Congress holds the key to achieving improved healthcare through better use of data

Sept. 26, 2017
Courtesy of Experian
Dan Johnson Executive Vice President, Health Strategy, Experian Health

It’s ironic that the very law enacted to improve digitization and sharing of health records is, in fact, the same obstacle to achieving true interoperability of electronic medical records.

Over the last decade, the federal government has provided more than $35 billion in incentives to improve data interoperability and access to electronic health records (EHRs). Investments made through the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 have resulted in a rapid digitization of health data. This federal contribution doesn’t count the considerable time and resources that providers and hospital networks poured into the transition from paper to electronic records.

Progress toward the digitization of records has been substantial. But because we can’t easily link and share comprehensive electronic medical records across the healthcare industry, we’re still coming up woefully short. A recent Government Accountability Office study found that relatively few patients access their health information, primarily because health records are difficult to compile in a seamless manner.

The good news is that a small change in the law could help the healthcare industry take a giant leap forward. Congress is currently considering reforming existing law that restricts the ability of healthcare clearinghouses to share the claims data they process and maintain. The Ensuring Patient Access to Healthcare Records Act, introduced during the last session of Congress by Rep. Cathy McMorris Rodgers (R–WA) and Sen. Bill Cassidy (R–LA), would unlock clearinghouse data so it could be linked and shared, all while keeping important consumer privacy and data security protections in place. These congressional leaders deserve praise for their efforts to find new ways to use data to improve health outcomes and patient access to data.

Valuable data is on HIPAA lockdown

Congress passed the Healthcare Information Portability and Accountability Act (HIPAA) in 1996 to ensure data privacy and security for medical information. The Privacy Rule implementing HIPAA applies to “covered entities” like health plans, healthcare clearinghouses, and certain healthcare providers. Under HIPAA, providers and plans may disclose protected health information to “business associates” that provide specific services. This means that when healthcare clearinghouses are engaging in activities like claims processing, they’re defined under the rule as both a covered entity and a business associate.

Clearinghouses handle an estimated 90% of all healthcare claims transactions in the United States. These companies have existed for decades—long before the idea that consumers should have access to their EHRs. Clearinghouses manage payment transactions that flow between payers and more than 5,000 hospitals, 900,000 doctors, 66,000 pharmacies, and 20,000 labs.

HIPAA’s dual restrictions on healthcare clearinghouses limit the use of this data for any purpose except processing claims. The result is that clearinghouses are prevented from playing a role in helping patients and providers easily obtain a full and historical view of healthcare visits, diagnosis, and treatment. The Ensuring Patient Access to Healthcare Records Act would allow clearinghouses to lead this effort.

Notably, the regulators who drafted the original HIPAA Privacy Rule in 1999 anticipated the restrictive nature of the business associate status for clearinghouses. The preamble of the proposed HIPAA rule noted, “As technology improves it is likely that clearinghouses will find ways to take advantage of databases of protected health information that aggregate records based on the individual subject of the information. This technology would allow more cost-effective access to clearinghouse records on individuals and therefore access for inspection and copying could be appropriate and reasonable.”

Legislation would remove the BA designation from clearinghouses

The technology for achieving data portability of comprehensive healthcare records envisioned by regulators nearly 20 years ago is achievable today if Congress enacts the Ensuring Patient Access to Healthcare Records Act. The act would help realize the benefit of interoperable health data that the government sought to achieve with the HITECH Act, EHRs, and other post-HIPAA programs.

The legislation would clarify that healthcare clearinghouses, regardless of their original status as a business associate under HIPAA, should be permitted to use and disclose protected health information in the same manner as other covered entities under the HIPAA Privacy Rule. This would let clearinghouses distribute data for all permitted uses under HIPAA while still ensuring that they meet the privacy and data security requirements of current law.

Patient matching technology would be improved

An effective patient matching technology could mean immense savings and efficiencies for our nation’s healthcare system. In 2008, the RAND Corporation estimated that such technology would deliver $77 billion in savings through error reduction, efficiency, and interconnectivity.

To create an environment of data portability, archived data from multiple clearinghouses would be linked through a non-vendor-specific universal patient identifier (UPI) algorithm. A UPI would associate all relevant health data with a unique individual, providing for the compilation of accurate medical histories that can flow throughout the healthcare ecosystem. This data would lead to not only tangible benefits to patients, but also to better public health outcomes, such as cost savings for payers and providers and a reduction in healthcare fraud and medical identity theft.

Improved data matching through a UPI would also help resolve a common problem that plagues our nation’s health system—a patient receiving the wrong diagnosis or lab results after being mistaken for another patient with the same name. Such problems lead to unnecessary treatments and surgeries that only further drive up costs for patients, providers and insurers.

Patients would benefit from a comprehensive view of their medical history

Patients would also benefit if the business associate designation for clearinghouses is removed. Their demand for access to their own health information could finally be met with the compiled historical data that clearinghouses could make available to patients, payers, and providers.

Just imagine patients being able to easily access their personal medical history, including dates of service, diagnoses and treatments for every healthcare event going back decades. This would replace the fractured and siloed nature of our current healthcare information environment with a seamless, interoperable system. Patients would no longer face the daunting task of assembling their healthcare history by relying on memory or spending an inordinate amount of time piecing together their medical history by requesting records from individual providers through fax or mail.

Providers would see reduced costs, improved efficiencies and better healthcare outcomes

With the business associate designation removed, clearinghouses would initially be able to provide a medical history checking system that healthcare providers could access through revenue cycle management products or an online portal. Data could also be provided in a virtual clearinghouse and integrated into health information systems and practice management systems. That way, providers could query a patient’s historical data consistent with their own preferred workflow process.

This would solve the challenge healthcare providers face with duplicate records. A hospital or doctor would now know me, Dan Johnson, from all the other Dan Johnsons who have received services from a doctor or hospital somewhere at some time over the past decades. My complete medical history, across all providers I’ve visited, could be used in clinical decisions. Think about all the time and resources healthcare providers spend trying to distinguish one Dan Johnson from another. Then, imagine the productivity that can be gained when these resources can instead be put to use improving clinical decisions.

Clearinghouses are already helping individual health systems create unique identifiers for their patients. However, productivity could be further enhanced if healthcare providers and clearinghouses could share data using the same UPI across enterprises.

The pharmacy industry is already pursing this effort. In 2016, the National Council for Prescription Drug Programs (NCPDP) partnered with Experian Health to standardize patient identifiers for the billions of transactions flowing through the pharmacy systems to solve the same duplicate records problem that confronts healthcare providers.

Coalition supports reform

A coalition of leading healthcare clearinghouses is actively supporting enactment of the Ensuring Patient Access to Healthcare Records Act and working to educate lawmakers and policymakers about the many ways the act would benefit patients and healthcare providers.

The Claim Your Health Data Coalition was established in 2016 by The SSI Group, Availity, and Experian Health and is committed to advancing the cause of unlocking the potential for data currently siloed within clearinghouse networks. Together, these three companies process hundreds of millions of individual claims safely and securely every year.

When she introduced the legislation in March 2016, Rep. McMorris Rodgers said, “By allowing patients to have access to their own comprehensive medical records, we can lower healthcare costs, address market inefficiencies and otherwise improve our health systems.”

It’s been said that “data is the new oil.” It’s time for Congress to ensure that data can be used responsibly and securely to drive real and positive improvement in healthcare delivery.

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