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Health Record Banks are Essential for Effective Health Information Infrastructure
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William A. Yasnoff, MD, PhD, FACMI WCIT 2014 Guadalajara, Mexico
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Health Record Banks are Essential for Effective Health Information Infrastructure
1.
Health Record Banks
are Essential for Effective Health Information Infrastructure William A. Yasnoff, MD, PhD, FACMI CEO, Health Record Banking Alliance Adjunct Professor, Health Science Informatics, Johns Hopkins University WCIT Guadalajara, Mexico September 30, 2014 © 2014
2.
2 © 2014
Outline Goals of Health Information Infrastructure (HII) Comprehensive Electronic Patient Records Population Health and Prevention The Health and Prevention Promotion Initiative (HAPPI): A Self-Funding Organization for Prevention, Population Health, and Electronic Records Next Steps
3.
3 © 2014
HII Goals Support the Triple Aim Better Health Better Care Lower Costs Challenges Prevention Population Health Consumer Tools Better Decisions Consumer Tools Avoid Errors Avoid Duplication Prevention Prevention & Population Health Comprehensive Electronic Patient Records
4.
4 © 2014
5.
5 © 2014
HII Goal 1: Individual Records Comprehensive electronic patient records when & where needed Individual (patient care) Aggregate (research, public health) Basic Requirements All information must be electronic all providers must use EHRs Mechanism to bring together scattered information for each person (“Health Information Exchange” or HIE)
6.
6 © 2014
Current Efforts are Failing HHS: Current efforts “alone will not be enough to achieve the widespread interoperability and electronic exchange of information necessary for delivery reform where information will routinely follow the patient regardless of where they receive care.” -- ONC/CMS RFI 3/7/13, p. 5 PCAST: HIE efforts through the states “will not solve the fundamental need for data to be universally accessed, integrated, and understood while also being protected.” – Dec 2010, p. 40
7.
7 © 2014
Adler-Milstein et al HIE Survey (Annals of Internal Medicine, May 2011) 179 HIEs surveyed Only 13 met Meaningful Use Stage 1 – 3% of hospitals, 0.9% of physicians Only 6 of 13 self-reported as sustainable None of 179 met expert panel definition of comprehensive system, calling “into question whether RHIOs* in their current form can be self-sustaining and effective.” (abstract) *Regional Health Information Organizations Current Efforts are Failing (continued)
8.
8 © 2014
Multiple HIEs have already failed Washington, DC Kansas Tennessee CalRHIO CareSpark (Kingsport, TN) – Long touted as national leader No patients currently receive care with guaranteed availability of comprehensive records from all sources Current Efforts are Failing (continued)
9.
9 © 2014
Why are HIEs failing? Substantial resources: $564 million Federal funds allocated March 2010 Challenges well known – Privacy – Stakeholder Cooperation – Sustainability Current Efforts are Failing (continued)
10.
10 © 2014
Wrong Path Trying to replicate manual process of contacting other providers directly for records Current Efforts are Failing (continued) HIE Index Other EHRs Assembly Clinician EHR Patient Encounter 5 4 3 1 2 Diagram © Health Record Banking Alliance, 2013. Used by permission.
11.
11 © 2014
Complex and Expensive All EHRs must be online 24/7 to respond to queries Real-time reconciliation of records Requires unique patient identifier – Politically impractical – Privacy threat Must have expensive 24/7 network operations center to monitor all contributing EHRs Current Efforts Can’t Work
12.
12 © 2014
Increasing Errors with More Data Sources Current Efforts Can’t Work (continued) Source: Lapsia V, Lamb K, Yasnoff WA: Where should electronic records for patients be stored? Int J Med Informatics 81:821-827, 2012.
13.
13 © 2014
Increased Liability Patients cannot review or annotate data Providers and HIE responsible for correctness No propagation of corrections Current Efforts Can’t Work (continued)
14.
14 © 2014
Not Financially Sustainable Current Efforts Can’t Work (continued) 0 10 20 30 40 50 60 70 80 90 100 0 20 40 60 80 100 Value of Info (%) Completeness of Information (%) Value vs. Completeness of Health Information Source: Yasnoff WA: Health Information Infrastructure. In Biomedical Informatics: Computer Applications in Healthcare and Medicine, Fourth Edition (Shortliffe & Cimino, eds.). New York: Springer-Verlag, 2014, pp. 423-441.
15.
15 © 2014
Unable to Protect Privacy Where can consumers indicate their privacy preferences? If data left at sources, consumers must set and maintain their preferences at every source too complex and inconvenient Current Efforts Can’t Work (continued)
16.
16 © 2014
Unable to Ensure Stakeholder Provision of Patient Information Stakeholder participation in HIE is voluntary – Difficult to get cooperation – Difficult to maintain cooperation Only patient requests for information must be honored by all stakeholders Current Efforts Can’t Work (continued)
17.
17 © 2014
Unable to Facilitate Robust Data Searching Distributed records sequential search Sequential search is too slow to be practical Current Efforts Can’t Work (continued)
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Consequences for Stakeholders Stakeholder Problems Health Plans/Insurers 1. Continually escalating costs 2. No comprehensive patient records Hospitals/ACO s 1. Inadequate/incomplete patient information on admission and in ER 2. Uncontrollable financial risk (e.g. from readmissions) 3. Ineffective/inefficient prevention activities Physicians 1. EHRs just “electronify” existing silo of patient records 2. No comprehensive patient records better care 3. Ineffective/inefficient prevention activities Patients 1. Preventable errors 2. Preventable adverse events 3. Unnecessary repeat tests/procedures 4. Continually escalating costs Government/C ommunity 1. Continually escalating costs 2. Prevention efforts ineffective/underfunded 3. Data unavailable for policy & research
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HIT Architecture Choices Distributed architecture – does not work Leave information in place; retrieve in real time when needed Problems – Inefficient – Error prone – Does not scale – Hard to protect privacy – Impractical to search data Centralized architecture (health record banks)
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Solution: Health Record Bank (HRB) 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 (in U.S.) Allows EHR incentives to physicians to make outpatient records electronic Operation simple and inexpensive
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http://www.healthbanking.org/video1.html What is a Health Record Bank?
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HRB Architecture Patient Records Clinician EHR Patient Encounter HRB 1 3 2 Diagram © Health Record Banking Alliance, 2013. Used by permission.
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HRB Rationale 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 Creates EHR incentive options Pay for deposits Provide Internet-accessible EHRs
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How HRBs Create Value Health Record Bank including free/subsidized EHRs for physicians More complete electronic health Enables delivery of record information optional services with compelling value Patients sign up for HRB accounts (recommended by physicians) Enables physicians to provide better patient care $
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HRB Business Model Costs (with 1,000,000 subscribers) Operations: $6/person/year EHR incentives: $10/person/year Revenue Advertising: ~$3/person/year (option to opt out for small fee) Reminders & Alerts: >= $18/person/year – “Peace of mind” alerts – Preventive care reminders – Medication reminders Queries: >$3/person/year No need to assume/capture any health care cost savings (!!)
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Pro Forma Example (Houston) ($1,000) $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 "Expenses ($K)" "Revenue ($K)" "Net ($K)" Month Initial Capital: $4.4 MM Breakeven: 16 months EBITDA Year 4: $41 MM+
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HII Goal 2: Prevention & Population Health Definition – Improving the health outcomes of a group of individuals U.S. not doing this well Per capita health care spending >2x other industrialized nations But outcomes poor – U.S. ranks 24th of 30 OECD countries in life expectancy Only 3% of spending on prevention while 75% of medical costs relate to preventable chronic conditions How can we improve?
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Prevention & Population Health Challenges New activity – Providers do not do this now – Must hire staff & establish procedures Inefficient for each provider – More costly per capita to focus on limited populations Benefit externalities – Member “churn” limits ROI for prevention – No incentive for long-term prevention investments
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Prevention & Population Health Potential Solution: Collaborative Community Prevention Organization All providers pool resources Community organization does prevention & population health for all Issues Ongoing funding Continuous provider cooperation – Initial capitalization – Annual operational funding Incentives good but not compelling Need comprehensive patient info
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Health and Prevention Promotion Initiative (HAPPI) Combine Community Prevention Organization with Health Record Bank Health Record Bank Provides needed information Ensures all-electronic records Generates revenue (apps, ads, data) Provides funds for itself and more Excess funds from HRB Pay for Prevention and Population Health
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How does a HAPPI work? PATIENT CONTROL CENTRAL REPOSITORY Stakeholder Cooperation ensures Electronic Patient Data provides Benefits 1. Clinical: Quality,Costs 2. Reminders/Alerts 3. Research produces pay for enables Prevention (stakeholder need) empowers Privacy protects Financial Incentives ensure Key Design Decisions Initial Steps: 1. Free/subsidized EHRs for physicians 2. Physicians recruit patients for free HRB accounts
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All Stakeholders Benefit Stakeholder Benefits Health Plans/Insurers 1. Lower care costs (better info) 2. Prevention lowers future costs 3. Sustainable after initial investment *** Hospitals/ACOs 1. Prevention services 2. Better info/tools for care 3. Patient portal 4. Sustainable after initial investment *** Physicians 1. Free/subsidized EHRs 2. Better info/tools for care 3. Prevention services Patients 1. Better care 2. Tools for health and prevention 3. Control over own records 4. Basic accounts free Government/Commu nity 1. Lower costs 2. Prevention 3. Information for policy & research *** key benefit
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The Triple Aim Better Health Better Care Lower Costs Challenges Prevention Population Health Consumer Tools Better Decisions Consumer Tools Avoid Errors Avoid Duplication Prevention Prevention & Population Health Comprehensive Electronic Patient Records HAPPI
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Next Steps Implement HAPPI Pilots Looking for candidate communities Need outside funding to reduce risk Disseminate Lessons Learned Organize HAPPI Projects in Multiple Communities
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SUMMARY HII Goals Include Prevention & Population Health Health Record Banks Can Provide Comprehensive Electronic Patient Records Needed Incentives for EHR Adoption Excess Revenue Combine Community Prevention with HRB Health and Prevention Promotion Initiative (HAPPI) HAPPI Successful HII & Achieving the Triple Aim
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Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678
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