By MICHAEL ARRIGO

The Titanic is still teaching us lessons.  Titanic’s history is often retold inaccurately with regard to safety equipment.  For example, many believe that short sightedness and greed of the builders led to the shortage of lifeboats.  For the April 15th 2012 100th anniversary of the sinking of Titanic,  The Wall Street Journal took a different view in the article, “The Real Reason for the Tragedy of the Titanic“  The Journal noted that popular beliefs about the shortage of lifeboats due to cost or aesthetics weren’t correct.  Rather, outdated government regulations were to blame.  I considered the possibility that the regulatory failure that contributed to the Titanic sinking high loss of life could provide us with a lesson about health care regulations.

British Board of Trade required vessels above 11,023 U.S. tons to carry 16 lifeboats. Titanic exceeded the requirements by four boats. But the ship was 46,328 tons. The Board hadn’t updated its regulations for nearly 20 years.  Chris Berg of WSJ writes that Titanic builders and designers complied with the regulatory standard of the day.  The builders tested the Transportation board “…to see whether regulators required it…” to add more lifeboats.   WSJ concludes, “Titanic’s chroniclers put moral narrative ahead of a historical one.  … British regulators assumed responsibility for lifeboat numbers and then botched that responsibility…it is hard not to see the Titanic disaster as a tragic example of government failure.”

In healthcare, politicians legislated the American Recovery and Reinvestment Act (ARRA), the HITECH Act, and the Patient Protection and Affordable Care Act (PPACA). But the responsibility to update the requirements about how HIT systems will support these mandates is held by the Office of the National Coordinator (ONC) for health and human services (HHS).  Each regulation has an extensive list of compliance requirements.

To monitor the effectiveness of these measures, we need to be collecting the right data and by analyzing the data, make course corrections when appropriate.  But the technology specifications supporting PPACA comparative effectiveness and payment reform aren’t working yet and fall short.  Few are looking closely and asking questions regarding how this technology actually supports the intent of the mandates.

Stage 2 Meaningful Use is available for public comment, but there is no information on how the interoperability standards truly collect, store and enable analysis of the right data. Illuminating this issue, I discovered that ONC Clinical Document Architecture (CDA) isn’t mature enough to specify the capture and sharing of data beyond an “encounter” or single visit of a patient by a health care provider.  There is a noble name for the current standard, a “Continuity of Care Document” or CCD.  But to truly measure effective health care, we have to measure patient wellness and track treatments over time, (“longitudinal patient records” as healthcare experts call it).  The data must be aggregated and shared in health information exchanges (HIEs) that span the continuum of care, geographies, and disparate health IT systems such as multi-vendor electronic medical records, and of course across health care providers.  The CCD standard of today doesn’t do that.  Just as the British Trade Board’s outdated regulations weren’t designed to comprehend a ship so large, the CCD isn’t designed for the larger vision of capturing enough data to measure patient health over time.

Are you surprised? I was.  If you are interested in the technical details, see this link from the web site Model-Driven Health Tools (MDHT) for CDA wherein the CCD specification clearly states regarding an Encounter, “…Shall contain exactly one…“  Make sure to search for “Encounter.”  Below is a screen shot of the document.  You’ll see the HL7, IHE, and HITSP references – these are all bodies involved with setting the standard.   This is despite the fact that the CDR in the introduction states, “…The CCR is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters…”

Continuity of Care Document Specification

Almost everyone who studies the problem agrees that longitudinal health records are beneficial, but as I look into how HHS and various standards groups within healthcare are hoping to do this, there are gaps that aren’t being addressed.  To accomplish that goal, ONC / HHS should continue the dialogue with commercial health IT companies, providers and health plans need to iterate these specifications.  The development of a standard, sharable digital XML file as a longitudinal data container, supported by electronic medical records, shared in HIE clinical networks could provide the data we need.   Just as Titanic’s vision was larger than the regulations of her day,  today we have a static standard born from regulations that won’t address the bigger vision we plan to build in healthcare.  We need to create a broader more innovative vision for continuity of care CCDs.  Defining the standard and implementing it will be  hard work that is probably best done by a small team of dedicated individuals that represent a cross-section of the health care economy.

Michael Arrigo is Managing Partner of No World Borders’ health care practice.

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When the Supreme Court hears Florida v. HHS, which contests  President Obama’s Patient Protection and Affordable Care Act (PPACA) known as health care reform, the U.S. Supreme Court is set to issue one of the most important decisions in its history.

If PPACA is repealed it will be interesting to see if it is repealed in whole or in part.  The Supreme Court of the United States (SCOTUS) may excise the individual mandate requiring health insurance coverage, or it could strike it down entirely.  There is an excellent discussion regarding a case that both sides are expected to use known as Wickard v. Filburn on Forbes and other cases entitled “The 10 Cases You Must Know To Understand The Obamacare Case“  Widely read conservative Hoover institution has a post today referring to ACA as “An Unconstitutional Misadventure” however it only addresses the individual mandate component of PPACA.  Let’s look at some of the proposed benefits in terms of efficiencies.  The biggest danger may be that popular press only review the impact of the Affordable Care Act in its simplest form, without reviewing several efficiencies that are embedded.

Note: our intent is to provide a non-partisan view of the HIT impacts, which are separate from the highly politicized consumer impacts.

You have no doubt read that the biggest resistance to PPACA is in response to consumers being required to buy health insurance.  The Constitutionality of this provision regarding the Commerce Clause of the Constitution is being heard because some believe that it over-regulates consumers for the apparent national good.

Many don’t realize that other legislative measures such as The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 are separate from PPACA.

From a clinical data and efficiency perspective, the HITECH Act is focused on creating efficiencies:
• Meaningful Use of Electronic Medical Records ($27 billion plus in stimulus funds to wire up the hospitals and physicians in this country so that health records are electronic enabling efficiencies, analytics, etc. as well as standards for health care data interoperability which are desperately needed in health care to modernize it and remove paper.  Estimates are $77 billion in cost savings over time for EMRs.)
• Health Care (Payment) Reform (using comparative effectiveness research [“…compare the effectiveness of different treatments for the same illness…”] to apply what the industry calls ‘quality measures’ to change physician payments from per procedure [FFS or fee for service] to pay for performance).  In essence this means that if a physician or hospital meets certain benchmarks of quality and patient population health they can receive more reimbursements for Medicare patients, and health insurance companies who support these health care providers can receive incentives as well.
• Health Information Exchanges (ability to share information across multiple physicians, hospitals, and geographies, realizing efficiencies and enabling some of the provisions of payment reform), although HIEs are impacted by PPACA because Health *INSURANCE* exchanges are viewed as the mechanism by which consumers will purchase insurance. HIEs that exchange information about population health may have actuarial impact and pricing impact on the policies offered by Health INSURANCE Exchanges.

There is less uncertainly about a mandate that is separate from PPACA.   We  provide services to clients who must transition to a new medical coding standard called ICD-10. ICD-10 is a HIPAA mandate. Although CMS has delayed ICD-10 it is appears certain that this mandate will go forward.

The World Health Organization (WHO) sets this standard, and it was mandated prior to Obama’s election by Health and Human Services (HHS) Centers for Medicare and Medicaid (CMS) that it had to be used in this country.  But CMS just announced a postponement in this mandate from October 1, 2013 to a future, yet to be specified date.
We’ve  taken on some ambitious speaking engagements this spring covering these areas. One where we’ll be presenting is the American Academy of Professional Coders (AAPC) in April is entitled, “How ICD-10 and Payment Reform impact Hospital Revenue Cycles.”

Follow the discussion on Twitter at http://www.twitter.com/marrigo using hash tags #PPACA and #SCOTUS as well as here on our blog.  Discussions available for health plans, hospitals and other providers at http://www.linkedin.com/groups?gid=1777488&trk=hb_side_g

Related Posts:

Patient Protection and Affordable Care Act (PPACA) Will Not Save Costs

Meaningful Use Assessment

ICD-10 Implementation Consulting Best Practices

ICD-10 Postponement Opens the Door to ICD-11?

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