The original sin of health records interoperability was the loss of consent in HIPAA. In 2000, when HIPAA (Health Insurance Portability and Accountability Act) first became law, the Internet was hardly a thing in healthcare. The Nationwide Health Information Network (NHIN) was not a thing until 2004. 2009 brought us the HITECH Act and Meaningful Use and 2016 brought the 21st Century Cures Act with “information blocking” as clear evidence of bipartisan frustration. Cures, in 2018, begat TEFCA, the draft Trusted Exchange Framework and Common Agreement. The next update to the draft TEFCA is expected before 2019 which is also the year that Meaningful Use Stage 3 goes into effect.
Over nearly two decades of intense computing growth, the one thing that has remained constant in healthcare interoperability is a strategy built on keeping patient consent out of the solution space. The 2018 TEFCA draft is still designed around HIPAA and ongoing legislative activity in Washington seeks further erosion of patient consent through the elimination of the 42CFR Part 2 protections that currently apply to sensitive health data like behavioral health.
The futility of patient matching without consent parallels the futility of large-scale interoperability without consent. The lack of progress in patient matching was most recently chronicled by Pew through a survey and a Pew-funded RAND report. The Pew survey was extensive and the references cite the significant prior efforts including a 100-expert review by ONC in 2014 and the $1 million CHIME challenge in 2017 that was suspended – clear evidence of futility.
Among many healthcare providers, it’s been long-standing conventional wisdom (CW) that hoarding patient data is an effective business strategy to lock-in patients — “He who holds the data, wins”. However…we’ve never seen any evidence that this actually works…have you?
We’re here to challenge CW. In this article we’ll explore the rationale of “hoarding as business strategy”, review evidence suggesting it’s still prevalent, and suggest 7 reasons why we believe it’s a lousy business strategy:
Data Hoarding Doesn’t Work — It Doesn’t Lock-In Patients or Build Affinity
Convenience is King in Patient Selection of Providers
Loyalty is Declining, Shopping is Increasing
Providers Have a Decreasingly Small “Share” of Patient Data
Providers Don’t Want to Become a Lightning Rod in the “Techlash” Backlash
Hoarding Works Against Public Policy and the Law
Providers, Don’t Fly Blind with Value-Based Care
In the video below, Dr. Harlan Krumholz of Yale University School of Medicine capsulizes the rationale of hoarding as business strategy.
We encourage you to take a minute to listen to Dr. Krumholz, but if you’re in a hurry we’ve abstracted the most relevant portions of his comments:
“The leader of a very major healthcare system said this to me confidentially on the phone… ‘why would we want to make it easy for people to get their health data…we want to keep the patients with us so why wouldn’t we want to make it just a little more difficult for them to leave.’ …I couldn’t believe it a physician health care provider professional explaining to me the philosophy of that health system.”
By KENNETH D. MANDL, MD; DAN GOTTLIEB;
JOSH C. MANDEL, MD
The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”
After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.
Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.
Epic reveals plans for a fifth campus, which is slated to include half a million square feet of office space and pay homage to literary classics like “Charlie and the Chocolate Factory” and “The Wizard of Oz.”
A Setback for MyMedicalRecords
A US District Court rules against MyMedicalRecords in its patent case against Walgreens, Quest Diagnostics, and others. MyMedicalRecords, a company that many label a patent troll, contends its patents covered a method of providing online PHRs in a private, secure way. However, a judge ruled that “the concept of secure record access and management, in the context of personal health records or not, is an age-old idea,” and is therefore abstract.
Despite the setback, I doubt MyMedicalRecords will stop demanding organizations to pay up or risk facing a lawsuit. I predict they’ll make some tweaks to their business plan, such as focusing only on organizations with not-quite-so-deep pockets that are willing to settle without a fight.
What Has $564 million Bought Us?
Sens. Lamar Alexander (R-TN), Richard Burr (R-NC), and Mike Enzi (R-WY) ask the General Accounting Office to review the ONC-funded health information exchanges to determine what exactly the exchanges created with the government’s $564 million in grant money.
It’s a valid concern, given the significant number of providers and regions still lacking electronic exchange capabilities and the millions that have been spent.
Physicians Reject Stage 2 Attestation
Fifty-five percent of physicians say they won’t attest for Stage 2 MU in 2015, according to a SERMO survey of about 2,000 physicians. Respondents cite several reasons for not attesting including financial concerns, difficulty engaging older patients, and lack of software usability.
Given the lackluster Stage 2 attestation numbers so far, the findings are not particularly surprising. It will be interesting to see what CMS and ONC intend to do in the face of the overwhelming evidence that many providers simply don’t think it is worth the effort.
On To Stage 3
The Office of Management and Budget is currently reviewing the proposed Stage 3 MU rules and will likely publish them in February. CMS states that Stage 3 will include changes to the reporting period, timelines, and structure of the program, including a single definition of Meaningful Use. CMS also adds that “these changes will provide a flexible, yet clearer, framework to ensure future sustainability of the EHR program and reduce confusion from multiple stage requirements.”
Can’t wait to see what is included. And, I can’t help but be a little amused that it’s been six years since the passage of the HITECH legislation and we are just now getting a definition for “Meaningful Use.”
Show Me the Money
Allina Health and Health Catalyst sign a $100 million definitive agreement to combine technologies, clinical content, and front-line personnel.
Rush University Medical Center will implement Merge Healthcare’s cardiology PACS.
Healthcare operating system platform provider Par80 closes $10.5 million in Series A funding led by Atlas Ventures, Founder Collective, and CHV Capital.
Health analytics provider Apervita, formerly knowns as Pervasive Health, completes an $18 million Series A round of funding led by GE Ventures and Baird Capital.
Teledermatology provider PocketDerm raises $2.85 million from an undisclosed investor.
Caremerge, developers of a care coordination platform, raises $4 million in a second round of funding. Investors include Cambia Health Solutions, GE Ventures, Arsenal Health, and Ziegler-LinkAge Longevity Fund.
Accenture Tapped to Continue Work on HealthCare.gov
Accenture, the consulting firm that was hired a year ago to fix the troubled HealthCare.Gov insurance exchange, is awarded a five-year, $563 million to continue its work on the federal site. The government hired Accenture Federal Services to repair the online marketplace after dropping its original contractor, CGI Federal.
The long-term contract with Accenture also signals CMS’s acknowledgement that a task as large as HealthCare.Gov is best run with leadership from an experienced, private-sector vendor.
Connecticut HIE Dissolves After Wasting Millions
A former board member for The Health Information Technology Exchange of Connecticut blames management for the failure of the entity, which was tasked to create statewide HIE but dissolved by the legislature last summer. The HITE-CT “wasted” $4.3 million in federal grants over four years “without accomplishing anything,” according to Ellen Andrews, who served as the board’s consumer advocate. State auditors also found deficiencies in state controls, legal problems, and a “need for improvement in management practices and procedures.” The state’s legislature is now developing a new exchange strategy.
Prediction: look for more HIEs to falter this year due to mismanagement and lack of sustainability.
Electronic Prescribing of Controlled Substances on the Rise
Electronic prescribing of controlled substances (EPCS) increased from 1,535 to 52,423 between July 2012 and December 2013, according to a study published in the American Journal of Managed Care. The percentage of pharmacies enabled for EPCS jumped from 13% to 30% during the same period.
The next task: figuring out how to get more than the current one percent of physicians to participate.
ONC Shares Lessons Learned from State HIEs
An ONC report on state HIEs finds that many exchanges lack a critical mass of data and are struggling with data sharing. The case study also found that the technical approaches, services enabled, and use of policy and legislation varied across states; collaboration among HIE participants is critical for success; and states are leveraging a variety of policy and regulatory levers to advance interoperability and data exchange.
CMS Seeks ICD-10 Testers
CMS is seeking approximately 850 volunteers for ICD-10 end-to-end testing in April, according to a CMS bulletin. Volunteers have until January 9to submit applications to participate in the April 26-May 1, 2015 testing week.
Pediatrics Report Increased EHR Use
Seventy-nine percent of pediatricians reported using an EHR in 2012, compared to 58% in 2009, according to a study published in the journal Pediatrics. Only eight percent of physicians say their EHRs include pediatric-specific functionality.
Modernizing Medicine Buys RCM Vendor Aesyntix
EMR developer Modernizing Medicine acquires Aesyntix, a provider of RCM, inventory management, and group purchasing services.
Presumably Modernizing Medicine was most interested in Aesyntix’s RCM component, which may create some concern among Modernizing Medicine’s current RCM partners, which include ADP/AdvancedMD, CareCloud, and Kareo.
Every day CIOs are inundated with buzzword-compliant products – BYOD, Cloud, Instant Messaging, Software as a Service, and Social Networking.
In yesterday’s blog post, I suggested that we are about to enter the “post EHR” era in which the management of data gathered via EHRs will become more important than the clinical-facing functions within EHRs.
Today, I’ll add that we do need to a better job gathering data inside EHRs while at the same time reducing the burden on individual clinicians.
I suggest that BYOD, Cloud, Instant Messaging, Software as a Service and Social Networking can be combined to create “Social Documentation” for Healthcare.
I define “social documentation” as team authored care plans, annotated event descriptions (ranging from acknowledging a test result to writing about the patient’s treatment progress), and process documentation (orders, alerts/reminders) sufficient to support care coordination, compliance/regulatory requirements, and billing.
November 16 marks the deadline for states to submit their plans for establishing a health insurance exchange—or HIX—either on their own or with some level of assistance from the federal government. For those states, a majority, according to Kaiser Family Foundation research, have yet to set up a HIX or develop concrete plans to do so. That’s an uncomfortably tight timeline in which to make some tough decisions.
According to the Supreme Court’s June ruling on the Affordable Care Act, states will no longer forfeit federal funding for Medicaid if they choose not to expand their Medicaid programs to all residents with incomes below 138 percent of the federal poverty level. Nevertheless, they must ensure coverage for an estimated 16 million currently uninsured people with an income between 100 percent and 400 percent of that poverty level. And by October 2013, each state needs to demonstrate that it has a HIX in place that can provide such cover: A user-friendly, one-stop shop for affordable healthcare, or affirmatively state that it intends to participate in the Federal exchange..
A HIX needs to have sufficient scale to support large and balanced risk pools. But there may not be sufficient numbers of uninsured state residents to make the HIX viable, particularly if a state is small, or has an extensive Medicaid program already in place. How will such states attract and sustain enrollment? How will they attract payers?
Typically, payer organizations collect premiums from employers and individuals, process claims, and engage in a variety of case management/disease management activities to encourage the appropriate use of medical resources. If they collect more premiums than claims paid, their medical loss ratio is less than 100% and they earn a profit.
In a world of accountable care organizations and healthcare reform, new reimbursement methods will include global payments to providers, which implies the risk of loss will shift from the payer to hospitals and clinicians. Payers will no longer need their large claims processing staff, nor create complex actuarial models. They’ll become very different organizations.
My prediction is that payers will become the health information exchange and analytics organizations that help hospitals and clinicians manage risk in a world of capitation.
I’ve said before that ACO=HIE+Analytics.
The payers are already making strategic acquisitions to build these new business models
2011 was a year of change and tumult. For a day by day look at the top stories of 2011, check out this impressive chart from the UK Guardian.
It was a year in which the economy sputtered worldwide, the Arab Spring toppled several regimes, and unprecedented acts of nature (severe weather, earthquakes) caused billions in worldwide damage.
What about the world of healthcare IT?
In 2011, Meaningful Use and Certification accelerated healthcare IT adoption and doubled implementation of EHRs throughout the country. Every aspect of the industry was stressed along the way
Vendors were challenged to add the features necessary for certification resulting in some “haste makes waste” lack of usability and workflow integration. GE admitted its faults and should be congratulated for its honesty, since many other vendors had the same problems but did not communicate them.
IT organizations created productivity miracles to meet meaningful use timeframes with limited staff and limited budgets. Many organizations will apply their meaningful use payments to general operations and not IT department budget increases, so the sacrifice of IT staff may remain unrecognized.
Providers had to radically change workflows to accommodate new business processes, resulting in staff turnover and short term frustration.