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Friday, March 4, 2011

Business Cases and MeaningfulUse

Recently Norman (@HITDefined on Twitter) pondered about Meaningful Use Stage 2 and 3, and wondered what I thought about it with respect to reporting lab results to public health regarding reportable and notifiable conditions.  I'm quoting his post summarizing his responses to the CCHIT Survey results below:
Submission of Reportable Lab Data (and reconciliation with orders). Respondents believe that this measure is not appropriate until we have more standardized lab results coding (beyond numerical values), transmission and implementation guidance.

I agree with this, this is why standards are important….. I wonder what MotorCycle Guy thinks about this.. Going to have to ask him on twitter I believe.
First of all, my thoughts on reportable conditions are that they should be reported by the groups that generate them, not necessarily by the recievers of the information.  Why?  Economically, there are more recievers than their are generators, so that reduces overall implementation costs. Generators of the results will also be able to report them sooner than the recievers of the information might, which offers further advantages to surveillance efforts.

Where some things get complicated: 
Hospitals have their own labs, and so are originators of information (from their laboratory information systems, which are often integrated with their EHR systems).  The Stage 1 menu set includes sending reportable condition data from hospitals, but realistically, this reporting should be from the hospital lab information system, not from the EHR.  Oh well, that rule is final, and unlikely to change in Stage 2 or 3.

What if a reportable condition is detectable using a rapid point of care test (for example, if Strep Throat was a reportable disease).  At that point Healthcare providers can be the originator of the information, and would have to report electronically.

On that last one, the real question becomes an issue of cost and ROI.  A small physician practice might not even have enough reportable activity to even make it worthwhile to automate this process, whereas the State or Local health department might certainly benefit from automation.  Going back to the principal of putting the cost burden on the organization that gains by it, it would seem that automation of reporting might best be addressed by state and local health departments (there are 50+ state health departments, and a heck of a lot more providers).

Interestingly enough, the cost equation also effects hospitals as well.  One of my standards colleagues from IHE/HITSP/HL7 works in the public health space.  They report that their local hospital spends about 30 minutes a day dealing with public health reporting in a paper process.  That's for a mid-sized hospital (more than 200 beds).

One of the challenges for the hospital is that they must report to both state and local public health, and cannot use the same processes for each.  That is SO broken.  If they have to report to state public health, why do they also need to report to local public health?  Couldn't local public health get their data from the state?  Or visa-versa.  Too many silos here, and making these transactions electronic won't necessarily make those silos disappear, and meaningful use won't solve that.

Assuming that 30 minutes is for one staffer for 7 days a week, that has a modest fully burdened cost of about $9100 / year.  What's an electronic submission interface going to add to their costs to set up and maintain?  If an interface costs $10,000 to implement (a conservative estimate, it could be lower), and 20% annually thereafter to maintain, and needs to be upgraded every few years for meaningful use, this may break even or even be a small savings for them.  So, where is the business case for the MU criteria?  In an ideal world these are all good ideas, but every one has a related cost, and an expected savings and benefit.  A lot of the meaningful use criteria has obvious business cases and benefits, but others are not so obvious, and the benefits are not necessarily to the providers.

One of the additional requirements for Stage 3 proposed was that patient contact information be reported in 30% of cases.  OK, so that could run afoul of state laws, regulations and policies.  While Federal HIPAA regulation grants an exception to public health regarding PHI, it only sets a floor, not a ceiling, and state laws can vary.  State public health agencies might also find it more cost effective to maintain systems that don't require PHI for reportable conditions, only gathering that data when necessary for public health needs. Managing PHI storage requires greater security, policy and technology investments, and so can be more costly.

Now, back to Norman's discussion, which is simply about codes for reporting.  There's really no reason that I can see why laboratories cannot report LOINC codes.  Many do so already for their required reporting to public health.  I think the real challenge is not technology, but rather avoidance of further commoditization of laboratory testing.  If the LOINC codes are the same, it becomes feasible to compare lab tests on an apples to apples basis.  The labs will argue that these are apples and oranges, but would the providers?  If so, they could use a more specific LOINC code that required a particular test method, but most don't seem to care.  My provider has switched back and forth between labs for reasons that are unknown to me for some of my labs, and I'm sure it's not the method used (it's just a lipids panel).  Meaningful Use is not a lever that presently applies to labs though, only to their customers, and so only very indirectly can it change the space. Ad as far as providers are concerned, it's not them, but their customers (who pass the costs on to the payers, who bills employers, who takes it out of our salaries).

So, I don't have any clear recommendations to make here.  I'm not familiar enough with the costs and potential savings for this issue to have an obvious resolution one way or another.  The technology is certainly present and capable of supporting the requirements, but as to whether these are the right requirements, what the benefits will be on healthcare spending, and whether the costs are reasonable is not something I have the answers to.  I DO know that I want my labs to use the same codes when they are measuring the same things, and that I want those codes to be LOINC. 

Putting requirements on labs and on state/local public health are other steps that could be used to lower costs, but Meaningful Use focuses on just one part (direct care delivery) of an entire healthcare system.

It would be interesting to see a report on costs, benefits and savings for the meaningful use criteria, broken down by who pays, who benefits, how, and where the savings goes.

I've written so often on these topics that I've created a new category (HealthROI) for this blog in which I'm going to gather this and related posts.  You'll also see it as a twitter hash tag.


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