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Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 2 of 2)

Posted on April 13, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article provided whatever detail I could find on the costs of poor communications and data exchange among health care providers. But in truth, it’s hard to imagine the toll taken by communications failures beyond certain obvious consequences, such as repeated tests and avoidable medical errors. One has to think about how the field operates and what we would be capable of with proper use of data.

As patients move from PCP to specialist, from hospital to rehab facility, and from district to district, their providers need not only discharge summaries but intensive coordination to prevent relapses. Our doctors are great at fixing a diabetic episode or heart-related event. Where we fall down is on getting the patient the continued care she needs, ensuring she obtains and ingests her medication, and encouraging her to make the substantial life-style changes that can prevent reoccurrences. Modern health really is all about collaboration–but doctors are decades behind the times.

Clinicians were largely unprepared to handle the new patients brought to them by the Affordable Care Act. Examining the impact of new enrollees, who “have higher rates of disease and received significantly more medical care,” an industry spokesperson said, “The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time…Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.” Just where the health providers fall short.

All these failures to communicate may explain the disappointing performance of patient centered medical homes and Accountable Care Organizations. While many factors go into the success or failure of such complex practices, a high rate of failure suggests that they’re not really carrying out the coordinated care they were meant to deliver. Naturally, problems persist in getting data from one vendor’s electronic health record to another.

Urgent care clinics, and other alternative treatment facilities offered in places such as pharmacies, can potentially lower costs, but not if the regular health system fails to integrate them.

Successes in coordinated care show how powerful it can be. Even so simple a practice as showing medical records to patients can improve care, but most clinicians still deny patients access to their data.

One care practice drastically lowered ER admissions through a notably low-tech policy–refering their patients to a clinic for follow-up care. This is only the beginning of what we could achieve. If modern communications were in place, hospitals would be linked so that a CDC warning could go to all of them instantly. And if clinicians and their record systems were set up to handle patient-generated data, they could discover a lot more about the patients and monitor behavior change.

How are the hospitals and clinics responding to this crisis and the public pressure to shape up? They push back as if it was not their problem. They claim they are moving toward better information sharing and teamwork, but never get there.

One of their favorite gambits is to ask the government to reward them for achieving interoperability 90 days out of the year. They make this request with no groveling, no tears of shame, no admission that they have failed in their responsibility to meet reasonable goals set seven years ago. If I delivered my projects only 25% of the time, I’d have trouble justifying myself to my employer, especially if I received my compensation plan seven years ago. Could the medical industry imagine that it owes us a modicum of effort?

Robert Schultz, a writer and entrepreneur in health care, says, “Underlying the broken communications model is a lack of empathy for the ultimate person affected–the patient. Health care is one of the few industries where the user is not necessarily the party paying for the product or service. Electronic health records and health information exchanges are designed around the insurance companies, accountable care organizations, or providers, instead of around understanding the challenges and obstacles that patients face on a daily basis. (There are so many!) The innovators who understand the role of the patient in this new accountable care climate will be winners. Those who suffer from the burden of legacy will continue to see the same problems and will become eclipsed by other organizations who can sustain patient engagement and prove value within accountable care contracts.”

Alternative factors

Of course, after such a provocative accusation, I should consider the other contributors that are often blamed for increasing health care costs.

An aging population

Older people have more chronic diseases, a trend that is straining health care systems from Cuba to Japan. This demographic reality makes intelligent data use even more important: remote monitoring for chronic conditions, graceful care transitions, and patient coordination.

The rising cost of drugs

Dramatically increasing drug prices are certainly straining our payment systems. Doctors who took research seriously could be pushing back against patient requests for drugs that work more often in TV ads than in real life. Doctors could look at holistic pain treatments such as yoga and biofeedback, instead of launching the worst opiate addiction crisis America has ever had.

Government bureaucracy

This seems to be a condition of life we need to deal with, like death and taxes. True, the Centers for Medicare & Medicaid Services (CMS) keeps adding requirements for data to report. But much of it could be automated if clinical settings adopted modern programming practices. Furthermore, this data appears to be a burden only because it isn’t exploited. Most of it is quite useful, and it just takes agile organizations to query it.

Intermediaries

Reflecting the Byzantine complexity of our payment systems, a huge number of middlemen–pharmacy benefits managers, medical billing clearinghouses, even the insurers themselves–enter the system, each taking its cut of the profits. Single-payer insurance has long been touted as a solution, but I’d rather push for better and cheaper treatments than attack the politically entrenched payment system.

Under-funded public health

Poverty, pollution, stress, and other external factors have huge impacts on health. This problem isn’t about clinicians, of course, it’s about all of us. But clinicians could be doing more to document these and intervene to improve them.

Clinicians like to point to barriers in their way of adopting information-based reforms, and tell us to tolerate the pace of change. But like the rising seas of climate change, the bite of health care costs will not tolerate complacency. The hard part is that merely wagging fingers and imposing goals–the ONC’s primary interventions–will not produce change. I think that reform will happen in pockets throughout the industry–such as the self-insured employers covered in a recent article–and eventually force incumbents to evolve or die.

The precision medicine initiative, and numerous databases being built up around the country with public health data, may contribute to a breakthrough by showing us the true quality of different types of care, and helping us reward clinicians fairly for treating patients of varying needs and risk. The FHIR standard may bring electronic health records in line. Analytics, currently a luxury available only to major health conglomerates, will become more commoditized and reach other providers.

But clinicians also have to do their part, and start acting like the future is here now. Those who make a priority of data sharing and communication will set themselves up for success long-term.

Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 1 of 2)

Posted on April 12, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

A host of scapegoats, ranging from the Affordable Care Act to unscrupulous pharmaceutical companies, have been blamed for the rise in health care costs that are destroying our financial well-being, our social fabric, and our political balance. In this article I suggest a more appropriate target: the inability of health care providers to collaborate and share information. To some extent, our health care crisis is an IT problem–but with organizational and cultural roots.

It’s well known that large numbers of patients have difficulty with costs, and that employees’ share of the burden is rising. We’re going to have to update the famous Rodney Dangerfield joke:

My doctor said, “You’re going to be sick.” I said I wanted a second opinion. He answered, “OK, you’re going to be poor too.”

Most of us know about the insidious role of health care costs in holding down wages, in the fight by Wisconsin Governor Scott Walker over pensions that tore the country apart, in crippling small businesses, and in narrowing our choice of health care providers. Not all realize, though, that the crisis is leaching through the health care industry as well, causing hospitals to fail, insurers to push costs onto subscribers and abandon the exchanges where low-income people get their insurance, co-ops to close, and governments to throw people off of subsidized care, threatening the very universal coverage that the ACA aimed to achieve.

Lessons from a ground-breaking book by T.R. Reid, The Healing of America, suggests that we’re undergoing a painful transition that every country has traversed to achieve a rational health care system. Like us, other countries started by committing themselves to universal health care access. This then puts on the pressure to control costs, as well as the opportunities for coordination and economies of scale that eventually institute those controls. Solutions will take time, but we need to be smart about where to focus our efforts.

Before even the ACA, the 2009 HITECH act established goals of data exchange and coordinated patient care. But seven years later, doctors still lag in:

  • Coordinating with other providers treating the patients.

  • Sending information that providers need to adequately treat the patients.

  • Basing treatment decisions on evidence from research.

  • Providing patients with their own health care data.

We’ll look next at the reports behind these claims, and at the effects of the problems.

Why doctors don’t work together effectively

A recent report released by the ONC, and covered by me in a recent article, revealed the poor state of data sharing, after decades of Health Information Exchanges and four years of Meaningful Use. Health IT observers expect interoperability to continue being a challenge, even as changes in technology, regulations, and consumer action push providers to do it.

If merely exchanging documents is so hard–and often unachieved–patient-focused, coordinated care is clearly impossible. Integrating behavioral care to address chronic conditions will remain a fantasy.

Evidence-based medicine is also more of an aspiration than a reality. Research is not always trustworthy, but we must have more respect for the science than hospitals were found to have in a recent GAO report. They fail to collect data either on the problems leading to errors or on the efficacy of solutions. There are incentive programs from payers, but no one knows whether they help. Doctors are still ordering far too many unnecessary tests.

Many companies in the health analytics space offer services that can bring more certainty to the practice of medicine, and I often cover them in these postings. Although increasingly cited as a priority, analytical services are still adopted by only a fraction of health care providers.

Patients across the country are suffering from disrupted care as insurers narrow their networks. It may be fair to force patients to seek less expensive providers–but not when all their records get lost during the transition. This is all too likely in the current non-interoperable environment. Of course, redundant testing and treatment errors caused by ignorance could erase the gains of going to low-cost providers.

Some have bravely tallied up the costs of waste and lack of care coordination in health care. Some causes, such as fraud and price manipulation, are not attributable to the health IT failures I describe. But an enormous chunk of costs directly implicate communications and data handling problems, including administrative overhead. The next section of this article will explore what this means in day-to-day health care.