Section 5.1 Following the Data in Healthcare
Hate to nag, but have you had a checkup lately? If you have been to the doctor for any reason you may recall that the doctor’s office is awash with data. First off, the doctor has loads of digital sensors, everything from blood pressure monitors to ultrasound machines, and all of these produce mountains of data. Perhaps of greater concern in this era of debate about health insurance, the doctor’s office is one of the big jumping off points for financial and insurance data. One of the notable “features” of the U.S. healthcare system is our most common method of healthcare delivery: paying by the procedure. When you experience a “procedure” at the doctor’s office, whether it is a consultation, an examination, a test, or something else, this initiates a chain of data events with far reaching consequences.
If your doctor is typical, the starting point of these events is a paper form. Have you ever looked at one of these in detail? Most of the form will be covered by a large matrix of procedures and codes. Although some of the better equipped places may use this form digitally on a tablet or other computer, paper forms are still ubiquitous. Somewhere either in the doctor’s office or at an outsourced service company, the data on the paper form are entered into a system that begins the insurance reimbursement and/or billing process.
Where do these procedure data go? What other kinds of data (such as patient account information) may get attached to them in a subsequent step? What kinds of networks do these linked data travel over, and what kind of security do they have? How many steps are there in processing the data before they get to the insurance company? How does the insurance company process and analyze the data before issuing the reimbursement? How is the money “transmitted” once the insurance company’s systems have given approval to the reimbursement? These questions barely scratch the surface: there are dozens or hundreds of processing steps that we haven’t yet imagined.
It is easy to see from this example, that the likelihood of being able to throw it all out and start designing a better or at least more standardized system from scratch is nil. But what if you had the job of improving the efficiency of the system, or auditing the insurance reimbursements to make sure they were compliant with insurance records, or using the data to detect and predict outbreaks and epidemics, or providing feedback to consumers about how much they can expect to pay out of pocket for various procedures?
The critical starting point for your project would be to follow the data. You would need to be like a detective, finding out in a substantial degree of detail the content, format, senders, receivers, transmission methods, repositories, and users of data at each step in the process and at each organization where the data are processed or housed.
