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Many of you may have heard
that The Centers for Medicare and Medicaid Services and Office of the National Coordinator for Health Information Technology held a “listening session” in Washington on May 3, 2013. The meeting was with stakeholders to discuss EHRs and billing. Hmmm…I bet many of you weren’t invited.
You may also have heard that The American Health Information Management Association is urging more research on the causes of higher levels of coding and reimbursement through the use of electronic health record. Sue Bowman, Senior Director of coding policy and compliance, hasreiterated their view, “The extent to which EHRs have led to improper reimbursement is unclear. EHRs produce more complete and accurate documentation and this could be leading medical providers to seek reimbursement for services they have always been providing, but weren’t properly documenting before. Higher levels of reimbursement do not necessarily equate to fraud.” [Good for AHIMA to share this very important tidbit the government bean counters must have overlooked when they estimated disbursements from their mandated EHRs!]
I’ve written several articles on coding the past year, emphasizing the issues that will and are resulting from too complicated a coding system. Here's one you might like to check out. IDC-10 Codes, There's Got to Be a BETTER Way!
This latest round about coding is a perfect example of the documentation mess we're in, except in the reverse. Now physicians are getting accused of seeking higher reimbursements because their EHRs are allowing them to more accurately document all the services they are providing - which are legally billable, by the way! Look at this from the physician’s side: They have expensive EHRs they've been mandated to implement. Now they have a capability to document and bill for all their services that they probably missed billing in the past due to “user/billing errors.” Doesn't it make sense that they would bill for all the services they provided - thus helping them pay for their EHRs, employee training, lost productivity, etc? Wow, if you’re healthcare provider in today’s healthcare world, you’re placed in a position of being “damned if you do and damned if you don’t.”
This reminds of our of complicated tax system. For those of us lucky enough to hire a good CPA, we can deduct everything coming to us, but those who can’t afford such professional services, you’re left to filing your taxes with only “street” knowledge that you’ve gathered over the years. And oh yeah, what you’ve learned may or may not be applicable to the newest tax rules, so you’re increasing your chances of being audited by the IRS.
Now back to Ms. Bowman... She’s recommending the development of a code of ethics for EHR vendors and users to design and use the system appropriately, guidelines to ensure features in an EHR are correctly used, development by CMS of a national set of coding guidelines for hospital reporting of emergency department and clinic visits, and education and training on coding with EHRs.
Forgive me, but on the vendor’s side, shouldn’t this be part of the licensing process for EHR software? There will always be some unscrupulous people in all professions, but is it necessary to make more laws to make sure docs are coding correctly? Remember, the new codes haveincreased from 13,000 to 55,000! Getting all the coding done correctly will be like finding a specific shell on the beach. There's a good chance you'll find the wrong shell? Coding accuracy will be a myth!
I would welcome dialog on the issue. It’s a big one for me and I’m hoping it gets you riled up a bit to!
The recent HIMSS 2013 meeting witnessed the emergence of mHealth as a significant component of health information technology (HIT). The meeting offered 35 educational sessions on mHealth. One of the meeting’s keynote speakers, Dr. Eric Topol, predicted a revolution in health care based on smartphones. Connecting a smartphone to a currently available bio-sensor allows anyone to monitor and share with a physician his vital signs, heart rhythm, sleep patterns or blood sugar, and soon other physiologic data as well. Eventually these systems will include software that will enable laypersons to interpret data and determine when physician involvement may be appropriate. The way each of us will learn to interpret our own body’s data will become a natural extension of the way we now interpret our own “internal body cues” and symptoms.
Meanwhile, progress within the more established parts of HIT has ground to a standstill. At the HIMSS meeting results of a provider survey conducted by the American College of Physicians and AmericanEHR Partners were presented. Among over 4000 surveys the percentage of clinicians that were “very dissatisfied” with their EMRs has increased by 10% from 2010 to 2012. 39% of EHR users would not recommend their EHR to a colleague (up from 24%). Satisfaction with EMRs has clearly deteriorated since the 2008 pre-Meaningful-Use study published in NEJMthat showed 93% of physicians were satisfied with their EMR. In the physician blogosphere the leading EMR story last week was about a physician class-action lawsuit against an EMR vendor who allegedly sold defective software and then abandoned the product. Outside of mHealth there is not a lot to cheer about in HIT right now.
Why is mHealth growing so fast while the rest of HIT is stalling? There are many reasons but three important reasons bear discussion.
First, most mHealth projects don’t take on every patient at once. An mHealth project designed, for example, to monitor congestive heart failure patients at home addresses only that population of patients and providers associated with a single diagnosis. A project with such a narrow, focused scope has a greater chance of success than a typical EMR project which must cover every patient and every physician regardless of diagnosis.
The other two reasons illustrate an important economic lesson. At the moment mHealth is a relatively unregulated industry. Any startup company can acquire a bio-sensor and/or write a mobile app for a smartphone and be off and running. There are no Meaningful-Use-type regulations that require all mHealth apps to operate a certain way or meet a minimum set of requirements. Barriers to entry are relatively low.
Third, many mHealth projects are marketed directly to consumers and are paid for directly by consumers. The just-released Samsung Galaxy S4 smartphone has a suite of built-in mHealth apps and available biosensors to monitor sleep, calories burned, heart rate and (Samsung implies) blood glucose. Consumers will purchase this phone like any other – with their own money. There are no third party payers involved. That means no insurance approval, no complex coding and billing, no politics ….so far less overhead and far more flexibility and speed. All you have to do is build a quality, useful product.
mHealth currently operates in a free market where products can be designed any way their creators choose. Their target customers choose what products to buy – or not to buy at all – and how much to pay. Many of these products will fail, but the ones that succeed may indeed revolutionize healthcare as Dr. Topol predicts.
EMR vendors, burdened by Meaningful Use requirements, have little bandwidth left to address customers’ real needs. As Meaningful Use requirements and EMR certification raise the barrier to entry into the market, the market is increasingly dominated by the largest vendors at the expense of the smaller ones. As competition is suppressed product quality and customer service both suffer. Given the AmericanEHR survey results it is no surprise that EMR vendors are now marketing to current EMR users who are unhappy with their present system. There are certainly plenty of those.
Unfortunately the freedom mHealth enjoys may soon come to an end. The FDA’s upcoming release of its final regulations of mobile medical applications is expected soon. These rules will likely impose an approval process similar to those already in place for drugs and conventional medical devices. One source estimates the cost of this approval process for a single mHealth product will be as high as $24 million. While that estimate seems high, there is no doubt that the cost of compliance will have a detrimental effect on the mHealth marketplace. Costs will go up dramatically, smaller companies will be forced out, and true innovation will slow as mHealth companies expend most of their resources on compliance. Those products that survive to reach FDA approval will no doubt seek third party payor reimbursement. With that will come loss of price transparency, driving up costs even further. The mHealth market will become as bloated and ineffective as the rest of the health care system.
Will the mHealth revolution survive? Time will tell.
Dr. Mike Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship and Residency at Vanderbilt University Medical Center. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. Dr. Koriwchak has been working with information technology since 1977. In medical school, he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 30 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.
In aviation, safety has always been the primary concern. In
fact, aviation’s safety record is so stellar that it is considered a model for
healthcare. That is quite a testament.
However, a retired pilot friend recently bemoaned that FAA
rules and regulations have overtaken concern about safety, and he postulates
that aviation is not better for the change.
“Now we’re only concerned about compliance…we have a cast of
thousands as support staff. When I started flying in 1964, Part 91 federal
regulations were about 30 pages. You could memorize it. Today, it is hundreds,
if not thousands, of pages and nobody can possibly know everything that is in
there. We are less safe today than we were 50 years ago,” he complained.
Making and keeping track of all those regulations costs
aviation a lot of money. It requires a boatload of federal regulators to
oversee them, and costs private carriers a bundle of money to hire people to
monitor every jot and tittle of the laws. And, he concludes, the passengers and
the airline employees do not benefit from this over-regulation.
Will Healthcare Follow Aviation Again?
Just about everyone in healthcare knows about the vaunted
aviation checklist, and how it has become standard procedure in many operating
rooms today. Books are written and consultants make good livings just teaching
the checklist method of philosophy. The checklist is a great tool. Healthcare
is better for following aviation down that path.
But is healthcare going to benefit by following the FAA down
the road to over-regulation? We can trip on our path toward safety by using
regulations as stumbling blocks instead of paving a smooth road to improved
quality and performance.
One Example From a Pharmaceutical Client
Just last week, I was observing a training class that I
wrote for a major pharmaceutical company. We were training hourly line
employees on procedures that affect product safety. To a person, they had one
complaint: standard operating procedures (SOPs) were becoming downright cumbersome. That makes it very difficult to follow, let alone implement them.
One veteran employee said when an incident occurs, someone writes
another procedure to address that specific event and adds it to the book of
procedures. With each new addition, nothing else in the book is deleted or
changed, and so it is becoming nearly impossible to follow. In fact, the
employee complained that SOPs are written in response to each incident,
meaning that many new SOPs only relate to one isolated event. The SOPs are
losing their meaning and rationale. It is just a jumble of unrelated knee-jerk
reactions to individual events.
The employee concluded that this practice was creating more
problems than it was solving by having a procedure manual that could not be
followed. There are now so many rules to follow, she said, the rules can no
longer be followed.
Is All of Healthcare Headed Toward Unwieldy SOPs?
With the passage of the Accountable Care Act, known
colloquially as ObamaCare, many believe that we are headed down a path of
over-regulation. Where common sense and good medical practice once dominated
the industry, healthcare practitioners (once called nurses and doctors) are
overwhelmed with rules regarding how they practice, to which the actual art and
science of medicine is taking a backseat.
At a recent visit accompanying a friend to a physician’s
appointment at a hospital center, we observed that we were two of only four
people sitting in a new waiting room with 25 chairs. There were two large
semi-circular reception desks – one with four and another with 12
stations – in this cavernous waiting room. Most of the stations were empty. While
we were waiting, a physician accompanied by a nurse and two receptionists
carried a brochure rack around the waiting area deciding where to place it. Let
me say that again. A highly-skilled physician specialist carried around a
brochure rack with his nurse and two receptionists trying to find a place for
it...for about 15 minutes.
In this brand-spanking-new facility where our doctor’s
office had been moved since our last visit (from a very modern, extremely
functional office building now sitting vacant in the parking lot), we also
observed not one, but two printers behind the smaller receptionist desk flanked
by a wall of paper files. We filled out our medical information on a clipboard,
which we have done for each of his visits for the last three years.
The Trend Is…
By personal experience as well as professional observation,
the trend is toward more regulation, more staff to track our compliance with
the rules, and an ongoing steady stream of paperwork to track our patients. Are
cost, compliance and safety mutually exclusive? They don’t have to be and
ideally shouldn’t be. But with the trend toward over-regulation, we may be
missing an opportunity to streamline and cost-cut while serving patients
better.
Instead of continuing to ramp up our regulatory oversight
into the stratosphere, perhaps it is time to – if I can paraphrase my retired
pilot friend – throttle back and re-evaluate what we are really trying to
accomplish.
Note: This case study is fictional. It was created to show what is possible for medical tourism to bring down the high cost of certain surgical procedures performed in US hospitals and to show that employers, especially those already using medical tourism as an option on their self-funded employee healthcare plans, can do with workers’ compensation claims. The costs mentioned below are from the following website:
Three construction workers, Juan, Pablo and Jorge, were working on a construction site; none of the men were operating heavy equipment. Juan was working with Jorge, putting up drywall, and standing on scaffolding, about 10 feet off the ground. Pablo working at the other end of the scaffolding from Juan, and Jorge painted drywall. As Juan went to reach for another sheet of drywall, he lost his footing, causing the scaffolding to buckle. But when Jorge tried to catch him, the scaffolding gave way, and all three men fell to the ground.
Juan, who was from Mexico injured his left hip. Jorge, from Costa Rica, injured his left knee. Pablo, from Colombia, injured his right knee. All three were sent to an orthopedic doctor’s office their employer selected from a list prepared by their state’s workers’ compensation bureau.
They were treated by the doctor and given prescriptions for pain medication. They were told they could return to work if they felt no discomfort. A week later, all three complained of pain and said they could not work. They filed workers’ compensation claims with their employer. When they went back to the treating doctor, he told them that since they initially did not complain of any serious pain or discomfort, he treated them for the contusions and other superficial injuries. Now he ordered that all three get MRIs for their injuries.
The MRI on Juan found a hip fracture that due to his age, suggested a total hip replacement, otherwise he would never be able to walk normally, or even work. Jorge’s MRI showed a fracture of the left kneecap, and Pablo’s showed a similar fracture, but on the right knee. It was further determined that both Pablo and Jorge had injured their ACLs as younger men playing soccer in their home countries, so it was recommended by the orthopedist that they both get knee replacements as soon as possible.
When their employer was informed of this by their insurance carrier, their Risk Manager happened to speak to the company’s Employer Benefits Manager, who recommended he look into getting the men treated in their home countries through medical tourism. The Risk Manager had never heard of medical tourism, so he asked the Benefits Manager to explain how it works. The Manager told him that the company is self-insured for their employee’s healthcare plan, and as an option, they allow their employees to choose to get treatment abroad through a medical tourism facilitator company they have contracted with.
When the Risk Manager heard about the self-funded plan option, he wondered if this could be something he could use for his three workers’ compensation claims. He told the Benefits Manager that the hip and knee replacements would cost $50,000 each. Even though the insurance carrier was going to pay for it, it was going to affect his claim severity, which would impact his experience mod, causing a rise in insurance premiums. The Benefits Manager told him that if they so choose, they can each get their surgeries in their home countries at lower cost, and at the same or better quality than in US hospitals. The Risk Manager asked the Benefits Manager to get him comparative prices for each procedure in the three home countries of the injured workers, and he would try to get the insurance carrier to go along with it.
The Benefit Manager sent the Risk Manager the following table comparing hip and knee replacement costs in the US with the costs for each in Colombia, Costa Rica and Mexico. As seen in the table below, a hip replacement in Colombia cost $6,500. In Costa Rica a hip replacement cost $12,500, and in Mexico a hip replacement cost $13,000. Knee replacements in each country were as follows: $6,500 in Colombia, $11,500 in Costa Rica, and $12,000 in Mexico.
The insurance carrier was unsure of the quality of treatment and skill of the treating physicians in those countries. As the company vouched for their quality and skill from the employees who had used it under the self-insured healthcare plan option, they agreed as long as the company was satisfied this was what the employees wanted. All three men, when told of the option of being treated in the US or in their home countries, opted to take the medical tourism option. What had made it possible for them to choose this as an option was the fact that the total cost of the procedure included airfare for each man and his spouse, plus accommodation, as well as the cost of the surgery and hospital stay.
As Juan had older children, his oldest married and living close by to the family; they could watch the other children while he and his wife were away. Jorge’s children would stay with his wife’s relatives nearby, and Pablo’s children would come with him and his wife, since he was able to find a low fare for the two young children. Also, the fact that the hospitals they were going to were some of the best in their home country, made them feel better of themselves that they could get such great care at a very good hospital. It would help their self-esteem and make their friends and families back home very proud.
When they returned to the US, they had healed much faster and in better spirits had they not chosen this option. Although they could not work again at their old jobs, they nevertheless got good jobs with the same company that did not put them in such dangerous positions before their accidents. They became more productive as a result and their employer was pleased with the outcome. The Risk Manager with the approval of the president of the company, included a medical tourism option for all future severe workers’ compensation cases.
Richard Krasner has worked in the Insurance and Risk Management industry for more than 30 years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. He has experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. Contact Richard or read Richard's blog.
As defined in Wikipedia, remote patient monitoring (RPM) is: “a technology to enable monitoring of patients outside of conventional clinical settings (e.g., in the home), which may increase access to care and decrease healthcare delivery costs.” I was a pioneer adopter of RPM as a BETA site for Medtronic’s Carelink wireless system which monitors implantable cardiac rhythm devices (defibrillators and pacemakers). RPM has gained significant attention because of recently mandated penalties for hospital readmissions for certain diagnoses (myocardial infarction, congestive heart failure, stroke, and chronic obstructive lung disease). RPM is seen as a way of remaining in physiologic contact with these patients who might be managed at home via care systems. There are conflicting study results regarding the utility of remote monitoring preventing hospital readmissions. Some studies show no decrease in hospitalizations, and others with significant benefit.
1. All remote monitoring is the same. There is no standard definition for RPM. Some studies utilizing only telephone interviews have been called RPM. Other RPM technologies use body sensors which deliver data from the person’s body in an automated fashion into a server and/or a smartphone via an app, and/or an EHR.
2. All remote monitoring is reimbursed. RPM of implantable cardiac rhythm devices has been directly reimbursed for many years in the USA. In fact, when it was first approved for reimbursement by CMS, it was approved at a higher level than in-office follow-up. Many years following USA approval of reimbursement, European countries are still variable with regards to reimbursement models. Besides RPM of implantable cardiac rhythm devices, – Not directly reimbursed but is an approved adjunct under the Home Health Resource Groups of the Prospective Payment System (HHRG PPS).
3. Patients and physicians will welcome and embrace remote monitoring. My first foray into remote patient monitoring introduced me into the psychological aspects of the technology as much as the bells, whistles, and clicks entailed in performing it. The first pushback from patients is that the technology is replacing the physician, and eliminating the patient-physician relationship. If the technology conveys true benefit to patient care (implantable cardiac device monitoring leads to early discovery of arrhythmias and even led to detection of an eventually recalled defibrillator system wire). What patients should know is that with any type of well-designed and thought out RPM system they will be more connected both literally and figuratively with their provider. Interestingly according to the 2012 Study of mHealth by Ruder Finn, 33% patients would like their physician to use a mobile platform for RPM to alert them of serious medical problems. The first reaction from physicians is that they will be deluged with useless generated data, and that the data will remain in cyberspace without them knowing about it. The first reaction is addressed with good design, with actionable (and customizable) alerts and a workflow system employing non-physician providers. The second concern is addressed below.
4. Remote monitoring should be totally automated. The most effective RPM systems have some sort of human interaction involved in closing the monitoring loop. This is advisable for a number of reasons. There needs to be individualization of programmed parameters and alerts. This will allow for actionable alerts that are both meaningful from the provider’s standpoint and beneficial to the patient. Data cannot e managed in a vacuum. There will be false positive and negative readings which must be correlated to the clinical condition of the patient in order to result in optimal management. Caregivers should be involved in the loop as well.
5. Remote monitoring is only for recently discharged patients. It is no secret that RPM has both garnered and generated extraordinary attention because of Medicare penalties for hospital readmissions. Regulatory requirements have driven much of digital technology adoption in the past decade. This includes EHRs, tools to determine and improve patient satisfaction, and patient portals. This is sad insomuch as one would hope that providers would invest in improved patient outcomes independent of mandates, following the tech adoption leads of the retail and finance sectors, focused on customer satisfaction and transaction outcomes. That being said, one would hope that the theoretical improvements brought to patients vis a vis decreased rehospitalizations (though 30 days is hardly a measure of long-term success) could extend to all relevant patients (those not hospitalized with chronic illness as well as those beyond the 30 day discharge period).
I have witnessed firsthand the dawn and benefits of RPM over time. I look forward to the partnerships of RPM, mobile health, health IT, and non-tech patient-centric care.
David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com
HEALTHCARE is globalizing, and Workers’ Compensation should be a part of that. There. I’ve said it, and I will explain why. When I attended the 5th World Medical Tourism & Global Healthcare Congress, last week at the Westin Diplomat Resort & Spa in Hollywood, Florida, sponsored by the Medical Tourism Association (MTA), I found just how big this growing industry is getting, and how many countries are getting on the bandwagon to provide lower cost healthcare at the same or better quality than U.S. hospitals are offering, with doctors trained in the U.S. or in other Western countries; the latest technology and medical equipment, and accreditation from the Joint Commission International (JCI), the International Organization for Standardization (ISO), as well as the U.S. Centers for Medicare and Medicaid Services (CMS).
In the paper, I discussed what medical tourism is, how it is being implemented into health care plans, the cost savings of medical tourism, as well as the issue of quality, which is equal to or better in many of these hospitals than most American hospitals provide. I then discussed the state of workers’ compensation medical costs, and finally, the legal barriers medical tourism faces, as well as the legal barriers to implementing medical tourism into medical provider networks for workers’ compensation, using three legal cases pertaining to medical tourism and workers’ compensation claims.
The first one, was in California, and was a case of domestic medical tourism. A cook at a convalescent hospital slipped and fell and injured his right elbow and back. Due to his weight, the treating physician, and his employer’s physicians recommended he lose weight, but since they did not tell him which weight loss clinic to go to, the claimant chose to go to a clinic three thousand miles from his home. The case wound up in the CA Supreme Court, which ruled in his favor, granting him temporary disability for the ten months he was at the Duke University clinic, and for all future costs of medical treatment.
The second case was also in California, and concerned a Mexican worker who fell off of a ladder. He was treated by the State Compensation Insurance Fund and a provider in his hometown of Tijuana. The medical reports were prepared by both the treating physician and another doctor. The Workers’ Compensation Appeals Board made an award to the claimant, the State Fund petitioned for reconsideration, on the grounds that both physicians were not licensed under California law. The Court of Appeals ruled in the claimant’s favor in this case as well.
The last case happened in Florida, and also involved a Mexican worker who was injured when a vehicle struck him as he was unloading trash in the right leg. He was hospitalized for a long period of time and had twelve surgeries to repair the fracture. He was seen by an orthopedist in Dallas, who recommended additional surgery. He never got the surgery in the US, as he returned to Mexico and did not have legal documents to return to the US. This case went to the Florida Court of Appeal which ruled that state law did not preclude the foreign physician’s treatment of the claimant in Mexico. They stated that Florida workers’ compensation law contemplates coverage for non-citizens, and they cited an earlier case in which the court held that undocumented workers were entitled to workers’ compensation coverage in Florida, and two later cases that held that “to construe the section 440.13(2)(a) in a manner that would limit authorized treatment for a claimant injured in Florida to a physician licensed in the State, or anywhere else in the US, would preclude workers (including illegal aliens) who return to their home country from receiving authorized remedial care for clearly compensable injuries.”
The Court of Appeal also stated that Florida law indicates that an injured worker is not prohibited from moving from his pre-injury residence in the state, and receiving treatment outside of the state. As the claimant was no longer living in Florida, the court held that this case was different from three other cases that the defendants cited, in that the claimant was already living in Mexico when he requested medical treatment. Therefore, the trial court did not err in directing the employer/carrier to authorize treatment by a Mexican physician, and the trial court’s decision was affirmed by the court.
These cases are by far not the last ones that will arise in regard to medical tourism and workers’ compensation, and with a growing working class population in the U.S. that is foreign born, there will most certainly be others in the future. And as such, getting these workers treated in their home countries where issues of language, culture, cuisine, family and friends supporting them are not a problem, it will become necessary for employers, workers’ compensation carriers, unions, and the claimant’s themselves to have the same options for treatment that they may be getting from their employer’s health care plan.
What is the difference if a knee or hip replacement is performed on a patient who is injured on the job, or crossing the street and gets hit by a car? There is none, so why should workers’ compensation be any different than health care plans already being implemented, or are being planned for in the future as the medical tourism industry grows, and more businesses arise to facilitate such tourism and more hospitals get in on the game around the world.
Among the nations represented at the Congress were many countries in Central and Latin America such as Mexico, Guatemala, Costa Rica, Nicaragua, Panama, Colombia, Chile, Brazil and Argentina as well as Caribbean countries such as the Bahamas, Barbados and Puerto Rico. Other nations represented there were Poland, Lithuania, Turkey, Thailand, Malaysia and Japan. With many workers comp cases involving both legal and undocumented workers from these countries and many others, using the medical tourism option will make sense because the claimant can get the best treatment available in his home country at reasonable costs in surroundings that will benefit his recovery and healing, which will allow him to return to work more quickly because being with family during a medical event has proven to be the reason why Latinos have better health outcomes than African-Americans.
By chance, on the third day of the Congress, I met a woman from Guatemala who is working with her American partner on developing medical tourism for self-funded health plans in Latin America. I discussed my paper with her and gave her my business card for her and her partner. They are partnering with Meritain Health/Aetna on creating these plans, and I mentioned to her that Aetna recently purchased Coventry Health Care. I told her it is possible that Aetna could use the work comp services side of Coventry to expand in that direction. Earlier in the day, also by chance, I met a woman from Canada who advises a subsidiary of Blue Cross and Blue Shield of Florida about workers compensation and medical tourism. I gave her my card as well, and sent her my resume and paper by email for her to pass on to her client.
Whether or not any of these two possibilities pan out for me is not really the point I am trying to make. As more and more health care companies implement medical tourism into their plans as options for individuals and groups, and as more and more employers, both self-funded, as well as those who get their health care through the commercial market, the pressure on both insurers and employers to lower the cost of health care as costs keep rising, will no doubt lead them to seek lower medical costs for their workers’ compensation policies as well. What is good for the goose is good for the gander.
But what it will take from the workers’ compensation side is much more difficult than what is already happening among such companies as Google and American Express, both of whom had representatives speak at the Congress about what they are doing with medical tourism for their employee’s health care, as is a company from Michigan who is also using medical tourism for their employee’s health care. With regard to workers’ comp, my paper outlines some of the legal barriers to implementing medical tourism into workers’ comp. Those laws will have to be replaced or amended to open up the workers’ comp arena to medical tourism.
Among some of the issues not covered in my paper, but that present both a problem and an opportunity, are the laws about distance from a claimant’s home a provider can be in order for the claimant to reasonably get to the doctor’s office. This would not be a problem for medical tourism, as the best way it could be utilized would be on a secondary care level. The next problem would be the Employee/Employer choice of doctor requirements states have in their workers’ compensation laws. Here too, this could also be good for medical tourism, if the employer or carrier realizes that local secondary treatment would be extremely costly to both, then finding a lower cost option domestically, or internationally, would allow medical tourism to benefit the workers’ compensation claimant.
Even if a state has laws stating that employees have a choice, like Washington State and Oregon has, then the claimant could choose from a list of providers the state has pre-selected to provide treatment abroad. Washington State already does that with a page on their website that takes you to pdf files that have lists of pre-selected doctors in certain countries. For this to be realized in other states, insurance companies, employers, business groups, unions and even workers’ rights organizations must get involved and lobby their state legislatures to change or amend their laws.
Medical tourism, once the purview of the wealthiest, has become more affordable to more people, as well as to those who are under-insured or uninsured. Self-funded plans and commercial insurance companies are choosing this as an option. For these employers to do so for their health care coverage, and not for their workers’ compensation coverage is like buying homeowners insurance, but not flood insurance or auto insurance. A house is certainly not a car, but neither is it always going to be flooded, but on the off-chance that it is, and it is situated in a flood zone, then it makes sense to buy both auto and flood insurance along with homeowners insurance. Workers’ Compensation should be no exception.
Richard Krasner has worked in the Insurance and Risk Management industry for more than 30 years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. He has experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. Contact Richard or read Richard's blog.
Last week I was reminded about how far we’ve come in
electronic patient records in just three years, when the annual signature event
in health IT, the Health Information Management Systems Society conference
known as HIMSS (pronounced HIM-Z), was held. Three years ago I spent the week
at HIMSS10, and at that time we hadn’t
even started up the Meaningful Use hill, let alone crested MU2.
Since then, we also have seen uptake rates for electronic
patient records and CPOE topping 50% in most provider venues without even
breaking a sweat. And, in my humble opinion, the leading news out of HIMSS13
was the fact that six leading electronic patient record systems will be working
together on establishing standards to advance interoperability. Whew! Never
thought we’d see that in the first half of the 21st century…
The progress is commendable. And as a long-time observer and
analyst in this field, while the cynic in me often says, “We wrote white papers
about that 20 years ago…it’s about time!”, the realist knows that fully
integrated electronic patient records requires a kind of sea change in the way
we provide service to patients – and that will only come over time with changes
in culture, which is why I have been talking about change management and
training as absolutely essential for a smooth transition – something that
studies are bearing out (see my Healthcare Talent Transformation blog post from last month).
But probably the biggest single factor in moving the needle
on uptake is the more than $10 billion we spent in incentives over the last few
years to encourage doctors and hospitals
to purchase the software systems. Unfortunately, after those billions have been
spent, only now are the top vendors getting together on establishing standards
for interoperability. I haven’t read the fine print, but I will guess that
those are probably not going to be free upgrades to those systems the tax payers
already bought and paid for. I would love somebody who knows about the
interoperability effort to post here with more details since time to publish
does not allow me to do the research. In the meantime, I might do a little
looking and report back in a few weeks, so stay tuned.
But the bottom line on the advantages of electronic patient
records boil down to a few major points, and at HIMSS13 it is clear we have
finally started to move the needle on some of these:
Uptake rates for physicians, hospitals and
computerized order entry (pharmacy, radiology, etc)
National (international would be *really* nice)
standards for interoperability
Fully integrated patient record including
dental, vision, mental health (we’re a looooong way from this one, but it is
critical to getting a good end-to-end snapshot of the patient in front of us.
Only ONE booth at HIMSS10 even offered software for mental health providers
and, no, it wasn’t integrated into the major software packages)
Ability to pull aggregated, de-identified data
for research for full population studies and post-approval FDA studies
The Falling Cost of Technology – Except in Healthcare
As envisioned by the planners, when we can capture the full
picture of a patient, and all providers have access to it, theoretically the
cost of healthcare should fall quite a bit. No more duplicate tests, the cardiologist
will know what the psychiatrist prescribed so we won’t have the drug-drug
interaction issues that currently cost us at least hundreds of millions a year
in adverse events and the attendant morbidity and mortality rates, we won’t be
writing and re-writing scores of sheets of repetitive patient documents for
each provider and patient encounter and having to physically store and transfer
them. And, the icing on the cake, when we have valid, comprehensive data on
full populations, we should know what works in which patients which will narrow
our treatment options to the ones most
likely to succeed the first time.
Technology usually brings with it a falling cost curve. But
the reality is, for now, we are still undergoing the transformation stage and
the transition is rocky and costly. The culture is still changing, the records
are still isolated in single offices or hospital systems, and we haven’t
completely solved how to interact with patients using an electronic interface
in the room, and especially, we haven’t solved how to take and capture complex
notes in an electronic record.
We aren’t there yet. But reports out of HIMSS13 suggest we
are getting there.
If you were at HIMSS13, we’d love to hear from you in the
comments section. And if, like me, you missed it, let me shamelessly hustle
what sounds like a great deal which is a three-hour debrief today, Wednesday
March 13 from 11 a.m. to 2 p.m. CST and access to full sessions online until
June, Here’s the link: HIMSS13
Online Sessions
And, what’s more, the online sessions are eligible for CE
credits.
Let me know what you think about HIMSS13, and
I’ll be reporting back when I learn more.
Patient engagement is a phrase that is everywhere now. It is part of the vernacular in advocacy circles, government, health technology companies, and payers. It used to signal a new healthcare ecosystem in which the patient is more of a spotlighted consumer; where reimbursement hinges on patient satisfaction, where the shortage of physicians dictates new care paradigms, and where the cost of healthcare must decrease as well as be redirected to wellness and home care from the more expensive treatments of preventable chronic diseases and institutional care. The Center for Advancing Health defines patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.” It is defined by an active role that patients play in their own care.
Each of these phases has a process corresponding to a stage of Meaningful Use. They are also provider-facing, in much the same way the Patient Centered Medical Home is. I agree fully with the framework of ‘INFORM ME’ preceding ‘EMPOWER ME’. But the accompanying narrative (“A healthcare provider in this phase demonstrates basic levels of patient engagement with an emphasis on the use of simple tools that make healthcare more convenient and accessible. This also includes providing patients with standard forms, both printable and electronic, and information about advance directives, privacy and specific conditions.”) implies that a patient will become informed if they can use simple technology tools. I would say that the technology is a tool, not a solution to informing patients. The technology itself must be put into a framework which involves human interactions and ‘EMPOWER ME’ refers to “advanced patient engagement activities through substantive use of health IT.” If the MU directive only requires 5% of patients to have patient portals, how substantive is it? Do patients need to wait for this third phase to be empowered? Should Stage 3 of Meaningful Use be a surrogate for true patient engagement?
Physicians and other providers need more than this framework to begin to engage patients. There needs to be a change in the mentality and culture of healthcare on the part of all stakeholders to empower patients before they become engaged. When my practice hired a nurse practitioner 13 years ago, referring physicians were livid that patients were seen (for routine follow-up, not consultations) by a non-physician. That culture has since changed dramatically, but took many years to do so. Empowerment or enabling will come simply with the realization of how much one can do with lifestyle changes to improve health and maintain wellness. This need not take years and should be independent of MU schedules and technology. Patient engagement is more conceptually restrictive and technology-oriented than patient empowerment. I submit that patient empowerment can come to those even unwilling or unable to use digital technologies. Without empowerment there can be no engagement. Engagement cannot be passively bestowed upon a patient because technology is available. Patient empowerment should start in schools. Children are always seeking to become enabled in all aspects of life, and I believe that teaching them how much they can do to keep themselves well will, if done appropriately, yield huge benefits. I applaud the efforts of the e-Health Collaborative. But we need not wait for MU to mature nor depend upon technology to have patients obtain the respect or responsibilities from others to become empowered, which only takes knowledge and a change of culture. Patient engagement will require technology including mobile health and other tools. there is no debate about that. Demographics and economics dictate this. I am a champion of technology. But for technology to succeed as an integral part of patient engagement, empowerment must occur first. Critics of engagement and empowerment will say that there are many patients and consumers who do not desire to participate in their care. I realize this and that topic is for another discussion. The above implies to those who wish to.
David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com
In my previous post I discussed what I believe to be the most important paths to patient engagement without technology. I would like to now follow-up and discuss how technology can promote patient engagement. This technology might be in the form of a health/medical app, a patient portal, information derived and transmitted via a sensor, or other type of digital health technology.
1. Technology is always to be utilized as an adjunct tool, not the sole solution. This is probably the most fundamental consideration. I chuckle when I hear of a technology presented as a ‘solution.’ Solutions do not occur in a vacuum. Technology must always be incorporated into some process, whether it is limited to the user or spans a network of individuals. Much data might be generated, but if it resides in a magic silo without it being filtered and translated into a meaningful actionable message, it is useless. It is also useless if the following four issues are not addressed.
2. It must be used with consideration of health literacy, ethnicity, and language. The patient experience is a phrase getting much attention these days. While there is little in the way of data correlation between quality and patient satisfaction, one cannot argue that intuitively if cultural, ethnic and language barriers are addressed with technology tools, the potential for reduced medical errors, better patient satisfaction and perhaps even better outcomes might result. In searching for such a tool, I found a unique and interesting technology called SpeechMed which incorporates language translation into connected platforms. Improving language literacy will undoubtably improve health literacy. Platforms should also take into account ethnic and cultural differences which might imply utilizing a different user interface for selected populations (as well as ages).
3. It must include the caregiver. Any technology aimed at self-management needs to take into consideration the caregiver. The importance of technology in assisting caregivers is discussed in a review entitled Family Caregiving and Transitional Care by the Family Caregiver Alliance. The role of technology and the caregiver has also been discussed in aprevious post by me.
4. It must be connected. I believe that the patient portal is the single most important key to patient self-management. It can serve as a repository for medical records including videos, pdf files, medical apps, and other content. For this piece of the puzzle to be most effective, it must permit connectivity from diverse technological sources. Barriers to this are economic and political, not technological. As the patient portal market and health information exchanges mature (Stage 2 of Meaningful Use which dictates the use of patient portals only requires that 5% of patients have them), I see connectivity becoming less of an issue. The development of open sourced platforms will also help in this regard. The patient portal can thus become the source of convergence of many different digital health technologies.
5. It must be endorsed, not despised by healthcare providers. Technological advances in therapies are expected and even anticipated by many healthcare providers. They are seen as symbols of progressive and modern medicine. Yet due in large part by experiences with EHRs, many providers to push back other types of digital technologies. If technologies are easy to use, are accepted by the patient and caregiver, provide demonstrated benefit, and deal with data in a filtered and algorithmic manner, attitudes would change. As a former practicing clinician who speaks with former colleagues daily, this is not a small barrier.
I look forward to hearing thoughts from readers about these points. Patient engagement is going to be a cornerstone of healthcare in the future. We must find the best ways in which to achieve it, with both humanistic and technological factors considered.
David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers. He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com
I think many of our readers will want to check this upcoming IT conference to be held in San Francisco. If nothing else, perhaps many of us can get out of the snowy east and midwest. Seriously, the presenters and topics look great!
"The 2013 iHT2 Health IT Summit is less than 30 Days away! Don't Miss this opportunity to join over 200 CIOs, VPs, and Directors of IT from hospitals, health systems, and larger physician practices.
Program Highlights:
Data Analytics in Healthcare - Featuring Kaiser Permanente, Catholic Health Partners & More
Evolution of Clinical Decision Support - Featuring Mayo Clinic, Dignity Health, Lucile Packard
Meaningful Use Stage 2 - Featuring CalHIPSO, Department of Public Health - San Francisco & More
mHealth Apps & Patient Engagement - Featuring Aetna, West Health, UCSF School of Medicine & More
How will the 2013 iHT2 Health IT Summit in San Francisco benefit you?
Learn best practices for leveraging data at the point of care, and how to get the most out of your EHR data
Discuss strategies for securing mobile devices and understand how to assess responsibility for PHI
Address best practices for improving performance & outcomes and understand how you can use Clinical Decision Support to meet new standards of care
Understand how Meaningful Use standards impact ACO operations and success, and the role the new ICD-10 will play in providers understanding their practices and outcomes
Discover mHealth tools that reinforce the provider-patient relationship, and best practices for integrating mHealth data into existing EHR and system infrastructure
Still Looking for Reasons to Attend?
We understand your time is valuable. Now more than ever, iHT2 is committed to providing programs which promote improvements in the quality, safety, and efficiency of healthcare through information and information technology.
Interested in attending or just learning more about the iHT2 Health IT Summit in San Francisco or upcoming Summits in Atlanta, Boston, and Fort Lauderdale? Please contact Matthew Raynor at matt@ihealthtran.com or call 561-748-6281.
iHT2 HIT Connect Interview:
Davin Lundquist, MD
CMIO
Dignity Health Medical Foundation
How has Dignity Health Medical Foundation benefited from using CDS (Clinical Decision Support) systems?
We have some basic CDS tools in place within our EMR, most related to medication ordering as well some meaningful use reminder alerts. We also use templates in our documentation to help prompt providers with what questions to ask patients who come in for particular types of visits or with particular problems. We have some order sets and a few care guides related to wellness visits. I would categorize all of these as “First Generation” Decision Support tools. We are actively pursuing technologies that will help us get to what I would call “Second Generation” Decision Support tools that are much smarter and actually incorporate patient specific information and prior results to prompt physicians with more point of care and contextual support for managing patients and their diseases.
Hear from Davin Lundquist, MD and more than 35 other C-Suite Health IT Leaders at the iHT2 Health IT Summit in San Francisco, March 26-27th at the Hyatt Regency San Francisco Airport
Click Here to View the Agenda
Click Here to Read the Interview in its Entirety
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