Patient-Controlled Health Record Banks: Where is the value for physicians?

1. Patient-Controlled Health Record Banks: Where is the value for physicians? Jeff Hummel, MD, MPH Medical Director for Clinical Informatics Qualis Health Spokane WSMA September 27, 2008

2. Overview of this session • What is the problem HRBs are trying to solve? • How do they work? • What will physicians have to do? • How will it make the physician’s job easier?

3. What do physicians do all day? • We make clinical decisions • Answering the, “what do I do?” question • The anatomy of a clinical decision: 4 steps • Gathering the information • Organizing the information • Making a decision • Carrying out the decision • For an information-rich profession, we don’t have the • right tools

4. Where is the information we need? • In our charts • Paper • EMR • In other doctors’ charts • In registries • In industry data bases • Our patients have it

5. Who pays for gathering information? • Mostly we do: • EMRs, chart room • Staff time calling for missing reports • Staff time asking patients about medications, • immunizations, allergies • Payers and employers do: • Duplicate testing

6. Who bears the cost when we don’t gather the information? • Patients do: • Wasted office visit time – patient leaves without getting their needs med • Delayed diagnosis • Decisions we make without all the information – medical errors • Payers and employers do: • Costs of medical errors

8. EMR Interoperability • EMRs are essential for gathering and organizing information in one’s own system. They still aren’t very good, but they’re better than paper • To be of real value, information from other systems must be available at the point-of-care • There are plans for EMRs to talk to each other: expensive, hard to scale and lack a business model • What if patients stored copies of key information and brought it with them to office visits, organized for our workflows?

10. How would this all work? • Who would operate a bank? • How would a patient sign up for an account? • How would information get into the bank? • Where would the information be stored? • If patients control the information, can we trust it? • Am I responsible for things I don’t know about? • How does the information get to the doctor? • What about privacy and security? • What’s the business model?

11. That’s what we want to find out • Currently 3 pilots in Washington State • Peace Health in Bellingham • INHS in Spokane • Community Choice Network in Wenatchee • Each one is affiliated with a consortium of practices • All are receiving a grant from HCA • There should be information on how well the pilots have worked by next summer

12. Who would operate a bank? • A trusted entity • A subsidiary to a consortium of medical practices • A consumer cooperative • A community • Not an insurance company • Not the government • Not the pharmaceutical industry

13. How do you get an HRB account? • Pilot HRBs all are affiliated with medical practices consortia • Pt’s identity is authenticated at doctor’s office • Pt is “provisioned” with a log-on and password • Pts are authorized to access own account and can authorize other authenticated individuals to access their account • Family members • Caregivers

14. How do data get into an HRB? • Direct feeds: • Provider data: • EMR medication orders • EMR lab/imaging results • Industry data: • Registries: Child Profile, Advance Directives • Medication: RxHub, SureScripts, Medicaid • Patient entered data: • Med List edit, allergy information • Administrative data

15. Where are the data stored? • Both the Bellingham and Wenatchee will store the data using Microsoft Health Vault as a platform • INHS will store its HRB data using Google • Technically there is no reason that the data can’t be store in a server run by any secure data warehouse

16. Can patients edit the information? • Pts will need to edit medication lists, allergies and advance directives • All Pt edits will be transparent to the viewer • Certain information will not be editable, although pts will be able to comment, e.g. “that cholesterol was done after I’d run out of my lipitor” • Lab results • Imaging studies

17. Pt centered decision support • Medication lists run clinical rules to support chronic illness care • Diabetes: identified by med list, generates prompts to assist monitoring labs and Tx goals • Asthma: identified by med list, generates prompts to support care plan and reminders to use spacers, or get flu shots • Demographic info runs clinical rules to help patients keep track of prevention goals including: Mammography, CRC screening, immunizations, etc

18. How can I trust HRB data? • What the patients will have is a copy. The EMR data will not be changed by the fact that a Pt has copy in their HRB • We already ask our patients to validate the information we have. If they say they stopped taking a medication we change our record to reflect that reality • Drug seekers will continue to seek drugs – some things never change

19. Am I responsible for other people’s data? • The HRB is designed to increase patient responsibility for their health information • The patient has a copy of information gathered by physicians in different places • The physician is responsible for information in her own record • If a patient brings information to the visit and it becomes part of a physician’s record then she is responsible for it as part of the history

20. How does the Pt share info with me? • Initially the patient will need to print a copy of a pre-visit summary and bring it to the office visit. • Validated Medication List & Allergies • Immunizations • Advance Directives • Administrative data • Later an office may be able to access and print directly with Pt permission • Direct download into EMR is problematic

21. What about Privacy & Security • Clear use agreement to follow the rules • Robust way to validate identity of all users • Government-issued ID • All users have affiliation and role • Validated users will be authenticated with log-on and password • Patients will get to decide who besides them can see their data: proxies, caregivers • Audit will give patients regular report on who has accessed their account

22. Who pays? Where’s the value? • Primary Care: • Reduced time/cost of getting information • Improved ability to meet outcomes target for Medical Homes revenue streams • Patients: • Better use of time with physician • Self-management support improves outcomes • Payers: • Less wasted time means more efficient use of office visits • Less redundancy

23. How does this make my life easier? • Reduced cost: Pre-visit summary contains information formatted to support office workflows • Demographic information reduces front desk work • Medication information reduces MA/LPN work • Increased revenue: self-management support function helps PCP meet NCQA targets and qualify for Medical Homes revenue streams

24. Does this mean I need an EMR? • You already need an EMR • The HRB is designed to support workflows whether or not you have an EMR • The HRB recognizes 2 essential facts that are only tangentially related to an EMR • We need right information supplied to us at the right time, organized so we can easily use it to make clinical decisions • We need our patients more involved in their own care &more responsible for their own information

25. Did we answer the questions? • What is the problem HRBs are trying to solve? • How do they work? • What will physicians have to do? • How will it make the physician’s job easier?

26. “You can’t give more than you get by giving it away. “ We get far more by giving control to our patients than we could ever get by trying to control it ourselves. Jeffrey Hummel, MD, MPH Qualis Health Medical Director for Clinical Informatics jeffh@qualishealth.org