Thursday, July 19, 2007

Crossing network boundaries

An interesting story by Jeff Krasner in the Globe today about an expansion of the physicians network in the Partners HealthCare System. For those of you unfamiliar with the business, every academic medical center (BIDMC, too!) tries to build an extensive network of physician groups and community hospitals to generate referrals to the main tertiary center.

There are federal rules that make it impossible to require doctors in the network to refer patients to the downtown hospital. This is indirectly noted in the story:

[The] chief executive of the Partners' physician organization said the affiliation agreement doesn't require Tri- County doctors to send patients to Partners hospitals.

But here's the key. If those community doctors are tied into a proprietary patient information system, they will tend to refer to the "mother ship" that hosts that information system (as well as to other affiliated hospitals). The story goes on:

But should they choose to send patients to Partners hospitals, referrals and medical records transfers will happen more smoothly.

This is an obstacle to enabling consumer choice of providers. So the societal issue is whether we should require that patient information systems be able to talk to one another so that referring doctors do not encounter this computer-generated friction in sending patients to an out-of-network tertiary hospital. What do you think?


KG said...

Short answer, yes. It's good for patients and payers. RHIOs are generally fizzling out (the Mass one is a unique case), and it's unlikely that the federal government will step in to a greater degree. The knight in shining armor appears to be .

Jaz said...

Why the feds won't just make this law but instead are trying to foster interoperability through some consensus grass-roots effort is beyond me, but still, AHIC is shouting loudly about interoperability and use of messaging standards such as HL-7.

My health record is mine, it needs to be as portable, accessible, and as secure as my credit history. For which, by the way, there's a law granting me free access.

HHS Health IT

State Level Health Information Exchange Initiatives

No-one needs anything but a browser to read this Web page. Any browser. On any computer. The only reason the Web (and the Internet as a whole) work is because it uses standard protocols. This is how the rest of the world works now. Health care really needs to stop trying to figure out "if" and start figuring out "when".

Interoperability is no longer an option.

Anonymous said...

My understanding from someone who knows a lot more about this than I do is that interoperability standards will probably be in place by 2009. Once they are, it is likely that CMS will pressure providers to store medical records electronically in a standard format, and private payers will probably follows CMS' lead. In this context, pressure means you can't accept Medicare patients unless you do this. Perhaps BIDMC's CIO might want to weigh in on just how far along we are with respect to interoperability standards and when he thinks we might have them.

From a patient's perspective, it would inspire confidence knowing that my records could be easily accessible to any provider anywhere on a timely basis when needed. From a healthcare system standpoint, it should be much easier to evolve evidence based standards and do outcomes research on large populations. If I were the Partners CEO, I think I would have enough confidence in the national reputation enjoyed by the organization's flagship hospitals that Partners should be able to attract patients based on the quality of its care. Partners (and all other hospitals) should embrace interoperable technology and, while they're at it, price and quality transparency.

Anonymous said...

I haven't even read the article (yet) but in my mind this should not even be a question. There must be national interoperability for the patients' sake. People move, for heaven's sake! It's bad enough the vendors try to hold the hospital systems hostage by not making their systems interoperable
(e.g. buy ALL your IT products from my system, or they won't work properly); but for the hospitals to do it to "capture" the patients is just outrageous, if it's truly happening.
This is one thing I think the feds need to enact into law sooner rather than later, no matter what one's opinion regarding the single-payer issue is. I hope Barry's information is right, that it's coming.

Anonymous said...

Having now read the article, I wonder if this alliance really is about the 2nd to last paragraph - that Dr's affiliated with Partners receive higher reimbursements due to its size. Reimbursements which, according to Charlie Baker's blog, are dictated by Partners to the insurance companies due to its size. Why P4P needs to be about value (outcome per dollar spent), not just quality.

Anonymous said...

Of course this move to sign up more physicians is about money, and market power. The more physicians Partners has in its network (even if they are not legally obligated to refer to Partners hospitals), the more patients will be referred to its hospitals and the more negotiating clout it will have with the payers (not that it needs any more). The antitrust laws in this area are either outdated and/or our elected officials lack the political resolve to do anything about this growing problem. At some point, even the Attorney General will have to concede that the market power of Partners is having an enormous impact on health care costs in Massachusetts, not to mention the structure and financial condition of the entire medical care delivery system. Whether anyone who has any power will actually ever do any thing about it remains to be seen...

Anonymous said...

Anon 6:44; I was referring to the Tri-County physicians' motivation to affiliate with Partners rather than, say, BIDMC.... as opposed to Partners' obvious interest in getting more docs.

Anonymous said...

The societal answer is clear: of course patient's records should be as portable as possible (as long as confidentiality is maintained). But financially, the current system probably generates more referrals for BIDMC. So what do YOU think, Paul? Would you advocate for increased consumer choice even if it hurts your bottom line?

Anonymous said...

I'm willing to take that risk, for sure, especially if actual quality and outcome results are also made public.

And, there is really no way to know if the current system helps BIDMC or hurts us.

Anonymous said...

I once wrote part of a report for Novartis about communication between the venues--the patient's doctor, their nursing home, assisted care center, rehab hospital, home pharmacy, and hospital--and found it almost didn't exist. This has to change! When I am hospitalized, the primary doctor never finds out (and certainly with this questionable hospitalist system rarely cares for you in the hospital--don't get me started on that mess). You can tell your doctor, "I was in the hospital"--but even if they sent you there to the ER or something, they rarely check back and see how it turned out. I had my doctor's nurse say once, "Last week when you called from the hospital (the ER, actually), did you ever get that abdominal surgery?" I said, "Do I look 4 days postop from major surgery to you?"

To limit this communication to those financially tied to each other does not benefit the patient.

This communication thing needs work big time!

ftrotter said...

Most lucid exposure I have seen on the political reasons not to interoperate. Well done.


Janak Joshi said...


Look around you . . . a major provider hospital network is working with Orion Healthcare in implementing RHIO's even before they have an EMR.

PHS is a world on it's own and and I think they have a fantastic business strategy to have implicitly tie community hospitals to the "mother ship". But what if I go from BIDMC to PHS to Lahey. What happens to my medical records? I may like a Cardiologist at BI but prefer my PCP @ Partners but like to go to Lahey for my GI procedure. If my PCP gong to tell me "I am sorry I dont care of you like your Cariologist but you can see him" and if you do - then BCBS will may not be able to reimburse you.

So as important as RHIO's are, they are still a fad in my opinion and there is no way, we will ever achieve a integrated hospital network without making the feds shout down interoperatability standards down the vendors throats.

I have McKesson EMR, someone has Epic and someone else has GE. Who cares . . . . should content be ubiquoutous to software?

It's like saying sorry my email is not going to work on your email domain.

You. Dr. Halamka, John Glaser, etc have the power to influence some of these decisions.

We owe it to the future of medicine in this country.

Anonymous said...

I am not surprised by Partners position on this matter. They have become a giant corporation. Because of the way their network was developed it will take the choice away from consumers in health care as well as jobs. If you have a conflict with one of their hospitals, you will not have the flexibility of moving around.

Anonymous said...

Speaking of EHR interoperability, see this news from DoD and the VA. Maybe their optimism will trickle to the private sector; maybe not.

If this link doesn't work, use the same URL except put a back slash after pathology and delete the rest, then click.

Anonymous said...

what percent of outpatient practices are currently using emr?
anyone have any idea?

Unknown said...

I'm coming late to this discussion. I do think that there need to be interoperability standards that allow the easy transfer of information between organizations. I do agree with Paul that if a proprietary application is hosted by the "mother ship," the practice will be more likely to refer to them. May be splitting hairs, however, I believe the key here is for the community practice - especially in this circumstance - to invest in a system independent from the "mother ship," and instead, work on interoperability protocols. This could preserve patient choice if interoperability standards are adopted by all Massachusetts hospital.

ndr said...

In my context in Canada, I would be quite glad if hospitals invested in IT to drive their business.

Regardless of the motive for the investment, it would be safer for patients if their record could move from primary/comunity care to the hospital.

But the early-mover advantage won't necessarily last. If hospitals have to compete to provide the best system to the community physicians, that will also be beneficial for patients (and the providers) and reintroduce 'choice' into the system.

'Choice' has to mean both winners and losers on the provider side. It seems to me that facilitating referrals and the movement of important patient information is as reasonable a way to win as offering lower weight times or better, safer care.