient forums. One of these forums, The Society for Participatory Medicine list, recently surfaced an important TED talk by Clay Shirky. Shirky describes how our tools reflect the management philosophy of the institutions that create them. It’s well worth watching.

ONC holds the key to dismantling the provider and patient lock-in at the core of institutional pricing leverage. ONCs leverage comes from mandated Direct secure messaging in Stage 2 Certified EHR Technology and the power of the purse over 40+ Direct-enabled state health information exchanges (HIE). Will ONC use these levers to put the power of referral and interoperability in the hands of physicians and patients?

Blue Button+ is a potent combination of Direct access in and out of the EHR with an open authorization technology called OAuth. By driving the state HIEs toward Blue Button+, ONC can shift the balance of market power away from institutions and toward the physician-patient relationship. Combined with reforms already underway including Health Insurance Exchanges that give patients an opportunity to choose health plans and shared savings incentives for physicians, the information liquidity benefits of Blue Button+ will be the third leg of the stool that leads down a market-driven road to The Triple Aim.

There are many challenges to the Blue Button+ vision. CommonWell, DirectTrust, and the understandable reluctance for state HIE bureaucracies to engage with individual doctors and patients. Everyone in the health care industry, it seems, prefers to do their business with nice, organized and managed corporations. Physicians, unfortunately are not all on board either. Given a choice of sharing power with patients or with their institution most physicians will pick the institution. The Hippocratic Oath is struggling to adapt to the Internet age of practically instantaneous and free connectivity.

CommonWell, DirectTrust and HIEs are tools focused on the institutions that already have too much pricing leverage. Bending the cost curve requires loosening the EHR lock-in on information by making connectivity, instantaneous, free and universal. This requires effective technology, security and privacy and it requires ongoing ONC support.

Stage 2 Direct EHR connectivity can provide the technology and, as a part of Blue Button+, it can provide the security and the privacy. However, only ONC policy and the corresponding HHS support for Blue Button+ in Medicaid-funded HIE programs can prevent the creation of vendor-controlled networks like CommonWell.

If ONC allows the EHR vendors to undercut the Direct connectivity mandate of Stage 2 with CommonWell and it undercuts its own Blue Button+ program by funding DirectTrust to bypass patient authorization the core of HITECH will be failure and EHR technology will continue to bend the cost curve in the wrong direction. ONC needs to err on the side of transparency and citizen engagement.

For its part, HHS has an even simpler choice. It can require Blue Button+ portals on all federally supported HIEs from day one and join patient advocates like Patient Privacy Rights in public support for privacy-preserving patient-directed health information exchange. All of us can and should comment on the CMS Request For Information about HIE due August 22.

Adrian Gropper, MD is Chief Technical Officer of Patient Privacy Rights and participates in Blue Button+, Direct secure messaging governance efforts and the evolution of patient-directed health information exchange.

24 replies »

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  5. Peter, I’ve been on numerous Markle panels starting with one led by Diamond and Shirky many years ago. That first panel predicted the tremendous consolidation of the EHR industry as a result of a very expensive technology certification bureaucracy. 4 years and $12B later, this forced march to Stage 1 has achieved its primary goal of EHR adoption but it has also had tremendous side effects in EHR quality, physician frustration and increased cost.

    My most successful Markle panel by far was the one that created Blue Button. One of the keys to that success was coordinated action by the federal health folks.

    My last Markle panel, was on health information exchange. It lasted over a year, and as far as I can tell, has had absolutely no impact in my state HIE or any other.

    I’m not sure how you define patient centricity. I use patient-directed exchange to mean provider-to-provider transfers that do not involve the patient as an intermediary. Patient-directed exchange does offer the patient a more fine-grained open authorization process than the old opt-in-and-out but it can do query and support policy-based authorization for research, emergency, and more. This is exactly what our Blue Button+ program is designed to do. It’s patient-directed exchange, done in an open process with diverse participation from a very dedicated and diverse community that includes EHR vendors and mobile app developers and non-profit think tanks and open data advocates like me.

    Stage 2 is ONC’s best shot at resurrecting the legacy of HITECH. Appropriate guidance can put the physician-patient relationship at the core of health information exchange and bring market forces to bear on the EHR vendors and institutions. This will increase transparency and reduce the need for technology regulation in Stage 3.

  6. Health information technology: a few years of magical thinking 2008 by Diamond and Shirky is a good foundation for understanding the problem especially since it was before many of the fixes put into place after 2008 that put us where we are now.

    Once the Internet gets its collective influence behind a specific topic change can occur. However the changes are disruptive and may lead to different lock ins based on other factors so that some animals are “more equal” than others.

    The best thing we can do is to clearly contrast the old model with the new one and show the risks associated with silo versus horizontal approach based on patient centricity.

  7. The iPhone store is a fine model because individuals decide what apps to use, not Epic or Kaiser.

    Unlike Blue Button, Blue Button Plus (BB+ was originally called the Automate Blue Button Initiative) does not presume any direct involvement of the patient beyond authorizing a physician or service – more or less what patients already do today.

    The big difference with Blue Button+ is a power shift away from the institution and into the hands of the individual physician. The physician can refer anywhere and offer any app without EHR vendor lock-in. Assuming aligned physician pay incentives and competing patient insurance options, increased transparency and mobility will drive costs down regardless of whether it’s Kaiser or Minute Clinic that’s providing the service.

  8. “Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. ” but your conclusion is flawed on so many levels.

    “They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing.” (What????)

    It is really hard to read past that obvious logic error. It is only in the last few years that more than a few outliers had EHR’s and we have had a lack of price and quality transparency for generations. Show me the correlation? One health care provider (Kaiser) now controls 40% of the CA market and they use one of those horrible siloed EHR’s (Epic) and egad they have the best quality outcomes at the lowest costs.

    “the powerful institutional customers” I assume you are referring to the govt? the largest purchaser of health care? If not who? Let the market decided (it clearly already has.. buy Epic)

    9 in 10 Americans has poor medical literacy skills so how does downloading their information solve any of this? There are very few elective procedures where it makes sense for a patient to shop based on price..

    Would you suggest patients do that for cancer treatment? When a spouse is being taken to the closest hospital for a heart attack? Once there and you can’t afford to have them transferred to a better one a mile away what do you do? The vast majority of cost in the health care system happens in the last year of your life and that is not a period when someone is capable of shopping for care.

    The few lasik and knee surgery examples provided to a highly educated wealthy portion of the population are NOT the use case. How does having your own records and the cost of care help the average American earning 42,000 a year with an 8th grade reading level

    BTW It wasn’t clear but are you really advocating for govt intervention to break up some secret EHR monopoly? Should we do that with the Iphone store too? Anyone out there can simply pay to implement the free EHR that the VA has or use one of the free ones offered in the open market.

  9. Sandra’s point is key to my argument about transparency and ONCs critical choice in interpretation of Meaningful Use Stage 2.

    If ONC and HHS allow vendors to create a back-door network like CommonWell to preserve the lock-in business model, patient-directed exchange via Blue Button+ will not provide transparency because patients will continue to have to beg for their data and physicians will have to beg for better, more interoperable IT.

    As long as all of the data types have to be exchanged via the front door, using Blue Button+, then the power of Stage 2 is amplified and transparency comes without the incredibly burdensome technology regulation currently being contemplated for Stage 3.

    ONC needs to side with the patients who say “Nothing about me without me”.

  10. Gotcha, on all points. And you get extra credit for the Milken quote. Was working in net TV news throughout that particular arc of epic venality, was in a chase car driving 100+ mph from NYC to Teterboro to catch footage of him flying off in his jet to whatever resort trip between sentencing and slammer.

  11. Don’t read in stuff that isn’t there.

    Opacity = Margin.

    Efficient Markets Hypothesis and all that. That lovely “Market Clearing Price” stuff of the ECON crowd

    The CEO of United Health Group, Hemsley, makes $40 million a year. In a truly transparent market he might well make 1/100th of that.

    “In the gap between perception and reality, there’s money to be made.” – Michael Milken, former Junk Bond King

  12. I dunno if you’re lumping me in with the “free market types” – I’m less categorizable than that, I think. I’m more of a grassroots logician, and the irony inherent in that phrase is not lost on me.

    My first question when approaching anything is “does it make sense?” If not, I work to make sense out of it. Ergo my fascination with healthcare cost/price/value. ‘Cause baby, they don’ make no sense.

    Beyond, of course, making perfect sense to those on the receiving end of the revenue delivery in healthcare.

  13. “Transparency – in care, in costs of care, in access to data across the healthcare landscape – does not yet exist. ”

    Margin is a function of opacity. Transparency minimizes margin, an irony utterly lost on the Free Market types.

  14. There seems to be a question as to what data is going to be exchanged – clinical data gathered in encounters (i.e., HL7 structured documents and unstructured data in various notes) or claims (coded) data. Do people have ideas on this? Even though both are possible, what’s relied upon will require one or the other. I question whether claims data is accurate or timely enough or even nuanced enough to adequately reflect clinical conditions. And I wonder if clinicians are supposed to apply the same level of care in documenting care and coding for billing (talk about double entry – maybe that’s already expected). I also am concerned about the idea that coded data for billing contains everything about a patient – are payers really entitled to every bit of their beneficiaries’ health data? I didn’t think so, but perhaps I’m behind the times.

  15. “Anyone who doesn’t ALWAYS get a second opinion prior to any surgery should have their head examined.” BOY HOWDY is that the truth! Thanks for the answer =)

  16. I did not pay $400 because my visit with the surgeon left me convinced that a knee arthroscopy was inevitable and that an ACL allograft repair was a significant probability. Either way, I would burn through my $2,000 deductible in an instant so the $400 MRI would not save me any money and I did not want to upset the surgeon that would do the arthroscopy.

    To continue the story, I got a second opinion after I got the MRI (that cost me $40 copay and $1.50 in parking) and it became quite clear that the arthroscopy would not change anything that I cared about. This itself saved the insurance company a great deal of money not to mention that the ACL allograft would have cost over $30,000 and has a one year long recovery and rehab period for me.

    Once again, the message is: Anyone who doesn’t ALWAYS get a second opinion prior to any surgery should have their head examined.

  17. Adrain, I gotta ask: did you not pay $400 because by paying cash, you would have rendered the service and its cost invisible to your insurer, and therefore to the calculation of your deductible? This is where insurers hose both themselves (by paying more than they need to) and the patient. Is it that the “negotiated rate” is grease for the providers? Is it that insurers are, to put it bluntly, dumb? I suspect it’s more the former than the latter, but I’d like to know for sure.

  18. Transparency – in care, in costs of care, in access to data across the healthcare landscape – does not yet exist. Data transparency might, or might not, enable cost transparency. Why? Because care and the cost of that care are still siloed within EHR systems.

    I see the zany humor in the fact that health IT grew out of the drive to automate medical billing. Oh, the irony. But we’re still left in the dark almost 100% of the time – patients, clinicians, even payers – because all the information is siloed. Getting access to all the data on your last hospitalization is terrific. Yet that care data will have no information on what that care costs, how much your insurer will pay, and how much you’ll be responsible for.

    BlueButton+ as a data-access protocol is terrific. But, since it was created by the VA, it wasn’t created with cost-reporting to the end-user(s) – patients, doctors, caregivers, even payers – as a top-of-line result of hitting that blue button.

    That said, I’m not feeling too “shiny happy people” about the big players in hospital EHR tech development banding together in CommonWell. It still seems that they’re focused on keeping their customers – big health systems – happy, with patients expected to sit down, speak only when spoken to, and be grateful for whatever they get.

  19. John, I think you’re making my point. The reason pricing is bizantine is because the patient can’t walk to someone who does post pricing and the doctor can’t suggest that the patient walk because they don’t have the prices either.

    I recently needed a knee MRI. Because of my $2,000 deductible, it cost me $1,400 out od pocket. Having started a radiology company some years ago, I know perfectly well that I could have paid $400 cash to get the same knee MRI by just calling around. This is not mysterious. In France, I believe the _average_ price of an MRI is $400. The difference in the US is that the doctor doesn’t know and doesn’t seem to care that this order cost me $900 and that neither of us could do much about it.

    Starting 2014, the doctor could be sending me the signed MRI order as a Direct message. My software could be looking up price and availability of an MRI in Boston and sending the doctor and me a reply as a Direct message within 10 seconds or so. That’s what Kayak does before I buy an airline ticket. The doctor will get this information in his EHR and my health record as a Direct message. Easy!

    Furthermore, with Blue Button+, my doctor and I could then decide which radiologist or the surgeon himself would be reading the MRI.

    I want to be treated as an individual in a market that treats me as a customer and I want my doctors to have the tools they need to act as my advocate. From the simple perspective of ONC policy on interoperability, this is all doable under Stage 2 and they just need to make it so. If they do, the market failures will not be laid at their doorstep.

  20. Adrian, you say, ” They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing.”

    Yet the recent TIME article on pricing demonstrated that pricing is something that is set by an archaic price list that has no rationalization or justification. And that if you simply hire an expert advocate, you can often negotiate on that pricing downward (if you’re paying full list price).

    Even if such price lists were made readily available (and nothing in Blue Button+ would do that, no?), we’re still dealing with an incredibly inflated price list — or pricing that varies widely by the kind of insurance you’re covered by — by a set of companies who have no incentive to change the way they do business today.

    EHRs — open or otherwise — as far as I can tell aren’t going to change the fundamental pricing problems in our system.

  21. CommonWell, I believe, is 12 to 18 months away. Blue Button+ is being defined today in an open process that the architects of CommonWell know well. athenahealth would be most welcome.

    I have met Jonathan Bush many times and he is one of the most delightful folks in the industry. I look forward to his thoughts on transparency and the role of lock-in as a contributor to extreme pricing in the US. Billing, after all, is at the core of athenahealth business model and value proposition.

    Does athenahealth have data that relates to the point I’m making in this post?

  22. I have said it before and I imagine I’ll say it again, many times: anyone who thinks athenahealth (where I work) would be involved with an effort to lock in information, increase costs, and perpetuate vendor-controlled IT silos has never met our CEO, Jonathan Bush. I don’t blame Mr. Gropper for his cynical first take in Commonwell. The HIT industry certainly hasn’t covered itself in any measure of glory when it comes to establishing the infrastructure for true information liquidity in healthcare. And the characteristics Gropper ascribes to Commonwell certainly do exist in our industry. But he is wrong in his idea of what CommonWell is all about. athena’s vision, since day one, has been “an information backbone that allows healthcare to work as it should.” We view CommonWell as a step toward achieving that vision. Mr. Gropper apparently sees it as an impediment to the same end. Only time and results will prove us right and him wrong.