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Hosted by Douglas K. Smith MD, CPHIMS           IT Voice of Clinicians

Meaningful Collaboration - Improving Healthcare Quality: One Collaboration at a Time?!
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Game Theory, Meaningful Use Stage III, Medicare, Uncategorized

Halamka: Stage 3 Meaningful Use Should Be Eliminated | Game Theory Suggests Why!

November 22, 2015by Douglas K Smith MD, CPHIMSNo Comments

I already had a ton of respect for John* as a person, and for his exceptional insight dedication to the healthcare industry and as an industry peer. But this November 5th article featuring took him up even a few more rungs on my respect ladder:

*John Halamka, M.D., CIO at Boston s Beth Israel Deaconess Medical Center, was a critic of Stage 3 of the Meaningful Use program even before it was finalized. Now with the final rule out, he d like to see Stage 3 eliminated altogether.

Source: Halamka: Stage 3 Meaningful Use Should Be Eliminated | HDM Top Stories

As a read it (…my head nodding “absolutely”), an interesting analogy struck me as to the whole Meaningful Use evolution: The “Game Theory”. The social economic “Game theory” studies how groups of individuals make decisions in order to maximize personal benefits while limiting risks or loss.

Decision Theory is a branch of Game Theory and “argues that preferences among risky alternatives can be described by the maximization of the expected value of a numerical utility function, where utility may depend on a number of things, but in situations of interest to economists often depends on money income”

Generally there is a single best way to play the game to maximize income and reduce risks and costs given the rules of the game.

For example, during the early days of the Meaningful Use program, the best game theory approach for a physician was early enrollment in the meaningful use program in order to maximize incentive payments but not to progress to Meaningful Use stage II that would subject the physician to increased costs. A typical physician would receive maximal payments in the first three years of meaningful use involvement.The best game theory approach would be to remain at meaningful use stage I level and minimize costs associated with advancing to Meaningful Use 2. This was the exact approach taken by best majority of physicians in the meaningful use program.

The rules of the game changed dramatically for the recently announced Meaningful Use stage III rules of engagement.

During Meaningful Use stage I, the compliance  requirements were low and the financial benefits were high. During Meaningful Use stage II, most physicians received a declining financial incentive and the compliance requirements and compliance costs were higher so very few physicians adopted stage II today. During stage III, most physicians have received all financial incentives and the rules of the game have changed from a financial incentive “carrot” to a compliance penalty “stick”. The change in the rules of the MU game would suggest the best play for physicians is to minimize penalties in order to maximize net gain because there’s no longer financial incentive to adopt increased compliance costs.

Unfortunately there’s also a parallel Medicare reimbursement “game theory” being played out over the past ten years. Although there is some variation, Medicare rates have decreased by up to 70% during the past 10 years. In many cases, physicians perform medical treatment for Medicare reimbursement rates at less than the cost required to provide the services.  The rules of the “Medicare Reimbursement Game” have changed each year for the past 10 years.

Many educated physicians have concluded the best play to the Medicare reimbursement game is to stop accepting Medicare patients because they cannot lose money on each case and make it up by increasing volume. In the private practice world where cost shifting is not as available as in-hospital practice, many physicians have ceased accepting new Medicare patients.

The combination of low Medicare reimbursement rates and increasing costs for compliance with the Meaningful Use stage III compliance mean that most physicians face increasing information technology costs to achieve Meaningful Use stage III compliance or face decreased Medicare reimbursement rates are penalties for not complying. When faced with this dilemma, many physicians have concluded the best play for the Medicare reimbursement/Meaningful Use game is to opt-out of Medicare reimbursement in order to avoid penalties associated with the Meaningful Use stage III program. Many of my colleagues have already come to this conclusion and have implemented this decision.

The social consequences of this best practice of medical game theory could be disastrous. If only 5 to 10% of physicians in the United States decide that the best practice of Medicare/MU game theory is to cease accepting Medicare and withdrawing from Meaningful Use, Medicare would likely collapse. Patients would be driven to already overloaded medical practices and thereby further diminishing their profit margin and likely causing these practices to adopt the same game theory best practice.

In the Game Theory, the only way to change the best practice decisions of educated players in the game is to change the rules of the game.

In general, this would be to increase the incentives for participation in Medicare by increasing reimbursement rates or by increasing financial incentives to adopt Meaningful Use stage III requirements or by very least delaying penalties.

Unfortunately the ONC and Congress have become intoxicated during the past ten years and have not yet sobered up to the realities of Medical Game theory: It is not in the best interests of a medical provider to invest capital to upgrade to meet MU stage 3 requirements in order to maintain the privilege of losing money on every Medicare patient. Doctors may not always be great businessmen but this is in the “no brainer” category.

Meaningful Collaboration(SM) is a healthcare provider centric approach to information sharing. A proxy collaboration platform is utilized to bypass these information blocking practices.

Meaningful Collaboration(SM) is a healthcare provider centric approach to information sharing. A proxy collaboration platform is utilized to bypass these information blocking practices


Meaningful USe was the EHR Carrot. Regulatory Controls including EHR de-certification, Federal False Claims Act, and Safe Harbors Act are the three headed Federal Dog nipping at the butts of EHRs systems.

Meaningful Use was the EHR Carrot. Regulatory Controls including EHR de-certification, Federal False Claims Act, and Safe Harbors Act are the three headed Federal Dog nipping at the butts of EHRs systems.

Accountable Care Organization ACO), Information Blocking, Interoperability, Meaningful Collaboration, Uncategorized

Information Blocking: A New Term and Promise of a New Era In Electronic Health Information Sharing

October 27, 2015by Douglas K Smith MD, CPHIMSNo Comments

Information Blocking: A New Term And Promise of a New Era In Electronic Health Information Sharing | At the intersection of health, health care, and policy.

Source: Information Blocking: A New Term And The Promise Of A New Era In Electronic Health Information Sharing

ONC-HIT Interoperability “Imminent Domain”?!?

This is a great summary article that calls attention to the ONC-IT shot off the EMR bow(s).  It start with a quote from Report on Health Information Blocking from ONC-HIT to Congress dated April 2015.

“[…] some business practices, though they may arguably advance legitimate individual economic interests, interfere with the exchange of electronic health information in ways that raise serious information blocking concerns. At some point, ONC believes that decisions to engage in such practices are unreasonable as against public policy […]”

This article points out that the ONC-HIT statements seem to put vendors on notice that business policies that get in the way of the ONC interoperability roadmap plans will not be tolerated. This is the cyber equivalent of the Federal “Imminent Domain” of the Monroe doctrine, Lincoln’s railroad imminent domain, and the imminent domain of the 1950s required to complete the US highway system under Eisenhower. My high school history teachers pointed out that Federal “Imminent Domain” is a pre-requisite for overcoming business conflicts of interest and local geographic business interests that could derail (pun intended) a national initiative such as the Lincoln transcontinental railway project.

The ONC-HIT report define “information blocking” as containing the following three components:

  1. Interference. There must be “an act or course of conduct that interferes with the ability of authorized persons or entities to access, exchange, or use electronic health information.”
  2. Knowledge. “The decision to engage in information blocking [must be] made knowingly.”
  3. No Reasonable Justification. Conduct must be “objectively unreasonable in light of public policy.”

These are fighting words but unfortunately the simple words “[must be] made knowingly” and “objectively unreasonable”remind me of the  burden of proof of Tobacco company “Knowing” that tobacco caused cancer. The legal debates went on for decades until memos and communications surfaced that demonstrated that the large tobacco companies had put business interests above the health of their clients.

The ONC-HIT suggests 4 potential actions (regulatory sticks) to replace the monetary carrots that created the EMR “too big to control” giants:

  1. Threaten to decertify EMR systems that are proven to engage in “information blocking”.
  2. Increase transparency about vendor behavior.
  3. Establish a a set of governance “rules of the road”.
  4. Clarifying HIPAA and other health information privacy laws will help remove the potential that exists today for provider organizations and vendors to use these laws as a cover to engage in information blocking.

While these Federal “sticks” may be successful in raising public awareness and appeasing Congress, history would suggest that similar to the Lincoln transcontinental railway project: it will be slow, expensive and may produce a nation of metaphorical displaced Indians and near-extinct buffaloes. Unless the Supreme Court rules about whether patients or proprietors own ePHI and whether the ONC-HIT railway has “imminent domain’ over the perceived squatting rights of the electronic medical records (EMR) dynasties that were created as an unintended consequence of the Federal “Meaningful Use” program.

The ONC-HIT interoperability train has left the [cyber train] station, it may be an interesting and very rough ride. We believe the inherent conflict between ONC-HIT interoperability roadmap and the EMR dynasties’ business incentive to block information sharing with inevitably lead to a Supreme Court showdown. In the meantime, we believe that the Accountable Care Organization (ACO) and shared risk initiatives will require “Meaningful Collaboration(TM)” between healthcare providers rather than just Meaningful Use to simply satisfy compliance requirements.

The basic concept of Meaningful Collaboration(TM) between healthcare stakeholders is a vendor neutral collaboration platform where stakeholders can share provider selected content similar to old hospital charts where doctors rounded at all hours and wrote succinct SOAP notes and contributed provider-centric external content. “Here is what you need to know” to render you consultation.

The radiology industry has experienced “information blocking” with each advance in technology as vendors create proprietary layers to improve business distinction and profitability. In an upcoming series of BLOGs I will discuss what we have learned form the past 30 years of Information Blocking in the Radiology Industry.

We hope for a High Speed Rail rather than Transcontinental Cyber-TrainWreck.

Douglas K Smith MD is ABPM Clinical Informatist and ABR certified radiologist, CHCIO, CPHIMS, serial doctorpreneur, inventor and “doctor centric software designer/developer”. 

Information Blocking by EMR sytems threaten to disconnect the ONC inteoperability roadmap.

Information Blocking by EMR systems threaten to disconnect the ONC interoperability roadmap.

Meaningful Collaboration allows medical providers within different EMR systems to collaborate and share content within a vendor neutral platform using a Unique patient identifier.

Meaningful Collaboration allows medical providers within different EMR systems to collaborate and share content within a vendor neutral platform using a variety of interoperability methods including: Application Programming Interface (API), HL7 FHIR, and web services connecting applications that may be required to provide supporting features. Meaningful Collaboration(TM) is an physician inspired approach of leveraging technology to foster collaboration between medical stakeholders to enhance care and improve efficiency of healthcare/

 

 

 

 

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