Monday, August 30, 2010

Healthcare Reform Models Focusing on Value to Consumers – Part 2


This post follows up on my previous one about Patient Centered Medical Homes (PCMHs), Accountable Care Organizations (ACOs), and Meaningful financial incentives models. In this post I focus on the issue of how to incentivize healthcare providers in PMCH-ACOs who render high value care to their patients.

According to a recent article by the New England Journal of Medicine:
The challenges to implementation of the PCMH model include two issues that lie beyond the direct control of the primary care practice. First, although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes. Second, although evidence suggests that increased investment in primary care can result in savings from several types of reductions…most primary care practices do not…share in these savings…and under the…fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall [Reference 1] .
These issues can be resolved if the PCMH model were implemented in the context of an ACO, which is:
…a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. Multiple forms of ACOs are possible, including large integrated delivery systems, physician–hospital organizations, multispecialty practice groups with or without hospital ownership, independent practice associations, and virtual interdependent networks of physician practices.
Regardless of the organizational structure, an ACO will not succeed without a strong foundation of high-performance primary care…investment in the PCMH model could accelerate the development of high-performing ACOs…Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care…[And] the payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity. [Reference 1]
Payment models to support such PCMH-ACOs could include:
…fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers. Performance measurement to evaluate the quality of care and to prevent potential overuse (in fee-for-service organizations) and underuse (in capitated ones) is a cornerstone of the model. [Reference 1]
[For a PCMH]…a primary care fee for all primary care or a blended payment of part fee-for-service and part monthly medical home fees, is beginning to take hold…But the most complex case is when a single global fee (or risk-adjusted capitation payment) is made for all of the care a patient needs—including preventive care, basic primary care, specialty care, emergency care, hospitalization, and post-acute care that is provided by numerous independent providers over a period of time. In that case, where should the payment go? If savings across the entire continuum of care are to be shared with providers, how should those savings be distributed?
[If the PCMH were also an ACO (PCMH-ACO), then]…physicians and other providers…agree to be accountable for the total care of patients, their outcomes, and the resources used in providing it. This solves the basic question of "to whom should I write the check" and leaves it up to the organization to decide how best to compensate providers for their contribution. [Reference 2]
In other words, providers collaborating in a PCHM-ACO work together to prevent and treat patients' health problems by focusing on delivering higher quality and lower cost care through use of cost-effective evidence-based guidelines, along with more efficient and coordinated workflow processes. Instead of paying each provider a separate fee for tests and services rendered, the PCHM-ACO team approach can adopt a combination of the following payments models:
  • The primary care physician (PCP) could receive fee-for-service payments plus additional fees for running the PCMH.
  • The PCP and specialists treating the patient could receive a flat fee for each patient to cover the entire episode of care, with the amount based on the severity of the patient's health problems; if they deliver high quality care at a cost lower than projected for similar patients, they would share the savings as well.
And as with any performance-based accountability system, it is important to determine the best ways to measure important aspects of care quality, minimize the cost of delivering such care, and reward those who accomplish these objectives, including:
  • Mak[ing] the performance rewards large enough to matter, but not larger than the actual benefit of the improved performance.
  • Creat[ing] measures that people can influence. Do not hold people accountable for problems outside of their control. [Reference 3]
Note that various types of performance measures have been endorsed by different organizations, including Physicians Quality Reporting Initiative (PQRI) process guidelines [Reference 5] and ones that:
…can be calculated using longitudinal administrative data…but it should be possible to get even richer data more widely available…One 'gaping hole' where more experimentation is needed…risk adjustment…We don't know how to case-mix adjust for episodes of care. We can't even agree on the definition of episode of care. [Reference 6]
The "richer data" mentioned above should include comprehensive clinical biopsychosocial data … [wellness wiki Reference 6].

And finally, a PCMH-ACO ought to have these four characteristics, which shared by all ACOs:
  1. …an evidence-based approach to medical care; using the body of medical evidence
  2. …heavy investments in information technology to organize data so that caregivers have the most accurate information available
  3. …quality and cost reporting—the ability to actually report on costs and how quality is affected
  4. …To be successful…the purchasers of healthcare [must] distinguish between the highest value of all the ACOs in that market and direct their people to those organizations…Price…or premium controls…[should be] based on quality and cost reductions…demonstr[able] through data on a defined population. [Reference 7]
In my next post, I'll discuss the health IT requirements for a sustainable PCHM-ACO.

References

[1] Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform http://healthcarereform.nejm.org/?p=2205

[2] Coherent and Transparent Health Care Payment: Sending the Right Signals in the Marketplacehttp://www.commonwealthfund.org/Content/Blog/Aug/Coherent-and-Transparent-Health-Care-Payment.aspx

[3] Financial Incentives Can Improve Public Sector Performance http://www.rand.org/news/press/2010/08/09/index1.html

[4] Building A Path To Integrated-Care Payment Systems http://healthaffairs.org/blog/2010/02/12/building-a-path-to-integrated-care-payment-systems/

[5] Physician Quality Reporting Initiative (PQRI) http://www.cms.gov/PQRI/

[6] Wellness Wiki http://wellness.wikispaces.com/Using+Claims+Data and http://wellness.wikispaces.com/Tactic+-+Deliver+Biopsychosocial+Healthcare

[7] Making Healthcare Accountable http://texasceomagazine.com/?p=418

Tuesday, August 10, 2010

Healthcare Reform Models Focusing on Value to Consumers - Part 1


Now that my company is beginning alpha testing of our truly next-generation referral manager software, and we have scheduled the public beta release for early Sept., I finally have some breathing room for another post.

During my absence from the blog these past few months, many important things have been happening in the healthcare industry. What I found most exciting is the recent focus on establishing and supporting:
  1. Patient Centered Medical Homes (PCMHs)
  2. Accountable Care Organizations (ACOs)
  3. Meaningful financial incentives models for clinicians and organizations demonstrating care quality improvement and cost control (i.e., cost-effective healthcare delivery bringing value to patients/consumers).
I've written about the PCMH model several times over the past four years (see this link). A PCMH is, in essence, a physician practice headed by a primary care physician, which provides coordinated care through collaborating interdisciplinary teams. These groups of sick-care and well-care practitioners focused on delivering high-quality preventive care and effective chronic disease management focused on demonstrating positive patient outcomes.

An ACO, which goes hand-in-hand with the PCMH, is a related model that focuses on "…the alignment of incentives and accountability for providers across the continuum of care" [Reference]. Together, the PCMH and ACO "…are helping organizations to create systems where care delivery is performed by a team of professionals led by the primary care physician and are held accountable for the care they provide…[T]he patient and the family are the major focus of the program. Engaging them into the process is key to the success. The programs that have been successful have [been] identifying patients at risk and developing a coordinated plan with the help of a multidisciplinary team" [Reference].

Financial incentives used in performance-based accountability systems (such as the PCMH/ACOs) have been found to help improve performance, resulting in better outcomes (more effective and efficient care). "…But creating an effective performance-based accountability system requires careful attention to choosing the right design for the system, which must be monitored, evaluated and adjusted as needed to meet performance goals" [Reference]. And, I'd add, the incentives must be great enough to matter.

For example, "pay for performance" (P4P) programs that give small financial incentives result in only modest care quality improvements since the potential financial reward represents only a small percentage of the overall physician pay and thus do not serve as a strong incentive. This doesn't surprise me. As I wrote three years ago at this link, we ought to be focusing on transforming from P4P to a "pay for value" (P4V) approach that rewards providers who deliver high-value care to patients/consumers that promotes the cost-effective prevention and treatment of illness, dysfunction and distress. Dealing with such a complex and controversial issue is certainly a challenge.

In any case, the three inter-related transformational models discussed above hold great promise! They provide useful approaches for improving our dysfunctional healthcare system. These strategies and processes are consistent with the Patient Centered Value Chain I wrote about three years ago at this link.

A key question remaining is: How should P4V be implemented so it fosters and supports PCMH/ACOs through adequate incentives and meaningful use of health IT?

The Federal government's Affordable Care Act offers answers to this question, although finding a solution is made more difficult--as stated eloquently by Karen Davis of the Commonwealth Fund--because the healthcare industry:
…is not like markets for other goods and services. Information on prices is not typically available, decisions…are often made in an emergency, and patients lack knowledge about the value of diagnostic and treatment services…or where to go for the best care with the best prospects for full recovery, functioning, and quality of life.
Nevertheless, the Affordable Care Act offers a solution by presenting:
...important provisions to increase access to information on the quality of physician and hospital care and establish multi-payer databases that will provide a more comprehensive picture of patterns of care across providers. It also begins to address the imbalance between primary and specialty care by increasing primary care payment rates under Medicare and Medicaid. [It seeks]…new ways of paying for and delivering health care, including 'bundled' methods of payment to encourage providers to work together across health care settings…[and] rewarding those who offer appropriate, high-quality, and efficient care.
These initiatives represent a move away from the current fee-for-service system…[and] can help improve transitions in care from one provider to another and one care setting to another. Many errors occur during these hand-offs and patients often experience frustrations due to inadequate communication among providers involved in their care. These initiatives are one important step in the evolution of a new payment system that will provide incentives to achieve the best results…and in doing so achieve savings from the elimination of wasteful, duplicative, or avoidable treatment.
[In addition to changing payment methods]…new health care organizations that are accountable for both patient outcomes and the resources devoted to care will need to be formed …[and supported with] better information, tools, and technical assistance to ensure that essential services are provided efficiently while quality, innovation, productivity, and prevention are enhanced. Safeguards will also be needed against potential under-provision of care or exercise of undue market power [Reference].
In my next post (part 2), I examine various financing models for paying for the kind of coordinated, high quality, affordable care PCMH/ACOs can deliver.

Wednesday, April 07, 2010

The Potential of Personal Health Records (PHRs) - Part 3 of 3

In my previous two posts, I summarized a deep conversation with a group of knowledgeable people about PHRs. I then offered an innovative, low cost, uncomplicated solution to deal with the concerns others raised. Following is a continuation of the discussion.
One commenter wrote:
…In reading about PHRs (or EMRs) I often end up wondering if the underlying premise is faulty. Many existing electronic records seem more like simple the health record equivalent of "brochureware;" putting the paper record up in a pretty online version, perpetuating rather than re-imagining the concept. [As I see it,] there are three key pieces to a PHR/EMR: the source data, how the data is authored/generated/input, and which data gets presented when to whom. (I suppose the analytics that act on the data are a fourth crucial piece). The third piece is truly a CRM [(customer relationship management] question, and the solution does not need to be a monolithic structure that tries to have all answers to all questions presented at once. It may be a bundle of solutions, looking and acting completely different for different users or even for the same user at different times. [We need] PHR solutions that break the existing paradigm.
I replied:
I'd add a fifth key piece, i.e., how to exchange/share the data securely and efficiently between disparate applications without busting silos. Also, when it comes to presenting the data, in addition to tailoring data sets to user needs, there should be a focus on how the same data get presented differently to different users (e.g., mapping terminologies to user roles, such as providing explanations for technical terms to patients). And I like the analytics to be tied to evidence based guidelines the provide decision support and instruction.
This requires a paradigm busting PHR solution in which bundles of solutions are made available. So, what we need is a flexible, affordable, modular solution that enables many different applications to work together (interoperate), which is the very kind of system I've been advocating using a pub/sub node-to-node architecture for exchanging encrypted data files, and using template-based PHRs to consume those data files, as well as to connect to most any third-party software programs and data stores.
Another commenter then wrote:
We need to keep in mind that, not until the focus of healthcare and wellness is changed one from being reactive & curative [to one focusing on] preventive healthcare strategies [for both] physical & mental health.
I agreed, stating that it is crucial to integrate sick-care with prevention/well-care from a mind (psychological) and body (biomedical) perspective.
I then responded to an earlier comment about PHRs in public clouds, PHR functionaliy, and consumers' willingness to enter data into PHRs:
Using public clouds using a centralized database for PHRs poses a security risk that has not been adequately addressed, although private clouds—e.g., behind a provider's firewall—appear more secure. And I still contend that local storage of encrypted data files makes the most sense in terms of security, accessibility and portability.
I also think that the best way to provide multifaceted ever-evolving PHR functionality is through PHR add-ons, i.e., applications that can be used in conjunction with any PHR to fill its function/feature gaps.
With regard to the willingness of consumers to enter data into a PHR, I suggest another factor has to do with the usefulness of the data being entered. If people believe it will help them (and their providers) deal more effectively with a health risk or problem, and for less cost, the more likely the person will spend the time doing it. If it's just a glorified medical record that mirrors what's in EMRs/EHRs, then there less incentive to do so.
Another commenter wrote about problems with PHRs from a practitioner's point of view, to which I replied:
The incentive to divulge "proprietary data and methods of the individual practitioner and/or the institution providing care," imo, depends on who gets the data and how it is used. Let's say, for example, that a primary purpose of HIEs (Health Information Exchange) is to be warehouses/repositories that accumulate and aggregate extensive data sets of biomedical, psychological and environmental patient PHI in de-identified form, along with the associated plans of care (both sick-care and well-care/prevention data http://wellness.wikispaces.com/Tactic+-+Well-Care+Sick-Care+Integration ).
Such an HIE would include disease registries, biosurveillance and treatment outcomes databases. Analyzing these data would provide key information helping to protect public health and enabling comprehensive treatment cost-effectiveness research that focuses on identifying and refining the evidence-based guidelines (protocols, pathways, treatments/procedures) most likely to be of greatest value to each patient/consumer dealing with a particular condition or risk factor. In this case, both patient and provider data are necessary, and, as such, the providers' identification could also be hidden (i.e., by de-identifying the treatment-related data). An HIE should not, on the other hand, be a centralized database of identifiable PHI since that would be silo-busting, which has many negatives as I've previously discussed. In any case, the kind of incentive you suggested (payment token) could help facilitate it.
And I responded to comments about the lack of usefulness of PHRs this way"
If a PHR actually helps a person handle their physical, mental, emotional and spiritual lives in a way that improves their health and quality of life, then it's useful. That's because there would be a significant difference in the data the PHR contains and the feedback & guidance the PHR provides. For example, in addition to the typical biomedical data and observations of daily living (ODL), the PHR would include substantial PHI regarding a person's emotional state, beliefs systems, interpersonal relationships, behavioral tendencies, etc., which are not part of any EMR/EHR, and some of which the person may not want to share with a physician (and which the physician may not need or want to know). So, it has to do with one's vision of what a PHR should/could be.
Bottom line: We've got to think in a whole different way about what PHRs should be!

Monday, March 29, 2010

The Potential of Personal Health Records (PHRs) - Part 2 of 3


In my previous post, I summarized a deep conversation I've been having with a group of knowledgeable people about PHRs. I then offered an innovative, low cost, uncomplicated solution to deal with the concerns others raised.

The solution I offered led to several questions and concerns about (a) security, privacy, access privileges; (b) getting hospitals, clinics, radiology centers, labs and physicians to send an electronic copy of patients personal health information (PHI) to a location where the patient has control over it; and (c) having the PHI be portable, accurate and complete. I answer these questions and address the concerns in this post.

First, here's a basic diagram of the architecture I proposed (a prototype of which we have demonstrated):


* Database Management Systems are software programs that manage databases. In healthcare, these databases are used by EMRs and EHRs and other health IT systems.

** In addition to providing send (publisher) & receive (subscriber), encryption & decryption, and authentication/authorization functionality, each pub/sub node connects with automated data processing templates for querying any databases, parsing any files, manually inputting data, transforming & translating the data, and presenting (rendering) the data.

*** Each data file (DF) is encrypted end-to-end (at rest and in transport) and can be in any data format (CSV, XML, XLS, HTML, etc.). They are stored locally, can be (a) composited (combined/integrated) when multiple publishing nodes send DFs to the same subscribing node, and (b) decomposited (broken apart) when a pub node is authorized to send only a subset of the DF's contents to a particular sub node.
Now to the technical concerns mentioned…

Security: End-to-end encryption of the DFs (including PKI methods). It is also possible to store the personal identifiers in a different DF (which could even be stored at a different location).

Privacy: "Granular level" data control by patient through PHR (see this link).

Access privileges (confidentiality): The human owner of a node can access and render a DF only with user name and password (or, preferably, with a biometric indicator). And the DFs contain only the PHI for which the person is authorized.

Sending an electronic copy of PHI from multiple sources/repositories to a location that the patient controls: Each publisher (provider, lab, etc.) node can do this by (a) querying a database to which it has rights, (b) storing the query results in DF with the transformations and translations required by each of its sub (i.e., patient) nodes, and (c) transmitting the DF to the sub nodes as an encrypted e-mail attachment (or other methods).

Portability: The node software and data processing templates are all modular object oriented applications, and the DFs are individual electronic files, so everything is very portable.

Accuracy and completeness (data integrity): Examples include data validation routines (assessing whether each data element is within predefined parameters), cross-checking data values from different sources, and identifying missing values.

Availability: Since the DFs and processing templates are stored locally on different computerized and storage devices, and since the DFs can be updated automatically via low-bandwidth and briefly connected means (such as e-mail), a recent version of PHI is available anywhere/anytime.

I do not claim to have all the answers, but do come to the table with 30 years of knowledge and R&D. We are seeking to expand our network of collaborators and are very open to creative ideas. Anyone interested in joining our team are welcome to join my company's LinkeIn group—Crafting the Future of Health IT with Novel Solutions—at this link (requires registration).

Other questions were also raised, including: (1) How best to share PHI among disparate systems; (2) How to increase PHR adoption; and (3) What makes a PHR truly useful to the patient and his/her providers in terms of improving care, self-maintenance, quality of life and, of course, controlling one's PHI to maximize privacy. In addition, I was asked if I ever considered Open Source and if we've tried to connect with the big online PHRs. Following were my replies.

Open Source. We have dipped a toe into the open source "waters," but got "stepped on" by the FOSS folks who claim that there is no such thing as a truly valid software patent, and that all software patent holders are greedy, manipulative frauds. After months of debate trying to seek an amicable solution, I left with a bad taste in my mouth (see this link). Nevertheless, I believe open source has a place—especially with commoditized (non-novel) programs—and we have offered an OS app at this link for converting XML to CSV.

Connectivity. MS HealthVault, Google Health and (I believe) Dossia are all public cloud PHRs. With all the security concerns over public cloud computing (see this link), we are shying away from them. We've made attempts, however, to get MS and Google interested in our novel node-to-node system (issue #1 above), but to no avail.

We have not yet written the interfaces you mentioned (also issue #1), although we have interfaces to legacy (X12) and relational databases, as well as XML and other document parsing routines. And although querying remote/external databases is the one method, we've found that having the DBMS run a query and generate an output stored in a CSV (or other delimited text file) is a simple alternative.

Adoption drivers/impediments. I agree that the lack of financial benefit to the database owners has been an impediment to PHR adoption (issue #2), and our crazy provider reimbursement model (pay for quantity, not for value) makes matters worse. It is one reason that we're currently focusing on using our technology in an application that supports information exchange of referral data between PCPs and specialists in patient-centered medical homes while (b) continuing to field test and enhance our PHR application in preparation of its commercialization through workplace wellness programs and other venues.

For the first time in my 30 years as a provider and software inventor/developer, the need to control costs and improve quality is becoming more widely recognized, in part because of the recent healthcare reform debates and the number of people suffering inadequate care. They say that true (disruptive/discontinuous) innovation—one that saves money, reduces complication, and improves overall value—is more likely to be accepted when an economy is in trouble. So, maybe the time is finally right!

PHR usefulness. As far as what makes a PHR useful (issue #3), I would say it's the ability to help the patient & providers (a) increase/improve knowledge and awareness of the patient's health risks and problems, (b) make valid decisions about how to deal with the patient's particular health risks/problems in the most cost effective ways, and (c) become increasingly competence (through education) in implementing the appropriate steps to avoid the risks from becoming problems and ameliorate the severity of existing health problems for a better quality of life. This should include a focus on biomedical & genetic, psychological/psychosocial, and environmental factors. And it should avoid information overload (see this link), while providing complete and accurate data.

[Come back later for part 3]

The Potential of Personal Health Records (PHRs) - Part 1 of 3

I've been involved recently in an interesting virtual discussion (at this link on LinkedIn) that focuses on personal health records (PHRs). This begins a multi-post thread about key issue concerning PHRs that we've been examining.

1. Quite a few comments referred to the need for PHRs to have real value for the patient (or a loved one) that provide value add by:
  • Providing data collection, analysis, feedback , instruction, follow-up care, decision-support tools, and patient-provider communications (e.g., instant chat, recorded voice, email/message, etc.) that:
    • Help individuals and their loved ones deal efficiently and effectively with their personal problems, including medical conditions, physical pain and psychosocial issues in order to improve a patient/consumer's health status (outcomes), save him/her money & time, and cut down on medical errors, omissions and unnecessary or ineffective treatments
    • Supply clinical data consist with Continuity of Care Documents/Records (e.g., diagnoses, medication lists/medication reconciliation data, allergies, problem lists etc.
    • Focus on prevention and self-maintenance (i.e., wellness) for even healthy people by including personally managed custom health/wellness programs, targeted incentives, health education, point of care updating and risk analysis, compliance and adherence motivations, and assistance in dealing with other personally (dis)stressful problems
    • Create empowerment and engaging experience for one's health management
    • Enable baby-boomer to help their aging parents and children who are in college through the healthcare process as needed.
  • Using social media to connect people and promote digital collaboration with their entire care team (primary, specialists, nurses, mental health, holistic med) and personal support network (friends, family, and those that are similar to them/social network) in order to nurture support/encouragement and to educate
  • Assisting with appointment preparation & scheduling, pharmacy, and insurance claims processes
  • Being interactional and easy and convenient to use (so simple to use "a caveman could do it").
2. PHRs must be flexible and evolving, connect/integrated with EHRs/EMRs, and accommodate any relevant standards by:
  • Being customizable and modular and used on an "agile" platform that enables it to connect with most other applications
  • Automatically sharing data with providers' EHRs (i.e., PHR-EHR integration):
    • One possible solution is providing database synchronization where there is a big central database on the server side (e.g., an HIE) and a large number of small databases each residing on a device; the central database contains data for all the devices while each device's local database only contains the device's private data and some shared data
    • Another is having the PHR contain actual data or pointers to that data that the patient could either hand to a provider on a flash drive, deliver via an e-mail attachment or URL, or download directly into the provider's EHR from a secure, authenticated site; the PHR could then become the individual's HIE
    • And the problem will continue as long as EHR companies are still building silos—no one has stepped forward to create a truly interoperable network and each continues to build its respective silo and wants control of the patient data.
    • Able to use HL7 and all other data exchange standards.
3. PHRs data must be controlled by the patient: The patient should be able to control what types of information go to which source; this should be automated so that only the only portions shared are those required for the appropriate level of the transaction with patient in control [note that this is a disputed point]

4. PHRs must have provider tie-in:
  • PHR adoption has to be driven from the provider side or we don't have complete solution; we need to provide for a environment that allows for that interaction and communication because patients do not have true access to their own medical information
  • Certain information in a PHR must be truly useful to the provider (clinician/practitioner), e.g., showing the longitudinal trend is important
  • Should not interfere with providers' workflows and be minimally intrusive
5. PHRs need payer tie-in:
  • Scalability to these solutions needs to come from payers support; enrollment in insured program would easily support the informational requirements of an initial PHR.
  • Most payers offer tethered PHR's, which are not really PHR's but histories of claim data
  • PHR's are a difficult value-added service for a health IT vendor to roll out because they are high risk with little to know revenue generation, so payers could fund their development and deployment [note that this is a disputed point]
There were also several mentions of "data silos" in this discussion. I noted that on another LinkedIn discussion (at this link) we've had a deep conversation about that issue and most have come to the conclusion that silos are important to keep, but crossing them in a controlled manner is essential. I present a brief summary of the discussion on my blog at this link), which includes a link to a simple and low-cost way to cross the silos.

I discussed why I have a problem with creating monolithic centralized databases that contain individually identifiable patient health information obtained by combining data from disparate local databases/repositories (silos). I argued that health information exchanges (HIEs) should only contain (a) pointers to the silos where the data are stored, (b) aggregated deidentified data for biosurveillance and research purposes and/or (c) identifiable data stored in individual encrypted data files.

I agreed that PHRs should contain data automatically retrieved from providers' EHRs, and the EHRs should contain data automatically retrieved from patient's PHRs.

I asserted that the patient should determine the data sets that can be shared between the EHRs and between the EHRs and PHR. These authorizations would be contained in a Trusted Partner Agreement (TPA) created when the patient and PCP first meet, and would be updated as necessary.

In a pub/sub node-to-node (app to app) "forward and store" communications environment, the publishing nodes would automatically select the data sets to be exchanged with their subscribing nodes based on roles rules reflecting in the TPA's authorizations. This low cost, uncomplicated solution would deal with the concerns others raised.

I then explained that I've been working on a very different type of PHR for several decades, which we're calling a personal health profile. It addresses most of the requirements we've been discussing for a useful PHR. See this link for a three-part post about it.

Continued at this link.

Tuesday, March 23, 2010

Should Personal Health Information Reside in Silos-Continued?

There have been several replies to my previous post about data silos.

They questioned my definition of "silo" as a "repository" and made the point that the existence of silos are not only caused to technological issues, but also to constraints involving:
  • Legal factors, such HIPPA, state regulations, contractual agreements  
  • Human factors, which are things that affect the input and output of the data, such as control issues, distrust, tradition, if it ain't broke don't fix it mentality, etc. 
I responded by saying that, to me, “repository” simply means “storehouse” (a place where data are stored). When a repository has constraints that prevent the data it contains from being shared with other repositories, then each of those repositories is a silo with respect to the other repositories. At the same time, however, any of those repositories that do share data are not respective silos. That is, a repository may be a silo with regard to one respository, but not another.

In any case, my previous post focuses primarily on the technological constraints of silo’ing with regard to incompatible software, databases, etc.

That means that a repository may be silo’ed from other repositories for:

Technical reasons, such as lack of software/database interoperability; this is a vendor/developer-related issue. However, if data are exchanged between repositories using paper, fax, voice, or other non-software/database methods—then the repositories would NOT be silos, imo, since data are being exchanged.

Nontechnical reasons, which include legal and human factors. In this case, even if the software/databases are able to exchange data between repositories, the repositories would not do so, which means that they continue to be silo’ed from each other.

Sunday, March 21, 2010

Should Personal Health Information Reside in Silos?

Over the past few weeks, I've been engaged in a conversation with an intelligent group of people about whether personal health information (PHI) should reside in disparate "silos" (repositories) that do not communicate with one another, or whether standards should be adopted that "bust" the silos by merging the information into a common warehouse (centralized database) that spans multiple unrelated healthcare organizations, agencies and practices.

Some argued that silo-busting centralization has benefits that include narrowing the number of places the data reside, improved auditability, and the ability trace and report access attempts and actual reads (i.e., "access/read tracing") more effectively than individual computers.

Others (including me) argued that silos have real value, as long at the PHI they contain can be readily and securely shared among "trusted partners," a model which I call "controlled silo-crossing." I proposed a novel and cost-effective way to do this through a federated, node-to-node, publisher/subscriber model we've developed, which is described at this link and elsewhere on this blog. Using this method for controlled silo-crossing provides major benefits, including the following:
  • Minimizes information loss. Busting silos leads to the loss of important information—i.e., data details and terminology/semantic nuances—because "local" data standards unique to different silos are destroyed in favor of "global" data standards required by monolithic centralized systems, as I discuss at this link.
  • Gives PHI control to the owners of that information. Both providers and patients should have their own silos and have control over who is allowed to cross them. That is, patients ought to authorize the individuals and organizations that have the right to obtain their PHI from their own PHRs and from their providers' EHR/EMRs. The authorized parties should: (a) get only information that meaningful/useful to them, (b) have that information delivered to them from any silos in which they reside, and (c) receive that information after it has been translated and transformed for use in their own respective silos. Also, if silos were busted, it presents the thorny issue of who should be in charge (be the boss) of the merged data?
  • Provides strong information security. Personally identifiable PHI in the physical possession of the parties owning and controlling it is inherently more secure than allowing third-party vendors to manage that information in centralized databases residing off-premises. This relates to the issue of "public cloud" security as I discuss at this link.
  • Enables auditing and access/read tracing. Auditing and tracing are handled effectively using node-based software residing in individual computers.
This all raises other questions: Who currently wants to cross silos and why?

Two entities are public health agencies and research (academic) organizations. Two others are Health Information Exchanges (HIEs) and the National Health Information Network (NHIN). They all require PHI from multiple silos to, for example, identify public health emergencies through biosurveillance (e.g., dangerous medications and medical devices, pandemics, bioterrorism, etc.), as well as to develop evidence based practice guidelines.

Another entity that wants to cross silos is healthcare providers who want to give their patients the best possible care by, for example, sharing PHI through patient centered medical homes, which I discuss at this link.

In addition, patients who understand the problems in healthcare would also support silo crossing. For example, anyone knowledgeable about the serious knowledge gap in healthcare—which I discuss at this link—would realize how important it is to have interdisciplinary teams of clinicians, their patients and researchers share information and collaborate to promote ever-better (higher-value, more cost-effective) care, and by having payers offer financial incentives to practices running certified medical homes.

To help realize this vision of controlled silo crossing, we ought to focus on revamping our culture into one in which value (cost-effectiveness) to the consumer is the upmost importance, and in which delivery of such value is a collaborative effort that is highly rewarded. The results, over time, would include:
  • Ever-better personalized evidence-based guidelines for prevention and care that patients and their providers use to improve results and lower costs by reducing waste, fraud, abuse, errors, omissions, ineffectiveness and inefficiencies would be dramatically reduced.
  • Providers would be more effective in diagnosing/testing, treating and preventing health problems in their patients, and would gain financially by doing so.
  • Providers would not have to worry about malpractice suits by following the evidence-based guidelines and offering sound justification for rendering alternate plans of care; this would also lower malpractice insurance premiums and the pressure for wasteful "defensive medicine."
  • Patients/consumers would be better able to manage their own health.
  • Payers would not have to pay for low value (expensive, unbeneficial) procedures and tests.
Bottom line: While centralized databases have their place, controlled silo-crossing is a key strategy for improving our healthcare system.

Discussion continued at this link

Wednesday, February 24, 2010

Data Silos, Core Measures, Performance Metrics, Outcomes, and Evidence-Based Guidelines

There has been a great deal of discussion about the need to exchange patient health information securely across disparate data silos while protecting patient privacy. I agree that this is an essential ingredient for transforming healthcare and have offered a solution in prior posts. But that's only one part of the big picture. We must also focus on the need for (and failure to) funnel comprehensive clinical outcomes measures to researchers who translate them into evidence-based guidelines reflecting cost-effective care. Health IT tools, therefore, should be competent in obtaining these data, delivering them to researchers, and then presenting the resulting guidelines to patients and providers as a means to improve and reward high-value care.

Case in point: The vast majority of "performance metrics" I've seen are based on "process measures" that evaluate care quality based on what was done instead of the outcomes/results of care. Unless this situation changes, care value (cost-effectiveness) is not likely to improve much. I've written about this situation years ago at http://curinghealthcare.blogspot.com/2007/05/knowledge-standards-and-healthcare_12.html. And interestingly enough, a recent article at http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100219/NEWS/302199990/1029# discusses the tension surrounding the use of "core measures" by the Office of the National Coordinator for Health Information Technology (ONC) and how they want to put more emphasis on outcome measures over process measures.

Bottom line: Sharing patient data is important, but using those data to improve care value systematically is a process that is largely overlooked. Today. This is a serious problem that must be addressed seriously.

Sunday, February 14, 2010

What is the Most Sensible way to Diagnose, Treat and Prevent Health Problems?


What is the most sensible—i.e., the least costly and most effective—process by which to:
  • Diagnose a particular patient's health problems
  • Treat those problems in order to increase the likelihood of getting the best clinical outcomes (symptom alleviation, blood text normalization, disease elimination, etc.)
  • Help people help themselves (e.g., prevent illness, manage chronic conditions, and deal effectively with psychological distress).
In some situations, this is common knowledge because the problem and remedy are both obvious (e.g., filling a tooth cavity, putting a cast on a broken arm or ice on a sprained ankle, removing a wart, testing a growth for skin cancer, etc.). But in very many situations:
  • A set of symptoms reflect a multitude of possible underlying problems
  • Comorbidity (two or more health problems exist at the same time, especially in persons with chronic conditions) complicate matters greatly
  • There are conflicting (no clear-cut agreed-upon) or inadequate guidelines/protocols/approaches for testing and treating certain conditions (see this link)
  • A person's mental/psychological state is affecting one's physical health (e.g., emotional stress affecting one's immune system) and visa versa (e.g., certain diseases affect one's emotions, thinking and behavior)
  • Medication side-effects and drug-drug interactions may be causing certain symptoms)
  • There is a significant influence of genetic as well as environmental factors
  • …and so on.
The unaided human mind typically cannot make useful sense of this incredible complexity, which is why we have a serious knowledge gap in healthcare (see this link).

What's needed is much more focus on better coordinated research—using both controlled studies and lessons learned from the field in everyday clinical practice—along with much greater use of EHRs and PHRs coupled with advanced decision-support tools. The goal ought to be the development of ever-evolving evidence-based guidelines focused on cost-effectiveness that are presented along a timeline of workflows (do A then B then C…) and/or using validated rules/algorithms based on mathematics and logic, which clinicians use to augment their experience and education.

If the healthcare industry move forward steadfastly in this rational direction, and rewarded providers for delivering high-value care, we'd be transforming our healthcare system in one that truly works.

Wednesday, February 10, 2010

A Novel Way to Share Personal Health Information


Patient health data are stored in disparate silos—separate islands of information residing in often incompatible EMR/EHR and PHR databases controlled by different hospitals, clinics and public health agencies, as well different group and solo practices. The question is: What is the best way for this personal health information to be shared securely between the people who need it to provide quality care to individual patients, protect populations, and perform research leading to valid evidence-based guidelines?

There's actually a simple, inexpensive and secure way to exchange data between any PHRs, EHRs, EMRs and public health/research/biosurveillance databases. As I've discussed in previous posts, it requires a paradigm shift from...
  • Monolithic, centralized, pull, synchronous systems—an architecture that's good behind an organization's firewall
to...
  • Distributed federation of asynchronous pub/sub nodes that push data from publishing to subscribing nodes—an architecture that's good for the kind of loosely coupled P2P networks crossing organizational boundaries that comprise the NHIN (National Health Information Network).
The latter architecture uses a node-to-node transport method, which is similar to the way the telephone system works. It enables everyone everywhere to exchange data with little cost and complexity, even when bandwidth is low and Internet access is intermittent. It enables massive interoperability. With it, scalability is a non-issue. It provides composite reports containing information from many disparate sources. And it allows data views to be changed instantaneously (even when offline), which increases understanding by, for example:
  • Data slicing, dicing and drilling down (i.e., breaking a body of information down into smaller parts, examining it from different viewpoints and dividing an information area up into finer and finer layers)
  • Switching from lists and tables to graphs
  • Answering ad hoc "what if" questions
  • etc.
In order to implement the above solution, you would connect pub/sub node software to every application in a mesh node network. And you would enable each node to do whatever data translations and transformations are needed to assure the right data gets to the right place in the right format. Then transmit the data to subscribing nodes in PKI encrypted delimited text files (such as CSV) via FTP, e-mail attachments, MMS, or whatever protocol desired. Upon receipt, the subscribing nodes can import the data into their local databases and/or render the data locally using customized templates that can operate interactively offline.

I discuss this solution in detail at this at my company's LinkedIn group at http://www.linkedin.com/groups?home=&gid=2697006&trk=anet_ug_hm&goback=%2Eanh_2697006. You're welcomed to join.

Monday, February 08, 2010

Is President Obama to Blame?


I recently received an anti-Obama e-mail with a link to a video that blamed the President for our country's current and future problems. This faulty/irrational way of thinking is a gross distortion of reality because no individual is responsible for our problems, not Obama, not Bush…no one!

Instead, our problems stem from a malfunctioning political-economic system and a misdirected culture. At its very core, our society is built on a foundation of beliefs and values that promote much of the negative side of human nature. The consequence is a political-economic system that, for example:
  • Allows money from special interests to dictate the actions of Congress
  • Repeatedly fails to fix our severely broken and unsustainable healthcare system (see this link)
  • Has created an overly lop-sided wealth and power distribution—with the wealthiest 10 percent of Americans having a larger share (about 50%) of total income than ever before (reference)—made worse by a lack of fiscal rules and regulations required to constrain irresponsibility and greed
  • Has enabled certain banks to become "to big to fail"
  • Engages in wars we can't possibly win by force (including military engagements and the war on drugs)
  • Created an education system in which American students performed worse in science and math than many other industrialized countries (reference)
  • …and so on.
Bottom line is that American political-economic system just doesn't work well for the vast majority of our citizens.

What we ought to be doing to fix our problems is focusing sincerely on reforming our political-economic system into one that:
  • Forces widespread transparency
  • Aligns the ought-tos with the can-dos
  • Provides an environment where all individuals are enabled to develop their positive potential
  • Is driven by empathy and compassion (e.g., living by the "Golden Rule" ethics)
  • Stops equating personal value (the inherent "worth" of one's self/ego) with personal wealth and power over others
  • Takes a long-term, big-picture view
  • Isn't fearful of fundamental change
  • Inhibits individuals from going into politics who are focused primarily on their own personal gains (e.g., by minimizing the money-politics connection through better campaign contribution reform and limiting politicians upon leaving office from becoming well-paid lobbyists for corporations they've helped)
  • Embraces both science and spirituality. 
Also, see this link for a discussion of convergence of 3 core healthcare reform issues: American values, personal responsibility, and pragmatic solutions.

So, what's standing in the way of such reform?

I contend that the answer, in large part, comes from analyzing this quote by Howard Zinn in a recent Bill Moyer's interview (at this link): "Democracy doesn't come from the top. It comes from the bottom. Democracy is not what governments do. It's what people do… whenever the government has done anything to bring about change, it's done so only because it's been pushed and prodded by social movements, by ordinary people organizing." And this quote takes from one of Zinn's books: "If democracy were to be given any meaning, if it were to go beyond the limits of capitalism and nationalism, this would not come, if history were any guide, from the top. It would come through citizen's movements, educating, organizing, agitating, striking, boycotting, demonstrating, threatening those in power with disruption of the stability they needed."

So, if things are so bas for so many, why don't "we the people" demand meaningful (aka radical) change?

Well, it takes certain ways of thinking and a good deal of motivation for people to pull themselves out of despair. They must transform their life views from being overwhelmed with a sense of hopelessness and helplessness to feeling hopeful, capable and having a clear direction by which they can actualize/realize their potential. This is possible, but not easy.

On the one hand, we all have the inherent capacity to change the way we think about ourselves, others, our current life situation and our futures. We can gain new knowledge and skills. We have the ability to become inspired and to act in constructive ways that enable us to develop their minds and bodies, and to attain a better quality of life.

On the other hand, the negative influences of our culture tend to foster the negative side of human nature to become dominant, which inhibit such positive thinking, learning and action. These negative influences include such things as:
  • Poor education, an unsafe living environment, racial prejudice, generations of poverty, propaganda and "spin"
  • Normal human thinking limitations (e.g., short-sightedness, over-generalization, low frustration tolerance, poor attention span, wishful thinking, close-mindedness, gullibility, misdirected focus, ignorance, influence of negative emotions, etc.)
  • Corporations who hire lobbyists to get laws passed that benefit them—i.e., creating the rules in their favor by "tilting the playfield"—which is often at the expense/detriment of the general public
  • Cultural attitudes in which "money makes the man," "winning the game is what matters" and "buyer beware" trump attitudes such as "leading a virtuous life matters," "how you play the game is what's important" and "focus on giving the consumer high value." 
And instead of supporting a "give me more of the pie" philosophy (i.e., "I deserve to be given more by the government as entitlements"), our culture should be promoting a "create your own pie" philosophy by:
  • Making available quality "ingredients," e.g., access to good education/training, availability of jobs, decent and affordable healthcare, safe neighborhoods and realistic reason for hope.
  • Promoting acceptance that the best pie a person has the potential to create will not necessarily be as "tasty" as other people's pies. That is, helping people realize that it's OK for some individuals to gain greater material rewards and power than others, as long as it's acquired in a virtuous manner (i.e., through honesty, integrity, value-creation, etc.), and as long as everyone's essential needs are satisfied (e.g., good food, healthcare, education and protection). 
It's my hope that grass-roots movements around the country focused on positive change will become powerful enough to exert the force needed to counteract the political, economic and psychological pressures preventing meaningful systemic reform. This appears to be the only reasonable way to avoid the meltdown of American Democracy.

Thursday, February 04, 2010

Curing Healthcare named a top 50 blog to learn about healthcare IT

According to the ratings, the blogs selected are updated on a regular basis to deal with an ever-changing field and present "relevant information along with a good following and a well-written and easy-to-comprehend blog." For the other blogs on the list, see this link -- http://mastersinhealthcare.org/2010/top-50-healthcare-it-blogs/

Thursday, January 28, 2010

Crafting the Future of Health IT with Novel Solutions

I just started a Linkein group--Crafting the Future of Health IT with Novel Solutions--located at http://www.linkedin.com/groups?home=&gid=2697006&trk=anet_ug_hm&goback=%2Eanh_2697006. You are welcomed to join!

The primary purpose of this group is to build and deploy novel health IT solutions that continually raise the bar of possibility and meaningful use. To help achieve this goal in a win-win manner, we are focused on combining group members’ products with my company’s novel architectural platform and supplemental (add-on) applications.

I started this group because I believe a good business strategy for small HIT companies in this economic climate focuses on collaboration and networking. As such, we are eager to form close business relationships with the individuals and companies that join this group.

To implement this strategy, we will share the details of our patented technology; provide very fair licensing agreements; support beta groups; and enable the cost-efficient interoperability between members EHRs, PHRs and any other clinical and business tools that provide added value.

My goal is to assist others in understanding what we have to offer in order form close collaborative business relationships that BENEFIT EVERYONE INVOLVED. After all, something as complex as improving the healthcare system in meaningful ways is a global effort requiring the voices, ideas, innovations and work of many (across multiple disciplines and nations), as well as the integration of many different technological approaches, both conventional and disruptive.

I encourage probing questions, challenges to my claims, business and technical suggestions, exploration of how third-party health IT products can interoperate using our architecture, etc. This kind of honest, critical, direct discussion and relationship-building is the purpose of our group.

I contend that though our combined knowledge, creativity and efforts we will develop an affordable, secure, ever-evolving and all-encompassing HIT system that will be envied by others and will never become obsolete.

Tuesday, January 19, 2010

Four Interlocking Issues about Fixing American Healthcare


Here are four interlocking issues that must be addressed if we Americans are ever to fix healthcare:
  1. Meaningful use of health IT vs. Minimally acceptable usefulness. I contend that health IT is used "meaningfully" only if it helps increase the effectiveness and efficiency of care (i.e., increases care value to the consumer). Although the Federal government is focusing on this value proposition, pressure from the healthcare industry may end up watering down the meaningful use definition to one of "minimally acceptable usefulness." And to be TRULY meaningfully used, EHRs ought to provide data and functions that support the following three value-enhancing models & processes...
  2. Patient-Centered Medical Homes (PCMH) vs. Uncoordinated care. The PCMH model, which provides oversight and coordination in the delivery of care is, thankfully, gradually gaining acceptance.
  3. Patient-Centered Cognitive Support (PCCS) vs. Inadequate information (ignorance), Information overload, and Lack of computerized decision support. PCCS, which consists of advanced software systems that help clinicians make informed decisions without information overload, is slowly gaining traction.
  4. Pay-for-Value (P4V) vs. Fee-for-Service (FFS). P4V, which focuses on the delivery of cost-effective care (i.e., high value to consumers) is being endorsed by some, but it has a long way to go before crowding out the FFS model in which "pay for volume" or "pay more for doing more" is actually a disincentive for cost-effective care (i.e, cost-effectiveness means less provider income/revenue under FFS).
Unfortunately, current day EHRs are not designed to support all those things, which means we ought to re-think the future of health IT design and capabilities. So, while it's important to have EHRs used widely across all healthcare facilities and disciplines/specialties--and while meaningful use criteria cannot be overly demanding considering their very early stage of today's EHR applications--there ought to be assurance by vendors that their products are flexible/adaptable enough to accomodate TRUE meaningful use.