March 17, 2008

Test Track
By Elizabeth S. Roop
For The Record
Vol. 20 No.6 P. 16

Two ambitious pilot projects—one in Oregon, the other in South Carolina—will, among other things, measure how well Medicare and Medicaid patients take to having their personal health records online.

There are two prevailing theories surrounding the electronic exchange of health information. The first is that enabling providers to view comprehensive medical records will improve care and reduce costs. The second is that giving consumers access to and control over their health information will encourage them to become more active participants in their own care.

These are theories that two government agencies are putting to the test through ambitious online health record programs targeting the Medicare and Medicaid populations. While far from identical, both projects share some common elements. Both will offer beneficiaries online access to their medical records and other health information, and both are expected to be starting points for grander schemes.

Oregon’s Health Records Bank
In November 2007, Oregon received a $5.5 million transformation grant from the Centers for Medicare & Medicaid Services (CMS) to create the Health Record Bank of Oregon, a secure online database of health records for the state’s more than 400,000 Medicaid beneficiaries. The goal is to improve care and reduce costs by providing the Medicaid office, physicians, hospitals, pharmacies, and other partners access to beneficiaries’ medical information.

Expectations are that online access to patient records will eliminate or reduce duplicate and unnecessary tests, ensure that duplicate prescriptions or those producing negative interactions are not written, and reduce medical errors resulting from incomplete information.

Medicaid “as a payer is looking for ways to lower costs and provide more and better care, but they are also looking for better health indicators,” says Greg Wenneson, project manager of the Health Record Bank. “The key is that this is a transformation grant. … It’s not a prototype project, although there may be some elements of that. It is a transformation of how we deal with patients, how patients have control, and how we can provide better and less expensive care.”

Currently in the planning stages, the Health Record Bank is expected to be online by the fall of 2009. During the first phase, anticipated in the spring of 2009, the bank will have a live pilot allowing patients and providers to view a patient’s medical history assembled from several sources, including past tests and existing prescriptions provided by other clinicians. Later phases will provide wider access to more patients and providers with richer sources of medical patient data.

The project is already garnering some praise within the health information industry. INPUT research recently called it one of the most significant projects of the year due to its strong legislative support, generous seed funding, thorough planning and analysis, and focus on utilizing open source technology that can be replicated easily and affordably as the bank expands statewide.

“Because health information exchange [HIE] is relatively new, a number of states are the front-runners in trying to get initiatives going. Oregon is one of them,” says Kristina Mulholland, social services and healthcare analyst at INPUT. “A couple of other states are trying, but Oregon is ahead of the curve. … They’ve done their homework. They aren’t just jumping into it.”

Mulholland notes that the prospects are good for the bank to achieve the “holy grail” of HIE: financial sustainability. Although the financial model has not yet been established, indications are that sufficient fees can be generated by charging providers to access records in the bank and charging consumers to maintain accounts beyond the Medicaid-supplied data.

Also at play is the project’s cost-effectiveness. Giving providers access to comprehensive medical records will reduce costs to Medicaid, individual patients, and—as the bank expands beyond Medicaid—providers and payers statewide.

“They are definitely taking the process slow, which is good,” says Mulholland. “They are starting with the Medicaid population because it is a transformation grant and because medical care eats up a huge part of the state’s budget. But once they do pilot testing, they will look toward statewide expansion. That’s why it is significant that the technology they want to use is open source, so that vendors, other states, other groups, and other exchanges can use the same standards so it can be replicated.”

Despite the high praise and expectations, creating a sustainable, functioning health records bank is not without significant challenges. An aggressive 18-month timeline is one of them. Overcoming security and privacy issues—and ensuring consumers understand that their data will be safe—is another.

Perhaps the greatest challenge, however, is finding common ground among the various stakeholders. “There is a dynamic tension between significant patient control to access of their records and the provider’s desire to be more HIPAA oriented. This has to be resolved, and we have to come to a common agreement between patient control advocates and provider and organizational payers’ [desire] to have more access to those same records,” says Wenneson. “We don’t have a solution for that yet. The stakeholders, which range from [Health and Human Services] to the providers and patients, will have to come to a more consensual agreement of where we want to go with this.”

Challenges notwithstanding, Wenneson is excited about what the Health Record Bank’s success will represent, not just for Oregon but the entire HIE industry.

“To some extent, this is an experiment on how well we can inhabit the same space with requirements that appear to be inconsistent. There really is consistency in there. We have to find it and move forward from that small kernel of ‘this is what we can agree upon.’ We need to build trust and a track record,” he says. “It’s not just about the capability to access the records, but to a greater extent—and that’s what is cutting edge—it is about putting the patient in more control of who can see their record.”

CMS in South Carolina
The CMS is in the process of launching a personal health record (PHR) pilot program targeting 100,000 South Carolina beneficiaries in Medicare’s fee-for-service program.
Under the direction of prime contractor QSSI, the project will involve importing two years’ worth of Medicare claims data into a commercial PHR from HealthTrio, LLC. In addition to claims data, participants will be able to enter personal information such as over-the-counter medications, prescriptions filled, and allergies, as well as any medical services that were not covered by Medicare and therefore are not included in the claims data populating the PHR.

A risk assessment tool and links to additional health information based on an individual’s medical history will also be available. Participants can also grant caregivers, physicians, and others permission to access their PHR.

The pilot project’s goal is to determine what it will take for Medicare beneficiaries to adopt and use PHRs. “People liken it to the financial model of using an ATM. Granted, it’s health information, but you’re still using a system that is accessing your information and putting it out there for you to use. Once upon a time, people fought that, but now you’d be hard-pressed to find too many people who go to a bank or who don’t do their banking online,” says Lorraine Doo, a senior policy advisor in the CMS’ Office of E-Health Standards and Services. “What are the things that changed that industry? What are the things that will change the health industry? What kinds of things have to change?”

It is not the CMS’ intent to build a Medicare PHR, she adds, but rather to determine how the agency can populate commercial PHRs that beneficiaries will actually use. The key will be creating standards that allow for data exchange from one PHR to another. “It doesn’t really behoove us to create anything new. What we want to be able to do is share the information we do have with the PHR [beneficiaries] choose,” she says. “In order for this to work—not just for Medicare but across the industry—we have to be able to do that.”

In fact, it was that desire to work with existing commercial PHR applications rather than building one from scratch that played a key role in the selection of QSSI, a relatively small technology company that has been awarded the prime contractor position on several other CMS projects. “Part of it was based on the tool they offer, and that’s HealthTrio, which already has a lot of experience working with claims data through PHRs offered by employers,” says Doo.

The HealthTrio PHR is a secure online personal health diary that allows users to view, evaluate, and update personal health information and utilize health management tools. Also part of the QSSI project team is Palmetto GBA, a wholly owned subsidiary of Blue Cross and Blue Shield of South Carolina that provides administrative services for the Medicare health benefit program.

Doo was reluctant to provide specific details about the project’s status or target launch dates but did say plans are in place for an education and information campaign targeting advocacy groups, physicians, and other organizations with access to seniors. The campaign will likely include demonstrations of the PHR and provide prospective participants with the opportunity to go online and check out the tool before making a decision about whether to register.

Another Link in the NHIN Chain
Regardless of whether the South Carolina and Oregon projects fly or fall, the information they reveal regarding consumer behaviors with online PHRs will be invaluable as the health information industry continues to push toward a national health information network.

By identifying barriers to adoption, testing models for financial sustainability, and finding ways to circumvent issues of competition and control, these projects and others like them will make a significant contribution to the growing body of knowledge of what it will take for successful, effective HIE.

“When we move forward and are successful in resolving the dynamic tension between patient control and the provider’s wish for more information, that is going to be a very interesting model and lessons learned moving forward in both how we approach the process of resolving that and the solution we come up with and can implement,” says Wenneson.

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.