Healthcare Talent Transformation

HIMSS 13: Progress on uptake and interoperability, so when do we see the cost benefit?

Peggy Salvatore, MBA

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 21^st 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.

 

DigitalHealth: Patient Engagement Does Not Imply Patient Empowerment

David Scher, MD, DLS Healthcare Consulting

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.

According to the National eHealth Collaborative, the Five Phases of the Patient Engagement Framework consists of:

1. INFORM ME
2. ENGAGE ME
3. EMPOWER ME
4. PARTNER WITH ME
5. SUPPORT MY E-COMMUNITY

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

Employee vs. Employer Choice of Physician Revisited: Additional Commentary on How Best to Incorporate Medical Tourism into Workers’ Compensation

Richard Krasner

Further research into the topic of Employee vs. Employer choice was prompted by a phone call I received over a week ago from an attorney in New York who handled workers’ compensation cases and is a consultant to carriers and businesses on workers’ compensation, group health and disability insurance, cost-containment, claims investigation and claim preparation. The call got me to think about what I had previously stated in my earlier post on the subject of employee vs. employer choice, and to my amazement, new research found that New York State allows employees, and not their employers, to choose the treating physician. I corrected my error in the original post, but decided that a further clarification and elaboration was needed.

Needless to say, when I came across a study by the Texas Department of Insurance comparing state workers’ compensation systems, I found more information, and decided to expound upon my previous writing. What I found was not just that there is employee vs. employer choice, but that choice of physician is determined by six additional categories. The first category is employee choice of physician. The second category is selection from a list prepared by the appropriate state agency. The third category is selection from a list maintained by the employer. The fourth category is employer choice. The fifth category is employer’s choice may be changed by state agency, and the final category is a after a specified period of time, choice falls to the employee.

As seen in Table 1, thirty states allow some form of employee choice of doctor, while twenty states allow some form of employer choice of doctor. This is important to bear in mind, for the purposes of incorporating medical tourism into workers’ compensation, as 60% of U.S. states allow employees to make the initial choice, and only 40% of U.S. states allow employers that choice, as seen in Figure 1, so that in order to incorporate medical tourism into workers’ compensation, it will be necessary to get employees to agree to it before getting their employers, or their employer’s carrier to do so.

Figure 1 – Pct. of Employee/Employer Choice

Table 1 – State-by-State Comparison of Statutory Provisions Relating to Choice of  Treating Doctor

Source: Texas Department of Insurance, Workers’ Compensation Research Group, Comparison of State Workers’ Compensation Systems, 2004.

Note: * If an employer and/or insurance carrier has a managed care arrangement for workers’ compensation, then injured workers are required to choose a treating doctor from within the employer’s or carrier’s network.

Note: ** If employer has designated at least two Health Care Organizations (HCOs), then the timeframe that an employer has to choose the treating doctor is normally extended.

Broken down even further into the three categories mentioned above for employee choice, as well as for employer choice, 24 states allow employee to have initial choice, which represents 80% of all states that allow employee choice. Four states allow the employee to select from a list prepared by the state agency, which is 13% of all thirty states, and three states allow employees to choose from a list maintained by their employer, which is 10% of all the employee choice states, as seen in Figure 2.

Figure 2 – Pct. of Employee Choice Categories

Ten states allow employers to choose the treating physician. Three states allow the employer’s choice to be changed by the state agency, and seven states allow the employee choice of doctor after a specified period of time has elapsed. As shown in Figure 3, half of the twenty states that allow employer choice, or 50%, allow for initial employer choice. The other 50% is split between states that allow the state agency to change the employer’s choice (35%), and the states that allow the employee to choose after a specified period of time (15%).

Figure 3 – Pct. of Employer Choice

To further complicate the matter, one state in the employee choice category, yet unknown, allows the employee to choice their treating doctor if they can prove that they or a family member has a record of previous treatment with a particular doctor. As shown in Table 1, five states allow workers to choose their doctor if the employer or carrier does not have a managed care plan; otherwise they have to choose from within the network. Seventeen of the employee choice states have unlimited choice of treating doctor, but are not ascertained in the report.

It would appear that in order to incorporate medical tourism into workers’ compensation, it would be useful for any facilitator or other entity such as an employer or carrier, to carefully read the statutes in each state they are conducting business in and have considerable workers’ compensation claims that might benefit from the lower surgical cost and quality issues medical tourism affords. To not do so would be foolish, and would create a great deal of confusion and doubt as to the whole efficacy of medical tourism, which would be a terrible mistake for the employee, his employer and the insurance carrier.

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.

Employee vs Employer Choice of Physician: How Best to Incorporate Medical Tourism into Workers’ Compensation.

Richard Krasner

One of the obstacles to incorporating medical tourism into workers’ compensation is the issue of Employee vs. Employer choice of treating physician. State Workers’ Compensation laws recognize four different categories of choice of physicians, Employer Only, Employer/Insurer, Employee/Employer and Employee Only.

Employer Only is self-explanatory; Employer/Insurer means that either the employer or his insurance carrier can choose the treating physician for the claimant. Employee/Employer means that the employee has the choice to choose the treating physician, or failing to do so, gives that right to his employer. Employee Only means that the employee can choose his physician.

Among the fifty states and the District of Columbia, a slim majority of states allow some form of employer choice as described above, and as indicated in Figure 1. As seen in Table 1, choice of physician is marked by an ‘X’ under each category for all fifty states and the District of Columbia.

Figure 1

Table 1

The percentage of states for each category is shown below in Figure 2, the majority of states, 48% recognizing Employee choice, but if you add together the Employer Only, Employer/Insurer and Employee/Employer categories, the majority of states would favor employer choice in whole or in part.

Figure 2

What this all means for medical tourism is this, the best approach to take in implementing medical tourism into the US workers’ compensation system is to get employers to choose it as an option for their injured employees who will need secondary treatment, i.e., surgery that would be more expensive in the U.S., but at a much lower and more reasonable cost and better quality in fully accredited hospitals in medical tourism destinations.

For self-funded employers, especially those already using medical tourism as an for their employees health care plan, doing the same with their workers’ compensation claims will allow them to realize considerable savings in workers’ compensation costs, as they are ready realizing in their health care costs. Employers, who are getting coverage on health care for their employees through the commercial market, will want to approach their workers’ compensation carriers to get them on board with a medical tourism option. Some commercial insurance companies that provide both health care coverage and workers’ compensation coverage would be the best companies to work with in this regard.

If there is some resistance on the part of employers and their insurers because of state workers’ compensation laws, then a concerted effort to amend, remove or change these laws will need to be considered, not just by a few companies, but across the board in the business world. To do anything less would be to allow the status quo to continue and to see medical costs for workers’ compensation claims to rise even higher when there is a viable and reasonable alternative available, within a relatively short distance from the US mainland in Central and Latin America, the so-called “rising stars” of medical tourism.

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.

 

Five Ways of Achieving Patient Engagement: Part 1: WITHOUT Technology

David Scher, MD, DLS Healthcare Consulting

If one looks at communications revolving around healthcare these days, whether emanating from political, healthcare economics, clinical, or technology spaces, the term patient engagement is invariably found as one of the cornerstones of the conversation.  This is no more evident than in the digital health technology space. One would think that patient engagement is only possible by hitching a wagon to the technology horse.  I would like to explore the issue with two posts, the first devoted to non-technical considerations and the second examining best practices of technology utilization in this regard.

1.     Listen to the patient.  Patient-physician communication is the basis for much of what transpires during the tenure of the professional relationship.  Lack of good communication has been cited for medication nonadherence.  William Osler, the father of modern American medicine famously stated that the patient will tell you the diagnosis with the narration of the history. Given the fact that most office encounters today last 15-20 minutes and that patients have comorbidities requiring attention, it is no wonder why many times they are not heard.  The physician is looking at the computer screen clicking off checks. The system is no longer geared towards human interaction and this creates a recipe for poor care, even if unintended.  This is why direct care or concierge medicine is becoming popular.  Both physicians and patients are returning to communicating in this setting. Other solutions need to arise to promote communication. Providing patients with pre-visit guidance in order to organize their thoughts and concerns might help.

2.    Motivate your staff to be as patient-focused as you are. Office and hospital staff should reflect the provider’s patient-focused approach to care. Many times they are too task-oriented and forget there is a patient who is the reason behind those tasks.  If the staff takes on the mindset of a stakeholder in the patient’s care and not just performing a job, the result will be a happier patient. Patient satisfaction surveys (an important part o the future healthcare landscape) will reflect this aspect of the care.  Patient-centered professionalism should be the goal of all ancillary staff.

3.    Demonstrate to the patient that you are an advocate.  Going to bat in front of an insurer for a patient who really needs a specific drug or procedure is something I always felt good about. Spending time on such matters is something physicians years ago (dating myself) went into the field thinking they would have to do.   However onerous, it is what patients need docs to do in critical moments. And patients do very much appreciate this. It is what made me feel good going to sleep at night.

4.    Show them your personal side.  Social media is a great way for providers to show their personal side.  This is not to say that personal interactions with patients should take place one on one, but a way in which patients see the personal (and hopefully appropriate) side of their healthcare professional.  I believe Twitter is a better forum for this than ‘friending’ between a provider and patient on Facebook.

5.    Individualized self-management.  Patients will partner with providers in their treatment plans with different levels of enthusiasm.  Some patients will require more support than others (motivational and material) and this should be discussed. Discussing patient engagement early on in the relationship is important.  It should also involve a caregiver who might be the one participating in the engagement on a larger scale. A provider who embraces co-management and is seen as both a partner and supporter of the patient will be appreciated.

The above might seem obvious to most people, but in today’s discussions surrounding patient engagement, the humanistic aspects of achieving this are lost in the vision of technology magically transforming how patients react to their medical conditions and to their healthcare providers.

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

Allscripts' MyWay problems far from over!

Jonena Relth, TBD Consulting

Talk on the "EHR Street" is still buzzing as we wait to see if the physicians' first class-action suit will be given it's day in court.

I think it is important to note that the docs asked the right questions BEFORE buying Allscripts MyWay.  Even more telling is the fact that the sales people answered yes to all the docs' inquiries.  If the docs aren't given their day in court about Allscripts MyWay EHR, MANY people will be up in arms and I would wager that many providers will dump Alscrips like a hot potatoe.

From the Medscape article:
"Robert Joseph's 3-provider clinic is one of the plaintiffs. The group purchased MyWay in June 2012 after sitting through a sales presentation, one of several they attended from different vendors. Joseph says that he asked the Allscripts reps targeted questions: Would MyWay be ICD-10-compliant? Would it meet phase 2 meaningful-use requirements? Would it include a specialty-specific module for pain management? Would there be responsive technical support? Was Allscripts committed to MyWay over the long term? Yes, he was assured, on all points. According to Joseph, Allscripts said that significant upgrades were in the works that would make it all possible...."

Read more: Huge Decision Coming for Doctors Who Sued EHR Company

I'd love to hear some convo on this - pro or con.  Is your practice still using MyWay EHR?

Please let me and our readers here from you -- I truly welcome comments! Conversation is the best way for us to learn from each other.

Jonena

TBD Consulting has a proven track record for ensuring staff and physician adoption of EMR/EHR system implementations as well as Lean Healthcare. Whether you need assistance to create a training department or organizational change department, help your existing training organization meet the needs of the ongoing changes, or simply need "extra hands" to meet your deadlines or ROI goals, please contact Jonena. She and her qualified staff are here to assist you with your organizational development, coaching and training initiatives.

Drop by our EMR/EHR Clinical Transformation Group in LinkedIn to learn the latest news and opinions on electronic health records. 

Or feel free to call our office today 602-263-1961. We'd love to hear from you!

Four Ways to Save $Billions on Healthcare

Kerry Willis, MD, www.aihinc.com

Dear Mr President,

I hope you are enjoying all the fiscal cliff stuff with the budget and I wanted to make you're aware of the healthcare fiscal cliff and some of the stuff that many large practices and especially small medical practices are facing in the next few years as the healthcare reform act is implemented.

Just Asking...Have you found time to read the ACA yet?

The ACA is a large bill and despite my best efforts I haven’t been able to stay awake to read it but that’s apparently something I share with you and most of the members of Congress. It does seem to be pretty far reaching and has what I like to think are unintended consequences of the actions that are forced by it and other federal acts that are conspiring to threaten to close a fifth of the providers who see patients for their primary care needs currently.

I think it’s important to incorporate technology into your practice but making it exceeding difficult and implementing more change than most medical practices can bear threatens to close the doors of many of us in the next 24 months. Many of the physicians who will close are older physicians who have served their communities well and through the good times and bad and I can’t imagine that losing them to retirement will do anything but make the shortage of doctors much worse.

We already need 50,000 additional doctors or other providers in the next few years with the expansion of the Medicaid program, and despite what some policy wonks think a Nurse isn’t a substitute for a well trained primary care doctor. I do believe that Physicians Assistants and FNPs can be an important supplement to the healthcare team, but the heart of the team has to be a high performing Physician.

    ...Unless, of course, you go with a two- tiered system of healthcare where those who can afford to see a Physician get to buy their way into see the doc and everyone else gets what they can afford. I think we can and should do better!

Non-medical wonks are trying to manipulate the delivery of healthcare:

You see Mr President, we are facing penalties for not having an e-prescribe system, an EMR and not doing quality reporting at the same time. Now you add implementing ICD 10 coding that will cost practices, small and large, tens of thousands of dollars.

    ...The purpose of the coding changes appears to be so the wonks and widgets folks will know we have suffered a Macaw attack rather than a bird attack as would. I’m sure this information is vital to those who know nothing about the delivery of healthcare but by demanding this information shows that they simply want to try and manipulate the care provided to folks in the two tiered system we are heading toward.

Do you realize who's calling the shots?

At a certain point, realizing that the same folks who designed the legal and IRS systems are designing healthcare delivery systems should serve to keep you awake at night and give you severe heartburn. I’m sure the Doctor who takes care of you in the ivory tower of the White house can figure out how to help you with those problems!

What we really need is to divorce coding from our payment systems and figure out better ways of
paying folks like me that eliminate the 40% administrative costs that decimate small practices. I realize that you don’t mean to deprive folks in rural areas of their ability to access primary care doctors, but that is the net effect of the unintended consequences thingy.

The Good News:

There is good news; however, as I have some suggestions to help you fix some of these problems. I really don’t expect much from my solutions as you have completely ignored my advice in the past. Our government has focused on the whims of the policy wonks who continue to amaze me that they are able to turn the lights on in the morning and get their shoes tied but here goes anyway.

1.    Adopt payment reforms that support the Medical Home Model and pay Doctors to make the transition to the model. There will be lots of whining from the wonks and the various academics that the model needs more study because it doesn’t have proven benefits in many of the smaller studies done. Most of the studies show an improvement in quality of care, and done properly, show reductions in ED visits and admissions as well as lower costs overall for readmissions to the hospital.

What we have proved with our current system is that it’s expensive, has limited access and it doesn’t serve the very sick very well at all. It’s loaded with excessive administrative costs and seems to be the play toy of every government agency that has spare time to harass and keep physicians from providing good care.

2.    Eliminate the annual Medicare deductable and make it simple for patients and doctors to know how much is owed for office visits. I really only know a little about this topic, but it tells me that deductibles are barriers to obtaining care. It doesn’t seem to make sense to me to place barriers to care in front of folks we want to keep in the offices of Doctors rather than in the waiting rooms of hospitals.  I just think that having patients coming to the office to prevent admissions for minor problems that become severe and end up with the patient admitted is a better idea than
our current system.

The complexity of administering the deductable system adds tens of millions of dollars to the administrative costs for patients and practices and the government. I just think there is a more understandable way to cost share than a 20% coinsurance after a deductable that changes every year is met with a fee schedule that is rarely set before Jan 14 each year.

3.    Just for kicks and giggles, let me recycle and old suggestion: Eliminate the SGR formula. You can do this in a budget neutral way by paying all physicians on the same pay schedule who don’t work in a rural health clinic or FQHC Clinics. The savings eliminated from not allowing hospitals to be subsidized for buying practices will level the playing ground and make the rules the same for all physicians.

If you need some additional savings, you might want to consider a national fee schedule for procedures like CT scans and MRI exams for the whole country. While I’m sure there are some marginal differences between salaries in New York City and Beaufort NC where I live, the costs of the
machines and the facilities don’t differ a lot and there would be additional savings from not have to administer different charges in far too many areas of the country.

4.    Eliminate Meaningful Use Three Rules and forget ICD 10. These two reductions would be associated with billions of dollars of savings for the government and our country and its healthcare providers and could be used to close the SGR gap if needed.  Losing the ability to properly code a mail box accident might be a huge loss to the wonks and widgets folks but to those of us who see patients will be forever in your debt. MU 3 rules have little to do with actually improving care and the elimination of them might lead to increased adoption and utilization of EMR’s by small practices. Asking for adoption of the Medical Home Model would be a better use of the funds and lead to enhanced savings for the government.  A Much Better Deal for the Money!

Well, I don’t want to overwhelm you with ideas all at once. I realize that my suggestions are the musings of a small town country doctor but you might want to consider them as they will fix many of the structural problems with our system. Most of them would prevent the death of small town Family Doctor practices in the future.

My best wishes for leading our government to actually advocate healthcare change that is positive and leads to savings for the government.

Let me know if I can help.

 

It’s Nice To Be Back or The More Things Change, The More They Stay The Same

Peggy Salvatore, MBA

After a hiatus, it’s nice to be back in the rotation in the Healthcare Talent Transformation blogging fold. Thank you, Jonena.

In scanning the headlines to find the latest news and reports on health IT, it is clear that while health IT uptake is moving along nicely since I last blogged here almost two years ago (!), actual health IT *integration* is slogging along.

On the plus side of the ledger, the feds have doled out millions in Meaningful Use incentives to Medicare and Medicaid doctors who bought patient record software and met some abbreviated version of compliance with Meaningful Use criteria. On the minus side of the ledger, the Meaningful Use criteria had to be abbreviated so providers could qualify for the incentives.

Just why is that? Two answers leap to mind. Either a.) the Meaningful Use criteria are too stringent to be met in the timeframe required or b.) providers and software are not prepared to meet them. My money is on a and b. An outtake from an article on Meaningful Use Stage 2 in the December 27^th edition of InformationWeek Healthcare explains:

Nearly half -- 47% -- of hospital and health system leaders are "somewhat confident" of their ability to meet the Meaningful Use Stage 2 requirements, according to a new KPMG survey. The respondents included 140 healthcare executives who completed a webcast poll.

In addition, 36% of the survey respondents said they were "confident," 4% said they weren't confident at all, and 11% didn't know what their level of readiness was to meet the criteria, which are part of the government's electronic health records (EHR) incentive program.

When asked to identify the biggest challenge in complying with the standards, the largest group of respondents (29%) cited training and change management...

… Jerry Howell, a principalin KPMG's healthcare consulting practice, in an interview with InformationWeek Healthcare…said he and his colleagues weren't surprised that so many respondents saw training and change management -- rather than technical aspects of implementation -- as their top challenges in Meaningful Use Stage 2. "We always felt reasonably confident that the leading software vendors would successfully create the technology capabilities to meet the Meaningful Use requirements," he said. Also, he noted, the transition from Stage 1 to Stage 2 is mainly about "using the technology effectively. That's contingent on the processes and people being right, which is all about change management."

The message in this blog feels as familiar as a favorite old sweater. The old sweater is this: Until we provide training to move providers up the curve to adopting health IT in a meaningful way (there’s that word again), we’ll be overlaying 21^st Century solutions on a 20^th Century mindset. And it will take a generation, instead of a few quick years, to integrate a fully functional electronic patient record system into our healthcare system, leaving us to continue to grapple with the inefficiencies and duplication that our paper-based system begets.

A vignette from a recent experience with a family member’s emergency care made it clear that things aren’t quite moving apace as we’d like to believe. A member of my family had a serious health scare over Thanksgiving, one that led us to seek an opinion at a top – some might say *the* top – healthcare institution in the US. We filled out paperwork on clipboards at several visits to inpatient and outpatient facilities. The provider did not have access to the records of the other caregivers in this person’s life in another state, and there are at
least three relevant ones, so they relied on us to provide that information either from memory or physically contacting them and providing it ourselves. We carried paper files from another “modern” facility to this hospital. We required a paper prescription to be carried in our pockets for an MRI back home, after which the physical MRI film had to be sent overnight via FedEx to be read at said top healthcare institution by their expert. Huh?

I am going to say something that nobody at the General Accounting Office wants to hear, let alone the people at Health and Human Services, which is that you just spent hundreds of millions of taxpayer dollars encouraging use of electronic patient record systems that aren’t quite ready for primetime by providers who aren’t quite ready to use them.  We’re peering over a fiscal cliff and staring at spending this money all over again sometime in the future on systems that are fully integrated by providers who are game to make them work.

It’s nice to be back.

Update: New government numbers out today show we've spent more than $10 billion in EHR incentives so maybe we can add an editor's note to the blog in the interest of accuracy.

The Healthcare Cliff

David Scher, MD, DLS Healthcare Consulting

The term ‘fiscal cliff’ is one familiar to most Americans and many outside observers of this periodic political posturing around the need to address hardcore financial issues facing the country.  If both political parties hashed out their differences and came to a (very) hypothetical agreement of significantly higher taxes, markedly reduced spending (including modest cuts to Medicare providers and Social Security), with a plan that would be estimated to decrease the deficit to almost zero, there would still be a large elephant in the room: rising healthcare costs. We have a healthcare cliff which has contributed significantly to the fiscal cliff.  US healthcare spending  was estimated to be 17.9% of the GDP in 2011 and costs are estimated to rise 7.4% in 2014 when a significant portion of health care reform legislation takes effect.

According to a report from The Commonwealth Fund published in May 2012, Australia’s per capita healthcare spending was one half ($3,445) that of the US ($7960).  Interestingly, according to the same study, Australians pay 51% and 60% less than Americans for all drugs and brand name drugs respectively.  Australia spends 8.7% of its GDP on healthcare compared to our 17+%.  When looking at tax rates, Australia has a 30% corporate income tax rate and an individual maximum income tax rate of 45% as well as a 10% VAT.  In the US, corporate rates are 0-39%, individual rates 0-35%, and no Federal VAT.  I am not an economist and don’t even play one on TV.  What I do know is that it doesn’t make sense to me or anyone to have this degree of healthcare disparity with the countries mentioned in the Commonwealth Report and at the same time have significantly inferior outcomes with regards to studied quality indicators [mortality from asthma in 5-39 year olds, myocardial infarction, diabetes lower extremity amputations, in-hospital fatality rates (w/in 30 days of admission) of heart attack and hemorrhagic stroke.] This brings to mind the comparison I’ve made in the past between healthcare and education systems and costs.  Throwing money at a problem is not the answer. Bigger newer technology isn’t the answer.  MRIs on every corner have not improved healthcare (and some might argue have harmed it) but have markedly driven up costs. mHealth technologies will become an important part of healthcare.  This needs to happen soon. They won’t be the complete answer to a healthcare cliff but will certainly do a lot to change thinking about the way in which care is delivered and paid for.

So what should legislators do? Sen. Mike Honda recently proposed legislation called the  Healthcare Innovation and Marketplace Technologies Act  The bill “establishes an Office of Wireless Health at the Food and Drug Administration (FDA) that will coordinate with other governmental agencies and private industry to provide recommendations to the FDA Commissioner on how to develop and maintain a consistent, reasonable, and predictable regulatory framework on wireless health issues. This office will not expand the mandate or responsibilities of the FDA, but rather it will seek to better clarify and simplify existing regulations.  Though well-meaning, it would seem that such a framework could increase the bureaucratic path rather than shorten it.  Consider if a technology is being looked at by multiple government agencies to determine if the FDA framework is relevant to it after it is submitted.  One could see this delaying the submission or approval process.

In addition, the Bill would establish an HHS program to support mobile health developers “build their devices in line with current privacy regulations.” Are mobile medical apps included in this program? Will this process involve only apps falling under the FDA mobile medical app scope? If so, how is privacy ensured with the other estimated 85% of mobile health apps? If it does not, then how is regulation enforced? Would Happtique’s App Certification Program (which will have publicly available standards soon addressing not only privacy, but safety, operability and content from which developers can blueprint) be more appealing in scope (By way of disclosure I am Sr Medical Advisor at Happtique)?

The bill would also create a low-interest small business loan program to encourage clinics and physician practices to purchase health IT technology and services.  Sound familiar? Have we not already seen the backlash in Congress with regards to Meaningful Use incentive payments? In addition, the bill would establish a tax incentive program to help health care providers deduct the cost of certain health IT systems, excluding electronic health record systems. This is possibly a good idea but is a tax break really a solution to mhealth adoption? Rep. Honda’s bill proposes to set up a grant program to provide support to health care providers who retrain employees for new health IT-related positions. The bill suggests new prize and grant programs like the Tricorder X prize. There are plenty of small and big prize competitions out there.  In my opinion,  the biggest prize should go to the technology that increases any X Prize type technology patient engagement to 100%. Exclusive of the last item, I believe all the previous proposals by Rep. Honda will create bureaucracies and add significant costs to government.  I understand that Rep. Honda is from Silicon Valley and represents technology businesses.  But the need is for legislation on the patient care side of things.  I would recommend reimbursement for proven mHealth technologies, Federal licensing for physicians to increase telehealth, FLEX spending account approval for mHealth, and incentives to payers and patients to adopt mHealth technologies where applicable.

The fiscal cliff will not be solved if the cost of healthcare is not tackled with the same intensity and at the same time.  It is my hope that mHealth technologies scaled to the needs of millions of patients are addressed soon by legislators and regulators in a meaningful way.  I understand the difficulties of mHealth start-ups.  But I believe if patients become the focus of these government bodies, development and adoption of mHealth happen faster and will be less costly. The healthcare cliff is here  now and 2014 will be a watershed. Let’s prepare earlier for it than we have for other cliffs by addressing patient concerns and needs, and realize that if we don’t, we will assuredly have many fiscal cliffs to come.

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

Five Imperatives for Better Patient Outcomes: Implications for Digital Health Technology

David Scher, MD,
DLS Healthcare Consulting

As both patient outcome and satisfaction gains more attention because it is becoming a basis for scaling healthcare reimbursement, management struggles to determine what constitutes a good patient experience and how best to achieve it. According to a recent survey, 84% of healthcare leaders identify a good patient experience as one of their top three priorities.  However there is no consensus on how to achieve this.  As an active participant in healthcare as a cardiologist for 20 years, I have my own frame of reference, but would like to inject digital health tech as an important variable in my assessment.

1. The patient has a good comfort level with the provider, even it is a new one.  There are many reasons why patients feel uncomfortable with their healthcare.  The erosion of the patient-physician relationship is a fairly recent phenomenon which has as its basis patients changing insurers and subsequently primary care physicians, time pressures of providers, and mutual mistrust. Adding insult to injury, many times (especially at non-routine office visits and during hospitalizations), a patient will see providers never seen before.  This scenario creates anxiety and decreases confidence on the part of the patient.  An EHR which is shared between the provider’s office and the hospital which houses the entire patient’s information is seen as a security blanket by the patient.  My office had an electronic record system accessible in the hospital and on my Palm Pilot mobile device in the 1990s. If I was seeing the patient of one of my partners in the ER and let it be know that I knew everything medically about him from the EMR, the look and feeling of relief was palpable.  EHRs level the playing field if treated with respect and providers pay attention to detail entered and modified appropriately during treatment.
2. An educated patient is a better patient.  Patients who ask the right questions are better patients. Those who take the initiative in both evaluating their providers well and making sure that they participate in shared decision-making increase their chances of having a better outcome. Bedside mobile health patient education tools are here.  Few institutions are aware of their existence let alone utilize them.  They can be placed on a patient or caregiver’s phone or tablet as an app, or transmitted via wifi to a large monitor. Educational videos pertinent to a patient’s condition, test, or procedure in advance of discharge or surgery for example will increase knowledge retention as well as help in risk management and readmission rates.
3. An efficient hospital is a safer place.  Institutions which keep track of patients, tests, materials, and have policies in place to ensure patient safety (surgical ‘time outs’, ‘Did you wash your hands?’, 90 minute ‘door to balloon time’ for heart attacks, etc) demonstrate a general commitment to patients. In the same vein, utilization of unique device identifier technologies for materials might avoid not having the right equipment at the right time in an emergency.  Patients who see order and methodologies in place feel more comfortable than one in which chaos reigns.
4. Communication must be a priority.  Handing off a patient among nurses and physicians at change of shift is the classic time for the creation of medical errors.  I used to listen as a fly on the wall many times and correct errors in these conversations involving patients I knew.  It was a bone chilling experience.  A mistake at that time could easily lead to a wrong test ordered, a wrong diagnosis, and dangerous middle of the night questions to a third-party healthcare provider who knew nothing about the patient.  Patients must be encouraged to ask questions especially about tests and medications and keep diaries about who sees them in the hospital.  If they are incapable of such, they need to have a caregiver present to do this. Many times this is still might even be done via tape recorder when the sign out nurse has already left and questions cannot be answered.  Telemedicine would be an ideal tool for a face to face electronic exchange of critical information. Patients who have providers who are familiar with their cases well feel better and more secure about the care they are receiving.
5. Patient assessment is not just for ‘paperwork.’ Patient assessments are made on admission, every shift, and more frequently according to appropriate clinical protocols. Designing assessments to be incorporated into clinical decision support algorithms and other tools to help healthcare providers at all levels would raise the level of importance and relevance of these assessments. I look forward to this being the case.  This might revive the importance of the physical exam and increase provider-patient interaction because the information gleaned might need to be more detailed or relevant to the patient’s clinical problems, not a standard myriad of check off boxes which are attended to solely for the purpose of ‘paperwork’ requirements by JCAHO.

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