Chapter 3: Aligning Health Information Systems in the Dynamic Healthcare Environment
Aligning Health Information Systems (HIS) in a Dynamic Healthcare Environment
The healthcare industry is highly dynamic and constantly changing.
Without robust Health Information Systems (HIS), it is currently impossible to effectively manage hospitals and clinics.
Key Issues and Drivers for Change in Healthcare
Payment Scheme as a Major Issue:
Historically: Fee-for-Service payment scheme, based on the quantity of visits or services.
Desired shift: Value-Based Care, which is quality-based, prioritizing patient outcomes over the number of visits.
Drivers for Change and Challenges:
Inadequate Quality: Compared to other developed nations, the quality of healthcare in the United States is not superior.
Shifting Focus from Acute to Chronic Care: Historically, focus was on acute care, but many patients now suffer from chronic illnesses.
Changing Population Structure: Longer lifespans lead to an aging population.
High Variability in Healthcare Processes.
Cybersecurity Threats.
Data Entry Burden: Knowledge workers (e.g., nurses) spend excessive time on data entry, diverting from direct patient care.
High Cost of Healthcare.
Shifting Healthcare Landscape Illustrated
Causes of Death Comparison (1900 vs. 2020):
1900: Predominantly infectious diseases like pneumonia, tuberculosis, and diarrhea.
2020: Predominantly chronic illnesses such as heart disease (No. 1), cancer (No. 2), and COVID-19 (No. 3).
Population Structure Changes:
The population pyramid has shifted upward over time (e.g., February 2010 to February 2020).
From the 1960s to projected 2060s, the pyramid shape is evolving towards a 'scarcity' shape due to longer lifespans in the U.S.
Summary of Major Issues
Payment Issue: Dominance of the Fee-for-Service model.
High Cost and Ineffective Care: While costs are soaring, the benefits (care quality) are not improving proportionally, leading to low overall productivity in the healthcare industry.
The Fee-for-Service model emphasizes quantity (number of visits) and often simplifies billing from the provider's perspective.
Escalating Healthcare Costs
Healthcare costs are continuously increasing.
In 2020, healthcare became the number one federal government expenditure.
Comparison of Health Insurance Premiums vs. Average Salaries (1999-2009):
Health insurance premiums increased by 130 \% .
Average salaries only increased by 38 \% .
Healthcare Expenditures as a Percentage of GDP:
1980s: Less than 10 \% .
2020: Close to 20 \% . This surge in 2020 was significantly influenced by the COVID-19 pandemic.
Drill-down on Spending Sources (2020):
Federal government spending increased significantly.
All entities (household, private business, state and local government) increased their healthcare spending.
Federal Government's Share of Healthcare Spending:
1990s: 17 \% .
2005: 23 \% .
2020: 36 \% .
Healthcare Employment Trends
During the initial COVID-19 slowdown in early 2020, employment dropped across all industries, including healthcare.
However, post-drop, healthcare industry employment increased significantly, outperforming the average for other industries.
The U.S. healthcare industry is characterized as labor-intensive, requiring more personnel to care for the same number of people compared to the past.
Shift Towards Value-Based Care
CMS (Centers for Medicare & Medicaid Services) Goal: Transition from Fee-for-Service to Value-Based Service payment schemes by 2030 for Medicare and Medicaid.
Current Status (2020): Still, 40 \% of payments remain tied to Fee-for-Service.
Institute of Medicine (Now National Academy of Medicine) Reports
"To Err Is Human" (1999):
Shockingly reported that 30 \% of healthcare spending is waste.
Annually, 44,000 to 98,000 patient deaths occurred due to hospital mistakes.
Components of this 30 \% waste include:
Unnecessary services
Excessive administrative costs
Inefficient delivery of services
High prices
Fraud
Missed prevention opportunities
"Crossing the Quality Chasm" (2001):
Defined healthcare quality across six key dimensions:
Safe care
Effective care
Patient-centered care
Timely care
Efficient care
Ethical care
Identified a significant gap between the reality of healthcare quality and the ideal.
Despite advanced technology in the U.S., there's a delay between innovation and widespread implementation.
The increasing prevalence of chronic diseases exacerbates this gap.
Inadequate Use of Information Technology
EHR System Adoption (2015):
Only 75 \% of hospitals used a meaningful EHR system.
Only 87 \% of clinics used a meaningful EHR system.
Interoperability Issues: Smooth sharing of patient data between different institutions is still a major challenge.
Many states are still in the '70s and '60s equivalent of interoperability, with some advanced ones in the '80s and '90s.
Adoption rates for EHRs remain too low.
HIPAA and Electronic Data Interchange (EDI)
HIPAA (Health Insurance Portability and Accountability Act of 1996):
Mandated the use of Electronic Data Interchange (EDI).
EDI Definition: A set of standards providing a common protocol or syntax for exchanging business documents electronically.
Various industries have their own EDI rules.
In healthcare, EDI is crucial for exchanging patient records and information.
Examples of EDI Transaction Sets:
850: Purchase Order
810: Invoice
997: Acknowledgment
HIPAA proposed pushing the use of EDI for tasks like sending invoices between institutions.
Population Health Management (PHM)
Definition: Refers to the process of improving the clinical health outcomes of a defined group of individuals through enhanced care coordination and patient engagement.
Key Characteristics:
Holistic View of Healthcare.
Develops services for a defined group, not just individuals.
HIS Plays a Key Role: Collects individual patient data, aggregates it, and identifies characteristics of specific groups (e.g., aged persons).
Focuses on quality-based care rather than quantity-based.
Connection to Value-Based Care:
Aims to achieve high value where Value = Quality / Cost .
Seeks to increase quality/benefit (often converted to dollar value) and decrease costs.
Proactive and Preventive Care: Value-based care emphasizes proactive measures and prevention (e.g., suggesting shingles vaccine based on age when getting COVID-19 vaccine).
Requires gathering extensive data, information, and evidence, which is facilitated by HIS.
Challenges: Information silos within healthcare systems (separated information).
Solution: Integrating information horizontally through HIPAA standards, EDI, networking, and large databases.
Review Questions
Question 1: HIPAA is a federal law that requires the creation of national standards to protect sensitive patient healthcare information from being disclosed without patient consent or knowledge. (HIPAA also addresses patient privacy issues).
Question 2: Population Health Management refers to the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement, supported by appropriate financial and care models.