Health Information Exchange edges closer to a sustainable business model (transcript)

This is the transcript of yesterday’s podcast interview with Dr. Albert Tzeel of Humana.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Albert Tzeel, National Medical Director of HumanaOne in Wisconsin.

He’s co-author of a study of the Wisconsin Health and Information Exchange (WHIE) in Milwaukee, which documents the cost savings to health plans when emergency department physicians use a Health Information Exchange.

Dr. Tzeel, thanks for being with me today.

Dr. Albert Tzeel:            Thank you for having me.

Williams:            What is the context for this study and why was Humana interested?

Tzeel:            Humana became involved as a part of the WHIE board of advisors with me as the representative back in 2007. Early in 2008, Kim Pemble Executive Director of the WHIE and a couple other folks approached me and said, “We really believe that there’s a great ability to impact costs, especially with what we’re doing in the emergency department linking program. We really need the opportunity to get our message out there and see what we can do to help plans save money and more importantly coordinate care for members.  Are you interested in possibly working with this on that?”

I said of course I’d be interested in doing that.

Then I took the idea and helped flesh it out and came up with an internal business case that we took through our internal processes.  Humana decided to provide an incentive to the exchange to help promote the querying of the Wisconsin Health Information Exchange by emergency department clinicians as they take care of our Humana members.

We thought that if payers could get some benefit maybe this could turn into a way of providing sustainability for exchanges. But in order to get payers to buy in, we had to show the business case.  So we went and created a pilot.  We looked at methods of what we would ultimately do to evaluate whether or not this made a difference and what this meant.

Lo and behold the paper that was published was the outcome of all that.

Williams:            What are the key findings of that paper? In particular I know that you did identify some fairly robust savings. What is the source of those savings?

Tzeel:            As we evaluated the data we determined that as a health plan we would save $29 per each individual ER visit for members that went to a facility where the Wisconsin Health Information Exchange was queried by doctors or clinical staff as part of the workflow, versus when our members went to facilities where there was no querying done.

I agree with you in what you said David, that’s a pretty significant savings.  The drivers of that are both improving coordination of care by providing a medical history at the point of care, but also decreasing redundancy of testing.

Typically if someone shows up in the emergency department in one facility and has a battery of tests done and then within a couple weeks or months shows up in another emergency department, if there’s no access to those tests, they’re going to be repeated. That just becomes wasted dollars to the system.

Our data showed that some pretty significant tests did decrease: laboratory tests and EKGs, but also just diagnostic imaging and even CT scans decreased.  Giving a CT scan in the emergency department setting is huge.  So being able to see that those types of tests were not needed to get the coordination of care that was provided to our members where the WHIE was queried was good.

That was very, very impactful.

Williams:            You mentioned a couple words I want to come back to and put them together.  One, you talked about an “incentive” and the other you talked about the “workflow.”

I’m familiar with some similar approaches that have been tried elsewhere that haven’t demonstrated savings. Often the issue has to do with integrating the data querying into the workflow of a busy emergency department. My guess is that the incentive is part of it, but there are probably some other elements to it as well.

Can you explain what really happens in the emergency department and what leads them to query the database versus not?

Tzeel:            Typically as individuals seek care in the emergency department, there’s triage done to see the severity of the condition and then a history is done.  A physical exam is done and then perhaps some laboratory data or whatever’s needed to help confirm the diagnosis and get a better idea of what’s going to be the ultimate disposition of this member.

Is it someone that can be sent home?  Is it someone that needs to admitted?  Depending on the complaint for which that individual comes to the ER, it can end up being fairly intense.  If it’s something non-specific like abdominal pain, there are a lot of different things that can potentially cause that so it becomes incumbent upon the physician to really be able to take a look.

I’ll give all the credit in the world to Kim Pemble and to the folks at the Wisconsin Health and Information Exchange.  They were able to establish relationships with the various facilities where WHIE access was going to be provided, and encourage providers to make this a part of the workflow because ultimately it will make the clinician’s job easier.

I will say that emergency department physicians here in Southeast Wisconsin, want to leave a track record of providing good care in our community. So the more information they have that allows them to make an informed decision, the better the care they can provide to the patient that’s lying down in front of them. In the paper we referred to a comment from one of the emergency department physicians who said that the information provided to emergency department physicians is like gold because it provides so much value to what they’re ultimately trying to do.

So the idea became that it almost became second nature for them in that the physician could access the WHIE database to see background information on the patient that they were seeing. Some of the facilities even had a clerk in the emergency department access the database and provide a printout that they could put right with the medical records, so when that doctor is seeing the patient they’re able to see what’s there and get a better idea of whether or not there’s more information needed, to follow up on or specific things they need to ask about.

So it became really like anything else that becomes ingrained as a habit. It was second nature to make it part of the workflow, to the point that when querying the database wouldn’t occur, I think that the physicians would be quite cognitive of that.  That’s really how it became ingrained.

With respect to the incentive portion, Humana wanted to make sure that the folks at the Exchange were able to be persistent to get the doctors to listen to their message and to be able to really work with them quite well.  So that was what led to our providing an incentive.

Although we set this up as a pilot with a finite time frame, now that we’re seeing a great return on investment this is something that we want to continue doing. And perhaps we can look at what other opportunities we have to expand.

Williams:            This study was conducted in Southeast Wisconsin on a fully insured population of commercial patients.  Do you consider these findings to be generalizable or do you think there are specific things about the geographic area or the patient population that would make you wonder about whether the results could be spread further?

Tzeel:            My opinion is that overall the findings can be generalizable.  When we looked at the data that we had, these were folks by definition had to have at least a couple ER visits and sometimes more than just two, so it wouldn’t be for someone who  just happened to come to the ER for one acute trauma and then wasn’t seen again.  These are folks that had a history of utilizing the emergency department for care.

The second thing is that one of our goals (and I don’t mean to digress) is to make sure that the exchange is queried for every patient.  We felt that it would be easiest for us to work on our fully insured population because Humana was willing to assume the risk. It wouldn’t have been fair to put our self-funded clients at risk if we didn’t see the cost savings.

The Business Health Care Group of Southeast Wisconsin, which is a very large client of ours that we’re the administrator for, heard about this and were very supportive. Even though they weren’t included in the analysis, they also helped support the WHIE through the same program that we were providing.

The question would be if we’re using a fully insured population, what does this mean for members that perhaps have government sponsored insurance: Medicaid, Medicare?  I would think that contractual reimbursements may be different in that respect but ultimately everything cancels out.

I do believe that given the types of conditions, and the fact that we’re seeing ER utilization increases just the same way that other major cities in the country are seeing, I think that it would be generalizable.

Williams:            As you mentioned, there has been an increase in the use of emergency departments for various reasons that you described in the paper, and that are not unique to your region or to Humana.  How does the use of a Health Information Exchange fit in with some of the other approaches that I assume Humana must employ in order to try to control the overall emergency department expense?

Tzeel:            It fits in quite well.  I believe that in a lot of respects it actually complements some of the other things that we do.

For example, certainly we’re trying to promote appropriate utilization of the emergency department.  There are some things that are emergencies and there are a lot of things that aren’t.  Some of the studies show that between 37 and 75 percent of visits to an emergency room are not truly emergencies.

So we want to make sure that folks use the ER appropriately. But whether they do or whether they don’t, if they do go to the emergency room, they will end up getting seen, so it behooves us to make the visit as efficient as possible for the physician by providing information that can be obtained through the WHIE and to encourage that doctor to utilize that information.

It’s neat in that a lot of data from hospitals can become available to that physician who’s taking care of the patient right in front of him or her. Some of the hospital systems here have also –because they’re already hooked up with a common Electronic Medical Record—started to provide data from their employed physicians to the WHIE.  Or if there’s a Federally Qualified Health Center or other entities outside the hospital, they can also provide data so that that gives more information to the emergency room physician who’s taking care of a patient.

Additionally there’s the ability to help with care management by providing comments about specific things about the patient. Things such as: “This is a patient that is in a care management program.  Please contact the following care manager.”

Williams:            The study is focused on the emergency department and that’s an obvious place to start. But is there value that’s broader if you look at it from the health plan perspective where you think you could save money if you go beyond the emergency department?  If we look three or five years down the road, would a lot of the value be elsewhere?

Tzeel:              As you said, I think some of it is actually related to timing.  Right now the main value is the emergency department.  I believe Willy Sutton said, “Why do you rob banks?  Because that’s where the money is.”

Why did we start with the emergency department?  Because that’s where we’re seeing a lot of utilization and can potentially make a big impact.  That’s where it is right now, but I do agree that there’s definite application beyond the emergency department especially for health plans.  I think that there is the ability to coordinate care.

We certainly have a lot of personal nurses or care managers that interact with our members and can help reinforce a lot of what’s going on.  The more information they have regarding conditions that a member has and where a member has gone to seek care the better.  There are some definite opportunities.

There are also going to be more opportunities for health plans to interact with facilities with the common goal to ultimately improve the health of our membership.

Williams:            Humana has been out in front in providing financial support to the WHIE. It sounds as though you’re building your business case and will perhaps be able to continue and extend the financial support.

Are you seeing other health plans follow the lead that you’re taking?  Are they seeing things in the same way?

Tzeel:            I think so to some extent.  I think it depends on where.

We got on board early.  I wasn’t really aware of many plans that were involved prior to our starting this three years ago.  Other health plans are starting to get engaged in certain geographies; California and Rochester, New York for example, and I think it’s all for the same reason.  The health plans believe that there’s opportunity to not just save money but to really improve the health of members that we serve.

My goal in trying to create the business case is to get the ones that are standing on the sidelines to come on board.  I will readily admit that, not for lack of trying, several of my counterparts here in Southeast Wisconsin haven’t come on board.  I think they agree with what we’re trying to do in principle, but they haven’t stepped up in terms of helping to create a sustainable model for a group like the Wisconsin Health Information Exchange.  I’m hoping that this helps bring them forward.

Williams:            I’ve been speaking today with Dr. Albert Tzeel.  He is National Medical Director of HumanaOne in Wisconsin.  Dr. Tzeel, thanks so much for your time.

Tzeel:            Thank you very much.

September 9, 2011

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