Public HIE’s – Leave No Doc Behind

Who's going to fill this space? (image courtesy of thsa.org)

A common and unfortunate trend in the Health IT community is a discursive lowering of public HIE’s to a sort of second class status. The thinking is that government funded HIE’s are not sustainable, and therefore not important because they probably won’t be around to exchange your grandkids’ data. Enterprise HIE’s are sexy, evoking visions of big name delivery systems and big name vendors throwing piles of money into the air as they eat caviar and discuss monetization of analytics or value-add services like e-prescribing and EMR-lite. Public HIE’s, on the other hand, are working to implement the most basic of functionality. And of course, whenever project Direct comes up, any organization who admits to putting faith in it becomes a laughingstock. “It’s nothing more than a fax machine.”

Well like it or not, some folks out there still can’t fax. I had the chance to sit in on a call today that changed my mind about the usefulness of the hundreds of Public HIEs struggling to get up and running across the country. I sat in on a public call by the Texas Health Services Authority, who serves as a local coordinator of HIE services and is based out of my new hometown, Austin. The call was to discuss the state of provider and consumer engagement initiatives as they relate to promoting information exchange across the state. In case you didn’t know, Texas is kind of big, so you can imagine the scope of these efforts.

5 New HIEs are being implemented after successfully undergoing the review process of their strategic business/operations plans. There is a massive “white space” initiative that aims to bring some level of connectivity (currently clinical care summaries and lab results as they’re defined in the Meaningful Use program) into the areas of the state where there is none. 5 Health Information Services Providers (HISPS…but let’s just call them vendors) have been approved for that effort, and they receive a $400/$5000 voucher for every provider/hospital they help plug in. In terms of consumer engagement, they’re redesigning the website to help local patients understand exactly what HIE is all about.

The CEO of the Healthcare Access San Antonio (HASA) was also on the call to share their progress there. I found it interesting that the biggest challenges they face aren’t coming up with sustainability models, or facilitating advanced clinical analytics capabilities as an incentive ‘value-add’ for hospitals to join. Rather, it’s simply getting doctors to pick up the phone. How are these organizations spending money? On brochures and website redesign to convince local pharmacies and doctors offices that they ought to be sending their basic scripts and meds data electronically to a website.

Brochures and Websites? To all the public HIE detractors out there, I’ll admit that this work is not sexy. It’s not revolutionary. But it’s very important. While the enterprise HIE’s of the world are training for marathons, the rest of the country is just trying to get moving. As a Health IT community, we should be encouraging these efforts rather than ignoring them. Have you visited your local REC website or looked into which organizations are working on basic adoption? Give it a spin. I’m looking forward to working with the THSA folks over the coming months to do what I can to help them engage consumers and providers. One thing HASA’s CEO said stuck with me: In talking about the importance of a good website, he said, “If we’re promoting technology in healthcare, then we need to be using it to communicate.” Given that I found out about THSA on Twitter, it seems like they’re on the right track.

 

HIMSS 2012

Note to Vendors: Consumer-centric does not mean Cars and Candy

I spent all of last week at the annual HIMSS meeting – the biggest Health IT conference on the planet. This year didn’t fail to deliver, with over 37,000 attendees joining the fray. It was held in Las Vegas at the Sands Expo Center, and the conference definitely kept up with the glitz and glam of it’s location: The opening keynote by Twitter co-founder Biz Stone was preceded by a classical violin player and half-naked gymnast trio. Theatrics aside, the sales floor was mobbed with thousands of vendors, and panel sessions tended to focus on either very specific groups or very general audiences. Here are some highlights of my week:

• Attending half a dozen meetings with high level execs from health information exchange vendors on behalf of Chilmark Research. Understanding their platform and service offerings is important to the work, but talking strategy with them in a market like today’s is fascinating.
• A nice speech by Aetna’s CEO about health reform and Aetna’s strategy moving forward. As a big national payer, they’ve shown a big push forward this year in their diversification strategy, both on the enterprise side (acquiring HIE vendor Medicity last year) and the soon to be announced iTriage deal on the consumer/mobile side.
• Ghostbar. ’nuff said (see picture below)
• A cool session by HIMSS Patient-Centered Payer Roundtable, which I am planning to help staff as a volunteer in 2012. They had four folks: a patient, a case manager, a physician, and an insurance executive. All of them offered a turn-by-turn explanation of the care model from their view as it related to one family’s complex health needs. I can safely say it’s the coolest thing I’ve seen come out of New Jersey since Bon Jovi’s last hit.

A few notes on topical trends of the conference:

• The general confusion related to Accountable Care Organizations was palpable, somehow. Broadly speaking, I think this is based on a lot of confusion in the healthcare trenches with exactly how to move forward on a changing list of priorities. As a small example, within a week’s time, it was announced that the ICD-10 conversion would be delayed, and that the Stage 2 Meaningful Use regs would be announced. The timing of these isn’t the point per se, but the seemingly month-to-month reprioritization of huge, expensive and complicated technological transitions is. With ‘accountable care’ still being touted as the care model of tomorrow, providers and vendors are seemingly happy to procrastinate a little bit.
• This was not a conference about the consumer. Despite the above panel sessions by HIMSS to try and loop it back around to effective, coordinated care, this is ultimately a trade show where business cards are exchanged, deals are announced, and money is spent on sales and marketing assaults on the hapless attendees. While I definitely benefited from a sponsored afterparty or two, seeing some tech aimed at individuals, or having a more prominent venue for patient voices would have been nice. There’s a good chance I just missed the specific events in all of the hubbub and the busy schedule, too.
• The latest announcement by Microsoft and GE to join healthcare IT forces (a.k.a. “Caradigm”) was met with a variety of responses by other vendors: jeering (the corny name), skepticism (the viability of technical/business integration) and unease (potential market share and collective resources). This one will be an interesting development to follow.

Viva Las Vegas

Health Plans and Health Information Exchange

Check out some of my thoughts on how health insurance companies are approaching the emerging market of health information exchange. It’s a two part post, with a few different strategies outlined, organized by how big the health plan is. In a nutshell, I hypothesize that the big national plans are going to make enterprise technology acquisitions to really diversify their businesses, while local health plans will rely on partnerships and local networks to get involved.

• Part One
• Part Two

Mark Bertolini at HIMSS

Mark Bertolini, Aetna’s CEO, gave a nice talk this afternoon. The victim of a bad ski accident that left him with neuropathy, a fractured neck and a still immobilized left shoulder,Bertolini is also a father to a son with a rare genetic disorder, to whom he has also donated a kidney. He’s also one of the few Fortune100 CEO’s who tweets. He covered the challenges of healthcare reform in today’s environment, as well as introduced Aetna’s latest foray into consumer healthcare in iTriage. Here are a few of the interesting thoughts that I wrote down:

• The Future of healthcare lies in Uncommon Connections.
• Healthcare to the patient today is like a hockey game: everyone has their own puck.
• Supply and Demand: In 8 years, we’ll have a 90k physician shortage. In 17 years, all baby boomers will be 65 or older.
• Introducing efficiency into our health care system is the only way forward. No Margin, No mission.
• Consumers are becoming more prepared to discuss their health than their doctors are. This is a one-way street: 500 million consumers around the world will be using health care apps in 3 years.
• It’s important to differentiate between “patients” who receive medical procedures and “consumers” who want to fit health more broadly into the rest of their lives. Convenience will be King for the latter.

 

Biz Stone at HIMSS 2012

Biz Stone just gave a keynote at the HIMSS 2012 conference. Here are the high level takeaways from his speech.

Lessons from Biz’s life

• We’re not built for understanding a world of limited information. Einstein said “Info is not knowledge.”  More info is not more knowledge…we need understanding to go with it.
• It’s not a triumph of technology, it’s a triumph of humanity.
• Opportunity can be manufactured.
• Creativity is a renewable resource.
• To succeed spectacularly, be ready to fail spectacularly.
• There is compound interest in altruism. Start now and align yourself with a cause. Over time you will have an impact.

Seven Assumptions

• We can change the world, build a business, and have fun. (You need all three)
• We don’t always know what’s going to happen
• There is a creative solution to any problem
• There are more smart people outside our company
• We will win if we always do the right thing for our users
• The only deal worth doing is a win-win deal
• Your co-workers are smart and they have good intentions

Prove It: The wrinkles of Evidence-Based Policymaking

Can you prove it?

Great article on the growing role that evidence plays in policymaking. Does evidence change minds? Are we shifting as a society and increasing the public demand to know, or are the ‘sellers’ – policymakers, marketers, companies, governments etc., simply responding to a growing call for (and availability of) proof? As the article starts off, historically, policymakers have seen evidence as a marketing gimmick rather than burden of proof.

“There was, [he] argued, a need to examine more thoroughly the evidence on which the proposed legislation was based. “We are looking at publishing the evidence,” replied the Minister, but “in the end, you pick the evidence which backs your argument.”

The idea of evidence-based policymaking vs. policy-based evidencemaking is an interesting one. An added wrinkle is the notion of making policy based on values – what if the evidence disagrees with what you want the law to enforce? Interesting example with everyone’s favorite topic, marijuana:

“Another, and opposite, problem was that the much vaunted commitment to the evidence only went so far. Coaker’s gaffe was just one example. It was a Labour Home Secretary, Alan Johnson, who in 2009 provoked one of the biggest science policy controversies of recent times by sacking an independent expert, Professor David Nutt, from the Advisory Council on the Misuse of Drugs. Nutt’s position was voluntary and unpaid, his job to provide frank and objective policy advice based on his scientific knowledge. Yet when the Professor criticised the government’s decision to recategorise cannabis from a Class C to a Class B drug, and argued that drug classifications should be based solely on the evidence of the harms they cause, the Home Secretary had him removed from the advisory council. Opinion polls indicate strong public opposition to any relaxation of the drug laws, including the downgrading of cannabis. Opponents of decriminalisation insist that heavy penalties are needed, in order to “send a message” that the use of drugs is morally wrong. New Labour’s putative commitment to “what works” was trumped in this case by the need to stay in line with public opinion.”

The piece goes on to discuss the role that ‘evidence’ played in restructuring the UK’s health care delivery system. This was/is a huge deal in the UK – in terms of the level of change they’ve introduced, think Obamacare x 10. When billions of pounds/dollars of government restructuring is at stake, the ‘evidence’ you’re basing it on suddenly comes under more scrutiny.

The role of evidence-based medicine is also at the root of NICE, one of the NHS’ lauded successes in controlling health care costs. In the US, the same idea is affectionately demonized as Death Paneling and Rationing. In the US, our policy is based on values – people have the right to demand as much care as they want. IN the UK, their policy is based on evidence – determine what’s effective based on looking at patients who received the treatment vs. didn’t, how they fared post-treatment, what their demographic and health profile consists of, and dozens of other factors.  Without taking a strong side (both have their pros and cons), suffice it to say, the policymaking framework is quite different.

Final thoughts:

1. I think that generally, the overavailability of evidence is a problem. If you can find some study to back up anything you want, then what’s the point? In grad school epidemiology we learned about the futility of this, using examples about things like the effect of drinking coffee on prostate cancer risks. There seems to be a new study every day. Which one do you trust? On a broader scale, with institutions sponsoring studies that are politically driven, how can policy be truly objective just because it’s based on research?
2. After reading this I haven’t come to a conclusion on whether it’s good that society is trending towards a veneer of accountability based on ‘evidence’ or whether this is just the evolution of marketing. In the TV series Mad Men, there’s a slow shift over the four seasons towards using study-based data to change advertising methods. If that’s a microcosm of what we’re seeing on the broader policymaking front, then consider me a more sober, non-smoking non-lascivious version of Don Draper.

The Evergreen State’s Insurance Rate Hikes

Washington is called ‘the evergreen state.’ The name apparently also applies to the health insurance plans in the state. The state insurance commissioner is trying to make three of the state’s biggest insurers cough up their surplus cash reserves. The way it’s supposed to work under the Affordable Care Act, states can only hike up premiums by a certain percentage each year, which needs to be approved by the state commissioner.

The problem is, while these three companies have been jacking up rates year over year (as any insurance plan in the country probably does), they’ve been stockpiling a collective $2.4B in cash (as any insurance plan in the country probably does). The irony is that these are ‘not-for-profit’ insurers. (Now, I consulted for not-for-profit insurance plans for several years, including one of the plans featured in the story, and despite the easy sarcasm you can come up with, I really do think that we’d all be better off if our health plans weren’t reporting ‘profits’ made from our health to shareholders. But that’s a different story.)

Look at these two graphs, it really tells the whole story:

 

Of course, a healthy health plan needs some levels of reserves in order to cushion against the risk of insuring millions of lives. That’s just how insurance works. What level of surplus or cash reserves is acceptable, however, is a more nuanced question. What the commissioner wants to do is to make health plans dig into those deep pockets before asking beneficiaries to cough up more dough year over year. Alternatively, there’s even the idea being tossed around that those health plans ought to issue refunds. It will be interesting to see how this plays out, because it could easily have national ramifications for non-profits around the country.

The Psychology of Type 2 Diabetes

Fantastic article in the Atlantic. Diabetes is everywhere: in health policy circles, on TV ads, in obesity debates. I’ve teed off on the unfair rap that type 2 diabetics get, but this piece takes it one step further and breaks down the pushes from each group. Diabetes is manageable – it’s just incredibly difficult. Like any other enemy, understanding it is the first step to defeating it – and we’re still making so many incorrect assumptions about peoples’ behavior. Here’s one example from the article:

“Essential public education campaigns also will be needed, starting with one to kill the lie that unhealthy food — also known as junk — is cheaper than healthy food. New York Times Magazine food columnist Mark Bittman demolished the myth of “cheaper” junk food in a September 2011 commentary in the newspaper. He calculated that to feed a family of four at McDonald’s costs a minimum of about $23 — compared to only $14 for a home-roasted chicken with vegetables, salad, and milk, or a mere $9 for canned beans with bacon, green peppers, and onions.

“The real challenge,” said Bittman, “is not ‘I’m too busy to cook.’ In 2010 the average American, regardless of weekly earnings, watched no less than an hour and a half of television per day. The time is there.” The “core problem,” he observed, “is that cooking is defined as work, and fast food is both a pleasure and a crutch.”

Brookings’ Latest on HIE’s

Just finished reading Brookings’ new report on Health Information Exchanges. It’s nothing groundbreaking but there are some good paragraphs in towards the end. It opens up with a seemingly pointless, highfalutin explanation of ‘megatrends’ (it’s Brookings, after all) before delving into the history of a handful of states: Indiana, Massachusetts, New York, Tennessee and California. It closes with a 10,000 foot analysis of health reform, stakeholder discordance and other bumps in the road ahead. And it’s full of really ugly tables made with 16-color palettes and fuzzy fonts.

It’s filed under the “governance studies” genre, so understandably the focus is not on results data or business strategy as much as it is on a softer, leadership and organization-oriented bent. It’s also important to note that by and large the paper focuses on state-level exchanges. Without expressing too much bewilderment about who their target audience for this paper could possibly be, here are some salient takeaways:

• Sometimes, federal money can hurt more than it can help. Particularly with state-level exchanges, organizations that take money lose focus on the single biggest challenge: sustainability, and wind up floundering. There are multiple examples in the paper, from a Tennessee RHIO (CareSpark) that fizzled out to a public-private match arrangement that’s worked in New York state.
• Providers will have to pay from day one in order for the HIE to be sustainable. This is never clearly hammered out by the authors, but if you’re at all familiar with the state of the HIE industry, this should be pretty obvious. What’s a more unique insight here is that coming up with a one-size-fits-all model might not be optimal. Primary data providers are also often primary funders (hospitals). Secondary data providers (clinics, physician networks, etc.) can be expected to pay for access to the information network depending on their size, financial health and other local criteria.
• Payment should be dynamic. Setup fees, subscription fees, membership models, value-added surcharges, grant matching and other arrangements are all discussed – I’d particularly encourage you to read the New York profile to see how creativity can be applied here.
• Organizations aiming for HIE should be intentional about their goals, something that never seems to make the headlines. As with virtually anything, setting a goal is the first step to hitting it. Whether it’s a target percentage of your providers enrolling, a target figure for data sent/received, or more specific quality markers, having a public set of goals would seem like a good idea. This is obviously covered in spades under myriad ACO metrics, but I can’t recall seeing an evaluation framework specifically for HIE. I’m sure ONC’s got something somewhere for grant recipients.
• Sidenote: I still don’t see the controversy about payer involvement with HIE’s – let them use the data and let them pay for it. Their incentive is very simple to understand: quality improvement programs like HEDIS/NCQA can offer health plans billions of dollars each year – just look at the MA Star Ratings payments. There’s a value in supplementing their claims data with provider data so their rates go up and they hit quality benchmark targets. So if you want payers to eventually throw money at an HIE, then it would follow that you invite a representative to sit on your board. If anyone can explain to me what the hangup is, please do so.

Thanks to some generous support from Chilmark Research, I’ll be able to fly out to Las Vegas in a couple of weeks to attend HIMSS12. I’m looking forward to seeing what the HIE chatter is all about. What I’m hoping for is discussion about sustainability (specifics – like payer-funded models) rather than vendor-pushed ‘presentations’ about new value-add layers they’ve tacked on.