By Adrian Gropper, MD
It's called Blue Button+ and it works by giving physicians and patients the power to drive change.
The US deficit is driven primarily by healthcare pricing and unwarranted care. Social Security and Medicare cuts contemplated by the Obama administration will hurt the most vulnerable while doing little to address the fundamental issue of excessive institutional pricing and utilization leverage. Bending the cost curve requires both changing physicians incentives and providing them with the tools. This post is about technology that can actually bend the cost curve by letting the doctor refer, and the patient seek care, anywhere.
The bedrock of institutional pricing leverage is institutional control of information technology. Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing. Pricing leverage comes from vendor and institutional lock-in. Region by region, decades of institutional consolidation, tax-advantaged, employer-paid insurance and political sophistication have made the costliest providers the most powerful.
The most powerful providers use information technology strategically to lock in both physicians and patients. HHS promotes this lock-in through Stark law safe harbors for EHR subsidy and $12 Billion of Stage 1 Meaningful Use subsidy. The EHR vendors have gladly evolved overpriced and non-interoperable technology to serve their institutional customers. Neither physicians nor patients purchase health IT. Our lack of market clout is frustratingly obvious in both my state medical society and the online patient forums. One of these forums, The Society for Participatory Medicine list, recently surfaced an important TED talk by Clay Shirky. Shirky describes how our tools reflect the management philosophy of the institutions that create them. It’s well worth watching.
ONC holds the key to dismantling the provider and patient lock-in at the core of institutional pricing leverage. ONCs leverage comes from mandated Direct secure messaging in Stage 2 Certified EHR Technology and the power of the purse over 40+ Direct-enabled state health information exchanges (HIE). Will ONC use these levers to put the power of referral and interoperability in the hands of physicians and patients?
Blue Button+ is a potent combination of Direct access in and out of the EHR with an open authorization technology called OAuth. By driving the state HIEs toward Blue Button+, ONC can shift the balance of market power away from institutions and toward the physician-patient relationship. Combined with reforms already underway including Health Insurance Exchanges that give patients an opportunity to choose health plans and shared savings incentives for physicians, the information liquidity benefits of Blue Button+ will be the third leg of the stool that leads down a market-driven road to The Triple Aim.
There are many challenges to the Blue Button+ vision. CommonWell, DirectTrust, and the understandable reluctance for state HIE bureaucracies to engage with individual doctors and patients. Everyone in the health care industry, it seems, prefers to do their business with nice, organized and managed corporations. Physicians, unfortunately are not all on board either. Given a choice of sharing power with patients or with their institution most physicians will pick the institution. The Hippocratic Oath is struggling to adapt to the Internet age of practically instantaneous and free connectivity.
CommonWell, DirectTrust and HIEs are tools focused on the institutions that already have too much pricing leverage. Bending the cost curve requires loosening the EHR lock-in on information by making connectivity, instantaneous, free and universal. This requires effective technology, security and privacy and it requires ongoing ONC support.
Stage 2 Direct EHR connectivity can provide the technology and, as a part of Blue Button+, it can provide the security and the privacy. However, only ONC policy and the corresponding HHS support for Blue Button+ in Medicaid-funded HIE programs can prevent the creation of vendor-controlled networks like CommonWell.
If ONC allows the EHR vendors to undercut the Direct connectivity mandate of Stage 2 with CommonWell and it undercuts its own Blue Button+ program by funding DirectTrust to bypass patient authorization the core of HITECH will be failure and EHR technology will continue to bend the cost curve in the wrong direction. ONC needs to err on the side of transparency and citizen engagement.
For its part, HHS has an even simpler choice. It can require Blue Button+ portals on all federally supported HIEs from day one and join patient advocates like Patient Privacy Rights in public support for privacy-preserving patient-directed health information exchange. All of us can and should comment on the CMS Request For Information about HIE due August 22.
Adrian Gropper, MD is Chief Technical Officer of Patient Privacy Rights and participates in Blue Button+, Direct secure messaging governance efforts and the evolution of patient-directed health information exchange.
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