It takes more than money

Just about a year ago I wrote about Britain's Connecting for Health program's privacy policy or, more appropriately, their lack thereof. Their approach at the time can best be described as "opt-NOT" -- patients getting care through the NHS would automatically have their data shared on the "Spine" (the national HIE). No fooling around with the niceties of opt-in vs opt-out -- patients could only opt-out by opting out of getting their care from the publicly-funded health service that they pay dearly for.

The NHS has since backed off from this stance and now allows an opt-out policy. That's still a far cry from the opt-in approach taken by MAeHC, and in the context of a burgeoning US movement toward "personally-controlled" health data management, it's downright archaic.

The latest report is that despite this change in policy, physicians themselves are rebelling against the system: 2/3 of NHS family physicians say that they will boycott data-sharing in the system according to a recent poll (see Family doctors to shun national database of patients' records). In a country where individuals have historically deferred to the government on issues of information access, this is a pretty stunning development.

Our policy in the MAeHC project is to allow patient opt-in, meaning that no information will be made available to other entities without the specific permission of patients. Our current opt-in rate is about 93%.

While an opt-in approach clearly has some short-term risks -- such as, slower adoption of systems by physicians, delays in achieving the benefits of clinical data-sharing -- it provides a firmer foundation for the overall enterprise. In the end, we won't be able to reap the benefits of clinical integration unless we build systems that both patients and clinicians can trust.

Wal-Mart's epiphany

So Wal-Mart is expanding health coverage to more of it's employees -- at least according to a story in today's New York Times. What caught my attention was the description of how they've shifted their view on health benefits -- what were once seen as pure costs are now seen as investments in the work force to improve "presenteeism" and absenteeism and thereby increase overall productivity.

Personally, I'd like to see us get rid of employer-sponsored health insurance, but I recognize that one positive aspect of it is that employers can instill market principles into health care delivery by acting as "smart buyers" of health care services on behalf of their employees. The fact that it's taken Wal-Mart, of all companies, this long to come to the realization that investing in one of their key factors of production just might improve productivity suggests that this "smart buyer" role may not be as compelling as we'd like to think. Maybe Wal-Mart's epiphany will accelerate this type of thinking among other employers.

Now, if we could just get Wal-Mart to invest in technology upgrades for their health care delivery supply chain, we might make better progress on the health IT front.....

Uh-oh....

I hope my Board doesn't read Computerworld:
"Whole Foods to restrict online postings by execs after CEO brouhaha"

Yet another plug I should have made.....

OK, so I'm still catching up. There's another shout-out that I keep meaning to make. The Partnership for Healthcare Excellence launched their website a couple of weeks ago. If you live in Massachusetts and haven't heard of them yet, you will soon.

Every Health Economics 101 class begins with a description of the basic tenets of competitive markets (many suppliers and demanders, homogeneity of products and services, full information, yada yada yada). The class then goes on to show how the health care delivery sector violates every tenet.

Health care markets deviate from the theoretical definition in a few ways. For example, consumers don't have enough incentive to worry about value-for-money (because insurance shields them from transaction prices), and they depend on their suppliers (ie, medical professionals) to tell them what services they need. Some of this deviation is structural -- the health care market is never going to operate like the auto or cereal industries because the stakes are too high and the services are too complex.

There is now a push for more tranparency in health care, which is edging the entire industry toward performance measurement and public reporting. The Massachusetts Health Quality Partners is one of the country's leading efforts in this area, the Massachusetts Quality and Cost Council is gearing up for more public reporting, and a bunch of states are already publishing reports on quality measures, hospital infection rates, costs, and medical errors (among them are Vermont, Pennsylvania, Florida, Missouri, Indiana, New Hampshire, and Massachusetts).

The real question, though, is whether consumers will make use of this information. Some believe that consumers will never act on such information, so it's a waste of time and effort. Others agree that consumers will never act on such information, but if their medical professionals will or their employers will, it's still worthwhile. Regardless, the hope is that public reporting will affect consumers in some way, whether directly or indirectly.

Employers can act as smart purchasers on behalf of patients to a certain extent, by locking in financial incentives to behave in certain ways and by demanding more from their health insurers or providers. The Group Insurance Commission tiers physicians and hospitals, for example, and structures financial incentives accordingly. Putting boundaries around what patients can demand will only get us so far, however.

What we'd all like to see is patients individually acting both as better consumers of their health care dollars AND better users of the health care system. Yet, it's hard for them to do this on their own -- our health care delivery system is too complex, and they've already become accustomed to playing a certain role in the physician-patient relationship. Actionable education is the key to bringing about this change, and that's where the Partnership for Healthcare Excellence comes in. Check out their site -- you might just learn something.....

Geek Doctor Emerges

So I've been greatly remiss in not putting in a plug for John Halamka's blog. I learn something new every time I talk to John, and now the world can too.

Best of luck John!

My kingdom for an inter-operable vendor!

The following was forwarded to me by one of our vendors (which is ironic, once you see the content).

The heads of the two leading health IT projects in the world -- Richard Granger of the UK's Connecting for Health, and Richard Alvarez, the head of Canada's Infoway -- spoke at a recent conference and complained loudly about the state of the health IT industry (see "NHS chief chides vendors for promising more than they deliver").

"Vendors! You can't do these projects without them, but many of the products proferred can't do the job," exclaimed Granger. Adding to the fray, Alvarez stated: "Vendors continue to say they can do it -- but they can't. We don't have a single vendor that is truly interoperable."

Noting that the American approach is to proceed more cautiously -- through standards development, certification, evaluation, ROI calculations and multiple panels and commissions -- Granger quipped: "Some people lack the spine...to bring about systemic benefits and seek only to engineer point-to-point benefits." This approach, he said, is "doomed to fail."

I've got only one thing to say about Granger's comments: Hear, Hear!!