Bots Rush In Where IT Fears to Tread

Guest post by Edgar Wilson.

Edgar Wilson
Edgar Wilson

Sherlock Holmes famously captured the popular imagination with his uncanny ability to make wild, but accurate, leaps of logic to solve mysteries. By observing Dr. Watson’s suit jacket sleeve, upon their first encounter, he was able to deduce that Watson was in fact a surgeon, in the British Army, and had recently returned from Afghanistan, where he had sustained an injury.

When he slowed down to explain his reasoning, it was easy to follow; what made his deductions impressive was how quickly he would skip from observation to conclusion. I’m no Sherlock Holmes, but it seems to me that chatbots are poised to take over much of modern healthcare.

Following the Clues: The Chatbots Did It

The reasoning goes something like this: As we’ve adopted EHRs across a dominant share of the healthcare system, a parallel push for greater patient engagement and data transparency has led to widespread use of patient portals. So, EHRs lead to patient portals.

As more data is moved to portals through EHRs and digital documentation, there is increased patient interest in and demand for other digital and remote encounters and health resources. This, along with improving technology and competitive solutions, is helping increase adoption of telehealth. So, patient portals lead to increased telehealth adoption.

Finally, although part of the premise and value of telehealth is enabling face-to-face encounters between caregivers and patients without respect to geography, hospital waiting rooms, or other physical barriers, it changes certain expectations. Like all mobile and web-based services, telehealth feeds a consumer mindset that expects everything on-demand, all but instantaneously, and highly customized at that.

While portable patient records facilitated by EHRs and interoperability can help this, customization and on-demand healthcare doesn’t just put pressure on records and data. Patients want fast and personalized answers. As customer service centers, tech support, banks and virtually every other consumer-facing industry has learned, a lot of the on-demand load can be pushed onto increasingly sophisticated chatbots.

So, telehealth leads to growing expectations for on-demand clinical encounters and chat, which is provided by chatbots.

The Case for Chatbots

Retail has previewed much for healthcare: See how customer service upgrades have turned everyone into “The Most Important Person Here” wherever they go, in person or online. Consumers demand personalization, expedition, authenticity and they want it all exactly when and where they want it. And now, see how AI is not yet taking over the world, but is making FAQs and other routine customer service interactions painless for those answering, and interactive enough for those asking.

Retail is even making inroads to healthcare, as consumer-facing devices promise to measure and track all manner of health metrics. Statistics-loving sports fans witness the increasing digitization and quantification of athletes, games, injuries and training, and they want a similar level of insight and precision for their own care. Mobile technology is redefining and disrupting even the oldest and most stable of markets and industries, bit by literal bit.

So how long until the dry, repetitive questions doctors routinely must answer in check-ups and physicals are ethically and effectively offloaded onto chatbots programmed to triage and educate patients without wasting valuable human resources? How long until using telehealth to keep nonemergency patients out of the emergency room merges with using chat and AI — the basic recipe for chatbots — to keep healthy but curious or concerned patients from wasting time and money going through full encounters simply to get their general questions answered?

It doesn’t take a lot of sophistication to realize the benefits of AI at scale. Google has all but taken over the modern world by connecting searchers with answers to their questions; Wikipedia has all but bankrupted the encyclopedia industry with free, accessible, general knowledge. In a world where health literacy is so lacking in the majority of the population, some interactive resources could go a long way to chipping away at ER overuse and healthcare overconsumption, just by giving people an alternative to seeing the doctor.

Automation of Care, Automation of Crime

As quickly as potential benefits can scale, very real risks and both moral and financial hazards scale even quicker.

The growing popularity and implementation of chatbots has given hackers and cybercriminals a new way to scam, defraud, and generally abuse unwitting consumers. Sometimes that means hackers take over a company’s chat system with their own bot and solicit data. Sometimes fraudsters attract visitors with a spoof website, then use a bot to similarly extract volunteered data at scale from misled visitors. However it is done, it scales almost as well as a more conventional data breach, and can be harder to detect or track.

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Prior Authorization in Healthcare: A Primer

Guest post by Saqib Ayaz, co-founder, Workflow Management & Optimization.

Saqib Ayaz
Saqib Ayaz

Have you ever faced the dilemma when you visited a hospital or a pharmacy and have been told that the impending treatment or even the prescription will need a prior authorization?

Prior authorization has been a topic of debate in the healthcare industry for quite some time and it is important to understand the process in detail to be able to take the informed decision when required.

What is Prior Authorization in the healthcare sector?

Healthcare industry, in general, is quite complex in nature with a large number of standard rules and procedures to be followed. The concept of prior authorization or pre-authorization as it is commonly called is generally used during the payment from the insurance partner.

Prior authorization in the medical industry is an intermediary step mandated by the insurance partner that requires an approval from the insurance company in order to take a decision on whether they will/will not reimburse the cost of a certain treatment/prescription/medicine. To put in simple words, healthcare prior authorization is a health plan cost-control process that requires obtaining approval before performing a service to qualify for payment.

Important points regarding prior authorization

Prior authorization predicament

Like any other process, there are pros and cons of the prior authorization process as well. While the process brings a certain accountability and cost containment for the players; fighting over prior authorizations costs several hours in lost productivity and an incredible amount lost in revenues as well, thus putting everyone in a difficult position.

The American Medical Association (AMA) along with the other stakeholders from the healthcare industry believes that prior authorization is actually a burdensome process that hinders the productivity and also timely access to treatment. The process puts a barrier for the patients in immediate need of the medical care by delaying the start of the necessary treatment/medical assistance required by the patient that can significantly impact the health outcomes.

The Current Reality

A recent survey conducted by the American Medical Association (AMA) reveals certain shocking findings:

What are the disadvantages of the Prior Authorization process?

The Road Ahead

Considering the inefficiency of the process of prior authorization and the various hurdles the patients seeking medical care faces, the American Medical Association (AMA) along with a group of experts from other medical and healthcare organizations came together in an effort to reform the inefficient prior authorization requirements imposed on the patients during the medical tests, devices, drugs, prescription and etc.

Purpose of the AMA and other medical organization coalition

The main purpose of the coalition represented by the hospitals, patients, medical group, pharmacists and physicians, is to make the process of pre-authorization simpler, faster and smoother.

The joint forum believes that the requirement of the pre-approval by insurers in the form of pre-authorization before patients can get the prescribed drugs or treatments can not only delay or interrupt medical services, but also poses the risk of medical complications due to delays in the process.

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What Jimmy Kimmel Gets Wrong About Healthcare

Editorial note: As of this publishing, the Graham-Cassidy healthcare proposal is likely dead, but the points made herein are still of importance.

Guest post by Naomi Lopez Bauman, director of healthcare policy, Goldwater Institute.

Self-appointed healthcare pundit Jimmy Kimmel is at it again.

Naomi Lopez Bauman
Naomi Lopez Bauman

A couple of nights ago, Kimmel used his late night show to lambaste Sen. Bill Cassidy of Louisiana, one of the Republican sponsors of the Graham-Cassidy legislation that would repeal and replace parts of the Affordable Care Act (ACA), commonly known as Obamacare. Kimmel claimed that the proposal would roll back patient protections and drive more people into the ranks of the uninsured.

While Mr. Kimmel’s heart is in the right place, he is mistakenly conflating the program’s intentions with unattained outcomes.

As a parent with children with a chronic illness, I have spent stressful days and very long nights in the pediatric ICU, and I’ve felt extremely grateful for having health insurance coverage and access to a high-quality children’s hospital. But I also know the frustration of having post-ACA coverage with zero in-network providers within a reasonable driving distance of the capital city in which we live.

Yes, you read that correctly. While we were eventually able to switch policies and now have local in-network providers, my family is far from unique in facing unintended consequences of the law.

While President Obama repeatedly promised that the average family would see premiums drop by an average of $2,500 per year, they have actually doubled. According to ehealth, an online insurance broker, the average family premium is now more than $1,000 per month, and the average deductible topped $8,000 per year. In other words, the average family not receiving significant ACA subsidies and buying insurance on their own could easily spend $20,000 per year before receiving any significant health insurance benefit.

And that may go a long way in explaining why the uninsured rate is creeping up for those who don’t qualify for significant exchange subsidies. In fact, the Congressional Budget Office estimates predict an overall increase in the number of insured.

Back in 2013, the Congressional Budget Office predicted that without the ACA, there would be 186 million people covered by private health insurance in 2016. Today, there are fewer people covered by private insurance—about 177 million—than what the CBO estimated would happen without the ACA.

Most of the coverage gains that have been achieved are the result of Medicaid expansion, a program already facing long waits to access care. Today, the patients most in need of help are now in the back of the line behind able-bodied adults as a result of handing out Medicaid cards to millions without any plan or viable strategy for caring for the most vulnerable.

Kimmel is right to passionately crusade for healthcare access and affordability, especially for the most vulnerable. But it is time to face reality. According to the U.S. Census Bureau, more than 27 million remain uninsured, and that number will likely climb. Premiums are skyrocketing, insurers have fled the market, provider networks are shrinking, and Medicaid expansion is harming those who need care the most.

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Healthcare Startups a Mixed Bag, But Success Still In Reach

Guest post by Wendy Dessler of Outreachmama.

Startups are taking the world by storm; it seems like now, you can’t possible go through the day without hearing the word, especially given that many—such as Joyable and Ruby Cup—are making a positive impact in the world. Still, you’d be surprised to find that there’s one industry in particular where startups get mixed results: healthcare. Like finance, law and education, healthcare is a field with one of (if not) the most extensive regulations.

It makes sense, given that lives are literally on the line. Equally as intriguing is that we are talking about a multi-billion-dollar industry (investors gave $16.1 billion to healthcare in 2015 alone), loaded with opportunity for tech startups to become successful while saving lives, improving hospital work flow, and speeding up research. That being said, we’ll examine the ways startups are succeeding in the healthcare industry, as well as why a startling number of them fail.

Startups that Are Doing It Right

Flatiron Health is one of a handful of successful startups that aced the healthcare industry. As reported by Inc., the young startup created a tech platform that shares data collected from cancer patients (information remains anonymous) with research and pharmaceutical facilities. As of now, 260 clinics use Flatiron Health’s cloud-based invention.

By sharing health information more easily, hopefully cutting-edge cancer treatments and medical options can be more readily available.

Majority of Healthcare Startups Are Not Cutting It

While Flatiron Health and other startups succeed in the world of healthcare, a majority are barely making it—if that. Forbes reports that as many as 98 percent of startups funded by angel investors fail in the healthcare industry because of a poorly thought-out business marketing strategy and uninspiring business model.

The Story of Healthcare.gov

Nonetheless, the tech startups that do succeed can make a huge difference in individuals’ lives. As is the case with Marketplace Lite, a young tech startup, rebuilding healthcare.gov from the ground up. As told by The Atlantic, healthcare.gov originally was a failing website. On launch day, only six people were able to sign up for healthcare insurance. The reason for such the low signup numbers had more to do with the site’s poor login features than the number of people trying to sign up.

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How to Reach Your Earning Potential in Health IT

Guest post by Karyn Mullins, executive vice president and general manager, MedReps.com.

Karyn Mullins
Karyn Mullins

From artificial intelligence developments to updated EHR technology, the future of health IT looks brighter with each passing year. As new developments and new technologies rise to the forefront of healthcare, health IT pros — new and accomplished — will need to do the same.

While medical sales remains a challenging and demanding career, my company’s 2017 Medical Sales Salary Report found sales reps are being rewarded for their efforts. Of course, there are a few different factors playing into a each reps’ earning potential.

The topics we examined are: product, market, job title, travel, and location.

With technology careers are in high demand, my team wasn’t surprised to find health IT sales reps are in the top three of the highest average total compensation category.

Whether you’re hoping to get started in the field, are still considered a ‘newbie,’ or are a veteran looking to kick your career up a notch, our report has key insights that can take anyone to their highest earning potential.

Here’s what the future of health IT sales looks like and how you can get to the top:

What they’re earning

The earning potential for any medical sales representative is impressive to most job seekers. To top off their large salaries, bonuses, and commissions, they’re also receiving added benefits like expense accounts, company cars, quality health benefits, and even 401k matching.

Topping the charts are those in health IT and software sales.

These reps make an average of $176,012 a year. To break it down, around $108,750 of that is base salary with an added average of $68,157 in bonuses or commissions. Biotechnology and medical/surgical devices were head-to-head for second and third place with average total compensations of $162,544 and $159,130.

How they’re doing it

There is no set mold for any particular medical sales job — and health IT is no different.

The MedReps report found many different factors affect the success of any medical sales job. Aside from the product category, market segments largely impact reps’ paychecks.

We found surgery/OR, pharmacies, and hospitals are all close competitors for those wanting to earn top dollar. Surgery/OR came in at the top with a total average compensation of $160,991, with pharmacies at $159,293, and hospitals rolling in closely behind in third with $158,155.

As most of us already know, medical sales is a challenging, but rewarding market for many reasons. Getting acquainted with products, learning the jargon, and gaining the trust of your customers takes patience, time, and dedication.

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American Health Data: Not Hackers’ Only Target, but Still Their Easiest

Guest post by Edgar Wilson.

Edgar Wilson
Edgar Wilson

The start of 2017 provided America’s health system with some global-scale schadenfreude when England’s NHS got caught up in a massive cyber attack. The “WannaCry” ransomware attack, which quickly spread across Europe from an epicenter in Ukraine, seemed to prove beyond any reasonable doubt that American EHRs and health data management systems were not unique in their vulnerability to hackers and thieves leveraging new digital weapons.

In time, this particular attack did manage to spread internationally from Europe over to America, but that only provided further evidence that ransomware, and cyber attacks more broadly, are a threat of seemingly unlimited potential. The failings of American healthcare to get its data safely organized look far less damning when the scale of cyber risk is made explicitly global, and even the NSA is caught off-guard by their own tools being turned into weapons in enemy hands.

Not Alone, but Not Ahead

Of course, that American hospitals weren’t the primary targets for once doesn’t remotely get them off the hook; nor does the jarring impact of this particular incident reflect a growing resilience among health data security in the U.S. American health data may not be alone in its vulnerability or attractiveness to thieves, but neither are our health systems leading the pack in protecting against ransomware, or any other form of cyber attack. Sadly, this wakeup call seems more likely to be heard outside of healthcare than within it; the scale makes it almost universally noteworthy, but otherwise it resembles a new status quo for data leaks in modern health systems.

Credit card data is relatively to protect; thieves are easily and quickly locked out of accounts, if not caught, thanks to everything from increased scrutiny by lenders and processing companies as well as consumer-facing transparency and 24/7 account monitoring via mobile credit card alerts and apps. Health data, by contrast, remains largely vulnerable. Clinics are not particularly good at recognizing fraud when thieves have a person’s medical data; hospitals have proven themselves no better at keeping that data secure in the first place. So compared to traditional identity theft leveraging plastic, digital health data presents a softer and more lucrative target end to end.

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The Importance of Online Medical Billing and Coding

Guest post by Saqib Ayaz, co-founder, Workflow Management & Optimization.

Saqib Ayaz
Saqib Ayaz

In the present age, finding a professional and reliable medical billing professional is very hard. Every physician knows the importance of an expert medical biller for the management of cash flow. It would not be wrong to call online medical billing and coding the bloodline of the medical facility.

In this age of technology, hiring a medical biller is not appropriate when you can use the software to get the work done quickly. You have to make sure that you select the best medical billing practice management system that will work for you for decades. All you have to do is enter your practice and the method you use for testing and it would be easy for you to manage everything.

Recently it has been found that most of the physicians have just started their practice and they do not find it important to get the healthcare consulting services. What they do is simply divide the tasks among their employees. As a result, they might save some money but most of the time it is hard to manage data.

Medical billing is not an easy task because there are many particulars that you have to take care of. A mistake in a single figure will disturb the entire calculations and you will have to suffer. Apart from that, you will waste your time and money.

So it is better that you get the online medical billing and coding tools. Here are some of the things that you must consider before selecting the management system.

1. Timely filing

When you are dealing with the insurance companies, you will get only a few days to file the claims. In case you have missed the deadline, you will not be able to appeal a denial.

When the insurance companies miss the services, it gets even worse because the claims are often sent on time. It means you will have to deal with a denial. Such kinds of issues occur when the services are sent in a batch. The insurance company sent you five services and it skipped the second one accidentally and now the company will not pay for it.

With the help of online medical billing and coding system, you can have the detailed records of the time and date when services were sent. They will help you to prove the mistakes and so your denial will be appealed. It would be easy for you to get the payments on time. Most of the workflow analysis in healthcare use the clearinghouse system for the accuracy of the results. It makes the results more effective. The best feature of the billing system is that they provide guaranteed results and you will not have to deal with the errors in the billing or filing.

2. Follow up on denied claims with online medical billing and coding

The insurance companies use different methods for denying the claims and they will easily give you a solid reason for it.

3. Improve your communication with providers

When you have to log and compile the medical bill you have to make sure that the billing system and provider company are in-step. The healthcare revenue cycle management system has given a specific code to every patient. With the help of billing tools, you will be capable of expediting this category. However, you have to ensure that you maintain and check the system regularly.

With the help of electronic billing system you will get the following benefits:

You will never have to deal with virus or data hacks. It will help you to keep your contracts up-to-date with your insurance and provider company. It will manage everything from the requirements of HIPAA to billing compliance.

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The Two Mountains to Climb After the Push to Overturn the ACA Failed

Guest post by Ken Perez, vice president of healthcare policy, Omnicell.

Ken Perez
Ken Perez

What a momentous few days in Washington were observed at the end of July! On July 25, Senator John McCain (R-AZ), dealing with brain cancer, made a dramatic entrance into the Senate Chamber and delivered an impassioned plea to return to regular order and bipartisan compromise, suggesting a process that would begin with the Senate Committee on Health, Education, Labor and Pensions (HELP) under chairman Lamar Alexander (R-TN) and ranking member Patty Murray (D-WA) holding hearings and producing a bill that incorporates contributions from both sides.

McCain’s suggestion was applauded by many senators on both sides of the aisle. The Senate voted to debate repeal and replacement of the Affordable Care Act (ACA), 51-50, with Vice President Mike Pence casting the tie-breaking vote.

The following day, the Senate rejected a bill to repeal the ACA without replacement, 45-55, and in the early hours of July 28, the Senate rejected the “skinny repeal” of the ACA, the Health Care Freedom Act of 2017 (HCFA), 49-51, with Republican Senators McCain, Susan Collins (ME), and Lisa Murkowski (AK) joining the 48 Democrats to defeat the bill. The skinny repeal would have repealed the individual and employer mandates, temporarily repealed a tax on medical devices, defunded Planned Parenthood for a year, provided more money to community health centers, and given states more flexibility in complying with ACA regulations. Thus apparently ended the Republican quest to repeal and replace the ACA, as Senate Majority Leader Mitch McConnell (R-KY) conceded, “It is time to move on.”

In the wake of the HCFA’s defeat, supporters of the ACA were euphoric, but two sobering challenges facing the U.S. healthcare system—one short term, the other long term—loom like imposing mountains.

The Short-term Challenge

The immediate concern is how to stabilize the troubled ACA individual health insurance marketplaces, clearly the Achilles’ heel of the health reform law. Health insurers continue to leave in droves, with 80 departing this past year and Anthem announcing on August 7 that it will leave Nevada’s ACA marketplace in 2018. Premiums are rising many times the growth of both the Consumer Price Index and U.S. healthcare inflation. Moreover, President Donald Trump is threatening to cut off the ACA’s cost-sharing subsidies, which work to prop up the marketplaces and shield some individuals from the premium increases. Obviously, such a move by the Executive Branch would not encourage bipartisanship.

The Long-term Challenge

Even more daunting than the travails of the marketplaces is how to bend the healthcare cost curve. The ACA has not materially slowed the growth of national health expenditures, which will rise by 5.4 percent versus 2016 and reach $3.5 trillion this year. To put $3.5 trillion in perspective, it amounts to 18.3 percent of the nation’s gross domestic product (GDP) and translates to almost $11,000 per person.

Additionally, nominal national health expenditures (not adjusted for inflation) are projected to increase by an average annual rate of 5.6 percent from 2016 to 2025, almost 1.5 times as fast as the growth in nominal GDP over the same period. As a result, healthcare costs will constitute a staggering 20 percent of GDP in 2025.

Conclusion

With the stalled effort to repeal and replace the ACA, Congress still must grapple with the hemorrhaging of the health insurance marketplaces and unacceptably high rates of healthcare cost inflation. Scaling these two mountains will require the kind of bipartisan compromise and collaboration that Senator McCain so passionately advocated.

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How to Avoid a Ransomware Attack and Mitigate the Damage If It Occurs

Guest post by Rachel V. Rose, JD, MBA, principal, Rachel V. Rose – Attorney at Law, PLLC.

 Rachel V. Rose
Rachel V. Rose

Why should physicians and providers care about the possibility of a ransomware attack? There are several reasons. First, it is disruptive both to patient care and to the revenue cycle. Second, it is costly in terms of time, IT capital, and if the attacker is paid, money. Finally, the time it takes to correct the attack, implement paper charting and communication, and subsequently revise the electronic medical record system can be arduous.

To understand the necessary precautionary measures and what to do in the event of an attack, it is first necessary to identify what ransomware is and how it works. A common definition of ransomware is “a type of malicious software designed to block access to a computer system until a sum of money is paid.”[1] A ransomware attack may target a business or an individual. The two categories of attacks are Denial of Service (“DoS”) and Distributed Denial of Service (“DDoS”). A DoS attack affects a single computer and a single internet connection, while a DDoS attack involves multiple computers and connections. According to PC World, three types of ransomware programs top the list – CTB-Locker, Locky and TeslaCrypt.

A common question that arises is whether or not to pay the ransom in order to have the data returned. The FBI advises not paying the ransom, advice that has been echoed by statistics.

“Kaspersky’s research revealed that small and medium-size businesses were hit the hardest, 42 percent of them falling victim to a ransomware attack over the past 12 months. Of those, one in three paid the ransom, but one in five never got their files back, despite paying. Overall, 67 percent of companies affected by ransomware lost part or all of their corporate data and one in four victims spent several weeks trying to restore access”

This leads us to the best ways to defend against an attack, as well as steps that should be taken if an attack occurs.

Proactive steps include: educating employees about social engineering, phishing and spear phishing, continuously making sure that software updates are installed, creating a layered approach to security defenses, limiting access to the network, making sure that policies and procedures are comprehensive and updated, and ensuring that data is backed up daily.

According to FBI Cyber Division Assistant Director, James Trainor, “These criminals have evolved over time and now bypass the need for an individual to click on a link. They do this by seeding legitimate websites with malicious code, taking advantage of unpatched software on end-user computers.”[2] Hence, recognizing the avenues that cybercriminals use to gain access and taking appropriate administrative, physical, and technical precautions can reduce the risk of an attack.

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How Technology Focused on Care Delivery and the Patient Experience Creates Healthier Communities

Guest post by James Calanni, J.D., MBA, chief technology officer, Community Health Partnership.

Jim Calanni

As the healthcare landscape evolves, today’s community health providers are in a unique position to design new care delivery initiatives that can support healthier individuals, families, and communities, powered by adopting innovative technology tools. According to a study on factors influencing healthcare service quality, published in the International Journal of Health Policy and Management, healthcare outcomes are enhanced when patients and healthcare providers collaborate in a supportive environment.

Care coordination is a vital component in improving the delivery of patient-centered healthcare and social services. This is especially true for high-risk populations, such as those going through transitions of care and those who belong to certain populations. Transitions of care include the time period around hospital discharge or transfer to a new healthcare setting, such as a long-term care facility or home health. These transitions leave at-risk patients vulnerable to loss of continuity of healthcare.

Populations requiring additional considerations include homeless, children in foster care and patients who over-utilize the emergency department for non-emergencies, to name a few. The goal of care coordination for these populations is to anticipate needs, collaborate with all providers of services, and to coordinate the wide array of health, social and supportive services for each group. The main goal is to improve the quality of care while avoiding costly hospital admissions and re-admissions.

To help optimize critical coordination efforts, technology solutions can help the entire care team of providers in various locations collaborate across the care continuum, raising awareness of an individual’s physical, behavioral, and social factors and driving whole-person care. Organizations like Community Health Partnership (CHP) – a Colorado Springs-based collaborative of local health providers – aim to align many care management activities throughout the community.

Here are some strategies healthcare providers and organizations should consider when designing innovative care delivery initiatives:

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