Monthly Archives: April 2012

The case for health information exchanges

Picture a medical  district that bundles more than half a dozen hospitals in the matter of a few square miles, toss in a patient population that walks in and out of every single hospital and what results is a yet another utterly forgettable night at work for an already harried intern.

Patient visits are everywhere, health information is everywhere, and in an environment of competing interests were coordination between care providers is systematically stymied, putting together the jigsaw of the patient’s medical history and care for a midnight admission becomes a nightmare come alive. This in fact should have been the patient’s nightmare as well, but no body is telling him  how hospital information systems refusing to talk with each other is putting his care on the back burner.

With the advent of the electronic medical records (EMR),  sharing health information between disparate care providers should have been easy. Turns out it is not.

There are challenges. Some technological but mostly to do with policy and practice.

First there is the issue with adoption of EMR itself. Not every provider still can manage to see the value proposition in EMR. But even when that has been sorted out, the idea of  sharing health information in exchanges is still a hard ball to sell to providers. They think they have nothing to gain by sharing and supporting such exchanges.

Care providers fear losing revenue that is currently generated by what would then prove be redundant care, were such information freely available. Furthermore in the current scheme of things, care providers are often asked to support such information exchanges, when in fact they are the ones who are losing money out of expensive information infrastructure they have to pony up, and the revenue they have to give up. And then there is the issue of inertia: “things were so much better the old-fashioned way” kind of attitude to overcome.

If it does not make an outright  business sense for care providers, who does a health information exchange benefit?  

Free flowing, standardized, interoperable health information will co-ordinate patient care by an order of magnitude. Such a scenario won’t be a chip at the stone incremental innovation; it will be a path breaking way forward.  Aggregating such data bases at a central or federated repository will help scale and  analyse such data at a population level thereby helping form epidemiological trends and predict disease out breaks. De-identified data sets can be used in research studies that will benefit society in the longer run.

Individual patient care will improve simply by the fact that information is freely available and care can be coordinated over geographical barriers. Patients can’t be stopped from moving from one hospital to the other, we can at least have their health records  move with them.

One of the major challenges today to ensure efficient and effective, yet affordable health care is to move patient care out from the hospital to the community and to design health interventions at a population level than at just the individual level. Such practices will need population level data; health information exchanges will achieve just that. And a tremendous amount of value will be created right there.

There in lies the value proposition to such information exchanges. This is a societal good that needs benevolent policy environment to grow to fruition.

To be fair, the Health Information Technology for Economic and Clinical Health (HITECH) Act  made policy provisions to encourage such information exchanges. More than half a billion dollars worth of funds were ear marked for state-wide adaptation of such information exchanges. In fact some form or the other of health information exchanges have been tried out as far back as the ’80’s. However thorny issues remain. Most of them as mentioned ahead, are policy and practice issues.

The states and the federal government have a magic wand they can flaunt here: the Centers for Medicare and Medicaid (CMS) by virtue of being the largest payer in this country can tie up payment with participation in such health exchanges. To be fair, hospitals and care providers should not be burdened by the costs of supporting such exchanges. Since  such exchanges are a societal good, such costs which can easily run into the 10’s of million of dollars to set up and millions of dollars each year to run, should come out of the public domain where such benefits are actually accrued.

Then there is the challenge of standardising such health information, so that information provided by one care provider is trusted by the other.

And there is the tricky issue of patient privacy: how to use such information to the greatest benefit without compromising on patient privacy. Who gets to see and use what, who sets permissions and who maintains the final custody of  the information, these are valid but challenging policy questions.

And finally though great technological advances have been made, challenges still remain on how to create interoperable databases and  use such information in a meaningful way in the doctors offices. Experiences from Indiana, that runs one of the oldest health information exchanges in the country show that oftentimes the final mile to the doctor’s office is the hardest mile to cover for such information exchanges.

Such challenges aside there is a real case for health information exchanges. This is an idea whose time has rightfully arrived. With a right set of policy environment, this might as well prove to be the be the leapfrogging health innovation we have all being dying to see.

The runaway patient

My patient ran away from the hospital.

This ordinarily is almost common place for a hospital bordering the south side of Chicago. In the last two years at the hospital, I had first grown surprised, and then helpless and finally weary to such mysterious absconding. This time however, it struck a chord.

Long before Mr B ran away, I had an inkling the new diagnosis of HIV would be difficult for him to accept. I had thus decided to recruit the help of counselors to join me discuss the diagnosis with him. If that was a thoughtful decision, it wasn’t any useful nonetheless. My patient showed little emotion during the discussion of his new diagnosis; however a little while later he was nowhere to be found.

Patients usually bolt out of the hospital because the pull of the street is too strong for them to resist. They come to the hospital when their bodies can’t take it anymore, but as soon as their as they gain any bit of composure, they are out of  the door. I have however, thus far, not had a patient who had bolted out because he was apparently traumatised by his new diagnosis.

A few years ago when I was a doctor halfway across the world, patients met a similar diagnosis with uncharacteristic resignation. Young housewives, growing up in grinding poverty, social oppression and lack of education had never really had any say whatsoever about how their lives had shaped up thus far. So if their husbands came home one day and then gave them the virus, that was just another of the upteen unfair hands life had dealt at them; there wasn’t anything for them to say or react about that. While their predicament was  profoundly unfortunate, their reaction was absolutely muted.

To these women HIV meant perennial ill-health, and burdensome stigma and discrimination in what was already a much marginalised existence. Here in America such barriers were not easily visible: treatment options were available and stigma if any was banished to the underground. Examples abound of people who had been able to overcome the crippling effects of the infection and lead a healthy and productive life. Rights groups and patient advocates were available. More importantly, my patient here had made informed choices about his own life; he had the chance to be the master of his own destiny. So while I had expected him to be shaken by the diagnosis, his running out of the hospital took me by a little surprise.

A few hours later, we traced our patient, and he returned to the hospital. He was visibly sorry for having run out, but it was not hard to gauge that he had been overwrought. By his own description, he blanked out and did not know what to do, so he ran away in a nervous frenzy.

I could not help rationalise how upsetting this new found diagnosis must have been for Mr B, but then my mind did a throwback to those housewives half way across the world; for them even an upset emotion was a luxury they could not afford; the grind of an overly unfair life had blunted their emotional responses to such an extent, their bodies did not even know how to react to a horribly unpleasant event. These women had been robbed of their ability to emote.

Such reminder brought me peace of mind- Mr B might as well have tripped into a hole right now, but is was no where the bottomless hole life could summarily consign you to. So what if he ran away from the hospital, that still is much comforting than an unaffected silence and an emotional void for a response.