Should "Value" Be the New Mantra in Health Care?

On  the Commonwealth Fund blog at this link is a new post titled: "Should "Value" Be the New Mantra in Health Care?"

 

This is good to see! I began blogging about the need to focus on Value to the Consumer back in 2007, starting with a post at http://curinghealthcare.blogspot.com/2007/10/path-to-profound-healthcare.html.

 Value is a complex issue that brings into light the notion of cost-effectiveness and how to compensate providers who demonstrate a commitment to high-value care via Pay for Value (P4V) models.

 I contend that a firm focus on value is the ONLY way to solve the daunting problems plaguing healthcare delivery. If we don't, costs will continue to rise without corresponding quality improvements, and cost reductions will likely result in worse care outcomes.

Defining a Rational Healthcare Value Network

A value network is a marketing concept that describes the social and technical resources (supply chain) within and between businesses. They account for the overall worth of products and services, including the collection of upstream suppliers, downstream channels to market, and ancillary services that support a common business model within an industry. The kind of value network that the healthcare system needs focuses on bringing increased value to healthcare patient (consumer) and reward providers for delivering high-value care.

Such a value network has four primary interacting components, as depicted in figure above. These components enable cyclical data flows—affected by drivers and impediments—that increase care value to the patient:

1. The green box refers to three types of data required to build the information and knowledge people need for increasing value across the supply chain. The education data refers to formal and informal ways that people share their knowledge, ideas, and experiences. Research data, on the other hand, is used in controlled clinical trials, outcomes and performance studies, various types of biosurveillance (e.g., post-market drug and device, public health), preferred clinical guideline development, and other types of research. Technology data refers to the date collected by EHRs and other health IT (HIT) tools, as well as streamed through durable medical equipment.


2. The five blue boxes refer the transformation of the data using a variety of HIT tools and clinical processes that promote the kinds of knowledge and understanding that fosters more effective and efficient care (services and products). They include (a) use of evidence-based guidelines, personalized care plans, decision support tools, and communication networks; (b) methods of information sharing and care coordination; and (c) patient empowerment. Each activity (process) in the blue boxes supports value by requiring quality handoffs and continuous measurement, assessment, feedback and acceptance at each breakpoint (the gap between each activity) to ensure value creation via continuous quality improvement (CQI).


3. The red box on the bottom refers to the technological, psychological, economic, and regulatory factors that promote or inhibit value to patient by influencing (driving or impeding) the blue box processes. Some of the key influences are listed in the box.


4. The purple box represents good patient outcomes; it is the desired result of using the data, tools and processes to increase value to the patient. The curved purple arrow pointing to the Data Types box indicates the need to provide data about the process, influences and outcomes of care across the entire supply chain via continuous feedback loops. The blue box activities and their related influences that help achieve the goal of higher quality at lower cost are reinforced; those that do not are modified or eliminated.

Leveraging health IT to promote value through CQI is a strategy that focuses on (a) learning from our past, current and futures practices to determine what results in the best outcomes at reasonable cost and (b) transforming this knowledge into high-value healthcare. This solution fosters greater care quality and affordability through (a) use of appropriate evidence-based guidelines and lessons learned; (b) implementation of personalized care plans and decision support tools; (c) information sharing among collaborative teams in social and technology networks; (d) informed decision-making; and (e) fostering patient compliance and responsible behavioral choices.

This CQI solution does not strive for zero defects (no errors of omission and commission) because perfection assumes infinite resources and knowledge, both of which are unrealistic. Instead, it is based on the Michael Porter’s value chain model, which assumes defects (errors) will occur and, therefore, we had better accept some reasonable level of tolerance, reconcile mistakes and poor outcomes, and strive to ensure ever-better outcomes at reasonable cost for a given condition.

Ensuring patient access to high-quality healthcare at reasonable cost through the value-driven CQI solution requires adherence to these critical process transformations:

• Supporting value for each primary activity through quality handoffs (the transfer of information, as well as authority and responsibility, during transitions in care across the continuum) along with ongoing measurement, assessment, feedback, and acceptance at each breakpoint (the gap between each primary activity).
• Assuring that all infrastructure or support activities (a) promote a seamless support relationship that benefits the primary activities, (b) avoid impeding the primary activities, and (c) follow CQI rules for each component across the entire healthcare spectrum.
• Operating with awareness of current healthcare system shortcomings that focuses on areas with quality improvement is warranted.
• Addressing the problems associated with defining quality in real time versus retrospective analysis, for both individual patient and aggregate data.
• Focusing on root cause identification to determine the factors preventing clinical outcome and cost improvement, instead of playing a “blame game,” which only exacerbates the problem.

ONC’s Direct Project: In Defense of Simplicity

Over the past year or so, I’ve been deeply involved in various Federal gov’t health IT initiatives, including the Direct Project and Query Health. This is first time, I believe, that the public (private sector “outsiders”) has had access to the inner-workings of the Office of the National Coordinator for Health Information Technology (ONC). While I’ve been delighted with this new level of transparency, I’ve been dismayed by the way the process tends to transform simple ideas and sensible goals—aimed at improving care quality and efficiency—into overwhelmingly complex, convoluted and costly technical specifications and requirements!

One of the reasons for situation is that people often “come to the table” with preconceived notions of what is possible and how do it. These narrow/closed mindsets are either unaware or prone to reject  technologies that provide simple inexpensive solutions through the “novel combinations of existing off-the-shelf components, applied cleverly to a small, fledgling value network”) in favor of conventional technologies (commodities) that lack those positive qualities. Following is just one example.

A few months ago, Dr. John Loonsk (CMO of CGI Federal) wrote a widely cited article at this link in which he criticizes the Direct Project’s reliance on SMTP (Simple Mail Transfer Protocol)—the simple method for transporting e-mail messages that’s been widely used since the early 1980s. His criticism is based on the fact that SMTP uses a “store and forward” process in which messages are stored locally (in the user's computer) and then sent to the recipient. He claims that SMTP is insufficient and thus should be augmented by types of Web Services, such as SOAP or RESTful methods, which tend to be considerably more complex than SMTP.

In his critique, Dr. Loonsk takes a “closed inside-the-box” view of SMTP-based e-mail. Following are my responses to his key issues. In contrast to his narrow conventional point of view, my replies take an “open outside-the-box” perspective of SMTP’s capabilities that incorporates a novel publish/subscribe (pub/sub) node-to-node desktop architecture (see this link for technical details).

Issue 1: Dr. Loonsk wrote that “the store part of SMTP…introduces new security concerns even with encrypted data.”

My reply: Since when is the encryption of stored files not enough? These days, it is free and easy to encrypt not only individual files, but even entire hard drives (or partitions) can be protected with bit-locker encryption. With this kind encryption of stored files, along with encryption of e-mail in transit (e.g., using PKI), Protected Health Information (PHI) is protected end-to-end (in transit and at rest), which is about as secure as you can get!

In contrast, the Web Services approach can leave PHI exposed at the web server, e.g., when Web Services provide the in-transit encryption and when they transform the PHI format as it passes between disparate EHRs. With the SMTP pub/sub node-to-node architecture, on the other hand, all encryption and PHI transformations are done by the sender prior to transporting the e-mail.

One more thing about XML security: Encryption vulnerabilities. According to an interesting (and technical) blog post by a cryptographic engineer, encrypting XML securely requires extra steps to prevent a "ciphertext" attack that exposes the encrypted XML content. The author concludes: "If your system is online and doesn't have a solid, well-analyzed protection against them, don't pretend that you're doing anything at all to secure your data. I wish I had a funny, pithy way to sum this all up. But honestly, I'm just a little depressed."

Issue 2: Dr. Loonsk wrote that “Because SMTP store and forward infrastructure can only do the push transaction, it is a limited platform standard and a technical dead-end in trying to address other transaction needs…a true U.S. health system all seem to need more [which does] not stop with the data that one provider anticipates another provider will need…[nor] with the assumption that providers will reliably initiate a store and forward SMTP transaction to move the right data to all that need them.”

My reply: The SMTP pub/sub node-to-node architecture actually enables both “pull” transactions whereby the request for the transmission of information is initiated by the receiver, as well as “push” whereby the request for a given transaction is initiated by the sender. To perform a pull transaction, the party who wants to receive the PHI (1^st party) e-mails a request for it to the party with whom the PHI resides (2^nd party). Upon receipt of the request, the 2^nd party responds by sending the requested PHI to the 1^st party. Either or both parties can do his manually or have it done programmatically (automatically) by the software. This simple solution resolves the SMTP push-pull issue. Nevertheless, as reported by ONC in 2009, push messaging is crucial because it is "...less complex and will be far more readily available to a broader range of providers than so-called 'pull' technologies.

Issue 3: Dr. Loonsk wrote that, unlike Web Services and REST, the SMTP infrastructure does not support HIE functions such as “unanticipated needs, unanticipated providers, reliable data access from unreliable senders, accumulation of data into longitudinal and population records, accessing registries and data for decision support, accumulating quality reporting data, querying to get more data when needed, a raft of directory services, and with team care, the shared management of care plans, problem lists and other data.”

My reply: The SMTP pub/sub node-to-node architecture actually does support these functions and we’ve demonstrated such capabilities with our software tools using SMTP.

Issue 4: Dr. Loonsk wrote that “One argument for SMTP has been that it is more accessible to small providers. In practice, implementations to date have involved more complexity than predicted and…[rely] on an outside organization – a Health Information Service Provider (HISP) to carry the technical load. If a HISP is necessary, a more robust platform standard like Web services or REST would seem to be just as achievable as SMTP.”

My reply: Unlike Web services or REST, the SMTP pub/sub node-to-node architecture I’ve been describing does NOT rely on a HISP since the desktop e-mail client (MS Outlook in our case) carries the technical load, not the HISP. To comply with the Direct Project requirements, however, we use a HISP for PKI certificate management and provider registries, but the actual e-mails pass right through the HISP from senders (publisher) to their recipients (subscribers).

In conclusion, the view of Dr. Loonsk and many others fail to realize how breakthrough innovations, like our novel SMTP architecture and apps, can accomplish what seems impossible to folks focused conventional technology. Though no doubt well-intentioned arguments by intelligent people, their criticisms do not provide good reason for denigrating the simple, sensible, survivable solution SMTP provides.

Data->Information->Knowledge: Formula for improving healthcare

As a clinician, health IT architect and computational model-builder, I’ve been focused for the past three decades on how to use health IT to transform data into information and information into knowledge, in a way that improve care value. I’ve come to realize that highly effective and efficient care delivery (including prevention, assessment of risk, and the diagnosis oand treatment of health problems) depends on useful, valid clinical knowledge providing evidence-based decision support.

This knowledge can help continually improve care outcomes though methods and tools such as patient-centeredcognitive support, computerized clinical decision systems, and evidence-based clinical practice guidelines/pathways. These things are necessary if we want bridge the knowledge gap.

 In any case, gaining this crucial knowledge depends on creating, continually evolving and disseminating useful, actionable, valid information and presenting it in a way that avoids overloading the clinician and patient.

 And generating such valuable information requires adequate amounts and diversities of valid and reliable data. Some of these requisite data can come from today’s "Big Data" stores, which are typically insurance claims (administrative) data. While such claims data have usefulness, they are grossly inadequate when it comes to creating the kinds of information and emerging the kinds of clinical knowledge necessary to improve care quality and cost in any truly meaningful way.

Understanding Patient Centered Medical Homes and Accountable Care Organizations: Part 1 of 2

I’ve been blogging about patient centered medical homes (PCMHs) for the past five years and accountable care organizations (ACOs) for the past two years. In this post, I discuss how these healthcare delivery models are similar and where there are significant differences. In a follow-up post, I will explain why we need both.

According to the American College of Physicians, a PCMH is:

...a model of care that puts the needs of the patient first. The medical home is the base from which health care services are coordinated to provide the most effective and efficient care to the patient. This includes the use of health information technology, the coordination of specialty and inpatient care, providing preventive services through health promotion, disease management and prevention, health maintenance, behavioral health services, patient education, and diagnosis and treatment of acute and chronic illnesses...Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. The medical home is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of patients...Quality and safety are the hallmarks of the medical home. Evidence based medicine, health information technology, and clinical decision support tools guide decision making to support patient care, performance measurement, patient education, [whole person orientation] and enhanced communication. Ensuring the coordination and comprehensive approach of the medical home model over time will improve the efficiency and effectiveness of the health care system and ultimately improve health outcomes (Reference).

The ACO model, on the other hand, is loosely define and has different sub-models. According to a recent article in ModernHealth titled “Forging the way: ACOs taking hold despite loose definitions,” an ACO is:

...a fashionable name for a loosely defined fix for U.S. healthcare, are the center of debate, gossip and conjecture among policymakers and the healthcare leaders. But the murky state of the model and poorly received draft regulations intended to clarify the sketch included in the healthcare reform law have not deterred plans among some hospitals, medical groups and payers to…reduce medical errors and waste with financial incentives for quality and lower costs…[by] more closely coordinat[ing] medical care. Markets with competitive or highly independent providers would likely need more time and options to develop accountable care than large health systems with an existing network of employed physicians…Providers who agree to join these endeavors are vulnerable to costly missteps that could put finances and patients at risk…Success will depend on several factors…including hefty financial incentives tied to quality measures and freedom for patients to choose providers (Reference).

ACOs can also be described as:

…vertically integrated organizations of care, which are at minimum composed of primary care physicians [PCPs], a hospital, and specialists…The intent is to coordinate care under the auspices of one organization…[and] providers are held directly responsible for the health of their patients and are evaluated based on their effectiveness, efficiency and quality of care in treating patients. [P]rovider members of ACOs work together across all of the specialties to develop care delivery programs which focus on outcomes and coordinating care…ACOs encourage physicians and hospitals to integrate care by holding them responsible for quality and cost (Reference).

Similarities between a PCMH and ACO

Based on these definitions, PCMH and ACO models both attempt to increase healthcare quality and reduce costs (i.e., deliver high value products and services) by (a) coordinating care, (b) being accountable for the care’s quality and efficient delivery, (c) having a strong primary care core, and (d) consolidating multiple levels of patient care.

According to a recent NY Times Op-Ed piece titled “Cut Medicare, Help Patients,”professors Emanuel and Liebman explain how PCMHs and ACOs provide “seeds of a solution” to controlling Medicare spending by enabling the country to take “a path to smart cuts” by focusing on the:

…need to stop paying for wasteful procedures…and empower doctors, nurses and hospitals to provide higher-quality and more efficient care… these reforms allow [bundled] payments…based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided [and can] eliminate spending on medical tests, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes. And they can be made without shortchanging patients…Smart cuts can also be achieved through better coordination of patient care.

These smart cuts would be an antidote to the “…ill-conceived cuts that…got serious consideration in the recent debt limit negotiations.” These ill-conceived cuts include: (a) Meat-cleaver cuts hack spending indiscriminately…across-the-board”; (b) “Cost-shifting cuts don’t actually reduce health care spending; they just shift costs from the government to the private sector;” and (c) “Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Both PCMHs and ACOs would receive financial incentives for controlling care costs and improving quality:

• "The incentives of the ACO are clearly different from the current fee-for-service reimbursement system. The focus of the ACO is to streamline its processes and care while exceeding the norm on quality and outcomes. If the organization spends less than projected, all members of the ACO share in the bonus payments thereby incentivizing effectiveness and efficiency. If, on the other hand, an ACO underestimates the cost of operation, the providers will earn less, thereby institutionalizing ‘accountability.’” (Reference).
• Different financial incentive models for PCMHs are just beginning to emerge. There are a few pilot projects of financial incentives for PCMHs. For example, (a) Health Plan of Michigan has announced an incentive program that encourages providers to become PCMHs by providing financial assistance during the practice certification phase (Reference; (b) six health plans in New York are paying $1.5M in incentives to create medical homes (Reference); and (c) the multi-state Safety Net Medical Home Initiative (Reference).

 PCMH and ACO Differences

While PCPs are core to the care delivery process in both models, a single independent PCP practice heads a PCMH; this is unlike an ACO in which many coordinated PCP practices working together headed a single organization that is typically a hospital or health plan. That means a PCMH is accountable for care cost and quality rendered by one PCP and the specialists treating a particular patient. In contrast, an ACO is accountable for care delivered across multiple PCPs, specialists and hospitals.

Other differences include the following ...

In an ACO, providers form a “tightly-coupled” network in which everyone operates under the same “global standards” by using the same preferred practice guidelines, health IT and centralized communications. This can:

• Streamline central management and control of patient information
• Promote “top-down” (hierarchical) decision making in which “weak voices” (i.e., people not high in the hierarchy) do not have much influence in how things are to be done
• Reduce clinician autonomy and empowerment.

In contrast, each PCMH is a “loosely-coupled” network of PCPs and specialists with its own “local standards” for clinical processes, health IT and point-to-point (decentralized) communications. This can:

• Provide personal management and control of patient information “owned” by each clinician
• Promote collaborative “bottom-up” decision making in which all involved clinicians have a meaningful say in how things are to be done
• Increase clinician autonomy and empowerment.

In my next post, I’ll discuss why both PCMHs and ACOs have an important role to play, as well as how they can operate within a health information exchange (HIE) to emerge clinical knowledge that is useful to everyone.

Webinar: Live Demonstration of our Medical Home Health IT Invention

Join us for a Webinar on August 10   

An idea conceived 30 years ago—for a simple, secure, low-cost way for people everywhere to collect, exchange and use relevant health information—is now a reality.

During this webinar, we will demonstrate and discuss how the ReAsure HealthNode™ (RAHN™) MedHome software offering enables the right people to share the right information at the right time, and to do it securely and for the right price. RAHN™ uses four beneficial methods to achieve this:

1. It obtains, combines and analyzes all types of health data from any sources with a powerful electronic processing engine
2. It protects the health data under lock and key with a state-of-the-art electronic file cabinet
3. It turns the health data into useful information with an ingenious electronic document designer
4. It sends the information through the Internet quickly and easily by secure electronic mail.

From a technical perspective, these software programs provide a desktop-to-desktop solution that bridges the HL7/middleware interoperability requirement to provide HIE-to-HIE interoperability in a fragmented clinical information exchange environment. They can work with any databases and data formats.

From a clinical perspective, our easy-to-use programs add translation and collaboration capabilities to help simplify a provider’s workflows and support clinical decision-making.

The webinar will focus on one of the RAHN™ MedHome programs, the Referral Manager application, which is currently in pre-production testing. This flagship software program enables primary care providers (family physicians, GPs, etc.) to manage referrals and coordinate care in patient-centered medical homes and other care settings.

It costs only $49.95, and you can download and install it yourself. There’s truly nothing like it! Come see for yourself.

Clinicians, researchers and health IT developers are welcome. We are very open to collaboration.

Title: Live Demonstration and Discussion of the ReAsure HealthNode MedHome Software Offering
  
Date: Wednesday, August 10, 2011
  
Time: 2:00 PM - 3:00 PM EDT   

Space is limited.
Reserve your Webinar Seat Now at:
https://www2.gotomeeting.com/register/865628378

---
System Requirements

PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees
Required: Mac OS® X 10.5 or newer

Is the Annual Wellness Visit Program a Farce?

Jane M. Orient, M.D.—Executive Director of the Association of American Physicians and Surgeons—recently sent an e-mail titled “The Medicare ‘Wellness Farce’ that ridicules the value of Medicare’s annual wellness visit (AWV) program. This is a healthcare reform program of the Federal government’s Affordable Care Act, which is meant to cut healthcare costs by promoting good health. While she believes it is likely to control spending somwhat, she conjectures that the “well care” is not a good thing for people who are ill because it will take money away from their “sick care” they need. Here closing sarcastic statement was: “It is much better for society to keep healthy people healthy than to lavish resources on keeping sick people alive. Isn’t it?

My response to that last comment is this: Keeping healthy people healthy AND keeping sick people alive are BOTH good for society. However, lavishing resources on keeping sick people alive insinuates uncontrolled spending since the word lavishing could mean extravagance and excessiveness.

A much better statement, therefore, would be: It is equally important to society to keep healthy people healthy as long as possible, as well as helping sick people manage or overcome their health problems, while wisely/prudently/judiciously distributing our limited resources. This statement implies the need to focus on two things largely absent from in our current healthcare system

1. It is crucial that the patient/consumer gets true value for the care received. That is, care cost-effectiveness must be the primary factor in determining how to spend our healthcare dollars.

2. A whole-person integrated care approach is the most rational way to go. This model does two things: It (i) brings together well-care and sick-care and (ii) focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body, emotions, thoughts (e.g., attitudes and expectations) and behaviors are interconnected. See this link for more: http://curinghealthcare.blogspot.com/2008/02/patient-centered-life-cycle-value-chain.html

Are Healthcare Services and Products Merely Commodities?

I had a discussion with someone who brought up an interesting point about insurers/payers who treat healthcare services (tests and procedures) products (medications, lab work, medical devices, etc.) to be commodities that are by paid piecework. This model is in sharp contrast to the Pay-for-Value/Value-Pricing model I've been proposing.

The idea that healthcare services and products as commodities is based on faulty reasoning. In reality, the services rendered by different providers, and the products produced by different manufacturers, are often not equally (a) effective in terms of safety and quality (degree of risk and benefit to the patient); (b) efficient in terms of speed and resource consumption; and (c) affordable in terms of overall cost. In other words, they are not equally cost-effective. As such, it is irrational to pay the same amount across the board for a particular type of healthcare service and product. A more sane approach would be to use a value-based model of pricing that pays more for the services and products that deliver greater value to the patient/consumer by being more cost-effective.

There are many reasons why American healthcare does not have such a value-based model. An excellent article recently published in NEJM (at this link) addresses this issue directly: The $640 Billion Question—Why Does Cost-Effective Care Diffuse So Slowly? Bottom line: There is little financial incentive, and great disincentive, to promoting cost-effectiveness in the current US healthcare system. Here’s a brief quote:

“To avoid financial crises in federal and state governments and turmoil for health care stakeholders, U.S. health care must become more cost-effective. The United States spends much more per capita on health care than do other developed countries, with broad outcomes no better than those of its peers...There are, however, individual U.S. physicians and health care organizations that deliver high-quality care at a cost roughly 20% lower than the average. If the rest of the U.S. health care industry followed their example…$640 billion would [be saved. The reasons for our failure to focus on cost-effectiveness] lie in the perceptions and behaviors of the major participants in health care.”

I’ve been writing about the need for a value-based healthcare system since 2007 (see http://curinghealthcare.blogspot.com/2007/10/path-to-profound-healthcare.html and http://curinghealthcare.blogspot.com/2010/08/healthcare-reform-models-focusing-on.html). It seems to me that fixing healthcare in the US (and our economy in general), requires (in part) that we transform our pathologically mutated model of capitalism (see http://curinghealthcare.blogspot.com/2008/02/us-healthcares-perverse-commercial.html) into a rational model based on rewarding delivery of value to the consumer!

Personal Health Information Security

We’ve been having an interesting technical discussion at LinkedIn (at this link) about health information security when trying to share patient data among multiple data silos. We’re examining issues concerning the security of cloud computing, e-mail, and information stored in local computers and mobile devices. We’re discussing the strengths and weakness of encryption, exploring reports of data breaches, and identifying the incremental risks of different security prevention approaches.

We’re also presenting and evaluating innovative security solutions, such as: (a) allocating a specific IPv6 block just to healthcare; (b) using a novel method that is impossible hack (even with brute force) by “scrambling and padding” patient data using multiple keys; (c) separating patient identifiers from the person’s clinical data; and (d) using globally unique IDs (GUIDs) to name patient data files and mapping the GUIDs to the actual patient identifiers.

These kinds of creative discussions and brainstorming are essential when seeking solutions to the daunting challenges facing healthcare reform. The important thing, imo, is to be open to all ideas and critically examine them in terms of strengths, weakness, problems and risks.

Related posts:

• Should Personal Health Information Reside in Silos?
• Who should Own a Patient’s Health Data, Where should they be Stored, and How should they be Exchanged (Part 2 of 2)
• Personal Health Information Privacy

Healthcare Reform "Value Promotion & Reward" Strategy

I've been writing about the need for high value healthcare for over four years. In the past year or so, more and more people have begun discussing the notion of value with regards to healthcare reform.

I've recently participated in one such discussion at KevinMD in a post about the tension between physicians and health policy experts (at this link) and another about how physician consolidation places health reformers in an ironic dilemma (at this link).

My comments focused on making the case that success healthcare reform models must be built on strategies focusing on (a) delivering high value care to every patient (client/consumer) by (b) enabling and rewarding the efficient delivery of high quality (safe & effective) “sick-care” (treating illness and dysfunction) and “well-care” (prevention and self-maintenance) within (c) a trust-worthy learning environment that promotes continuous, demonstrable improvement in care value.

Such strategies measure value as quality divided by cost, which is a measure of cost-effectiveness.

Key tactics of this value promotion & reward strategy are:

• “Value-pricing,” which means paying more for healthcare services and products proven to be more cost-effective (and vice versa)
• Patient-centered cognitive support, which consists of advanced health IT systems that help practitioners/clinicians/providers avoid information overload as they: (a) gain deep knowledge patients’ problems and risks, along with sharp awareness of the most cost-effective diagnostic, treatment and prevention options and (b) use that knowledge and awareness to make valid decisions, take competent actions and achieve good outcomes 
• Shared decision-making, during which health practitioners educate patients about their treatment options in understandable language that takes into account patients’ individualized needs, circumstances and preferences
• Practice-research collaboration (knowledge networks) that generate and disseminate ever-evolving evidence-based preferred practice guidelines and self-help recommendations
• Healthcare delivery models assuring access and availability of high-value care to everyone.

Related posts:

The Need for a Value-Pricing Model in Healthcare
Enabling EHRs to Improve Care
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

The Need for a Value-Pricing Model in Healthcare

We must reduce overall healthcare costs and improve quality, which would increase value to consumers (patients/clients), improve their quality of life, and increase access.

The metric for Value is Quality divided by overall Cost. Quality is the effectiveness of (a) treating illness/dysfunction treatment (as measured by risk-adjusted clinical outcomes, such as changes in a patient’s signs and symptoms); (b) preventing illness/dysfunction (wellness); and (c) stabilizing chronic conditions (disease management). Overall costs—including the cost of meds, tests, treatments and equipment/devices—rises because of inefficiency, waste, errors/malfunction resulting in additional care, excessive tests and procedures, over-prescribing, excessive risk, failure to select good lower cost alternatives, administrative & operational overhead (including malpractice insurance), etc.

From a consumer’s perspective, therefore, greater value care is more cost-effective care.
I contend that we should all be focusing how to increase healthcare value by:

• Rewarding providers and manufacturers who deliver higher-value services and products
• Enabling physicians and other practitioners to deliver high-value care through health IT, care coordination, ongoing clinician-researcher collaboration to build and evolve value-enhancing evidence-based guidelines, etc.
• Enabling consumers to distinguish between high- and low-value services and products
• Reducing providers’ economic burdens by lowering medical school costs through subsidies and malpractice insurance rates for high-value providers.

This is the essence of a “Value-Pricing” (Pay for Value) model of healthcare; it is a sensible alternative to the insane open-ended fee-for-service (pay for volume) model and the restrictive salary-only model.

The policy wonks, healthcare providers, researchers, payers and consumers ought to be debating how to make Value-Pricing a reality since it is the only rational way to achieve the ultimate goal presented above. All other conversations simply miss the point!

Related posts:

Healthcare Reform "Value Promotion & Reward" Strategy
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

Federal Health IT Strategic Plan for 2011-2015: Comments

The Office of the National Coordinator for Health Information Technology (ONC) is seeking public comment on the Federal health IT strategic plan for 2011-2015. On their Health IT Buzz blog, they listed five goals that they hope will "unlock the vast promise of electronic health information to improve decision making, help individuals better manage their health, and improve the health system’s capacity for rapid learning. Following is a comment I posted there.

As a healthcare clinician (psychologist), researcher and health IT inventor/developer who has been focused on such issues for 30 years, the ONC goals, in general, are acceptable to me. Assuming, however, that providing ever more cost-effective (i.e., high-value) care to the patient/consumer is—or at least it should be—the overarching objective of the ONC strategy, then the following issues ought to be clearly addressed, imo.

One issue is the need for clinicians to collaborate with researchers and IT technicians via loosely coupled social networks (that cross professional, regional and organizational boundaries). The clinicians should primary care physicians and specialists across all settings, from in solo practice to large hospitals and integrated care organizations. They should deliver all types of healthcare, including conventional and CAM “sick care,” as well as “well care” (focused on prevention, health optimization and self-maintenance). These diverse groups of professionals would represent a “whole-person integrated care” approach that addresses biomedical, psychological and mind-body (biopsychosocial) factors/problems/conditions.

The clinicians in these collaborative networks would do two important things:

1) They would use health IT tools that build a research data warehouse with process and outcomes data, as well as lessons learned. This information exchange must be done securely and protect patient privacy.

2) They would also share and discuss ideas to guide the evolution of health IT by, for example, defining:

• Information models that depict what need to know and how they need the information presented;
• Where the information comes from (e.g., input by the clinician/office staff or received directly from the patient via a PHR);
• Ways to use the IT tools so they fit it into clinical workflows; and
• The kind of decision support they would want to receive (such as “patient-centered cognitive support,” [Reference].

The researchers, in turn, would generate evidence-based results by performing aggregate analyses on the patient and treatment data in the data warehouse, along with any relevant data from controlled clinical trials and lessons learned shared from everyday clinical practice.

The researchers and clinicians would then collaborate to transform the results into patient-specific recommendation in the form of preferred practice guidelines, protocols and clinical pathways. These recommendations ought to go beyond comparative effectiveness and focus on cost effectiveness [Reference].

The IT technicians would incorporate these recommendations into clinical decision support systems (CDSSs).When clinicians vary from these evidence-based recommendations, a CDSS should (a) enable clinicians to justify why they was such variance, (b) track what was done instead and (c) determine how varying from particular recommendations affects outcomes and costs.

A second issue is the need for lifetime whole-person health records that use of different models to adapt clinical terminologies, data sets, analytics/rules, data input forms, reports/views and user interface to a clinician’s particular requirements. There should also be a way for patients to input data to, and receive relevant data from, their providers’ EHRs.

Finally, a third issue is the need for tools and policies that support “new models of care, such as patient centered medical homes and accountable care organizations, [which] must emphasize value-driving elements of advanced primary care -- enhanced access, better care coordination, use of health information technology to support care transformation, and payment models that reward coordinated care” [Reference]. This means, in part, changing the payment model to one that incentivizes clinicians who focus on delivering high value (cost-effective) care to their patients by paying more to clinicians who take the time to use EHRs, CDDS, participate in the social networks discussed above, and focus on demonstrating continuous improvement in both quality and efficiency.

Enabling EHRs to Improve Care

In last month’s Archives of Internal Medicine, researchers at Stanford University released results of a three-year study that found EHRs in the ambulatory setting did not improve the quality of care [Reference]. There are, however, a number of limitations to the study, including the use of process measures (what was done) instead of outcome measures (the results of care) to measure care quality, the use of data that was collected around five years ago, and the fact that the doctors’ ability to use the EHRs properly were not assessed. Nevertheless, the study’s results do raise serious concerns.

To me, these findings are no surprise. I wonder why anyone would assume that today’s minimalistic and immature EHRs (in which I include EMRs)—along with a healthcare system largely based on pay-for-procedure/fee-for-service economic models—would boost care quality or efficiency. I’m not saying EHRs can’t help improve care dramatically; instead, I’m asserting that EHRs must be greatly enhanced—in both their usefulness and usability—before significant benefits can be realized.

The core issues, as I see them, are (a) EHRs’ failure to provide patient centered cognitive support and (b) our economic model in which financial incentives, such as pay-for-performance, fail to promote better quality [Reference].

One thing that’s needed is much better clinical decision support (CDS) from next-generation EHRs. The EHRs should provide CDS based on ever-evolving, individualized, evidence-based guidelines and pathways that focus on increasing value to the patient. In addition, the EHRs should deliver to researchers comprehensive (de-identified) data collected from everyday clinical practice. The researchers would use these data, along with controlled clinical trials, to develop and continually improve personalized CDS guidelines/pathways supporting diagnostic and treatment decisions for physical and psychological sick-care and well-care (prevention).
The other thing needed is to incentivize providers who deliver high value (cost-effective) care to the patient. Data from the EHRs would be used to calculate such incentives.

Constructing the Ultimate EHR

I just started a discussion on LinkedIn that focuses on answering the questions: How can the EHR be transformed into the cornerstone of a comprehensive health IT system that fosters continually increasing care value (cost-effectiveness)? This “Ultimate EHR” discussion follows a discussion at LinkedIn in which reasons for EHR failures have been examined thoroughly. The purpose of the current discussion is to use the knowledge of such failures to guide the construction of a blueprint of an EHR that helps providers achieve the best possible outcomes at the least possible cost. The link to the discussion is: http://linkd.in/hUPJqf

Here's the introduction

In addition to discussing conventional methods, participants in this discussion are encouraged to present their innovations, creative ideas, and novel strategies. We will examine and critique these technologies, concepts and approaches in order to define a next-generation EHR that helps transform clinical data into actionable information and evidence-based knowledge aimed at increasing healthcare value (quality and efficiency) ; e.g., see http://bit.ly/eal8CS and http://bit.ly/hoQKTG.

We will seek creative solutions to daunting challenges such as determining the best ways for EHRs to:

• Evaluate data integrity to help assure the data contained are valid
• Securely exchange patient data between disparate “silos”
• Build lifetime medical records that provide the specific information tailored to the need of clinicians from every type of specialty/discipline, and in every healthcare setting, through use of different models that adapt the clinical terminologies, data sets, analytics/rules, forms, reports/views and overall UI to the end-users particular requirements
• Promote a strong and productive link between scientific research and clinical practice (“bench to bedside”) by (a) delivering de-identified patient data from everyday clinical practice to central repositories where researchers use them in developing evolving evidence-based personalized guidelines (http://bit.ly/giw1kF) and (b) propagating those guidelines—using clinical decision support functionality—without fostering “cookbook” medicine or stifling innovation
• Improve decision-making by providing patient-centered cognitive support (http://bit.ly/EzWgF)
• Manage expansive and every-changing clinical data standards, including terminologies, care processes and outcome measures
• Support the delivery of “whole-person integrated care” (http://bit.ly/7BVuA5)
• Handle images of all kinds (http://bit.ly/hu3NCH)
• Interoperate with other health IT tools
• Accommodate ALL meaningful use requirements, now and forever?

 All questions, comments and ideas are welcomed.

Healthcare Reform Models Focusing on Value to Consumers – Part 3

My two previous posts (starting at this link) and this one discuss on how to bring high value to the healthcare consumer. I examined the two important models of healthcare delivery--the Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs)--and explored meaningful financial incentives models. In this post, I discuss issues concerning health information technology (HIT).

I defined high-value healthcare as cost-effective products and services that keep people well and improve the health & wellbeing of people who are ill. Providers (clinicians and healthcare organizations) who want to deliver such high-value healthcare require more than a desire to give their patients top quality affordable care. They also need a wealth of knowledge about the best way to prevent, diagnose and treat a wide range of health problems. This not only means continually learning, but also having access to latest evidence-based research and the guidance needed to use one’s knowledge in a way that fosters the best diagnostic and treatment decisions.

The only way to achieve high-value healthcare is to reform our current healthcare system, so it focuses on these two goals:

• Enabling all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
• Enabling all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

Such a high-value healthcare system presents daunting challenges, however. One is being overload with overwhelming amounts of new information appearing daily. Another is the limited capacity of the unaided human brain to acquire, retain, recall and apply complex information about the human body and mind. See, for example, this link about the knowledge gap. Add to this the fact that we have a broken healthcare system full of perverse incentives (e.g., pay for procedure/volume rather than for delivering value), and there’s little wonder why healthcare in America is lower quality and much more expensive than in many other countries.

One crucial element of a high-value healthcare system it the sensible use of advanced HIT. That’s because HIT has the potential to bridge the knowledge gap and foster providers’ ability to deliver higher value care. The HIT industry, however, is having difficulty understanding what has to do; it has largely failed to develop the tools providers and patients need to increase healthcare’s value.

Consider this: The cornerstone of HIT—the electronic health record (EHR)/electronic medical record (EMR)—has been around for about 30 years. One would think, therefore, that today’s EHR/EMRs are successful. Well, knowledgeable experts have been having a great discussion at the HIMSS Linked-In group about this topic, with well over a thousand comments posted thus far. While some of the commenters believe that EHR/EMRs have been successful, most do not. The group gave many reasons for their failure, which focused primarily on technology, people and money.

From an HIT perspective, I indicated that before we can discuss EHR/EMR success or failure, we should first describe its primary goals. We could then determine whether the tools are achieving those goals. I therefore created a chart that defines three levels of EHR/EMR capabilities (weak, moderate and strong), the requirements for achieving success at each level, and the degree of usefulness of each level.

=====================================

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

Healthcare Reform Models Focusing on Value to Consumers - Part 1

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).

PCHM

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.

ACO

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: Pay for Value

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?

Affordable Care Act

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.

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!