William A. Yasnoff, MD, PhD, FACMI WCIT 2014, Guadalajara, Mexico

1. Health Record Banks: Business Considerations
William A. Yasnoff, MD, PhD, FACMI
Managing Partner, NHII Advisors
Adjunct Professor, Division of Health Sciences Informatics
Johns Hopkins University
WCIT
Guadalajara, Mexico
September 30, 2014
© 2014

2. 2 © 2014

3. 3 © 2014
Overview: “Big Data” has Value
 Need critical mass (“Big”)
 Most of population
 Need repository with comprehensive
records for each person (“Data”)
0
20
40
60
80
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.

4. 4 © 2014
Funding Options for
Health Information Infrastructure
1. Public funding
 Additional taxes unpopular
2. Capture health care savings
 One stakeholder’s “savings” is
another’s “lost revenue”
 Timing, magnitude, and distribution of
savings
– Unproven
– Difficult to predict
3. Leverage new value of comprehensive
electronic patient records

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Health Record Banking:
Community Paradigm Shift
Fetch & Show
• Based on manual “fetch & fax”
• Inefficient & expensive
• Prone to error (record sources unavailable)
• Impractical to search data
• Hard to protect patient privacy
• No sustainable business model
Repository
• Based on “deposit to account”
• Efficient & inexpensive
• Reliable & secure
• Searchable for public health & research
• Privacy assured via patient control
• Each community has one (or more) health
record banks
• Each patient has an account
in a single health record bank
Health
Record
Bank

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http://www.healthbanking.org/video1.html
What is a Health Record Bank?

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Health Record Bank (HRB)
 Secure community-based repository
of complete health records
 Access to records fully controlled by
patients (or designee)
 “Electronic safe deposit boxes”
 Information about care deposited
once when created
 Operation simple and inexpensive
 Enables effective business models by
leveraging value of “Big Data”

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Health Record Bank Architecture
Patient
Records
Clinician
EHR
Patient
Encounter
HRB
1
3
2
Diagram © Health Record Banking Alliance, 2013. Used by permission.

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Clinical Encounter
Health Record
Bank
Clinician EHR
System
Encounter Data
Entered in EHR
Encounter
Data sent to
Health
Record Bank
Patient
Permission?
NO
DATA NOT
SENT
Clinician
Inquiry
Patient data
delivered to
Clinician
YES
optional
payment
Clinician’s Bank
Secure
patient
health data
files
Health Record Bank Operation

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HRB Rationale
 Operationally simple
 Records immediately available
 Deposit new records when created
 Enables value-added services
 Patient control
 Trust & privacy
 Stakeholder cooperation (HIPAA in
U.S.)
 Low cost facilitates business model
 Can include EHR incentive options to
assure all-electronic data
– Pay for deposits
– Provide Internet-accessible EHRs

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How HRBs Create Value
Health Record Bank
provides
free/subsidized EHRs
for physicians
More complete
electronic health
Enables delivery of record information
optional services with
compelling value
Patients sign up for
free HRB accounts
(recommended by
physicians)
Enables physicians to
provide better patient
care
$

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HRB Revenue Sources
1. Individuals
2. Health Care Professionals
3. Hospitals
4. Health Plans
5. Health Insurers
6. Public Health Departments
7. Policymakers
8. Researchers
9. Advertisers

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HRB Services:
1. Individuals
 Reminders & Alerts
 Peace of Mind
– Loved ones notified of emergency
treatment
 Prevention Advisor
– Reminders of needed tests and
procedures based on demographics
and medical records
 Medication Refills (may be sponsored)
– Text messages when due

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HRB Services:
2. Health Care Professionals
 Automatic patient reporting of
normal/unchanged lab results
 Patient intervention alerts
 Quality measures

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HRB Services:
3. Hospitals
 Access to patient summary in
Emergency Department
 Medication reconciliation
 Patient intervention alerts
 Reduce costly record requests
 Quality measures
 Targeted prevention/population
health

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HRB Services:
4. Health Plans
 Patient intervention alerts
 Quality measures
 Sponsorship of premium HRB
services for members  reduced
costs
 Targeted prevention/population
health interventions

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HRB Services:
5. Health Insurers
 Patient intervention alerts
 Quality measures
 Sponsorship of premium HRB
services for members  reduced
costs
 Targeted prevention/population
health interventions
 Analysis of de-identified utilization
data

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HRB Services:
6. Public Health Departments
 Surveillance
 Disease/condition
incidence/prevalence
 Treatment effectiveness in population
 Targeted prevention initiatives

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HRB Services:
7. Policymakers
 Monitor effects of policy changes
 Assess cost and value of care
 Assess effectiveness of prevention
efforts

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HRB Services:
8. Researchers
 Find subjects for clinical trials
 Aggregated statistics in population
 Correlations
 Trends
 Monitor for adverse events

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HRB Services:
9. Advertisers
 Targeted messages based on
disease/condition (with patient
permission)
 Services of interest
 Discounts
 Special offers

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HRB Business Model Example
 Costs (with >= 1,000,000 subscribers)
 Operations: $6/person/year
 EHR incentives: $10/person/year
– Cloud-based EHR
$5K/physician/year
– In U.S., 300 million
population/600K physicians = 500
people/physician
– $5K EHR/500 people =
$10/person/year
 Total cost $16/person/year

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HRB Business Model Example
 Revenue
 Reminders & Alerts: >=
$18/person/year ($60/year x 30%
penetration)
– “Peace of mind” alerts ($20/year)
– Preventive care reminders ($20/year)
– Medication reminders ($20/year)
 Researcher Queries: >$5/person/year
 Advertising: ~$3/person/year (option
to opt out for small fee)
 Total revenue = $26/person/year
 No need to assume/capture any health
care cost savings (!!)

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HRB Business Model Example
 Bottom Line
 Total cost = $16/person/year
 Total revenue = $26/person/year
 Net profit $10/person/year
 $10,000,000/year with 1,000,000
subscribers

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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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Health and Promotion
Prevention Initiative (HAPPI)
 Link HRB with Community Population
Health Organizations
 Use HRB profits to fund population
health
 E.g., half of profits for 1 million
population = $5,000,000/year
 Aligns interests of healthcare
stakeholders IF there are incentives
for 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

29. 29 © 2014
Summary
 “Big Data” has value
 Need critical mass (“Big”)
 Need repository with comprehensive
electronic patient records (“Data”)
 Possible mechanisms for funding HII
 Taxes  unpopular
 Capture health care savings  untenable
 Health Record Banks facilitate business
models by generating value from data
 Revenue from many stakeholders
 Health Record Banks can be profitable
WITHOUT capturing health care savings

30. 30 © 2014
Paradigm Shift
Fetch & Show
• Based on manual “fetch & fax”
• Inefficient & expensive
• Prone to error (record sources unavailable)
• Impractical to search data
• Hard to protect patient privacy
• No sustainable business model
Repository
• Based on “deposit to account”
• Efficient & inexpensive
• Reliable & secure
• Searchable for public health & research
• Privacy assured via patient control
Health
Record
Bank

31. 31 © 2014
Questions?
William A. Yasnoff, MD, PhD, FACMI
william.yasnoff@nhiiadvisors.com
703/527-5678