Public Outcry Over Patient IDs
THE MOVE TO ASSIGN EVERY MAN, WOMAN ANDchild in the U.S. a medical ID number is so volatile the Department of Health and Human Services (HHS) is extending its implentation deadline in order to better explain the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
According to Solomon Appavu, director of HIS financial control at Cook County Hospital in Chicago, the unique ID for patients will ease the burden of transferring patient data from one organization to another. It also could mean the creation of a national database for maintaining patient medical information. "Today there is a master patient index for each organization," he explains. "Healthcare organizations are beginning to come up with enterprisewide solutions, but when you have a national patient identifier you can envision a national master patient index."
Appavu, who leads the ANSI Healthcare Informatics Standards Board’s Unique Health Identifier task force, wrote a 180-page white paper explaining the unique health identifier for patients. He says the biggest obstacle to implementing this unique ID is assuring patients and physicians that every computer system used in the healthcare industry is secure, and that only individuals authorized to gain access will be able to do so.
"The news media seem to be focusing on information from those opposed to the unique patient identifier," he says. Citing the public hearing in July by the National Committee on Vital and Health Statistics (NCVHS), an advisory group to the secretary of HHS, Appavu adds: "Most of the people that testified said they would like to have the unique patient ID."
In his analysis of this identifier, Appavu stressed that there must be six components to create a complete patient identifier. Each of these components must be considered in context with the others for the ID to perform as it should. The areas to consider are:
- identifier scheme (numeric, alphanumeric, etc.)
- identifying information
- mechanism to hide or the tool to encrypt the ID
- technology infrastructure including the software, hardware and communication technologies to search identify, match, encrypt, etc.
- administrative infrastructure including the Central Governing Authority.
HIPAA’s unique patient ID is going to happen--regardless of popular opinion against the measure. According to Appavu, the best strategy for healthcare’s information technology specialists is to continue setting up and improving security measures within their own organizations for current and future information systems. "To address the privacy concerns of the public, [healthcare organizations] need to have good privacy and security methods in place," he says.
Following the NCVHS public hearings, officials from the American Health Information Management Association announced they favor adoption of unique health identifiers "only if comprehensive federal confidentiality legislation is enacted first."
For more information on the Unique Patient ID or HIPAA, visit NCVHS’ Web site at http://aspe.os.dhhs.gov/ncvhs/Index.htm.
Y2K Tops List of Priorities
THE YEAR 2000 BUG HAS TUNNELED ITS WAY TOthe top of every technology professional’s "to do" list. When asked to identify the top five information systems priorities, officials of 340 integrated delivery systems overwhelmingly indicated that the year 2000 crisis is their organization’s top IS priority. The results were compiled by GartnerGroup IT Healthcare in its ninth annual IDS Market Segment Database.
Ironically, the year 2000 issue wasn’t so much as whispered in last year’s survey. "I couldn’t believe it," says Gartner research director Dave Garets, who went back to the old records to verify its absence. "Y2K wasn’t mentioned by anybody." But this year "it was 2-to-1 the hottest [issue] over the next hottest [issue]--clinical information systems," he says.
The findings lead experts to believe that although it has now caught the attention of healthcare executives, planning for the problem only now means you’re late for the dance. "It’s obvious that healthcare organizations have awakened to the need," Garets says. "But it has taken them too long." If organizations haven’t yet moved from assessment to remediation, they need to consider the fact that all their systems won’t be ready in time and their next task will be to prioritize what will get fixed, he says.
But provider organizations aren’t the only ones scrambling for contingency plans. After receiving an "F" from a house subcommittee that graded the largest government agencies on their Y2K readiness, the Department of Health and Human Services is pulling out the stops to fix the problem.
The Health Care Financing Administration (HCFA), the HHS department that administers Medicare and Medicaid, received particularly heavy criticism because of its heavy reliance on computers for provider reimbursement. HCFA is so behind in its year 2000 revamp that administrator Nancy-Ann Min DeParle asked the House Committee on Ways and Means to delay implementing the portions of the Balanced Budget Act of 1997 that affect HCFA.
Renovating all computer and information systems "must be our top priority," says DeParle, who requested that updates be postponed for prospective payment systems for outpatient hospital care and home health services, among other things. This would delay reimbursement increases for providers.
But opponents like the Federation of American Health Systems claim that the prospective payment system updates are routine to HCFA and shouldn’t require a major overhaul. They say it’s critically important for hospitals to know in advance and plan for those reimbursement changes for capital budgeting purposes.
IDS officials say they expect to spend an average of $5 million to fix their Y2K problems, according to an earlier GartnerGroup survey. Garets says that number is far too low when you consider all medical devices and information systems that need to be fixed or replaced. And after Jan. 1, 2000, healthcare organizations should expect to shell out legal fees from litigation. "IDSs should expect to pay $10 million to $20 million or more," he says. "In fact, I know of several IDSs that are spending over $100 million on the Y2K problem."
Money shouldn’t be an issue when dealing with Y2K, says Joel Ackerman, executive director of the Rx2000 Institute in Minneapolis. "My question is, ’what do you have going on that’s more important, other than the day-to-day care?’" Rx2000 is lobbying Congress to provide government assistance to provider organizations, including low-cost loans.
But more important than financial assistance is to get the government to persuade, or even force vendors to disclose information about their products, says Ackerman who testified before the U.S. Senate special committee on the year 2000 technology problem. "We found that you can’t rely on the information coming from vendors," he says. "A lot of times it’s inaccurate."
For more information on year 2000 programs for healthcare organizations, visit the Rx2000 Institute’s Web site at: www.rx2000.org.
Telethon Targets Internet audience
THE INTERNET IS ADDING A NEW DIMENSION TOcharity telethons. Two Way Communications in Chicago designed and administered a Web site for Children’s Memorial Medical Center, Chicago, during a recent fund-raising telethon/radiothon. Held in cooperation with the Children’s Miracle Network, the "webathon" gave the public a chance to view the telethon schedule, learn more about the medical center and the Children’s Miracle Network and pledge contributions online. For the Medical Center, the site offered a chance to extend its fundraising reach beyond the Chicago area and its usual group of contributors.
Two Way Communications, which creates interactive marketing plans, builds Web sites and purchases online advertising for clients, designed and administered the webathon on a pro bono basis in support of a commitment to children’s charities, says Paul Bryant, Two Way executive vice president for creative operations.
Visits to the site during its most active period totaled more than 32,000, he says, and according to Courtney Dunakin, associate director of annual programs for the Children’s Memorial Fund, pledges increased from $3.2 million in 1997 to $3.75 million this year. Dunakin would not credit the entire 17 percent increase to the Web site, although it did help to raise awareness in another audience. "We were thrilled," she says. "We were educating the ’Net public, which is a different group from those who watch us on television."
Several well-known Internet sites donated banner advertising space directing users to the webathon page. Bryant says the ads targeted young men, who are the primary Internet users, and yielded a two percent "click through" rate, which is average.
Although the online pledge rate was low--about 240 pledges--Bryant says visitors took time to browse and hopefully learn about the charity. Two Way Communications and Children’s Memorial are working on an expanded site for next year’s event.
No Way to Save a Buck
EARLIER THIS SUMMER A SOFTWARE COMPANY ALliance gave a hospital its version of a scarlet letter, proclaiming that Bayshore Medical Center in Pasadena, Texas, had been using unlicensed software: Imagine a huge, shameful red "U" slapped on the hospital’s walls.
Public embarrassment is one of the tactics Washington, D.C.-based Business Software Alliance (BSA) wields in its fight against illegal software use. With members such as Microsoft, Lotus Development and Novell, the group targets misuse of general business applications.
Bayshore Medical Center agreed to delete its unlicensed software, purchase the copies it needs and pay BSA $103,500 in fines. Software companies hope news about the settlement will encourage other healthcare organizations to be more careful about how they manage their software. They want to make it more expensive for businesses to copy software than to buy it legally in the first place.
"A lot of companies are lax, thinking, ’if we get caught, it’s a parking ticket,’" says Bob Kruger, BSA vice president of enforcement. "It ends up costing a company a lot more than it realizes."
The last time a healthcare organization was pilloried was in 1996 when BSA announced a $161,000 settlement with Provident Hospital in Chicago. But there have been other cases besides these two: BSA settles about 300 cases a year; about 90 percent of those cases don’t receive any publicity, Kruger says. "Healthcare related businesses--hospitals, medical practices and health insurers--show up with regularity in what we do. He declined to mention specifics of other piracy cases.
BSA investigations start with tips, usually from disgruntled employees who call the anti-piracy hotline: (888) NO-PIRACY. That’s also what started the investigation at Bayshore Medical Center. Ultimately, BSA found several different software programs that were being used without adequate licenses.
"For a business deciding if this is a risk it wants to take, not only should it consider the potential consequences, it should ask itself if it has any unhappy employees, or plans to have any in the future," Kruger says. "Unless the answer is ’no,’ the company is just one call away from an investigation."
By agreeing to a settlement, paying a fine and purchasing new software, Bayshore ended up spending "a lot less than the damages would have been, had we taken the matter to court," Kruger says. Under federal copyright laws, an infringer is liable for up to $100,000 per use of copyrighted software.
"The problem [with healthcare organizations] is that a lot of information systems are not managed out of the information systems department," says Ivo Nelson, president of Houston-based consulting firm Insource Management Group. "A CIO can’t control it in an environment that doesn’t report to him."
The industry’s move toward consolidation also lends well to software piracy, Nelson says. Healthcare organizations have sometimes applied their existing licensed software to new acquisitions, without considering how that constitutes a change in their licensing agreement. "What the vendors expect is if you run my software in three other hospitals, you pay me three times as much money," he says.
Both software companies and healthcare organizations have grown more careful about crafting licensing agreements that clarify the kinds of changes in use that should trigger increases in payments, Nelson adds.
--John Manning is a freelance writer based in St. Paul, Minn.
IT is the Battle Cry of Former Surgeon General
SOLDIERING INTO HIS EIGHTIES, FORMER U.S. SURgeon General C. Everett Koop is employing information technology weapons as he leads an aggressive campaign on behalf of the nation’s health. "We can use high technology to cut costs by investing dollars wisely in the right kind of medical information technology," he says. "This will provide better, more accessible healthcare at a lower cost for all of us."
After founding the C. Everett Koop Institute at Dartmouth College in Hanover, N.H., which develops and manages educational, community health and telemedicine programs, Koop established the Koop Foundation Inc. (KFI) in 1993.
Not-for-profit KFI, based in Rockville, Md., leads research and development initiatives to improve health information systems using state-of-the-art technologies and business processes.
There is an opportunity for huge savings with the use of advanced health informatics tools, KFI president George Anderson says, reporting the findings of a Health Information Infrastructure (HII) project process reengineering analysis. Such tools, he continues, will be necessary to manage the healthcare issues of the future: quick access to healthcare, preventive medicine, self medical care management and Web-accessible information.
KFI receives funding from the Department of Commerce’s National Institute of Standards and Technology for two major Advanced Technology Program (ATP) projects: the Health Information Infrastructure (HII) and the Health Object Library Online (HOLON). Beth Israel-Deaconess Medical Center, Boston; Meta Software Corp., Cambridge, Mass.; Oracle Corp., Redwood Shores, Calif.; and Wizdom Systems, Inc., Naperville, Ill. are also contributors to both projects.
HII’s emphasis is on enterprise infrastructure, with plans to deploy advanced concepts and technologies including integration tools, knowledge repositories and reengineering methods.
HOLON focuses on middleware architecture messaging, Internet access, standards, security and confidentiality, intelligent agents and objects, legacy systems interfaces and point-of-care medical records. An object-oriented, digital library, HOLON uses open software standards for connectivity and complements other standards-based efforts.
Consumer informatics is another promising area for HOLON architecture. "It is safe to say that we have seen a firestorm in the demand for online health information and support," says Kevin Patrick, a preventive medicine specialist and senior advisor of health and medical information issues for Berkeley, Calif.-based Windom Health, a HOLON consortium member.
Public and preventive health professionals see real potential for using HOLON technology to interact with patients in their home, via the Internet. The advantages are compelling: lower administrative costs and consumers engaged in long-term relationships. After a more than 20-year wait, Patrick says, "The timing may now be right."
But Koop has never put all his eggs in one basket, or even two. With a lifelong vision of empowering consumers with the information they need to better manage their health, Koop also heads Empower Health Corp. of Austin, Texas. As chairman of the board, Koop shares his name--and credibility--in the new Web-based, for-profit venture.
Launched in July, Dr. Koop’s Community (www.drkoop.com) includes extensive references, an interactive drug system and hosts interactive health forums and a chat group.
Need for Speed
AETNA U.S. HEALTHCARE IS PROMISING REIMBURSEment within 15 days if physicians submit their HMO claims electronically. Offering payments in less than half the time it normally takes to be reimbursed is Aetna’s strategy for better serving its customers, while enticing technology-wary doctors into paperless transactions.
"There’s a lot of noise in the industry about providers being paid on time and accurately," says David Kirshbaum, general manager of electronic commerce for Aetna U.S. Healthcare. "We decided we could really make a difference by paying their claims more quickly, if they would agree to a high degree of compliance with electronic commerce."
Physicians who sign up for the new program, dubbed E-Pay, are given the software required to submit their electronic claims for free. Under the program, Aetna has 15 days to settle the claim from when it is received. E-Pay claims are flagged in Aetna’s system and handled first.
Physicians, however, must have the infrastructure to handle electronic claims. At the simplest level the practice needs a PC with a modem to send claims to Aetna’s clearinghouse, Envoy/NEIC. "About 80 percent of the practice management systems have an Envoy module built into them," Kirshbaum says. "If the provider has one of those systems, it’s really almost as simple as turning on the Envoy module and connecting to NEIC." What may be required is for physicians to upgrade their practice management systems, he says.
If physicians like the sound of 15-day payments, but don’t have computer systems to send claims electronically, Aetna business partner’s Envoy/NEIC and IBM Global Healthcare Solutions pay them a visit to prepare the network.
For solo Manhattan practitioner Bernard Schayes, who had a network already in place, the decision to go with E-Pay was easy. "This is the first program where a payor assures us we will be paid within two weeks. It’s a pretty major step forward."
But E-Pay isn’t for everyone. Kirshbaum admits that many small practitioners still don’t want to computerize their practices, regardless of the potential benefits. Others don’t have enough Aetna members as patients to make the program worthwhile. "It may not be effective for them to just pump electronic claims through that one mechanism," Kirshbaum says.
Schayes, who describes himself as marginally more technically adept than his medical peers, has relative confidence in Aetna’s ability to control the technology. "I wouldn’t be surprised if there were certain glitches, but I’m confident they will eventually be worked out." The major reason to embrace e-commerce is because physicians are being paid less and less and asked to do more and more, he says. "The more technology I use, the more time I can spend with my patients."
Cognizant of Oxford’s woes, which were blamed on a poor computer infrastructure and its software failing to handle the large number of electronic claims it received, Aetna is taking a cautious approach to the initiative. E-Pay is being rolled out slowly, to physicians in northern New Jersey, New York City and surrounding areas first. "We are going to focus on these two markets until we feel that we can absolutely guarantee delivery," Kirshbaum says. "When we’ve got them in order, then we’ll move through the rest of the markets." Aetna officials say E-Pay will be in all of their HMO markets by the end of 1999.
Though the program is new, Aetna U.S. Healthcare has automated transactions for about two years--since the merger between Aetna and U.S. Healthcare, Kirshbaum says. To handle an increase in electronic claims, however, Aetna recently beefed up its network capacity.