Are your efforts focused on strangers or friends?
By Jon Hamdorf
My belief is that we place a higher priority in the interoperability conversation around ‘strangers’ to our hospitals and health centers and tend to forget about our ‘friends’. By placing this emphasis on strangers rather than friends, we are missing out on addressing critical health needs of some of our highest consumers of health resources. Subsequently, this is financially detrimental to our healthcare organizations and damaging to a class of patient that requires more than traditional health services to treat their health needs.
Let’s define strangers and friends. Strangers are patients that have never set foot in your hospital, health center or emergency room. These are patients who may have been referred or transported based on the criticality of situation or type of health service you provide. Friends are the people you see all the time in your hospital, health center or emergency room. These are the frequent flyers; the drug seekers; the patients that have comorbidities and have multiple health access barriers (transportation, eligibility, education) to effectively manage their health.
Yet when it comes to talk of interoperability, my experience is that discussions tend to migrate toward the scenarios about sharing patient data in the case of referrals or transfers rather than the management of high utilizers within a community. Then we dive right into the ‘usual suspects’ technology needed to support that sharing of data—HL7 CDA, HL7 FHIR, XDS, SNOWMED CT, etc.—all the while forgetting that there is an entirely other kind of patient that we need to consider. How can interoperability help identify these patients within the community, develop strategies to get them the help they need, and ultimately, reduce the burden on our health resources by helping these patients more effectively manage their health?
There has been some research done around how to effectively manage the high utilizer population within urban metropolitan areas. Typically, the research is funded through a charitable organization and utilizes a person (typically called a Community Health Worker) or group of people to try to identify and help manage high utilizers with common conditions within the community. However, these projects are never properly staffed and often rely on manual identification of patients through EMR reports and then manual sharing of information on Excel spreadsheets between organizations. While the information is shared, it is neither timely nor effective. Most of the time the reports are shared once a month and by that time most of the patients have already visited multiple ER’s multiple times.
In addition, since a majority of these people are uninsured, under-insured or insured through Medicare, the hospitals providing care to them are not getting reimbursed or are getting hit with 30-day readmit penalties if the patient gets admitted to another hospital. Most of the time, the initial hospital providing care to the Medicare patient doesn’t even know about the readmit penalty until their initial claim is rejected by CMS. This is critical because in my experience, most the high utilizer patients are Medicare patients between the ages of 35 and 55. If that seems odd to you (especially since most people don’t qualify for Medicare until 65), remember that people have access to Medicare benefits at any age if they qualify for disability programs through the Social Security Administration (such as the End-Stage Renal Disease program). To give you an example of how big of a problem this is, some hospitals write-off as much as a million dollars a month caring for these patients.
We need to include the management of these patients in our conversations about interoperability. Interoperability is not only necessary when a patient is referred or transferred, but also critical when managing high utilizer patients in our communities. This would include communicating in real-time to community ER’s when a high utilizer patient presents, informing their health home/primary care provider, and their community health worker if they have one. By including these patients in our interoperability strategies, we can save money, free up resources, provide the most effective and efficient venue of care, and give these patients a higher quality of life.
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Jon Hamdorf is a contributing writer for AXIS.
