Leveraging Health Information Technology and Health Information Exchange for Value-Based Healthcare Initiatives
In a country where healthcare spending is 16 percent of the gross domestic product, and much higher than other industrialized countries, the United States – according to many leading employers – is losing its competitiveness and ability to compete globally. According to the Organisation for Economic Cooperation and Development, healthcare spending per capita in Switzerland – the next most costly OECD country – is only 68 percent of that in the U.S.; in Canada, it is only 57 percent; and in the median OECD country it is less than 44 percent of the U.S. level.[1]
Americans are increasingly feeling the pain of rising healthcare costs. According to a recent survey conducted by the Kaiser Family Foundation, 21 percent of employers reported that it is “very likely” and 28 percent reported that it was “somewhat likely” that they would increase the amount that employees pay for health insurance in the coming year. Health insurance premiums for workers and their employees have skyrocketed by 87 percent since 2000, the survey found, while workers’ earnings have risen by only 20 percent over the same time period.[2]
Increasing costs are not the only issue concerning the nation’s largest payers and employers. According to a study published in The New England Journal of Medicine, U.S. adults receive about half of recommended healthcare services.[3] And, despite documented benefits of timely preventive care, a Commonwealth Fund-sponsored U.S. Scorecard on Health System Performance indicates that not even half of adults (49 percent) receive preventive and screening tests according to guidelines for their age and sex. And poor quality translates into higher costs. According to the same Commonwealth Fund report, the current gap between national average rates of diabetes and blood pressure control and rates achieved by the top 10 percent of health plans translates into an estimated 20,000 to 40,000 preventable deaths and $1 billion to $2 billion in avoidable medical costs.[4]
Federal Efforts Driving Toward ‘Value-Based Healthcare’
Concerns about cost and quality are driving the federal government to take action. On August 22, 2006, President Bush issued an executive order calling for healthcare programs that are administered or sponsored by the federal government to make available cost and quality information to their beneficiaries, as well as to utilize HIT systems and products that meet recognized interoperability standards.
Department of Health and Human Services (DHHS) Secretary Michael O. Leavitt has spoken frequently to public audiences, calling for action to drive better care and lower costs, through four cornerstones, which are detailed in DHHS’ Prescription for a Value-Driven Health System:
- Connecting the System: Every medical provider has some system for health records. Increasingly, those systems are electronic. Standards need to be set so all health information systems can quickly and securely communicate and exchange data.
- Measure and Publish Quality: Every case, every procedure, has an outcome. Some are better than others. To measure quality, we must work with doctors and hospitals to define benchmarks for what constitutes quality care.
- Measure and Publish Price: Price information is useless unless cost is calculated for identical services. Agreement is needed on what procedures and services are covered in each “episode of care.”
- Create Positive Incentives: All parties – providers, patients, insurance plans and payers – should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively priced healthcare.[5]
The Institute of Medicine released in September 2006 a report entitled “Rewarding Provider Performance: Aligning Incentives in Medicare,” which provided a series of recommendations related to pay for performance, recognizing that “existing (payment) systems do not reflect the relative value of healthcare services in important aspects of quality, such as clinical quality, patientcenteredness and efficiency.”[6]
A majority of emerging policies and initiatives within both the public and private sectors, related to what has most recently been coined as “Value-Based Healthcare,” introduce the notion that the use of health information technology (HIT) and health information exchange can play an integral part in increasing the likelihood that increases in quality and efficiency will result from these initiatives. And efforts are now under way to articulate specifically how HIT and health information exchange can play a critical role in rapidly emerging quality and efficiencyfocused programs.
Continued Advancement in HIT and Health Information Exchange Efforts at the National, State and Local Levels
While policies related to improving quality and efficiency are quickly moving to the front burner, so are those related to the use of information technology. Over the last year, interest in and recognition of the importance of HIT and health information exchange to improve our nation’s health and healthcare has grown significantly, bringing a number of policy changes. In addition to the executive order issued by President Bush in August 2006, DHHS Secretary Leavitt in 2005 launched the American Health Information Community – a multistakeholder, publicprivate sector body charged with providing input as to how to make health records digital and interoperable while assuring that privacy and security are protected. On July 27, 2006, the U.S. House of Representatives passed the Health Information Technology Promotion Act (H.R. 4157), which was anticipated to be conferenced in the 109th Congress, with the Senate version of the bill passed in November 2005.
A number of states are also moving forward – in parallel with federal efforts – to develop and adopt policies for improving health and healthcare through HIT and electronic health information exchange. State legislators are increasingly recognizing the role of HIT in addressing healthcare challenges, with 121 bills introduced in 38 states since 2005 – 64 of which were introduced in the first seven months of 2006. Thirty-six of such bills in 24 states were passed in the legislature and signed into law.[7] State legislatures are not the only policy makers driving change in states – U.S. governors are increasingly recognizing the value of HIT in addressing their healthcare goals. To date, 11 U.S. governors have issued an executive order designed to drive improvements in health and healthcare through the use of IT.
At the same time, the number of collaborative health information exchange initiatives at the state, regional and community levels has grown considerably over the last three years. In September 2006, the eHealth Initiative (eHI) released the results of its Third Annual Survey of Health Information Exchange at the State, Regional and Community Levels, analyzing results from 165 responses from initiatives in 49 states, the District of Columbia and Puerto Rico.
According to eHI’s survey results, 47 percent of the 165 respondents identified themselves as being in the advanced stage of development, with 26 of such initiatives identifying themselves as “fully operational.” Survey results indicate an increasing level of maturity in the functionality of these health information exchange efforts, with at least one-fifth of all initiatives now electronically transmitting claims, dictation, emergency department episodes, enrollment/eligibility, inpatient and outpatient episodes, laboratory results and radiology results.[8]
Survey results also indicate that the most common functionalities of such efforts are those related to care delivery, with more than one-fifth of respondents claiming that they are offering the following services: clinical documentation (26 percent), results delivery (25 percent), consultation/referral (24 percent), electronic referral processing (23 percent) and alerts to providers (20 percent).[8] In addition, such efforts are continuing to expand services provided to support improvements in the quality and effectiveness of healthcare. Twenty percent of all respondents are currently providing disease or chronic care management services. Eleven percent of respondents are providing quality performance reporting for purchasers or payers, while an additional 7 percent expect to provide this service within six months. Ten percent are providing quality performance reporting for clinicians, with an additional 14 percent intending to add this service within six months.
The Role of HIT and Health Information Exchange in Promoting Value-Based Healthcare
Emerging value-based healthcare initiatives are designed to improve the quality, safety and efficiency of healthcare.Many of these initiatives, including those recently announced by DHHS, involve the measurement and reporting of data related to quality and cost and the alignment of incentives around such measures of performance. Getting from “here to there” on value-based healthcare will require several components including agreement on a common set of performance measures; the creation of information infrastructure, capabilities and policies to support data collection and measurement; the alignment of incentives to facilitate improvement; and the development of mechanisms to support providers through the transformation process.
Policy makers are turning to bodies such as the National Quality Forum, the Ambulatory Quality Alliance and the Hospital Quality Alliance to identify a common set of measures to be used to evaluate performance. A number of pay-for-performance and incentives programs are cropping up across the country, including those licensed by Bridges To Excellence and those sponsored by individual health plans. To address the information infrastructure required for data collection and performance reporting, a number of plans are aggregating claims data to ease the burden of collection and reporting.
A review of the performance measurement sets emerging from initiatives such as the Ambulatory Quality Alliance and the Hospital Quality Alliance, the National Quality Forum, CMS’ Doctor’s Office Quality Program, the AMA-sponsored Physician Consortium and the National Committee for Quality Assurance reveals that in addition to the use of claims data, considerable chart pulls are required to populate measurement sets – an activity which is difficult to accomplish in the small practice environment.
As state, regional and community-based health information exchange initiatives continue to mature across the U.S., they offer an opportunity to address rapidly emerging performance measurement and reporting requirements, while at the same time, supporting clinicians with “feedback loops” or mechanisms for quality improvement at the point of care.While electronic health records alone cannot fully address requirements related to quality improvement and reporting, once they are populated through health information exchange efforts with information that resides in entities across the healthcare system – including medication histories, laboratory results or information about the patient from other provider or payer locations – they can begin to serve that purpose.
Health information exchange initiatives, which, according to eHI’s survey results, are primarily multistakeholder-based and led by nonprofit organizations, offer a mechanism both for building trust and creating a policy and technical infrastructure for health information sharing, using a method that fosters mutual agreement among providers, purchasers and payers – which is similar to the infrastructure needed to support emerging performance reporting and value-based healthcare initiatives.
The confluence of efforts surrounding not only information technology and health information exchange, but also requirements for and the alignment of incentives with value-based healthcare, create an opportunity for transformation in the U.S. healthcare system. As pressures on the system for quality and efficiency improvement continue to grow, policy makers at the national, state and local levels should align policies related to quality with those related to HIT – enabling the infrastructure currently being built in communities across America to support the mobilization of data for care delivery, to also support requirements for quality and efficiency improvement. Both efforts require trust, the engagement of multiple stakeholders, special attention to information-sharing policies related to privacy and confidentiality and an electronic data infrastructure. Alignment on these two fronts has the potential to fast-forward efforts to improve the quality, safety and efficiency of healthcare for all Americans.
Endnotes
- Reinhardt UE, Hussey PS, Anderson GF. 2004. US Health Care Spending in an International Context. Health Affairs. 23(3): 10-25.
- Henry J. Kaiser Family Foundation/Health Research and Educational Trust. Eighth Annual Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. 2006.
- McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003; 348:2635-2645.
- The Commonwealth Fund. Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, New York: The Commonwealth Fund. 2006.
- Leavitt, MO. 2006. Better Care, Lower Cost: Prescription for a Value-Driven Health System. Washington, D.C.: Department of Health and Human Services; 2006.
- Committee on Redesigning Health Insurance Performance Measures, Payment and Performance Improvement Programs. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, D.C.: Institute of Medicine; 2006.
- eHealth Initiative. States Getting Connected: State Policy Makers Drive Improvements in Healthcare Quality and Safety Through IT. Washington, D.C.: eHealth Initiative; August 2006.
- eHealth Initiative. Improving the Quality of Healthcare through Health Information Exchange: Selected Findings from eHealth Initiatives Third Annual Survey of Health Information Exchange Activities at the State, Regional and Local Levels. Washington, D.C.: eHealth Initiative; September 2006.
