Patients often can’t be trusted to tell the truth about their health. They downplay their unhealthy behaviors, forget which medicines they are taking, misunderstand their diagnoses and conflate the names of drugs.
That’s why it can take courage to prescribe a powerful drug for a new patient, even though the patient needs the medicine. He or she could be allergic to it or taking another drug that will interact badly with it.
And then there are the bad apples — the patients who lie about their conditions to obtain painkillers or other medicine so they can get high or sell the drugs to others.
Regional and state health information exchanges are expected to mitigate the problems that arise from incomplete or inaccurate patient histories by enabling doctors and other health care providers to share their records.
But development has been slow, and there is little reason to think it will soon accelerate. The networks depend on providers to acquire standards-compliant electronic health record (EHR) systems and then participate in exchange networks.
One reason doctors have been reluctant to invest in such systems is that much of the financial benefit accrues to the payers, not the providers. Information technology helps the payers — insurance companies, government programs, employers and patients — avoid duplicative testing and prescriptions and prevent ailments from worsening, among other cost-controlling effects.
Claims-based records With EHR adoption lagging among providers, some payers are now underwriting a different approach — claims-based records. Such systems compile information from insurance claims and deliver it to health care providers and/or patients via the Web.
In Illinois, New Mexico, Oklahoma and Texas, for example, the company that operates the local Blue Cross Blue Shield health plans is launching Blue Care Connection, which aggregates claims data with any information voluntarily provided by providers and patients. The resulting records are available to doctors and other providers, and 11 million patients also have access to their personal health records.
About 90 percent of the information comes from claims data, including diagnoses, treatments, prescriptions and lab test results. The company, Health Care Service Corp. (HCSC), uses the data to generate automatic reminders and recommendations for patients and providers on wellness, the care of chronic conditions, treatment options and the like.
The data warehouse will also generate new knowledge about the best treatments for patients, said Joe Taylor, a vice president at HCSC.
The public sector’s role Governments, which are major health care payers through the Medicare and Medicaid programs, are moving in the same direction.
Missouri is spending $25 million this year on health IT projects, including the creation of a paperless Medicaid program. The Web-based Missouri HealthNet will allow doctors to obtain Medicaid authorization for certain treatments, view patients’ medical and medication histories, prescribe drugs electronically, receive alerts about allergies and needed tests, and more. Gov. Matt Blunt is touting the program as the first step in creating a statewide EHR network.
In a tour across Missouri to promote the initiative, Blunt visited a Jiffy Lube location to make the point that the auto-care chain has more complete and accessible records about customers and their cars than a typical doctor has on his or her patients.
“It is unacceptable in the 21st century that Jiffy Lube is more technologically advanced than our health care system,” said State Senate President Pro Tem Michael Gibbons, who accompanied Blunt on the tour. State officials expect Missouri HealthNet to improve physician satisfaction with the Medicaid program, enlist pharmacists in the effort to ensure that patients comply with their health regimens, improve continuity of care and bolster dis
ease-management programs.
In addition to physician services, the integrated system will support Web-based access to information for patients, pharmacies and payers.
State officials have built the system gradually, beginning in 2002 with a tool for managing prescription benefits. That feature saved the state $43 million in its first year, said George Oestreich, deputy director of the state’s Division of Medical Services.
Administrative benefits In mid-2006, state officials began implementing the full-scale physician Web portal and training an initial group of 3,600 doctors to use the system, called CyberAccess.
The system’s chief appeal for doctors is the ability to obtain prior authorization for tests, treatments and medications in real time, said Will Saunders, president of ACS Heritage, a subsidiary of Affiliated Computer Services. ACS is the state’s prime contractor for health IT.
CyberAccess cuts paperwork and speeds treatment, Saunders said. After using the tool for several months, doctors learn which treatments and medications Medicaid will authorize and which ones the program won’t cover, and they stop trying to order the latter.
As a result, denials of prescriptions and other treatments requiring preauthorization have dropped from about 30 percent to less than 2 percent, he said. “They’ve actually learned the rules and changed their practice” of medicine, he said during a session at the Health IT Summit in Washington in March.
Doctors also appreciate the system’s up-to-date information, he said. For example, they can see what prescriptions their patients had filled on the day they go to the pharmacy, he added.
Oestreich said the state continues to add features to CyberAccess. For example, online precertification of imaging procedures saved the state $4.4 million in the first quarter of this year, he said.
In the next fiscal year, the state plans to develop a database of health records for patients who will soon become eligible for Medicaid. It will improve continuity of care when patients move in and out of Medicaid by sharing data with private payers, Oestreich said.
Doctors can also import data from their electronic medical record (EMR) systems into CyberAccess, and the state will soon make laboratory test results available online.
“As we add additional value, we think it will be in the physicians’ best interest to use the tool,” Oestreich said. Down the road, Missouri might build interfaces with physicians’ EMR systems to give doctors a more integrated source of patient data, he added.
Missouri is delivering a patient Web portal to 1,000 Medicaid recipients in its first phase, Saunders said.
Tennessee’s initiative In Tennessee, the state is paying $3.3 million to a Blue Cross Blue Shield subsidiary called Shared Health to provide claims-based EHRs for about 2.2 million Medicaid recipients and other participants in government health programs. Doctors and patients can use the Web-based system for free.
Antoine Agassi, director and chairman of the state’s eHealth Advisory Council, said it’s too early to measure the impact of the initiative, which went into production in 2006, but “people who use it feel it’s invaluable.”
Shared Health officials declined requests for an interview, but indications are that physician participation is below expectations.
That’s not an unusual situation. “The adoption rate is not where we’d like it to be,” said Dr. William Gerardi, a clinical adviser to HCSC. In Missouri, officials said about half the doctors who have the CyberAccess tool are using it.
For many years, mistrust has marked the relationship between health plans and providers, and some think that attitude could be an obstacle to persuading doctors to use tools supplied by health plans, no matter how useful the tools might be.
“Being able to see which [other] physicians her patient has seen is actually fairly useful information” to a doctor, Gerardi said. He said he believe
s physicians will also value patient-entered information, such as family medical histories and the use of over-the-counter medications.
“This is not meant to supplant electronic medical records, the adoption of which we fully support,” he added. “It’s meant to enhance whatever processes that physician has in their office.”
However, in a presentation at the World Health Care Congress in April, Taylor showed slides that repeatedly used the label “EHR” when discussing HCSC’s Blue Care Connection. And ACS is touting its Missouri system as a comprehensive EHR product.
How good is claims data? Unlike EMR systems, claims-based systems combine administrative processes, such as prior authorization of treatments, with medical records. Despite that extra functionality, they could meet the simplicity test Tennessee Gov. Phil Bredesen advocated in a speech at the Healthcare Information and Management Systems Society’s annual conference in February.
Bredesen said health IT is bogged down in too many technical issues — such as complex, conflicting standards — and developers should aim for simplicity.
If that’s the goal, a Web-based system that provides a summary of important aspects of the patient’s health might be just what the doctor ordered. Besides being free and relatively easy to use, claims-based systems don’t require doctors to enter any additional data because claims supply the necessary information.
But how good is claims data? A 2004 study published in the journal Medical Care found that claim forms showed the correct primary diagnosis slightly more than half the time. For secondary diagnoses, doctor’s offices submitted correct information just 27 percent of the time. Other researchers have come up with comparable findings.
What’s more, claims data lacks some important details and nuance because of the universal coding scheme and the way it is used. For example, the scheme does not distinguish between a severe case of diabetes and one that’s under control, and providers don’t always use the diagnostic codes that indicate the spread of cancers. Furthermore, symptoms such as pain or fever usually don’t show up at all.
A next-generation coding system exists that will allow for more fine detail. However, the U.S. health care industry has not yet adopted it, and when it does, the system will take years to implement. In the meantime, the data on claims-based EHRs can be sketchy.
Diagnostic and treatment codes were designed for billing purposes, and some suspect that physicians can and do manipulate them to maximize their revenues or get insurers to pay for something that isn’t covered. If a physician does inflate a diagnosis to justify a certain treatment and it shows up on the patient’s record, that diagnosis might affect another doctor’s treatment of that patient.
Dr. Mark Frisse, director of regional initiatives at Vanderbilt University’s Center for Better Health and a leader of a regional health information exchange, said a claims-based EHR system might be better than none.
“It’s an open question whether it’s a clinical record,” he said, adding that he would like to see studies of how claims-based records affect care. “I would like to know that use of these codes does not in some instances mislead clinicians, posing a potential safety risk.”
Asked about health plans offering claims-based records, Frisse said, “I think their strategy is questionable” because doctors will most likely prefer other kinds of EHRs. Although he said it is unlikely that claims-based systems will develop into full-fledged EHRs, he questioned whether such systems are set up to protect patients’ privacy.
In the end, despite his reservations, Frisse said deployment of claims-based systems “is an experiment worth doing."
Government Health IT presents Liesa Jo Jenkins, executive director of CareSpark, in this recent eSeminar, where she shared her experiences and insight into building a health information exchange that enhances community health, rewards regional collaboration and drives economic progress.
