Readers Write

Gary Baldwin, for HealthLeaders Media, May 6, 2008

Time to open up the mailbag and acknowledge some of the great letters I have received. My article, “Say What?” easily drew the most mail since I began writing this column. I thought the column might irritate people in the PR biz, but they enthusiastically supported me. “Although I’m in the profession, I’m embarrassed by the examples you posted; you would think people in communications would write in English,” wrote Stacy Brucia of the Hodges Partnership. One fan, Beth Friedman, even sent a Web site that lets writers weed out the “bull.”

I run a PR firm specializing in healthcare, and I used to be a writing professor at BU. I agree with you wholeheartedly. And doesn’t the word “unique” drive you crazy?

Gary Woonteiler
Woonteiler Ink

As a long time writer of press releases for startup tech companies, who spent a number of years in network security–first I sighed with relief that my last release wasn’t in here, but then I considered sending you a hyped-up, jargon-filled release to see if I could get covered in your column. Good read–thanks for the laughs.

Tamyra Hyatt
Director of Marketing

Claims Quagmire
My take on the tangled state of claims processing drew this heated response, from one reader who asked not to be identified. While I am not in a position to “take sides” on the payer’s role in this, I will say that getting health plans to talk–on most topics–can be very frustrating. I had some notable exceptions in my article, fortunately, such as Dave Boucher, vice president of healthcare services, BlueCross BlueShield of South Carolina. Boucher referred to the “black hole” of claims. Our May issue, which includes part 2 of my claims series, examines how BCBS of SC is attempting online, real-time claims adjudication for providers. It is looking to at least curtail some of the intermediary action that seems to drive everyone nuts. But I would be glad to hear from other payers and clearinghouses out there as well, particularly in response to this letter:

Just look at the history of how payers have complicated the claims transaction environment every time we have tried to implement standard transactions:

  • UB92; each payer corrupted the implementation guidelines for various fields in the claim within weeks of implementing this claims format.
  • HIPAA v4010; most payers corrupted the implementation guidelines again for various claims fields. We can only hope that the new v5010 will become more of a “standard.”

A single payer model (Medicare) would significantly simplify the claims environment. Supplemental insurance would add more complexity but those costs could be pushed back at the payers providing the supplemental insurance. Also, if you don’t follow protocol you go to jail; that is a great incentive to follow the rules and standards!

The payers are the major problem children for the claims environment no ifs ands or buts about it. But, good luck in dis-intermediating them any time soon – they have a great deal of power over Capitol Hill.

Name withheld by request

Data Sharing
Several people wrote in response to my essay, “On Carts and Horses.” They raised additional points about why regional data efforts, while a good idea, may be a while in coming.

I read with interest your article “On Carts and Horses” in the April 8 issue of HealthLeaders Media IT online and had previously read the essay in Health Affairs, “The State of Regional Health Information Organizations: Current Activities and Financing,” which you cited.

While I agree with your assessment that the chances for a sustainable data exchange model would improve if local hospitals and medical groups first got their own IT houses in order, it still seems to beg the question “how”?

A clear revenue model to support data exchange efforts beyond enabling legislation, Stark safe harbors and grants has not emerged. Hospitals and large medical groups already struggle financially and small physician practices that still account for more than half of the nation’s providers are even worse off. While serving the greater good – improved patient care – by investments in EMRs and other enabling technologies is an interesting argument, a clear ROI for hospitals and physician practices is not in sight.

Fortunately, the nation’s health plans are emerging as the drivers of successful and sustainable patient information-sharing networks that can serve as the foundation for the future of Web-powered healthcare. Payers are natural economic sponsors for information-sharing technologies that benefit patient care. They have the financial resources and the physician networks to deliver these technologies with considerable economies of scale and accrue significant financial benefits justifying their investment.

Along the way, hospitals and physician practices also benefit.

Health plans are also the source of critical and actionable data that better reflects the care received by patients than individual providers could easily reproduce. For example, a provider may document a prescription, but payer data can document it was filled as well as all the other prescriptions written and filled for that patient.

Although fierce competitors, health plans have figured out that it is possible to preserve competition, create real operating value for themselves and the provider community while at the same time creating the nation’s largest clinical and financial health information exchange that now reaches over 400,000 physicians.

Michael L. Hodgkins, MD
Chief Medical Officer
NaviMedix, Inc.

Thank you for your excellent editorial, “On Carts and Horses.” Having been a part of the California CHIN (Community Health Information Network) in the late 1990s, what has been happening in the RHIO movement oddly sounds all too familiar, if not almost an exact replay. Security, a patient identifier and immature technology were major hurdles back then. Also, as you pointed out, politics was the coup de grace of that early effort…we were way ahead of ourselves too.

Today it’s RHIOS and everyone tried to sell one like they were selling a super highway—tough to do when the medical community only sees, wants or can afford a cow path. Your editorial also reminded me that nobody really wanted to buy a CHIN in the late 90s…anybody wanna buy a RHIO?

Thanks again. Really enjoy your thoughts; you’re a great writer.

Jim Bloedau, founder
Information Advantage Group
San Francisco, CA

You probably know that the RHIO idea has been recycled (under various acronyms) repeatedly since the 1980s. The general problem is that almost none of the clinical information networks (and perhaps absolutely none) have adequate economic benefit to cover the cost. Sharing information is of little use unless there is a business objective to 1) frame information requirements, 2) circumscribe a set of processes, and 3) achieve a competitive advantage (in cost, quality or both). In many networks we are actually asking competitors to share information. Go figure.

Tim Breaux

Thank you for drawing attention to the political roadblocks that stand in the way of the next level of progress in swapping personal health information electronically, and in particular the obstacle of reliable identification (On Carts and Horses, March 2008). True, focusing on a RHIO before electronic record systems mature among would-be partners in a RHIO is a problem just the same as it was in the mid-‘90s with CHINs. The movement to a connected system of health information calls for a lot of advance work that plays out in frustrating ways. It seems that every step of progress, every bashing of a barrier, brings the next under-anticipated obstacle into view.

Two decades ago, converting paper charts into a usable computerized form was considered a challenge for the age, and the advent of the electronic medical record truly was a big step forward. But the medical-group or hospital-organization focus of an EMR eventually exposed the lack of patient focus in electronic record-keeping. It was for the benefit of health professionals, at a time when those in healthcare saw the wisdom of making the electronic record a force for managing health and promoting wellness by tracking all available data and encounters on a patient. Once the need to aggregate data from many sources into one electronic health record was recognized, the next barrier ahead was how to do that. In mid-2004, I covered the advent of that problem as a reporter in the aftermath of the Office of National Coordinator’s four-pronged “framework for strategic action.” The typical reaction I got to the urgency of interoperability was, “Huh?” But in a few short years the challenge of interoperability is high on the priority list because of that push for a patient-focused EHR.

The ONC and many public-private partnerships are hard at work bringing down the interoperability barrier, as if it’s the final obstacle to achieving e-records and connecting networks. But when all the pieces of a patient-focused record become available to be aggregated for the benefit of a care professional, how does that happen when a patient is identified in many proprietary ways in source records systems, and identity can’t be precisely determined? This is the next barrier that will come into view as interoperability becomes ably addressed. The typical reaction, like interoperability four years ago, may be, “Huh?” But without a unique identifier, the margin of error in aggregating records may not be acceptable.

Since the HIPAA controversy of a decade ago, the issue of a unique health identifier for individuals has remained a political problem and still hot to the touch. But that doesn’t make it any less a problem. Left unresolved, the marathon effort for data exchange--in RHIOs or by any other method--will not have crossed the finish line.

John Morrissey
The National Alliance for Health Information Technology
Chicago, IL

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at
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