A Health Plan Prescription for Health Information Technology

Published on: 
Supplements and Featured Publications, Special Issue: Health Information Technology — Guest Editors: Sachin H. Jain, MD, MBA; and David B, Volume 16,

Using their own technology, health plans can provide valuable data and capabilities to move adoption of health information technology systems forward.

The economic stimulus law of 2009 included incentive payments to encourage providers and hospitals to adopt and "meaningfully use" electronic health records. One resource was excluded from these regulations: patient data from the patient's health insurer, although health insurance companies tie together multiple sectors of the healthcare industry in a single patient-centered data form known as the claims history. They also have considerable experience with information technology (IT). As a result, they are uniquely positioned to move adoption of health IT systems forward. Health plan technologies should be included in the meaningful-use requirements. The result will be additional functionality, which in the end will improve quality, lower costs, and improve individual health.

(Am J Manag Care. 2010;16(12 Spec No.):SP29-SP30)

The healthcare industry has been slow to adopt technology to disseminate information. Our banks can alert us when we have a low balance in our checking accounts, but the majority of our physicians would be hard pressed to alert us when a blood test is due. Healthcare is one of the last remaining industries where paper records are the norm, often resulting in uncoordinated, unusable, and inefficient information.

Prescriptions still are written with pen and paper. Many providers, from physicians to hospitals to pharmacies, have electronic billing systems, but even so we print and mail hundreds of millions of paper checks for payment. The vast majority of doctors do not use an electronic health record (EHR). For the providers who do use EHRs, their systems are usually electronic silos of information, unconnected to other important stakeholders.

These problems—and many others—have kept healthcare shackled to the past. But the recent debate over how to reform our health system to deliver better care at lower cost has brought these issues to the forefront. One critical part of the solution is to create a meaningful patient-centric medical record. As the introduction to the recent book Paper Kills 2.0 points out, the benefits are clear:

Updated, accurate, and comprehensive patient information at the point of care will prevent medical errors and will allow physicians, nurses, and providers to make better, more informed decisions. Electronic access to information will reduce duplicative and unnecessary tests and treatments. Automating cumbersome, manual processes will streamline workflow, eliminate inefficiencies, and lower costs. These are facts.1


The economic stimulus law of 2009 and the recently passed health reform legislation provide a road map to how patient care and patient information need to be integrated, protected, disseminated, and made available to patients and providers to enable a more efficient model for healthcare delivery. The economic stimulus includes tens of billions of dollars in incentive payments to encourage providers and hospitals to adopt and “meaningfully use” EHRs. The incentives can be sizable: up to $64,000 per physician or millions of dollars per hospital. The initial requirements for obtaining these payments, from using certified technology to specific clinical functions, are overly prescriptive and bureaucratic (symptomatic of the overall laws themselves), but they do begin to address the critical priority of creating an electronic record that follows patients no matter where they go in the health system.

One resource was excluded from these regulations: patient data from the patient’s health insurer. Insurers are the only members of the healthcare continuum that really know where any given patient receives all of his or her care. Meaningfuluse requirements focus on the important goal of furthering the adoption and use of clinical information technology (IT) systems, but they omit the valuable data and capabilities that health plans can provide using their own technology.

Just as Web sites such as Amazon and eBay have multiple retailers in a single location, the health plan ties together multiple sectors of the healthcare industry in a single patient-centered data form known as claims history. Test results, images, a record of procedures performed, prescription drug histories, disease management programs, demographic information, and many other vital pieces of patient data put health insurance companies in a unique position to bring healthcare into the 21st century.

Although the government may provide the financial incentives, health insurance companies can help providers with better software and better access to information. Unlike most practice providers, health insurance companies have considerable experience with IT. Many have sophisticated IT departments working on how to be more efficient—and how to assist providers with becoming more efficient as well. This IT expertise coupled with new technology and integrated systems can help providers adopt and use cutting-edge technology, as the financial incentives in the stimulus legislation were designed to do.

Electronic health records integrated with health plan data or other technologies that can link to patient data can save time and money through easier installation and regular updates of the information. Providers can see what healthcare services their colleagues in other facilities or other sectors of the industry have provided for specific patients. Another advantage is the ability to add the costs of tests, procedures, and medications to the software. Currently, the ordering physician does not know these costs. When physicians can see what each item costs, they can start to make more costeffective decisions, which can lead to savings in the long run.

The federal government also is investing millions of dollars in state health information exchange programs. Although these health information exchange programs will likely connect hospitals at some point in the future, it is unclear how well they will connect to the bulk of practice providers in the ambulatory setting. With the health insurance company as a central hub of information, the benefits of the health information exchange programs can be leveraged for the much larger healthcare community.

In addition, the health insurance industry can finally engage patients in their care in a more meaningful way. At the same time as they help physicians install EHRs, health insurers can provide patients with a personal health record. Through the use of SNOMED CT (Systematized Nomenclature of Medicine— Clinical Terms), medical terminology can be translated into easier-to-understand “lay” language. Controls can be put into place so that the provider sees data before the patient does, but ultimately, the patient can have access to understandable medical information. Patients also can better exercise privacy controls, so that sensitive information can be protected.

Armed with this usable medical information in a secure environment, patients are in a better position to understand their health and engage with providers. By using clinical data and health plan data, health insurers can better target care coordination and wellness programs, as well as assist with medical home pilots, all of which are key parts of the new health reform law.

Through better exchange of information, better health outcomes and cost savings can be achieved both nationally and at the health plan level. Without the health plans intimately involved in this architecture of information, a lot of money will be spent, yet a truly complete, secure record with privacy controls will likely be lacking.

To better move health IT adoption forward, health plan technologies should be included in the meaningful-use requirements. These requirements already include many vital

functions, from computerized physician order entry and tracking medication allergies to quality reporting and e-prescribing.

Health plan data and technologies can complement these tools with additional functionality, which in the end will improve quality, lower costs, and improve individual health. Health insurers and providers can and should be important partners to move medicine out of the dark ages and into the enlightenment of the 21st century—sooner rather than later. The technology is there. The incentives are there. Let’s make sure that regulation is not what stands in the way of progress.

Author Affiliations: From the Center for Health Transformation (NG), Washington, DC; and HealthTrio (MH), Centennial, CO.

Funding Source: The authors report no external funding for this report.

Author Disclosures: Former Speaker of the House Newt Gingrich is founder of the Center for Health Transformation. Dr Hasan is chairman and chief executive officer of HealthTrio, a member of the Center for Health Transformation. He was previously founder, chairman, and chief executive officer of Foundation Health Systems, Inc, and HealthNet.

Authorship Information: Concept and design (NG, MMH); acquisition of data (MMH); analysis and interpretation of data (MMH); drafting of the manuscript (NG, MMH); critical revision of the manuscript for important intellectual content (MMH); and supervision (NG)

Address correspondence to: Newt Gingrich, Founder, Center for Health Transformation, 1425 K St NW, Ste 450, Washington, DC 20005. E-mail:

1. Merritt D, ed. Paper Kills 2.0. Washington, DC: Center for Health Transformation Press; 2010