REVIEW URRENT C OPINION
The value of healthcare data in ophthalmology Nicholas G. Anderson a, John Pollack b, and David Williams c
Purpose of review The healthcare system creates a vast amount of data that are utilized by a wide variety of entities for a multitude of purposes. Physicians have traditionally been unable to control who has access to their data or how their data are used. The widespread adoption of the Electronic Health Record (EHR) by physicians will create a larger and more valuable healthcare data market with broad implications for the healthcare system. It is, therefore, important for physicians to understand the evolving healthcare data market and the importance of maintaining ownership of and control over their electronic health data. Recent findings Several entities, including private health insurance companies, federal payers, medical societies, and pharmaceutical companies are increasingly utilizing healthcare data to drive reimbursement policies and commercial initiatives. Summary Given the critical importance that EHR data will play in multiple aspects of the healthcare industry, it is in physicians’ interest to maintain ownership and control of the healthcare data that they generate. It would be prudent for physicians to exercise caution before relinquishing data rights to entities that may sell the data to payers or other customers with whom physicians’ interests may not be aligned. Keywords American Medical Association Physician Masterfile, electronic health records, healthcare data, healthcare data mining
INTRODUCTION
HEALTHCARE DATA SOURCES
The healthcare system creates a vast amount of data, and these data have significant value across the healthcare industry. Major data sources include outpatient prescription data, insurance claims data, and pharmaceutical distribution data. A wide variety of organizations in the data, health insurance, pharmaceutical, medical device, and healthcare research industries utilize these sources of healthcare data. Although it is physicians who generate the majority of the healthcare data, they have traditionally been unable to control who has access to their data or how their data are used and have been unable to capitalize on their data’s economic value. The development and widespread adoption of the electronic health record (EHR) by healthcare systems, hospitals, and physicians promises to create a much larger, more granular, and more valuable healthcare data market with broad implications for the healthcare system. It is, therefore, important for physicians to understand the evolving healthcare data market and the importance of maintaining ownership of and control over their electronic health data.
Retail pharmacy prescriptions are one of the largest sources of healthcare data. When a physician’s prescription is filled by a retail pharmacy, many pharmacies sell multiple data elements from that prescription to data mining companies, such as IMS Health. The data mining companies in turn aggregate data from multiple prescriptions and multiple pharmacies into a single database and sell that information to customers, such as pharmaceutical companies. Prescription information that is collected and sold includes the name, dose, and quantity of the medication, the date of the a
Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee, bDepartment of Ophthalmology, Rush University Medical Center, Chicago, Illinois and cDepartment of Ophthalmology, University of Minnesota, Minneapolis, Minnesota, USA Correspondence to Nicholas G. Anderson, MD, Southeastern Retina Associates, Assistant Clinical Professor, Department of Surgery, University of Tennessee Medical Center, Knoxville, TN 37919, USA. Tel: +1 865 588 0811; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:191–194 DOI:10.1097/ICU.0000000000000047
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Retinal, vitreous and macular disorders
KEY POINTS The development and widespread adoption of the EHR by healthcare systems, hospitals, and physicians will create a much larger, more granular, and more valuable healthcare data market with broad implications for the healthcare system. Physicians should maintain ownership and control of the healthcare data that they generate. Physicians should exercise caution before relinquishing data rights to EHR vendors or other entities that may sell the data to payers or other customers with whom physicians’ interests are not aligned.
prescription, and the prescribing physician’s name. Because of privacy regulations, patient identifiers are not sold, but each patient is assigned a unique alphanumerical identifier that allows longitudinal tracking of individual patients. Using outpatient prescription data, the data miner can, therefore, develop and sell detailed reports on individual physicians, including the number of prescriptions they write for specific medications, trends in brand-name versus generic utilization, and changes in prescribing habits following sales representative visits or new product launches. An extensive patient profile can also be created using de-identified patient data, including which medications an individual patient is taking, how long they have been taking them, when they start a new medication, and when they switch from one medication to another [1]. Prescription data mining is a significant revenue source for pharmacies, pharmacy benefits managers, and data miners. One national pharmacy retailer, for example, valued its ‘purchased prescription files’ at US$749 million in a 2010 Securities and Exchange Commission filing [2]. Medical insurance claims data are another major source of physician and patient information. Nearly, every physician–patient encounter generates claims, including office visits, diagnostic services, surgical and office procedures, and officeadministered medications. Health insurance companies, including secondary Medicare payers and Medicaid payers, sell those claims to data mining companies. The purchased claims data include physician name, patient demographics, clinical information, including diagnosis codes, procedure codes, and drug codes, and financial information, including charges, reimbursements, and co-pay information. Data mining companies aggregate claims data from multiple payers to develop a detailed report on individual physicians, including the number and mix of patients they see, the 192
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number and type of surgeries, procedures, and diagnostics they perform, as well as their in-office drug usage [3]. Data mining companies also collect data from pharmaceutical distributors and manufacturers. The data miners purchase sales data directly from pharmaceutical manufacturers and pharmaceutical distributors on pharmaceutical purchases from healthcare providers and other purchasers. Although individual physician data are typically not included in the reports, detailed information can be generated on physician practices, surgery centers, and other healthcare entities. These data can be used to determine utilization patterns and can be tracked over time [4].
THE AMERICAN MEDICAL ASSOCIATION PHYSICIAN MASTERFILE Data mining companies also obtain physician demographic information from other sources to correlate clinical data sources with specific physicians and to provide industry with physician demographic and contact information. The American Medical Association (AMA) ‘Physician Masterfile’ is one source of such information [1]. This is a database that includes all United States physicians regardless of whether they are members of the AMA. The AMA began compiling physician data almost 100 years ago and now includes information on approximately 1.2 million physicians, about twothirds of whom are not AMA members [5]. A physician is entered into the Masterfile upon entering medical school and remains in the Masterfile even after death [6 ]. The Masterfile contains detailed information on physicians, including name, date of birth, sex, address, telephone number, medical school, medical school graduation date, postgraduate training information, present employment and type of practice, practice locations, and practice manager [7]. The AMA generates an estimated $45 million in annual revenue from the Physician Masterfile [8]. Although physicians are automatically opted-in to the Masterfile, the AMA does allow physicians to restrict their information from being viewed by pharmaceutical sales representatives and their direct supervisors. However, only approximately 5% of physicians have actually opted-out, possibly because of lack of awareness of the Masterfile and/or their ability to opt-out [5]. To opt-out, physicians submit an online request through the AMA’s Physician Data Restriction Program (PDRP) webpage (https://apps.ama-assn.org/PDRP/locate.do). The PDRP is limited and does not preclude pharmaceutical companies or other industries from purchasing or viewing a physician’s data. Only &
Volume 25 Number 3 May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The value of healthcare data in ophthalmology Anderson et al.
sales representatives and their direct supervisors are denied access to physician data, other company officials may still view data from physicians enrolled in the PDRP [8]. There are no strong compliance or enforcement mechanisms in the program. The AMA’s formal Do Not Release policy allows a physician to completely prevent his or her data from being viewed by pharmaceutical companies. To opt-out completely, a physician is required to print, sign, and return a letter to the AMA. However, by submitting that letter a physician also precludes state licensing boards and hospital credentialing committees from viewing his or her data without providing additional written authorization for those individual entities [6 ]. Currently, physicians are automatically optedin to allowing their demographic data to be aggregated and sold. A more preferable model may be one in which physicians are automatically opted-out of data sharing and sales, and those physicians who wish to allow their information to be shared or sold could opt-in with multiple options of entities with whom they would authorize to view their data. For example, physicians could have the option to opt-out of having their data viewed by the pharmaceutical industry while still allowing it to be shared with credentialing boards. &
HEALTHCARE DATA IN THE ERA OF ELECTRONIC HEALTH RECORD The breadth and granularity of healthcare data is increasing significantly, as physicians continue to transition to EHRs. As the utilization of this data source increases, so will its value. The value of EHR data for all of medicine is estimated to grow to US$5 billion by 2020 [9]. The question of data ownership has, therefore, become critical in the era of EHR [10 ]. Several interested parties, including patients, physicians, and EHR vendors may appropriately lay claim to EHR data. Some EHR vendors recognize that data generated by physicians are owned by the physicians, whereas other EHR vendors add clauses to their contracts transferring all rights for sale of de-identified data to the EHR vendor [11]. Those vendors can then sell de-identified medical record data as an ancillary revenue stream. Although EHR data will potentially have a positive effect on the healthcare system, it may also be used in ways that may be of concern to physicians. Payers may use EHR data to create national ‘benchmarks’ to support their payment policies at both local and national levels. Payers commonly use utilization data to subdivide physician networks into ‘performance’ tiers, and then use differential copayment or coinsurance rates to promote physicians identified as more cost-effective and to reduce &
the impact of physicians identified as less costeffective [12]. Some ophthalmologists have been dropped altogether by insurance companies [13]. EHR outcomes data will also play a critical role, as health insurers migrate away from fee-for-service payment models and toward value-based or outcomes-based payment models [14]. Value-based payment models reward healthcare providers for meeting quality and efficiency goals, rather than for simply rewarding quantity of work, as in feefor-service models. EHR data will be an important source of data for health insurers and government payers in determining physician payment. In a recent survey of health insurers, 82% of the respondents said that development of new payment models was a ‘major priority’ for their organizations. Sixty percent of respondents predicted that value-based models will support more than half of their businesses. Nearly, three-quarters of the insurance executives said their companies planned to implement automated data acquisition from providers within the next 12–18 months [15 ]. As payers move toward these value-based and outcomes-based payment models, physicians will need access to utilization and outcomes data, so they can successfully negotiate contracts and remain sustainable under alternative payment models. Payers have independent access to physician utilization data through claims data and other data sources. Physicians will need access to their own utilization metrics to generate cost estimates in alternative payment models. Similarly, access to outcomes and quality data will become more and more important. Physicians will need to equal access to this type of data. To accomplish this goal, physicians need to be sure that they maintain ownership and rights to their data, and that their EHR vendors make their data available for analysis. The American Academy of Ophthalmology (AAO) launched the Intelligent Research in Sight (IRIS) data registry in 2013 [16]. IRIS allows physicians to upload their EHR data for aggregation with data from other AAO members. Benchmarking and quality measurement analyses are performed and used to help practices achieve pay-for-performance incentives and participate in Maintenance of Certification programs. Participation requires physicians to grant the AAO a royalty-free license to utilize all de-identified data submitted to IRIS. Although the AAO does not currently commercialize de-identified practice data, the royalty-free license permits it to do so in the future. Other medical societies, such as the American College of Cardiology, already sell information from their EHR data registries to the pharmaceutical industry and other industry customers [17].
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&
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193
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Retinal, vitreous and macular disorders
EHR data can be thought of as intellectual property and should belong to the physicians who create the data. A physician’s EHR data disclose how he or she treats patients and manages specific conditions, which procedures, diagnostics, and pharmaceuticals he or she utilize, and the outcomes that result from those treatment modalities and utilization patterns. As such, it is reasonable for physicians to be hesitant about relinquishing their intellectual property rights to EHR vendors or other entities. Physicians typically do not directly benefit from the commercialization of their healthcare data. In its native state, EHR data have essentially no monetary value to individual physicians and physician practices. There are several reasons for this. First, regulatory statutes prohibit physicians from selling their data to pharmaceutical companies or medical device makers either directly or through entities in which they have an ownership interest. Secondly, individual physician and practice data have little value unless these are combined with data from a large number of demographically diverse physicians and practices. And finally, data stored on EHR servers are not in a saleable format. In order for it to be marketable, the EHR data need to be converted into an analyzable data format, stripped of all patient identifiers in compliance with the Health Insurance Portability and Accountability Act, stripped of physician identifiers in compliance with Office of Inspector General statutes, and aggregated with data from a demographically and geographically diverse group of physicians.
CONCLUSION The healthcare data mining industry currently acquires, aggregates, and sells vast amounts of detailed information about physicians and their patients. However, physicians do not directly benefit from this valuable data that they unknowingly contribute to the industry. Given the critical importance that EHR data will play in multiple aspects of the healthcare industry, it is in physicians’ interest to maintain ownership and control of the healthcare data that they generate. It would be prudent for physicians to exercise caution before relinquishing data rights to EHR vendors or other entities that may sell the data to payers or other customers with whom physicians’ interests are not aligned. It is advisable for physicians, their administrators, and their attorneys to carefully read User Agreements in EHR vendor and other contracts to assure that the data are owned by the physicians and that they understand the implications of having their data potentially sold by the vendor.
194
www.co-ophthalmology.com
Acknowledgements N.A., MD, D.F.W.s, MD, MBA, and J.S.P., MD, cofounded Vestrum Health, LLC in an effort to help retina specialists and other physicians gain greater control of their data. Conflicts of interest N.A., MD: COVALENT MEDICAL, INC: Founder, Stockholder; DEROYAL INDUSTRIES, INC: Intellectual Property Rights; GENENTECH, INC: Speaker, Honoraria; RAPID PATHOGEN SCREENING, INC: Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder. J.S.P., MD: CLARUS ACUITY GROUP: Founder, Stockholder; COVALENT MEDICAL, INC: Founder, Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder. D.F.W., MD, MBA: COVALENT MEDICAL, INC: Founder, Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Orentlicher D. Prescription data mining and the protection of patients’ interests. J Law, Med Ethics 2010; 38:74–84. 2. Baynes T. Walgreen accused of selling patient data. Reuters. 2011. 3. Wilson J, Bock A. The benefit of using both claims data and electronic medical record data in healthcare analysis. White Paper Optum Insight. 2012. 4. Leichter SB. The influence of drug distribution data on diabetes care in the community. Clin Diab 1999; 17:166–167. 5. Fugh-Berman A. Prescription tracking and public health. J Gen Intern Med 2008; 23:1277–1280. 6. AMA Physician Masterfile. [Accessed on 8 January 2013] http://www.ama& assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile. Important information for physicians regarding the AMA Physician Masterfile. 7. American Medical Association. Presentation: AMA Professional Physician Data. Department of Database Licensing. 2009. 8. Steinbrook R. For sale: physicians’ prescribing data’. N Engl J Med 2006; 354:2745–2747; 2745. 9. Singer N. When 2þ2 equals a privacy question. New York Times. 2009. BU4. 10. Shay DF, Gosfield AG. EHR data control: a practical primer. Dermatology & World. 2012. Analysis of legal issues surrounding the ownership of EHR data. 11. Practice Fusion User Agreement. [Accessed 6 December 2013] http:// www.practicefusion.com/pages/user-agreement.html. 12. Thomas JW. Economic profiling of physicians: what is it? Developed for the American Medical Association June 2006. 13. Walter K. Academy urges CMS to address united healthcare medicare advantage terminations. American Academy of Ophthalmology ‘‘Eye on Advocacy’’ Blog. November 8, 2013. 14. McCan N. American Society of Cataract and Refractive Surgery/American Society of Ophthalmic Administrators Winter Update 2013. Reported in: EyeWorld. [Accessed 10 September 2013]. http://www. eyeworld.org/ article-reporting-live-from-ascrs-asoa-winter- update-2013. 15. Porter Research. The health plan readiness to operationalize value-based & payment models study. 2013. http://www.nbch.org/nbch/files/ccLibraryFiles/ Filename/000000002854/Availity_Study_on_Plan_Readiness_to_Operatio nalize_New_Payt_Models.pdf Analysis of payer motivation and readiness in transitioning to value-based payment models. 16. Sternberg P, IRIS: an extraordinary opportunity to improve outcomes. American Academy of Ophthalmology 2013. 17. American College of Cardiology Corporate Support Catalogue. [Accessed on 10 September 2013] http://www.cardiosource.org/ACC//media/Files/ ACC/Support%20the%20ACC/C1202_2012Corporate_Support_Catalog_ highres.ashx.
Volume 25 Number 3 May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The value of healthcare data in ophthalmology Nicholas G. Anderson a, John Pollack b, and David Williams c
Purpose of review The healthcare system creates a vast amount of data that are utilized by a wide variety of entities for a multitude of purposes. Physicians have traditionally been unable to control who has access to their data or how their data are used. The widespread adoption of the Electronic Health Record (EHR) by physicians will create a larger and more valuable healthcare data market with broad implications for the healthcare system. It is, therefore, important for physicians to understand the evolving healthcare data market and the importance of maintaining ownership of and control over their electronic health data. Recent findings Several entities, including private health insurance companies, federal payers, medical societies, and pharmaceutical companies are increasingly utilizing healthcare data to drive reimbursement policies and commercial initiatives. Summary Given the critical importance that EHR data will play in multiple aspects of the healthcare industry, it is in physicians’ interest to maintain ownership and control of the healthcare data that they generate. It would be prudent for physicians to exercise caution before relinquishing data rights to entities that may sell the data to payers or other customers with whom physicians’ interests may not be aligned. Keywords American Medical Association Physician Masterfile, electronic health records, healthcare data, healthcare data mining
INTRODUCTION
HEALTHCARE DATA SOURCES
The healthcare system creates a vast amount of data, and these data have significant value across the healthcare industry. Major data sources include outpatient prescription data, insurance claims data, and pharmaceutical distribution data. A wide variety of organizations in the data, health insurance, pharmaceutical, medical device, and healthcare research industries utilize these sources of healthcare data. Although it is physicians who generate the majority of the healthcare data, they have traditionally been unable to control who has access to their data or how their data are used and have been unable to capitalize on their data’s economic value. The development and widespread adoption of the electronic health record (EHR) by healthcare systems, hospitals, and physicians promises to create a much larger, more granular, and more valuable healthcare data market with broad implications for the healthcare system. It is, therefore, important for physicians to understand the evolving healthcare data market and the importance of maintaining ownership of and control over their electronic health data.
Retail pharmacy prescriptions are one of the largest sources of healthcare data. When a physician’s prescription is filled by a retail pharmacy, many pharmacies sell multiple data elements from that prescription to data mining companies, such as IMS Health. The data mining companies in turn aggregate data from multiple prescriptions and multiple pharmacies into a single database and sell that information to customers, such as pharmaceutical companies. Prescription information that is collected and sold includes the name, dose, and quantity of the medication, the date of the a
Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee, bDepartment of Ophthalmology, Rush University Medical Center, Chicago, Illinois and cDepartment of Ophthalmology, University of Minnesota, Minneapolis, Minnesota, USA Correspondence to Nicholas G. Anderson, MD, Southeastern Retina Associates, Assistant Clinical Professor, Department of Surgery, University of Tennessee Medical Center, Knoxville, TN 37919, USA. Tel: +1 865 588 0811; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:191–194 DOI:10.1097/ICU.0000000000000047
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Retinal, vitreous and macular disorders
KEY POINTS The development and widespread adoption of the EHR by healthcare systems, hospitals, and physicians will create a much larger, more granular, and more valuable healthcare data market with broad implications for the healthcare system. Physicians should maintain ownership and control of the healthcare data that they generate. Physicians should exercise caution before relinquishing data rights to EHR vendors or other entities that may sell the data to payers or other customers with whom physicians’ interests are not aligned.
prescription, and the prescribing physician’s name. Because of privacy regulations, patient identifiers are not sold, but each patient is assigned a unique alphanumerical identifier that allows longitudinal tracking of individual patients. Using outpatient prescription data, the data miner can, therefore, develop and sell detailed reports on individual physicians, including the number of prescriptions they write for specific medications, trends in brand-name versus generic utilization, and changes in prescribing habits following sales representative visits or new product launches. An extensive patient profile can also be created using de-identified patient data, including which medications an individual patient is taking, how long they have been taking them, when they start a new medication, and when they switch from one medication to another [1]. Prescription data mining is a significant revenue source for pharmacies, pharmacy benefits managers, and data miners. One national pharmacy retailer, for example, valued its ‘purchased prescription files’ at US$749 million in a 2010 Securities and Exchange Commission filing [2]. Medical insurance claims data are another major source of physician and patient information. Nearly, every physician–patient encounter generates claims, including office visits, diagnostic services, surgical and office procedures, and officeadministered medications. Health insurance companies, including secondary Medicare payers and Medicaid payers, sell those claims to data mining companies. The purchased claims data include physician name, patient demographics, clinical information, including diagnosis codes, procedure codes, and drug codes, and financial information, including charges, reimbursements, and co-pay information. Data mining companies aggregate claims data from multiple payers to develop a detailed report on individual physicians, including the number and mix of patients they see, the 192
www.co-ophthalmology.com
number and type of surgeries, procedures, and diagnostics they perform, as well as their in-office drug usage [3]. Data mining companies also collect data from pharmaceutical distributors and manufacturers. The data miners purchase sales data directly from pharmaceutical manufacturers and pharmaceutical distributors on pharmaceutical purchases from healthcare providers and other purchasers. Although individual physician data are typically not included in the reports, detailed information can be generated on physician practices, surgery centers, and other healthcare entities. These data can be used to determine utilization patterns and can be tracked over time [4].
THE AMERICAN MEDICAL ASSOCIATION PHYSICIAN MASTERFILE Data mining companies also obtain physician demographic information from other sources to correlate clinical data sources with specific physicians and to provide industry with physician demographic and contact information. The American Medical Association (AMA) ‘Physician Masterfile’ is one source of such information [1]. This is a database that includes all United States physicians regardless of whether they are members of the AMA. The AMA began compiling physician data almost 100 years ago and now includes information on approximately 1.2 million physicians, about twothirds of whom are not AMA members [5]. A physician is entered into the Masterfile upon entering medical school and remains in the Masterfile even after death [6 ]. The Masterfile contains detailed information on physicians, including name, date of birth, sex, address, telephone number, medical school, medical school graduation date, postgraduate training information, present employment and type of practice, practice locations, and practice manager [7]. The AMA generates an estimated $45 million in annual revenue from the Physician Masterfile [8]. Although physicians are automatically opted-in to the Masterfile, the AMA does allow physicians to restrict their information from being viewed by pharmaceutical sales representatives and their direct supervisors. However, only approximately 5% of physicians have actually opted-out, possibly because of lack of awareness of the Masterfile and/or their ability to opt-out [5]. To opt-out, physicians submit an online request through the AMA’s Physician Data Restriction Program (PDRP) webpage (https://apps.ama-assn.org/PDRP/locate.do). The PDRP is limited and does not preclude pharmaceutical companies or other industries from purchasing or viewing a physician’s data. Only &
Volume 25 Number 3 May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The value of healthcare data in ophthalmology Anderson et al.
sales representatives and their direct supervisors are denied access to physician data, other company officials may still view data from physicians enrolled in the PDRP [8]. There are no strong compliance or enforcement mechanisms in the program. The AMA’s formal Do Not Release policy allows a physician to completely prevent his or her data from being viewed by pharmaceutical companies. To opt-out completely, a physician is required to print, sign, and return a letter to the AMA. However, by submitting that letter a physician also precludes state licensing boards and hospital credentialing committees from viewing his or her data without providing additional written authorization for those individual entities [6 ]. Currently, physicians are automatically optedin to allowing their demographic data to be aggregated and sold. A more preferable model may be one in which physicians are automatically opted-out of data sharing and sales, and those physicians who wish to allow their information to be shared or sold could opt-in with multiple options of entities with whom they would authorize to view their data. For example, physicians could have the option to opt-out of having their data viewed by the pharmaceutical industry while still allowing it to be shared with credentialing boards. &
HEALTHCARE DATA IN THE ERA OF ELECTRONIC HEALTH RECORD The breadth and granularity of healthcare data is increasing significantly, as physicians continue to transition to EHRs. As the utilization of this data source increases, so will its value. The value of EHR data for all of medicine is estimated to grow to US$5 billion by 2020 [9]. The question of data ownership has, therefore, become critical in the era of EHR [10 ]. Several interested parties, including patients, physicians, and EHR vendors may appropriately lay claim to EHR data. Some EHR vendors recognize that data generated by physicians are owned by the physicians, whereas other EHR vendors add clauses to their contracts transferring all rights for sale of de-identified data to the EHR vendor [11]. Those vendors can then sell de-identified medical record data as an ancillary revenue stream. Although EHR data will potentially have a positive effect on the healthcare system, it may also be used in ways that may be of concern to physicians. Payers may use EHR data to create national ‘benchmarks’ to support their payment policies at both local and national levels. Payers commonly use utilization data to subdivide physician networks into ‘performance’ tiers, and then use differential copayment or coinsurance rates to promote physicians identified as more cost-effective and to reduce &
the impact of physicians identified as less costeffective [12]. Some ophthalmologists have been dropped altogether by insurance companies [13]. EHR outcomes data will also play a critical role, as health insurers migrate away from fee-for-service payment models and toward value-based or outcomes-based payment models [14]. Value-based payment models reward healthcare providers for meeting quality and efficiency goals, rather than for simply rewarding quantity of work, as in feefor-service models. EHR data will be an important source of data for health insurers and government payers in determining physician payment. In a recent survey of health insurers, 82% of the respondents said that development of new payment models was a ‘major priority’ for their organizations. Sixty percent of respondents predicted that value-based models will support more than half of their businesses. Nearly, three-quarters of the insurance executives said their companies planned to implement automated data acquisition from providers within the next 12–18 months [15 ]. As payers move toward these value-based and outcomes-based payment models, physicians will need access to utilization and outcomes data, so they can successfully negotiate contracts and remain sustainable under alternative payment models. Payers have independent access to physician utilization data through claims data and other data sources. Physicians will need access to their own utilization metrics to generate cost estimates in alternative payment models. Similarly, access to outcomes and quality data will become more and more important. Physicians will need to equal access to this type of data. To accomplish this goal, physicians need to be sure that they maintain ownership and rights to their data, and that their EHR vendors make their data available for analysis. The American Academy of Ophthalmology (AAO) launched the Intelligent Research in Sight (IRIS) data registry in 2013 [16]. IRIS allows physicians to upload their EHR data for aggregation with data from other AAO members. Benchmarking and quality measurement analyses are performed and used to help practices achieve pay-for-performance incentives and participate in Maintenance of Certification programs. Participation requires physicians to grant the AAO a royalty-free license to utilize all de-identified data submitted to IRIS. Although the AAO does not currently commercialize de-identified practice data, the royalty-free license permits it to do so in the future. Other medical societies, such as the American College of Cardiology, already sell information from their EHR data registries to the pharmaceutical industry and other industry customers [17].
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&
www.co-ophthalmology.com
193
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Retinal, vitreous and macular disorders
EHR data can be thought of as intellectual property and should belong to the physicians who create the data. A physician’s EHR data disclose how he or she treats patients and manages specific conditions, which procedures, diagnostics, and pharmaceuticals he or she utilize, and the outcomes that result from those treatment modalities and utilization patterns. As such, it is reasonable for physicians to be hesitant about relinquishing their intellectual property rights to EHR vendors or other entities. Physicians typically do not directly benefit from the commercialization of their healthcare data. In its native state, EHR data have essentially no monetary value to individual physicians and physician practices. There are several reasons for this. First, regulatory statutes prohibit physicians from selling their data to pharmaceutical companies or medical device makers either directly or through entities in which they have an ownership interest. Secondly, individual physician and practice data have little value unless these are combined with data from a large number of demographically diverse physicians and practices. And finally, data stored on EHR servers are not in a saleable format. In order for it to be marketable, the EHR data need to be converted into an analyzable data format, stripped of all patient identifiers in compliance with the Health Insurance Portability and Accountability Act, stripped of physician identifiers in compliance with Office of Inspector General statutes, and aggregated with data from a demographically and geographically diverse group of physicians.
CONCLUSION The healthcare data mining industry currently acquires, aggregates, and sells vast amounts of detailed information about physicians and their patients. However, physicians do not directly benefit from this valuable data that they unknowingly contribute to the industry. Given the critical importance that EHR data will play in multiple aspects of the healthcare industry, it is in physicians’ interest to maintain ownership and control of the healthcare data that they generate. It would be prudent for physicians to exercise caution before relinquishing data rights to EHR vendors or other entities that may sell the data to payers or other customers with whom physicians’ interests are not aligned. It is advisable for physicians, their administrators, and their attorneys to carefully read User Agreements in EHR vendor and other contracts to assure that the data are owned by the physicians and that they understand the implications of having their data potentially sold by the vendor.
194
www.co-ophthalmology.com
Acknowledgements N.A., MD, D.F.W.s, MD, MBA, and J.S.P., MD, cofounded Vestrum Health, LLC in an effort to help retina specialists and other physicians gain greater control of their data. Conflicts of interest N.A., MD: COVALENT MEDICAL, INC: Founder, Stockholder; DEROYAL INDUSTRIES, INC: Intellectual Property Rights; GENENTECH, INC: Speaker, Honoraria; RAPID PATHOGEN SCREENING, INC: Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder. J.S.P., MD: CLARUS ACUITY GROUP: Founder, Stockholder; COVALENT MEDICAL, INC: Founder, Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder. D.F.W., MD, MBA: COVALENT MEDICAL, INC: Founder, Stockholder; VESTRUM HEALTH, LLC: Founder, Stockholder.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Orentlicher D. Prescription data mining and the protection of patients’ interests. J Law, Med Ethics 2010; 38:74–84. 2. Baynes T. Walgreen accused of selling patient data. Reuters. 2011. 3. Wilson J, Bock A. The benefit of using both claims data and electronic medical record data in healthcare analysis. White Paper Optum Insight. 2012. 4. Leichter SB. The influence of drug distribution data on diabetes care in the community. Clin Diab 1999; 17:166–167. 5. Fugh-Berman A. Prescription tracking and public health. J Gen Intern Med 2008; 23:1277–1280. 6. AMA Physician Masterfile. [Accessed on 8 January 2013] http://www.ama& assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile. Important information for physicians regarding the AMA Physician Masterfile. 7. American Medical Association. Presentation: AMA Professional Physician Data. Department of Database Licensing. 2009. 8. Steinbrook R. For sale: physicians’ prescribing data’. N Engl J Med 2006; 354:2745–2747; 2745. 9. Singer N. When 2þ2 equals a privacy question. New York Times. 2009. BU4. 10. Shay DF, Gosfield AG. EHR data control: a practical primer. Dermatology & World. 2012. Analysis of legal issues surrounding the ownership of EHR data. 11. Practice Fusion User Agreement. [Accessed 6 December 2013] http:// www.practicefusion.com/pages/user-agreement.html. 12. Thomas JW. Economic profiling of physicians: what is it? Developed for the American Medical Association June 2006. 13. Walter K. Academy urges CMS to address united healthcare medicare advantage terminations. American Academy of Ophthalmology ‘‘Eye on Advocacy’’ Blog. November 8, 2013. 14. McCan N. American Society of Cataract and Refractive Surgery/American Society of Ophthalmic Administrators Winter Update 2013. Reported in: EyeWorld. [Accessed 10 September 2013]. http://www. eyeworld.org/ article-reporting-live-from-ascrs-asoa-winter- update-2013. 15. Porter Research. The health plan readiness to operationalize value-based & payment models study. 2013. http://www.nbch.org/nbch/files/ccLibraryFiles/ Filename/000000002854/Availity_Study_on_Plan_Readiness_to_Operatio nalize_New_Payt_Models.pdf Analysis of payer motivation and readiness in transitioning to value-based payment models. 16. Sternberg P, IRIS: an extraordinary opportunity to improve outcomes. American Academy of Ophthalmology 2013. 17. American College of Cardiology Corporate Support Catalogue. [Accessed on 10 September 2013] http://www.cardiosource.org/ACC//media/Files/ ACC/Support%20the%20ACC/C1202_2012Corporate_Support_Catalog_ highres.ashx.
Volume 25 Number 3 May 2014
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