E-health interventions may be widening health disparities rather than shrinking them.
That’s what a study published in the Clinical Journal of the American Society of Nephrology found. The study looked at roughly 2,800 patients at four university-affiliated nephrology offices in western Pennsylvania from 2010 to 2012. The findings showed that patients who were poor, black, older, unmarried or on Medicare or Medicaid were less likely to use electronic health record portals to manage their chronic kidney disease.
The online portal the patients had access to gave them the ability to look at lab results, communicate with their providers, get prescription refills, review their medical information and schedule or change appointments.
But of the almost 40% of patients who used the portal, those patients were most likely to be white, married, young, on private insurance and with a higher neighborhood median household income.
“Despite the increasing availability of smartphones and other technologies to access the Internet, the adoption of e-health technologies does not appear to be equitable,” Khaled Abdel-Kader, M.D., senior author of the study and assistant professor of medicine at Vanderbilt University, told NPR. “As we feel we are advancing, we may actually perversely be reinforcing disparities that we had been making progress on.”
Abdel-Kader added that previous studies — including one that looked at patients with diabetes — have found similar results in which underserved patients and populations are less likely to use patient portals.
He told NPR that he believes the solution lies in understanding why people aren’t using the portals and to make sure they have tools that work for them.
In the case of this recent study that Abdel-Kader helped write, he believes possible obstacles that kept patients from using the portal include lack of confidence and skills in accessing health information online, low comfort level of communication with their provider via the portal and security concerns.
Mallika Mendu, attending physician and director of quality and process improvement in the renal division at Brigham and Women’s Hospital in Boston, told NPR that the potential for making existing health disparities even worse should be “panic inducing,” especially because many people in vulnerable and underserved populations deal with chronic disease.
Mendu thinks that people from underserved populations therefore need to play a role in the design of these e-health interventions and technologies. She also suggests that providers work to understand their patient population before creating these tools by surveying patients ahead of time to figure out how they access the Internet, whether patients are willing to receive training and what types of technologies they like to use.
As the healthcare industry labors to achieve better interoperability, some providers are pointing fingers at their peers. Nearly every healthcare provider says it’s willing to share clinical information with other providers, but noticeably fewer providers believe the reverse holds true.
Nearly one-in-five (18%) providers that responded to a KLAS Enterprises LLC. interoperability report said the main competitors of their organizations are unwilling to share clinical information, while only 2% said the same of themselves. More than half (55%) also identified their organizations as “proactive and willing” in the sharing of clinical data, while roughly half that percentage put their competition in the same category. Whether these statistics reflect the truth, it’s clear some providers have trust issues when it comes to sharing clinical information with other healthcare facilities. None of the respondents reported any instance of a vendor deliberately tampering with the flow or information, or otherwise engaging in “information blocking.”
Though examples of information blocking weren’t exposed in KLAS’ research, the U.S. Office of the National Coordinator for Health IT (ONC) is convinced some vendors are doing it. In a report given to Congress earlier this year, ONC condemned the practice and later created a complaint webpage where providers can file grievances concerning vendors’ health IT products. Information blocking was on top of the ONC’s list of possible reasons why a provider might resort to using the complaint page.
The KLAS report found athenahealth, Inc. is the vendor that’s easiest for customers to connect with, followed by EHR powerhouses Epic Systems Corp. and Cerner Corp. Both customers and non-customers of Cerner found the vendor easy to connect to.
Non-Epic customers were critical of the vendor and flustered by its use of self-imposed standards, one of the reasons its systems are perceived by some within industry as “closed technology,” according to a section of the report that listed vendors’ strengths and weaknesses. Customers praised athenahealth’s ability to establish both simple and complex connections and its decision to not saddle customers with integration costs.
It seems like health IT is in a perpetual, super-charged cycle of announcements, unveilings and acquisitions ranging from the recent Salesforce foray into healthcare, for example, to IBM Watson Health’s plan to buy VNA vendor Merge Healthcare Incorporated.
Now comes what one media wag called “stealthy San Francisco-based digital healthcare startup” Amino Inc., with an innovative, consumer-oriented system for shopping for the best doctors with the best skills and covered by your insurance, using health data — including from insurers — that Amino has quietly collected for two years.
Clearly, co-founder and CEO David Vivero knows how to amass, manipulate and monetize data given his background as a former Zillow vice president and founder of another real estate site, Rentjuice, which was acquired by Zillow for $40 million in 2012. Vivero’s experience searching for doctors and insurance to treat his rare health condition inspired him to start the new company.
But what has caught the eye of many observers (including mine) is the quality of this seemingly out-of-nowhere venture’s executives, advisers and board of directors, which includes former ONC Chief Privacy Officer Joy Pritts.
Pritts’ participation is intended to help answer questions that will inevitably crop up about privacy of the health data that Amino plans to handle. (The company says all protected health information remains anonymous to ensure privacy.)
Amino claims it has already gathered big data for about 893,000 physicians, 3.9 billion healthcare interactions, more than 800 conditions, procedures and specialties patients can search, and the medical experiences of 188 million American people.
When I tried a free search for orthopedic surgeons to do ACL replacement surgery (which I had done seven years ago after a skiing accident), Amino searched its database of nearly a million docs and came up with my actual surgeon, the estimable Michael Brown, M.D., of UMass-Memorial Medical Center’s sports medicine clinic, in Worcester, Mass., as the second choice.
The first choice was Brown’s gifted colleague in the same clinic, Nicola DeAngelis, M.D.
Try it by plugging in a few details about yourself, your condition and what kind of doc you’re looking for here.
Many in healthcare agree that big data, data analytics and data sharing in healthcare are important. In fact, many are greatly investing in these areas. For example, Marc Probst, CIO at Intermountain Healthcare in Salt Lake City, said his organization is heavily investing in data analytics and John Halamka, CIO at Beth Israel Deaconess Medical Center in Boston is a huge advocate for data sharing, especially because data sharing and data analytics helped his wife overcome breast cancer.
However, a Bloomberg Business article argues otherwise.
Based off the documents of a U.S. Department of Health and Human Services (HHS) investigation, the article recounts the experience of two women –a mother and a daughter — back in 2008. A clinician called up the daughter, who was a prospective customer applying for health insurance, to ask her why she had left the names of several medications she was taking off the application she submitted to Aetna, the article said.
The clinician then proceeded to name the medications, the dates they were prescribed and the doctors who prescribed them. But the woman insisted that the information was wrong, the article said. As it turns out, those medications were her mother’s, and this slip-up inadvertently exposed medical conditions the mother had been hiding from her daughter.
After the mother filed a complaint with HHS, it was discovered that the women’s medical records had been mixed up in a database maintained by a supplier to Aetna, the article said. Eventually, HHS determined no privacy violations had occurred because the two women figured out the link between the records themselves and were not told by Aetna or the supplier, the article said.
Ifeoma Ajunwa, an assistant professor of law at the University of the District of Columbia in Washington, told Bloomberg that medical data is legally shared with more third parties than many Americans realize.
“A major concern with prescription databases is that they provide ample opportunities for invasions of privacy,” Ajunwa said in the article.
Although the mother-daughter incident occurred in 2008, the Bloomberg article argues that because the medical data industry is projected to surpass $10 billion by 2020, according to McKinsey & Co., this story is a cautionary tale of how big data can go wrong in healthcare.
“The emergence of shared medical records makes errors all the more dangerous because they can propagate more easily between providers,” the article said.
Although the sharing of data can increase the chance of mistakes and mix-ups, it’s important to recognize that these types of occurrences are nothing new in the world of healthcare and such mistakes have and can still happen regardless of data sharing, and regardless of whether a patient’s record is electronic or paper-based.
Healthcare professionals and groups noticed the signs that the the Office of the National Coordinator for Health IT (ONC) is shifting its focus from the meaningful use program to health data interoperability. Now, many of those groups are questioning why ONC designated 2024 as the year by which nationwide interoperability can be achieved.
In a letter addressed to Karen DeSalvo, M.D, national coordinator for health IT, the board chair of the American Academy of Family Physicians (AAFP), Robert Wergin, M.D., expressed the group’s concern with the path of ONC’s recently-finalized Shared Nationwide Interoperability Roadmap.
The AAFP letter called on ONC to delay meaningful use and asked ONC to dedicate more of its energy to promote national interoperability, something AAFP believes can be achieved this decade — by 2019. The letter’s firm message is summed up in one sentence: “We do not have until 2024 to improve interoperability.” ONC must show more urgency in guiding healthcare technology vendors, health systems, physicians and others to cooperate for the sake of healthcare interoperability, the AAFP asserted.
The ONC’s distant interoperability end date could be due to several agency officials departing the office in the last year-plus. DeSalvo could be next after her nomination as assistant secretary of the Department of Health and Human Services. Those personnel moves and recent downsizing of the meaningful use program have kept ONC busy working on tasks unrelated to interoperability.
From 2015 to 2017, eligible professionals will only have to satisfy 10 meaningful use objectives. That number was cut from the previous total of 18 as part of recent changes made by ONC and CMS. Critical access and eligible hospitals were also cut a break. Those facilities, originally expected to meet 20 meaningful use objectives during that period, will now only be required to meet nine. Those changes weren’t totally unexpected because ONC hinted at its 2015 annual meeting that it was pleased with the adoption level of EHR systems and that it was zoned in on nationwide interoperability.
Disaster has not yet ensued since the transition to ICD-10 on Oct. 1.
While there have been pockets of discontent, reports from the medical coding front have been largely positive about the changeover that had caused many healthcare providers fear and worry, though many also said during the run-up to ICD-10 that they were prepared.
Indeed, two major payers, Humana Inc. and UnitedHealth Group, the nation’s largest health insurer, said this week that business has been “smooth” and “normal,” Forbes Pharma and Healthcare writer Bruce Japsen reported.
“It’s been pretty smooth so far,” a Humana ICD-10 implementation specialist told Forbes in the Oct. 13 news post. “Almost everyone who is submitting claims is getting it right.”
And a UnitedHealth vice president said the giant insurer has seen only a “slight uptick” in claims denials amid normal call volumes, Forbes reported.
CNBC recently carried another good news ICD-10 story.
Meanwhile, in an interview last week with SearchHealthIT, Shivani Mishra, a senior marketing associate and ICD-10 specialist with cloud EHR and billing vendor athenahealth Inc., largely echoed the insurer representatives’ sentiments.
Mishra said the claims denial rate in the early days of the ICD-10 implementation, as monitored by athenahealth, was running at about 14%, roughly the same percentage as a few days before the changeover.
By Oct. 8, the end of the first full week of ICD-10, that rate had fallen to 8%, according to athenahealth’s real-time monitoring service on its Web site. Check out the ICD-10 performance of the company’s clients here.
“It’s not quite Y2K, but it’s still early,” Mishra said.
She was referring, of course, to the much-ballyhooed fretting over the transition of computer and timing systems when the 20th century changed to the 21st century at midnight on Dec. 31, 1999.
As everyone knows now, nearly nothing unusual, let alone horrible, happened after that transition.
On a personal note, I experienced the Y2K non-event as a newspaper reporter assigned to sit in the emergency command center in Worcester, Mass., with city officials from around 10 p.m. on Dec. 31 into the early morning of the new century.
We all were prepared for the worst, but I was forced to report — after driving around the city for a few hours around dawn — that most signs of city life were apparently completely normal. It was eerie, but welcome.
All of this is not to say that bigger problems won’t develop as ICD-10’s profusion of about 70,00 codes — up from ICD-9’s approximately 17,00 – -and attendant increased complexity inevitably trigger rejected claims and probably reduced productivity for at least a while among some providers.
But it’s been pretty hard to find really bad ICD-10 experiences far.
Again, it’s still early.
Physicians who have ICD-10 Medicare claim problems can report them online to the American Medical Association.
Two U.S. senators introduced a bill into Congress that could simplify and expand the practice of telemedicine for the benefit of American veterans. Joni Ernst (R-Iowa), Mazie Hirono (D- Hawaii) and eight other senators co-sponsored the bill, the Veterans E-Health & Telemedicine Support Act of 2015 (VETS Act), which would permit U.S. veterans to receive remote care in their homes, regardless of whether the veteran and caregiver are located in the same state.
The current law allows the U.S. Department of Veterans Affairs (VA) to waive state telemedicine licensure regulations only when both the patient and provider are in federally owned facilities. Under the VETS Act, qualified VA healthcare professionals could offer remote care, including mental healthcare, across state lines.
State telemedicine licensure is a complex issue, even for those treating patients in a more mainstream setting outside of the VA. Each state’s medical board controls the telemedicine licensing process, creating irregularities concerning what qualifications are required of physicians and what services they are allowed to perform remotely in different areas of the country. In most states, physicians must be fully licensed to offer telemedicine services, while others require separate telemedicine licenses. Patients can receive physical checkups through telemedicine under the laws of more than a dozen states.
The bottom line for civilian patients and their caregivers is they must be aware of their state’s telemedicine stipulations, something that veterans won’t have to concern themselves with should the VETS Act become law.
Ernst issued numerous tweets after the bill’s release. Her message was that the VETS Act will help conquer “unneeded hurdles” preventing veterans from receiving treatment via telemedicine across state borders.
— Joni Ernst (@SenJoniErnst) October 8, 2015
“The VETS Act will build on a VA telemedicine program that removes barriers to accessing care, particularly for veterans in rural areas,” Hirono said in a release. Telemedicine doesn’t only help those in rural areas. Vendors at this year’s American Telemedicine Association conference displayed products, including hospitals video carts, that target city-based healthcare organizations and their patients.
When Karen DeSalvo, M.D., national coordinator for health IT, elaborated last week about the final stage 3 meaningful use rules that ONC and CMS had just released, one had to wonder if these would be among her last public pronouncements as the top ONC official.
After all, while it is not yet official, DeSalvo has been in effect confirmed as assistant secretary of the Department of Health and Human Services (HHS), the parent mega-agency of ONC and CMS.
DeSalvo, a former city health commissioner of New Orleans whose post-Hurricane Katrina work has been lauded in many quarters, has already received unanimous consent to her nomination by President Obama from the Senate Health, Education, Labor and Pensions Committee, despite the fact that her nomination hearing in August was canceled.
The committee’s chairman, Tennessee Republican Lamar Alexander, obtained the unanimous approval for DeSalvo and sent the matter to the full Senate, in which the nomination is expected to go through just as easily.
Alexander is a moderate, but he managed to secure every vote on the committee — even from the most partisan members — for DeSalvo. That means her approval by the full Senate (a hearing has not yet been scheduled) is all but guaranteed with such bipartisan backing for DeSalvo, who is well-liked on both sides of the political aisle.
Which brings us to the question of who, if anyone, will run ONC when and if DeSalvo departs for the full-time HHS job (she has been serving for a year now in dual roles as ONC chief and HHS acting assistant secretary for health).
For a brief period last October, DeSalvo appeared to step down from the ONC after her appointment to the acting HHS job in the wake of the Ebola crisis, and ONC COO and Deputy Coordinator for National Operations Lisa Lewis was briefly at the ONC helm as acting national coordinator.
But DeSalvo quickly announced in a blog post that she would serve in both capacities.
By the time DeSalvo leaves again, the Obama administration, while not in official lame duck status, will be in that nether-period a year from the 2016 presidential election, during which top agency officials start quitting for other jobs.
Accordingly, we can probably expect even more turnover at ONC, which has already seen a host of departures of key officials over the past year.
In the context of all that, DeSalvo’s remarks during a media conference call last week about changes that relaxed rules for the EHR incentive program appeared, at least to me, to signal a sort of soft exit for meaningful use itself.
And DeSalvo, who has championed health IT interoperability during her tenure at ONC, seemed to deliver a mixed message about interoperability.
One of the notable changes (poorly received by patient advocates but applauded by many providers) was to lower the threshold for the so-called view, download and transmit measure to a single patient per provider being able to immediately see or receive his electronic health records. The rule used to be 5% of patients.
DeSalvo argued that despite the virtual gutting of one of the key interoperability measures, the new meaningful use regulations would ultimately lead to better access to records for all because of improved interoperability in other areas.
“As a part of that overall strategy to get to interoperability, we take advantage of some of the opportunities we have, and for the office of the national coordinator, our certification program and the certification of electronic health records helps us to move to a more interoperable health system,” DeSalvo said.
In order to not only truly achieve population health but also accurately measure its success, it may mean sacrificing some efficiency. At least, that’s what Sandro Galea, M.D., dean of the Boston University School of Public Health, thinks.
In a Harvard Business Review article, Galea writes that one of the great challenges that population health initiatives face — the Institute for Healthcare Improvement’s “Triple Aims” and the Affordable Care Act (ACA), for example — is how to measure success.
The issue here is that when it comes to measuring outcomes, the focus is on the group of individuals as a whole. Therefore, researchers and clinicians do not always take into consideration the various circumstances individuals may be facing, Galea said.
“That’s unfortunate because, as every business person knows, what gets measured is what gets managed,” Galea said.
Often what happens is population health initiatives target what Galea calls “low-hanging fruit” — in other words, the groups of people that are more easily accessible and more open to changing their behavior.
This dilemma inevitably widens health gaps, improving the health of some while marginalizing other communities and leaving them behind.
Take behavioral intervention apps that help people quit smoking, for example. “People who can neither afford a smartphone nor lead lives organized enough to be driven by apps are left out, widening the health gap between app users and non-users,” Galea said. “Closing those gaps should be at the heart of efforts to measure and improve population health, even if it means sacrificing some efficiency.”
And, in Galea’s opinion, here’s why we should be willing to accept these sacrifices even though the cost of healthcare is a top concern right now:
- Health equity could bridge social divides and yield larger dividends than simple cost savings.
- Narrowing health gaps drives much of healthcare.
- Poor health in some groups ultimately threatens the health in all groups. Take the recent Ebola epidemic in West Africa, for example: “While concern about the health of West Africans may feel like a distant problem for some of us, their health in an age of ready travel is inextricably linked to the health of Americans — an inescapable fact that should impel even the most cost-conscious among us to call for investment in better health for all,” Galea said.
Galea believes there are several ways the measurement of health indicators can be changed so that metrics can better account for inter-group differences:
- Make closing the health gaps between groups a prime objective — for example, closing the gap between those who have access to mobile apps and those who don’t.
- Include relative indicators of health along with absolute indicators in metrics. Therefore health systems would be required to measure factors that may differ, like race, ethnicity and income, for example, and would also be required to tabulate, report and hold themselves accountable to relative achievement across these groups.
- Establish incentives that promote both efficiency in improving numbers and equity in closing gaps.
Stage 2 of the meaningful use program is too complicated. Because of its sophistication, most physicians and hospitals haven’t successfully attested to stage 2 and ONC shouldn’t rush into stage 3 of meaningful use, Chairman Lamar Alexander (R-Tenn.) asserted at a U.S. Senate Committee on Health, Education, Labor and Pensions meeting last week.
Alexander gave other reasons why plans to finalize stage 3 should halt, including that industry groups also recommend a delay. He also discussed a U.S. Government Accountability Office (GAO) report that showed meaningful use requirements are interfering with communication between EHR systems. More than half (10 of 18) of the healthcare organizations polled in the GAO report said that attesting to meaningful use redirects resources away from interoperability efforts.
Karen DeSalvo, M.D., the national coordinator for health IT, also spoke at the Senate committee meeting on Oct. 1, but didn’t directly respond to Alexander’s stage 3 meaningful use plea. She mentioned making electronic health information more available, creating a health IT safety framework and simplifying regulatory requirements to cut down on providers’ administrative tasks as the current goals of ONC. Encouraging interoperability, reducing information blocking and promoting patient engagement were also listed by DeSalvo as areas in which ONC can help control how health IT data is used.
Senator Alexander’s comments targeted stage 3 of meaningful use, something that DeSalvo hardly mentioned in her testimony. She brought up ONC’s proposed 2015 Edition Health IT Certification Criteria, but only as it related to improving care coordination and population health. DeSalvo mentioned meaningful use when she shared how ONC tailored part of stage 3 in response to advisory committees’ calls for ONC to use application program interfaces and Health Level 7’s Fast Healthcare Interoperability Resources (FHIR) standard in its interoperability efforts.
Alexander and DeSalvo both said that health IT should be designed with patients’ needs in mind. “The whole purpose of this [meaningful use] program is to benefit patients,” Alexander said.