Skip to Content

Multimedia

Perspectives from the Field: Interview with Bianca Frogner, PhD, October 13, 2015

Tue, 2016-03-15 11:33 — healthinfolaw_admin
https://www.youtube.com/watch?v=SvkPa7n9Nc0
application/pdf iconInterview_Frogner Final.pdf

Perspectives from the Field Interview Series 
Interview with Bianca Frogner, PhD.
Associate Professor and Health Economist, University of Washington Department of Family Medicine
October 13, 2015
Interviewer: Jane Hyatt Thorpe
 
Questions:
 
1)  Would you please tell us a little bit your work and how it intersects with health information exchange? 
2)  Besides using information directly for patient care, what other potential benefits are there in health information exchange for the health care system?
3)  What are some barriers or challenges to fully realizing the benefits of health information exchange?
4)  What do you see as the most promising long-term solutions to these challenges?
5)  In the meantime, do you recommend any strategies that health care providers and policymakers can use to maximize the use and exchange of health information, both for patient care and for overall improvement of the health care system? 
 
Transcript:
 
Question 1
 
JHT: Welcome to the Health Information and the Law Perspectives from the Field Interview Series. Today we’re speaking with Bianca Frogner, PhD, who is an Associate Professor and Health Economist in the Department of Family Medicine at the University of Washington. Dr. Frogner is also the Director of the Center for Health Workforce Studies. Welcome, Bianca. Thank you so much for joining us today.
 
BF: Thank you for having me
 
JHT: We’re thrilled. We’re going to launch right into our questions here. Would you please tell us a little bit about your work and how it intersects with health information exchange?
 
BF: Sure. So, I’ll approach this from two different angles. One is my role as a Health Economist. In my work, I do a lot with data. My own research interest has been about trying to better understand the patient’s experience with care at all different levels. As part of that, I have had some interest in mobile health applications (apps) and what has been coming out onto the market that helps patients better connect with the health system. In trying to understand which mobile health apps are the best for patients to use, one needs to figure out an evaluation mechanism by which one can pick out the best apps from the ones that are just clicking information with no meaningful use. I’ve had some ongoing research interest in trying to develop a rapid evaluation system of the mobile health apps out there that take into account how mobile health applications might actually connect back to the system as one criteria to figure out the best quality apps out there. My other role as a Health Economist and an educator is trying to figure out how to train people to understand the data that they get into their hands. Actually, when I was spending some time at George Washington University in my prior job as an Assistant Professor there, I trained Health Administrators in the area of quantitative data or quantitative methods for them to understand the information that could potentially come of a system of health information exchange. In my role as the Director of the Center for Health Workforce Studies, or CHWS, as we call it, we have a couple of projects that are ongoing that think about emerging skills that might be related to health information exchange. Specifically, we have an ongoing study where we are looking at job search engine data to understand and identify how often health information technology (health IT) skills are being requested among different health care occupations. One challenge is trying to figure out what health IT skills we should be picking. Among the skills that we are going to focus on are data analytic skills, as well as skills about trying to manage different information systems. What we want to know is in which occupations these skills are being requested and in which different settings these skills are being requested. Those are just a couple of ways in which I see where my current work is intersecting with health information exchange. 
 
Question 2
 
JHT: That’s wonderful. Clearly, you focus a lot on patient engagement, use of information, and making the mobile health tools useful and accessible as well as training people to work in this field. So we’ve talked a lot about benefits for health information exchange beyond just direct care of the patient. Could you elaborate more on your perspective on the expanded potential set benefits in health information exchange for the broader health care system?
 
BF: Sure. So, as you mentioned, health information exchange, there’s this hopeful promise that it will improve patient health. I think the real importance of the use of health information exchange is to help the health system perform better. With all of this information that is coming, I think health systems, which would include hospitals as well as physician offices, can connect better so that they can better account for each other’s performance. I think with the Accountable Care Organization concept that came under the Affordable Care Act, there is this movement with financial incentives in place to have these different providers who didn’t work together before to work more closely together. The challenge for them is trying to figure out how to move the data across the different systems. The real opportunity here is that once they get the systems in place, they can really share how each place is doing in a more real-time manner while before, people would have to pull together paper in order to communicate across the different kinds of providers. Hopefully, as the systems become more sophisticated over time, providers can use this information in a way that helps them strategize how best to target their program improvement efforts in order to identify the patients that need the best care at the right time. It also allows these providers to communicate better with insurance companies to identify what is working and what is not. Specifically, it would be to say, “OK these types of treatments are leading to better improvements versus those are not.” Also, I think that these health information systems have a real potential to help improve population health, not just the patients’. At the end of the day, these systems would allow different providers and insurance companies to look at all the patients that they serve in aggregate and allows them to learn from one patient population and maybe apply those learnings to another. 
 
Question 3
 
JHT: That’s wonderful.  You mention in particular the financial incentives, which, I think, have been a great assistance to hospitals and eligible physicians in particular. Obviously the progress, I think, has moved slower than everyone would have hoped. There are clearly some barriers or challenges to fully realizing the potential that you described. What, in your mind, are some of the primary barriers or challenges that still exist to realizing these benefits?
 
BF: Right. So, there are a few major barriers that exist that do make peoples’ motivation to use health information exchange and health IT in general a little daunting. One, is that interoperability is still a challenge. Especially when connecting personal health devices like a Fitbit back into an electronic health record (EHR) system. I think patients are very excited to be able to monitor their own health but then they get a little bit discouraged if they bring this information to their providers and they don’t have a good way to show this information to a provider or the provider doesn’t know how to integrate that information back into their system to keep a record of it so that they can come back to it over time. Another barrier is for smaller providers, especially out in rural areas. The smaller physician offices, practices with less than 20 people in it, probably even less than 10, some of those places are still struggling to get an electronic health record system into place that can actually communicate with a hospital or other providers. The investment cost for a small provider to adopt an EHR system is quite heavy and while the HITECH Act of 2009 did help to alleviate some of those financial pressures, there are still quite a few challenges around maintaining and getting the right skills in place to actually use these systems. I think another area of challenge is that there is a bit of an information overload. While it is great to have all of this data, I think sometimes there is almost too much information. We, being researchers and people in the field of collecting this kind of data, haven’t quite figured out how best to leverage this data to be meaningful to a provider or to patients to be of use. To link with that, our workforce isn’t really trained yet to understand this data or know how to interpret it. Maybe, most people who work in the workforce have had at least one course in statistics along the way but that’s not quite the same as learning over time how to manipulate data, how to interpret graphs and tables in a way that can really provide meaningful health guidance back to the patient.
 
Question 4
 
JHT: I think that’s all very, very telling. Oftentimes when we talk about barriers or challenges there is a focus on finances or operational structure but I think your comment about information overload is quite perceptive, actually. There is so much information, this whole concept of big and small data; how do we work with it and how do we interpret it both for research purposes and clinical purposes and for patient engagement I think has been a challenge. From your perspective, thinking about how we will continue to tackle these challenges, what do you see as the most promising long-term solutions to these challenges?
 
BF: Well, I do hear that community colleges came to be very keen on the fact that health information technology, health information exchange, these different solutions to the improvement of patient health are coming out here but, the workers are lagging in the skills to leverage these new tools. So, community colleges are really seeing an opportunity here to train workers, especially those that already have a job. In other words, they are training incumbent workers to actually get the right skills to train up the workforce to best use this information. They’re really seeing this as a call that is coming from the employers, such as hospitals or other major providers. They’re going to the community colleges and saying “Can you please help create a curriculum for us to address how to take data to that next stage?” So it sounds like, for some community colleges out there, they already started thinking about this early on under the HITECH Act and under the American Recovery and Reinvestment Act, where they got some money to actually develop curriculum, to think about health IT. At that time, in 2009-2010, the focus was more on just trying to get the systems up and running. Now, I can hear on the ground that the educators are realizing they need to move the conversation to that next step of; how do you take all of this information and make it usable? There are some federal acts out there, such as the Workforce Investment and Opportunities Act, WIOA, that help provide some financial incentives to help colleges and even employers to think about ways to train up the workforce to be able to have the skills that are most needed today, among them being able to use health IT. The long term solution here is to educate our workers that are already in place rather than training up a brand new workforce. So, it is taking people who we already have, who already know a lot about healthcare, and trying to give them those extra sets of skills to better understand how to integrate health IT and data analytics into their job. I think that the conversation is moving away from saying “We need people who just do health IT” to “Everybody needs to have some skills around data and knowing how to use it and manage it.” I think the software issue around interoperability will sort itself out over time. I think some of the information overload will also sort itself out over time as there are different entrepreneurs out there who are trying to find more user friendly and creative ways to display data. I think some of that will sort itself out in the next 5-10 years. In the meantime, we need to train up a workforce that will be able to take that information once it is displayed all nicely.
 
Question 5
 
JHT:  That’s really interesting and in our prior interviews we never looked at this from a workforce perspective. I think that is critical. How do we use that information? How do we make sure people on the ground are trained and able to work with information and collect information? So as you’re thinking about hospitals, other major providers, community colleges, some funding, in terms for colleges and employers to train their workforce, from a workforce perspective what do you think are the best strategies that will continue to foster the creation of new programs or onsite training of current work force to really think about evolving the workforce towards a place where there is better use, recognition, understanding, etc. of health information technology and exchange?
 
BF: Sure. I think generally in the field of healthcare as we’re in this post Affordable Care Act era, there is definitely a conversation of how can we get our health workers out into the field and helping the population where they live rather than trying to bring them in to the health care system. I think as far as improving that conversation we really should also be having that conversation of: what kinds of data skills can we give these individuals to go out there and talk to their patients and help them work with these different monitoring tools that these patients and individuals are adopting? For example, long term care is a growing area and in terms of both health care demand and it is also where there are a lot of job opportunities. We see a lot of Home Health Aides that are being demanded these days and among the health workers out there. What we need to think is “OK- if that’s where the jobs are and that’s where the patients are, what are the data skills or what are the information skills that we need to give these individuals that can help them keep the patients out of the hospital and in the community?” I know there has been some discussion around focusing on community health workers and better understanding what their skills and capabilities are. Are there opportunities there that they can be trained in a way to manage patient health using all the data out there, in the community, without necessarily using big electronic health record system? I think it is important to focus on how we can really connect all of this individual level of data that’s being collected by folks out in the community and make it connect back to the larger health system. But we shouldn’t have the patient wait to get back into the hospital figure out how to interpret that information. We need to have them not only connect in that way and have that information given back to the provider, but I think that we need to deliver back messages to individuals while they’re in their home; how they’re doing, and give them some sense that they’re doing well without necessarily just waiting until they see a provider. I think part of this means that we need to have conversations with providers at every level. Not just physicians but talking to the pharmacists, medical assistants, home health aides, and community health workers to ask them what are the barriers that they’re facing when approached with information through these individual monitoring systems like Fitbit. What do they want to do with this data and what do they think they can do with this data? I think we need to talk to the patients more and have a conversation and ask, well, what do you hope to get out of the data? What is it that you really want to learn? Right now, a lot of the conversation around collecting data is driven by people like me who are researchers, who have our own questions to answer. Or, it is driven by people who are actually programming these different software or devices and they have their own beliefs about how information should be used. We really need to talk more to the actual providers and patients, the users of this data, to understand what they want, what they need and what kinds of barriers they face and to figure out what kind of training do we need to give both patients and health care workers.
 
JHT: Wonderful, Bianca. This has been incredibly insightful and we really appreciate your time and your expertise.
 
BF: Thank you, well I enjoyed this very much.
 
Further Resources:
 

Perspectives from the Field: Interview with Lucia Savage, Esq., October 14, 2015

Thu, 2016-03-03 12:15 — healthinfolaw_admin
https://www.youtube.com/watch?v=CSagGhQeyRQ
application/pdf iconInterview_SavageFinal.pdf

Perspectives from the Field Interview Series
Interview with Lucia Savage, JD
Chief Privacy Officer, Office of the National Coordinator for Health Information Technology, United States Department of Health and Human Services
October 14, 2015
Interviewer: Jane Hyatt Thorpe
 
Questions:
1)  Would you please tell us a little bit about ONC and your work as Chief Privacy Officer?
2)  What do you see as the main thrust of ONC's current role in advancing greater use and exchange of health information? 
3)  As we continue to move towards a "transformed" health system supported by Health IT, what do you see as the most prominent remaining barriers or challenges to broader exchange of health information across providers and settings of care, as well as other stakeholders? 
4)  Please describe your view of the federal vision for interoperability and the immediate steps ONC is taking to move towards that goal.  
5)  Looking forward, what strategies do you think will be the most effective towards achieving interoperability and ubiquitous exchange of health information across the care continuum?  
 
Transcript:
 
Question 1
 
JHT: Welcome to the Health Information and the Law Perspectives from the Field Interview Series. Today we’re speaking with Lucia Savage, JD, who is the Chief Privacy Officer for the Office of the National Coordinator for Health Information Technology (ONC) at the U.S. Department of Health and Human Services (HHS). Welcome, Lucia. Thank you so much for joining us today.
 
LS: I’m happy to be here!
 
JHT: Great! I’d like to start with having you tell us a little bit about the Office of the National Coordinator and your role as the Chief Privacy Officer.
 
LS: Sure. This office was created in 2004 by an executive order by then President George H. W. Bush and in 2009, Congress created it in statute as part of the American Recovery and Reinvestment Act in the subpart called HITECH. They charged ONC with a few obligations. One is to make federal regulations regarding what the technology that is certified electronic health records technology is required to do to receive a certification. Another piece of that statute was to create this office, the Chief Privacy Officer’s office. This office is particularly charged with being a subject matter expert for the National Coordinator for Health IT, and the Secretary, and really all of the Executive Branch about what should be the privacy and security standards pursuant to which we grow the use of health information technology (health IT) in the health sector overall. Not just the traditional delivery setting of hospitals and physicians’ offices, but really across the burgeoning world of health IT in general. 
 
Question 2
 
JHT: That’s wonderful and such a critical role. I know, since its inception, the Office of the National Coordinator has worked to encourage greater health information exchange, to improve health care delivery, and that has included policy-making, dissemination of grants and other forms of funding, developing implementation of certification standards that you mentioned, convening stakeholders and really thinking about these critical issues related to privacy and security. So, as you’re thinking about the role of the Office of the Chief Privacy Officer and ONC more broadly, what do you view as the main thrust of ONC's current role in advancing greater use and exchange of health information? 
 
LS: Well, ONC has made really great strides since HITECH in actually getting physicians’ offices to adopt electronic health record technology. Now, what we have to do is build on that foundation. From a privacy and security standpoint, what we have to do is bring the same power that exists right now for the physicians themselves with their electronic health records to the process of privacy compliance. I call that computable privacy. We need to get to a point where people understand how the data will move electronically. In the normal course of healthcare, when they are asked to or given the opportunity to express choices about where their data will move, those choices are captured electronically so that the process of capturing those choices doesn’t slow down and interfere with interoperability itself. So it’s a lot of looking around the corner. What does the technology allow us to do in the future? Let’s go there. 
 
Question 3
 
JHT: That’s great and that actually leads to the next question. I think, as you have indicated, there is a great benefit of the use of health information technology and health information exchange in particular both to improve the quality of care delivery and reduce costs, but the technology and the infrastructure continues to evolve. As we know, there have been a number of financial incentives and certification efforts particularly through the Office of the National Coordinator and the Centers for Medicare & Medicaid Services (CMS) in particular, but we are still seeing some lag in the full use and adoption of health IT, particularly across settings of care.  As we continue to move towards this concept of “computable privacy,” what do you see as the most prominent barriers or challenges to being able to take that look around the corner and really take this to a more universal avenue of exchanging health information? 
 
LS: One of the really great, elegant things about the HIPAA Privacy Rule is that now it is sort of media agnostic. There was a funny tweet a few weeks ago from my colleague Steve Posnack (@HealthIT_Policy) about carrier pigeons. It’s actually true that you could theoretically write down somebody’s protected health information, put it in a little leg band and send it off by carrier pigeon because the HIPAA privacy rule is media neutral. It was written that way in the very beginning 15 years ago and we need to take advantage of that today. So, that’s a really big thrust of the work we are doing in collaboration with the Office for Civil Rights. We detailed a lot more of that in our final Interoperability Roadmap which was released last week on the 6th of October and is available at healthit.gov. We have a really good foundation right now to interoperably move the data electronically for patient care and care management and even to bring family members into the care process, but we’re not taking advantage of the rules we have. That’s one piece of it. The second piece of it is that on top of HIPAA, as GW knows, we have a lot of additional rules. The stew that is our privacy rules environment is very confusing to non-lawyers. It’s pretty confusing the lawyers themselves but it’s worse for the providers and the office managers on the ground. We have a very long road ahead of us to both help harmonize that and to bring the power of computing to help people do what they need to do for privacy compliance.
 
JHT: I’d like to drill down a little further on that issue that we refer to as the “complex web” of rules and regulations that govern health information, and I know that we have all talked about the important role of harmonization of those rules. Could you talk more about direct steps from your office to work towards greater harmonization of the rules and being able to translate this very complicated information to the folks on the ground who need to know “May I share?” “May I not share?” and how is this information flowing?
 
LS: Sure! One of the most complicated health care situations we have in America is people who have comorbid physical and mental health conditions. I’m going to put substance abuse to the side because there’s a specialized rule for that. Take my mother. She’s 87 years old, COPD and she’s bipolar. (I have permission to talk about her all the time, so I do.) We need to get to a place where all of the physicians treating that patient have access to the same information and they’re working in concert to make sure that the patient remains healthy. Whether it is through kidney function tests, or how much asthma medication, or whether allergies to that medication that are triggering psychiatric results, all of that stuff needs to be accounted for. The way that we do that is by giving the physicians access to all of the information. The problem is that we have this really complicated rules environment that sometimes results in the data not being available to the entire care team. We need to accomplish two things. We need to create less confusion about those rules and at the same time we need to recognize that a lot of those specialized rules are intended to protect people from health status discrimination. We have a very complicated policy challenge which is preserving important protections against discrimination and removing confusion so that data can move and people’s health can improve. The one step that we’re doing, and we’re a small federal agency as far as federal agencies go, but we will be starting down a path this fall working with the National Governor’s Association (NGA) and a select group of states where we will be facilitating, helping those states understand their Medicaid population is, the various tradeoffs about health status discrimination, complicated rules, how computers could or could not help them alleviate the complexity of the rules or facilitate compliance so that physicians feel more comfortable sharing the data and the health benefits and economic benefits of that better health for the patient.
 
JHT: That’s wonderful and we will look forward to hearing the results of that work that you are doing. This is a critical issue particularly at the state level where they are trying to develop and implement new models of care that frankly, their success depends upon the ability to share information across different types of providers and beyond the care continuum as well in some circumstances.
 
LS: That’s exactly right and this year I’m privileged to have an Army war college fellow working in my office and it has been really eye opening to me to be exposed to the statistics about how this impacts military readiness. Some people really serve the country, literally are putting their lives on the line, and are we giving them the care they need to be well out in the regular world?
 
JHT: I know, probably the scale of the lessons learned from some of those experiences.
 
LS: Yes.
 
Question 4
 
JHT: I’d like to go back. You mentioned the updated Interoperability Report released on September 6th, I think the iterations of this report and the feedback from the community has been a wonderful step towards really opening up this dialog and helping folks understand what is truly meant by interoperability. I thought that now would be a nice time to share your view of the federal vision of interoperability and again the steps that the Office of the National Coordinator are taking to move towards that vision.
 
LS: Sure. First of all, I need to correct you the date was actually October 6th, a few days ago. So, we released a number of things last week. Before the 6th, we released the Federal Health IT Strategic Plan which we are required by federal law to produce and do produce periodically in updated form. That is a plan for how the federal government can support the achievement of interoperability. One of the things it calls out is that the federal government could more effectively use its purchasing power. In the same way that the US Department of Veterans Affairs (VA) and Department of Defense (DOD) did with their recent acquisition of a new records system, we could have that same kind of assertive procurement occur in other domains. For example, what are the insurance companies who service federal personnel supplying? How they are supporting interoperability? That would be just one example. On the tail of that, last Tuesday we released our Interoperability Roadmap. This is a vision for how to get from where we are today to a learning health system in 10 years for all healthcare stakeholders. Federal government has a piece of that pie, private healthcare providers, or what I would call retail providers, have a piece of that pie, insurers, businesses, and individuals/consumers. We talk about different things that we think each of those organizations could do and things that ONC commits to doing. So, from ONC’s perspective and from my chair thinking about privacy, what we can do is work with the NGA to bring our expertise about privacy and health IT to the states. We can give the a more specific view of the pros and cons of the environment they find themselves in, and then of course the states are free to choose what they do with that information. There are other calls to action in there as well. For example, we want consumers and providers to engage more in a dialog about their own health. We want consumers to have better access to the information that they have a right to by law. So, all of that is in the Roadmap. It is a little too detailed for me to get into a lot of examples for you here today, but there will be a series of blog posts coming out about it. People should watch healthit.gov to get the highlights about it from the blog posts.
 
Question 5
 
JHT: So finally, looking forward, based on your experience at ONC and of course your exceptional prior experience, what strategies do you think will be the most effective towards truly achieving interoperability and exchange of health information across the care continuum? 
 
LS: I’m a strong believer in consumer demand. I think that we collectively as a society need to figure out a way to make the advances in health IT meaningful beyond the people who are ill. So, right now, a person who is ill or someone like myself who is helping to care for an ill person, this is a really key thing. What are my mother’s lab results this month? How is she doing? Did she take her medications? Our caregivers across the country are exhausted and frustrated because it is hard for them to access this information and do their job as caregivers. So, that’s a thing we need to solve for our population that’s ill. More importantly, I always think about the airbag example. Airbags were a car experiment. Chrysler put one in a car as a vanity item, and it was so wildly popular that pretty soon everyone put in airbags. At first, they were buy-ups but now they just come. You wouldn’t buy a car without an airbag. At some point down the road we will have a population where most people will prefer physician who has the power of computing to help them avoid errors and ensure that tests are taken and things are read properly and the data they have in front of them is the data they need for care. It may not be tomorrow but it will come in the future because we have that in the rest of our consumer world.
 
JHT: Wonderful. I think that’s really helpful and I think that in particular as we think about more and more opportunities for consumers to access their information, to use their information and to share their information with caregivers as well, this will continue to resonate. Again Lucia, we really appreciate your time today and we look forward to continuing this dialogue with you. Thank you.
 
LS: Thank you for having me and I look forward to working together in the future.
 
JHT: Wonderful, thanks. 

 
Further Resources:
 

 
 
 
 
 

Perspectives from the Field: Interview with Dr. Bruce Siegel November 6, 2014

Tue, 2015-11-03 12:21 — healthinfolaw_admin
https://www.youtube.com/watch?v=1p3dXGz6p7o
application/pdf iconSiegel final transcript.pdf

Perspectives from the Field Interview Series
Interview with Bruce Siegel, MD, MPH
President and CEO, America’s Essential Hospitals in Washington, DC
November 6, 2014
Interviewer: Jane Hyatt Thorpe
 
 
Questions:
 

1)  Please tell us a little bit about what you do and how it intersects with health information exchange? 
2)  Besides using information directly for patient care, what other potential benefits are there in health information exchange for public hospitals and the health care system in general?
3)  What are some barriers or challenges to fully realizing that potential, especially for public hospitals?
4)  What do you see as the most promising long-term solutions to these challenges?
5)  In the meantime, do you recommend any strategies that public hospitals and other health care providers can use to maximize the use and exchange of health information, both for patient care and for overall improvement of the health care system? 
 
Transcript:
 
Question 1
 
JHT: Welcome to the Health Information and the Law Perspectives from the Field Interview series. Today we are speaking with Dr. Bruce Siegel, President and CEO of America’s Essential Hospitals. Bruce, thank you so much for joining us today. Would you please tell us a little bit about your current position and how it intersects with health information exchange?
 
 
BS: Sure. I am the head of America’s Essential Hospitals and we are a trade association based in Washington, DC, that champions hospitals who care for the most vulnerable. So, our hospitals can be hospitals with lots of Medicaid patients, lots of uninsured, who are really serving a safety net mission in their community. For them, health information exchange is a very big deal and is something that could bring really enormous benefits. Our hospitals are all working diligently to achieve the benchmarks and milestones of Meaningful Use. Actually, some of them were the early adopters. The first electronic health records in hospitals in our country probably started either at Eskenazi Health in Indianapolis or at Boston Medical Center in Boston. Our member hospitals have been really at the forefront, really have been the early adopters of health information technology and exchange. 
 
Question 2
 
JHT: That’s great. Can you comment a little bit more? You mentioned how health information exchange can have enormous benefits for the populations that you are serving, primarily the Medicaid, uninsured, and the safety net, can you expand a little bit upon the benefits for those patients in particular?
 
BS: Sure. I think it is important to know a little more about our patients. Our patients are very diverse. Most of them are racial and ethnic minorities. Most come from low income households. Many have chronic illnesses. Many have behavioral health issues. They are people who have not gotten a lot from health care systems, frankly, but who have many needs and are a very diverse group. They are people often who for many years never had a medical home. They may have had no usual source of care. They would be interacting with multiple providers across the community and unfortunately, sometimes the care is not as coordinated as it should be. They have gone from emergency department to emergency department or to a doctor’s office or they have been seen in a homeless health clinic. They really are the most vulnerable and sometimes there is sort of that patchwork of the clinical services and social services in their community. Because of that, their needs are very complex and tracking all of this information around their care is absolutely essential but also very hard. So if somebody has been seen in multiple sites and it’s hard to link those records, if those records can’t communicate to one another, then we see instances where folks come in to the hospital or the emergency department, or the clinic, and we don’t know what happened to them before. So, we can’t give them the right kind of care. Or, we wind up duplicating tests that they’ve had before. So, health information exchange is a huge challenge for our patients and for our hospitals, but also it could be hugely important in tying all of this together and rationalizing the sorts of care our patients are getting.
 
JHT: That’s very helpful. So that’s obviously very specific in terms of using information directly in patient care to encourage coordination and integration of care that may be received across a number of settings. Could you speak a little bit about other potential benefits that there may be for health information exchange, particularly for public hospitals as well as the health care system in general. Perhaps this may be things such as quality improvement or, you mention, disparities reduction. So, thinking a little bit more beyond patient care, what are some other benefits you see for health information exchange?
 
BS: Well, first of all there is the whole role of public health and population health here. So, I think all hospitals in America are now being challenged to look beyond just caring for a patient for a given episode to really improving the health and wellness of an entire community. That will require linkages between the health care system and the public health system. For some of our members, especially our public hospital members, that’s already in place. So, for instance, if you have Contra Costa Regional Medical Center in the bay area of California, they are very much part of and linked to their county health department. So, their records around immunization, records around things that are happening around public health can be linked to the clinical records more easily in places like that. But, in other communities where linkages need to happen there are no natural connections. Starting to build that will be important for all hospitals in America, but, I would say, first and foremost, for our hospitals because they are dealing with the greatest gaps in care and the greatest gaps in health. Another critical role for health information exchange and technology is that it is helping us to fight disparities and close the gaps. Most of our patients are racial and ethnic minorities, most are low income. In many of our hospitals over 100 languages are spoken. We need to be able to understand who our patients are and health information and technology can help us do that by making it simple for us to ask and get data on a patient’s language preferences, or their race and ethnicity. We can start to understand who our patients are and what the services are that they need. I had one hospital, for instance, who didn’t realize that they were registering hundreds of Spanish speaking patients per month until they started asking these questions and putting it into their health information system. In other cases, we know that there are hospitals across America who are working to improve quality but they find that the quality they are providing isn’t the same for all of their patients. Health information and technology and exchange will allow us to know who our patients are, figure out the quality of care we are providing to each group and figure out a way to begin to close those gaps. That sort of role for disparity reduction could be really, really critical for electronic health records and the whole enterprise of health information if we wired in from the get go. 
 
Question 3
 
JHT: That’s great. So, these are some really wonderful concepts obviously, talking about fighting disparities and looking at public health and population health. Obviously, we are not to this place that you describe where all of these linkages are happening. I’m hoping you could comment on some of the barriers or challenges, especially for public hospitals, that are faced in trying to fully realize this potential of health information exchange.
 
BS: We see a number of barriers. Some of the barriers deal with standards. There are too many health information systems out there that don’t talk to one another. We are looking to a day when we, as a nation, will really get to a point where information can flow seamlessly between systems, where we don’t have silos, where we don’t have these different ecosystems of health information that don’t speak to one another. We’re not going to get to a point where a patient can move between sites and know that they will get the best care at every site until we solve this problem. I would make that the number one issue for us around health information and exchange. As health systems, we have other challenges as well. Most of our hospitals lose money. The average Essential Hospital in America has a negative margin while most other hospitals in America have a positive margin. So, for us, resources are very thin. That plays out in a couple of ways. Putting these systems in takes money, it takes capital, and clearly, the federal programs that have been put into place, the stimulus programs and others have helped, but it’s still a big lift for the hospitals that care for the most vulnerable who have razor thin or nonexistent margins. But, beyond the capital, there is also the question of just recruiting; retaining the kind of staff you need to actually put these systems into place and to keep operating them. Again, that is a struggle with finances and that is a struggle with dollars. In a competitive market where you are trying to attract those same people that a richer hospital across the city is attracting, it is harder to do that and will put even more pressure on our mission and being able to do the things that we need to do. The third thing I’d mention is something that probably doesn’t get talked enough about. That is the whole issue of work flow and productivity. Our hospitals are some of the most complex hospitals in America. They’re almost all teaching hospitals, they have big trauma centers, transplant programs, many of them today have now been designated as Ebola referral hospitals by their states. These are very complicated environments and are very large environments. Often with hundreds of thousands of patient encounters, even millions, every year. When you put in new technology into such a complex environment, where you have people from the hospital, the medical school, the public health agency, and all sorts of disciplines working under one roof, it’s complicated. It’s hard. Often it can lead to a drop in productivity. Things get slower as people get used to these new systems and try to figure out how to use them. We saw one hospital that needed about 20-25 hours of training per physician just to make sure that they knew how to enter data in the right way and could be accurate in their documentation. Some of our hospitals have thousands of physicians working under their roof and they are some of the largest training centers in America and in the world. So, you can imagine the expenses and just the productivity drops that come in a situation like this is another big challenge for us in moving ahead.
 
JHT: That’s really interesting, particularly the workflow and productivity. I agree that I think it is one of the issues that gets the least amount of attention but in some ways can be one of the most critical issues that providers face in particular when they are trying to move forward with these systems.
 
BS: It can. And I think it has been underestimated. I don’t think we recognize the both human and financial costs around it and it doesn’t just go all away at once. I know a lot of people who think “oh once you get past initial installation you won’t have to worry about that again.” But, the honest fact is that these systems require upgrades, it’s a good thing, they need to be modified, and they need to be changed over time. These are not going to go away and this reality of our environment is here with us to stay.
 
Question 4
 
JHT: Absolutely. So, in thinking about these barriers you have identified in terms of standards, scarce resources, and work flow and productivity, what have you see as some of the most promising solutions or activities to address these challenges and those hospitals that have been able to overcome in part some of these barriers?
 
BS:  I would say they have overcome it through will. They have overcome it because they know it is the right thing to do. Certainly, would we like to have more resources to do it? Sure. But I think that all of our members are committed and they know this is the future and that it is the right thing to do for our patients, especially the most vulnerable. When I see the promise of this and I see the benefits, I see things like the San Diego Beacon Program which is one of our member hospitals at UCSD. They have basically built a virtual safety net that links the hospitals, the community clinics, emergency medical services and others into one web that is built around an individual patient, not built around the hospital or the clinic. I think they are seeing some real results in terms of keeping people healthier and keeping them out of the hospital. We are seeing the same thing in Cleveland right now. If you look at the things that have happened at Metro Health in Cleveland, where they bolted together the public hospital, the private nonprofit hospitals, the community health centers of Kaiser Permanente, they have seen real results in less waste, fewer preventable admissions in the ER visits, and, actually closing disparities in things like high blood pressure control, hypertension control. That is another example. I think that we are at the beginning stages, despite the challenges, of seeing starting to see some real payoff here. And actually, I think that the big payoff may happen in the safety nets first with some of the most complex patients in some of the most unforgiving environments who will benefit most from the ability to move real, useful information from place to place along the continuum.
 
Question 5
 
JHT: So I’m thinking about the successes you’ve highlighted, are there any particular strategies that you would suggest, in particular for public hospitals and other providers as well, so they can continue to maximize the use and exchange of health information, both for patient care as we talked about earlier as well as sort of overall improvement of the delivery care system?
 
BS: I think that public and safety net hospitals have built really large, sometimes comprehensive systems of care. They have hospitals, they have clinics, they are often linked to the public health agency, but despite that, I think their challenge is to move beyond that, to build those bridges to people they haven’t spoken to before. In the case of San Diego, that was the community clinics. In the case of Cleveland, that was linking across hospital systems; not just linking within the safety net but beyond the safety net. I think that strategy is going to be absolutely critical. We’ve seen in this country a tough ten years economically. We’ve seen more people in need and more people vulnerable. We’re going to see more people on Medicaid. So I think the challenges of the safety net and the issues around health information and exchange will go beyond the safety net. They will extend to all parts of the health system and everyone is going to have to have skin in this game. Building those bridges that go beyond our four walls, beyond honestly our hospital system to link in others are going to be absolutely critical to the future. I don’t think that will always be easy. I think it may be politically difficult. I think it will be important. As part of that, we want to be able to measure quality and outcomes across those entire systems. So, simply measuring how I do around sepsis or how I do around readmissions is not going to be the whole picture or even a real picture of what is happening in a community. Instead, we will see strategies like in Cleveland where you really have community-wide performance measurement where you see a community-wide, honest self-examination of how we are doing for the people who rely upon us. Where the people don’t view the improvement activity as something they do in their own practice or within their own hospital, but as what they do literally and figuratively as a community where they get together and spend the time to figure out these problems across these systems and silos. We are starting to see this in some places. But most of our communities in America are still far from that. That is going to be future strategy that really makes sense in this environment. One of the things I mentioned is how picking up providers who see low income patients really don’t have continuity of care and maybe moving between different sites, perhaps, too often. We also know that one of the things driving the patients to these readmissions is the inability for the patients to get to the right medications or any medications in a timely way. One of the promises of health information exchange is the ability to do medication reconciliation electronically, to really allow people who have disruptions in care to have the right meds continuously. To not see changes or unplanned changes in what they are taking or gaps in what they are taking that could lead to them going downhill or needing to be readmitted. This is one of the many areas where health information exchange can make a difference especially for our patients.
 
JHT: This has been really helpful Bruce, thanks again for joining us today. We really appreciate your insights especially in terms of public hospitals and the opportunities and challenges that they face as they move forward with greater use of health exchange and information. 
 
Further Resources:
 

Perspectives from the Field: Interview with Dr. Mehret Mandefro, June 2, 2015

Tue, 2015-08-18 15:00 — healthinfolaw_admin
https://www.youtube.com/watch?v=VKGtlR9D_4g
application/pdf iconMandefro final transcript edited.pdf

Perspectives from the Field Interview Series
Interview with Mehret Mandefro, MD, MSPH
Chief Medical Officer for Amida Technology Solutions
June 2, 2015
Interviewer: Jane Hyatt Thorpe

 
Questions:
1) Please tell us about your work and your organization with respect to health information?
2) How is the health care system changing the way health data is accessed and used?
3) What are the most significant barriers to achieving these changes?
4) What strategies would you recommend to encourage greater use and exchange of health information across the health care system by stakeholders?
5) Are there any special concerns about access to data that should be addressed by policymakers?
 
Transcript:
 
Question 1

 
JHT: Welcome to the Health Information and the Law Perspectives from the Field Interview Series. Today we are speaking with Mehret Mandefro, who is the Chief Medical Officer for Amida Technology Solutions. Welcome, Mehret. Thank you so much for joining us. We’re very appreciative to have your time today and we have a serious of questions that we would like to review with you and are looking forward to our discussion. So, jumping right in, please tell us about your work and your organization with respect to health information and the exchange of health information.

 
MM: Sure. Well, first of all, thank you for having me. I’m excited to be a part of this conversation. Amida is an open source data company with a long-standing track record in health. Our CEO, Peter Levin, co-created and led the Blue Button project while he was the Chief Technology Officer at the Department of Veteran Affairs and I was actually his White House Fellow at the time. So, we’ve been working on health informatics for the past 6 years now, actually. Obviously, a lot has happened in that space. Blue Button has gone on to be the most widely used personal health record and our company has built on its success by building other Blue Button components. Namely, the tool or software we’ve built is called the Data Reconciliation Engine, the DRE, and it is an infrastructure component that accepts health data in a variety of formats and consolidates it into an easy to use structure. So the DRE allows enterprises and consumers to reconcile health information from different sources into one single master health record. We believe that access to health information is a vital precondition for enabling a value based care system, enabling patient-centered care, because it allows consumers to actually have the means and the opportunity to make informed choices about their health.

 
Question 2

 
JHT: That’s wonderful. So, obviously over the last six years you have seen a lot of changes. What have you noticed that are some of the most prominent ways the health care system itself is changing in terms of the way health data is accessed and used?

 
MM: So, historically, health data has been trapped in institutions with proprietary systems and customized data format. On top of that there have been poor incentives, misaligned interests, and HIPAA regulations that have all kind of made it difficult to share this information and that climate is what has drastically changed. Now, we have standardized formats, formats like the Blue Button, and incentives between stakeholders. For example, payers and consumers are aligned in a way that they never have been in the past. It is actually in the interest of payers to know everything they can about their patients in order to take care of them better, instead of using health data to select out the sickest ones. I think in addition to that, consumers now have a legal right to access the health information on a medical record in electronic form. Which means institutions actually have to share it by law and, there are obviously also financial incentives for sharing this information that institutions have never had - for example, Meaningful Use. I guess the last aspect of the change that I think is particularly important is the growing consumer demand for this data. Because of things like wearables and fitness tracking devices, consumer attitudes are changing when it come to wanting to access data. Health care systems have to rise up to meet that demand. So, for all of those other reasons, the landscape of health data and how it is accessed is totally changing.

 
JHT: That’s great. Actually, for some of our audience members who may be less familiar, would you mind if we took a step back and you could provide, perhaps, just a brief overview of Blue Button and some of the components that you are building to further enable Blue Button?

 
MM: Sure. Blue Button started at the VA. The first pilot project was at the VA. It was essentially a way for veterans to get access to their care and it partly leapfrogged the standards discussion. The first version of Blue Button was literally an ASCII file that made it easy for people to get their health information. CMS then joined on and it grew wider. So, there are multiple kinds of formats. But, essentially, it made it easy to extract the data. Then, HHS took over the Blue Button project and it has become kind of a service mark and they started to market it more widely. So, now even private sector companies (lots of payers, insurers, etc.) have pledged to use the Blue Button. I think it’s actually over 500 private and public sector organizations. It has become less of a format and more of a way of talking about access to data. So, if you log into patient portals you might see that icon, that Blue Button icon, so that’s what I mean when I say it is a service mark. We ingest multiple kind of Blue Button formats now with the DRE and essentially it’s more of a back end tool we’ve built. Most of our customers are actually enterprises. We are in the weeds of the data plumbing and allowing our enterprise customers to ingest various formats into an easy to use structure.

 
Question 3

 
JHT: That’s great. So, thinking about looking ahead, you talked about how some of the barriers to access and use of health data have been tackled, in terms of proprietary nature, misaligned incentives, obviously you reference the Meaningful Use program and growing consumer demand. What do you think still remains as the most significant barriers to continue to further use and access of health information both on the provider and as well as on the consumer end and others who are in the lifecycle of the health care system?

 
MM: In my opinion, I think that the most significant barriers continue to be cultural. It’s actually not the technology. There’s actually great technology that allows you to do this. By cultural, I’m really referring to, essentially the lack of an enabling environment to support the growing demand consumers have for their data and also the lack of an enabling environment to make it easy for providers to share that. I think, framed alternatively, you can talk about these cultural barriers to just supporting patient engagement and encouraging patients to actually own their data. What the Meaningful Use requirements lay out is kind of ahead, unfortunately, of where institutions are still at. Very practical examples are patient portals. Patient portals exist right now but they are kind of anemic, and they are not exactly a top priority for a lot of institutions. Obviously, there are exceptions to this, but I think from what I’ve seen in the work with Amida, patient portals continue to be an afterthought and if they do exist, there is a very limited utility of data and the scope. So it doesn’t engender or encourage certain use from the consumer side and I think part of that cultural problem is reluctance intuitions still have to share this data because there is still a question of ownership. A lot of institutions still believe that patients don’t own their data and that’s a real problem. You can understand how widespread this problem is if you look into your own health care use and ask the institutions where you receive care, you’d be surprised at what some of the official policies are around who owns this data and that’s a problem. Obviously, it creates a tension between the growing consumer demand for health data and the structures that are set up in order to meet that demand, but overall I think we focus too much on the provider side of the equation. I think there’s a lot more that needs to be done on the demand side of the equation. Far too many consumers are still not participating in their care in the way they should and still don’t know that they have the right to access their care the way that they do. I have two elderly parents who I take care of and I was trying to get my father’s health records and it was actually a battle. I couldn’t believe how hard it was for me to get it and I’m obviously empowered and educated in the universe of health data. So, I think we have a long way to with changing the culture around it.

 
JHT: And when you say institutions, reluctance of institutions to share and release information, I just want to clarify my understanding is you are talking about hospitals, physician practices, other healthcare providers in general where people are interacting with the actual health care delivery system.

 
MM: Right, think largely hospitals. I have less interaction with the smaller provider care networks in my current position; I’m more dealing with large hospitals and enterprises. But, yeah, I would even include some of the payers in this.

 
JHT: I’m fascinated too by your comments about consumer engagement, I think it’s a challenge, and one of the things that struck me was that I was recently at a meeting for the Office of the National Coordinator where there was a group of payers who were presenting on their efforts related to encouraging their provider networks to share and exchange health information at greater rates. What actually struck me, frankly, was the focus on their providers and their provider networks and the fact that they hadn’t really jumped the hurdle to thinking about patients. I’m very intrigued by your comments about encouraging, pushing consumer demand because I think that’s the other side of the coin that has received less attention and as you noted, has been one of the barriers. As you mentioned with your elderly parents, uncertainty about what they can or cannot access, hesitation on the institutional perspective on what they can or can’t share, or the payer perspective. What have you found, working with hospitals and the larger enterprises in terms of ways to break down those cultural barriers, ways to better enable and empower patients to become more engaged in their healthcare?

 
MM: Yeah, you know I think technology has a real role here which is why I’m so excited about what Amida is doing about putting technology into the hands of users that could start to build this culture around patient-centered care. I mean, the idea of patient-centered care has been out for quite a while – it’s not a new idea. It’s just that, we haven’t been practicing in a system; i.e. we were in a volume based system where listening to patient voice and empowering patients wasn’t incentivized on any side of that equation, right? So, I think that part of what technology can do is help put people truly at the center of their health information flow. So, for example, when that happens, issues or barriers in the past like HIPAA kind of go away because it is the patient who owns the data. People always forget that HIPAA came at a time when third parties were exchanging all of this information on behalf of patients. It’s a whole different conversation when you’re actually saying that the patient is in control. I think part of how you build demand and part of how you change culture is empowering patients with tools like technology and making it easier for them to do that. I think the other piece of it is that there needs to be a lot more done around patient education efforts when it comes to demanding these rights. I think a lot of people don’t realize that they have this right to access their health information. When I told my father, he had no clue that the doctor was supposed to provide this information and actually that there is even a time requirement around how long you should wait, and guess what- if you don’t get it, you can actually complain. The idea for patients and, obviously I have taken care of patients as well, that they can kind of talk back to their doctors is kind of foreign. Some of this is having a broader conversation around health literacy, actually, and even changing the dynamics of how people think about participating in that care. At Amida, we very much believe that access to actual health information, your health information, is the first step in redesigning the flow and engendering a new culture around how you access data.

 
Question 4

 
JHT: That’s great and that makes a lot of sense. You mentioned earlier that patient portals exist but they are somewhat anemic, they haven’t been widely adopted on the patient end. In your reference to technology and putting technology in the hands of the users, have you found that there are better types of technology, or forms of technology, that are better suited for consumers or that have given a better chance of breaking down these barriers to patient access?

 
MM: I don’t know about types but with technology I think about functionality. Very critical capabilities for all portals to have are view, download, and transmit capabilities. There are still tons of portals that are just views, you just kind of look at it but you can’t actually interact with your data. In order to empower patients to actually have a voice in their care process, to own health, the holy grail of patient-centered care is shared decision making and shared power. People not only have to have the access to view it, but they need to download it, they need to talk with their caregivers, talk to people about it, they need to actually interact with it to use it in some kind of way and then they need to be able to share. All three of those functionalities are incredibly important, I think. As well as the other functionality is this idea that hopefully the access to health information is starting to be bidirectional so it’s not just about receiving the information from the medical record or from your laboratory or from your pharmacy, but it’s also patients having the ability within these portals to actually upload their own notes and thoughts about care so that communication is something that can truly be shared. Because the minute you enable something like that through technology, the entire flow of that clinic visit will change. You can imagine a situation where your primary care provider will have seen what the patient concerns are so that when that patient walks in you don’t have to wait for them to share that information, you can just say, “Oh I see that these are some concerns. Let me address that.” I think those are the kinds of proactive steps the providers have to take in order to level the playing field to every clinical encounter.

 
Question 5

 
JHT: So in thinking about greater access to and use of to information by the patient population in particular, have you seen or experienced issues in terms of data integrity or data security that are involved with some of these forms of technology and different types of functionality where you may have providers and patients supplying information to the platform for the data?

 
MM: Yeah, you know, I think, obviously, data integrity, security – Amida actually has a cyber-security background as well – I think they’re very important, but I think we have put too much time focusing on data collection overall. I think the data is definitely out there and we have ways of making sure that we can access it but, I think, in my opinion, where we should be placing the focus, especially from a policy perspective, is on the actual use of the data. So the security question should be: who is using my data and for what purpose? So said differently, the question is more: is someone doing something nefarious or unauthorized with my data? I don’t think we’re having that conversation in Health IT. There’s good news here, because there’s actually technology that allows us to track the use of data. We need to start thinking very broadly about block chain technology and the use of health data, which actually allows you to track flow of data.  Block chain technology is widely applied in economic applications, like Bitcoin technology uses it, but it has yet to be applied widely in health and health data and I think it represents the next frontier of policy concerns regarding access and security.

 
JHT: So, in thinking about that, and in thinking about the role of policy makers in particular, what would be your advice or guidance for policy makers in general to be thinking about what would help further, as you’re saying, greater focus on the use of data, and then also thinking about who’s tracking and using the data for particular purposes as well?

 
MM: I think we need to look outside of health to see how others are dealing with this. One thing that is very clear to me is that although 95% of Amida’s work has been in health care, issues with data interoperability and security and integrity are obviously not unique to health. Data accumulates in isolated silos in many sectors and individuals want on-demand access to their data in all of these sectors. There are ways that other sectors have solved some of those problems that I think could benefit the health sphere. So, I think the application of block chain technology in the economic field and understanding that better from a health policy perspective could be huge.

 
JHT: Mehret, thank you again for joining us today. This has been a wonderful conversation about patient use and access to information and the tools that Amida is building.  We greatly appreciate your time and expertise and look forward to more conversations with you in the future. Thank you.

 
Further Resources:
•       Learn about Amida Technology Solutions on their website

•       Health IT describes the Blue Button initiative

•       Video explaining Amida’s DRE (Data Reconciliation Engine)

•       Health Information & the Law Comparative Map on the Right to Access Medical Records

Perspectives from the Field: Interview with Guy Collier, August 20, 2014

Wed, 2015-08-05 14:58 — healthinfolaw_admin
Guy Collier
Partner at McDermott, Will & Emery LLP in Washington, DC
https://www.youtube.com/watch?v=Yti5lMt2ESU
application/pdf iconCollier transcript final to post.pdf

Perspectives from the Field Interview Series
Interview with Guy Collier, JD, MPH
Partner at McDermott, Will & Emery LLP in Washington, DC
August 20, 2014
Interviewer: Jane Hyatt Thorpe
 
Questions:
 
1) Would you please tell us a little bit about your current position and how it intersects with health information exchange?
 
2) What do you see as the most promising efforts to reform the health care delivery system through greater use and exchange of health information?
 
3) What are the most significant barriers (legal or otherwise) to achieving these reforms?
 
4) What role does the law play in hindering or facilitating effective use and exchange of health information?
 
5) What strategies would you recommend to encourage greater use and exchange of health information across the health care system by physicians, patients, and payers?
 
Transcript:
 
Question 1
 
JHT: Welcome to the Health Information and the Law Perspectives from the Field interview series. Today, we’re speaking with Guy Collier, who is a partner in the law firm of McDermott Will & Emery in Washington, DC. Welcome Guy, thank you so much for joining us today. Let’s start by having you tell us a little bit about your current position, and how that intersects with health information exchange?
 
GC: Sure. I am a partner in the health industry advisory practice group at McDermott in the Washington office. My practice is exclusively health care and primarily large integrated provider systems and academic medical centers, including all components of the academic medical center. So, I encounter health information issues frequently on the transactions we are doing for our clients in those areas and also discrete regulatory issues that come up from clients regarding health information, privacy, security, and other things of that nature.
 
Question 2
 
JHT: So, in working with your clients on a variety of issues you have probably witnessed a number of efforts - some of which you probably are successful and some of which may not be successful to really transform health care delivery, the system and also to greater enable the use and exchange of health information. From your perspective, what are some of the most promising efforts to transform health care delivery and to make greater use of health information?
 
GC: Well, I think there are really 3 and they all have the same purpose, ultimately, which is to not only make care more seamless among providers, different provider locations and different provider types, but also to generate meaningful data around quality and outcomes -- obviously, something that we have been working on for 25-30 years as we head towards a system that is driven by quality and outcomes and not simply by unit of service. This becomes more important. What I see specifically are really three things. One is the widespread adoption of the electronic medical record by health systems across the country. Most of our clients fall into either the Epic camp or the Cerner camp depending on the nature of the beast. Academic medical centers tend to prefer one vender over another. It is very widespread at this point. Folks are really coming out of the implementation process and they’ve spent tens of millions of dollars -- hundreds of millions of dollars -- on this process. But it’s a good thing. When you go into most academic medical centers today, they have a very fulsome Health IT platform. Everybody is using handhelds, and within that system people can speak to each other real time. I think that has been really encouraging. The second observation is the attempt to link community physicians to the Health IT platform through a variety of means. When health systems, hospitals, and academic medical centers purchase providers, when they employ providers directly, or when they structure contractual relationships, professional service agreements, and other sorts of contractual relationships with the individual practitioners, they are able to step out the Health IT platform to them, subject to some of the regulatory constraints. We’ll talk about that, and I think that’s tremendously helpful. Then, the third area is really in the ambulatory clinic space. It’s in the community health center, federally qualified community health center, and non-federally qualified. Particularly, we see initiatives around linking community health centers with each other in a given geographic area. These are truly the safety net providers in an area. We were lucky enough to work on an initiative right here in DC, probably 4 years ago, with the DC Primary Care Association to implement a city-wide electronic medical record platform across the primary care providers, or at least in the health clinics. I think that is another very encouraging sign. So I think those are the things I see on the provider side that give me some degree of encouragement.
 
Question 3
 
JHT: That’s wonderful, and obviously those have led to a number of successes in a number of areas. As you have been working through these issues with your clients I’m sure you’ve encountered some challenges or barriers to these reforms. Could you share with us what you think are some of the most significant barriers, legal or otherwise, to pursuing these reforms?
 
GC: Right. Well, I think the most significant barrier now is the inability to achieve full integration -- to link community primary care physicians and community health centers into a true, integrated system of care. It is still a very fragmented system. We may link the academic medical center components together, we may link a given nonprofit hospital system’s facilities together, we may get their physicians into the system, but for the physicians not in the system who are out in the community delivering primary care, or those community health centers who aren’t fully electronic nor fully linked to the neighboring hospital systems, it’s still a fragmented system of care. I can go to my primary care provider at the University of Missouri Health System and it’s terrific because he and all of his colleagues and every component at the University of Missouri is linked. So, they are on this wonderful electronic platform. I can access them by email, they can refill prescriptions, we can do everything electronically, but as soon as I step outside that system, I am really on my own in terms of other providers who are not part of the network -- other care sites who are not part of the network. They don’t link; there is no way for them to link. The biggest barrier I see, Jane, is continued fragmentation.
 
Question 4
 
JHT: And obviously, thinking about these issues from a legal perspective, I think there are some ways that the law can help facilitate more effective use and break down some of these challenges, mainly fragmentation, that comes from the inability to integrate or be interoperable. In some ways, there are perceptions that the law can actually hinder these efforts. In your experience, what role does the law play in hindering these efforts, and on the flip side what role does the law play in facilitating these efforts?
 
GC: Well, I think that’s a great question and a complicated question. I think the primary barrier legally is not HIPAA. I think that HIPAA was long overdue and is an important set of protections both in terms of privacy and security. Yes, it was added cost to all providers, but there are so many common sense ways through the permissible uses under the statute through appropriate authorization and consent to really work around HIPAA. So, I don’t see that as a barrier. HIPAA is a good thing, has been a good thing, and continues to be. But some of the regulatory statutes, Jane, that you and I have worked with over the years are still problematic. Particularly, when you go outside a closed system to step-out your health IT platform to independent community physicians who may be volunteer members of your medical staff but are not employees, we still face two issues. The cost is tremendous and I think cost is a significant barrier across the entire spectrum. We’ve got the regulatory barriers that come out of the federal program anti-kickback law and the federal ethics in patient referrals law, which, you know quite well, will prohibit remuneration to a physician unless it fits a designated exception under the ethics and patient referrals law. So, even with the attempted relief under these statutes two years ago where, basically, the feds tried to loosen those requirements and allow accessibility to a provider health IT platform, not prohibit it here, but still requiring a significant copay -- 15% if I recall -- it’s still an impediment. The statutes are still an impediment and the cost itself is an impediment to really stepping this out to the primary care provider. So again, if you’re an academic medical center and you’ve got 600 captive employed faculty practice plan physicians, that’s fine. That works well. But, if you’re an open staff model, as many of my clients are in the academic space, and you happen to have 2,000 physicians who are not part of your faculty practice plan, you may get your health IT platform out to some but likely not all of them. So, again, I think that those regulatory statutes have not given us the sort of relief that would be necessary to achieve full integration here.
 
JHT: (Agreeing) And even with the continuation of those, I would believe it was last December, there’s hope that they will give greater responsibility particularly to long term care. In some of the sectors of the industry that haven’t increased their options as far as electronic health records like hospitals and physicians, but I agree with you it is still limited.
 
GC: Yes, and that’s a great point. We didn’t mention long term care, the whole post-acute sector whether it’s free standing outpatient rehab, long term care, skilled and intermediate long term care facilities, they are in many ways largely outside this system. And that’s where a lot of care -- particularly in the long term care setting towards the end of life -- is where a lot of care happens. So, yes, they are not nearly as integrated as we would have hoped.
 
Question 5
 
JHT: So, looking ahead, you understanding we’ve talked a lot about promising efforts, some barriers. When you’re working with your clients and you’re thinking about furthering the reform of the delivery system and greater use exchange of health information, particularly, both across the system as you were talking about but also breaking down that barrier of being able to share outside of the health care system, or a particular health care system; what strategies would you recommend or do you think hold the best merit for really advancing delivery system reform through greater use of health information?
 
GC: Well, that’s a loaded question and a great one. We see our provider clients really going in full-bore for this. They have spent enormous sums of money and they take a year, a year and a half, two years to implement, and some have had a significant financial impact on those systems just because of the sheer magnitude of the cost here. But to really wrap in the disparate elements, the independent physicians who are not employed, the alternative site providers, diagnostic imaging, long term care, free standing rehab, I think it takes a couple of things. It takes statutory mandate to do that but it also takes money. I think we are looking at funding from the states, as the Medicaid “payor,” and we know from health reform what a difficult task that is, since we had many states opting not to expand Medicaid because of the fear of cost escalation. We need contribution from the states; we need contribution from the feds, enhanced hard dollars, maybe flowing through the Medicare program to incentivize providers to get in to the game, the electronic information game, and from commercial payers as well -- who have their own set of concerns under health reform with what the exchange business will look like and whether they can maintain appropriate reserves and margins and so forth. But I think they’ve got to get into the game financially. So, I think we need to see, not to simplify it, but I think in many ways this is all about the money. And I think we need to see a real infusion of funds here because this is very expensive stuff. It’s difficult enough for hospitals, but when you step down to the community health center or the long term care provider or the freestanding rehab clinic, this stuff is wildly expensive and may be prohibitive. So, I think we need much more in the way of financial resources.
 
JHT: That’s really helpful and I think that we have explored that from a number of perspectives. It’s interesting to focus on the financing, we obviously think a lot about the legal policy challenges or barriers but at the end of the day, this is an expensive proposition. While there is more funding than there has historically been, it’s still limited in nature. As you said, in some situations, it even comes with restrictions in terms of how it can be used or how tools and resources can be shared. So, that’s really helpful.
 
GC: Right. And I think that, just to sum up, Jane, if you take a step back and look at the environment now, we have these conflicting pressures because our clients are consolidating like crazy. They are acquiring each other; they are merging, academic medical centers getting out of the clinical business, staying in the academic and the research business but getting out of the clinical business, so we see tremendous consolidation. In large part it is driven by the fear of the unknown; the fear that under shrinking Medicare and clearly shrinking Medicaid dollars, it’s going to be a very difficult environment for folks. We see combination, we see this need to consolidate and the fear of shrinking reimbursement, and at the same time, those very fears prohibit people from maybe putting the amount of resources into this that they need to. Folks look at things like days of cash on hand, and when a health system drops from whatever the number is, 230 days cash on hand to 100 days of cash on hand, they are nervous. The bond rating agencies are nervous, everyone is nervous. So, even though this is exactly what they should be doing, those same pressures that are driving consolidation sometimes lead them to back off from a wholesale adoption. Again, that’s even more acute in case of these alternate site providers we talk about who just don’t have the capitalization to do that. One footnote, we do see some significant private equity activity with alternate site providers and even specialty physician groups. With that private equity play, we may see some capital dollars free up for some of these providers. But, right now they tend to be clustered around some more lucrative specialties, as you might imagine, things like anesthesiology.
 
JHT: Right, right. Wonderful. Well this has been incredibly helpful; we really appreciate you spending time with us today.
 
GC: My pleasure. You guys are doing great work and it is an absolutely fascinating area and it’s a large hill given the fragmentation of our health care system, the number of providers and the number of payers. It’s a daunting task, as you know.
 
JHT: Yes it is. Wonderful, well thank you again.
 
Further Resources:

 

 

Perspectives from the Field: Interview with Dr. Kavita Patel, July 30, 2014

Thu, 2015-06-04 13:27 — healthinfolaw_admin
Kavita Patel
Fellow and Managing Director for Clinical Transformation and Delivery, Center for Health Policy, The Brookings Institution
https://www.youtube.com/watch?v=ZOH5FFiAn80&feature=youtu.be
application/pdf iconPatel Interview Transcript final edited.pdf

Perspectives from the Field Interview Series
Interview with Kavita Patel, MD, MS
Fellow and Managing Director for Clinical Transformation and Delivery, Center for Health Policy, The Brookings Institution
July 30, 2014
Interviewer: Jane Hyatt Thorpe
 
Questions:
 
1) Please introduce yourself and tell us how what you do intersects with health information exchange?
 
2) What do you see as the most promising efforts to reform the health care delivery system through greater use and exchange of health information?
 
3) What are the most significant barriers to achieving these reforms?
 
4) As a practicing physician, how are you seeing health information use and exchange evolve in the delivery of health care? 
 
5)  What are the greatest challenges physicians face in moving towards use of EHRs and other forms of HIT to support health information exchange across the care continuum and with patients?
 
6) What strategies would you recommend to encourage greater use and exchange of health information across the health care system by physicians?  By patients?
 
Transcript:
 
Question 1
 
JHT: Welcome to the Health Information & the Law Perspectives from the Field Interview Series. Today, we are speaking with Kavita Patel, Managing Director for Clinical Transformation and Delivery at the Engelberg Center for Healthcare Reform [now the Center for Health Policy] at the Brookings Institution. She is also a practicing primary care internist at Johns Hopkins Medicine. Welcome, Kavita! Thank you so much for joining us today. Would you please tell us a little bit about your current position and your work and how it intersects with health information exchange?
 
KP: Sure, thank you for having me! I am currently in two capacities working on health information exchanges, one at a policy level for my role at the Brookings Institution, where I take the lead on a lot of technical advising for new payment models and how we think about changing our delivery system, and the topic of information (just generically) is literally on everyone’s conversation list when we do talk about delivery system reforms. I also work at the practical level as a clinician and I’m in an accountable care organization, we’re a patient-certified medical home and do a lot of population health type of work, we also talk about information. And so, the concepts of what a health information exchange and just the basic importance of data in a timely fashion as well as how we think about transmitting information to other stakeholders, that is something I play on both sides of from a policy level and a practical level.
 
JHT: That’s wonderful, so you have a bird’s eye view really of the policy issues and then also the policy issues in practice as you apply them to your practice.
 
KP: Right! Exactly.
 
Question 2
 
JHT: Speaking of payment reforms, what do you see as some of the most promising efforts to reform the health care delivery system, particularly through the greater use and exchange of health information?
 
KP: The biggest promise around exchange of health information is in literally the action of having parties who are invested in a patient, or a family, or a population’s health have access in a timely fashion, but the kind of modality in which that information is exchanged is just as important. So we have technical infrastructure right now for you and I to, if we can get past some of the privacy regulatory concerns that I think are important, but if we can go even a step beyond that, we have access to lots and lots of data. So when we talk about exchanging data, people feel sometimes “Well, if we set up a cloud server and have a password and username, and you can kind of go into a system and look up your information, that’s data exchange,” but that’s actually not what I found as the most valuable aspect. It’s really, “How can someone like me at a clinical level, when I’m dealing with patient’s issues, think about the data exchange that would be the most relevant to other parties.” That can be the basics—lab information, demographics, clinical data around medications—but often times it’s actually trying to capture what I need to convey in a very succinct format, and what is it that the receiving party really needs to look at in a quick and efficient manner. I’ve been on the receiving end of what I would say are literally dumps of data that then I honestly don’t have the time, desire, or incentive to look through. So I think meaningful data exchange is still something that our country is struggling with even when you’re working in a closed system where everyone has the same medical record and has access. Think of a Kaiser or some of these systems that have been around for a lot longer, these more evolved systems; it’s easier, but it’s not reflective of much of the real world. So, I can give a story from a patient today who called me from an ER that’s not affiliated with my clinic and he was telling me how the ER doctor was asking him a lot of questions, and he was like, “Well, let me call my doctor because I don’t know these answers.” I don’t have a way to push information—getting back to what’s a value and benefit of a health data exchange or health information exchange. I actually don’t have a way to transmit that right now, except to do the good old fashioned phone call or fax, and that’s it. I think that our country is still trying to get into what meaningful health information exchange is.
 
Question 3
 
JHT: So it sounds like, from your perspective, trying to move forward to achieve more meaningful data exchange is one of the key goals, and you mentioned privacy issues as well as just basic infrastructure issues of how do you send or supply meaningful data in a timely way. Are there other barriers that you see to achieving these goals?
 
KP: Yeah, I think something that comes up a lot when I’m doing payment reform work at a policy level that I don’t know if clinicians think about is the integration and incorporation of administrative and clinical data. So, a lot of what I just talked about, and a lot of what you see health information exchanges that are being built around the country—Indiana, Cincinnati, New York, Colorado—I’m familiar with a lot of the regional efforts. When you see these efforts, a lot of this comes from kind of tranches of data, some are administrative, some are clinical. Rarely do you see a meaningful integration of the two. So, when we think about information that’s really important to new delivery models for doing accountable care, like I mentioned in the ACO environment that I’m in, I need to not only understand what’s happening to my patients clinically, but I need to know how is this patient’s total cost of care been over the year. Are there some flags around some prescription drugs? Could I have been doing a better job because I see now that they are paying out of pocket for something that they didn’t tell me about that was on tier 3 of the formulary? Some of those things really are not sufficiently described within the clinical data infrastructure and you need access to administrative data. So I think that the conversations around health information and health data exchanges in general would benefit from perspectives of people at various points of the delivery system, not just the clinical front line, but also the medical directors, the practice administrators, and people who are also thinking about the larger policy framework of what the data exchange means.
 
Question 4
 
JHT: That’s very interesting. So connecting, from your perspective, the policy issues with the practical issues, and thinking about those issues in a more coordinated way. As a practicing physician, I’m sure you’ve seen use of health information exchange of information evolve over the years. What do you think are some of the most promising changes that you’ve seen?
 
KP: Promising changes just in practice?
 
JHT: Yes, trying to exchange and use health information for improved delivery?
 
KP: I think the most clear example to me has been automated alerts around emergency room and hospital discharges. It sounds tragically simple, but in the majority of the country right now, we have no idea when patients are actually going to an emergency room, or are admitted to a hospital, or even worse, are discharged from a hospital. And I think the incorporation of what we call automated discharge alerts or automated admission alerts into the data exchange is, has been, huge. What it gets at – there’s a phrase of meeting patient’s where they are – that’s how we think about person-centered care/patient-centered care – we don’t have the information to actually do that. I have no idea where patients are getting their care unless they’re right in front of my face. So I think that one of the most meaningful developments has been the integration of kind of real-time utilization data like I said, like ER use or admission or discharge. And I think that’s been a tremendously valuable asset. Another aspect of data information exchanges that’s—in the District of Columbia, that I know we’re trying—is around medications. So there’s been a lot of conversation around the use of controlled substances, and I know there’s a lot of national attention on that. In our District of Columbia Information Exchange we now have a broad network to know how patients are receiving substance prescriptions to: 1) try to understand and curb any abuse that may be happening but then 2) to highlight that there may be a patient with a real problem if we know they are seeking behavior, seeking drugs and there’s behaviors that are going to other facilities. And it sounds amazing that in 2014 we didn’t have that before, but we didn’t. So I think those are two kind of tangible developments that shine in the use of information exchanges.
 
Question 5
 
JHT: That’s great, and I think we’re definitely seeing more and more physicians and other providers move towards use of electronic mechanisms for sharing information either with a registry or participating in automated alerts, or other types of information exchanges. What do you think remain and what are some of the challenges that physicians still face moving towards greater use of electronic health records and other forms of health information technology to support sharing health information?
 
KP: I do think—so, there’s the infrastructure barrier, right? I know we’ve had conversations and there’s certainly money that’s been devoted to getting doctors to get electronic health records. But we’re still at kind of bare bones with Meaningful Use Stage 1. I mean, if you look at kind of what goes in to meeting the criteria for basic Meaningful Use requirements. One, most doctors would tell you that they’re not as clinically relevant, and they’re nowhere near where you and I would think as patients - what we want our doctors to have information around, just even something as basic as interoperability is not part of Meaningful Use Stage 1 or even Stage 2. You know, these conversations are so political about when to do these things, but I think that’s a big one. The infrastructure needed—even if you pay doctors—they’ll get an EMR that isn’t necessarily compatible with other ones because we don’t have interoperability, so you can have an electronic health record if you decide to invest in it, but you won’t speak to anyone else’s records. That’s a big barrier. That’s a huge problem. So I would say that’s two barriers. Getting the infrastructure in place and then interoperability and ability to speak to each other. I think the third one is also pretty basic. And that’s this kind of behavioral characteristic about sharing information in general. So, I’ve even called and spoken to other doctors’ offices trying to get information about one of my patients, and the doctors will say “Well, for HIPAA reasons I can’t do that. You need to have the patient call us and they need to fax us this form.” If you actually look at the barriers to how information can be exchanged that’s clinically relevant in real time for an actual patient, honestly it will frustrate you, even if those two doctors and their offices have those electronic health records in place. So, I’m not saying that HIPAA’s not a concern, but I do think that it tends to still be cultural for practitioners to not share information, and there’s something we need to do. There’s a big movement among patients about owning their data, like the Blue Button Initiative at the federal level and Medicare, where you can download your own data and it’s yours, and I think that’s really at its infancy. I think we need more movement to have patients have and own their medical records, but it also needs to be in a format that’s not just 500 page data dumps that make no sense. And that gets back to the information in exchanges being meaningful. Doctors like me don’t just want your past 20 years of medical records. We need certain pieces of information, and it’s how do you get that out of the system into the hands of someone who needs it.
 
JHT: So it sounds like some of the things you may be referencing in terms of discharge documentation or care summary records, things of that nature that would actually encompass or collapse a broad range of information into a usable document that can either be shared by the patient or shared electronically but would help foster a culture of sharing.
 
KP: Right, I’ve often thought of it—as I’ve told my own patients—as an executive summary of your medical problems. So, I’ve told my own patients, “In your medical record I’ve got what I would say is an active problem list. I don’t care about something that happened 30 years ago, but here are my active problems and here are my surgeries I’ve had and here are my active medications.” I’ve actually said, “If you do nothing else, you need that information along with your most recent set of labs.” And that will help me more than anything in probably the binders of data you bring me. So I think getting people to also understand exactly what you said, but also getting them to understand it at a practical level is where we still have a disconnect.
 
Question 6
 
JHT: Definitely. So, in thinking about the three challenges you identified—infrastructure, interoperability, and then changing the culture around sharing—what strategies are you seeing or do you think hold the greatest promise for encouraging greater exchange of health information across providers and with patients?
 
KP: So I do think the number one thing is to advance the Meaningful Use interoperability recommendations. There’s been a lot of politics around it. You can imagine the influences and interests of keeping the proprietary products proprietary and not sharing, but I think that could be the most important thing. If my EMR could talk to that doctor’s EMR, I don’t need to get on the phone and beg them to fax me something. So, I think that’s a huge policy issue that’s out there. And it’s not that the policy community hasn’t weighed in on what these interoperability standards should be, they’re just not being implemented. And so I think implementing those and enforcing those would be a huge policy directive. I think a second thing is more of that pragmatic piece of education of clinicians, you know, that exchanging information is not going to get you into legal trouble. I have to be honest: a lot of what doctors do, when they don’t want to send information, has nothing to do with not wanting to help; they don’t want to get into trouble and get flagged with a HIPAA violation. And I know that because there are even times when I feel that way. So, I think that those two things, the Meaningful Use interoperability standards implementation and enforcement paired with just education that a lot of us get from our colleagues and professional societies would be two big, two huge ways to overcome these obstacles.
 
JHT: Wonderful! Well, Kavita, we really appreciate your time this morning. This has been incredibly helpful.
 
KP: Great, thanks so much for having me!
 
Further Resources:
 

Perspectives from the Field: Interview with Dr. Robert Berenson, July 28, 2014

Fri, 2015-02-06 15:31 — healthinfolaw_admin
Robert Berenson, MD
Institute Fellow, Urban Institute; Former Vice-Chair of MedPAC
https://www.youtube.com/watch?v=dD8KJ4ckFMA
application/pdf iconBerenson Interview Transcript final.pdf

Perspectives from the Field Interview Series
Interview with Robert Berenson, MD
Institute Fellow, Urban Institute; Former Vice-Chair of MedPAC
July 28, 2014
Interviewer: Jane Hyatt Thorpe
Questions:
1)  Please introduce yourself and tell us about your work related to healthcare delivery, quality, and payment?
 
2)  What do you see as the most promising efforts to improve health care delivery and reform payment systems? 
 
3)  Do you think the increasing ability of providers and payers across the care continuum to track and share patient information in a more longitudinal manner using electronic health records and other forms of health information technology will benefit these efforts?
 
4)  What are the most significant barriers to achieving the reforms you noted previously?  
 
5)  In the health policy literature, you’ve discussed the threat of market consolidation as a (perhaps unintended) consequence of incentives to improve quality and better coordinate care (including incentives to use electronic health records).  Can you explain that concern?
 
6)  What do you see as the best solution to that problem?
 
7)  Can the health care system increase transparency and realize the benefits of greater exchange of health information to support improved quality of care across the care continuum without creating market conditions that drive up prices? 
 
Transcript:
Question 1
 
JHT: Welcome to the Health Information and the Law Perspectives from the Field interview series. Today, we’re speaking with Dr. Robert Berenson, fellow at the Urban Institute and board-certified internist.  Welcome, Bob. Thank you so much for joining us today. Would you please tell us a little bit about your work and how it is related to health care quality, delivery, and payment?
 
RB: (Laughing) That’s what I do, I work in health care quality, delivery, and payment. I practiced medicine for twenty years but then made the move into policy, and so I spend most of my time analyzing and making recommendations about new payment models, new organizational delivery models, expressing concerns about overly optimistic use of performance measures on quality, but that’s what I do, get involved.  My major focus is on Medicare because I spent a number of years at CMS in charge of payment policy in Medicare, but a lot of my work extends to private payers, and to some extent, Medicaid as well. 
 
Question 2
 
JHT: Wonderful. So you mentioned a lot of the new reforms and efforts working to improve health care delivery and payment systems.  What do you see as the most promising efforts to improve health care delivery and payment reform?
 
RB: Well, I think the efforts around setting up accountable care organizations (ACOs), having physicians (with or without hospitals) taking responsibility for quality and prudent spending I think is a very promising development.  I do have some concerns that we’re not approaching it with the right payment approach, but that gets down in the details.  But basically, getting physicians to move from doing services based on fee schedules to actually doing population-based health, meaning trying to preserve and improve the health of the population for which they’re responsible, I think, holds great promise. 
 
JHT: As a follow-up to that question, you mentioned moving physicians from a fee-based schedule to more of a population health perspective, what do you think are some of the tools that can help physicians move in that direction?
 
RB:  Well, there are tools like electronic health records, like more data about performance, but ultimately, I think it’s about culture and leadership. I was actually involved as a private physician doing population-based payment 25 years ago, and we didn’t have some of the fancy stuff, the tools I guess we’d call them, that we have today and we were able to do it differently. So I actually think getting financial incentives improved and having a commitment to doing things differently is a good part of what needs to happen. The tools become mechanisms to achieve it. 
 
Question 3
 
JHT: So, as we know, there have been incentives for using electronic health records and other forms of health information technology, mainly to support providers and payers in sharing information across the care continuum.  Do you think continuing to move down that path of enabling providers to share information more broadly within a care team or even externally to a care team will help move toward a more population-based perspective of health care delivery?
 
RB: I think so, but I think people ignore one of the major obstacles to that which is that, for the most part (and since I don’t practice, I’m not daily involved with electronic health records), but people tell me that the vendors have developed software that is so oriented to the documentation requirements for payment under fee-for-service that the real potential of electronic health records is being missed. And here I’m not referring as much to information exchange as the electronic software not emphasizing enough decision support, registry functions, those kinds of things, it’s oriented very much towards documentation for the purposes of getting a high level of office-visit payment, that I think that’s been missed as an obstacle to the full implementation of electronic health records.  It’s become sort of a data dump with lots of cut and paste from previous encounters just to justify coding.  I’ve written about this and yet it doesn’t get much attention.  But I basically agree with you that there is real potential for information exchange.  There I would say it’s necessary but not sufficient.  There have been estimates of savings that would accrue by reducing the redundancy of tests and imaging and minor procedures, but that redundancy will only disappear if we have payment models that give physicians and other clinicians incentives to reduce that redundancy.  So the electronic health records and information exchange if properly used would provide the information, but in a fee-for-service system, there’s no reason to reduce that redundancy.  So, to just repeat the point, I think the electronic health record and health information exchange is necessary but not sufficient to change physician behavior, or I should say, clinician behavior.
 
Question 4
 
JHT: So it sounds like, from your perspective, two of the significant barriers to achieving a more population health-focused perspective of care delivery as well as payment reform are the fact that the electronic health record and perhaps other health information technology solutions aren’t necessarily geared towards true care delivery transformation and are more oriented towards the current payment system which then acts as an additional barrier to truly achieving payment reform. 
 
RB: Yep, I think that’s exactly right
 
JHT: And do you think there are other barriers to achieving these reforms that we’ve talked about?
 
RB: Well, there’s a related barrier that we haven’t talked about, which is, taking my premise that the real potential lies in accountable care organizations (ACOs) built on primary care (which is sometimes called patient-centered medical homes), the danger is that instead of achieving efficiency, reducing costs, improving quality, and passing that back to consumers in the form of reduced premiums, that those integrated entities decide to keep the savings for themselves, and by being able to achieve market power to raise prices.  So it could well be that the ACO might be more efficient - there are at least theoretically some economies of scale, better access to capital to get better electronic health records and other technologies - but they also have the ability to raise prices on payers, and we’ve seen evidence of that.  We’ve seen consolidation in the provider market, horizontally, with hospitals forming mega hospital systems, and now through ACOs, we’re seeing vertical integration with doctors becoming either employees of the hospitals or part of joint ventures with hospitals.  Unfortunately, as long as we have a predominantly fee-for-service system, that results in raising prices and in fact raising the cost of health care rather than reducing it.  So we have to move towards integrated care but we also have to address this concern about market power that consolidation and integration produce.
 
Question 5
 
JHT: So it sounds like what you’re saying is that the potential for market consolidation that may be happening through the formation of these patient-centered medical homes, accountable care organizations, where physicians are coming together and perhaps taking advantage of the incentives that are available for use of electronic health records as well as these new care delivery models, that there may be some unintended consequences of that, namely raising prices on the consumer. Is that correct?
 
RB: Yeah, I think so. I’m less concerned about medical homes, that primary care practices would have that kind of market power, as I am about integrated hospital/physician organizations or single specialty groups that get market power, but that’s the general concern, that this is an unanticipated policy consequence.  I’m a little suspicious that some of the hospitals that are employing physicians in the name of forming integrated care  to do population health and be more efficient, that that’s just the public presentation of what they’re doing, and in fact, what they’re really doing is just taking advantage of the flaws in the rules around fee-for-service.  One of the examples in Medicare and for private payers is that a hospital gets paid about twice as much for the identical service performed in the outpatient department as it would be paid for the service performed in a physician’s office.  So in some cases, you have the physician who used to be independent now has a plaque on the door saying they’re part of the outpatient department.  It’s in the same location, it’s got the same personnel, the services are identical, but now they get twice as much money because there’s a facility fee associated with it. So, it is hard and challenging to figure out which hospitals’ systems are really developing new models like accountable care organizations with integration to actually change their business practices, change their business model, and which ones are really doing it to just take advantage of flaws in fee-for-service.
 
JHT: Thinking in addition to the payment mechanisms here, particularly fee-for-service, with the formation of accountable care organization and other integrated forms of care, one of the benefits often can be easier sharing of patient information, or access to patient information across the care team.  However, on the flip side, thinking from a market perspective, we’ve seen some instances where the information has been hoarded to maintain market share or patient share, so to speak.  Is that something you’re encountering in the work that you do as well, seeing the hoarding of information for market power as well?
 
RB: That’s interesting.  No, I’m not aware of that phenomenon but I don’t find it surprising. I do find surprising that some of the IT systems don’t talk to each other even when they are from the same vendor.  There doesn’t seem to be a commitment, as we’ve proceeded with meaningful use, to actually get information exchanged, but the part about hoarding is not one that I’m aware of.
 
Question 6
 
JHT: Going back to the question dealing with the impact of market consolidation as a consequence of the multitude of incentives that are available, when you’re thinking about changes to the fee-for-service system, the underlying payment system, what do you think are some of the best solutions to address payment mechanisms that might break down some of these concerns with market consolidation?
 
RB: Well, this does get into the nitty-gritty of the new payment models.  If, in fact, one moved to a payment model that’s akin to what used to be called capitation (that’s become a dirty word so we don’t use it much anymore) but the equivalent of that is, let’s say, a percentage of premium deal, where the provider system gets a percentage of the health plan’s premium that they’re marketing in the marketplace, then there’s a counter-incentive against raising prices.  That premium is established as a community-wide premium, any health care system that demands higher prices for their services in that thing would be self-defeating, because all they’re getting is a percentage of that premium.  So that is the kind of payment mechanism that could address pricing. Clearly, the systems that are already getting high prices will resist that.  They would much rather have what’s currently being used in Medicare and amongst most private payers, which is comparing spending to your historic spending. In other words, taking your historic spending, trending it forward by some inflation factor, and then comparing whether your new spending is more or less than that target. That essentially builds in the pricing distortions that already exist in the marketplace. The point I would want to emphasize here which I haven’t done so far is that there are extraordinary pricing differentials that are basically unjustified. This was well documented by the Attorney General of Massachusetts report from 2011, which found that hospital prices varied 100%, 150%, from each other, based not on the quality of care produced, not by the teaching mission, not by socioeconomic factors of the patients, but simply as a function of market power.  And so, some hospitals were getting Medicare or a little more than Medicare as their rates, and others were getting 2 times Medicare or even more than that.  There has recently been documentation of some hospitals that are getting 500% of Medicare.  And what’s the justification for that?  It’s because they can. It’s a market negotiation between a health plan and hospital, and in some cases the health plan has no alternative but to use that hospital or health care system, and the result is paying extraordinarily high prices.  I guess my point is that this is not an issue that has gotten a lot of attention, and it deserves it.  One could ask the question whether not-for-profit hospitals deserve their not-for-profit status if they are able to negotiate payment rates that are exorbitant like that and pay their executives huge salaries, it’s not clear what the social benefit is, but that’s another issue that one could look at.
 
Question 7
 
JHT: So, you mentioned the Massachusetts Attorney General report that involved greater transparency of price information, there are obviously a lot of efforts underway to increase transparency of price information as well as quality information, and some of these efforts are supported by the exchange of health information to yield this information.  Do you think these efforts to continue to increase transparency of price and quality information will be a benefit, or do you think they will have unintended consequences related to market conditions that are driving up prices?
 
RB: I think both.  One of the real values of that transparency is to shine a spotlight on the issue.  I think it’s embarrassing to a hospital system if that kind of data reveals outrageously high prices at a time when people’s premiums are still rising significantly, I think that is useful.  At the same time, in terms of actually affecting behavior, there’s some reason to believe that when you publicly release hospitals prices (I’m picking on hospitals because that’s the easiest area to produce prices and hospitals do represent a significant percentage of health spending), when you produce everyone’s prices, the hospitals that have been relatively low-priced look and say “I want what that guy’s got!,” and in fact, it can have a perverse effect to increase prices.  Indeed, the Federal Trade Commission (FTC) says that in some circumstances, not just in health care but across other sectors of the economy, transparency of prices can be anti-competitive.  So it’s something of a complicated topic.  I think that the pressure for transparency is such that we’ll go there and then the question is what do we do with those entities whose prices are extraordinarily high.  There are probably market-based and regulatory approaches to dealing with that.  On the quality side, again, generally, I’m in favor of transparency of information.  My concern is that in many important areas of health care delivery, we don’t have good measures of quality.  I’ve been concerned and have written about my concern about taking measures that we do have and exaggerating their importance.  The most absurd, which is now current law, is that by 2017, CMS (Centers for Medicare and Medicaid Services) will be obligated by law to provide a value-modifier, an index of every physician’s value - they’re supposed to consider both quality and spending to determine a value index for every physician. Well, it’s crazy.  We don’t have measures that can do that.  CMS has to pick a handful of measures, some of which have very little to do with the physician’s overall quality, and somehow attribute spending through the whole system to an individual physician and come up with this value index.  It’s quality measurement run amok!  I think there are some good measures and I’m all for publishing those measures but I have great concerns about overdoing or not recognizing the limitations of the quality measures that we now have.  In very many important areas, we do not have good measures of quality, so the concern is that we’re going to use marginally important ones to fill in the gaps, and that will be very misleading.  
 
JHT: Wonderful. Well, we very much appreciate your expertise and the perspectives that you’ve shared with us today. Thank you!
 
RB: Ok!
 
Further Resources:

 

Perspectives from the Field: Interview with Pat Montoya, August 11, 2014

Wed, 2014-11-19 17:04 — healthinfolaw_admin
Pat Montoya, MPA, BSN
Project Director, New Mexico Coalition for Healthcare Quality, HealthInsight New Mexico
www.youtube.com/watch?v=FzZYq4L3DwA
application/pdf iconMontoya Interview Transcript.pdf

Perspectives from the Field Interview Series

Interview with Patricia Montoya, MPA, BSN

Project Director, New Mexico Coalition for Healthcare Quality, HealthInsight New Mexico

Click here to access Patricia Montoya's biography.

August 11, 2014

Interviewer: Jane Hyatt Thorpe

 

Questions:

1) Please introduce yourself and tell us how what you do intersects with health information exchange?

2) What do you see as the most promising efforts to reform the health care delivery system through greater use and exchange of health information?

3) What are the most significant barriers to achieving these reforms?

4) What do you think the role of the states should be in reforming the health care system?

5) What strategies would you recommend to encourage greater use and exchange of health information across the health care system by physicians, patients, and payers?

 

Transcript:

Question 1

JHT: Welcome to the Health Information and the Law Perspectives from the Field interview series. Today, we’re speaking with Patricia Montoya, Director of the New Mexico Coalition for Healthcare Quality. Welcome, Pat. Thank you so much for joining us today. Would you please tell us a little bit about your current position and how it intersects with health information exchange?

PM: Sure. Thank you very much for having me. It’s a pleasure to be here today and to have been a part of this group. As you mentioned, I am the Director of the Aligning Forces for Quality Initiative in New Mexico, which is the New Mexico Coalition for Healthcare Quality, hosted at HealthInsight New Mexico, and we have been at this work since 2009. The focus of Aligning Forces for Quality is bringing together multi-stakeholders – those who provide care, pay for care, and receive care – to really improve both the quality and efficiency of care and help everyone reach the value proposition in health care. So, as a result of that, we are looking at what we can do to create more efficiencies in the system, which is impacted by health information exchange. So, for instance, when we look at health information exchange, we go beyond just the technical term that many people think about when we talk about a health information exchange in a state to how and where is health information exchange needed. So, for instance, we’re doing some public reporting, and that’s about increasing transparency in health care on quality measures as to how both hospitals and medical groups, or physicians, are doing in their quality of care, but at the same time, we’re also looking to reduce readmissions and to improve care transitions/care coordination. That is where it’s so imperative that we have a functional health information exchange that allows for information to be exchanged between the different sites of care, whether it be ambulatory to a hospital, if a patient is admitted, or if a patient is being discharged, being transitioned back to their provider so that there can be the appropriate follow-up, thus reducing a readmission.

 

Question 2

JHT: Wonderful. That’s incredible work. What do you see as some of the most promising efforts to reform health care delivery through greater use and exchange of health information as you’ve described?

PM: Well, I believe that the most promising efforts are that we will, at some point, really reach those efficiencies and truly get to that point of not only efficiency but better quality, more patient-centered care. As a result of all that, we’ll be seeing hopefully reduction in health care costs. I do believe that if we can get all of the health IT that we have going on out there in communities and states around the country truly functional and connected to each other, we will actually create what could be called a system of care. I think that’s one of the challenges we have right now, that we don’t truly have a system; we have many silos in which we provide care. And the many inefficiencies and the cost and the loss of quality or patient-centeredness as a result of that not being able to connect all those different parts providing care to an individual.

 

Question 3

JHT: It sounds like one of the most significant barriers you see to achieving this efficiency, better quality, and sharing of information is the fact that while there are advances in the use of health information technology, there have been challenges in terms of connecting the systems together and connecting the providers together, and I think there’s been a lot of discussion (at the federal level and the state level) around interoperability or lack of interoperability. Could you speak a little bit more about this barrier and ways in which, at the state level through your organization, you’re trying to address this lack of interoperability or lack of connectedness across the silos?

PM: Sure. Well, definitely this interoperability is the major issue, not only in local communities and states but across the country. Even today, although there has been a major focus on health information exchanges from the federal government since 2003, 2004, we have very few fully-operational statewide HIEs (Health Information Exchanges) that have really come up and are actually successful in creating all those connections. One of the big reasons is because of the lack of interoperability. You know, you ask what role can the state play and unfortunately, at this point in time, there is not an easy fix for the state at this time because, what has happened is that, from the federal level, as there has been this push and flow of dollars to implement electronic records and also to create HIEs and all-payer claims databases (APCDs) and all these different systems in health technology, there has not been enough focus and effort at the top, frankly, to encourage and push the vendors to assure that there is this interoperability. Therefore, when a delivery system or practice chooses a vendor for their health technology implementation, they look and ensure that they perhaps meet meaningful use criteria, but that doesn’t mean that they will be able to be connected to others or to their exchanges locally. So, one of the things we see here in our local market is that we have three large hospital systems, with three different EHRS. So, for example, one of our large hospital systems has an Epic system, and they can work and connect within their system statewide, and they can even connect to Epic around the country, but that Epic system doesn’t connect with, say, the Cerner system that is at another hospital or is not providing a direct connect to the HIE. So, it’s one of those challenges, from the very beginning, where the vendors have been out there providing products but there has not been an effort … and probably lessons learned, if we were to go back in time, would be to say as those federal dollars were released, there probably should have been more of an emphasis on the state at that point being in a role of coordination to assure that those types of efforts would occur, so that there would have been a real partnership. That wasn’t necessarily the case, so therefore we now have these disparate systems – all of which are fine systems but not necessarily creating the linkages that were hoped for.

JHT: That’s very interesting, especially the fact that there are good systems but they’re not connecting. So, it sounds like, in terms of the barriers to achieving interoperability, you mentioned the vendors in particular, creating systems that can’t talk to each other. Have you experienced other challenges, perhaps at the physician or hospital level, to achieving interoperability as well?

PM: Well, yes. One of the things that we’re seeing is that all of these provider groups, whether it be physician’s offices or hospitals, they have invested a lot of their own money into their systems, and what they keep finding is that every time they turn around, in order to get themselves to a different level of being able to connect, they’re having to keep adding to their system, which keeps adding to their cost. So, I think, what we’re seeing even more so now is more resistance on the provider side, saying: “We thought this was a good idea, we moved forth with implementation, we know technology is here to stay, we do believe ultimately it will help improve care, increase efficiency, and help reduce cost, but now we’re finding ourselves having to keep adding additional dollars to our bottom line for this investment because of the lack of interoperability.” So I do see us at some point in time kind of reaching this deadlock where providers who have invested already in their systems will say: “We’ve gone this far and we’re not going to do any more.” And so I do think it’s a really critical and important time to start having more strategic discussions, not just at the federal level but across the environment with everyone involved about where we are, what are the appropriate next steps, and what is the best roadmap to get there. Because I think that if we keep operating the way we have been until now, I think we’re just going to keep hitting this one-off type of situation where we may pick up one group that gets connected but not everybody will truly be there so you have a fully-functioning system.

 

Question 4

JHT: So you’ve mentioned a couple of times the efforts at the state level and the federal level, assessing where we are now and strategically thinking about the path forward, actually think about how we achieve more ubiquitous connection. Are there particular activities that you think the states and/or the federal government could take to help move forward past this deadlock you’ve described?

PM: I’m not one for saying that having more meetings is always beneficial, but I do think that really thinking about a summit or a meeting or a convening around health technology connectivity in the future that would include all the stakeholder partners (and that’s the other piece that has probably occurred, not necessarily intentionally but at a particular point in time, that’s where things have been) - when I say including all stakeholders, I include representatives from the states and from the feds that are working on health technology as well as key stakeholder organizations – the hospital association, the medical societies, as well as some of the pioneers in this area. I don’t want to leave the thought out there that this isn’t working at all and is not working anywhere. I think there have been a few successes in some fully-operational or more operational-type exchanges going on, but it just hasn’t been across the board, it’s been more haphazard and not systemic. I think that’s the challenge we have. For instance, in the city of Cleveland, they’ve created their own Health Information Exchange and they can do a very good job across their system there because they all went with the same vendor, and again, they have that same issue of being able to connect nationally with anybody that has their vendor but if it’s not their vendor, they run into some of the same issues. So I think those are some of the areas that I’m not aware of work going on and where I think it would be helpful to get a clearer idea of where things are on that roadmap and where the best practices and successes have been achieved so there is more of a goal towards which to work.

 

Question 5

JHT: That makes good sense. So, in your experience, working with New Mexico in particular, are there any strategies that you have found, working in your community, that have really facilitated greater exchange of health information, understanding the barriers we’ve talked about, but perhaps strategies that you think would be useful in pushing forward greater interoperability and greater exchange of health information.

PM: Well, I think, as with anything around health care or this particular area of health care, [we need] clarity about what we’re trying to achieve and why we’re doing it. You know, I do believe that everyone is in it to improve patient care and everybody is talking about patient-centered care and how we create this better health care system. So, I think being clear on the vision of what we’re trying to achieve and then starting to look at some strategies to get there. One of the things that we find with our regional collaborative here at the local level is that bringing all the different players to the table and laying the groundwork, having everybody on the same page, is very important. That also leads to building trust, which is so critical in all of this, and then realizing that everybody at the table comes to it with a different lens. The vendors are all there to do a good job, but their lens is very different from those who are providing care as the direct provider or the hospital administrator who is looking to reduce readmissions because he or she is going to be penalized by CMS. And so, it’s really keeping in mind that there are so many different lenses, so the more we can lay out that vision that I believe most folks would agree to, the better off we’ll be. I can tell you that right now in New Mexico, we have been on the road to building an HIE since 2004, with some positive movement and some starts and stops, and some exchange occurring now but not fully-functioning and not statewide. So when I mentioned having three different delivery systems that have three different electronic health records (EHRs), they are not necessarily a part of that exchange at this point in time. So we may have input from rural hospitals, but that may not be impacting our large urban population, which is a little over a third of the population in the state. So as we looked at the HIE, we started talking about all-payer claims database, which is another whole area of technology, and looking at quality measures as well as cost measures. So the question is, well, can you get that out of a health information exchange? There’s a lot of non-clarity out there, in that, depending on who you talk to, some people will say yes, you can get what you need in an APCD from an HIE. Well, more than likely, you can’t because a lot of it has to do with the infrastructure, the technology, and how the data is being provided. So those are some of the things that need to be looked at and we’re starting to ask this question here in New Mexico before building or putting in place more HIE infrastructure at high cost, is there something we have built or begun to build that we can create connections to. So it’s going beyond just the electronic records to, how does an HIE interrelate or connect with an APCD or with a health insurance exchange (HIX), which many states are also building? And so, that’s one thing that I think states need to very much be focused on at this point in time as they look forward to building their health infrastructure.

JHT: That’s very interesting, and I think, good thinking for going forward. Well, Pat, we very much appreciate your time today. This has been very helpful. Thank you!

PM: Thank you!

 

Further Resources:

•       HealthInsight New Mexico:

–      http://healthinsight.org/newmexico

•       HealthInfoLaw.org materials on quality measurement and reporting:

–      http://www.healthinfolaw.org/topics/65

•       HealthInfoLaw.org materials on health information technology:

                        –      http://www.healthinfolaw.org/topics/58

Perspectives from the Field: Interview with Jeff Levi, July 21, 2014

Wed, 2014-10-29 22:20 — healthinfolaw_admin
Jeff Levi, PhD
Executive Director of the Trust for America's Health and Professor, Department of Health Policy, Milken Institute School of Public Health, George Washington University.
www.youtube.com/watch?v=hYDW64oQ_tE
application/pdf iconLevi Interview Transcript final.pdf

Perspectives from the Field Interview Series

Interview with Jeff Levi, PhD

Executive Director of the Trust for America's Health and Professor, Department of Health Policy, Milken Institute School of Public Health, George Washington University.

(http://healthyamericans.org/pages/?id=67) 

July 21, 2014

Interviewer: Jane Hyatt Thorpe

 

Questions:

1) Please introduce yourself and tell us how what you do intersects with health information exchange?

2) How can health information exchange be used to improve public health?

3) What are some barriers or challenges to greater use and exchange of health information in the public health system?

4) What do you see as the most promising solutions to these challenges?

5) How does the current emphasis on use of electronic health records and other health information technology tools to support health information exchange for healthcare delivery affect the use of information in the public health system?

6) Are there ways in which the public health system uses information more effectively than the health care system, and are there lessons to be shared from the public health experience?

 

Transcript:

Question 1

JHT:  Welcome to the Health Information and the Law Perspectives from the Field interview series. Today, we’re speaking with Jeffrey Levi, PhD, who is the Executive Director of Trust for America’s Health.  Welcome, Jeff. Thank you so much for joining us today. Would you please tell us a little bit about your current position and how it intersects with health information exchange?

JL: Well, Trust for America’s Health does advocacy work around prevention and the public health, trying to encourage a stronger public health system, and we’ve been spending a lot of our time lately on the intersection of public health and the reforming health care system.  Certainly central to that is how health information technology is transforming what we in public health can learn about the public and the public’s health, and also provides new opportunities for partnership with the health care delivery system.

 

Question 2

JHT: Wonderful.  Can you expand a bit about health information exchange in general and how that can be used to improve public health?

JL: The public health system, until now, has really been dependent on very narrow streams of data – things that have been required by law to be counted (disease surveillance, primarily infectious disease surveillance) and relatively small, but often population-based, studies of other health factors that may be affecting the public’s health. What electronic health records/health information technology affords us is an opportunity to look at much larger sets of data, much more comprehensive sets of data, much greater ability to track people’s lives through the health care system, and really get a much more granular understanding of what is going on in a community. In the past, every time we wanted to learn something new about the health of a population, we’d have to layer on an additional surveillance system, so we’d keep adding one disease at a time.  HIV is a good example – we were doing STD surveillance, HIV came along, we added a very complex HIV surveillance system.  Now hepatitis is a concern, so people are saying that we now need to create a separate, siloed, hepatitis surveillance system.  In fact, we can turn to electronic health records, we can turn to health information exchanges, to provide us a lot of the information that we used to be collecting from these siloed surveillance systems, and learn so much more, not just about the specific conditions that people have, but also, how well they’re accessing care, how well they’re responding to care, and who we’re missing.  And that’s a tremendous opportunity for public health if we know how to take advantage of it.

JHT: It sounds like when you’re referencing larger sets of data, opportunities for potentially big data in this field, more information about individuals as well as communities, population-level data.  Is that part of what you’re thinking too – being able to mine information from very, very large (or “big”) data sets?

JL: That’s right, and I think one of the challenges in public health is that right now, our systems have only allowed us to answer the questions that we have thought of, and when we have new questions, we are creating new systems. Now, we’ll be able to mine this big data to answer new questions as they arise and, if we analyze it properly, to discover things about the public’s health that we might not have thought to ask. 

 

Question 3

JHT: What are some of the greatest challenges or barriers that you’ve seen to greater exchange of health information in the public health system, whether it be related to uses of specific technology, or you referenced the very siloed approach, but from an overall perspective, what are some of those greater challenges?

JL:   Well, I think the biggest challenge is just technical capacity. Many health departments do not have either the staff or the physical hardware to be able to take advantage of bigger data sets. Many of them have not established the relationships with their local health information exchanges to perhaps do that in a cooperative way. So, we have a large training and capacity problem.  You know, I think one of the big challenges around meaningful use, for example, has been that the public health community has really pushed for more public health measures associated with meaningful use.  On the other hand, the meaningful use exercises often show that there’s no one on the other end at the public health department that can really take advantage of this – there are still some reporting systems and some health departments that are using fax machines to exchange data. So we have a long way to go on the public health side, which requires an investment, in some cases, of resources and, in some cases, training.

 

Question 4

JHT: So, on the other end of the spectrum, thinking about these barriers and challenges, what do you see as the most promising solutions to these challenges, in terms of hardware or capacity or staff resources?

JL:  Oh, I think the exciting opportunities are twofold.  One, as health departments create stronger relationships with the health care delivery system and with health information exchanges, I think people will see tremendous opportunities. We’ve actually seen an example or prototype of that in the efforts that CDC supported in getting a better handle on data and investigating healthcare-associated infections, which was one of the first times that public health has really been able to utilize electronic health records at a hospital level to do disease investigation and to really mine out the challenges that a particular hospital may be facing. So I think we see the beginnings of that.  And I think the other part that I think is exciting is that CDC has actually adopted a new surveillance strategy to move their existing siloed systems to more of a common platform that can take advantage of the changes in health IT.  So, I think it will take some time to get there but I think we’ve gotten past the point of resistance to change and now are seeing more people moving toward “how do we create the capacity to take advantage of these opportunities?”

 

Question 5

JHT: You’ve referenced the Meaningful Use program, which provides incentives for uses of electronic health records in the health care delivery system, and obviously, there’s been a lot of focus on encouraging electronic health records and health information technology, particularly as it relates to health care delivery.  Has that emphasis in any way impacted the collection and use of information on the public health side of health care?   So do you think that the current emphasis on the health care delivery side is having beneficial impacts on the public health side?

JL: Well, I think certainly just creating the technological capacity would never have happened with public health alone. I think collecting this level of data would never have happened just with a public health purpose. But I think the flip side is that public health probably has not been as engaged in the design of these systems as might have been preferable, at least from a public health perspective.  So to some degree, public health is coming to the table a little bit late, and therefore, needs to be adapting its requests and its needs to a relatively established system, so I think that’s a little bit of a challenge.  I also think there have always been firewalls between the health care system and public health to some degree, except for when there has been legally mandated reporting, and the privacy issues that public health confronts and the privacy issues that the health care system confronts can often be used as an excuse not to collaborate.  

 

Question 6

JHT: So, thinking about the use of information on the health care delivery side and the public health side, and understanding your response to the last question that there has been a big push from the health care delivery side, are there ways in which information is being used on the public health side and lessons that can be learned from the public health side that may better inform efforts on the health care system side?

JL: So, I think one example of that is the degree to which in many communities the public health system is using health care data as almost a quality assurance approach.  It could be something like electronic lab reporting, something like hemoglobin A1C results, so you can see by practice who’s doing a better job or not, but also by zip code and by neighborhood to see where there are pockets, in this case, of uncontrolled diabetes, where there can then be community-level interventions. Because the link between public health and the health care delivery system is not just about the health of individuals but also about population health. What public health brings to the table is knowledge, experience, resources, and programs that can intervene at the community level, outside the clinical setting, that can then reinforce what is happening in the clinical setting. We’re not going to get control over the really expensive chronic diseases that are really driving health care demand and health care cost, unless we’re doing stuff inside and outside the clinic.  Using data to help target what needs to be done outside the clinic, I think, can be really innovative and make a difference, and is something that public health is bringing to the health care system as something that can be of benefit to the health care system, so it is a bi-directional advantage.

JHT: Wonderful. Well, thank you so much for your time. We really appreciate it.

JL: My pleasure.

 

 

Further Resources:

•       Trust for America’s Health:

–      http://healthyamericans.org/

•       HealthInfoLaw.org materials on quality measurement and reporting:

–      http://www.healthinfolaw.org/topics/65

•       HealthInfoLaw.org materials on public health data collection and reporting:

–      http://www.healthinfolaw.org/topics/67

 

Perspectives from the Field: Interview with Dr. Neil Calman, June 30, 2014

Wed, 2014-10-29 22:11 — healthinfolaw_admin
Neil Calman, MD
President and Chief Executive Officer, Institute for Family Health; Chair, Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai
www.youtube.com/watch?v=7hzr4MQl2PY
application/pdf iconCalman Interview Transcript final.pdf

Perspectives from the Field Interview Series

Interview with Neil Calman, MD

President and Chief Executive Officer, Institute for Family Health; Chair, Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai

(http://www.institute2000.org/about-us/leadership/executive-staff/neil-calman-md-abfp-faafp/)

June 30, 2014

Interviewer: Jane Hyatt Thorpe

 

Questions:

1)  Please introduce yourself and tell us about your current position. 

2)  How does what you do intersect with health information exchange?  [Alternative: how do community health centers use health information, beyond treating patients?]

3)  What potential benefits are there in health information exchange for community health centers and the overall health care system?

4)  What are some barriers or challenges to fully realizing that potential? [Here, perhaps raise issue of not being able to share with other professionals and support services outside of immediate treatment team.]

5)  What do you see as the most promising long-term solutions to these challenges?

6)  In the meantime, do you recommend any short-term strategies that community health centers can use to maximize the use and exchange of health information for patient care and overall system improvement?

 

Transcript:

Question 1

JHT: Welcome to Perspectives from the Field, a series of interviews with experts in the field, brought to you by Health Information and the Law, a project of the George Washington University’s Hirsh Health Law and Policy Project and the Robert Wood Johnson Foundation.  Today we are speaking with Dr. Neil Calman, President and Chief Executive Officer of the Institute for Family Health. 

Hello, Dr. Calman, how are you? 

NC: I’m great, how are you?

JHT: Good, good.  Thank you so much for joining us today.  We’ll get started.  Would you please introduce yourself and tell us a little bit about how the work you’re doing with community health centers in particular intersects with health information exchange?

NC: Sure.  I run the Institute for Family Health, which is a network of 29 locations, which are all federally-qualified health centers.  Some of them are homeless health care programs, some of them are school health programs; the majority are what you would know as full community health facilities with primary care, mental health, and dental. So, we are spread over 150 miles and therefore have relationships with many different groups of specialists and many different groups of providers in the community who help us with what are now called social determinants of health, help us with our patients in terms of dealing with housing problems and social issues, and we also have many affiliations with different hospitals. So, you can imagine that in this era of electronic health information, that the sharing of information between these different providers is critically important.  And so we’re deep in the throes of, in some cases, just figuring out how doctors can transmit information from primary care doctors to specialists and back; in some cases, trying to work on electronic connectivity with our emergency departments and our inpatient units; and in some cases (and I think, most challenging) trying to figure out how to link in providers who aren’t really traditionally health care providers but who are helping our patients with their social, economic, housing, and other needs.

 

Question 2

JHT: Wonderful.  I want to come back and make sure we focus on some of the challenges you spoke to, particularly sharing information outside the immediate treatment team, but before we talk specifically about challenges, could you review with us what you perceive to be the key benefits of greater exchange of health information between providers and patients and others who are working with community health centers as part of your system?

NC:  Well, I don’t think that there’s any question that we’re talking about benefit here. You know, the traditional modes of communication were grossly inefficient, people trying to pick up the telephone and calling folks and leaving messages and trying to get calls back when we were in session with other patients – it created an almost impossible barrier to efficient transfer of information.  So I think the electronic transfer of information has really enabled people to communicate asynchronously but at the same time much more efficiently across these boundaries.  And, in fact, we’ve noticed a lot better communication between hospitals, emergency rooms, and doctor’s offices as we’ve been able to do more and more electronically.

JHT: And is your experience that the exchange of information between community health centers, hospitals, and other providers is happening through the use of electronic health records or are there other modes of exchange that community health centers are using?

NC: Well, I think we’re still, depending on who’s on the other end, we’re still using the telephone, still handing people things that are written on paper to bring to other providers, you know, we’re using fax whenever electronic communication isn’t available.  So, we’re kind of doing this however we can, but I think the move is generally towards more electronic communication.

 

Question 3

JHT: Great.  A little bit earlier, you referenced some of the challenges to fully moving towards the use of electronic health records or communicating electronically, and it sounds like, obviously, there continues to be movement towards that, still using phone and paper where necessary but really trying to move towards exchanging information electronically. What are some of the greatest challenges that you find that community health centers, in particular, are facing in terms of greater use of electronic exchange of health information?

 NC:  Well, I think the greatest challenge for us is that the people on the other side of this exchange have very varied capabilities.  So, you know, we have hospitals where we have no electronic connectivity to be able to exchange, for example, a discharge summary from the hospital to the Institute. However, we’ve been kind of piecing together things that we’ve been able to do, which is create kind of a discharge document on the hospital’s side and even something that we can securely transmit over to our health centers that may not be part of a formal exchange mechanism.  We’re working with “Healthix,” which is a local, regional health information exchange.  They connect some of our hospitals and we can get some real time notifications of people who are admitted to the emergency room or to the hospital, but still are unable to get discharge information back at the time of discharge.  We have a linkage with Ellenville Regional Hospital, which is a small, critical-access rural hospital, where they actually have a module of our electronic health record system that we’ve installed in their emergency room so that when they see a patient in their emergency room that doesn’t have a source of primary care, they can actually go and book an appointment right into our system for the follow-up and attach information that they think we would need to be able to follow up with the patient. So, it’s like every one of our hospitals has different kinds of capabilities, and so we’re kind of piecing this stuff together until the grand day when all of this electronic exchange will take place, in what I think will be a fairly seamless kind of format. 

JHT: So, from what you’re saying, it sounds like now it’s primarily based on the partnerships and the relationships you have with other health care providers in the area, where you may have patients in common as they’re traveling perhaps between your centers, the emergency room, and other specialists, and it’s really based on those connections you have with those other providers.

NC:  Yes, that’s true, and when the other providers are using the same software that we use, which is Epic, there’s actually a module that enables us to almost be able to access their entire medical record that’s on the other side, whether it’s from the hospital to the center, or from the center to the hospital, with the patient’s consent.  So that’s like the highest level of integration but clearly, there are many systems out there, and so when people are on different systems, you know, the integration at that level goes away and you depend upon regional exchanges, or we’re just beginning to be able to go live in a very limited way with Direct protocols, Direct exchange.  So we’re using the tools available to us as they evolve, and very dependent on our partners, as you said.

JHT: For those in our audience who may be unfamiliar with Direct, can you spend a couple of minutes just explaining how that Direct, query-based interaction works?

NC: Well, I think the Direct interaction is really – the best way to understand it is to think about it as kind of the “electronification” of the facts, but with the ability to send a document, which some people call a CCD, and to be able to transmit a document that has various components of information that would be relevant to that particular transaction, and it gets securely transmitted using a standardized protocol.  It’s similar to the way one would imagine a fax going back and forth, a standard document that might get printed by a computer.  That’s the most simplistic way of thinking about it and in a sense, it really creates an almost magical way for people to be able to transfer information from one place to another because, as we think about the incredible variety of information transfers that need to take place, you know, being able to standardize some sort of document is a good starting point.  It’s only a starting point because if you think of the information that needs to be transferred for different purposes, in some sense, we’re going to need to create a model upfront that enables us to make a smart transfer of information, so that the cardiologists get the cardiac information that they need in much more detail, whereas the podiatrists or foot specialists aren’t going to need all that but are going to need any information that’s relevant to the treatment they’re doing.  Otherwise, I think we’re just going to be flooding people with information and it won’t really be all that useful. So, you know, it’s a start, to be able to create a standardized document for transfer, and I think it’s a great start.  Once that protocol is widely implemented, it will enable us to transfer very specific pieces of information to the specialists that we use and the hospitals when we’re referring patients, and to get information back in a usable format that can then be incorporated directly into our electronic health record, so it doesn’t necessarily have to come back as a document file, but it’s actually information that can be incorporated into a patient’s record.

JHT: So, so far we’ve talked primarily about sharing information with other physicians or with a hospital, but earlier in our interview, you referenced sharing information with other support services, housing and things of that nature.  What challenges have you encountered in trying to share patient health information with the broader community beyond immediate care providers?

NC: Well, I think that’s a mountain that’s yet to be climbed.  You know, to try to figure out the consent process so that patients really are consenting to this wide-open availability of their information to people who aren’t really health care providers, and I think that has a lot of concerns both on the provider’s side and on the patient’s side, in terms of what information is relevant to somebody.  If you’re sending somebody for assistance with housing, information about any possible disabilities, cardiac conditions, pulmonary conditions, things that might affect the type of housing that would be suitable for them would be relevant information, but other information of a more personal nature, maybe information about prior bouts of depression, abortions, or other kinds of things that people might not think is really relevant, and isn’t really relevant, to those kinds of transfers shouldn’t be transferred. So the ability to segment the information and figure out what’s important to be transferred is a whole issue there as well.  And I think, most importantly, technically, the kinds of systems people are using in these agencies aren’t really health care, electronic health record systems, so they’ve been left out of the loop of this whole development of standardized protocols for the transfer of information, and that needs to be re-looked at as well.  So I think we’re still quite a ways away from that possibility, but a lot of people are far along in the development of care management, care coordination software that sort of works as a stand-alone to link health providers with others, and how those things eventually integrate into electronic health records, I think, remains to be seen. 

 

Question 4

JHT: So you referenced some care transitioning, care coordination tools and software – do you think that’s probably the most promising long-term solution to some of these challenges, perhaps aligned with greater patient engagement and thinking about patient consent forms and how patient consent would relate to sharing this information beyond immediate care providers?

NC: Yes, I think that is the most likely the way that it’ll develop.  The only thing is that we don’t want to add back the inefficiencies that paper brought us.  And so, the idea of being able to create that document that would then get sent to a care coordination or care management kind of software and be able to capture information back into the electronic health record is a piece that still needs to be developed.  So that providers who are seeing a patient aren’t going to have to write down their whole social history and then have to write it again into another software program that would be used for care coordination.

 

Question 5

JHT: So, given some of these challenges but also some of these promising potential longer-term solutions, what in the short term - obviously, given the work that you’re doing, overcoming some of these challenges, enabling broader flow of information between providers as well as with other types of support services that may be beyond the immediate care team - are there any short-term strategies that you would recommend overall to help maximize the exchange of health information within the patient care system as well as outside the patient care system? 

NC: Well, I’ve always believed that patients should be at the center of the decision and so, for me, if I were the software developer, I would be producing this information in a format so patients could literally check boxes as to what parts of their record they would want to be revealed, and in so doing, would also be consenting for that information to be sent, and then to also indicate who they would want it to be sent to.  So I would put the patient back in the center or hub of this information transfer piece, because I think providers are going to do this badly and they’re not going to be able to check in with patients all the time to know what kind of information is relevant, what kind of information people are going to want to be transferred, and it’s only going to take a few missteps for somebody to just say, “you know what, I’d really rather have my information locked down because I really don’t want everybody knowing everything about me.” So I think if we don’t get the patient back in the middle of this decision somehow and enable them to indicate which pieces of their information they want shared with whom, I think it’s going to be a very difficult process to make this work. 

JHT: And in your work, what have you found to be the most effective tools or resources to really put the patient back in the middle and have that level of engagement where they’re able to make more informed decisions about consent and with whom their information is shared, etc.?

NC: Well, we haven’t really been able to deal with the “with whom their information is shared” piece in any kind of significant way because the software just doesn’t support that, but I think we have been able to engage a large number of our patients, now I think numbering almost 25,000, by using the patient portal into our electronic health record system, which not only gives them access to their electronic health record but, through a system that we worked on with the National Library of Medicine called MedlinePlus Connect, the patients can actually hyperlink from the terminology that they see in their medical record to MedlinePlus to be able to understand what those terms mean, what the lab results mean, and even to look up their medications.  So, I think that there is an ability to use some publicly-available tools like that – MedlinePlus Connect is available for connectivity to any electronic health record system that uses standard nomenclature and I think that using tools like that and using electronic health record patient portals, people will choose to become much more involved in their own care.  So our patients are communicating with our providers and - you know, it’s not a rapid uptake.  I mean, we’ve been up to this probably for close to 5 years now and we only have about 25,000 of our 100,000 patients signed up, which is not a great number but considering that we work with a really underserved population, many of whom don’t have access to computers at this point, I think that that’s not bad.  We’re now moving towards trying to engage people a lot more through their smartphones and other electronic devices that we think are even more prevalent. To me, that’s the major tool that we have available to us right now.

JHT: Wonderful. Well, this has been incredibly helpful and we really appreciate your time today, Dr. Calman. We’ll be posting materials relevant to this interview shortly. Thank you again!

 

Further Resources:

•       Institute for Family Health:

–      http://www.institute2000.org/priority-areas/

•       Information about Direct:

–      http://www.healthit.gov/policy-researchers-implementers/direct-project

•       Information about MedlinePlus Connect

–      http://www.nlm.nih.gov/medlineplus/connect/overview.html

•       Summary of HIPAA:

–      http://www.healthinfolaw.org/federal-law/HIPAA

•       HealthInfoLaw.org materials on HIT:

–      http://www.healthinfolaw.org/topics/58

 



Welcome to Health Information & the Law

Please provide the following information and continue to the site.

by Dr. Radut.