Simple change to federal law has only upsides for patients, providers, payers
When it comes to complex healthcare laws, rules, and regulations, it’s often difficult to find solutions that have wide-ranging benefits across the healthcare industry. One piece of legislation before Congress, however, has the potential to transform our healthcare system in ways that immediately benefit patients, providers, and payers.
As I wrote in a recent article in this same publication, when HIPAA was created in the late ’90s, there was preamble to a rule that specifically stated that one day technology would enable the data held by clearinghouses to be made available and used in meaningful ways, and at that point, the Business Associate (BA) status for clearinghouses should be removed.
That day is here.
The Ensuring Patient Access to Healthcare Records Act, H.R. 4613, would remove the BA status from clearinghouses, which are the only covered entities under HIPAA that also carry the BA designation. So data currently archived in clearing-houses could be used to provide health histories on nearly the entire U.S. population.
This data, which has use limitations because of the original HIPAA law, would facilitate improved patient record matching; create a secure, universal patient medical record; and finally allow technological innovation that leads to true interoperability in healthcare. Just as important, the legislation wouldn’t change or limit the patient privacy and data security protections afforded under existing law.
As Congress considers this legislation, it’s important for our elected officials’ stakeholders—patients, providers, and payers—to understand the practical, real-world implications of the proposed change in the law.
What it would mean for patients: We’ll empower and engage patients by giving them access to their own—complete—medical records.
First, and most importantly, there’s no way for patients to access a complete electronic health record from a central source.
The Office of the National Coordinator for Health Information Technology (ONC) points out in a recent report that “more and more patient health information is available electronically—but patients and caregivers still face challenges in accessing their data. Patient portals may not include all the information patients need—and what’s there may be inaccurate or incomplete. And often, health data can’t be shared electronically or transferred to other health care providers.1”
As healthcare consumers, we all have experienced these frustrations. Compiling your personal health history would mean going back to every doctor who ever treated you or every hospital where you received service; requesting some form of records; dealing with archaic paper-based processes like mail or fax; and manually aggregating them in a single, consistent digital format.
Despite the federal government spending tens of billions of dollars in the past several years, efforts to encourage, and even mandate, the exchange of patients’ health information among providers have fallen flat. Doctors and hospitals still can’t (or don’t) share data in meaningful ways, and patients are left holding the bag.
We’re not achieving interoperability. We’re stuck with inoperability.
Here are some common examples:
- A corporate employee relocates to a new city and switches doctors as part of the move. She takes time out of her busy schedule to call and write her previous providers and insurance company to authorize them to fax records to the new doctor. Staff at the new office create a new patient record by manually inputting the information they received via fax into their electronic medical record (EMR) system, which does not communicate with any other providers. The new record may or may not be complete or accurate.
- A busy young professional starts a new job, but his primary care doctor is not in network on the new employer’s health plan. He is forced to find a new doctor and essentially start a new record with the new provider, with no personal history. He starts the process to transfer records but gives up in frustration when asked to write and mail a letter of consent.
- A retired couple maintains a summer home in a different state. There’s no way for their records to follow them during different seasons, and they aren’t tech-savvy enough to manage different patient portals, so their providers get only half the picture.
- A mother is injured in a car accident on a family road trip and needs emergency medical care. Doctors in the random location have no way to reference important, personal medical context beyond what she or her family members can report verbally and what they have committed to memory.
Each of these scenarios—and many more—could be improved by connecting central repositories that house historical health records on individuals and still meet the important data security and privacy obligations under the law.
Additionally, it would encourage and enable patients to get more engaged in their own healthcare. Patient engagement is vital to population health outcomes, managing chronic conditions, and a myriad of other challenges. But the reality is that patients won’t engage unless or until they’re equipped with their own information. We can, and should, empower patients by giving them a single place to log in for their whole health history—a self-service access point unaffiliated with any provider or insurance company.
What it would mean for providers: We’ll support providers’ quest for integrated care by painting a more complete and accurate medical picture for every patient.
Fragmentation is a widely recognized flaw of the U.S. healthcare system. But it doesn’t have to be accepted.
The aforementioned ONC report goes on to say, “In the current records request process, patients and health systems are often at odds, as each struggle through an inefficient system to accomplish needed tasks with limited resources. But ultimately, these two user groups have the same goals—and shared needs. That means that improving the records request process is a win-win.2”
Consider the possibilities if every healthcare provider in the U.S.—including doctors, hospitals, nurses, etc.—had direct, easy, immediate access to a more comprehensive view of patients’ health history, with robust information on where patients have been, who they’ve seen, specific treatments, tests, and medications. What if providers had access to the very same universal medical record as patients themselves, so everyone operated with the same information?
Fitting all these puzzle pieces together—pieces that currently are widely scattered with no discernible pattern—would yield a bigger, more defined picture than any patient or guarantor will ever be able to recall.
It will lead to more informed clinical decision-making, allow open communication among providers, force more integrated and coordinated care, improve overall quality of care, and result in more prudent use of valuable healthcare resources.
If, for instance, a doctor could see that a patient received a similar diagnosis during a visit five years ago, and was prescribed a medication which led to a hospital visit two weeks later, a repeat of this event could be avoided. This not only allows better care to be provided this time around, but it avoids a costly hospital visit.
Ridding our healthcare system of this type of repetition and the billions of dollars of waste it creates is a tenet of value-based payment models. But providers must have access to more useful and relevant data if they’re ever expected to combine clinical efficiency with fiscal responsibility.
Imagine, if instead of relying on their patients to recount their drug history, different healthcare providers and pharmacists could use shared data from a single source to prevent adverse reactions to multiple medications, decrease rehospitalizations and eliminate other preventable complications.
The same data used to build a fuller, more meaningful profile at the individual patient level also could be used to improve population health management. Providers can start to analyze cohorts of individuals by practice and treatment patterns to find ways to deliver a more consistent, cost-effective continuum of care, with a specific focus on preventive care measures that build on strides made with evidence-based practice methods. Combining one healthcare system’s EMR data with years of health history from visits to other, unrelated, medical facilities would clearly lead to better outcomes.
All of this is contingent, though, on providers’ ability to correctly identify patients and track their flow-through and use of the healthcare system. Instead of relying on specialists, hospitals, outpatient centers, and primary care providers to proactively share data with one another, which we have proven doesn’t happen, activities would be automatically logged in the patient record and accessible for all to see, for any episode of care.
Better data will lead to better care coordination, which will lead to higher quality at a lower cost.
What it would mean for payers: We’ll help payers operate more efficiently, manage risk, and improve wellness programs.
Just like providers, health plans are all-in with the movement toward wellness, population health management and consumer-driven healthcare. But they could be more effective partners in this pursuit if they had access to shared data on patients’ medical history.
When an insurance company covers a patient population for an employer, for example, the payer has no valuable data until covered employees begin making visits and claims are submitted. With no relevant history on the patient population beyond those patients who were previously covered, the payer may not be aware that certain patients struggle with chronic conditions like diabetes or congestive heart failure. There’s zero visibility across payers.
This challenge was exacerbated by the Affordable Care Act. Some of the patients now covered had never been covered before; there is no way for insurance companies to accurately assess risk without a health history. Rates on the individual marketplace have risen sharply every year as payers have struggled to adjust.
Unlocking the data would allow for more accurate risk assessment for patients and groups—not to mention reduce payers’ administrative burden, as well as fraud detection and prevention.
Health plans also recognize the immense value of linking patient data for wellness programs, population health management and other initiatives that improve patient outcomes. There even have been some organic, albeit unsuccessful, efforts within the industry to link data across payers.
They need rich, portable data linked across payers and clearinghouses to bridge gaps in care, help patients stay healthy, avoid unnecessary use and reduce healthcare’s overall cost.
Linking pharmacy data to medical claims data, for instance, in the same way Medicare does today, would give insight into what was diagnosed versus what was prescribed and how it affected the ultimate patient outcome for that episode of care.
You can learn more from the Claim Your Health Data Coalition.
References
- Improving the Health Records Request Process for Patients: Insights from User Experience Research. Office of the National Coordinator for Health Information Technology. 2017. 5. https://www.healthit.gov/sites/default/files/onc_records-request-research-report_2017-06-01.pdf
- Improving the Health Records Request Process for Patients: Insights from User Experience Research. Office of the National Coordinator for Health Information Technology. 2017. 11. https://www.healthit.gov/sites/default/files/onc_records-request-research-report_2017-06-01.pdf
Comparing the patient journey
THE WAY IT IS
Linda is a working mother of three. During a recent annual visit, she told her primary care doctor about some health concerns. The physician ordered a test at the local hospital, which Linda scheduled the following week. It was noted in her chart but not accessible to anyone else.
The hospital shared the test results with the primary care doctor, who referred Linda to a specialist for follow-up.
Linda had to fill out a pile of paperwork at the specialist’s office because she was a new patient. After examining Linda, the specialist ordered a different test at a nearby outpatient center. When the test results came back, the specialist prescribed Linda two medications to help with the issue.
The new medications triggered an adverse event when mixed with Linda’s existing medications, and Linda was hospitalized within two days.
A hospitalist stabilized Linda and released her in 24 hours, but her primary care doctor wasn’t aware of the events until she scheduled a follow-up visit the next week. Her doctor tracked down the test results and medication information from the specialist and pharmacy and prescribed a new medication that helped resolve her issue without complications.
THE WAY IT COULD BE
Linda told her primary care doctor about some health concerns. The physician ordered a test at the local hospital, which Linda scheduled the following week.
The hospital shared the test results with the primary care doctor, and they were automatically loaded into her EMR. Her doctor referred Linda to a specialist for follow-up.
After examining Linda and referencing her medical history, current medications and recent test results noted in her medical record, the specialist gave Linda a medication to help resolve her issue.
Linda’s healthcare experience was faster, easier, and cheaper and produced a better outcome because of the information sharing in her universal health record.
