How Do We Redesign Healthcare? Speakers: Steven Krein, Cofounder and CEO, StartUp Health Andrew Cohen, Vice President and Partner – Healthcare Practice, Cognizant Dan Munro, Author, Casino Healthcare Moderator: David Kirkpatrick, Chief Techonomist (Transcription by RA Fisher Ink) David Kirkpatrick: …Dan Munro, who you’re about to hear from, wrote one of my favorite articles in here [the magazine]…the lead article in it is Dan’s, because he has such a compelling point of view on the architecture of the American system and he wrote a book called Casino Healthcare, which is an excellent, scathing indictment of our system, which he may summarize, in 10 minutes. Dan Munro: Thank you very much, and I look forward to the opportunity to talk to you today. I thought I’d try and frame this a little bit relative to my background, the book, the article, and then what I wanted to do was kind of a short story on patient identification, in part because patient identification I think represents a great short story looking through the lens of technology, innovation, and policy. And it starts with another companion book that I strongly recommend, which is by Dr. Bob Wachter, who wrote The Digital Doctor. If you haven’t read that, that is an excellent book on the evolution of the electronic health records system. He works as a clinician at the University of California, San Francisco, which is I believe an Epic shop, and his lens into the entire electronic health records system is phenomenal. And one of the first things he identifies, which is what I’m keying off with patient identification, is that the first thing that we have to do in the healthcare system is we have to figure out who the hell you are. [LAUGHS] And that comes back to patient identification and how we do that today. So how we do it today is typically by name. We use social security number, we use a birth date, we may use an address, and then we cram all of those numbers into an algorithm that then tries to do what’s called patient matching, in the sense that any hospital system has a thousand John Does, has a thousand Mary Smiths. We’ll get into that in a little bit, but the algorithms are what are used to do patient matching and mismatching so that we begin the process of understanding who you are. The problem with all of those fields and all of those numbers is that they aren’t ANSI- recognized and they’re not ISO-certified. So there’s no standardization around those that we Transcript from Techonomy Health in NYC, May 16, 2017 p. 1 Techonomy Media Inc. www.techonomy.com can really apply to, so they aren’t really intelligent numbers. There’s nothing intelligent behind them. And what do I mean by that? So the patient mismatching problem that we wind up with as a result of that is that in a large enough hospital system, they’re going to lose about $17 million a year on denied claims just on patient mismatching. Intermountain Healthcare in Utah spends about $5 million a year just on patient matching. Kaiser Permanente has about 10,000 Maria Gonzalezes in their database. And there’s a facility in Houston that has over 250 of the same name with the same birthdate. So when you see the size and scope of this, you begin to understand it. About 8–14% of all medical records have incorrect data. So the cost to correct this in the system represents hundreds of millions of dollars a year. Anybody know what this number is? I wouldn’t expect you to. It’s actually what’s called the Tire Identification Number. This is a number that the National Highway Transportation Safety Administration dictated that the tire industry use for every passenger vehicle tire. And it’s been in use since 1971. Why is that important? It’s important as a consumer if there’s a recall on that tire, you can do it by that identification number. And it’s an ISO-certified number that is represented by that as well. Anybody know what this number is? This one’s a little bit more common. VIN, excellent. So yes, it’s a number that’s been applied to—and there’s a huge history behind this, in part because each of the auto manufacturers in the US established their own vehicle identification numbers starting in about 1954. The problem was that they weren’t unified. And so again, in 1981, the National Highway Transportation Safety Administration dictated that all of the manufacturers use a standard number that is ISO-certified. And the beauty of a technology like Carfax isn’t the fact that we can do that on a mobile phone, which we can, but that it’s predicated on a VIN number that can be looked up for recall information to see if that vehicle has been stolen, to see if it was a part of a flood. So vehicle identification number is another example of identification. The more recent example is probably through the TSA. How many people here have a known traveler number? Wow. Great example, right? And you have to pay into that system, because you recognize that there is a value in exchange for that. We haven’t found that yet in healthcare, but we’re getting there. And we started to try and recognize that with a legislation back in 1996 called HIPAA. Anybody know what the P stands for? Audience: Portability. Munro: Great. I don’t often get that. In any event, it’s mandated through Health and Human Services, but it’s regulated by HealthIT.gov, which is also ONC. And before we go any further, I do want to dissuade everybody from the idea that there’s a HIPAA compliance. Nobody is HIPAA-compliant. There’s no certifying governing body out there that says you’re HIPAA- compliant. HHS doesn’t do that. ONC doesn’t do that. Transcript from Techonomy Health in NYC, May 16, 2017 p. 2 Techonomy Media Inc. www.techonomy.com So what is it that they do do? So there’s basically three principal rules associated with HIPAA: the privacy rule, the security rule, and the breach notification rule. They simply issue that as a rule that organizations have to abide by. But it’s up to the organizations to prove that they’ve done that individually, which they typically do through an audit. And those audits are third- party-generated, they cost a lot of money, and they’re done annually. And so most companies can’t afford to do that, or they simply don’t do that and simply indicate that they’re HIPAA- compliant. And the fact is they’re not. And more recently, HIPAA came out with a cloud computing guidance which is equally critical. Buried underneath the legislation in 1996 were two other pieces of HIPAA that were long forgotten. One was the national patient identifier and the other was the national provider identifier. So two years after they implemented HIPAA, or after the legislation passed, in 1998, Congress stepped in, defunded the national patient identifier and said in effect, “HHS, you are prohibited from spending any money on developing a national patient identifier.” But we do have to this day a national provider identifier. So every doctor in the system has in effect a national provider identifier. So the reason that they argued against that, and the reason they said they wanted to defund it, was because of security and privacy. That argument falls by the wayside today in light of the breaches that we’re seeing relative to healthcare generally. This is simply for one year, and these are the top ten breaches, and it’s over 111 million records for just 2015. And we’re seeing more of that of course as the years go on. So these are the organizations that have lobbied heavily for the government to step back in and provide a National Patient Identifier. Not surprisingly, one of the lead organizations that’s lobbying heavily is HL7, which is the standards organization for the healthcare industry. But there are other groups as well. HIMSS, CHIME, AHIMA, all of these organizations have lobbied Congress heavily, saying, “We need a national patient identifier. Please give us a national patient identifier.” But there’s another group behind that, and I don’t want to say that these people are anti-national patient identifier as much as they’re silent relative to the need for a national patient identifier. So it’s not that they’re lobbying against one, it’s that they’re not lobbying for one. And I think until we get more industry involvement in that, it’s not likely to happen. The reason why is partly the basis of the article and then also of the book, which is the idea that what we have isn’t a dysfunctional government but a lot of regulatory capture. So these companies in effect are working collectively with Congress, with legislative organizations, to protect their interest and naturally set barriers for these kinds of events to happen. Munro: The revenue that’s associated with keeping it that way is enormous, and that’s how we get to $3.5 trillion a year. Transcript from Techonomy Health in NYC, May 16, 2017 p. 3 Techonomy Media Inc. www.techonomy.com Kirkpatrick: We’ll come back to some of the other scathing points you make about the system, Dan.