offene Ablage: nothing to hide

I've come to look forward to the Massachusetts Heath Data Consortium's annual HIT conference because--although speakers tout the very real and impressive progress made by Massachusetts health providers--you can also hear acerbic and ruthlessly candid critiques of policy and the status quo. Two notable take-aways from last year's conference (which I wrote up at the time) were the equivalence of old "managed care" to new "accountable care organizations" and the complaint that electronic health records were "too expensive, too hard to use, and too disruptive to workflow." I'll return to these claims later.

The sticking point: health information exchange

This year, the spears were lobbed by Ashish Jha of Harvard Medical School, who laid out a broad overview of progress since the release of meaningful use criteria and then accused health care providers of undermining one of its main goals, the exchange of data between different providers who care for the same patient. Through quantitative research (publication in progress), Jha's researchers showed a correlation between fear of competition and low adoption of HIEs. Hospitals with a larger, more secure position in their markets, or in more concentrated markets, were more likely to join an HIE.

The research bolsters Jha's claim that the commonly cited barriers to using HIEs (technical challenges, cost, and privacy concerns) are surmountable, and that the real problem is a refusal to join because a provider fears that patients would migrate to other providers. It seems to me that the government and public can demand better from providers, but simply cracking the whip may be ineffective. Nor should it be necessary. An urgent shortage of medical care exists everywhere in the country, except perhaps a few posh neighborhoods. There's plenty for all providers. Once insurance is provided to all the people in need, no institution should need to fear a lack of business, unless it's performance record is dismal.

Jha also put up some research showing a strong trend toward adopting electronic health records, although the small offices that give half the treatment in the United States are still left behind. He warned that to see big benefits, we need to bring in health care institutions that are currently given little attention by the government--nursing home, rehab facilities, and so forth--and give them incentives to digitize. He wrapped up by quoting David Blumenthal, former head of the ONC, on the subject of HIEs. Blumenthal predicted that we'd see EHRs in most providers over the next few years, and that the real battle would be getting them to adopt health information exchange.

Meanwhile, meaningful use could trigger a shake-out in the EHR industry, as vendors who have spent years building silo'd projects fail to meet the Stage 2 requirements that fulfill the highest aspirations of the HITECH act that defined meaningful use, including health information exchange. Meanwhile, a small but steadily increasing number of open source projects have achieved meaningful use certification. So we'll see more advances in the adoption of both EHRs and HIEs.

Low-hanging fruit signals a new path for cost savings

The big achievement in Massachusetts, going into the conference today, was a recent agreement between the state's major insurer, Blue Cross Blue Shield, and the 800-pound gorilla of the state's health care market, Partners HealthCare System. The pact significantly slows the skyrocketing costs that we've all become accustomed to in the United States, through the adoption of global payments (that is, fixed reimbursements for treating patients in certain categories). That two institutions of such weight can relinquish the old, imprisoning system of fee-for-service is news indeed.

Note that the Blue Cross/Partners agreement doesn't even involve the formation of an Accountable Care Organization. Presumably, Partners believes it can pick some low-hanging fruit through modest advances in efficiency. Cost savings you can really count will come from ACOs, where total care of the patient is streamlined through better transfers of care and intensive communication. Patient-centered medical homes can do even more. So an ACO is actually much smarter than old managed care. But it depends on collecting good data and using it right.

The current deal is an important affirmation of the path Massachusetts took long before the rest of the country in aiming for universal health coverage. We all knew at the time that the Massachusetts bill was not addressing costs and that these would have to be tackled eventually. And at first, of course, health premiums went up because a huge number of new people were added to the roles, and many of them were either sick or part of high-risk populations.

The cost problem is now being addressed through administrative pressure (at one point, Governor Deval Patrick flatly denied a large increase requested by insurers), proposed laws, and sincere efforts at the private level such as the Blue Cross/Partners deal. I asked a member of the Patrick administration whether they problem could be solved without a new law, and he expressed the opinion that there's a good chance it could be. Steven Fox of Blue Cross Blue Shield said that 70% of their HMO members go to physicians in their Alternative Quality Network, which features global payments. And he said these members have better outcomes at lower costs.

ACOs have a paradoxical effect on health information exchange Jha predicted that ACOs, while greatly streamlining the exchanges between their member organizations, because these save money, they will resist exchanging data with outside providers because keeping patients is even more important for ACOs than for traditional hospitals and clinics. Only by keeping a patient can the ACO reap the benefits of the investments they make in long-term patient health.

As Doris Mitchell received an award for her work with the MHDC, executive directory Ray Campbell mentioned the rapid growth and new responsibilities of her agency, the Group Insurance Commission, which negotiates all health insurance coverage for state employees, as cities and towns have been transferring their municipal employees to it. A highly contentious bill last year that allowed the municipalities to transfer their workers to the GIC was widely interpreted as a blow against unionized workers, when it was actually just a ploy to save money through the familiar gambit of combining the insured into a larger pool. I covered this controversy at the time.

A low-key conference

Attendance was down at this year's conference, with about half the attendees and vendors as last year's. Lowered interest seemed to be reflected as none of the three CEOs receiving awards turned up to represent their institutions (the two institutions mentioned earlier for their historic cost-cutting deal--Blue Cross Blue Shield and Partners HealthCare--along with Steward Health Care).

The morning started with a thoughtful look at the requirements for ACOs by Frank Ingari of Essence Healthcare, who predicted a big rise in investment by health care institutions in their IT departments. Later speakers echoed this theme, saying that hospitals should invest less in state-of-the-art equipment that leads to immediately billable activities, and more in the underlying IT that will allow them to collect research data and cut down waste. Some of the benefits available through this research were covered in a talk at the Open Source convention a couple years ago.

Another intriguing session covered technologies available today that could be more widely adopted to improve health care. Videos of robots always draw an enthusiastic response, but a more significant innovation ultimately may be a database McKesson is developing that lets doctors evaluate genetic tests and decide when such tests are worth the money and trouble.

The dozen vendors were joined by a non-profit, Sustainable Healthcare for Haiti. Their first project is one of the most basic health interventions one can make: providing wells for drinkable water. They have a local sponsor who can manage their relationship with the government, and an ambitious mission that includes job development, an outpatient clinic, and an acute care children's hospital.