Monday, October 01, 2007

Think Small and Don't Rock the Boat

This post refers to two related articles. One is “RHIO experts talk about problems, future of movement” and the other, which is a response to the first, is “Key to RHIO success: Stop thinking big.” Following are my thoughts on all this.

Let’s begin with some definitions. RHIOs (Regional Health Information Organizations) are “consumer-centric” governing entities focused on improving care value (i.e., care quality, safety and affordability) by enabling healthcare providers (hospitals and clinicians) to share patient information securely. This information sharing is done through Health Information Exchanges (HIEs), which tie together providers—via centrally controlled or decentralized networks—using different computer technologies. And, although it is rarely discussed, a RHIO may also include Emergency Information Exchange (EIE) networks, which help first responders rescue, triage and transport victims to trauma centers when disaster strikes.

In the first article, several people involved in disbanded RHIOs were interviewed about the problems they faced and the insights they could offer. I was struck by some of the comments made.

One gentleman said:
"One problem with RHIOs…is that they provide the bulk of their benefits to patients and health plans, people and entities that, according to our current healthcare payment structure, either don't pay at all for RHIO startup and operational costs, or pay a disproportionately small share … It does not make sense for a RHIO to have a consumer-centric model because, even though it’s a noble idea to put the patient first, … the technology [they need] will be funded by ... the federal government and the providers themselves … This model fails for two reasons. First, each entity is already managing an incredible list of internal priorities. Second, each entity currently operates at a different level of technological readiness. Through collaboration, without the restraints of a formal structure, [a] RHIO initiative is free to build partnerships through pilot projects among ready and interested entities...
So, according to the interviewee, many healthcare providers do not consider improving patient care a priority because it requires the use of technology to exchange patient information, which eats into their profits. This, in a nutshell, is why providers are out to destroy consumer-centric RHIOs.

While I don’t know how many providers agree with his conclusion, I know one thing for sure: It’s disgusting that our healthcare system puts patients and their providers in such a rotten position! Making providers choose between profit and quality is reprehensible!!! Shouldn’t our healthcare system encourage and reward providers for improving the quality and efficiency of care their patients receive?!?

With this question in mind, let’s turn to the second article, which is a response to the one I just discussed. In it, a person from the well-respected Markle Foundation is interviewed about his thoughts on RHIOs. His main point is that RHIOs ought not focus on putting in the technical infrastructure required for exchanging data
“...[until the] stakeholders can begin using it [otherwise it will lead to] debates over funding, business models, data ownership and any number of other issues that have prevented or significantly slowed the development of RHIOS.”
Instead, he suggests that RHIOs
“...start small and create a sort of ‘value chain’ between payers [insurers] and providers that builds on incremental success. Eventually, RHIOs, as originally envisioned, will logically emerge.”
He goes on to say that the way to start is by having payers share their patient data with providers for free. Then, once the providers using the data
“…grow to appreciate and depend on it … chances are providers will be more eager to share their data...[and eventually]…all entities on a patient's care team [will be willing to] share richer data… including real-time best practice and clinical decision support [information]. In effect, this would serve as the foundation for the larger, system-wide health information exchange necessary for reforming healthcare.”
OK, let’s see if I have this straight. Payers collect claims (administrative) data, which are used primarily for payment purposes; they don’t offer much useful clinical information for improving care quality and efficiently. Sure, it’s important for a practitioner to have certain claims data, such as what diagnoses, procedures, medications, and immunizations a patient has received in the past, if they don’t already know it.

But, unlike claims data, rich clinical information—which no payer collects—is much more useful to providers. Such information includes:

• Changes in a patient’s lab test results over time in response to different treatments and conditions
• Symptoms a patient has reported and is reporting
• History of vital signs
• Treatment guidelines best suited for the patient
• Plans of care being implemented by different providers
• Outcomes of prior care
• Imaging studies (e.g., x-rays).
• Functional status
• Risk factors
• Drug interaction warnings
• Etc.

THIS is the kind of information that helps improve care quality and avoids costly errors by supporting clinical decision, but it is not what payers are able to share with practitioners (even if they wanted to).

The article concludes with this:
“So, ironically, the key to RHIO success is to stop thinking big. Instead, we should focus on smaller initiatives that generate some legitimate return on investment. Once everyone involved begins to see the results, interest and enthusiasm will build until we have ourselves a legitimate trend. And some functioning RHIOs.”
WOW!!!! Ironic indeed!!! The conclusion after all this: STOP THINKING BIG …Do as little as possible, as slowly as possible...And whatever you do, don't try too hard to change the healthcare system and improve patient care!!!

So, this is the “wisdom” of the day: We ought not to try to solve the big problems with patient right yet. We shouldn’t be wasting our time looking for innovative, low-cost ways for exchanging rich clinical information for better care outcomes. We should avoid shaking things up because it might annoy certain providers. After all, providers have other priorities—which focus on maximizing profits—and a consumer-centric approach to increasing value would actually decrease profits in our backward healthcare payment system.

Conspicuously absent from this “wisdom,” however, is any mention of changing the system itself to bring greater value to healthcare consumers! How wise is this wisdom?

I have to tell you, I’m just sick of this!!! Why do I even bother?!? I’ve been banging my head against an immovable wall for the past 25 years promoting innovative ways to deal with these problems cost-effectively. The response: I’ve been ignored and dismissed, attacked and ridiculed, and accused of self-promotion. I’ve been told repeatedly: “Wait …take it slow …think small …don’t try to change much.”

Let’s face it, the healthcare payment system simply isn’t designed to promote care value. Providers who strive to deliver high value care are punished financially. Inefficiency (waste and redundancy) and ineffectiveness (fix it, then fix it again when it breaks) are rewarded, while efficiency and effectiveness are punished. This is why providers are justified in fearing they will go broke if they:
  • Keep their patients healthy through good well-care (including prevention and effective self-management of chronic conditions)
  • Help their patients recover quickly and cost-effectively when they are ill by using clinical decision tools, exchanging patient health information electronically, collaborating and coordinating care in multidisciplinary teams, etc.
  • Spend more time with patients to make sure they understand what their patients need, how they feel, what they prefer, and what they must know.
WHAT’S WRONG WITH THIS PICTURE!!! WHERE’S THE SANITY? WHY THE HELL SHOULD WE FEAR ROCKING THE BOAT!!! OUR HEALTHCARE SYSTEM IS SO BROKEN IT’S SCARY!!! IT NEEDS RADICAL CHANGE AND IT NEEDS IT NOW!!! Don’t believe me, see this link.

Does anyone disagree? Does anyone even care?


Either way, I say more about all this in my next post and I offer a sensible path forward.
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