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Fixing the Medical Information Problem
By Alton Brantley, MD, PhD, for HealthLeaders News, April 24, 2007
Who owns, controls, and has access or possession of a person’s medical information? This is a fundamental question that seems to be holding back the use of technology to reduce risks and cost to patients and to control expenses to insurers and state and federal governments. To date, the arguments have been to have (a) people maintain personal health records, (b) healthcare providers maintain electronic medical records, or (c) the federal government define national interoperable records. Each approach has good arguments for it, but significant arguments against it.
For example, the PHR is an excellent idea for patients who are technologically capable, honest, and reliable. However, this approach fails when patients do not have access to computers or comfort using them, are not willing or able to maintain a PHR, or are seeking care fraudulently. (Just ask any emergency care physician about this point.) In order to make clinical decisions, physicians and other healthcare professionals need access to information with some level of integrity. They should have access to complete information, not just fragments. Indeed, fragmentary information is part of today’s medical management problem.
Healthcare organizations such as hospitals and physician offices can and should be using electronic medical record systems to improve delivery of care. Most hospitals have multiple computer systems oriented to managing care processes in the laboratory, radiology department, intensive care areas, operating rooms, and diagnostic areas. Many are putting in EMRs to coordinate inpatient care, including computerized provider order entry systems. Similarly, physicians are moving to EMRs in their offices, coupled with billing systems to handle insurance claims and records.
The federal government has taken the position that everyone should have an electronic health record. It is funding efforts to create interoperability among health providers to define and implement regional health information organizations. However, any federal information management initiative seems to hit the wall of privacy concerns. Today, we have people arguing that the inability of the government to protect the privacy of their health information is their greatest fear. Opposing this concern is the fact that the federal government, through Medicare and various military programs for active duty and retired military personnel, is the largest single provider of health insurance coverage.
All of these perspectives seem to ignore the health insurance industry. After the patient, health insurance companies are the greatest beneficiaries of cost of care savings. The more cost-efficient patient care is, the less medical loss the company accrues. Insurance companies are essentially information processing organizations, receiving claims, matching them to policies, and providing periodic statements based on diagnoses and charges. In addition, health insurers are private enterprises with both fiduciary duties to the insured and with legal protections for privacy. Keep in mind that the Health Insurance Portability and Accountability Act was fundamentally oriented towards allowing people to change insurance companies without incurring significant increases in premiums. The privacy and confidentiality components were secondary issues which rose to the fore as their specificity and complexity became apparent. And, most importantly, HIPAA mandated that insurance companies use electronic document interchange for claims management.
We seem to have three apparent options:
All this is occurring in a setting where medicine is increasingly complex (because of scientific advances in diagnostic and treatment options) and increasingly burdensome (because of regulatory and reporting issues). There are more than 5,000 hospitals and almost 200,000 physicians practicing in private offices, but only about 1,000 health insurance companies and perhaps another 1,000 managed care companies and health maintenance organizations.
Insurance companies would seem to be a good compromise for archiving medical data over the long term for a variety of operational and financial reasons. While over 40 million people don’t have health insurance, a significant majority does. The government could choose to handle healthcare insurance, akin to the way automobile insurance is handled, by requiring people to have commercially available policies, requiring standardized and realistic policies, and subsidizing the payment of premiums for Medicare, Medicaid, and indigent citizens.
Insurance companies are already required to provide electronic data interchange, and healthcare offices and facilities already can connect with them either via the Internet or by direct secure networks. Further, insurance companies now share medical risk and policy information with other insurers. By mandating that insurance companies be able to migrate the medical data to another insurance company, interoperability is achieved. Insurance companies then would have all available information to adjudicate a claim as a by-product of the record retention service they provide, eliminating delays and speeding payment for services.
Hospitals would not eliminate their internal information systems, but their EMRs would function as they do now to retain and communicate inpatient data, improve care, support clinical decisions, and reduce medical errors. With the increasing complexity of healthcare, advanced clinical systems in hospitals are becoming essential. Their systems would have access to the medical information of the insurer upon admission and would push information to the insurer as it becomes finalized. Hospitals, however, could eliminate many health information management functions. There would no longer be a need to print, file, collate, store, archive, and retrieve binders of papers. Valuable facility space would become available and personnel expense would be greatly reduced. Health information management would truly become a management function, and part of the overall information technology structure of the organization.
A by-product of this activity is that the referring physician office, with access to the same insurer, would be able to follow immediately the activity on his patient, as well as gain access to pertinent clinical information needed for follow-up of the patient. Since the insurer would be the single point of coordination of all care of the patient from the financial perspective, all physicians billing the insurer would also be providing clinical information, improving physician-to-physician communication. Then, physician EMR systems can evolve to become more focused on continuity of care and preventive medicine, both of which reduce costs to the insurer.
Insurance companies would not be required to develop the technology to handle such capabilities, but would be required to provide the service. This would create business incentives for technology companies to build the necessary interoperable and record management capabilities, to include the requisite security capabilities, and to compete for a very significant revenue stream subject to product performance and market forces.
Insurance companies are not the most respected organizations in today’s health system. Certainly this approach would cause concern to some patients and physicians. But insurance companies are regulated entities. By increasing their service to the health system this way, they become more engaged in health improvement and cost control.
There are a number of wins in this structure. The patient, physician, and insurer would have access to needed information. The cost of the system is borne by the beneficiary of its use--the insurer. Nongovernmental control of the information provides needed privacy. Interoperability is achieved by involving the lowest number of participants, and can be imposed with simple extension to existing regulation. Hospitals can reduce unnecessary expense and invest in systems that reduce medical errors and improve clinical services.
Alton Brantley, MD, PhD, is an internist, medical oncologist, and computer scientist who has worked in universities and academic and not-for-profit health systems. He has served as a consultant to technology, informational services, pharmaceutical, medical product, and healthcare organizations. He can be reached at AltonBrantley@CCIGroup.org.
You can contribute to HealthLeaders IT. Read our editorial guidelines to find out how.
For example, the PHR is an excellent idea for patients who are technologically capable, honest, and reliable. However, this approach fails when patients do not have access to computers or comfort using them, are not willing or able to maintain a PHR, or are seeking care fraudulently. (Just ask any emergency care physician about this point.) In order to make clinical decisions, physicians and other healthcare professionals need access to information with some level of integrity. They should have access to complete information, not just fragments. Indeed, fragmentary information is part of today’s medical management problem.
Healthcare organizations such as hospitals and physician offices can and should be using electronic medical record systems to improve delivery of care. Most hospitals have multiple computer systems oriented to managing care processes in the laboratory, radiology department, intensive care areas, operating rooms, and diagnostic areas. Many are putting in EMRs to coordinate inpatient care, including computerized provider order entry systems. Similarly, physicians are moving to EMRs in their offices, coupled with billing systems to handle insurance claims and records.
The federal government has taken the position that everyone should have an electronic health record. It is funding efforts to create interoperability among health providers to define and implement regional health information organizations. However, any federal information management initiative seems to hit the wall of privacy concerns. Today, we have people arguing that the inability of the government to protect the privacy of their health information is their greatest fear. Opposing this concern is the fact that the federal government, through Medicare and various military programs for active duty and retired military personnel, is the largest single provider of health insurance coverage.
All of these perspectives seem to ignore the health insurance industry. After the patient, health insurance companies are the greatest beneficiaries of cost of care savings. The more cost-efficient patient care is, the less medical loss the company accrues. Insurance companies are essentially information processing organizations, receiving claims, matching them to policies, and providing periodic statements based on diagnoses and charges. In addition, health insurers are private enterprises with both fiduciary duties to the insured and with legal protections for privacy. Keep in mind that the Health Insurance Portability and Accountability Act was fundamentally oriented towards allowing people to change insurance companies without incurring significant increases in premiums. The privacy and confidentiality components were secondary issues which rose to the fore as their specificity and complexity became apparent. And, most importantly, HIPAA mandated that insurance companies use electronic document interchange for claims management.
We seem to have three apparent options:
- Asking physician offices and hospitals with generally very low margins to figure out how to contribute health information to other healthcare organizations at additional cost but with only indirect benefit
- Expecting the federal government to solve a pressing problem in a short time without the trust of the populace
- Requiring individual patients to manage their information
All this is occurring in a setting where medicine is increasingly complex (because of scientific advances in diagnostic and treatment options) and increasingly burdensome (because of regulatory and reporting issues). There are more than 5,000 hospitals and almost 200,000 physicians practicing in private offices, but only about 1,000 health insurance companies and perhaps another 1,000 managed care companies and health maintenance organizations.
Insurance companies would seem to be a good compromise for archiving medical data over the long term for a variety of operational and financial reasons. While over 40 million people don’t have health insurance, a significant majority does. The government could choose to handle healthcare insurance, akin to the way automobile insurance is handled, by requiring people to have commercially available policies, requiring standardized and realistic policies, and subsidizing the payment of premiums for Medicare, Medicaid, and indigent citizens.
Insurance companies are already required to provide electronic data interchange, and healthcare offices and facilities already can connect with them either via the Internet or by direct secure networks. Further, insurance companies now share medical risk and policy information with other insurers. By mandating that insurance companies be able to migrate the medical data to another insurance company, interoperability is achieved. Insurance companies then would have all available information to adjudicate a claim as a by-product of the record retention service they provide, eliminating delays and speeding payment for services.
Hospitals would not eliminate their internal information systems, but their EMRs would function as they do now to retain and communicate inpatient data, improve care, support clinical decisions, and reduce medical errors. With the increasing complexity of healthcare, advanced clinical systems in hospitals are becoming essential. Their systems would have access to the medical information of the insurer upon admission and would push information to the insurer as it becomes finalized. Hospitals, however, could eliminate many health information management functions. There would no longer be a need to print, file, collate, store, archive, and retrieve binders of papers. Valuable facility space would become available and personnel expense would be greatly reduced. Health information management would truly become a management function, and part of the overall information technology structure of the organization.
A by-product of this activity is that the referring physician office, with access to the same insurer, would be able to follow immediately the activity on his patient, as well as gain access to pertinent clinical information needed for follow-up of the patient. Since the insurer would be the single point of coordination of all care of the patient from the financial perspective, all physicians billing the insurer would also be providing clinical information, improving physician-to-physician communication. Then, physician EMR systems can evolve to become more focused on continuity of care and preventive medicine, both of which reduce costs to the insurer.
Insurance companies would not be required to develop the technology to handle such capabilities, but would be required to provide the service. This would create business incentives for technology companies to build the necessary interoperable and record management capabilities, to include the requisite security capabilities, and to compete for a very significant revenue stream subject to product performance and market forces.
Insurance companies are not the most respected organizations in today’s health system. Certainly this approach would cause concern to some patients and physicians. But insurance companies are regulated entities. By increasing their service to the health system this way, they become more engaged in health improvement and cost control.
There are a number of wins in this structure. The patient, physician, and insurer would have access to needed information. The cost of the system is borne by the beneficiary of its use--the insurer. Nongovernmental control of the information provides needed privacy. Interoperability is achieved by involving the lowest number of participants, and can be imposed with simple extension to existing regulation. Hospitals can reduce unnecessary expense and invest in systems that reduce medical errors and improve clinical services.
Alton Brantley, MD, PhD, is an internist, medical oncologist, and computer scientist who has worked in universities and academic and not-for-profit health systems. He has served as a consultant to technology, informational services, pharmaceutical, medical product, and healthcare organizations. He can be reached at AltonBrantley@CCIGroup.org.
You can contribute to HealthLeaders IT. Read our editorial guidelines to find out how.
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