Diagnostic Information SystemSM Stakeholder Benefits:
RHIO/HIE benefits

-enhances the interrelated processes of test results reporting, viewing and sharing and incentivizes both physician ambulatory EHR  adoption and the utilization of RHIO/HIE patient data aggregation and integration services.

-for the first time(1) provides physicians with a clinically integrated, comprehensive, and consistent view of cumulative patient test results in their offices and clinics, hospitals and long-term care facilities.

-facilitates the efficient electronic viewing and sharing of all results across the continuum of care and provides a simple solution for a costly and dangerous national clinical data management problem

-Using a common user interface to present comprehensive data from a wide variety of testing sources in an integrated, patient-centered manner can provide important clinical, business and societal value. Clinicians, patients, public and private payers and test results providers can all appreciate the cost, patient safety and quality of care benefits as short-term “wins” with long-term value. Such an explicit demonstration of the HIE value proposition can help develop a community-wide vision of compelling business value and secure vested interest and trust among the many HIE stakeholder entities.
(1) Of the 20 fully functional RHIO/HIEs in the United States and the dozen that were self-sustaining in December 2007, most early successes involved the delivery of laboratory and radiology test results to physicians where a consensus exists that the return on investment is most achievable. However, none of these RHIOs/HIEs is yet offering its physician users a comprehensive, clinically integrated and standardized reporting format. (See Indiana HIE 2007 Annual Report)
Unlike the existing variable reporting formats that display fragmented and incomplete test results data, this new technology tool will enhance instead of hinder physician workflow. By helping doctors across the care continuum minimize redundant testing and retesting, the annual reduction in private and public payer claims costs, employer premiums and consumer co-pays will explicitly support the business case and encourage stakeholders to contribute the annual transaction or subscription fees needed to ensure RHIO/HIE sustainability. 

John Halamka, MD, CEO of the Massachusetts Regional Health Information Organization (RHIO) called MA-SHARE, has spent 4 years working with stakeholders in Massachusetts to create a sustainable business model for health information exchange. According to Dr. Halamka, the big lesson learned in the two Massachusetts statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. Their hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for their community. To achieve sustainability, he believes the initial efforts must be expanded to meet the needs of the common marketplace. Solving the industry-wide test results reporting format problem is one of the most important clinical needs. (See below: http://geekdoctor.blogspot.com/are-regional-health-information.html)

Physician benefits
-incorporates the “voice of the physician end user” into ambulatory and hospital EHR and RHIO/HIE test results reporting product design and use

-speeds and facilitates viewing and analysis of each patient's cumulative test results
-ease of access to the same, clinically logical presentation of test results information across all patients, care sites, and medical specialties

-ease of use with a intuitive, clinically integrated, comprehensive and consistent format to increase the speed and safety of patient care

-helping physicians minimize duplicate testing because of lost results or results unavailable in time is ideally suited to a consumer-directed industry with outcomes-based payment

-helps reduce malpractice liability hazards and risk associated with fragmented and incomplete medical record-keeping

Hospital and Community Testing Facility benefits

-helps capture and retain physician customer base through a differentiating and superior results reporting service

-increases evidence-based screening and sporadic testing volumes

-decreases facility results reporting expenses and archival test results data storage costs

- facilitates reducing hospital ALOS

- reduces hospital malpractice exposure and risk

- increases effectiveness of hospital UR and QA processes

- increases testing facility contracting leverage with private and public payers

Private and Public payer benefits

- incentivizes EHR  adoption, acceptance and use in physician offices

- produces cost and quality data to benchmark testing sites, provider performance and clinical outcomes.

- reduces waste and cost of inappropriate inpatient and ambulatory patient test usage and retesting and hospital ALOS

- incentivizes patient referral to preferred testing sites

- reduces training and integration costs for hospital clinics, Integrated  Healthcare Systems, individual office and clinic physicians and community-based physician group practices. 

-enables authorized all-payer and public health access to standardized, longitudinal patient test results data repository

-facilitates clinical decision support and chronic disease management initiatives

 Pharmaceutical & PBM Company benefits

- incentivizes physician EHR  adoption, acceptance and use

- enhances physician and patient drug knowledge at the point of care

- reduces drug development cycle length and expense

- decreases drug promotional material expenses

- facilitates monitoring and avoidance of drug side effects and drug-drug interactions.

- enables authorized access to longitudinal test results data repository for clinical trials and post-market surveillance.

Retail Pharmacy benefits

- enhances the clinical pharmacist role in a consumer-directed marketplace in demand management, medication profile review, medication reconciliation and therapeutic monitoring.

- enables authorized access to longitudinal, cumulative test results data repository at the retail point-of-sale

- facilitates physician, pharmacist and payer collaboration in prescription drug benefits management and formulary-driven drug utilization

PHR benefits 

-A standardized reporting format that enables efficient viewing and sharing of cumulative test results by patients and their primary care and specialist physicians

-enhances the existing sporadic test results reports of the harmonized HL7/ASTM Continuity of Care Document (CCD) standard medical history summary for EHRs, PHRs and RHIOs/HIEs)

-A useful technology tool for first responders and personnel in hospital Emergency Rooms, Urgent Care Centers and retail-based clinics. 

February 25, 2008:

Are Regional Health Information Organizations (RHIOs) Sustainable?
As CEO of the Massachusetts Regional Health Information Organization (RHIO) called MA-SHARE, I have spent 4 years working with stakeholders in Massachusetts to create a sustainable business model for health information exchange.

MA-SHARE’s first effort in 2004 was the MedsInfo project, a state-wide medication history exchange pilot based on payer claims data. We learned a great deal about privacy, workflow, data expectations, and health information exchange operations. The project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations given the lack of integration of the data into clinician workflow and the inherent incompleteness of the data (only 66% of patients had medication data in our regional payer databases as of 2004). As of 2007, the two largest national e-Prescribing exchanges, RxHub and SureScripts, have much more complete networks and we've integrated the former MedsInfo functionality into our e-Prescribing utility, described below.

In 2005 and 2006, working with the Markle Foundation and the Office of the National Coordinator, we developed a Nationwide Health Information Network implementation pilot based on a state-wide master patient index called the Record Locator Service. The pilot demonstrated the value of the emerging clinical data exchange architecture to support provider-to-provider data exchange, personal health records, and biosurveillance. The architecture worked well, but the project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations required to maintain the Record Locator Service.

In 2006 and 2007, we implemented a state-wide e-Prescribing gateway. We've transmitted over 100,000 electronic prescription transactions through our exchange and we are live with formulary enforcement, eligibility checking, dispensed medication history including drug/drug interaction checking and routing to retail/mail order pharmacies. The stakeholders have found value in paying for the cost of ongoing operations of this infrastructure since it reduces costs to the payers by enhancing the use of generics/formulary medications, it reduces costs to pharmacies by eliminating paper workflows and it improves workflow for providers by streamlining renewal workflow. We've implemented our e-Prescribing gateway at CareGroup, Partners and soon Children's Hospital. We will work in 2008 to expand the use of the gateway to connect to vendor systems such as Cerner and Meditech, as well as to encourage its use in more institutions.

In 2007, we implemented our "push pilot" using national standards to share discharge summaries and emergency department summaries among caregivers. We use the same software application that routes prescriptions between providers and pharmacies to securely route documents provider to provider. This clinical data exchange approach is truly low cost and simple. All that is required is a sender which can summarize tabular and narrative data in the format specified by HITSP and an organization which can receive this data via direct integration into an electronic health record, secure email or fax. Cerner, MEDITECH, eClinicalWorks and GE Centricity are among the EMR vendors supporting the design and implementation of this project. We are optimistic that the value to the stakeholders of exchanging clinical summaries will be sustainable based on cost avoidance. By eliminating the expense of chart copying, mailing, and paper-based record storage, hospitals seem willing to fund health information exchange of summaries out of projected cost savings. It's also a great political win for the hospital, since pushing clinical summaries keeps the primary caregivers and referring physicians well informed, enhancing their satisfaction.
It provides care continuity by ensuring all caregivers (inpatient, outpatient, Emergency Department, rehabilitation, and long term care facilities) are given a consistent medication list, problem list, laboratory summary, and discharge narrative. As personal health record services such as Microsoft HealthVault, Google's Health efforts and Dossia through Indivo Health are more widely deployed, we may also push data directly into personal health repositories at patient request.

MA-SHARE’s budget in 2008 is approaching the same kind of sustainablity we've achieved with our financial data exchange, NEHEN. All 'lights on' operations are funded by the stakeholders plus $250,000 is available each year for new projects and enhancements. No grant funding or soft money source will be used in 2008. Our hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for our community. The big lesson learned in our statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. To achieve sustainability, the initial efforts must be expanded to meet the needs of the common marketplace. We believe our push model addresses this issue.

Health Information Exchanges in the US are in tenuous financial shape. We've been exploring sustainable business models in Massachusetts for 4 years. Many RHIOs still depend on grants, which eventually end and thus are not a good business model. I believe that Health Information Exchanges will evolve to meet the local business needs of many communities but that a nationwide health information network linking together these local exchanges will not be widely deployed until more consistent funding is available.

In many ways, data exchange is a public good, which is hard to support entirely from local stakeholders. Additional funding from federal and state sources would help. The level of investment in healthcare information exchange in Canada and the UK far exceeds that in the US. I hope that Bush's 2004 commitment to have every clinician in the country wired by 2014 will be met with increases in funding to support it.
Posted by John Halamka. November 17, 2008 at 7:40 AM 1 comments  

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Which Came First, the MRI or the Inflation?
Gary Baldwin, for HealthLeaders Media, February 12, 2008
Like the chicken-and-egg conundrum, healthcare has its own longstanding riddle: Does technology lower costs or raise them? In search of an answer, I spent an afternoon last week poring through an exhaustive report from the Congressional Budget Office.

Technological Change and the Growth of Health Care Spending suggests that technology does as much to spur costs as to contain them. Surprisingly well written for a government document, the CBO treatise lays out the case that:

  1. healthcare costs are rising in an unsustainable way and
  2. the advent of new technology is a primary culprit.


"On the basis of review of the economic literature, CBO concludes that roughly half of the increase in healthcare spending during the past several decades was associated with the expanded capabilities of medicine brought about by technological advances," it says.

Despite its potential to improve care and outcomes, new technology can spur price increases in several ways, the report says. For example, the very power of diagnostic imaging results in increased deployment. A diagnostic scan may be less expensive than costly surgery. "But by their nature they invite much greater use and therefore tend to increase total spending compared with previous methods," the report says. Likewise, life-extending coronary and dialysis procedures have become commonplace. True, patients are living longer, but in the meanwhile, they are running up more bills and creating more demand.

The report, however, does not lay the rising cost of healthcare exclusively at the doorstep of older people, saying that while elderly people incur higher costs than younger ones, the overall contribution of an aging population to spending is often exaggerated. Other social factors, such as rising obesity, also are driving up costs.

Technology creates its own silent time bomb of future cost. Consider IT storage. The unit cost of disk space has dropped remarkably in the last few years. Alas, the demand for more space has gone the other way. Modern hospitals now measure their data centers in terabytes. And as more images work their way into digital archives, the budget for storage will continue to grow--even though the hardware may be shrinking in cost and physical size alike.

The report is short on specific solutions to this problem, only suggesting that Medicare should revisit its payment policies on high-tech procedures. Ironically, the presence of health insurance in the first place may drive up costs, because it insulates consumers from the real cost of medical technology. We already know that technology races far ahead of the ethical debate around its use--witness the controversy on stem cell research. Now we can add that technology also races far ahead of our understanding of the economics surrounding its use.

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.

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