America spent 17.3% of its gross domestic product on health care
in 2009 (1). If you break that down on an individual level, we spend
$7,129 per person each year on health care…more than any other country
in the world (2). With 17 cents of every dollar Americans spent keeping
our country healthy, it’s no wonder the government is determined to
reform the system. Despite the overwhelming attention health care is
getting in the media, we know very little about where that money comes
from or how it makes its way into the system (and rightfully so…the
way we pay for health care is insanely complex, to say the least). This
convoluted system is the unfortunate result of a series of programs that
attempt to control spending layered on top of one another. What follows
is a systematic attempt to peel away those layers, helping you become
an informed health care consumer and an incontrovertible debater when
discussing “Health Care Reform.”

Who’s paying the bill?

The
“bill payers” fall into three distinct buckets: individuals paying
out-of-pocket, private insurance companies, and the government. We can
look at these payors in two different ways: 1) How much do they pay and
2) How many people do they pay for?

The majority of individuals in
America are insured by private insurance companies via their employers,
followed second by the government. These two sources of payment
combined account for close to 80% of the funding for health care. The
“Out-of-Pocket” payers fall into the uninsured as they have chosen to
carry the risk of medical expense independently. When we look at the
amount of money each of these groups spends on health care annually, the
pie shifts dramatically.

The government currently pays for 46% of
national health care expenditures. How is that possible? This will make
much more sense when we examine each of the payors individually.

Understanding the Payors

Out-of-Pocket

A
select portion of the population chooses to carry the risk of medical
expenses themselves rather than buying into an insurance plan. This
group tends to be younger and healthier than insured patients and, as
such, accesses medical care much less frequently. Because this group has
to pay for all incurred costs, they also tend to be much more
discriminating in how they access the system. The result is that
patients (now more appropriately termed “consumers”) comparison shop for
tests and elective procedures and wait longer before seeking medical
attention. The payment method for this group is simple: the doctors and
hospitals charge set fees for their services and the patient pays that
amount directly to the doctor/hospital.

Private Insurance

This
is where the whole system gets a lot more complicated. Private
insurance is purchased either individually or is provided by employers
(most people get it through their employer as we mentioned). When it
comes to private insurance, there are two main types: Fee-for-Service
insurers and Managed Care insurers. These two groups approach paying for
care very differently.

Fee-for-Service:

This
group makes it relatively simple (believe it or not). The employer or
individual buys a health plan from a private insurance company with a
defined set of benefits. This benefit package will also have what is
called a deductible (an amount the
patient/individual must pay for their health care services before their
insurance pays anything). Once the deductible amount is met, the health
plan pays the fees for services provided throughout the health care
system. Often, they will pay a maximum fee for a service (say $100 for
an x-ray). The plan will require the individual to pay a copayment
(a sharing of the cost between the health plan and the individual). A
typical industry standard is an 80/20 split of the payment, so in the
case of the $100 x-ray, the health plan would pay $80 and the patient
would pay $20…remember those annoying medical bills stating your
insurance did not cover all the charges? This is where they come from.
Another downside of this model is that health care providers are both
financially incentivized and legally bound to perform more tests and
procedures as they are paid additional fees for each of these or are
held legally accountable for not ordering the tests when things go wrong
(called “CYA or “Cover You’re A**” medicine). If ordering more tests
provided you with more legal protection and more compensation, wouldn’t
you order anything justifiable? Can we say misalignment of incentives?

Managed Care:

Now
it gets crazy. Managed care insurers pay for care while also “managing”
the care they pay for (very clever name, right). Managed care is
defined as “a set of techniques used by or on behalf of purchasers of
health care benefits to manage health care costs by influencing patient
care decision making through case-by-case assessments of the
appropriateness of care prior to its provision” (2). Yep, insurers make
medical decisions on your behalf (sound as scary to you as it does to
us?). The original idea was driven by a desire by employers, insurance
companies, and the public to control soaring health care costs. Doesn’t
seem to be working quite yet. Managed care groups either provide medical
care directly or contract with a select group of health care providers.
These insurers are further subdivided based on their own personal
management styles. You may be familiar with many of these sub-types as
you’ve had to choose between then when selecting your insurance.

• Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO):This
  is the closet managed care gets to the Fee-for-Service model with many
  of the same characteristics as a Fee-for-Service plan like deductibles
  and copayments. PPO’s & EPO’s contract with a set list of providers
  (we’re all familiar with these lists) with whom they have negotiated set
  (read discounted) fees for care. Yes, individual doctors have to charge
  less for their services if they want to see patients with these
  insurance plans. An EPO has a smaller and more strictly regulated list
  of physicians than a PPO but are otherwise the same. PPO’s control costs
  by requiring preauthorization for many services and second opinions for
  major procedures. All of this aside, many consumers feel that they have
  the greatest amount of autonomy and flexibility with PPO’s.
  
• 
  Health Management Organization (HMO): HMO’s
  combine insurance with health care delivery. This model will not have
  deductibles but will have copayments. In an HMO, the organization hires
  doctors to provide care and either builds its own hospital or contracts
  for the services of a hospital within the community. In this model the
  doctor works for the insurance provider directly (aka a Staff Model
  HMO). Kaiser Permanente is an example of a very large HMO that we’ve
  heard mentioned frequently during the recent debates. Since the company
  paying the bill is also providing the care, HMO’s heavily emphasize
  preventive medicine and primary care (enter the Kaiser “Thrive”
  campaign). The healthier you are, the more money the HMO saves. The
  HMO’s emphasis on keeping patients healthy is commendable as this is the
  only model to do so, however, with complex, lifelong, or advanced
  diseases, they are incentivized to provide the minimum amount of care
  necessary to reduce costs. It is with these conditions that we hear the
  horror stories of insufficient care. This being said, physicians in HMO
  settings continue to practice medicine as they feel is needed to best
  care for their patients despite the incentives to reduce costs inherent
  in the system (recall that physicians are often salaried in HMO’s and
  have no incentive to order more or less tests).

The Government

The
U.S. Government pays for health care in a variety of ways depending on
whom they are paying for. The government, through a number of different
programs, provides insurance to individuals over 65 years of age, people
of any age with permanent kidney failure, certain disabled people under
65, the military, military veterans, federal employees, children of
low-income families, and, most interestingly, prisoners. It also has the
same characteristics as a Fee-for-Service plan, with deductibles and
copayments. As you would imagine, the majority of these populations are
very expensive to cover medically. While the government only insures 28%
of the American population, they are paying for 46% of all care
provided. The populations covered by the government are amongst the
sickest and most medically needy in America resulting in this
discrepancy between number of individuals insured and cost of care.

The largest and most well-known government programs are Medicare and Medicaid. Let’s take a look at these individually:

Medicare:

The
Medicare program currently covers 42.5 million Americans. To qualify
for Medicare you must meet one of the following criteria:

• Over 65 years of age
  
• 
  Permanent kidney failure
  
• 
  Meet certain disability requirements

So you meet the criteria…what do you get? Medicare
comes in 4 parts (Part A-D), some of which are free and some of which
you have to pay for. You’ve probably heard of the various parts over the
years thanks to CNN (remember the commotion about the Part D drug
benefits during the Bush administration?) but we’ll give you a quick
refresher just in case.

• Part A (Hospital Insurance):
  This part of Medicare is free and covers any inpatient and outpatient
  hospital care the patient may need (only for a set number of days,
  however, with the added bonus of copayments and deductibles…apparently
  there really is no such thing as a free lunch).
  
• 
  Part B (Medical Insurance): This part, which you must purchase, covers
  physicians’ services, and selected other health care services and
  supplies that are not covered by Part A. What does it cost? The Part B
  premium for 2009 ranged from $96.40 to $308.30 per month depending on
  your household income.
  
• 
  Part C (Managed Care): This part, called Medicare Advantage, is a
  private insurance plan that provides all of the coverage provided in
  Parts A and B and must cover medically necessary services. Part C
  replaces Parts A & B. All private insurers that want to provide Part
  C coverage must meet certain criteria set forth by the government. Your
  care will also be managed much like the HMO plans previously discussed.
  
• 
  Part D (Prescription Drug Plans): Part D covers prescription drugs and costs $20 to $40 per month for those who chose to enroll.

Ok,
now how does Medicare pay for everything? Hospitals are paid
predetermined amounts of money per admission or per outpatient procedure
for services provided to Medicare patients. These predetermined amounts
are based upon over 470 diagnosis-related groups (DRGs) or Ambulatory
Payment Classifications (APC’s) rather than the actual cost of the care
rendered (interesting way to peg hospital reimbursement…especially
when the Harvard economist who developed the DRG system openly disagrees
with its use for this purpose). The cherry on top of the irrational
reimbursement system is that the amount of money assigned to each DRG is
not the same for each hospital. Totally logical (can you sense our
sarcasm?). The figure is based on a formula that takes into account the
type of service, the type of hospital, and the location of the hospital.
This may sound logical but often times this system fails.

Medicaid:

Medicaid
is a jointly funded (funded by both federal and state governments)
health insurance program for low-income families. Eligibility rules vary
from state to state and factors in age, pregnancy, disability, income
and resources. Poverty alone does not qualify an individual for Medicaid
(there is currently no government-provided insurance for the American
poor…despite the fact that almost all first world countries have such a
system…enter the current health care debate) but is a significant
factor in Medicaid eligibility. Each state operates its own Medicaid
program but must adhere to certain federal guidelines to receive
matching federal funds (you may be familiar with California’s MediCal,
Massachusetts’ MassHealth and Oregon’s Oregon Health Plan due to their
recent media coverage). Medicaid payments currently assist nearly 60
percent of all nursing home residents and about 37 percent of all
childbirths in the United States.

How are the bills paid?

We
now understand who is paying the bill but we have yet to cover how
those bills are paid. There are two broad divisions of arrangements for
paying for and delivering health care: fee-for-service care and prepaid
care.

Fee-for-Service

As we
mentioned briefly while discussing PPO’s, in a fee-for-service
structure, consumers select a provider, receive care (a.k.a. “service”)
from the provider, and incur expenses (a.k.a. “a fee”) for the care.
Deductibles and copayments are also required as previously discussed.
Pretty simple. The physician is then reimbursed for their services in
part by the insurer (i.e. a private insurance company or the government)
and in part by the patient, who is responsible for the balance unpaid
by the insurer (the return of the unanticipated medical bill despite
your overpriced insurance). Again, the major downfall of the
fee-for-service approach is that medical professionals are incentivized
to provide services (and by this we mean any and all services they can
legally request or must request to be protected legally), some of which
may be nonessential, to increase their revenue and/or “C.Y.A.” (revenue
that has steadily decreased as insurance companies continue to lower the
amount they pay medical professionals for their services).

Fee Schedule

A
fee schedule operates in the same way that Fee-for-Service does with
one exception: instead of using the “usual, customary, and reasonable”
amount to reimburse medical professionals, states set fees to be paid
for specific procedures and services. The reimbursement is very low
($.10-.15 on the dollar) and barely covers the actual direct cost of
providing the care. Physicians may chose to opt into the plan or not
(starting to see why a doctor might not be so excited about this plan?).
Would you sign up to be paid 10 cents for every dollar you charged for
your work? Try the insurance reimbursement approach next time you go out
to eat. We’ll come bail you out of the Big House if things go awry.
What happens when the insurance system does this? You get the Wal-Mart
approach to medicine (high volume, low quality). Not the kind of heath
care we recommend.

Pre-Paid

Pre-paid
health care? Like a phone card? Not exactly–but close. The pre-paid
system evolved out of the insurance company’s desire to share its risk (
a.k.a “pooled risk”) with health care providers. Essentially, they
wanted the doctors to have some skin in the game. In the pre-paid
system, insurers make arrangements with health care providers to provide
agreed-upon covered health care services to a given population of
consumers for a (usually discounted) set price-the per-person premium
fee-over a particular time period. What does that mean? It means that
Dr. Bob gets paid, say, $30 per month to take care of Joe the Plumber
including his blood work and x-rays. If Dr. Bob spends less than that
caring for Joe, he makes money. If Joe is sick every month and needs
lots of tests and follow-up visits, Dr. Bob could lose money caring for
Joe. The set monthly fee paid to the doctor for taking care of a patient
is set up on a per-member, per-month (PMPM) rate called a “capitated fee.”
The provider receives the capitated fee per enrollee regardless of
whether the enrollee uses health care services and regardless of the
quality of services provided (not a good thing in our book).
Theoretically, providers should become more prudent and subsequently
provide services in a more cost effective manner because they are
bearing some of the risk. Often times, however, less care is provided
than is needed in hopes of saving money and increasing profits. In
addition, physicians are incentivized to cherry pick the youngest and
healthiest patients because these patients typically require less care
(i.e. they are cheaper to keep healthy). We like that doctors are
encouraged to keep patients healthy but we have to worry about the ways
in which they are being encouraged to reduce costs (as little care as
possible?). Again, the incentive system falls short and encourages
providers to act unethically.

The Take Home Message:

Health
Care in the United States today is complex and messy at best. The
layers on top of layers of failed attempts to correct the system
continue to encourage the wrong behavior in both patients (out of fear
of medical bills) and providers (out of fear of bankruptcy). We have yet
to provide every American citizen with medical care (something that
goes without saying in most 1st World countries…even Cuba has it!). We
spend more money on caring for our citizens than any country in the
world yet we continue to lag behind in terms of national health
outcomes. We think it’s safe to say that we’re not getting the best bang
for our buck. The ultimate solution? We wish we knew. Only time will
tell where the system goes from here. Our goal: to help you better
understand the system as it stands today in hopes of developing a more
effective, efficient, and comprehensive system for the future. Are you
with us?

References

1. Levey N. Soaring cost of healthcare sets a record. Los Angeles Times. Feb 4 2010.

2. McKenzie J, Pinger R, Kotecki J. An Introduction to Community Health, 6th Ed. Jones and Bartlett Publishers. 2008.

3. Bodenheimer TS, Grumbach K. Understanding Health Policy. 5th Ed. Lange Medical Books/McGraw-Hill. 2002.

4.
Kaiser Family Foundation. “EXPLAINING HEALTH CARE REFORM: How Do Health
Care Costs Vary By Region?” Brief #8030. December 2009.

The post Who’s Paying For Health Care appeared first on New Health and Fitness.

How Does Benzoyl Peroxide Fight Acne?

Benzoyl peroxide works as a peeling agent on your skin. As a topical
drug, benzoyl peroxide is effective in treating mild to moderate cases
of acne. It starts by acting as an antiseptic, and its anti-inflammatory
properties help to soothe your skin. As an antiseptic, benzoyl peroxide
fights off bacteria on the surface of your skin and assists in the
reduction of yeasts, as well.

Side Effects of Benzoyl Peroxide

As with treatment for any skin condition of illness, it is important to
talk with a specialist to find out how you will be affected. It is
common for benzoyl peroxide treatments to cause initial dryness and
irritation. Those with more sensitive skin could suffer from itching,
burning, and swelling at the site of application.

Tips for Using Benzoyl Peroxide for Acne

If you have sensitivity to other acne treatments, it is a good idea to
talk to your doctor about using benzoyl peroxide before you do so.
Benzoyl peroxide comes in either gel or cream products with a
concentration of 10 percent or less. Since benzoyl peroxide causes
dryness, it is a good idea to start at a lower concentration (2.5
percent for example) and let your skin build up a tolerance. Research
indicates that benzoyl peroxide is safe and effective for acne treatment
at 5 to 10 percent, but it may take a few weeks before your skin is
used to the product at that concentration. It is not advised to use
benzoyl peroxide treatments for acne during pregnancy, as it has proven
to be unhealthy to the fetus.

Source:

(1). “Acne Facts.” American Academy of Acne (www.aad.org). n.p., n.d. Web. 16 Apr. 2014.

The post Benzoyl Peroxide and Acne Treatment appeared first on New Health and Fitness.

Defining a Health Information Exchange

The
United States is facing the largest shortage of healthcare
practitioners in our country’s history which is compounded by an ever
increasing geriatric population. In 2005 there existed one geriatrician
for every 5,000 US residents over 65 and only nine of the 145 medical
schools trained geriatricians. By 2020 the industry is estimated to be
short 200,000 physicians and over a million nurses. Never, in the
history of US healthcare, has so much been demanded with so few
personnel. Because of this shortage combined with the geriatric
population increase, the medical community has to find a way to provide
timely, accurate information to those who need it in a uniform fashion.
Imagine if flight controllers spoke the native language of their country
instead of the current international flight language, English. This
example captures the urgency and critical nature of our need for
standardized communication in healthcare. A healthy information exchange
can help improve safety, reduce length of hospital stays, cut down on
medication errors, reduce redundancies in lab testing or procedures and
make the health system faster, leaner and more productive. The aging US
population along with those impacted by chronic disease like diabetes,
cardiovascular disease and asthma will need to see more specialists who
will have to find a way to communicate with primary care providers
effectively and efficiently.

This efficiency can only be attained
by standardizing the manner in which the communication takes place.
Healthbridge, a Cincinnati based HIE and one of the largest community
based networks, was able to reduce their potential disease outbreaks
from 5 to 8 days down to 48 hours with a regional health information
exchange. Regarding standardization, one author noted, “Interoperability
without standards is like language without grammar. In both cases
communication can be achieved but the process is cumbersome and often
ineffective.”

United States retailers transitioned over twenty
years ago in order to automate inventory, sales, accounting controls
which all improve efficiency and effectiveness. While uncomfortable to
think of patients as inventory, perhaps this has been part of the reason
for the lack of transition in the primary care setting to automation of
patient records and data. Imagine a Mom & Pop hardware store on any
square in mid America packed with inventory on shelves, ordering
duplicate widgets based on lack of information regarding current
inventory. Visualize any Home Depot or Lowes and you get a glimpse of
how automation has changed the retail sector in terms of scalability and
efficiency. Perhaps the “art of medicine” is a barrier to more
productive, efficient and smarter medicine. Standards in information
exchange have existed since 1989, but recent interfaces have evolved
more rapidly thanks to increases in standardization of regional and
state health information exchanges.

History of Health Information Exchanges

Major
urban centers in Canada and Australia were the first to successfully
implement HIE’s. The success of these early networks was linked to an
integration with primary care EHR systems already in place. Health Level
7 (HL7) represents the first health language standardization system in
the United States, beginning with a meeting at the University of
Pennsylvania in 1987. HL7 has been successful in replacing antiquated
interactions like faxing, mail and direct provider communication, which
often represent duplication and inefficiency. Process interoperability
increases human understanding across networks health systems to
integrate and communicate. Standardization will ultimately impact how
effective that communication functions in the same way that grammar
standards foster better communication. The United States National Health
Information Network (NHIN) sets the standards that foster this delivery
of communication between health networks. HL7 is now on it’s third
version which was published in 2004. The goals of HL7 are to increase
interoperability, develop coherent standards, educate the industry on
standardization and collaborate with other sanctioning bodies like ANSI
and ISO who are also concerned with process improvement.

In the
United States one of the earliest HIE’s started in Portland Maine.
HealthInfoNet is a public-private partnership and is believed to be the
largest statewide HIE. The goals of the network are to improve patient
safety, enhance the quality of clinical care, increase efficiency,
reduce service duplication, identify public threats more quickly and
expand patient record access. The four founding groups the Maine Health
Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health
Information Center (Onpoint Health Data) began their efforts in 2004.

In
Tennessee Regional Health Information Organizations (RHIO’s) initiated
in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri
Cities region was considered a direct project where clinicians interact
directly with each other using Carespark’s HL7 compliant system as an
intermediary to translate the data bi-directionally. Veterans Affairs
(VA) clinics also played a crucial role in the early stages of building
this network. In the delta the midsouth eHealth Alliance is a RHIO
connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist
Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis
Health System, St Jude, The Regional Medical Center and UT Medical.
These regional networks allow practitioners to share medical records,
lab values medicines and other reports in a more efficient manner.

Seventeen
US communities have been designated as Beacon Communities across the
United States based on their development of HIE’s. These communities’
health focus varies based on the patient population and prevalence of
chronic disease states i.e. cvd, diabetes, asthma. The communities focus
on specific and measurable improvements in quality, safety and
efficiency due to health information exchange improvements. The closest
geographical Beacon community to Tennessee, in Byhalia, Mississippi,
just south of Memphis, was granted a $100,000 grant by the department of
Health and Human Services in September 2011.

A healthcare model
for Nashville to emulate is located in Indianapolis, IN based on
geographic proximity, city size and population demographics. Four Beacon
awards have been granted to communities in and around Indianapolis,
Health and Hospital Corporation of Marion County, Indiana Health Centers
Inc, Raphael Health Center and Shalom Health Care Center Inc. In
addition, Indiana Health Information Technology Inc has received over 23
million dollars in grants through the State HIE Cooperative Agreement
and 2011 HIE Challenge Grant Supplement programs through the federal
government. These awards were based on the following criteria:1)
Achieving health goals through health information exchange 2) Improving
long term and post acute care transitions 3) Consumer mediated
information exchange 4) Enabling enhanced query for patient care 5)
Fostering distributed population-level analytics.

Regulatory Aspects of Health Information Exchanges and Healthcare Reform

The
department of Health and Human Services (HHS) is the regulatory agency
that oversees health concerns for all Americans. The HHS is divided into
ten regions and Tennessee is part of Region IV headquartered out of
Atlanta. The Regional Director, Anton J. Gunn is the first African
American elected to serve as regional director and brings a wealth of
experience to his role based on his public service specifically
regarding underserved healthcare patients and health information
exchanges. This experience will serve him well as he encounters societal
and demographic challenges for underserved and chronically ill patients
throughout the southeast area.

The National Health Information
Network (NHIN) is a division of HHS that guides the standards of
exchange and governs regulatory aspects of health reform. The NHIN
collaboration includes departments like the Center for Disease Control
(CDC), social security administration, Beacon communities and state
HIE’s (ONC).11 The Office of National Coordinator for Health Information
Exchange (ONC) has awarded $16 million in additional grants to
encourage innovation at the state level. Innovation at the state level
will ultimately lead to better patient care through reductions in
replicated tests, bridges to care programs for chronic patients leading
to continuity and finally timely public health alerts through agencies
like the CDC based on this information.12 The Health Information
Technology for Economic and Clinical Health (HITECH) Act is funded by
dollars from the American Reinvestment and Recovery Act of 2009.
HITECH’s goals are to invest dollars in community, regional and state
health information exchanges to build effective networks which are
connected nationally. Beacon communities and the Statewide Health
Information Exchange Cooperative Agreement were initiated through HITECH
and ARRA. To date 56 states have received grant awards through these
programs totaling 548 million dollars.

History of Health Information Partnership TN (HIPTN)

In
Tennessee the Health Information Exchange has been slower to progress
than places like Maine and Indiana based in part on the diversity of our
state. The delta has a vastly different patient population and health
network than that of middle Tennessee, which differs from eastern
Tennessee’s Appalachian region. In August of 2009 the first steps were
taken to build a statewide HIE consisting of a non-profit named HIP TN. A
board was established at this time with an operations council formed in
December. HIP TN’s first initiatives involved connecting the work
through Carespark in northeast Tennessee’s s tri-cities region to the
Midsouth ehealth Alliance in Memphis. State officials estimated a cost
of over 200 million dollars from 2010-2015. The venture involves
stakeholders from medical, technical, legal and business backgrounds.
The governor in 2010, Phil Bredesen, provided 15 million to match
federal funds in addition to issuing an Executive Order establishing the
office of eHealth initiatives with oversight by the Office of
Administration and Finance and sixteen board members. By March 2010 four
workgroups were established to focus on areas like technology,
clinical, privacy and security and sustainability.

By May of 2010
data sharing agreements were in place and a production pilot for the
statewide HIE was initiated in June 2011 along with a Request for
Proposal (RFP) which was sent out to over forty vendors. In July 2010 a
fifth workgroup,the consumer advisory group, was added and in September
2010 Tennessee was notified that they were one of the first states to
have their plans approved after a release of Program Information Notice
(PIN). Over fifty stakeholders came together to evaluate the vendor
demonstrations and a contract was signed with the chosen vendor Axolotl
on September 30th, 2010. At that time a production goal of July 15th,
2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN’s
CEO. Keith brings twenty six years of tenure in healthcare IT to the
collaborative. His previous endeavors include Microsoft, Bellsouth and
several entrepreneurial efforts. HIP TN’s mission is to improve access
to health information through a statewide collaborative process and
provide the infrastructure for security in that exchange. The vision for
HIP TN is to be recognized as a state and national leader who support
measurable improvements in clinical quality and efficiency to patients,
providers and payors with secure HIE. Robert S. Gordon, the board chair
for HIPTN states the vision well, “We share the view that while
technology is a critical tool, the primary focus is not technology
itself, but improving health”. HIP TN is a non profit, 501(c)3, that is
solely reliant on state government funding. It is a combination of
centralized and decentralized architecture. The key vendors are Axolotl,
which acts as the umbrella network, ICA for Memphis and Nashville, with
CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include
a gateway to the National Health Institute planned for late 2011 and a
clinician index in early 2012. Carespark, one of the original regional
health exchange networks voted to cease operations on July 11, 2011
based on lack of financial support for it’s new infrastructure. The data
sharing agreements included 38 health organizations, nine communities
and 250 volunteers.16 Carespark’s closure clarifies the need to build a
network that is not solely reliant on public grants to fund it’s
efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten
grants were awarded in 2011 by the HIE challenge grant supplement.
These included initiatives in eight states and serve as communities we
can look to for guidance as HIP TN evolves. As previously mentioned one
of the most awarded communities lies less than five hours away in
Indianapolis, IN. Based on the similarities in our health communities,
patient populations and demographics, Indianapolis would provide an
excellent mentor for Nashville and the hospital systems who serve
patients in TN. The Indiana Health Information Exchange has been
recognized nationally for it’s Docs for Docs program and the manner in
which collaboration has taken place since it’s conception in 2004.
Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana
Beacon Community has a level of collaboration and the ability to
organize quality efforts in an effective manner from its history of
building long standing relationships. We are thrilled to be working with
a community that is far ahead in the use of health information to bring
positive change to patient care.” Beacon communities that could act as
guides for our community include the Health and Hospital Corporation of
Marion County and the Indiana Health Centers based on their recent
awards of $100,000 each by HHS.

A local model of excellence in
practice EMR conversion is Old Harding Pediatric Associates (OHPA) which
has two clinics and fourteen physicians who handle a patient population
of 23,000 and over 72,000 patient encounters per year. OHPA’s
conversion to electronic records in early 2000 occurred as a result of
the pursuit of excellence in patient care and the desire to use
technology in a way that benefitted their patient population. OHPA
established a cross functional work team to improve their practices in
the areas of facilities, personnel, communication, technology and
external influences. Noteworthy was chosen as the EMR vendor based on
user friendliness and the similarity to a standard patient chart with
tabs for files. The software was customized to the pediatric environment
complete with patient growth charts. Windows was used as the operating
system based on provider familiarity. Within four days OHPA had 100%
compliance and use of their EMR system.

The Future of HIP TN and HIE in Tennessee

Tennessee
has received close to twelve million dollars in grant money from The
State Health Information Exchange Cooperative Agreement Program.20
Regional Health Information Organizations (RHIO) need to be full
scalable to allow hospitals to grow their systems without compromising
integrity as they grow.21and the systems located in Nashville will play
an integral role in this nationwide scaling with companies like HCA,
CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data
repository for all patients information that can be accessed from
anywhere and contains a full history of the patients medical record, lab
tests, physician network and medicine list. To entice providers to
enroll in the statewide HIE tangible value to their practice has to be
shown with better safer care. In a 2011 HIMSS editor’s report Richard
Lang states that instead of a top down approach “A more practical idea
may be for states to support local community HIE development first. Once
established, these local networks can feed regional HIE’s and then
connect to a central HIE/data repository backbone. States should use a
portion of the stimulus funds to support local HIE development.”22 Mr.
Lang also believes the primary care physician has to be the foundation
for the entire system since they are the main point of contact for the
patient.

One piece of the puzzle often overlooked is the patient
investment in a functional EHR. In order to bring together all the
pieces of the HIE puzzle patients will need to play a more active role
in their healthcare. Many patients do not know what medicines they take
every day or whether they have a living will. Several versions of
patient EHR’s like Memitech’s 911medical id card exist, but very few
patients know or carry them.23 One way to combat this lack of awareness
is to use the hospital as a catch-all and discharge each patient with a
fully loaded USB card via case managers. This strategy also might lead
to better compliance with post in patient therapies to reduce
readmissions.

The implementation of connecting qualified
organizations began earlier this year. To fully support organizations to
move toward qualification the Office of National Coordinator for HIE
(ONC) has designated regional education centers (TN rec) who assist
providers with educational initiatives in areas like HIT, ICD9 to ICD10
training and EMR transition. Qsource, a non-profit health consulting
firm, has been chosen to oversee TNrec. To ensure sustainability it is
critical that Tennessee build a network of private funding so that what
happened with Carespark won’t happen to HIP TN. The eHealth Initiatives
2011Survey Report states that of the 196 HIE initiatives, 115 act
independently of federal funding and of those independent HIE’s, break
even through operational revenue. Some of these exchanges were in
existence well before the American Recovery and Reinvestment Act in
2009. Startup funding from grants is only meant to get the car going so
to speak, the sustainable fuel, as observed in the case of Carespark,
has to come from value that can be monetized. KLAS research reports that
54% of public HIE’s were concerned about future sustainability while
only 35% of private HIE’s shared this concern.

Hospital Implications of HIP TN (A Call to Action)

From
a Financial perspective, taking our hospital into the future with EMR
and an integrated statewide network has profound implications. In the
short term the cost to find a vendor, establish EMR in and outpatient
will be an expensive proposition. The transition will not be easy or
finite and will involve constant evolution as HIP TN integrates with
other state HIE’s. To get a realistic idea of the benefits and costs
associated with health information integration. we can look to
HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37
million dollars in avoided services and 15 million in productivity
reduction. Specific areas of savings include paper or fax costs $5
versus $0.25 electronically, virtual health record savings of $50 per
referral, $26 saved per ED visit and $17.41 per patient/year due to
redundant lab tests which amounts to $52 million for a population of 3
million patients. In Grand Junction Colorado Quality Health Network
lowered their per capita Medicare spending to 24% below the national
average, gaining recognition by President Obama in 2009. The Santa Cruz
Health Information Exchange (SCHIE) with 600 doctors and two hospitals
achieved sustainability in the first year of operation and uses a
subscription fee for all the organizations who interact with them. In
terms of government dollars available, meaningful use incentives exist
to encourage hospitals to meet twenty of twenty five objectives in the
first phase (2011-2012) and adopting and implement an approved EHR
vendor. ARRA specified three ways for EHR to be utilized to obtain
Medicare reimbursement. These include e-prescribing, health information
exchange and submission of clinical quality measures. The objectives for
phase two in 2013 will expand on this baseline. Implementation of EHR
and Hospital HIE costs are usually charged by bed or by the number of
physicians. Fees can range from $1500 for a smaller hospital up to
$12,000 per month for a larger hospital.

Perhaps the most
compelling argument to building a functional Health Information Exchange
is patient and community safety. The Healthbridge reduction in disease
outbreak detection of 3-5 days is a perfect example of this safety
benefit. Imagine the implications in the case of a rampant virus like
avian or swine flu. The goal is to avoid a repeat of the 1918 influenza
outbreak and ultimately save the lives of our most at risk. Rick Krohn
of Healthsense makes the case for a socially responsible HIE that serves
those who are chronically ill, uninsured and homeless. As the taxpayers
ultimately bear the societal burden for our country’s healthcare
coverage, the need to reduce redundancies, increase efficiency and
provide healthcare worthy of the United States is imperative. Right now
our healthcare is in the Critical Care Unit it’s time to stabilize it
through operational excellence starting with our hospital. Let’s rebuild
the Tower of Babel and enhance communication to provide our patients
the healthcare they deserve!

The post Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges appeared first on New Health and Fitness.