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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
- 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)
- 18. 18 © 2014
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
- 19. 19 © 2014
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)
- 20. 20 © 2014
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
- 21. 21 © 2014
http://www.healthbanking.org/video1.html
What is a Health Record Bank?
- 22. 22 © 2014
HRB Architecture
Patient
Records
Clinician
EHR
Patient
Encounter
HRB
1
3
2
Diagram © Health Record Banking Alliance, 2013. Used by permission.
- 23. 23 © 2014
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
- 25. 25 © 2014
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
$
- 26. 26 © 2014
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 (!!)
- 27. 27 © 2014
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+
- 28. 28 © 2014
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?
- 29. 29 © 2014
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
- 30. 30 © 2014
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
- 32. 32 © 2014
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
- 33. 33 © 2014
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
- 34. 34 © 2014
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
- 35. 35 © 2014
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
- 36. 36 © 2014
Next Steps
Implement HAPPI Pilots
Looking for candidate communities
Need outside funding to reduce risk
Disseminate Lessons Learned
Organize HAPPI Projects in Multiple
Communities
- 37. 37 © 2014
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
- 38. 38 © 2014
Questions?
William A. Yasnoff, MD, PhD, FACMI
william.yasnoff@nhiiadvisors.com
703/527-5678