Saturday, November 23, 2013

What's next for EHRs

On Nov 14, the HIT Policy Committee sent recommendations to the HIT Standards Committee on three key areas for future EHR capability:  query for a patient record, provider directory management, and data portability and migration.  An article on the recommendations can be found here.

These recommendations were the result of many months of deliberation by the Information Exchange Working Group, of which I have the privilege of being Chair.  These three functional capabilities are very important because they address key needs important to health care delivery but that won't be adequately met by the market on its own.

query for a patient record
Meaningful use has approached interoperability in a deliberate and methodical fashion.  Stage 1 focused on adoption of EHRs, and routinizing use of HIE capabilities that already existed in the market (primarily eprescribing and lab results delivery).  Stage 2 took it one step further to move the market to adoption of "push" capabilities among providers and between providers and patients.  The new recommendation on "query" takes the final step to enabling "pull" or "query" functions among providers.  While it will still take many years for the market to create business practices and infrastructure to support seamless inter-connectivity among all providers and patients, the "query" requirement will make EHRs finally fully capable of being the building blocks of that larger interoperability vision.

provider directories
This is mostly a "clean-up" recommendation from Stage 2.  As the HISP market starts to take shape based on the Direct requirements of Stage 2 MU, a clear obstacle to more seamless integration of HISPs is the lack of standards for provider directory transactions -- being able to look up a provider and his/her security credentials from one system to another.  This recommendation will enable one EHR system to discover a provider, their routing address, and their security credentials, and will also enable EHR systems (or standalone provider directories) to respond to such electronic provider directory searches.

data portability and migration
I personally know of someone whose doctor changed EHR systems only to find that the medical records got matched to the wrong patients during the migration.  Imagine the disastrous consequences that could result from such errors!  Current market predictions are that 20-30% of providers will be changing their EHR systems in the next few years, for a variety of reasons.  Data migration -- the ability to transfer data from one EHR to another -- will thus become an increasingly important issue in the market.  As EHR systems and EHR users enhance their ability to apply quality and decision support tools to clinical data, there are important safety and quality risks to having incomplete and/or error-filled data migrations from one system to another.  Data portability refers to the transfer of data from one EHR system to another to support a patient's desire to change physicians, for example.  It is similar in many ways to the data migration need which is why we included this use case in our recommendation.

There is a balance that needs to be struck between the scope and specificity of government regulation, on the one hand, and the strong desire and need for market flexibility and innovation.  We already have examples of where this can go awry.  I believe that these recommendations are judicious in covering only areas that are important to society and that also won't get fixed by the market on its own.

Monday, November 11, 2013

More tales of health care cost and quality

An interesting article in the Wall Street Journal goes through the pros and cons of concierge medicine.  I’ll admit, my view of concierge medicine has been largely negative up until now.  Probably having to do with my being as confused as society is about whether we should treat physicians as if they have a special calling (saint-like) or as if they are business people with special skills (pro athlete-like).  Anyway, this article does convincingly make the case that concierge medicine isn’t just rent-seeking behavior but is actually value-creating in the economist’s sense for some people.  And ironically ObamaCare may have actually shored up the business case for concierge medicine.

The more interesting piece of the article was actually a tangential reference they made to a study from the North Carolina State University.  The study apparently reviewed the expenditures of the patients of a particular concierge practice and found that the longer office visits allowed by the concierge business model led to health improvements which ultimately decreased out-of-pocket payments (presumably through lower utilization of something – office visits?  medications?)!

Now, I realize that there is plenty of literature out there on PCMH savings, but the evidence still seems to be spotty and it’s still unclear from most of the studies whether the savings are net or gross savings, which is important because PCMH requires considerable investment to make the model tick.  And of course there’s the ground-breaking work of the Alternative Quality Contract in Massachusetts, which showed small but significant savings compared with controls, but again, the savings clearly are gross savings, not net of investments by Blue Cross and/or the participating providers.

The intriguing point about the WSJ reference is that the result suggests net value to both patient and provider.  Concierge practices are supposed to improve the quality of care – that’s why people join them.  In terms of who gains what, the common wisdom is that patients benefit through higher quality of care, and providers benefit from higher income.  In this case, both patients and providers seem to have gotten a financial gain -- the patient saved 12% out-of-pocket, and the provider has a profitable business and so is presumably better off than before.  It also seems that not only did quality of care improve, it improved by a lot because it resulted in lower utilization of some type of medical service.  I don’t think the WSJ reporter even had a clue that such a finding would be somewhat of a blockbuster if confirmed.  

I’ve contacted NC State to get a copy of the study – hopefully they’ll respond.