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The Impact of Health Disclosure Laws on Health Information Exchanges WEIS 2011

The Impact of Health Disclosure Laws on Health Information Exchanges WEIS 2011. Idris Adjerid Alessandro Acquisti Rema Padman Rahul Telang Julia Adler-Milstein. Introduction & Motivation.

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The Impact of Health Disclosure Laws on Health Information Exchanges WEIS 2011

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  1. The Impact of Health Disclosure Laws on Health Information ExchangesWEIS 2011 Idris Adjerid Alessandro Acquisti RemaPadman RahulTelang Julia Adler-Milstein

  2. Introduction & Motivation • HIE - A project or initiative focused around electronic health data exchange between two or more disparate organizations or stakeholders • Increased digitization and sharing of patient health records raise privacy concerns • Evidence suggests that privacy concerns have been and continue to be a significant concern for HIEs: • Consistently ranks first or second in terms of HIE concerns on the annual eHealth Initiative Survey • In 2010, ACLU brought suit against the Rhode Island HIE on privacy grounds

  3. Research Objective • Evaluate the impact of health disclosure laws on the emergence and success of Health Information Exchanges • Two alternative hypotheses: • Laws limiting disclosure of health information negatively affect HIE growth and success. • Stronger privacy protections may increase the cost of technology adoption and risks involved in health information sharing • Limiting disclosure of health information positively affects HIE growth and success • Stronger assurances to patient groups, privacy advocacy groups, and regulatory bodies resulting in increased cooperation and participation

  4. HIE Dynamics • Common HIE models • Regional health leaders form independent initiatives to facilitate health information sharing • Subscription/Transaction based models • Treated as Public Good • Relatively Homogeneous in Organization Types • 85/88 Operational HIEs are independent non-profits or function under a non-profits • Incentives for HIE Adoption • Efficiency gains for payers and insurers • Quality and Competitive gains for providers • Federal Incentives (HITECH) • State Incentives

  5. HIE Formation - Overview • Administrative Framework • Payment, Funding, TOU Agreements • Technological Infrastructure • Community Outreach & Support Pharmacy Clinic Group Practice Home Health Insurer Health Information Exchange Hospitals Long term Care Lab Urgent Care

  6. HIE Data – Definition & Sources • Publicly available data from the E-Health Initiative Survey on Health Information Exchanges • Includes a list of Health Information Exchanges by state from year to year, and other metrics • We use data from 2004 to 2009 • We validated and augmented this list through online research and communications with HIE representatives • HIE Survey Data from 2007, 2008, and 2009 (Adler-Milstein et al 2009)

  7. Health Privacy Disclosure Laws • Consent and Disclosure of Health Information governed by: • Federal Laws • Health Insurance Portability and Accountability Act (HIPAA) • Health Information Technology for Economic and Clinical Health Act (HITECH) • State Statutes: • General Health Disclosure Legislation (Not HIE specific, Prior to Data) • HIE-Specific Legislation • Combination of state HIE and General Health Disclosure Laws define between-state variation in disclosure requirements State Health Disclosure Laws State HIE Laws: Privacy and Others HITECH Act February 2009 1996 - HIPAA Enacted 2009 2004 State Health Disclosure Laws HIE Data

  8. Legal Data – State HIE Laws • HIE Laws - Legislation pertaining to HIEs and generally involve spurring or encouraging HIE activities in a state • Passed in More Recent Years • Interesting Variation for Disclosure Requirements • We categorized states into one of five groups: • ProHIE and No Consent (11 states) • “Evaluate Any changes in State laws that are necessary to protect the privacy and security…” (Md. Code Ann., § 19-143 ) • ProHIE and Consent (7 states) • “Patients and health care providers shall have the choice to participate in the HIE…” (R.I. Gen. Laws § 5-37.7-4 ) • ProHIEOnly (3 states and D.C.) • Privacy Only (3 states) • No HIE Law (26 states)

  9. Analysis - Overview • Cross-Sectional Analysis • Summary Statistics • Econometric Model • Results • Panel Analysis • Econometric Model • Results

  10. Cross-Sectional Analysis • Motivation for Cross-Sectional Analysis • Evaluate HIE Outcomes of Interest • Explore the relationship between HIE outcomes and Health Disclosure Laws • Cross-Sectional Data as of the end of 2009 • Covariate of Interest: General Health Disclosure Legislation • Passed prior to the prevalence of HIE efforts • Control for subsequent HIE legislation • Endogeneity concerns

  11. Cross-Sectional Analysis – Key Measures • We identified five key indicators of HIE activity in any given state

  12. Cross-Sectional Analysis – Econometric Model • Because other factors may affect the development of HIEs in a state, we performed additional analysis to better model this correlation with our various dependent variables TotalHIEstate= 0 + 1*DisclosureLaw+ 2*Population + 3*PopulationSquared+ 4*BroadbandAccess + 5* DemocraticState+ 6*PerCapitaGDP+i*HIELaw+  • Estimate Via Poisson Regression • Our data is best categorized as count data which are highly non-normal and poorly estimated by OLS

  13. Results – HIE Counts

  14. Results – Operational and Failure Rates • We find a consistent Positive Association between Health disclosure Laws • Correlation does not fade with the inclusion of various state controls • Other considered covariates were measures of GDP (Health & Computer), measures of legislative professionalism, and state education levels

  15. Panel Analysis - Motivation • Our Cross-sectional model can only provide some evidence of correlation between health disclosure laws and HIE activity, but we cannot make any claim about causation • IV approach may mediate some of these concerns, but IV’s from previous literature raise concerns (IV Analysis in Appendix of presentation) • Panel-Analysis allows us to at least address fixed-effects and controls for other factors • Covariate of Analysis: HIE Laws vary in the time period with differing privacy protections • Captures health disclosure laws as fixed effects (passed prior to our dataset)

  16. Panel Analysis – Econometric Model • Two Dependent Variables (Semi-Annual 2004-2009) • Operational HIEs • Total HIEs – Does not include failed HIEs (successful entrants) • Fixed Effects Regression used to estimate basic model for evaluating the effect of various HIE Laws TotalHIEst& Operational HIEst= o + i*HIELawst+i* HIELawst*HealthDisclosureLawss+ 1*Fundingst+2*StateDesignatedHIEst+3*Populationst+4*PopulationSquaredst +5*PerCapitaGDPst +θs +λt+st • Control for other aspects of law that may be encouraging HIE growth • Funding • State Designated Entity • State Scale Effects • θsState Fixed Effects and λtTime Fixed Effects

  17. Panel Analysis - Results

  18. Panel Analysis – Results

  19. Panel Analysis – Results • Robust to Inclusion of Various Other Measures: • HIT Adoption Measures • EMR Adoption • CPOE adoption • Healthcare Characteristics State Measures • Managed Care Penetration • Over65 • No Significant Difference in HIEs between conditions • Breadth of Sharing (Results, Inpatient, Outpatient) • Amount of Patients Covered • Percent of Hospital Beds covered in region • Independent vs. Subsidiary Organization

  20. Summary of Results • So How do Privacy Protections Impact HIE Progress? • It Depends: • Find that of all HIE promoting initiatives, only those that include strong privacy considerations (consent) encourage growth and success • This effect is driven strongly by the states that also have pre-existing health disclosure legislation • Find that privacy protections without incentives has a strong detrimental effect on HIE growth and success • However, effect based on a small number of states (3)

  21. Limitations • Data limitations • Although a comprehensive dataset, still a small dataset • Measurement of some outcomes difficult, such as failed HIEs • Effects based on sometimes small number of “policy interventions” across states • Analytical limitation common to other studies examining cross-state differences

  22. Questions?

  23. Appendix: HIE and Consent • Patient consent has been a central concern with respect to privacy and HIEs • Opt In, Opt Out, No Consent • Federal and State Laws don’t provide requirements for consent for many HIE contexts • Covered Entities under HIPAA are not required to solicit consent prior to disclosure of health information for treatment purposes • State Health Disclosure Laws generally echo these requirements with few states going beyond HIPAA requirements • However, state laws do provide additional enforcement power • HIE Laws may apply more broadly than general health disclosure laws (beyond providers and payers) and also may provide requirements beyond current state statutes

  24. Appendix: IV Results

  25. Appendix: Endogenous Passing of HIE Laws Trend of Operational HIEs relative to HIE Laws • Prior to the passage of these laws (2004-2006), there are small differences between the states • A growing difference between states with and without HIE laws (Not Significant)

  26. Appendix: Endogenous Passing of HIE Laws Trend of Operational HIEs relative to Specific HIE Law Type • HIE promoting legislation with weak privacy protections seem to have initially more activity but maintain trajectory • HIE promoting and strong privacy projections seem to display a sharp increase in HIE activity around the passage of these laws • Little growth for states with HIE only and Privacy Only legislation

  27. Appendix: Potential Causes • Given that health data privacy sensitivities exist even in states with weaker legislative protections, state with more prescriptive legislation dealing with privacy may result in a less ambiguous operating environment for HIEs • Restrictive legislative environments force the “privacy issue” resulting in HIEs that are foresighted in terms of handling privacy concerns, engaging the local community, and developing mitigating technologies and policies • Privacy protections without accompanying incentives may inhibit HIE entry and success due to fears of overly restrictive regimes (all stick and no carrot)

  28. Overview of Operational HIEs (2009)

  29. Legal Data - Health Disclosure Laws • State Health Disclosure Law: • Laws that (at a minimum) limit the disclosure of patient health information (through consent requirements) by physicians, hospitals, health management organizations, and insurers • Didn’t include laws that restrict only specific types of data (HIV, Mental Health, etc.) or narrowly applicable • Resources • The State of Health Privacy: A Survey of State Health Privacy Statutes, Georgetown University, Washington, DC, 2002 • Compilation of State Privacy Laws by the Privacy Journal, Updated 2010 • Various state legislative references • In our data we find 21 states with health disclosure laws and 29 (and D.C.) without

  30. Overview of Health Disclosure Laws

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