Adding Incremental Value Beyond Sharing Claims

On July 30th, the Centers for Medicare & Medicaid Services (CMS) announced the “Data at the Point of Care” (DPC) pilot at the White House Blue Button Developers Conference. Blue Button 2.0 was intended to present four years of Medicare Part A, B and D data to beneficiaries through Health Level 7’s Fast Healthcare Interoperability Resource (HL7 FHIR) standard. DPC presents this same information to providers using a similiar application programming interface intended for bulk data file sharing (e.g., all beneficiaries in a shared savings accountable care organization). Four of Farhad Manjoo’s “Frightful Five” (Apple, Facebook, Google, Amazon and Microsoft) were present at the event agreed to begin testing the proposed specifications.

Does access to claims really make a difference in direct healthcare delivery? Miller et al. suggest that claims data lack the clinical details to determine if care is high-value or low-value. In a systematic review of health information exchanges, only two of the six included studies with quasi-experimental or randomized, controlled study design found a beneficial effect. One study found an increase in redundant specialist referrals from emergency departments. In my own conversations with healthcare providers, claims information might merit review if it met the following criteria:

  1. Is the information new? Does the claim highlight an event that would not otherwise be present in the provider’s electronic medical record?
  2. Is the information true? For diagnostic accuracy, “raw” claims may require some processing before reliably identifying diagnoses. The treating facility may also influence diagnostic validity. Smaller hospitals without dedicated stroke units were less likely to accurate code stroke severity compared to larger hospitals with stroke units. For care provided, claims data have been shown to underestimate performance on diabetes-related quality measures and preventive care.
  3. Does the information suggest changing the current course of action? Does the claim (or information held by the person submitting the claim) represent information that changes the probability that this patient has a particular diagnosis or needs to placed on a more effective treatment plan?

If displaying claims doesn’t lead to higher value, how else might DPC encourage higher quality healthcare? Claims data could identify an individual’s entry and tenure within a diagnostic pathway or treatment episode. Alternatively, claims data owned by the individual could serve as a record locator service to identify where relevant health records might be stored. For those of us living outside New Hampshire, we could use the claims information to request copies of our encounters at medical facilities who have submitted claims on our behalf. The Blue Button 2.0 framework could be leveraged to allow individuals to control what information is shared with specific providers or healthcare entities.

As we struggle to develop a personal health information paradigm that provides both a comprehensive view of the patient for care teams and empowers patients to direct who has access their medical records, the CMS announcement could provide additional direction about how best to move forward without relying on a medical record bank, a health information exchange or an electronic medical record aggregator. Advances in the HL7 FHIR standard to allow consumers and providers to request additional information (e.g., radiology images, consultations, operative reports) that could be shared with new members of the care team. Other data sources (e.g., blood glucose monitors, blood pressure readings, daily weights) could be added to the individual’s claim history to provide additional context to the member’s “official medical record.” Additional research would be needed to determine if this level of data access resulted in higher-value healthcare.