Last week I reported on consumer mistrust of health organizations, a gap some are trying to bridge with Web portals. That gap may get bigger, if a recent study that crossed my desk has any merit. Now, the analysis may not have the sexiest title: "Automated billing/payment process can reduce U.S. health care costs without sacrificing patient care." Furthermore, it was commissioned by PNC. Considering that PNC is a financial services firm whose product line includes electronic claims processing may give rise to skepticism. Borrowing a simile from my editor, it's like an orange grower commissioning a study on the merits of OJ in the morning.
However, there is one finding in this report that is truly outstanding. After interviewing 150 hospital executives and 50 commercial health plan executives, the researchers at Chadwick Martin Bailey discovered that an extraordinary amount of claims resubmission is taking place. I've heard this plenty of times anecdotally, but do not recall a comprehensive study on the topic. "Respondents reported submitting 5,000 claims per month to insurance companies for payment. Hospital executives reported that, on average, one in five claims they submit is delayed or denied, and that 96 percent of all claims they submit in an average month must be resubmitted at least once. Insurance companies go back to providers twice, on average, to get all the information they need to pay a claim."
Written in the dry language of a white paper, this report is sparing on the exclamation points and adjectives of disbelief. Yet, when I read that virtually all claims are resubmitted at least one time, I know that something is seriously wrong. The problem, asserts PNC, is the absence of electronic data interchange transactions along the food chain that connect providers and payers. Even hospitals that use EDI to submit claims struggle: They average three re-submissions per claim. Hospitals without EDI technology resubmit an average of 11 times! (My exclamation point.)
According to the study, all this administrative inefficiency is costing the industry dearly. The executives on both sides of the aisle estimated that "just over 30 cents of every dollar spent on healthcare in the U.S. currently goes toward administration." The ticking time bomb here is consumers. In a corollary study, PNC asked 1,000 consumers how much administrative overhead would be warranted in our healthcare system. Answer: less than 10 cents on the dollar. "Seven in 10 said they would be 'highly upset' if overhead hit 30 percent." Is that a mob forming outside the hospital?
Ironically, the facilitation of electronic submissions was one of the cornerstones of the original HIPAA legislation. More than a decade ago, in the name of administrative simplification, the legislation called for standardized electronic formats for claims submissions. Apparently we have a long way to go. You may be interested in hearing the thoughts of Lisa Miller, whom I recently interviewed on this topic. Lisa, chief technology officer at Payformance Health, was honored by the Workgroup for Electronic Data Interchange for her analysis of the ROI of HIPAA electronic claims standards. Her cost benefit analysis, done for the National Committee on Vital and Health Statistics, focused on technological conversions related to the HIPAA legislation. "We mandated a standard that had not been tested and we paid a price for that," she told me. "We have not recouped the ROI potential that was there."
The industry jumped full bore into the privacy provisions of HIPAA. It may be time to revisit the basics of electronic claims submissions. That issue may not be as sexy as a stolen computer with identifiable health data. It is a critical business issue nevertheless. If we can't unravel the claims submission tangle, consumers may have one more reason to feel estranged from the healthcare system they rely on. And CEOs will have even more difficulty financing the care we all cherish.
Oak Hill Hospital in Brooksville, FL, has made $700,000 in improvements to its surgical department. The investment includes upgrades to thecystoscopy department and other improvements to the facility's operating rooms.
Until recently, personal health records have taken a back seat to electronic medical records as the healthcare industry continues its struggle to establish health data exchange standards. That prioritization is shifting as consumers demand a viable healthcare technology in which to store and access their personal healthcare information.
The shift is exemplified by the recently released draft Health Level 7 (HL7) guidelines for the development of PHRs. Donald Mon, vice president of practice leadership for the American Health Information Management Association, described the HL7 PHR model as the "fraternal twin" of the organization's EHR model. According to Mon, "The pairing of the two (models) provides a framework for standards-based interoperability between the consumer and the provider."
Several variables have contributed to the strong upswing in consumer interest. One is the broad usage of electronic records in other areas of consumer life such as banking. The concept of online banking, once viewed as extremely suspect in an era of identity theft, has proven to be an efficient and safe method of managing one's personal finances. Consumers are beginning to expect the same level of online service and accessibility to their personal information within the healthcare arena.
Additionally, PHRs address a growing need to have a centralized data repository for healthcare records--a need that has been brought to the forefront of Americans' sensibilities with the major disasters experienced during the past several years. A portable health record could also serve individuals' more mundane needs by providing 24x7 access to insurance claims data and coverage, pharmacy data (i.e., prescription information), laboratory results and more while traveling, changing providers or insurers, or seeing a specialist. However, PHRs are not limited to providing convenient access to healthcare data; they may also deliver quantifiable benefits in terms of improved care and oversight, reduced healthcare costs, and decreased abuse and waste of healthcare services.
Through this platform of shared healthcare information, patients embrace greater responsibility for their own care by researching healthcare concerns, tracking their health status, and leveraging this expanded access to their medical data to make appropriate, cost-effective healthcare decisions. To support this patient empowerment evolution, most PHRs supply an online health risk assessment tool, whose results are then used to define online wellness and disease management programs. Often, the patients that benefit from this 24x7 resource would normally not have received formal disease management care from their healthcare providers.
As the PHR platform matures, the patient experience will expand into the realm of continuous care with real-time alerts for prescriptions, test results and behavior flags. The PHR could flag potential drug-drug interactions based on the patient's prescription list, send email reminders to schedule screening tests or to refill prescriptions, and offer lifestyle suggestions based on the patient's healthcare status and inputted behavior (for example,, home-monitored data for blood pressure, glucose, or peak flow). This online healthcare management contributes to superior patient compliance with disease management protocols; thus, contributing to improved patient well-being, a reduction in traditional healthcare system usage and a decrease in overall healthcare costs.
With the numerous acknowledged benefits of PHRs, why is there a delay in wide-scale adoption? One major issue is that much of the information that could be centralized within PHRs currently exists within disparate, non-integrated sources. For example, medical record details, laboratory results, prescription refills, and appointment schedules would need to be provided by a patient's provider. In contrast, the insurance claims data and coverage, as well as past pharmacy data, would be available through insurers. One solution is to link the PHR with the EMR, assuming that the given patient's provider has implemented an EMR solution. However, relying on eventual EMR deployment could postpone the broad adoption of PHRs for years.
Furthermore, significant concern still exists over the ability to maintain the security and privacy of healthcare data when the data is shared among various healthcare systems. Since PHRs do not fall under HIPAA's legal protection, some vendors do not encrypt the data; consequently exposing it to theft, or in a worse-case scenario, to an outright sale of the healthcare data. In a related dilemma, healthcare providers debate how to transfer PHR information securely to another provider and how to receive equivalent information into the PHR from other providers. Providers also worry about potential liability issues that could result from the lack of process in distinguishing between patient-entered and professional- grade healthcare data in the PHR. For instance, could relying on potentially inaccurate or insufficient data inputted by patients lead to suboptimal decisions about care?
Another looming question remains: "Who will pay for the PHR?" The most popular answer is insurers. Many see them as the greatest beneficiaries thanks to reduced fraud, greater oversight and decreased management costs. Additionally, insurers would be the natural suppliers of much of the needed patient information for PHRs. In fact, several HMOs already offer PHRs to their members and promote it as a value-added customer service.
Employers, facing runaway healthcare costs are also embracing PHRs. Dossia, a non-profit consortium, which now includes Applied Materials, AT&T, BP America, Inc., Cardinal Health, Intel Corporation, Pitney Bowes Inc., sanofi-aventis and Wal-Mart, is creating a Web-based PHR that will enable its 5 million employees and their dependents as well as retirees to gain access to their personal health data. Dossia plans a limited roll out of this benefit in late 2007.
Other potential providers of PHRs include hospitals (with links to EMRs and laboratory systems), physicians and large employers. Although some hospitals and employers have embraced this role, physicians have shied away from this added cost burden that offers little financial incentive.
Vendors have historically driven the development of PHRs, but overall, have not been profitable business ventures given that none of the stakeholders wish to pay for the PHR solution. Moreover, vendors are typically not able to offer seamless integration to the various EMRs and laboratory systems due to the lack of industry standards for data exchange.
Given the significant barriers that exist, why should we push for PHR implementation at this time? Because every step in furthering our understanding of the types of individuals that use PHRs, which functions they find most valuable, and which quantitative and qualitative behaviors result from PHR usage, will aid in the development of future PHRs. These baby steps will help us to establish best practices for privacy issues and secure data transactions - laying a rock-solid foundation for the future of online healthcare management and delivery.
Jodi Amendola is CEO of Amendola Communications, a national marketing communications firm serving the healthcare and e-healthcare industry. She can be reached at Jamendola@ACmarketingPR.com.
It may be dwarfed by the massive HIMSS show, but the American Medical Informatics Association conducts a conference that offers plenty of insight into heath IT. I attended this year's event, held here in Chicago in mid-November, and came away inspired as always. AMIA is primarily attended by clinical informatics research specialists. These are the folks doing the heavy lifting of turning electronic data into usable format. Many of the topics are esoteric, such as "a rationale for parsimonious laboratory mapping by frequency."
AMIA's broader strength is the insight it offers to emerging technologies, such as what researchers dub "consumer informatics." The consumer panel examined the gulf between patients and caregivers. Presenters described a digital divide that is only in part about Web access. It is an important topic, particularly given the widespread interest in personal health records and online data sharing with patients. As Rita Kukafka pointed out, a "mistrust of the medical community" can hinder the relationship. Kukafka, a member of the department of biomedical informatics at Columbia University, described how a public health program in Harlem is attempting to bridge the gap using Web technology. The project's Web site, "healthyharlem.org", offers a number of user-friendly resources and an easily navigable design. In her view, personal health records reflect a shift in patient roles. No longer mere "recipients" of services, connected patients will play a more pro-active--and responsible--role with clinicians who serve them.
Yet, the technology may be racing ahead of the public's capacity to embrace it. Consider the presentation by Catherine Smith, from the University of Wisconsin-Madison. She regaled us with her study of "obscene expression in consumer health." Smith analyzed 10,000 posts from three dozen bulletin boards that discussed health issues. Most people prefer slang or vulgarity to clinical terms. Mentioning what she labeled a "reaction against clinical terminology," Smith cited the flap around the word vajajay as an example.
Smith was far too polite to lambaste the linguistically challenged participants in medical chat rooms, so I will say what she did not. Until the American public can mature, and get past this juvenile mentality around sex, body parts, and organ system functions, we will not be meaningful participants in online personal health records, let alone in meaningful patient-physician relationships. The New York Times article quotes Carol A. Livoti, a Manhattan obstetrician and gynecologist, as saying that vajayjay and other euphemisms and slang offend her and can render women incapable of explaining their symptoms to health professionals. "I think it's terrible," Dr. Livoti said. "It's time to start calling anatomical organs by their anatomical name. We should be proud of our bodies."
Smith observed that public discussions of health issues often lead to either the "nursery or the gutter." Neither offers much value to clinical documentation. So as healthcare organizations open up their medical records to patients, they may encounter a vocabulary gap. Smith was too embarrassed to mention many of the terms she uncovered, so she listed them on a hand-out that itemized terms by clinical category, dictionary definition, and pertinent obscenity. The thought that such translation sheets would need to be part of the online dialogue with patients certainly gives pause.
AMIA Hot Quote: "If you take 10 health records each with one error and collate them, you now have one record with 10 errors."
-An audience member describing a pitfall of regional data sharing at a RHIO panel.
Medtronic and other medical-device makers are attempting to obtain protection from multimillion-dollar product liability lawsuits in a case before the U.S. Supreme Court. In the case, Riegel v. Medtronic, the court will decide on whether patients can file product-liability lawsuits over devices cleared for sale by the FDA's approval process.
YourCity.MD, a Web site targeted at physicians and consumers, has gone live in approximately 300 U.S. cities. Consumers can use the site to search for local physicians by name, specialty, hospital affiliation and travel distance. Physicians can sign up for a free listing and have access to patient feedback, peer reporting tools and patient information handouts.