One of the top issues at HIMSS19 this month was the need to rethink and broaden services provided to patients. Jacob Reider, former federal deputy national coordinator of health IT, has thoughts on how to do that. As CEO of the Alliance for Better Health, Reider has gathered a network of social service not-for-profits, connected them by technology, and is contracting with managed-care organizations to handle all of the social determinants of health related to their Medicaid members in upstate New York. He spoke with Modern Healthcare Editor Aurora Aguilar shortly after the federal government's announcement on rules to improve interoperability. The following is an edited transcript.
MH: What's your reaction to the proposed rules released by the CMS and ONC?
Reider: The part of the CMS regulation that says payers have to share clinical data with consumers might reduce payer enthusiasm in acquiring clinical data. Historically, payers don't capture much clinical data. They haven't adopted the standards used in the health information technology of health systems. Some companies have bought health IT firms to capture and analyze this data. Optum is the best example. Centene and Humana also recently bought companies to do this.
As the industry figures out how to better manage clinical data, we might see that health systems, as they take on more risk, are going to maintain that type of clinical analytics capability and the payers might do less of it. Payers might say, “Well gosh never mind. We don't want that data because then we're going to have to figure out how to share it with that consumer. Just leave the data in the health system and give them the risk.”
MH: But shouldn't insurers want that data to track outcomes and cost?
Reider: This is the question, right? How do we measure outcomes and if the payer has shifted risk to the care providers, maybe the billing data is all they need? So if Mr. Jones goes to the hospital because of a congestive heart failure exacerbation, that's an outcome the payer knows about because they just paid for it.
I don't know that it's as clear as some people think it is. It's possible the health systems might manage the clinical data long term. The question is, should payers spend the hundreds of millions of dollars that it's going to take to evolve their information systems? Or should they let the information systems that were built to manage and maintain clinical data do what they do and do it well?
MH: Are the proposed rules the approach you would use to fix interoperability?
Reider: You need to think about the four A's. The first step is acquiring information. And if you acquire gobbledygook then you have to clean it up. So you must acquire information in a way that makes sense. After you acquire it, you aggregate it. After you aggregate it, you analyze it. Then you act on it, creating new data, and that gets acquired.
It's a cycle. How do we solve the problem? Well, we have to capture data that's valuable and rich. If we capture DoctorSpeak or free text, and I'm not saying free text is bad, but it's much harder to extract the meaning of what somebody was talking about if it's free text. I think with EHRs we went too far in the checkboxes and drop-downs and all of that, and then we put all this massive burden on the highest-paid person in the room.
I would solve the problem by creating systems that capture the semantics, the richness of the information, meaningfully at the start. You've probably by now used Google's new email tool that auto-completes your sentence. That's natural language processing. It's real-time processing that takes into account context and then we can interpret what someone's going to say. We're starting to see this sort of tool in health information technology—notice I didn't say electronic health records—HIT that starts to anticipate our needs and guide us to the right place.
So my nirvana is capturing data well and making sense of it from the start. I think we're probably another five to 10 years away from really doing that. HIT now is the maturation of these billing systems that we built 30 years ago. I worked at Allscripts for many years. I'm not saying anybody was bad, we did the best with the tools that we've had.
MH: Let's talk about the Alliance, which works specifically with Medicaid patients. What's it changing?
Reider: When we look at Medicaid members, they seek help in places that may not be the best places for them to seek help. This program's goal is to help people stay healthy. And the consequence is that we spend less money caring for this population because they aren't going to the emergency room for a sore throat.
We're taking government money and investing it where we can actually help these folks make better decisions for themselves. The key is what do they want to achieve? And how do we help them achieve it?
Historically, we've conflated social care and medical care. And what this work has allowed us to do is make more investments in social care and (therefore) fewer investments in medical care. And we're seeing healthier people and lower costs. We've been tracking this for 4½ years now. We've reduced preventable ER use by about 10%. Our goal is 25%.