Using HIE as a Tool to Bend the Cost Curve

What do you do when 1 percent of a city’s population makes up 30 percent of hospital costs? And 13 percent of patients account for 80 percent of the costs? If you’re Jeffrey Brenner, M.D., a physician working in one of the poorest cities in the country, Camden, N.J., you attack the problem head on. And hospital data gathered in a health information exchange is at the heart of the effort.

Last week I attended an inspiring webinar featuring Dr. Brenner and sponsored by Reporting on Health, an initiative of the University of Southern California’s Annenberg School for Communication & Journalism.

Brenner, the executive director of the nonprofit Camden Coalition of Healthcare Providers (CCHP), has worked for several years with community groups to develop programs to provide this small percentage of hospital service “super users” with better, more coordinated care to keep them out of the hospital and decrease the cost to the system. CCHP’s social workers and health promoters, some of them AmeriCorps students, help patients, almost all of whom are covered by Medicaid, Medicare or both, navigate the healthcare system and community services available to them.

The Camden HIE is cloud-based with a centralized data model. The original founders are Cooper Health System, Virtua, and Our Lady of Lourdes Health System. The HIE is currently used by more than100 healthcare providers in Camden as well as by several of the coalition’s projects. The data can be used to identify patients for possible enrollment in the Coalition’s Care Management and Care Transitions programs. For instance, when there is an admission, discharge or transfer in one of the three member hospitals, that data flows into the HIE, allowing CCHP to analyze it and consider an intervention. Data about the chief complaints in local emergency rooms showed that three of the top four complaints are head cold, ear infection and soar throat. All three of those should be dealt with in primary care settings rather than emergency rooms, Brenner said. CCHP used the HIE data to identify high-cost “hot spots” — high-rise buildings where a large number of these super users of the hospital emergency rooms live. By identifying and working with these patients on patient-centered care coordination issues, they have been able to cut down on emergency room use and in-patient stays. One strategy involved opening a primary care clinic in the lobby of one of the two high-rises identified.

Brenner, who has been working with a coalition of stakeholders to create a Medicaid accountable care organization, had some blunt things to say about how healthcare is provided in this country and how it is covered by the media.  “The business model of hospitals is much the same as those of hotels and airlines,” he said. They are volume-based and related to occupancy. They are not in the business of keeping people out, but in filling the beds. The same is true for CT scanners and MRIs, Brenner noted. Once you’ve got this misalignment of financial incentives, it’s very hard to change the system, he added.

Concerning the media, Brenner said he was disappointed with reporting and public dialog about the Affordable Care Act. “It seems like most of the focus has been on how are we going to pay instead of what we want to buy,” he said. “It’s as if we went to a car dealer and spent the whole time talking about the financing and none talking about the features of the car.” He encouraged journalists to find and describe good models of care such as Ryan White Clinics, which provide primary medical care and case management to adults with HIV or AIDS, regardless of financial eligibility, and Assertive Community Treatment Centers designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia.

“Embed yourselves in clinical programs,” he suggested to the reporters listening, “and talk about the attributes of good care. Good care is face-to-face and responsive, and by providers who understand your illness.” Most of us aren’t getting that kind of care, he suggested, because we are “lost in the delivery system.”

Brenner said the healthcare system is headed for a crisis because it is providing fragmented and unnecessary care. Data can be used for quality improvement and care coordination efforts, but hospitals often treat that data as business intelligence they don’t want to share, he added. “It is a real public policy challenge to free that data,” he said. “We are not going to fix the system without access to data.”