Thursday, May 29, 2008

The May, 2008 CBO Report: Evidence on the Costs and Benefits of Health Information Technology (Publication number 2976).

The recently published report by the Congressional Budget Office summarizes well the dilemma faced by those who argue for adoption of health information technology based on formal analyses:

No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits. Some analysts believe that the adoption of such systems could provide substantial savings by lowering the cost of providing health care, eliminating unnecessary health care services (such as duplicate diagnostic tests), and improving the quality of care in ways that might reduce costs (by diminishing the likelihood of adverse drug events, for example). Other analysts expect little effect on costs but some improve-No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits. Some analysts believe that the adoption of such systems could provide substantial savings by lowering the cost of providing health care, eliminating unnecessary health care services (such as duplicate diagnostic tests), and improving the quality of care in ways that might reduce costs (by diminishing the likelihood of adverse drug events, for example). Other analysts expect little effect on costs but some improvement in the quality of care. Another school of thought holds that health IT could bolster the quality of care but also increase expenditures on health care services— because improvements in quality would stimulate demand for additional services.

CBO's critique of the RAND report is in part due to the difference in mission. RAND more or less measures an idealistic potential outcome. CBO must focus on the likely outcome and the true impact of Congressional intervention. Take gravity as an example. RAND would claim that the impact of a falling rock will depend on mass, resistance, and gravitational pull. CBO would claim that little Congress can do will impact the mass, the velocity, or the resistance. (CBO would perhaps explore the cost of measures mandating attaching a parachute to the rock and the resulting effect on impact.)The RAND research focused primarily on savings that the use of health IT could generate by reducing costs in physicians’ practices and hospitals and hence had a different scope. RAND also ignored neutral or negative reports. CBO questions their rationale for doing this.

The RAND analysis itself notes that its estimate is of health IT’s potential savings and costs depends on an optimal - but perhaps not likely - state : "We use the word potential to mean ‘assuming that interconnected and interoperable EMR systems are adopted widely and used effectively.’ Thus, our estimates of potential savings are not predictions of what will happen but of what could happen with HIT and appropriate changes in health care.”

RAND assumed a constant rate of adoption. CBO would assume the increasing rate of adoption currently observed. Since CBO's savings estimates are based in part on the extent to which legislation encourages adoption, savings due to adoption alone will be exaggerated by the RAND report relative to the CBO report.

RAND assumes that internal hospital costs are reduced to an extent proportional to hospital stay. That is, if the length of stay is reduced by 10%, so will the costs. Although this may be true for fixed costs (beds, personnel) as currently measured, the variable costs are unlikely to change significantly since in many respects throughput efficiencies are realized by performing the same tests and providing the same intensity of services as would have been provided anyway. If a patient is improving, variable costs of care decrease closer to discharge. If the patient is failing and subject to increasingly intense interventions in a effort to save a life, variable costs can be expected to increase until either death or clinical improvement ensues.

Savings incurred by replacing paper medical records with electronic health records exhibit the same dependency on fixed and variable costs. If an organization is large, changes in variable costs can translate to lower labor costs. If an organization is small - a solo practice, for example - personnel costs are essentially fixed and financial benefits are only realized if volume is increased and revenues are therefore enhanced using the same labor pool.

One criticism of the RAND study seems questionable to this reviewer. Using a traditional microeconomic argument, CBO assumes that lower costs will lead to lower prices and, consistent with economic theory, lower prices mean higher demand. This demand would offset some savings. It would be welcome news to see this theory play out where prescription drug adherence is concerned. Many reports suggest that individuals do not take beneficial cholesterol-lowering or other disease-prevention drugs in part because of the relative costs of these drugs; in general, rather than taking such medications monthly for a sometimes indefinite period, individuals take such drugs intermittently or cease taking them after several months. Here, lowered prices through greater efficiency may lead to greater adherence programs - particularly if other means of reminding and encouraging patients can be identified. But translating this to broader interventions is perhaps questionable.


The CITL study limited its scope to savings from achieving full interoperability of health IT, explicitly excluding potential improvements in efficiency within practices and hospitals. It essentially measured the long-term (15 year) savings when migrating from a theoretical state of complete paper to an equally theoretical state of idealized comprehensive use; it compares the potential savings from a bygone era with a Nirvana which may never be realized.

CBO echoes criticisms already made on unrealistically high estimates for laboratory administrative expenditures. It made equally generous assumptions about high degree of redundant test elimination. CITL, for example, assumed virtually all telephone costs would be eliminated from e-prescribing transactions

General Methodology

CBO helpfully distinguishes between the dynamic of savings incurred "internally" from those that are "externalities". They state:
  • Internal savings are those that can be captured by the provider or hospital that purchases the system; they are most likely to be in the form of reductions in the cost of providing health care—that is, improvements in the efficiency with which providers and hospitals deliver care.
  • External savings are those that the provider or hospital that purchases the system cannot realize but that accrue to another such provider or perhaps the relevant health insurance plan or even the patient. Such savings might arise, for example, from the newfound ability of participants in the health care sector to exchange information more efficiently.

CBO points out the relative maturity of internal cost savings examples within highly integrated delivery systems like Kaiser but emphasize the relative immaturity of knowledge where more disparate settings are incurred. They recognize that where health information exchanges are concerned, it is early in the game. They state "estimating the impact of some potential sources of savings, especially those arising from greater exchange of information among providers, insurers, and patients, is especially difficult because health IT networks are in an early stage of development."

Yet CBO does mention the positive effects. Their argument is one of degree. Among the areas in which savings may be realized are:

  • Eliminating paper records. Savings are less if practices are small (i.e. high fixed personnel costs) or if systems are not used effectively.
  • Reducing transcription services
  • Avoidance of duplicate tests. Here the issues are those of actual availability of previous test results; awareness of the test results; and avoidance of revenues if providers have an incentive to repeat the tests. Most estimates of redundant tests are small. These may be larger if test results from a broader range of sites are available
  • Reduction of radiology services. CBO suggests that most evidence supports the actual type of test ordered but little in the way of test reduction. (Our experience in Memphis suggests that some high-cost tests are reduced using a regional exchange).
  • Prescription drug costs. Although CBO mentions lack of incentives, their most compelling argument is that because of "strong incentives," health plans and PBMs "may already be capturing a substantial portion of those savings."
  • Improved productivity. Most studies are restricted to isolate roles and not to overall system productivity. Demonstrations of productivity are more compelling in some hospital environments than in ambulatory environments. Transcription costs can be reduced significantly.
  • Reduction in hospital length of stay. CBO points out that slight reductions in length-of-stay are not commensurate with cost reductions. They also emphasize correctly that the current financial incentives for LOS reduction are sufficient to accelerate more effective adoption independent of legislative imperative. Adoption just makes good business sense.
  • Quality. The connection between quality and EHR use remains conjectural but presents many long-term opportunities. One cannot improve what one does not measure so the extent to which one measures the right thing affords promise. CBO discounts the potential savings primarily because they are conferred upon patients and intermediaries rather than those who make the initial investment.
  • Adverse drug events. CBO reviews the conflicting data on in-patient settings and the dearth of data on ambulatory settings. CBO recognizes that "avoiding even a fraction of the errors that now occur in inpatient and outpatient settings could yield significant savings" but claims that some of these errors may be addressed by current systems. One could argue, however, that although drug-drug interactions are common in pharmacy systems and there are multiple fail-safe mechanisms, comprehensive drug-disease, drug-allergy, and drug-lab interactions are in a relatively primitive state because of lack of standards (e.g., for allergies), lack of uniform clinical decision support mechanisms, and lack of widespread incorporation of these data in uniform ways.
Although lowering of administrative costs are mentioned in a systemic sense, CBO does not mention revenue cycle acceleration and coding accuracy - one of the principle drivers for some practitioners.

CBO brings into light the theoretical value of incorporating clinical decision support and evidence-practice into systems in a effort to improve quality on a systematic basis. Although results again are conflicting at this early stage, the potential seems intuitive.

The CBO report also emphasizes research and comparative effectiveness. The report states: "And some potential areas of research and analysis remain largely unexamined. They include the ways in which the delivery of health care services might change in response to the efficiencies that health IT offers and how the large amounts of clinical data available through EHRs could contribute to analyses of the comparative effectiveness and cost-effectiveness of different treatments." Similarly, public health reporting and disease surveillance are in their early stages; the potential is there but the jury is out.

CBO report also includes a good summary of costs incurred to incorporate health care technology into ambulatory practice. Total initial costs are said to range from $25 - $45 per physician; ongoing costs range from 12-20%. New subscription based systems may eliminate much of the up-front costs and lower annual operating costs. Smaller practices incur higher per practitioner costs. (Even ASP models will not lower the per-clinician training costs and the considerable practice transformation opportunity costs).

Explaining Low Rates of Adoption
The CBO Report poses many explanations. These include the significant investments in choosing and implementing systems, the lack of identifying measurable financial returns. Although the authors are skeptical of adoption based only on quality or revenue improvements, they suggest that physicians "might change their thinking if they knew that they would be directly compensated for implementing a health IT system or if they could report data on the quality of care that they provided—data for which they were being compensated— only by using such a system."

The CBO report mentions the "free rider" effect of support through intermediaries. Because technology should help practitioners provide care for al of their patients, once a technology is adopted, all intermediaries will benefit whether such intermediaries made an initial investment or not. Only uniform means of enforcing certain outcomes or performance measures would seem to provide an incentive for all intermediaries to participate. This degree of coordination should not be expected and may, in the eyes of some, be viewed as collusion."

CBO identifies two major roles played by the federal government. The first is as a payer; federal contributions to Medicare and Medicaid account for approximately 25% of the total American health car spend. The second role is as a market-maker. Health care may be a public good that cannot be optimally conferred without a federal-government that eliminates the "free-rider problem. Combined, federal roles provide a network effect that, properly managed, could create new opportunities for lower costs and higher clinical values. The returns - one could argue - are to society as a whole.

But the government is not neutral in all of this. By virtue of the CBO charge to examine the marginal benefit of federal intervention to accelerate a trend that is already underway, one has difficulty identifying those who really change their behavior on the basis of a federal incentive from those who would change their benefit anyway. If one wishes to subsidize motive rather than results, one must end with the treacherous logic that favors punishment over incentive. Indeed, the only way to make sure one is not providing a causative reward for uniquely good behavior is to avoid all rewards for good behavior and instead focus on punishing for undesired behavior. But this response is also flawed. One could argue that some who do not adopt technology do so for good reasons but all would be punished without respect to motive.

The CBO report provides an excellent summary of the current challenges in identifying the unique value of health information technology. Left with this conundrum, it is easy to fall into the trap of accelerating mandates and punitive schemes rather than accelerating the need to address the many unanswered questions raised by the current state of technology in health care. The CBO report plainly demonstrates that we do not yet understand how a federal effort can be ideally structured because we do not clearly understand the cause and effect of the various interventions. But the CBO does not refute an obvious conclusion: making this system work and moving from clearly confusing and possibly dangerous paper-based approaches is both essential and inevitable.

This is a report worth reading carefully. The CBO is to be congratulated for their public contribution.

In a talk delivered to the Markle Foundation Connecting for Health Steering Group on June 19, Dr. Blackford Middle noted the report gave a "reasonable review and summary of the literature on HIT value." Some CITL report aspects "were not represented well." These include:
  • A fundamentally different purpose for the report - the impact of funding
  • Value of un-standardized (level 3) vs standardized (level 4) interoperability
  • They failed to note how CITL accounted for the current HIT context; CBO factored in existing provider-payer data exchanges, and existing lab and pharmacy integration
  • CBO treated costs of providers information systems but inadequately treated the internal benefits; their notion of data exchange was relatively restricted.
  • CITL differed with CBO on lab administration costs; phone call rates - but these were not key determinants of overall value
  • CBO's critique did not discuss some of the limitations of HIEI model limiations. The CITL model was more expansive and included realizing savings through quality improvements and the potential clinical benefit.
In the same discussion Zoe Baird noted that it isn't so much the report as how it is depicted to the public. Initial reports were rather unitarian in the view declaring that benefits are not there. CBO - recruiting a broad and talented array of health care economists - has emphasized a broader and more constructive mesage.

Sunday, May 25, 2008

Puerto Rico

Because of the close contest between two Democratic presidential candidates, something unusual is happening. For a few brief days, the eyes of the Nation will be turned on the Commonwealth of Puerto Rico. To some, Puerto Rico is an ancestral home; to others, it is a tourist destination; to those who help forge policy, it is a potential laboratory for health care reform.

Among the diverse states and territories constituting the United States, Puerto Rico is unique. Puerto Rico was ceded from Spain to the United States through the Treaty of Paris in 1898; it has governed through a formal civilian structure since the passage of the Foraker Act in 1900. Since the passage in 1917of the Jones-Shafroth Act the United States Congress has characterized the Commonwealth as an “organized but unincorporated” territory of the United States. Under this Act, residents were granted U.S. citizenship by statute and since that time have served in the United States military service. This Act affirmed a primary responsibility of the United States in maintaining control over economic, defense, and other basic governmental affairs and reiterates the United States Congress’s authority to overrule actions taken by the Commonwealth Legislature.

In 1947, the U.S. Congress approved a law allowing the election of the governor by the people of Puerto Rico. On July 3, 1950, the U.S. Congress passed the Puerto Rican Federal Relations Act. This law gave Puerto Rico the right to establish a government and a constitution for the internal administration of the Puerto Rico government and “on matters of purely local concern.

In 1993 most of the government’s health care facilities and services were sold and their management turned over to non-government entities generally under managed care arrangements. This far more decentralized system radically changed the Department of Public Health’s influence and authority in provisioning care services.

Although the impact on efficiency and quality is controversial there is some consensus on the unintended consequences of these moves. As is the case in the 50 states, the health care delivery could benefit from less fragmentation; it would provide more good if organizations providing preventive services, health promotion, and health maintenance were better coordinated; its diverse regions and communities require a better fit of health care services; it needs a stronger infrastructure for monitoring quality, financing health care services, improving outcomes, and providing consumers with greater empowerment and choices. It is, in a nutshell, facing the same challenges as those of the 50 states and other territories - but one can argue that its situation is even more acute.

Puerto Rico’s ability to combine local and federal financing for health care programs is hobbled by its unique relationship with the Federal government. In contrast to “incorporated territories” that may petition for statehood, the “unincorporated territory” of Puerto Rico is not subject to the Constitution’s Tax Uniformity Clause on all Federal duties, imposts, and excise. Although Puerto Ricans do pay import/export taxes, commodity taxes, and payroll taxes (Medicare, Social Security) most are not required to pay Federal income tax.

Although Puerto Ricans do not pay federal income tax, few would have a significant tax burden: the median household income in Puerto Rico is only 34% of the U.S median household income (2000 census) and less than half of that of citizens in the State of Mississippi.

While many health indicators in Puerto Rico are more ominous even than those published for Mississippi, in 2006 the latter state received 78.6% in federal support for every Medicaid dollar spent (the FMAP or federal matching assistance percentage), while Federal spending caps first initiated in 1968 have limited Puerto Rico’s matching percentage to an effective rate of 18%.

The 50 states can receive up to 90% reimbursement through Medicaid for critical health information technologies; Puerto Rico is not eligible for these supplements. According to 2005 Congressional testimony by Governor Anibal Acevedo-Vila, had FMAP been allowed to operate without the cap instead of the 18% effective rate of the previous year, the Commonwealth would have received $1.7 billion dollars in federal Medicaid support instead of the $219 million received. Translated to monthly amounts, federal Medicaid support in the states approximated $330 per month per participant; the amount in Puerto Rico was about $20 per month.

Funding and health care status are only a part of the obstacles Puerto Rico faces. Its health care delivery system, health care resources, and health care financing mechanisms have been said to have been in a state of decline since the introduction of managed care programs in the early 1990s. The hospital beds per capita in the Commonwealth are less than 2/3 the average across the 50 states; salaries for health care professionals of all types are lower and emigration to the 50 states is common. As vital care resources emigrate from the Commonwealth, some believe that a growing number of Puerto Rican residents needing chronic or long-term care will emigrate as well, shifting the financial burden for care to these same states.

It is within this context of controversy, internal dispute, and at times acrimonious dialogue with the Congress and Federal Executive Branch that Puerto Rico must navigate a course to health care reform. The creation, financing, and administration of such reforms very much depends on the perception – in Washington, among the Congress, and within the Commonwealth – on the rights and responsibilities of all parties within this historically unique and volatile relationship.

Puerto Rico's voice - and their subsequent actions - may say a lot about how other parts of the Nation can address similar urgent health care financing and delivery concerns.


Saturday, May 17, 2008

Incentives for e-Prescribing

Recently, and around the time of a hastily-called meeting by the Brookings Institution on e-prescribing, I was asked about incentives.

I have been following this only peripherally, so I made a lot of calls and sent a lot of emails. I drew some conclusions that may be my own bias filtered through what I want to hear, but I present them nonetheless.

The Southeast Michigan e-prescribing initiative is one of the most impressive success stories. Incentives to prescribers were $500 - $1000 with recurring incentives with P4P. Some up-front funds were used for infrastructure.

This writer believes the most important determinant of success was the involvement of every significant organization involved in the effort. Rather than just focusing on the prescriber, this project was initiated by employers (the auto makers) and involved actively retail pharmacies, plans, PBMs, SureScripts/RxHub, vendors, and prescribers. I believe it was the strength of this guiding community coalition that made this project an ongoing success.

Details can be found through a Powerpoint Presentation or through a search engine.

A similar experience was found in Horizon BCBS of New Jersey – one of the groups involved in the CMS e-prescribing trials last year. In this case, a commitment had been made over time.

One could therefore argue that a similar, broad-based cultural shift had taken place by the time the trials were initiated.

There are many examples in which plans provided significant financial incentives to practitioners but where results were wanting. In most of these efforts, physicians were provided with some combination of hardware, eRx software, mobile phones, telecommunications subsidies, and P4P approaches. In one effort, the program increase total reimbursement 1% (not just eRx-associated) if one met certain simple adoption milestones. Practitioners received another 1% if used a more extensive EMR system. Additional funding of another 5% or more could be attained if one met other P4P milestones. Interest in the program was low. The incentives (particularly the 1% of total increase in plan payments, did not seem to foster change. No pharmacy participation was mentioned.

Prematics seems to have a different approach. This vendor focuses on the high prescribers. Payment is through plans or other intermediaries to the vendor, and not to the practitioner. Payments are based on transaction fees in the range of $1-2. These fees are correlated with the estimated savings of $55 for every brand-to-generic shift. This model assumes and works towards linkages with pharmacies and other involved stakeholders. It focuses “incentives” to the prescriber on ease of use, flexibility, and convenience. These payer-to-vendor models do not preclude additional provider compensation for pay-for-performance, outcomes, or more effective and efficient medication management programs. Such incentives just aren't used to capitalized the infrastructure (and one wonders what happens to the self-pay patients; are they "free riders"?)

In my view, the e-prescribing pilots suggest the following:
  • Adoption is low but increasing rapidly as critical masses are achieved in communities.
  • It is a system-level issue involving pharmacies, providers, intermediaries and other critical programs.
  • Training and expertise may come from national or state-level expertise, but the real change happens locally.
  • Systematic, community-based approaches like SE Michigan take the most effort, but the guiding coalition and the critical mass focusing on the cultural and organizational issues suggests a far higher likelihood of success.
  • Incentives for a single provider have to be significant (at a minimum of 5% increase), but the Prematics model suggests that simply providing better systems more responsive to workflow might foster adoption. (Were I in practice, I am not sure I'd want to have my infrastructure costs assumed by a payer or intermediary, since, this is money that could be paid directly to providers for services.)

From the intermediary or employer side, brand-to-generic shifts so offset many of the costs; the question is: can the same shifts be assured without e-prescribing? I think perhaps so; certainly PBMs push drug trend before eRX (through tiered co-payments), and the differential profits realized by retail pharmacists influenced a lot of pharmacy generic shift behavior.

This brief posting is not particularly comprehensive or rigorous. But the simple question is:
  • To what extent does X incentive to one party in a transaction lead to Y results independent of the incentives to other parties in the transaction? (i.e. can you just give money to physicians and expect results if the system in which they practice is not ready for change?)
  • To what extent - and how - do system-wide or community-based initiatives involving more parties influence adoption and use? what are the overall costs and benefits of these?

To me, community-based approaches involving pharmacy, prescribers, intermediaries, employers, and government are the best way to go.

Tuesday, May 13, 2008

For-Profit Health Information Exchanges

In a May 8, 2008 Government Health IT article written by Nancy Ferris entitled "For-profit HIEs are the answer, entrepreneur says," Dr. Elliott Menschik, president of HxTechnologies, is quoted extensively from a recent Capitol Hill Steering Committee on Telehealth and Healthcare Informatics. (All quotes are taken from Ms. Ferris' article and not from primary sources.)
Dr. Menschik's company "began with grant funding from the National Institutes of Health, but that funding ran out last year. Now Menschik is in discussions with two large insurers in the Philadelphia area, Independence Blue Cross and Aetna, about sponsoring the project." "Working with radiologists, his company is developing a for-profit HIE that will deliver radiology images to doctors in Philadelphia....In New Jersey, HxTechnologies is building the New Jersey Health Information Exchange for a client, the AmeriHealth subsidiary of Independence Blue Cross."

According to Ms. Ferris, Menschik's claims that the current push for “altruism-driven” HIE is not getting results because “the lowest common denominator approach paralyzes participants.” Ferris states that the "need to achieve consensus on every issue slows the process to a crawl, and fear of antagonizing anyone means that the actions with the greatest potential impact are avoided. The projects are dependent on grants that eventually end, leaving the HIE without enough funds."

His model focuses on health plan funded-radiolology information exchanges. (Think of it as a pharmacy benefits manager for radiology.) Indeed, many pharmacy data aggregators, laboratory information providers, and other data services also are for-profit in structure. (But not not necessarily profitable at this juncture.)

If the coverage is reflective of Dr. Menschik's views, his concerns on the lowest-common-denominator have been justified by the glacial pace of the NHIN as broadly constituted. But the alleged slow pace of a broadly constituted NHIN in no way should lead one to conclude that the only alternative is to embrace models such as Dr. Menschik's as the only alternative. We need both.

According to Ms. Ferris, Dr. Menschik suggests that "for-profit, businesslike HIEs are the way to go in the current environment, according to a company president who says the free enterprise model can deliver results better, faster and cheaper. "

Are these claims true?
  • Better? For whom? For patients? providers? plans? all of the above?
  • Faster – if mobilizing capital is important, perhaps. But to what end?
  • Cheaper? How will we know since we won’t know the true price buried within the cost structures of health plans and intermediaries nor will we have any comparisons if transparency efforts do not advance.

A Flawed Argument
The argument placing for-profit models in opposition to non-for-profit models is flawed. The claim that one model provides a solution to one problem does not refute the validity of a claim that is not the logical opposite but rather a complement directed at different tasks. Specifically, a radiology exchange funded by health care plans does not in and of itself refute the value of a broader, community-based health information exchange, particuilarly since these exchanges in some way serve as an imperfect proxy for a consumer-focused health care information system. Furthermore, the "for-profit" vs. "non-profit" argument is secondary if not irrelevant. A more important argument is over the rising role of heavily-funded and economically "disruptive" personal health care records offered by Microsoft, Google, Intuit, Dossia, and many others.

The issue is raising capital. Health plans - for-profit or non-profit - get much of their capital simply because they get our money first and essentially distribute it, whereas new models for innovation - be they new technologies, new drugs, or new approaches to information management - can only thrive if they obtain new capital (via IPO or angel funding) or by trying to demonstrate value to the health plans and other intermediaries who already have our health care dollars.

Dr. Menschik's company sounds like a good idea. If the numbers work, it will bring immediate value to payers. Like a PBM, this approach is almost certain to garner the attention of intermediaries with fiscal responsibilities. Like other initiatives to constrain costs, it almost certainly will demonstrate cost savings and will incur the wrath of some who lose revenue (e.g., Dr. Menschik's radiology colleagues). Like other initiatives, the costs of the infrastructure may be high.

In the final line of the article, Ms. Ferris states that "substantial amounts of federal funding for HIEs would be a good alternative to the business-driven efforts he [Menschik] is advocating. But that kind of financial support does not seem likely to be forthcoming...."

This is the point. The real struggle is among the advocates of a purely driven health care system and the advocates of a system dominated by intermediaries. As Menschik's model would suggest, there may be room for both. But the success of one model devoted to certain purposes and markets does not necessarily support the claim that other models will fail either financially or from the perspective of the public interest. And purely for-profit endeavors are to be found in both.

The article begins with the following assertion: "Public-private partnerships to develop health information exchanges? Forget about it. "

I would suggest that the consumer public will not "forget," nor will the next generation remain totally reliant on information whose access is withheld and decisions made by invisible intermediaries. Consumers will want a growing seat at the decision-making table and a rising interest in how their health dollars are spent. Whether this is through for-profits or non-profits, independent companies or community partnerships, is yet to be determined. One size may not fit all.

Thursday, May 8, 2008

Memphis Health Information Exchange Beginning 3rd Year of Clinical Operations

On May 3, 2008, our Memphis-based health information exchange has been in operation for two years. Funded by AHRQ, the State of Tennesse, and Vanderbilt and governed by the non-profit MidSouth eHealth Alliance, the Exchange has come a long way

TheExchange currently has 356 people using the system for clinical care.

  • Physician / Provider roles - 199
  • Nurse roles - 109
  • Registrars and unit clerk functions - 48
These numbers will change as the last major system goes "near real time" in the next few weeks and as more ambulatory care providers are introduced to the program. The number of clinicians will increase and the number of registrars and unit clerks will decrease dramatically.

Data are accessed by authorized personnel in 30 sites, including 11 emergency rooms, 15 primary care clinics, and 4 hospitalist groups. Expansion to other emergency department settings is taking place in May and June of 2008. Access is only through two-factor authentication and secure Web browsers in restricted settings. 100% of access transactions undergo some form of audit. Use is restricted to clinical settings. No aggregate data or metrics are kept. Patients may "opt out" at the institutional level.

The Exchange grants secure access to almost 3 million patient encounters.

  • Total number of unique individuals - 1,050,000
  • Total number of unique individuals with clinical data (not
    just claims) - 809,000
Our latest inventory of data elements from the two-years of operation counts:
  • Over 64 million laboratory tests (growing at an average of 88,000 test results a day).
  • 1.3 million radiology reports (growing at almost 2,000 per day)
  • Over 16 thousand dictated discharge summaries
  • Over 218 thousand anatomic pathology reports
  • Approximately 40 thousand other clinical notes
(Follow this link to compare with our February 2008 update)

More data and implications will soon be found at our Regional Informatics Site