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Thursday, November 16, 2017

Data Philosophy and Game Theory

It's Dirk Stanley's fault.  He asked on FB:

#CMIO #CNIO #Informatics #HealthIT and other #ClinicalJedi, need your help : Philosophically, which is more important? 
1. Data in
2. Data out 
3. Both are equally important 
All opinions welcome.

My response was pretty straightforward:
Data in, else we would not be where we are today. We need data to act, and can always get it ourselves, and trust it better when we do. But, if all are playing for optimal payoff, it could be viewed as a zero sum game, and so best view is both.

But at the same time it needs a heck of a lot more explanation.

Data sharing as presently practiced by healthcare organizations is in some ways a zero sum game, and in some ways not.  

It's not a zero-sum game for healthcare organizations. The lack of accessible data used in healthcare decision making results in efforts to obtain data. With current practice (fee-for-service), the healthcare organization will do what is necessary to obtain that data (order the test, do the assessment, et cetera).  And it will get paid to do it, so there is little to no additional cost.  For some of the testing, there is little gain (many lab tests are low-margin, commodity items), and others substantial gain.  For example, an MRI can cost $1-3K or even more, and when all is said and done there is definite value going to the creators of the data.

The data, thus gathered, also becomes an asset of the healthcare organization which gathered it, which has value to the organization when they use it, but could help a competitor in some way if they share it.  Sharing that data with a competitor has a cost. The organization has little to gain by the sharing of that data, and something to lose (potentially) if they access data shared by another party.

Victor Dubreuil - 'Money to Burn', oil on canvas, 1893There's a money to burn in this system. Between healthcare organizations, it isn't a zero sum game. The patient (or their payer) is continuously pumping in cash to the system to fill the data needs of the healthcare organization, and which supports the care of that patient when they stay within the same organization.  As soon as the patient moves to a different healthcare organization, they lose the value of that data, that ultimately, they (or their employer) paid for.  

Where the zero-sum part comes from is that what the provider gains with regard to acquiring data, the patient (or their payer) loses. As long as that remains the case, there's little incentive to reduce duplicate testing.  I watched this recently as a young person I know went through a month repeating almost the same tests they had gone through previously to diagnose a chronic illness because more than 3/4 of the way through that process she was forced to change healthcare providers (due to a forced change in health insurance).  There was NO reason for them to refuse the additional testing (getting the diagnosis is critical to their health), and no value for their new healthcare provider to use the previously performed tests. Their payer was out the money for the repeated testing, even though those tests had been done previously.

In the rest of the world of business, when I pay for something to be done, I own that thing. If it a work of intellectual property, I paid for it, I own it, and I have easy access to use it. In healthcare, when a patient pays for a test (or a payer pays on their behalf), the data is treated as if it is owned by the organization that ordered the test (gathered the data), and as the patient I don't always have easy access to it.  I can only benefit from it as long as I maintain a relationship with that healthcare organization.

I can see how game theory could be applied to this situation, such that a system of value-based care could be designed where the greatest value is when there are incentives for data sharing.


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