Telemedicine

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

5 ways technology makes behavioral health care better

Are you old enough to remember the pre-concert security searches for recording devices that were once part of every live music experience? Yes, musicians once had some semblance of control over bootleg audio and video.

But the proliferation of tiny hand-held computers that happen to also make phone calls ended all that. Now, tossing music-lovers who pull out a phone to record would empty entire arenas save a few luddites with flip phones and mullets.

Sometimes silently, other times with great fanfare, technology has wormed its way into almost every aspect of life. Much has been written about the use of electronic health records in healthcare, for example, but EHRs are just one example.

In behavioral health, EHR adoption lacks financial incentives so the rate of adoption has lagged that of acute care. And still technology creeps into the way we provide behavioral health care, in many ways transforming and often improving treatment, compliance and reporting.

One could argue that the potential for positive disruption is greater in behavioral health than in any other subset of medicine and healthcare. So how, exactly, is technology upsetting the behavioral health apple cart in beneficial ways?

  1. Improving correlation of health information: There is a strong likelihood that a patient with bipolar disorder or a similar affliction is also self-medicating with drugs and alcohol. Sure, a caregiver somewhere along the way might notice the physical signs of abuse, but they also might not. A comprehensive EHR that includes patient data from coordinated providers would provide that information, just as it would when the bipolar patient shows up at the ER with a broken arm.

    According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes. Therapists might sometimes have the luxury of just treating a mental illness, but around half the time they will also be working with an addiction problem and must aware of both.

  2. Making care available outside urban areas: The numbers suggest mental health counselors are jockeying for clients in urban areas and scrambling to meet overwhelming demand in rural sections of the country. Rates of alcoholism, opiate abuse and generally risky behavior are higher outside of major cities, creating a burgeoning healthcare crisis in the parts of the economy oriented around agriculture and energy.

    With few promising alternatives, much of the push to resolve America’s rural health conundrum is now focused on telehealth, and with good reason. Telehealth has proven effective thus far in treating depression and PTSD. According to a 2012 Institute of Medicine report, telehealth also increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. 

  3. Boosting the bottom line: A comprehensive EHR combined with robust revenue cycle tools and services ensures that behavioral health care providers are compensated more reliably for the care they provide.

    “An EMR is an investment because it provides long-term benefits and may be an important tool for reducing the cost of expenses,” writes Carol Turso in Behavioral Healthcare.

    Turso uses the example of a social services organization that over three years after implementing an EHR reduced bad debt by 93 percent, lowered outstanding accounts receivable of more than 151 days from 24 to 9 percent, and trimmed the time staff spent per week entering remittances and payments from 40 hours to 10 minutes. In every instance, these EHR benefits improve the organization’s bottom line. Even if they don’t technically create new revenue, they are still financially relevant.

  4. Enabling self-directed care: At its core, self-directed care is empowerment focused on dealing with pain and frustration, getting regular exercise, eating well and communicating with counselors and family. Self-directed care engages the patient more fully in the care process, even in some instances allowing patients input on how and where to spend the money applied to their treatment.

    In recent years, the self-directed care model has gained more currency in the provision of behavioral health care. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, technology, especially mobile phones, offers support and assistance. 

  5. Giving kids something to do: Do mobile devices keep kids off drugs? The jury is still out, but it’s one explanation for a steady downward trend over the last decade of teenagers experimenting with drugs and alcohol. Correlation, of course, is not causation, which is why the National Institute on Drug Abuse plans to make this the subject of a study over the next several months.

    While many teenagers seem as addicted to mobile phones as they might be to marijuana, parents will probably rest easier knowing the former might be preventing the latter.

The proliferation of technology, especially in healthcare, is something that must be monitored over time and re-evaluated regularly. As some healthcare economists have pointed out, technology drives up healthcare costs more than any other factor.

But behavioral health, specifically, will never have to invest in massively expensive tools like MRI machines, creating an opportunity for the grassroots use of relatively affordable handheld and desktop technology that over time can affect measurable change in the lives of patients.  

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Cures Act: A bag of holiday gifts for healthcare

On Tuesday, President Obama signed the 21st Century Cures Act, codifying a broad and far-reaching effort to achieve medical breakthroughs in Alzheimer’s and other debilitating afflictions through improved, streamlined, well-funded research.

The Cures Act gives particular attention to cancer and Vice President Joe Biden’s Cancer Moonshot initiative, which hopes to transform research and make certain varieties of the illness either manageable or history.

“God willing, this bill will literally, not figuratively, literally save lives,” Biden said at the signing ceremony. “But most of all what it does … is gives millions of Americans hope. There’s probably not a one of you in this audience or anyone listening to this who hasn’t had a family member or friend or someone touched by cancer.”

The Cancer Moonshot illustrates well how most of the Cures Act focuses on research and additional funding for the National Institutes of Health and similar agencies. But it also focuses on bettering the current provision of healthcare by improving behavioral health care and healthcare IT.

Viewed from a high level, Congress is focused on stemming the tide of mental illness and opioid addiction in America, as well as making sure healthcare information flows freely and safely among providers to improve patient care. Read on for highlights.

Mental Illness and Addiction

Via the specific proposals below, the Cures Act endeavors to better fund mental health care and opiate addiction, improve leadership and planning, ramp up research, enforce parity and improve preparedness among police and in the legal system.

  • Over the next two years, the Cures Act provides $1 billion in state grants for opioid abuse prevention and treatment. Specific parts of the proposal include prescription drug monitoring, healthcare provider training and better access to treatment programs. Indeed, block grants to state agencies are clearly aimed at helping individuals break out of the addiction cycle that so often includes homelessness and limited family support.
  • Grants will also go to higher education and professional training programs to put more mental health professionals in the field.
  • The Act also creates new positions—an assistant secretary for mental health and substance use, and a chief medical officer—in the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Apparently not a sanctioned SAMHSA component previously, the Center for Behavioral Health Statistics and Quality is now codified in the Cures Act, as is the requirement that SAMHSA create a strategic plan every four years to identify priorities and strengthen the mental health workforce.
  • Mostly through reauthorizations, the Cures Act provides funds for mental health programs that pay specific attention to some vulnerable populations: college students, women and children.
  • Mental health parity, already a law but sometimes inadequately enforced, will become more of a focus for HHS, which is being asked to draw up a federal and state compliance action plan.

Healthcare IT

While there are efforts in the Cures Act to improve the functionality of EHRs and access to records for patients, the real focus is on improving the flow of information.

  • Apparently fed up with allegations of information blocking, Congress included in the Cures Act $15 million in funding for improved interoperability and less information blocking. Some of the money will support a voluntary framework for information exchange and some will go to HHS to investigate claims of information blocking and punish the blockers to the tune of $1 million per violation. The Government Accounting Office is also required to evaluate patient access to personal health information and why it might sometimes be difficult to get.
  • Congress is also requiring HHS to change the terms of Meaningful Use to include interoperability. Moving forward, healthcare IT vendors must develop application programming interfaces (APIs) and apply real-world tests of interoperability to EHR systems.
  • If the Cures Act has a measurable impact, EHRs will become more patient-centric. Incorporated language speaks to making patient records more simple and easier to use, and continuing to grow Health Information Exchanges (HIEs) to expand patient access to care.
  • A new HIT Advisory Committee will make recommendations to the national coordinator on a host of healthcare IT concerns. Of particular interest will be the segmentation of data so that only select parts of a patient record can be shared and sensitive data related to mental illness and drug addiction can be closely controlled.
  • The Advisory Committee will also have the authority to make recommendations on population health, healthcare for children, telemedicine and other potential improvements to healthcare available through IT.

At nearly 1000 pages, the Cures Act obviously includes much more than the greatest hits included here. The curious might visit this highlights document and find specific objectives that perhaps are more relevant and important.

As with all federal legislation, efficacy is measured by impact over time, not number of pages or total appropriations. With the Cures Act, we can hope that the grant money will make a significant difference at the local level and that patient health information will flow more freely between coordinated providers. A cancer breakthrough wouldn’t hurt, either.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

WSJ: Medsphere chairman talks new health IT and barriers to acceptance

Few if any physicians, administrators or policy experts have more experience in the American healthcare arena than Kenneth W. Kizer, MD. The Medsphere chairman and director of the Institute for Population Health Improvement at UC Davis has served as the top health official for California and undersecretary of health for the VA. Kizer was also the founding president and chief executive for the National Quality Forum, which focuses on healthcare performance measures and quality standards.

Kizer recently had a conversation with Laura Landro of the Wall Street Journal on population health, healthcare IT and barriers to adoption of various technologies. Included below are some of the interview highlights. Click the link at the bottom to access the full WSJ article.

What is population health?

“The term population health was introduced about a decade ago to recognize the important role that factors other than health care have in determining health outcomes … Many people are surprised to learn that these social determinants of health have more to do with reducing preventable deaths and improving population health than health care itself.”

How does technology improve population health?

“Many of the new information and communication technologies have begun to be used in health care in recent years …These new technologies necessitate that we fundamentally redefine what access to health care means, since access is no longer only about face-to-face visits. Information can now be exchanged between caregivers and patients in multiple ways, which means we can design innovative ways to tailor health care to someone’s individual needs and lifestyle. The stage is set for a virtual-care revolution … These technologies also can help overcome transportation, language and other access barriers to health care for rural and inner-city populations.”

What keeps that technology from being effective?

“Perhaps at the top of the list is health care’s conservative culture, which is notoriously slow to embrace new ways of doing things, followed by lack of health-insurance payment for most virtual-care methods. Lack of payment can undermine an effective method of virtual care by making it economically nonviable … Additional barriers to virtual care include lack of infrastructure—both technological and in terms of personnel—concerns about data accuracy and reliability, especially for wearable devices, and interoperability problems among technologies, which tend to complicate collecting and analyzing the data … Overcoming these barriers will require concerted collaboration between government, health-care providers and technology vendors.”

How does technology integrate care?

“New virtual-care technologies such as health-information exchanges allow providers in different health systems to quickly and securely share information—for example, about medications, allergies or lab tests.”

How can technology and digital patient data improve outcomes in patient populations?

“Social media can be used to track infectious-disease outbreaks such as influenza and food-borne illnesses. Online immunization registries and portals can help parents and schools ensure children are appropriately vaccinated. Electronic health records can be especially useful for identifying patients who need close monitoring or extra effort to avoid emergency visits and hospitalizations. Linking electronic health records with other virtual-care technologies is being used to support new models of care like community paramedicine, in which paramedics provide home health checks or other basic services.”

Click on Wall Street Journal to read the entire excerpt from the conversation between Dr. Kizer and the Journal’s Laura Landro. 

Is telemedicine the key to making addiction treatment work?

In a world where only the wealthy suffered from addiction, we wouldn’t have to worry so much about the effectiveness of treatment or who was going to pay for it.

But most people don’t live in Malibu or have access to Betty Ford, so efficacy matters.

Especially to insurance organizations, including the federal government, which have become increasingly more hesitant in recent years to pay for inpatient addiction treatment when it seems no one can demonstrate what actually works.

“Substance abuse providers generally have insufficient data to demonstrate the effectiveness of their treatments,” writes Health Data Management reporter Joe Goedert. “As a result, insurers are becoming highly distrustful of addiction treatment; and reimbursement amounts are falling as payers start to move to value-based contracting.”

The use of telehealth and telemedicine to track the effectiveness of treatment among those plagued by addiction is only the most recent trend in remote patient care. According to the American Telemedicine Association, about half of all states have passed laws mandating coverage by insurers of telemedical services. The legislation could prove useful to insurance companies and CMS if telemedicine provides better data on what works in treating addiction.

Map Health Management, a data analytics firm focused on behavioral health and addiction treatment, is working with insurers to determine effective treatment modalities and identify care providers that effectively maintain a relationship with patients after they leave the hospital. Telehealth / telemedicine offers a tool that both enables these efforts and makes them cost effective.

According to Map Health Management CEO Jacob Levenson, the effective use of telehealth technologies may be so important to effective addition treatment in the future that they become the dividing line between failure and success for providers.

“Some 30 percent to 40 percent of providers may not be in business within five years because they can’t adapt,” Levenson told Health Data Management.

Telehealth is one component in an innovative opioid treatment research project being conducted in Washington, DC. In a departure from the norm, the program is oriented around the practice of Edwin Chapman, MD, in partnership with Howard University’s Urban Health Initiative.

In this impoverished corner of the nation’s capital, Dr. Chapman’s patients in the study average 52 years of age and 10 years of incarceration. About 60 percent live with hepatitis C, 10 percent are HIV positive and all are long-term users of opioids, primarily heroin.

Chapman’s experience showed him that the opioid replacement buprenorphine effectively stabilized his patients’ addiction issues enough that they could face other life challenges so long as they had access to comprehensive care, including psychiatric services. While access to the opioid replacement was available, care and counseling were not.

So Chapman and Howard Professor Chiledum Ahaghotu, M.D., worked together to create the Buprenorphine Integrated Care Delivery Project model.

“I was looking to improve care for vulnerable populations, and to avoid an overutilization of [high-cost] resources,” such as emergency care, says Ahaghotu.

Thus, the project incorporates three essential components:

  • Comprehensive care coordinators work closely with both primary care and behavioral health providers to help develop patient-centered care plans.
  • A shared electronic health record platform across all providers delivers services to the patient. Patients consent to share their health data with various providers.
  • A telehealth program allows Chapman's patients to see him as well as a behavioral health specialist during the same office visit.

The entire project is funded by a four-year grant from Washington, DC’s, department of health and aims to reduce the cost of addiction treatment, which generally costs Medicaid roughly five times that of a typical Medicaid patient.

If the DC project and others like it prove effective in reducing incidences of drug relapse and lowering costs of treatment, you can be sure that the federal government and private insurers will notice and implement policies aligned with what works. Evidence suggests telehealth and telemedicine solutions will be a part of that overall solution. 

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

FHIR will not save us. We need national patient identifiers.

Graham Grieve is a data architect who thinks like a mountain climber.

“You build a mountain, you stand on top of it and see a bigger mountain that you can go and stand on top of,” Grieve said in an interview with HIStalk. “The urgent need to build bigger mountains never goes away. We’ll just keep climbing up the stack towards a useful system.”

Setting aside the idea of “building” mountains, Grieve is describing something very familiar to seasoned hikers and climbers—a false summit. When you are so close to the mountain, and we are all so very close to health IT and the constant interoperability updates, it’s impossible to see the higher peaks in the distance.

Which begs the question: When will we summit this range?

“Each mountain is about a 10 to 15 year building process,” Grieve says. “That’s how it has gone historically.”

In other words, we probably can’t even see the next peak from where we’re standing, the initial false summit still looming above us.

In his conversation with Mr. HIStalk, Grieve makes a compelling argument for modifying expectations, working diligently and putting all the pieces in place to ensure future success.

For example, Grieve is working on HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification enabling EHRs to exchange information. If you’re one of the many that hope FHIR becomes healthcare’s silver bullet, Grieve would like you to rethink that expectation.

“There’s people out there who think that with FHIR we’ve solved all the problems,” he says. “We haven’t, because we’re not authorized to solve lots of the problems.”

Primary among these other problems is the lack of a single patient identifier via a Master Patient Index (MPI) for use across the American healthcare system. Quite simply, FHIR alone is not a fix.

“Yup. MPI is unavoidable,” Grieve told Forbes blogger and author Dan Munro, whose analysis of interoperability and MPI is highly valuable and relevant (see, for example, automobile industry reference and link below). 

And why don’t we have MPI in place already? Because in 1998, long before interoperability approached Kardashian-like frequency on the Internet, Congress passed and President Clinton signed a law forbidding federal funding of any effort to create national patient identifiers. This was two years after Congress mandated the creation of a patient identifier when they passed HIPAA.

(Staying with the mountain metaphor, one might believe the two years between legislative acts were the peak of health IT lobbying and campaign contributions.)

As we all know, incentives for EHR adoption have expanded the use of health IT platforms to somewhere in the neighborhood of 75 percent. But with few standards for exchanging patient data, we’ve created silos of patient information and a system that still benefits just about everyone in it more than the patient. Health IT vendors have enriched themselves with tax dollars. Hospitals are using EHRs to keep patients from going elsewhere and gobbling up small physician practices. Status quo incentives remain for influential segments of the overall health IT marketplace.

As former hospital CEO and THCB blogger Paul Levy wrote, “We’ve been swindled.”

And it’s not like this kind of situation is completely new. People are not cars, to be sure, but a similar scenario endured until 1981 in the automobile industry. Chaos convinced the National Transportation Safety Administration (NTSA) to implement the national Vehicle Identification Number (VIN) system to more effectively track thefts, accidents, damages and recalls. The use of VIN numbers also makes businesses like CARFAX possible.

It’s clear that VIN numbers enabled the NTSA to more actively and accurately track the sale and registration of autos. It’s also clear that automakers had no financial incentive to resist the national standard other than to avoid accurate tracking of defects that could put driver safety at risk, making VIN implementation as much a moral issue as anything else.

National schemes? A moral component? Congressional discretion? That scenario should sound familiar to you.

Indeed, as quoted in Bob Wachter’s book The Digital Doctor, UCSF Medical Center CIO Michael Blum called Congress’s failure to establish a universal patient ID “the biggest single failure in the history of health IT legislation.”

“Our national interest does not coincide with those corporate strategic interests,” says Levy.

In other words, what patients lack is an organized lobby, which is unfortunate since it seems that all roads on the health IT progress roadmap eventually lead back to Congress.

“There’s a number of industries where they have data sharing arrangements of one kind or another,” says Grieve. “Those things are possible and they work to some degree. They need some kind of governmental interference or mandate to make them happen. Very often, most of those industries wouldn’t go back to the chaos they had before.”

This is disconcerting. On the one hand, the current Congress is passing legislation like the 21st Century Cures Act that mandates interoperability without mandating a certain standard. On the other, a previous Congress avoided the responsibility of creating the prerequisite for interoperability in a national patient identifier.

“Standards arise in a broken market,” Grieve told HIStalk. “We’re trying to move the market to a better, stable place.”

We have one prerequisite—a broken market. We need Congress to implement the other—a national identifier. Yes, an adoptable data exchange standard like FHIR is necessary, but without a national patient identifier it is not sufficient. Until then, every goal we achieve in the foreseeable future will be a false summit. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Are jackalopes and information blocking similar?

Looking to dupe urbanite travelers, bartenders and bar owners in rural Western taverns sometimes fasten antelope horns to the head of a large jackrabbit. They then mount the whole thing, hang it over the bar and tell visitors looking for a craft brewed IPA to watch for vicious jackalopes when they’re out and about.

So, are we having a jackalope moment in health IT? Do we believe in something we can’t see?

The suggestion has been made that some vendors are actively engaged in “information blocking”—a basic refusal to exchange patient data with other systems. Either that or they’re charging boatloads of money to do so, which is framed as a form of information blocking in a way, but not exactly.

The anecdotes, claims and counterclaims about information blocking are flying.

A vice president from Athenahealth says some vendors are charging $1 million to build an interface, a half million to maintain it and $2 every time a doctor uses it to send data. An Epic vice president says they don’t ever engage in information blocking activities “if they exist at all.” (Honestly, with recent news about EHR costs at Partners, who wouldn’t look askance at Epic?)

Congress certainly believes information blocking exists. The 21st Century Cures act, recently approved via unanimous vote in the House Energy and Commerce Committee, makes “information blocking” a federal offense and would fine doctors, hospitals and health IT vendors $10,000 for each offense.

Karen DeSalvo, the national coordinator for health information technology, believes it exists. “We have received many complaints of information blocking,” she recently told the New York Times. “We are becoming increasingly concerned about these practices.”

And there’s enough anecdotal evidence to suggest the practice is actually happening, though the causes, frequency and motivations regarding information blocking remain unclear.

“In 2014, ONC received approximately 60 unsolicited reports of potential information blocking,” ONC stated in an April 2015 report to Congress. “In addition, ONC staff reviewed many additional anecdotes and accounts of potential information blocking found in various public records and testimony, industry analyses, trade and public news media, and other sources.”

And this sleuthing revealed that “Most complaints of information blocking are directed at health IT developers.”

“Many of these complaints allege that developers charge fees that make it cost-prohibitive for most customers to send, receive, or export electronic health information stored in EHRs, or to establish interfaces that enable such information to be exchanged with other providers, persons, or entities,” the ONC report to Congress continues. “Some EHR developers allegedly charge a substantial per-transaction fee each time a user sends, receives, or searches for (or ‘queries’) a patient’s electronic health information.”

This is also not a surprise. Businesses exist to externalize costs and increase revenue. The role of government is to act as a watchdog on industry, assuming it usually won’t manage itself. Yes, government can create excessive regulations that get in the way of innovation, but the argument here is for balance and restraint, not wholesale retreat.

And if there is one thing about health IT we can probably all agree on, it is that balance and restraint have not been achieved. We probably can’t even see it from where we’re standing.

“Every technology has an adoption journey,” wrote John Halamka on his personal blog. Among other titles, Halamka is CIO of the CareGroup Health System, CIO and Dean for Technology at Harvard Medical School and a practicing emergency physician. “The classic Gartner hype curve travels from a Technology Trigger to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.”

As you may have guessed, health IT is in the Trough.

“It was a five-year project and we're just at the beginning of where we're supposed to be. We're on course. It's all OK,” Halamka said in an interview with HealthLeaders Media. “It's not information blocking. It's not HIT vendors being reluctant or hospitals holding their data hostage. If the definition of information blocking is that the vendors have all hired Chief Information Blocking Officers who spend their nights thinking about ways to restrict information flow, I've never seen it. Find me one example.”

In fact, ONC seems to have found quite a few. And they are not, to be clear, using the hiring of a “Chief Information Blocking Officer” as a working definition.

We know that the technology exists to interoperate and share patient records because other industries do this kind of thing in their sleep. We know that the incentives and / or regulations are not there yet to force real, active, collaborative interoperability.

So, it seems we have two choices: Congress can pass regulations to enforce certain industry behavior, which some members are working towards, or we can wait for the market to spawn an upstart that finds a way to succeed without blocking information and / or charging outrageous fees. Or both.

Halamka may be sanguine about the existence of information blocking, but on this we part ways. I’m not convinced that Nessy exists, that Bigfoot wanders the Pacific Northwest, or that rabbits sprout horns. I do believe, however, that corporations will test the limits of federal regulations, putting the onus on Washington, DC, to find balance.

Oh, and if you’re ever in a bar with a jackalope hanging on the wall, don’t order the Rocky Mountain oysters. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Telemedicine, Security
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