Tag: datavant

Where did all the emergencies go?

April 30th, 2020 by
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Do you need me?

When COVID-19 hit, hospitals knew they would see a decline in elective surgeries and routine visits. After all, they canceled them! But the volume of patients visiting the emergency room has also dropped dramatically, and no one can seem to fully explain it. Sure, maybe we could expect fewer car crashes and skiing injuries. But heart attacks and strokes? If anything it seems like those numbers should be going up due to higher stress levels. Yet, the analyses in cardiac care during the pandemic show a sharp decline not only in elective cardiac procedures, but also in cardiac catheterizations for acute heart attacks, specifically, those with ST segment elevations – the most life threatening type.  

Conventional wisdom tells us that the drop in ER visits is a bad thing. Patients must be dying at home, outcomes must be worsening, and the patients that do survive will show up as train wrecks once the pandemic subsides. Those assumptions are probably true to a certain extent, but the open question is how true?   Acute conditions and complications warrant acute care.  But in the routine care of behavioral health and other chronic conditions such as diabetes and hypertension, extensive overuse of the emergency room rather than other ambulatory settings has been a prime area of concern and debate for several years.  

We know that ERs are overused in normal times. And we think they’re underused now during the pandemic, but to what extent should be analyzed and debated as we inform the necessary adaptation of our systems of care.  We expect to see an incredible amount of variation in ER utilization as the situation unfolds, by specific patient populations, urban vs rural settings, and geography-specific COVID-19 case burden. 

We are encouraged that Datavant has convened a wide variety of industry players to construct a COVID-19 Research Database, a set of de-identified data sets made freely available to enable rapid studies at scale.  The new initiative fills an important gap between quick observations that are available from small sets of real world data and clinical trials, which are robust but slow.

The ER phenomenon we’re discussing is not completely unprecedented. Researchers (and ER staff) have long observed the ‘big game effect’ – where ER visits decline as people defer them to watch their favorite team. (The Health Business Blog first reported on it in 2005: Red Sox’ success eases health care crisis.) Some, but not all, of those visits are avoided entirely without negative consequences. The COVID-19 pandemic provides an opportunity for a much longer time series. Let’s use it as a chance to study what’s going on so we can apply the lessons learned as we emerge.

What could explain sustained, lower utilization of the ER? There are a few possibilities:

  1. Many seemingly serious problems resolve on their own when people just wait. If people avoid the ER out of fear, the ‘tincture of time’ will often do the job.
  2. Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
  3. The momentum and logic of the ER setting makes matters seem more serious than they really are. Once someone appears there’s always something to find. (As a doctor colleague once told me, “Show me someone who’s perfectly healthy and I’ll give him a full workup to demonstrate otherwise.”)
  4. The ER is the entry point for admission to the hospital. Under fee for service, hospitals need to admit patients to make money. Depending on the proportion of available beds during these uncertain times, hospitals may be even more economically motivated than usual to fill open beds. So, once a patient arrives, they may be staying.
  5. A significant portion of ER traffic is composed of so-called ‘frequent fliers.’ Usually, they are tolerated, but in the current environment, ER staff are motivated to triage non-COVID-19 patients away from the hospital as efficiently as possible. Once this becomes evident, the ‘frequent fliers’ ground themselves.
  6. How many times have you called your doctor’s office or pharmacy and heard the recording say, “If this is a medical emergency, hang up and dial 9-1-1”? That definitely got people used to the idea that the ER is a good place for care. Clearly people are ignoring that messaging now!

So what should we do with this unexpected information?

  1. More finely tune financial incentives to discourage unneeded utilization while not discouraging needed care. We know from experience that bluntly requiring large patient financial contributions drive down both good and bad utilization.
  2. Educate people about the downside of ER visits (infection risk, treatment that’s too aggressive, likelihood of admission to hospital, provider that doesn’t know you) to balance out the current bias for ER care. People will be more receptive now and won’t immediately think that health plans are only trying to ration their care. 
  3. Consider other changes in benefit design to help the decreased utilization persist, including increased access and reimbursement for home services, telehealth, and remote management tools.
  4. Encourage physician offices and others to make better efforts to intervene quickly and prevent people from going to the ER just for convenience. This could include on-demand availability of telehealth consultations and other digital/remote management for which they would be reimbursed.

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By healthcare business consultant David E. Williams, president of Health Business Group and Surya Singh MD, president of Singh Healthcare Advisors.

Future of Health Data –the Big Brains convene!

October 22nd, 2019 by
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Katyal, von Eschenbach, Shulkin and Siddiqui

A quiet revolution is underway in healthcare data. A decade after the HITECH Act spurred the rapid adoption of electronic medical records, we are seeing the resulting data being integrated with other sources such as insurance claims, clinical registries and social determinants of health to produce richer data sets for analysis and action.

As we’ve noted in our own consulting work, Datavant has emerged as a key player in connecting disparate data sources at the patient level while protecting privacy. The company’s methodology anonymizes patient identifiers with a unique patient key, matches records across data sets, and enables data exchange.

So I was excited to attend Datavant’s Future of Health Data Summit in Washington, DC earlier this month. As one would expect from a company that strives to organize and present data efficiently, accurately, and clearly, it was a quality event. The day featured 40-minute panels with strong moderators and 3-4 expert panelists along with keynotes from luminaries such as former FDA Commissioner Robert Califf, CDER Director Janet Woodcock, and former Senate Majority Leader Tom Daschle.

The closing panel, Healthcare Policy, Value-Based Care and Data Sharing was typical of the program. Moderator Neal Katyal (former Acting US Solicitor General) made the most of the expertise of panelists David Shulkin (Former VA Secretary), Mona Siddiqui (Chief Data Officer, HHS) and Andrew von Eschenbach (former FDA Commissioner).

They were all passionate about the ability to finally leverage healthcare data at scale. Shulkin talked about using data to prevent suicides of veterans. The highest incidence is in the first year after discharge, when they risk falling between the cracks as they transition from the DoD to VA system. Siddiqui bemoaned the difficulties of confronting the opioid crisis with 2-year old data, and von Eschenbach spoke of the potential to transform the whole healthcare system by improving care and reducing costs.

Shulkin seemed the most skeptical about where things are headed in the near term, predicting incremental change in the healthcare system as the most likely outcome of the fight between Medicare-for-All Democrats and Republicans who want to crush federal involvement. When Siddiqui gushed about the potential to use the planet’s largest healthcare data set (from CMS) in hackathons and challenges and system redesigns, Shulkin interjected that working with the government was, “not for the feint of heart,” and “,not a great strategy for a young company.”

There was an interesting back and forth about how to get the public comfortable with data sharing, how to overcome the decline of public trust in general, and how to address privacy from a policy and technological standpoint.

The panelists generally agreed that patients would be on board if they saw how use of data could help with their own care, and that even spectacular data breaches wouldn’t completely erode patients’ trust in the system. We have become accustomed to such breaches with our financial data, after all.

Shulkin thought people would get really upset if they learned that their data was for sale. I disagree -I think consumers are already coming to terms with their data being sold throughout the rest of the information economy; it’s by no means unique to healthcare.

In closing, von Eschenbach said he was “incredibly optimistic” due to the tremendous energy coming into the process right now. It’s a chaotic environment, he said, but we’ll look back in five years and be grateful for today’s chaos.

Shulkin pointed to the large number of healthcare data companies formed over the past three years, using that as an indicator of the level of optimism in the field. It wasn’t evident to me that he fully shares this optimism.

And Siddiqui presented herself as a realist but also a bit of a visionary and optimist, who is thinking about the healthcare system that we want to have. For her –and many of us– it’s one that’s more technology enabled, virtual care enabled, and homecare centric.

I’m heading to the HLTH conference in Las Vegas next week. I hope it’s as worthwhile as the Datavant event!


By healthcare business consultant David E. Williams, president of Health Business Group.

Life Image CTO Janak Joshi discusses real world evidence (RWE) –podcast

August 12th, 2019 by
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Real world evidence?

Real World Evidence (RWE) is becoming more important in US healthcare, but the fragmented system and lack of interoperability makes it hard to collect and analyze. In this podcast, Life Image CTO Janak Joshi discusses  the state of the field and how it’s evolving.

Overview:

  • (0:12) How would you describe the evolution of medical data?
  • (2:36) Real world evidence and real world data are becoming more prominent in healthcare –and for good reason. What are some of the challenges in assembling RWD and RWE? How can they be overcome?
  • (6:36) Is it really true that unstructured notes are becoming quantifiable and useful?
  • (9:46) There are major efforts by the US government and private sector to improve interoperability and end data blocking. You have groups like CommonWell and Carequality –now working together. What’s the current state of play and how are things changing?
  • (13:56) You talk about data brokers like Datavant and HealthVerity. How much of their success is because the US system is so broken? Do you see them having the same success elsewhere?
  • (17:31) Promoters of AI and Machine Learning –including Life Image—tout the opportunity to revolution healthcare with these new techniques. Is it for real or overhyped? And how does interoperability tie in?
  • (22:20) What are you most excited about over the next few years?

By healthcare business consultant David E. Williams, president of Health Business Group.