"No Patient Left Behind"

I have been doing a lot of consulting in healthcare information systems. I'm happy about this work for several reasons: it is interesting in both technical & sociocultural dimensions, in fact, most of the impediments to the evolution of these systems are not technical, but rather cultural & political. This shouldn't be a surprise... Also, I think it is critical work. Improvement in medical information systems is, I believe, one of the things that could most help our healthcare system. David Harrington, VP & CTO of MedicAlert (the 'bracelet company'), asked me to be on a panel at the Healthcare in the 21st Century Workshop held in Alexandria, VA on 25-27 October 2005. There were several keynote speakers including Janet Marchibroda of the eHealth Initiative (a non-profit advocacy group) & Robert Kolodner from the Veteran's Administration There was one consistent theme in the evolution of healthcare that was quite distressing (to me). All of the keynote speakers, & every person from either the Government or the payers (insurance companies) that spoke agreed that value-based purchasing was going to be instituted in various ways over the next few years in healthcare & that it would change the way healthcare was delivered, administered & paid for. This is a polite way of saying pay-for-performance. There are several ongoing efforts to develop a set of between 100 & 200 criteria that provider performance would be evaluated against. These range from financial metrics to medical criteria (like how often beta blockers are administered after myocardial infarction). Each 'pay incident'” (doctor's visit, emergency room treatment, planned medical procedure, etc.) would be evaluated against these criteria & a dollar reimbursement amount would be determined. Poor 'performance' would result in lower fees. Of course, the rub is that we know from painful experience that you get what you measure, so the expectation is that healthcare delivery would evolve to address these metrics - think '“No patient left behind' (sorry, that was a value judgment.). If this actually happens, & again, every speaker felt it was a matter of when not if, it will substantially change not only the business models for healthcare provision, but also its delivery. Clinicians & providers of all types: hospitals, laboratories, clinics etc., will be evaluated with respect to a set of criteria developed & administered by governmental, non-medical, entities. I can think of few impediments to the true improvement of our healthcare system than this.

Much of the Workshop was devoted to exploring new models in healthcare delivery - the primary focus of this exploration was in discussing current experiences with healthcare information sharing, mainly in the entities called Regional Healthcare Information Organizations or RHIOs. These are sociopolitical organizations that agree to use technology to share clinical, demographic & financial information about patients across a region, such as a county or other bounded geography. The idea is that information is provided at the point of care, regardless of where it comes from across the system. You show up at the emergency room of a hospital in your area that you have never been seen at before, & all of your clinical & relevant personal information is available to the treating clinician. I know, there are a lot of potential privacy & other issues with this - topics for another post... I have been advising on the technology of such a system in Santa Barbara County (CA) for the California Healthcare Foundation (CHCF, http://www.chcf.org/). This system is called SBCCDE (Santa Barbara County Care Data Exchange, http://www.sbccde.org/index.html). The development of the CDE software was funded by the CHCF & the system is deployed & should be in active use by the end of this year. There are several RHIO efforts ongoing in Massachusetts. See the material on MA-Share (http://www.mahealthdata.org/ma-share/) Much of the discussion at the Workshop was about the possibilities of success for the RHIO & associated models. The consensus was that doing the right thing would not be enough to ensure success. Healthcare information sharing organizations would have to be successful businesses. There does not appear to be a consensus on what such a model would be & no RHIOs in this country (that I know of) are currently successful businesses, although there are some in Europe & Israel that appear to be. Do you think that information sharing at any geographic level will improve healthcare delivery? Would you prefer to be responsible for your own medical records yourself & carry a hard disk (USB or otherwise) around with you so that they would be available? Should a neutral broker manage your healthcare records & make them available? Let me know what you think - futuresense@hartzband.com