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Perspectives from the Field: Interview with Dr. Kavita Patel, July 30, 2014

Kavita Patel
Fellow and Managing Director for Clinical Transformation and Delivery, Center for Health Policy, The Brookings Institution

Perspectives from the Field Interview Series
Interview with Kavita Patel, MD, MS
Fellow and Managing Director for Clinical Transformation and Delivery, Center for Health Policy, The Brookings Institution
July 30, 2014
Interviewer: Jane Hyatt Thorpe
1) Please introduce yourself and tell us how what you do intersects with health information exchange?
2) What do you see as the most promising efforts to reform the health care delivery system through greater use and exchange of health information?
3) What are the most significant barriers to achieving these reforms?
4) As a practicing physician, how are you seeing health information use and exchange evolve in the delivery of health care? 
5)  What are the greatest challenges physicians face in moving towards use of EHRs and other forms of HIT to support health information exchange across the care continuum and with patients?
6) What strategies would you recommend to encourage greater use and exchange of health information across the health care system by physicians?  By patients?
Question 1
JHT: Welcome to the Health Information & the Law Perspectives from the Field Interview Series. Today, we are speaking with Kavita Patel, Managing Director for Clinical Transformation and Delivery at the Engelberg Center for Healthcare Reform [now the Center for Health Policy] at the Brookings Institution. She is also a practicing primary care internist at Johns Hopkins Medicine. Welcome, Kavita! Thank you so much for joining us today. Would you please tell us a little bit about your current position and your work and how it intersects with health information exchange?
KP: Sure, thank you for having me! I am currently in two capacities working on health information exchanges, one at a policy level for my role at the Brookings Institution, where I take the lead on a lot of technical advising for new payment models and how we think about changing our delivery system, and the topic of information (just generically) is literally on everyone’s conversation list when we do talk about delivery system reforms. I also work at the practical level as a clinician and I’m in an accountable care organization, we’re a patient-certified medical home and do a lot of population health type of work, we also talk about information. And so, the concepts of what a health information exchange and just the basic importance of data in a timely fashion as well as how we think about transmitting information to other stakeholders, that is something I play on both sides of from a policy level and a practical level.
JHT: That’s wonderful, so you have a bird’s eye view really of the policy issues and then also the policy issues in practice as you apply them to your practice.
KP: Right! Exactly.
Question 2
JHT: Speaking of payment reforms, what do you see as some of the most promising efforts to reform the health care delivery system, particularly through the greater use and exchange of health information?
KP: The biggest promise around exchange of health information is in literally the action of having parties who are invested in a patient, or a family, or a population’s health have access in a timely fashion, but the kind of modality in which that information is exchanged is just as important. So we have technical infrastructure right now for you and I to, if we can get past some of the privacy regulatory concerns that I think are important, but if we can go even a step beyond that, we have access to lots and lots of data. So when we talk about exchanging data, people feel sometimes “Well, if we set up a cloud server and have a password and username, and you can kind of go into a system and look up your information, that’s data exchange,” but that’s actually not what I found as the most valuable aspect. It’s really, “How can someone like me at a clinical level, when I’m dealing with patient’s issues, think about the data exchange that would be the most relevant to other parties.” That can be the basics—lab information, demographics, clinical data around medications—but often times it’s actually trying to capture what I need to convey in a very succinct format, and what is it that the receiving party really needs to look at in a quick and efficient manner. I’ve been on the receiving end of what I would say are literally dumps of data that then I honestly don’t have the time, desire, or incentive to look through. So I think meaningful data exchange is still something that our country is struggling with even when you’re working in a closed system where everyone has the same medical record and has access. Think of a Kaiser or some of these systems that have been around for a lot longer, these more evolved systems; it’s easier, but it’s not reflective of much of the real world. So, I can give a story from a patient today who called me from an ER that’s not affiliated with my clinic and he was telling me how the ER doctor was asking him a lot of questions, and he was like, “Well, let me call my doctor because I don’t know these answers.” I don’t have a way to push information—getting back to what’s a value and benefit of a health data exchange or health information exchange. I actually don’t have a way to transmit that right now, except to do the good old fashioned phone call or fax, and that’s it. I think that our country is still trying to get into what meaningful health information exchange is.
Question 3
JHT: So it sounds like, from your perspective, trying to move forward to achieve more meaningful data exchange is one of the key goals, and you mentioned privacy issues as well as just basic infrastructure issues of how do you send or supply meaningful data in a timely way. Are there other barriers that you see to achieving these goals?
KP: Yeah, I think something that comes up a lot when I’m doing payment reform work at a policy level that I don’t know if clinicians think about is the integration and incorporation of administrative and clinical data. So, a lot of what I just talked about, and a lot of what you see health information exchanges that are being built around the country—Indiana, Cincinnati, New York, Colorado—I’m familiar with a lot of the regional efforts. When you see these efforts, a lot of this comes from kind of tranches of data, some are administrative, some are clinical. Rarely do you see a meaningful integration of the two. So, when we think about information that’s really important to new delivery models for doing accountable care, like I mentioned in the ACO environment that I’m in, I need to not only understand what’s happening to my patients clinically, but I need to know how is this patient’s total cost of care been over the year. Are there some flags around some prescription drugs? Could I have been doing a better job because I see now that they are paying out of pocket for something that they didn’t tell me about that was on tier 3 of the formulary? Some of those things really are not sufficiently described within the clinical data infrastructure and you need access to administrative data. So I think that the conversations around health information and health data exchanges in general would benefit from perspectives of people at various points of the delivery system, not just the clinical front line, but also the medical directors, the practice administrators, and people who are also thinking about the larger policy framework of what the data exchange means.
Question 4
JHT: That’s very interesting. So connecting, from your perspective, the policy issues with the practical issues, and thinking about those issues in a more coordinated way. As a practicing physician, I’m sure you’ve seen use of health information exchange of information evolve over the years. What do you think are some of the most promising changes that you’ve seen?
KP: Promising changes just in practice?
JHT: Yes, trying to exchange and use health information for improved delivery?
KP: I think the most clear example to me has been automated alerts around emergency room and hospital discharges. It sounds tragically simple, but in the majority of the country right now, we have no idea when patients are actually going to an emergency room, or are admitted to a hospital, or even worse, are discharged from a hospital. And I think the incorporation of what we call automated discharge alerts or automated admission alerts into the data exchange is, has been, huge. What it gets at – there’s a phrase of meeting patient’s where they are – that’s how we think about person-centered care/patient-centered care – we don’t have the information to actually do that. I have no idea where patients are getting their care unless they’re right in front of my face. So I think that one of the most meaningful developments has been the integration of kind of real-time utilization data like I said, like ER use or admission or discharge. And I think that’s been a tremendously valuable asset. Another aspect of data information exchanges that’s—in the District of Columbia, that I know we’re trying—is around medications. So there’s been a lot of conversation around the use of controlled substances, and I know there’s a lot of national attention on that. In our District of Columbia Information Exchange we now have a broad network to know how patients are receiving substance prescriptions to: 1) try to understand and curb any abuse that may be happening but then 2) to highlight that there may be a patient with a real problem if we know they are seeking behavior, seeking drugs and there’s behaviors that are going to other facilities. And it sounds amazing that in 2014 we didn’t have that before, but we didn’t. So I think those are two kind of tangible developments that shine in the use of information exchanges.
Question 5
JHT: That’s great, and I think we’re definitely seeing more and more physicians and other providers move towards use of electronic mechanisms for sharing information either with a registry or participating in automated alerts, or other types of information exchanges. What do you think remain and what are some of the challenges that physicians still face moving towards greater use of electronic health records and other forms of health information technology to support sharing health information?
KP: I do think—so, there’s the infrastructure barrier, right? I know we’ve had conversations and there’s certainly money that’s been devoted to getting doctors to get electronic health records. But we’re still at kind of bare bones with Meaningful Use Stage 1. I mean, if you look at kind of what goes in to meeting the criteria for basic Meaningful Use requirements. One, most doctors would tell you that they’re not as clinically relevant, and they’re nowhere near where you and I would think as patients - what we want our doctors to have information around, just even something as basic as interoperability is not part of Meaningful Use Stage 1 or even Stage 2. You know, these conversations are so political about when to do these things, but I think that’s a big one. The infrastructure needed—even if you pay doctors—they’ll get an EMR that isn’t necessarily compatible with other ones because we don’t have interoperability, so you can have an electronic health record if you decide to invest in it, but you won’t speak to anyone else’s records. That’s a big barrier. That’s a huge problem. So I would say that’s two barriers. Getting the infrastructure in place and then interoperability and ability to speak to each other. I think the third one is also pretty basic. And that’s this kind of behavioral characteristic about sharing information in general. So, I’ve even called and spoken to other doctors’ offices trying to get information about one of my patients, and the doctors will say “Well, for HIPAA reasons I can’t do that. You need to have the patient call us and they need to fax us this form.” If you actually look at the barriers to how information can be exchanged that’s clinically relevant in real time for an actual patient, honestly it will frustrate you, even if those two doctors and their offices have those electronic health records in place. So, I’m not saying that HIPAA’s not a concern, but I do think that it tends to still be cultural for practitioners to not share information, and there’s something we need to do. There’s a big movement among patients about owning their data, like the Blue Button Initiative at the federal level and Medicare, where you can download your own data and it’s yours, and I think that’s really at its infancy. I think we need more movement to have patients have and own their medical records, but it also needs to be in a format that’s not just 500 page data dumps that make no sense. And that gets back to the information in exchanges being meaningful. Doctors like me don’t just want your past 20 years of medical records. We need certain pieces of information, and it’s how do you get that out of the system into the hands of someone who needs it.
JHT: So it sounds like some of the things you may be referencing in terms of discharge documentation or care summary records, things of that nature that would actually encompass or collapse a broad range of information into a usable document that can either be shared by the patient or shared electronically but would help foster a culture of sharing.
KP: Right, I’ve often thought of it—as I’ve told my own patients—as an executive summary of your medical problems. So, I’ve told my own patients, “In your medical record I’ve got what I would say is an active problem list. I don’t care about something that happened 30 years ago, but here are my active problems and here are my surgeries I’ve had and here are my active medications.” I’ve actually said, “If you do nothing else, you need that information along with your most recent set of labs.” And that will help me more than anything in probably the binders of data you bring me. So I think getting people to also understand exactly what you said, but also getting them to understand it at a practical level is where we still have a disconnect.
Question 6
JHT: Definitely. So, in thinking about the three challenges you identified—infrastructure, interoperability, and then changing the culture around sharing—what strategies are you seeing or do you think hold the greatest promise for encouraging greater exchange of health information across providers and with patients?
KP: So I do think the number one thing is to advance the Meaningful Use interoperability recommendations. There’s been a lot of politics around it. You can imagine the influences and interests of keeping the proprietary products proprietary and not sharing, but I think that could be the most important thing. If my EMR could talk to that doctor’s EMR, I don’t need to get on the phone and beg them to fax me something. So, I think that’s a huge policy issue that’s out there. And it’s not that the policy community hasn’t weighed in on what these interoperability standards should be, they’re just not being implemented. And so I think implementing those and enforcing those would be a huge policy directive. I think a second thing is more of that pragmatic piece of education of clinicians, you know, that exchanging information is not going to get you into legal trouble. I have to be honest: a lot of what doctors do, when they don’t want to send information, has nothing to do with not wanting to help; they don’t want to get into trouble and get flagged with a HIPAA violation. And I know that because there are even times when I feel that way. So, I think that those two things, the Meaningful Use interoperability standards implementation and enforcement paired with just education that a lot of us get from our colleagues and professional societies would be two big, two huge ways to overcome these obstacles.
JHT: Wonderful! Well, Kavita, we really appreciate your time this morning. This has been incredibly helpful.
KP: Great, thanks so much for having me!
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