December 4, 1998

Mr. Jeffrey Blair
Dr. Simon Cohn
Co-Chairs, Work Group on Computer-Based Patient Records
National Committee on Vital and Health Statistics

Re: December 8-9 Work Group Hearings

Dear Mr. Blair and Dr. Cohn:

Thank you for your invitation to testify at the initial hearings of the Work Group on Computer-Based Patient Records. The Work Group has an important charge, and I regret that I cannot attend. Should the Work Group so desire, I would be pleased to offer oral testimony at a later date. In the meantime, I am pleased to submit these written comments representing a purchaser perspective on the need for computer-based patient records and the government’s role in fostering their development and use.

As you know, the Pacific Business Group on Health (PBGH) is the preeminent large business coalition in California, and one of the most active employer coalitions in the country. PBGH is dedicated to improving the quality of health care and moderating rising costs. Its 33 member companies represent approximately 3 million employees, dependents, and retirees, and over $3 billion in annual health care expenditures.

PBGH’s initiatives fall in four key strategic areas: Cost, Quality, Data, and Partnering. The Data initiative is focused on remedying the current information deficit in health care. Specifically, clinicians do not have ready access to the data and information they need to provide optimal care, health plans do not have the data they need to manage care, and employers and consumers do not have data on quality to use in assessing the performance of plans and providers. To this end, we helped to organize the CALINX (California Information Exchange) initiative. CALINX’s mission is to champion standardization and collaboration in the exchange of electronic health care information among California’s plans, providers, and purchasers. Administrative responsibilities for CALINX are shared among PBGH, the California Association of Health Plans, and the National IPA Coalition.Other leadership partners include the American Medical Group Association, the California Healthcare Association, and the California Medical Association.

The Need for Computer-Based Patient Records

Prior to the formation of CALINX, PBGH developed a vision statement for health care information, which presents the business case for the computer-based patient record (CBPR), as we see it. Please see the attachments labeled “PBGH Year 2000 Health Care Information Vision” and “PBGH Data Implementation Framework.” As you can see, the CBPR is at the core of the information system that we view as essential to support purchaser, plan, provider, and consumer needs. We view the business case to be so compelling that the universal adoption of CBPRs is inevitable. At the same time, we observe that progress towards this end is very slow, and we would strongly endorse any efforts to speed up the process.

Resistance to the Use of Computer-Based Patient Records

The importance of CBPRs has been well established. Why, then, has their adoption proceeded so slowly to date? The following reasons are often given:

• Lack of uniform national data standards, which inhibits the ability to exchange information between trading partners
• Concerns among consumers regarding a perceived threat to the privacy of their medical information
• Lack of a business case for providers to invest in the necessary new technology. There is a lack of appreciation by physicians of the value of using CBPRs in their practices. Many physicians are feeling pressure to improve their productivity. Unfortunately, in the ambulatory setting, the CBPR is often viewed as an impediment, rather than an enhancement to physician productivity.

Role of the Government

How then can the government assist in overcoming these barriers? We would suggest the following:

1.Establish uniform national data standards for the CBPR. As we understand it, this is a key role for NCVHS. It has worked well so far in standardizing the HIPAA-mandated administrative transaction data sets, and should be pursued in the CPBR arena as well. We understand that clinical data standards are not fully developed; yet the need for standardization is just as compelling as it was for administrative data sets. Thus, NCVHS should make every effort to hasten progress on the adoption of national standards for clinical transactions.

2.Establish guidelines for protecting the privacy and confidentiality of patient records. Members of the public are rightfully concerned about uses to which their personal health records might be put and about how those records will be protected against unauthorized access. Thus, privacy legislation that strikes the appropriate balance between safeguarding patient-specific information and enabling the use of this information to improve population health is essential. The need is urgent because the lack of such safeguards is inhibiting the improvement of health care information. Thus, we would urge NCVHS to do everything in its power to persuade the government to stop delaying action on this important issue.

3.Adopt a standard individual health identifier. Again, it is impossible to measure or manage population health without the ability to link information from various sources, and to do so requires the adoption of a standardized individual health identifier. We understand NCVHS’s position that action on this matter should wait until after privacy legislation has been enacted. We are concerned, however, about the slow pace of the legislative process, and we hope that NCVHS will be ready to recommend a specific identifier as soon as such legislation is enacted. The Pacific Business Group on Health is already on record as favoring the use of the Social Security Number as the core of a national individual health identifier system.

4.Sponsor research aimed at creating the business case for adoption of CBPRs by providers. There is clearly a role for the government in demonstrating the value of CBPRs in clinical practice. Studies to date have largely been conducted in the academic setting or in large multispecialty group practices, and few of these studies have been subjected to peer review. What is needed are demonstration projects that can form peer-reviewed case studies of the value of the CBPR to clinicians in the typical community setting. Such studies should consider the relation of CBPRs not only to cost and productivity, but to patient outcomes as well. Results should be widely disseminated.

5.Encourage federal agencies that purchase health care to provide incentives for the adoption of up-to-date information technology by providers. A final role of government is as purchaser. We urge federal and state governments to join with the private sector in providing incentives – financial and otherwise – for the necessary investment in IT by ambulatory-based providers. These incentives should include mandates for data on clinical quality performance that will need to be generated by automated systems. This, more than anything else, will help to speed up the adoption of CBPRs.

Once again, we appreciate this opportunity to express our views to your Work Group at this time. We wish you well in carrying out your charge.

Sincerely,

David S. P. Hopkins, Ph.D.
Director of Health Information Improvement

Encls.

Cc: J. Michael Fitzmaurice, Ph.D.
Patricia Powers
Peter Wald, M.D.

PBGH Year 2000 Health Care Information Vision

The global vision is of a health care information system (IS) that supports value maximization at all levels: community, employers, plans, and providers. The system includes: (1) an electronic medical record to capture the data at the point of care; (2) an electronic data interchange capability for sending and receiving data, with appropriate safeguards for patient confidentiality; and (3) built-in, automated feedback mechanisms for continuous process improvement.

For the COMMUNITY(1), the system will provide an information base for value-driven competition, maximization of public health, and minimization of regional practice variation.

For PURCHASERS, it will provide an information set for value-based purchasing, where value reflects both the health of the workforce (and other covered individuals), customer satisfaction, and total health-related costs, with an appropriate focus on preventive care.

For HEALTH PLANS, the IS will enable them to maximize (1) the value they add to the delivery of health services and (2) administrative efficiency.

For PROVIDERS, the IS will enable them (1) to optimize health care production processes to achieve best outcomes at least necessary cost for their enrollees and (2) to maximize administrative efficiency for the group and its individual providers. To do this, the system must include the following:

a)Immediate access to all relevant information at the point of care to enable health professionals to maximize the integration of information and knowledge into their practices;

b)Measurable quality indicators for individual and group outcomes; and

c)Support for continuous process improvement as a self-correcting mechanism to optimize value for patients and purchasers (“better, faster, cheaper”).

“GET IT, MOVE IT, USE IT”

(1) By “Community,” we mean individual employees, the general public, and responsible public health authorities

PBGH DATA IMPLEMENTATION FRAMEWORK

6/24/96

12/9/98