Transcript A Sustainable Business Model for a RHIO: Win-Win

Introduction to Health Record
Banks
William A. Yasnoff, MD, PhD, FACMI
Harvard University. Cambridge, MA. October 15, 2012
Where are Patient Records?
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Medical Knowledge Explosion
Provider Response: Specialization & Subspecialization
Result: Patient Records Scattered
 No one has access to comprehensive
longitudinal patient records
 Records are on paper so can’t be
processed, organized, accessed easily
Public health reporting incomplete, delayed
Health Information Infrastructure
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Goal: “Comprehensive Electronic
Patient Information When and Where
Needed”
Components
 EHRs – all information electronic
 Health Information Exchange (HIE)
– mechanism for finding,
aggregating, and delivering
comprehensive records for each
person
Completeness of Information
Value vs. Completeness of Health Information
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Value of Info (%)
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60
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40
30
20
10
0
0
4
20
40
60
80
Completeness of Information (%)
100
“Fetch and Show” HIE Approach
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Improve cooperation by allowing
stakeholders to retain data
Eliminate trust problems of central
repository
Use Internet to exchange data rapidly &
inexpensively (need standards for
interoperability)
Development encouraged with very
modest funding from 2004-8
$564 million to states in 2009 (HITECH)
Analysis of Scattered Model
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Relates directly to existing process for
obtaining “outside” records at office
visits
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Contact “outside” provider
Ask for records (typically sent by fax)
Addresses “if only this could be
automated” wish of providers
Does not scale
Does not allow searching
Example of automating “how we do it
now” vs. using IT to solve the
underlying problem
What is a Health Record Bank?
http://www.healthbanking.org/video1.html
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Analysis of Health Record Banks
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Advantages
 Patient consent
– Forces stakeholder cooperation
– Ensures privacy (each patient sets
own privacy policy)
 Central repository
– Searching  value-added services
Challenges
 Disruptive
 Minimal funding (so far)
Potential Issues
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1. Obtaining the Patient Records
11. Historical & Paper Records
2. Ensuring Comprehensive Records
12. Security of Repository
3. Ensuring Patient Participation
13. Need for Standards
4. Implementation Strategy & Cost
14. Operational Efficiency
5. Financial Sustainability
15. Handling Images
6. Patients Withholding Records
16. Handling Mental Health Records
7. Assuring Patient Privacy
17. Master Patient Index for Deposits
8. Why Hasn’t This Been Done?
18. “Out of Town” Patient Visits
9. Has Already Failed (e.g. Google)
19. Use of Data for Research & Policy
10. Public Health Reporting
20. Existing Efforts Are Solving This
…
HII Business Model Problem
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How Can HII be Sustained?
 Why build if it cannot be sustained?
 Critical early question for any IT
system
Persistent Unsolved Problem
 Involves both cost and value
Three Business Model Categories (not
mutually exclusive)
 Taxation
 Leverage Health Care Savings
 Leverage New Value Created
HII Business Model:
Option 1 - Taxation
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Rationale: HII is public good, all should pay
Possible mechanisms
 Excise tax on health insurance claims
(VT)
 Excise tax on hospital charges (MD)
Essentially “universalizes” HII component
of healthcare
Politically unpopular & difficult
 Especially when amount is non-trivial
 Early $50B/yr estimated cost 
$166/person/year [$55/mo for family of 4]
HII Business Model:
Option 2 – Leverage Savings
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HII expected to reduce health care costs by
3-13% [8% is a good working estimate]
 8% x $2.6T = $208 billion/year
Problems
 Savings not proven
 Allocation and timing of savings?
 “Savings” = “Lost Revenue”
Has consistently failed in communities
 No responsible CFO will pay now for
unproven future savings
HII Business Model:
Option 3 – Leverage New Value
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Rationale: Stakeholders should be willing to
pay for new value created by HII
Examples of new value
 Replace paper delivery of lab results (75¢)
with electronic delivery [Indianapolis]
 Reminders and alerts
– “Peace of Mind” – ER notification
– Prevention Advisor
– Medication refill reminders
 Research queries (require searching)
 Advertising (to consumers)
Questions?
William A. Yasnoff, MD, PhD
[email protected]
703/527-5678
BACKUP SLIDES
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ISSUES
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1. Obtaining the Patient Records
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Need providers to transmit records on
request
 Request from “RHIO” or “HIE” may or may
not be honored
 Request from patient MUST be honored
under HIPAA
– If patient requests electronic records
(e.g. via health record bank), they must
be provided in electronic form
MU Stage 2 “view, download, and transmit”
reinforces patient access to records
ISSUES
2. Assuring Comprehensive
Records
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All records must be electronic
 Need >85% physician adoption
Free EHRs for physicians paid by health
record bank
 Cost is $10/person/year
– 600K physicians needing EHR
– 300 million population
– 500 people/physician needing EHR
– Internet-accessible EHR ≤ $5,000/year
 $10/person/year
Also incentivizes patient signup
Completeness of Information
Completeness Required for Value
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90
Value of Info (%)
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70
60
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40
30
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10
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0
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20
40
60
80
Completeness of Information (%)
100
ISSUES
3. Ensuring Patient Participation
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No upfront or ongoing required costs
 Optional services for a fee OK
Recommendation from trusted source:
physicians
Minimal signup effort
 Waiting room of physician office
With physician recommendation, 90%+
patient compliance anticipated
Need to incentivize physicians to sign
up patients (e.g. with free EHR)
ISSUES
4.HRB Implementation Strategy
PATIENT CONTROL
Key
Design
Decisions
ensures
Stakeholder
Cooperation
protects
Privacy
enables
provides
Financial
Incentives
CENTRAL REPOSITORY
results in
Low Costs
pay
for
ensure
Electronic Patient Data
produces
Benefits
1. Clinical: Quality, Costs
2. Reminders/Alerts
3. Research
Estimated Startup Costs: $5-8 million
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Health Record Bank Organization
RESPONSIBLE FOR:
Policy
Governance
Oversight
Community Non-profit
ISSUES
Community Board of Directors
Executive Director
Other communities
use same HRB
Other Staff(Optional)
regulate via
contract
% of
profit
HRB Corp. (for-profit)
HRB Operator Board of Directors
Management
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Marketing
Operations
Customer Support
RESPONSIBLE FOR:
Obtaining Capital
Operating HRB
5. Financial Sustainability
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Costs (with 1,000,000 subscribers)
 Operations: $6/person/year
 EHR incentives: $10/person/year
Revenue
 Advertising: $5/person/year (option
to opt out for small fee)
 Optional Reminders & Alerts:
>= $18/person/year
– “Peace of mind” alerts
– Preventive care reminders
– Medication reminders
 Queries: ?
No need to assume/capture any
ISSUES
health care cost savings (!!)
6. Patients Withholding Records
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Patients already withhold records
 13-17% in surveys
 Without control, these patients will opt out
If patients don’t control records, who is
trusted enough to do it on their behalf?
In HRB, patients will be warned when they
choose to suppress information
Physicians are not liable for consequences
of withheld information
ISSUES
 Fully documented in HRB
Potential exceptions to patient control to
prevent fraud (e.g., controlled substances)
7. Assuring Patient Privacy
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Health record banks NOT covered by HIPAA
 But HIPAA allows information release
without consent for treatment, payment,
operations
Health records banks ARE covered by
 ECPA – Electronic Communications
Privacy Act (1986)
– Consent of subscriber required for any
access by private party
 Federal Trade Commission enforcement of
online privacy policies
– Can shut down sites in violation
ISSUES
8. Why Hasn’t This Been Done?
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Technology
 Tools now allow rapid deployment
Difficult for Existing Stakeholders
 Existing healthcare stakeholders are
competitors
 Will be wary of another stakeholder’s
health record bank
Desire to use information for competitive
advantage
 Many healthcare stakeholders do not want
to share information
No obvious source of startup funds ISSUES
9. Has Already Failed (e.g. Google)
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Google Health Failure
 National focus
– Didn’t achieve sufficiently comprehensive
information to generate value for any
specific consumers
 Trust
– Privacy policy did not fully protect users
– Inherent distrust
 Business model
– Based on “search”
– Not an effective health record bank model
HRB Examples
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Washington State Pilots (4)
 Inadequate funding  insufficient marketing
 Very small communities  cannot achieve
sustainability
Harvard U’s MyDataCan (just started)
 Trusted by consumers (double encryption)
 Obtain comprehensive records
 “App Store” business model
 Includes personal data beyond health
ISSUES
10. Public Health Reporting
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Health Record Banks can provide public
health reporting
 Immunizations
 Surveillance
– Lab tests
– Diseases
– Syndromes
More timely reporting
More complete reporting
Reporting done “on behalf of” providers
 Consent not required (by law)
ISSUES
11. Historical & Paper Records
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Not normally collected by Health Record
Bank
Optional scanning services can be used
– pdf files (“images”) of paper records
– ? OCR processing so content available
– Cost is a challenge
Over time, most historical records become
less important
 Issue of historical and paper records is a
temporary issue (in general)
 But there are exceptions, e.g., old EKG
ISSUES
12. Security of Repository
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Central repository prerequisite for security
 Network security is unsolved problem
 Need information in one place to assure
protection
Less information “exposure” in central
repository
 Transmitted only once for each use (vs.
twice in distributed model)
Massive breach risk independent of ISSUES
storage
 Mechanism for retrieval either way
 Encryption of data at rest reduces risk
13. Need for Standards
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All health information infrastructure
requires standards
 Regardless of architecture
ONC/CMS activities are successfully leading
to widespread use of standards
Health Record Banks eliminate an entire
class of interoperability
 With HRBs, only interoperability is
between HRB and provider
 Otherwise, all systems must be
interoperable with all others
(challenging!)
ISSUES
14. Operational Efficiency
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Source: Lapsia et al, Int J Med Informatics (in press)
Operational Efficiency (cont.)
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Source: Lapsia et al, Int J Med Informatics (in press)
ISSUES
15. Handling Images
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Not likely to be stored in Health Record
Bank (at least at first)
 Very large storage requirements
 Available from other sources
 “Pointers” to images are sufficient
Will store imaging reports
HRBs may store “small” images
 e.g., EKGs
ISSUES
16. Handling Mental Health
Records
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Probably better to avoid mental health
records at first
 Very sensitive
 Public policy issue
 Leave decision about deposit to patients
Patients can decide what information is
available, so can suppress mental health
records if they wish
Mental health medications would likely be
included
ISSUES
17. Master Patient Index for
Deposits
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Deposits with ambiguous identification can
be held by health record banks
 Investigate manually to determine correct
patient
 Correspondence between provider
identifier and HRB account can then be
established
Over time, accurate mapping from provider
identifiers to HRB accounts  effective MPI
Patient access to records is another
opportunity to find and correct errors
ISSUES
18. “Out of Town” Patient Visits
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Each patient’s data available in one
place
 Accessible anywhere via Internet
Route new information to existing
record
 Direct deposit to remote health record
bank (via MU Stage 2 “transmit”)
 System of forwarding “foreign”
deposits among health record banks
(later)
 Information deposited by patient
ISSUES
19. Use of Data for Research &
Policy
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Clinical Trial Subjects
 Ask HRB subscribers if they want to be
notified if they qualify for clinical trials
 Researchers will pay fees to send messages
to potential subjects
Reports from data for research & policy
 Ask HRB subscribers if their data can be
aggregated into reports for research &
policy (with anonymity protected)
 Share revenue from fees with users as
incentive (“interest bearing” HRB accounts)
ISSUES
20. Existing Efforts
are Solving This
(10 slides)
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Health Information Infrastructure
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Goal: “Comprehensive Electronic Patient
Information When and Where Needed”
Components
 Electronic Health Records (EHRs) – all
information electronic
 Health Information Exchange (HIE) –
mechanism for finding, aggregating, and
delivering comprehensive records for
each person
EHR Adoption
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CMS incentive program is very helpful
Adoption increasing rapidly
But … expected best outcome is 50%
adoption by physicians in 2015
How can adoption by vast majority of
physicians be assured?
Health Information Exchange(HIE)
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Mechanism for finding, aggregating, and
delivering comprehensive records for each
person
Distributed /Scattered /“Fetch and Show”
Model
 Allow stakeholders to retain data
 Use Internet to exchange data rapidly &
inexpensively (need standards for
interoperability)
 Maintain index of record locations in
each community
 Aggregate each patient’s records when
needed
Scattered Model
Pointer to
Encounter
Data Added
to Index
Hospital Record
Laboratory Results
Specialist Record
Records
Returned
Requests
for Records
Clinician EHR
System
Encounter
Data Stored
in EHR
Patient
Authorized
Inquiry
Index of where patients
have records
Temporary Aggregate
Patient History
LHII
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Clinical Encounter
Patient data
delivered to
Physician
U.S.
Hospital Record
Laboratory Results
Specialist Record
Records
Returned
Requests
for Records
Authorized
Inquiry
from LHII
another
LHII
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Index of where patients
have records
Temporary Aggregate
Patient History
LHII
Patient data
delivered to
other LHII
Analysis of Distributed Model
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Relates directly to existing process for
obtaining “outside” records at office
visits
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45
Contact “outside” provider
Ask for records (typically sent by fax)
Addresses “if only this could be
automated” wish of providers
Does not scale
Does not allow searching
Example of automating “how we do it
now” vs. using IT to solve the
underlying problem
PCAST Report (12/2010)
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“HIEs have drawbacks that make them illsuited as the basis for a national health
information architecture.”
 Significant administrative burdens
 Lack of financial sustainability
 Lack of interoperability
 Architecture does not allow effective
scaling
HIE Survey (Ann Int Med 154,10:666-71, 2011)
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179 HIEs Surveyed
Only 13 met Meaningful Use Stage 1
 Covering 3% of hospitals, 0.9% of docs
 Just 6 of these 13 financially sustainable
None of the 179 HIEs met criteria for
“comprehensive system”
“These findings call into question whether
RHIOs in their current form can be selfsustaining and effective in helping U.S.
physicians and hospitals engage in robust
HIE to improve the quality and efficiency of
care.” [abstract]
Consumer-Mediated HIE:
Health Record Bank (HRB)
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Secure community-based repository
of complete health records
Access to records completely
controlled by patients (or designee)
“Electronic safe deposit boxes”
Information about care deposited
once when created
 Required by HIPAA
Allows EHR incentives to physicians
to make outpatient records electronic
Operation simple and inexpensive
HRB Solves HII Problems
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Privacy
 Patient control
each person sets their
own privacy policy
Stakeholder Cooperation
 Patients request data
all stakeholders
must provide it (by law)
 HRB profit allocations to data partners
Making Information Electronic
 Business model provides free EHRs for
physicians
Financial Sustainability
 New compelling value for patients
~$23+/person/year recurring revenue
ISSUES
BACKUP SLIDES
Health Record Bank Operation
Health Record Bank Rationale
Where are Patient Records?
PCAST Report Recommendations
Questions?
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ISSUES
Health Record Bank Operation
Encounter
Data sent to
Health
Record Bank
Clinician’s Bank
Patient data
delivered to
Clinician
optional
payment
Secure
patient
health data
files
Clinician EHR
System
YES
Encounter Data
Entered in EHR
Patient
Permission?
NO
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Clinical Encounter
Clinician
Inquiry
DATA NOT
SENT
Health Record
Bank
BACKUP SLIDES
HRB Rationale
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Operationally simple
 Records immediately available
 Deposit new records when created
 Enables value-added services
 Enables research queries
Patient control
 Trust & privacy
 Stakeholder cooperation (HIPAA)
Low cost facilitates business model
Can create EHR incentive options
 Pay for deposits
 Provide Internet-accessible EHRs
BACKUP SLIDES
Where are Patient Records?
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53
Medical Knowledge Explosion
Provider Response: Specialization & Subspecialization
Result: Patient Records Scattered
 No one has access to comprehensive
longitudinal patient records
 Records are on paper so can’t be
processed, organized, accessed easily
Clinical and policy decisions based on
incomplete data
BACKUP SLIDES
PCAST Recommendations (12/10)
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Recommendation 1: Distributed System of
Record Elements Tagged with XML Metadata
 Protected by “digital rights management”
 Held in multiple repositories
 BUT … DRM failed for music & movies
(with only one data type and one access
option)
Recommendation 2: Create “Universal
Exchange Language” for Interoperability
 $20-40 million over a few months
 BUT … Problem has been unsolved for
decades
BACKUP SLIDES