October 19, 2010 Testimony to the National Committee on Vital and Health Statistics

Arnold Milstein, MD
Medical Director, Pacific Business Group on Health
Professor of Medicine, Stanford University

Thank you for the opportunity to address this topic on behalf of the Pacific Business Group on Health and its more than 50 large employer sponsors of California health benefits plans.

We endorse the well articulated concept paper released by the NCVHS on May 26 and agree with its premise that a convergence of evolving HIPAA rules, the HITECH Act, PPACA and ICD-10 offers an unprecedented opportunity to correct our current scarcity of actionable information to improve health and the value of the US health system.   If the scarcity is promptly relieved, US employers and their employees can do much more to help speed our national journey across the wide chasm that separates the current US level of health and patient experience  from what our extraordinary level of per capita health spending could enable. This large shortfall in US health system performance undermines the global competitiveness of US employers and their workforces.

Public policies that prioritize short term progress on the following eight US health information system enhancements would be especially useful in efforts by large employers and their employees to improve the value of their health spending  These enhancements fall into three groups: scope of data collection,  data usefulness, and due speed.


1. Routine collection of standardized electronic information on patient-reported health status and experience of care. These two components of the “triple aim” represent consumers’ essential purpose in seeking health care  There is no inherent reason why this information can’t be routinely and economically collected at the inception and close of most patient contacts with the health system and at patient-tailored intervals thereafter.  Electronic versions of the Dartmouth Coop Instrument illustrate one feasible element of such a data collection system for multiple health care service types.

2. Routine collection of standardized information on whether any high risk or high cost non-emergency clinical service meets current appropriateness criteria and was subject to a robust shared decision-making process.  While we await universal adoption of sufficiently robust EHRs to enable such routine information collection,  we recommend establishment of clinical registries to serve this purpose.  Registries should also be initiated to track outcomes and care processes for health conditions generating substantial disability and health spending, unrelated to a specific high risk or high cost discrete health service.

3. Routine collection of standardized information on the payable charge for every service or service bundle.

4. Routine collection of standardized information on each patient’s health care-relevant quality of life and end of life preferences, if authorized by a patient.


5.  Conversion of all EHR information into structured data in standardized formats.

6  Linkage of all personally-relevant health and health care information about a person on a real time basis, so it is available to inform the health and health care decisions of patients, as well as of their clinicians and in-home care-givers if authorized by patients.

7  For patients and clinicians who request it, continuous generation of active decision prompts whenever there is a new opportunity to take an action likely to improve health or health care affordability to the patient.


8  Use of the Secretary’s authority to adjust Medicare, Medicaid, and S-chip payment as needed to encourage most providers  to meet the above-described seven priorities within 4 years.