The purchased care disconnect

By Peter Buxbaum
11:15 AM

MultiCare Health System, a private health network based in Puyallup, Wash., has a contract with nearby Madigan Army Medical Center to treat trauma patients. Once MultiCare's treatments are finished, it delivers its reports back to Madigan"by fax.

The scenario illustrates a disconnect between the military and a growing number of purchased care suppliers that now threatens to slow down progress by the Defense Department in creating an all-electronic health record system.

"Sixty-five percent of the care we provide is outside our direct care military system and is not captured in our electronic health record," said Chuck Campbell, chief information officer of the Military Health System (MHS).

MHS, a unit within the Office of the Secretary of Defense, is striving to assemble a complete electronic health record of its beneficiaries using two key health IT systems: AHLTA, its electronic health record application, and the Central Data Repository (CDR), a set of computer databases designed to warehouse data on all clinical encounters of MHS beneficiaries.

MHS has not developed this technology for the sake of efficiency alone. AHLTA is designed to provide a complete medical record to the clinician, and that, in turn, is thought to help reduce errors in the care of wounded service members, improve treatment outcomes and shrink military health costs.

The problem is that, in reality, there are two military health systems. The direct-care system is operated by the military in its own facilities and with its own providers. The purchased-care system consists of private organizations contracted to provide healthcare services to members of the armed services and other system beneficiaries. The purchased-care system has now grown to dwarf direct care.

At a congressional hearing in April, the surgeons general of the armed services expressed alarm at the growth in purchased care. "Purchased care was supposed to be a gap filler, but now it has twice the budget of direct care," said Lt. Gen. Eric Schoomaker, the Army surgeon general.

"Military treatment facility commanders don't have visibility to what is happening on the network side," added Vice Adm. Adam Robinson, the Navy surgeon general.

Widening gap
The growth of the purchased-care system has meant that there is a growing gap between MHS's aspirations to capture all medical encounters electronically and the reality that more and more data simply has no way of getting into MHS systems. It also has sent military and private providers scrambling to bridge the divide.

Most of those efforts have focused on interim solutions in anticipation that an ultimate solution will eventually present itself. That solution is in the works, at least conceptually, in the form of the National Health Information Network (NHIN), a system based on standards that would allow messages from different providers and networks to flow seamlessly among them.

The NHIN will succeed or fail partly through the efforts of the departments of Defense and Veterans Affairs, which are now harmonizing their clinical data to make their electronic health systems interoperable. But even if and when the NHIN is built, a major obstacle to transferring data between the military's direct- and purchased-care providers will remain: the lagging acceptance of electronic health record technology among commercial care providers.

The TRICARE Management Activity, the MHS organization that manages purchased care, has a policy on capturing reports from providers outside the direct-care system. TRICARE contracts require that a consult report be returned to the primary initiating provider within 10 days, noted TMA spokesperson Bonnie Powell. The purchased-care contractor "electronically send[s] the report back to the referring" facility.

But while TMA can set policy, it is likely honored more in the breach than in its observance. One thing is certain: purchased-care-provider reports are never sent back to MHS's Clinical Data Repository as computable data.

Does not compute
A Navy pilot program at Pensacola Naval Hospital in Florida experimented with a process by which outside reports were incorporated into the MHS electronic record by scanning paper documents as PDF files or receiving them through BrightFAX, an electronic faxing system that delivers faxes as image files via e-mail.This procedure recently became Navy policy, according to Capt. Bob Marshall, director of clinical informatics at the Navy's Bureau of Medicine and Surgery. Even then, the resulting document "is not computable, but it is viewable," said Marshall. "In most cases, unless you're doing disease surveillance, this is good enough."

But Lt. Col. Hon Pak, the Army chief medical information officer, said that MHS lacks sufficient capacity to store large volumes of imaged documents. "We can't store that many consults because it would break the CDR," he said. "The best we can do is get the consults back in electronic fax format."

Pak noted that MHS is developing an imaging and document repository, the Healthcare Artifact and Image Management Solution (HAIMS), which would provide additional capacity. But the contract to develop HAIMS was awarded only in April 2009. "In the meantime," said Pak, "there is no standardized process" to capture imaged documents.

MultiCare Health System, the private network which has the trauma contract with Madigan, now faxes Madigan reports of patient care, said Maggie Lohnes, the company's administrator of clinical information management. MultiCare and Madigan have investigated the exchange of electronic records and have built a business case in support of that proposition. Once MHS was convinced of the program's efficacy, MultiCare installed a Madigan test server in its facility.

But it's a baby step. "The server is outside Madigan's firewall," said Lohnes. "The intent is to start transmitting TRICARE consults electronically from MultiCare to Madigan" before the end of this year.

PHRs to the rescue?
Another effort to bridge the digital divide between direct and purchased care involves the use of patient-controlled personal health records (PHR). The theory behind PHRs is that better informed patients will take more responsibility for managing their own health, leading to better outcomes, as well as lower costs. PHRs have the added advantage of being cloud- or Internet-based, thus offering a way to easily cross institutional barriers.

The Military Health System introduced a personal health record pilot in December 2008, called MiCare, at Madigan Army Medical Center. The project has recently been extended to the Navy National Medical Center in Bethesda, Md., and the civilian Riverside Health System, a Newport News, Va.-based hospital system which treated 8,807 military patients last year under the TRICARE health plan.

MiCare allows beneficiaries to choose between two free Web-based PHRs: Microsoft HealthVault and Google Health. Both serve as patient-controlled repositories for health information downloaded from AHLTA, as well as from civilian providers, plans and pharmacies, at the patient's choice. The beneficiary can also decide whether, and to what extent, to share information with healthcare providers.

"We are working on various approaches to get purchased-care documentation into the PHR," said Col. Keith Salzman, Madigan's chief of informatics. (See sidebars.)

But there are a number of problems associated with using PHRs as an electronic bridge between the direct and purchase care systems. One is that the use of PHRs is entirely voluntary. "If the patient does not sign up, there is no connection," said Salzman. Madigan's MiCare pilot currently boasts 400 enrollees.

Pak is skeptical whether MiCare will gain sufficient tract

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