Author: Scott Rupp

Optimizing Workflows with AI/ML In 2024

Dr. David J. Sand

Responses from Dr. David J. Sand, chief medical officer, ZeOmega.

The healthcare industry is fraught with workflow challenges that impact care quality and costs, but tools like AI and ML have sparked a turning point. These technologies are opening new doors for healthcare organizations to streamline processes and automate tasks with accuracy, allowing staff to focus on matters that require their hands-on attention. David J. Sand, MD, MBA, addresses the need for workflow automation and explains how AI/ML can be a game-changer.

What staffing hurdles are payers and providers facing this year, and why is workflow automation the solution?

Two of the biggest challenges facing the healthcare industry are staffing adequacy and the cost of staffing. COVID took its toll on the healthcare workforce, igniting a spike in labor needs that had a lasting impact on organizations. Consequently, healthcare labor costs surged by 57% post-pandemic and now constitute over 50% of hospital expenses. These financial burdens have severely impacted the industry and contributed to 73 healthcare organizations’ (including 12 hospitals and health systems) bankruptcies in 2023.

Finding and retaining employees is a longer-standing issue that can be partly attributed to factors like staff burnout, spurred by heavy workloads laden with administrative tasks. The industry is also experiencing demands for escalating salaries and workforce strikes from staff who feel overburdened by the escalating pressure to balance workloads laden with administrative duties and meet patients’/members’ needs.

It is more important than ever for healthcare organizations to look at ways to optimize workflows and automate time-consuming manual processes so staff can focus their time on pressing member/patient issues that require hands-on involvement. Technology provides excellent opportunities to improve utilization management by reducing time spent on administrative duties, ultimately reducing staff burden, saving costs, and improving patient/member experience.

How will technology help organizations alleviate staff burden and automate processes in 2024? Can you share any examples of areas in which it may be most impactful?

When we think about how and where technology can assist in healthcare, it’s useful to think in terms of peripheral, or care-adjacent, tasks that don’t involve actual hands-on treatment. Envision repetitive tasks with little variation and processes or workflows that inform our practice. While many of these applications are discrete, they are really part of a continuum.

Ambient listening is one area that is gaining widespread acceptance. The ability to listen and transcribe has become commonplace in many industries. Complaints about the provider looking at the screen rather than the patient, as well as the alternative cost of hiring a human notetaker, can be relieved. Data generated by digital scribes can be mined with natural language processing in real time using keywords and phrases to call relevant insights from the medical record or trigger care recommendations based on large language model queries of, hopefully, rigorously curated big data.

Our challenge is not to just have enough granularity in the data for precision propensity matching but to have adequate outcome data associated with the recommendations. By generating accurate, specific, and consistent recommendations, automated workflows can eliminate unwanted variation caused by human bias, lack of information, or even intentional discretion. The elimination of unwanted variation is the definition of Quality. Analysis of the spoken words can similarly save time dedicated to repetitive and tedious assessments. Contextual information such as speech cadence, tonal variation, and other characteristics can be used to objectively complete and reliably compare behavioral health assessments, potentially more accurately than self-reported measures.

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Automation and Digital Tools Help Address Provider Workflow Challenges

Patty Riskind

Responses by Patty Riskind, CEO,  Orbita.

It might be a new year, but healthcare is dealing with old problems:

Too much time spent on administrative tasks. Staff struggling to keep up with high call volumes. Patients waiting too long for care or falling through the cracks altogether. Services delayed or cancelled because patients were not appropriately prepared.

It’s past time for healthcare to adopt workflow automation and patient self-service tools to address these challenges. Other industries embraced these options years ago, documenting better performance and higher satisfaction among staff and consumers.

Where do bottlenecks occur and what solutions are available to improve workflows related to the patient care journey?

Obstacles impede these pathways in two significant ways:

How can these tools support the complex nature of healthcare, as well as ensure the information provided is accurate?

Early generations of chatbots failed healthcare. Rarely did they provide patients the information they needed, resulting in dead ends, inaccurate answers and an unacceptable level of drop-offs.

But today’s virtual assistants and online tools are smarter and more responsive. Developers leverage conversational AI so patients can pose questions in the words and phrases they are comfortable with. Interactive dialogs probe for more details to add context. This means the virtual assistant can zero in on the precise answer the patient is looking for.

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Success In Healthcare M&A: The Critical Role of Background Screening  

Valerya Poltorak

By Val Poltorak, head of US Regulated Industries, Sterling

Merger and acquisition (M&A) activity within the healthcare industry has experienced a slow decline over the past couple of years due to the economy’s downturn. However, as we approach 2024, the forecast predicts that M&A activity could rebound. Hospital and health systems are looking for ways to alleviate operational and budget control challenges due to staffing shortages and high wage inflation. In a report by KaufmanHall, hospitals and health systems who underwent M&A in 2023 indicated that financial distress was a key transaction driver.

In this ever-changing environment, healthcare organizations must navigate the challenges, complexities, and risks involved in the M&A process. Some of these risks include omissions of material information, conflicts of interest, verification of credentials, or past criminal activities. To safeguard heath systems’ interests, investments, and reputation, while protecting their patients, an in-depth review and investigation of an organization and its employees should be an integral part of all investment deals.

Mitigate Risk by Introducing Background Screening Providers into the M&A Process

Partnering with a reliable background screening provider early in the M&A process is critical for success. These organizations play a vital role in navigating the complex and often public nature of the process, and can assist healthcare organizations in hitting the reset button on deals and acting as liaisons with the integration teams.

A background screening provider can help hospitals and health systems involved in a M&A by:

The sooner a background screening provider is looped into the developing deal, the better they can position the merging organizations for success.

Digging Deeper: How Due Diligence Can Uncover More Information 

Due diligence is an integral part of all healthcare mergers and acquisitions that go beyond standard background checks. A standard background check is meant to help organizations make an informed selection on job candidates by determining their criminal history and verifying their credentials. Due diligence investigations, on the other hand, seek to take this one step further and uncover information not disclosed by a subject or a business entity. They paint a full picture for your hospital or health system, and can be your first line of defense in protecting your organization from serious financial issues, reputational damage, and even legal repercussions.

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Choosing the Right Outpatient Drug Rehab That Accepts Medicaid

Selecting an inpatient drug rehab accepting Medicaid is vitally important to individuals looking for treatment, yet each facility offers different approaches and may impose different requirements upon individuals – some may need extra documentation or may incur out-of-pocket expenses.

Benefits

Individuals living with substance use disorder (SUD) often face obstacles when seeking treatment for their disorder, but Medicaid and other government-funded insurance programs offer assistance in accessing care they require. Coverage depends on state but generally most Medicaid plans cover at least some aspect of addiction treatment such as medically necessary services, counseling sessions or even more advanced therapies; additionally, some states provide tailored options tailored specifically to individuals’ specific needs.

State laws dictate that Medicaid recipients possess at least some minimum health coverage. Furthermore, they must possess either a mental illness or physical disability requiring treatment; or in some instances both conditions combined, and the individual will need to demonstrate they require attention as part of a serious medical condition that requires care.

People looking into attending a drug rehab that accepts Medicaid should research the center online or call directly for more details about its guidelines and requirements, cost considerations, and applying for Medicaid coverage. Healthcare providers or local resources may also be helpful when seeking more information about attending rehab facilities that accept this insurance option.

Eligibility

Medicaid is a health insurance program that covers an array of medical expenses, such as addiction programs. Unfortunately, not everyone qualifies for it; eligibility requirements differ between states but generally have similar rules regarding income eligibility; individuals should aim to meet at least 133% of the federal poverty level before qualifying for Medicaid; some states may even set higher income eligibility thresholds than this minimum threshold value.

Individuals seeking eligibility should meet income requirements as well as other criteria, including age, disability status or mental illness. Individuals interested in outpatient rehab centers that accept Medicaid should contact their local Medicaid office or program provider for more information on determining their eligibility. In many instances the state will also request a copy of an applicant’s medical history in order to ensure adequate coverage for addiction program services.

Medicaid’s coverage for addiction programs varies depending on the type of rehabilitation program chosen and an individual’s specific needs. While inpatient drug rehab programs tend to last several months, outpatient programs could last as long as one or more years and cover medications like Methadone and Suboxone as part of its coverage.

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Arming Patients with Accurate Medical Information To Improve ER Outcomes, Wait Times

Jennifer Devening

By Jennifer Devening, CEO, YourHealth.

In the controlled chaos of the emergency room (ER), time and accuracy are of the essence. Not only do they impact care outcomes, but also quality, safety, costs, and patient satisfaction. With wait times and costs for emergency care rising, the ER is a prime target for efficiency, productivity, and cost improvement strategies.

The state of the ER

Of the nearly 140 million annual ER visits reported by the Centers for Disease Control & Prevention, more than 13% resulted in admission. Less than half (~42%) of patients were seen in fewer than 15 minutes. What’s more, driven by staffing shortages and higher demand, ER wait times are creeping upwards, increasing to 2 hours and 40 minutes in 2022 from 2 hours and 35 minutes in 2021.

Those same headwinds are driving up ER costs. According to Syntellis, ER labor costs increased by nearly 50% between January 2020 and January 2023 even as ER visits declined by 9.5% over that same period. One casualty of overcrowded and understaffed ERs is accuracy, particularly when it comes to patient histories.

One recent study concluded that medication histories performed in the ER are largely inaccurate and incomplete after finding discrepancies in 27% of medication lists obtained during triage. Of those, nearly 10% involved discontinued medications and nearly 28% involved missing medications. Thirty-eight percent of patients reported taking a non-prescription medication not listed in their electronic medical record.

Given the percentage of ER visits resulting in admission, errors made during ER triage carry through to impact safety and outcomes for inpatients. One study found that up to 67% of patients admitted to a general medical ward had at least one error associated with their medication history.

Further, inaccurate or incomplete medication histories can lead to adverse drug reactions (ADRs), which can prolong hospital stays by anywhere from 1.5 days to nearly five days, according to the U.S. Department of Health and Human Services. ADRs are attributed to approximately 6.5% of all hospital admissions, many involving drug-drug, herbal, and/or supplement interactions.

Many of these medical safety errors result from inadequate reconciliation during admission, with one medical center estimating that approximately one in 10 patients with inaccurate medication lists are likely to suffer an adverse drug event (ADE) that causes physical or mental harm or loss of function. ADEs are also associated with longer hospital stays and higher care costs.

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Interoperability and Prior Authorization Are on FHIR

Joe Gagnon

Responses from Joe Gagnon, CEO, 1upHealth.

The recently released CMS Interoperability and Prior Authorization final rule is a pivotal measure to reshape the industry. By laying the groundwork for expanded access to health information and streamlined prior authorization processes by mandating the use of FHIR APIs, this regulation takes a critical step toward using comprehensive, timely data to support value-based care initiatives, reduce costs, and improve outcomes.

As stakeholders navigate the ever-changing interoperability landscape, the first step is tapping FHIR APIs to ensure compliance and adaptation to shifting tides. From there, organizations can look beyond compliance to see how FHIR APIs can open the door to next-level innovation and usher in a future where efficiency, collaboration, and patient-centric care take center stage. 

  1. What are three ways the new CMS interoperability and prior auth rules will impact healthcare organizations?

Overall, the new rules serve as a critical foundation for expanding access to health information and improving the prior auth process in healthcare.

For all stakeholders, the collective FHIR APIs provide the ability to use comprehensive, timely claims and clinical data to support value-based care programs by implementing a common data approach to leverage historical patient data to maximize quality outcomes for patients. These initiatives are critical to reducing healthcare delivery costs while maximizing patient quality in real time. Additionally, as acutely acknowledged by CMS in its rule commentary, while many patients over the course of a year can have a significant number of providers, it is likely that they will only have one or two payers, thus making the making payer the prime hub in a hub-and-spoke style data sharing model.

For payers, if the FHIR APIs are implemented and utilized as advised by CMS, the respective APIs will not only have the ability to materially improve the ability to share relevant data in a more timely manner, it will also significantly reduce the cost and administrative burden of such data sharing. Today, many payers have entire departments that are focused on packaging and sending data to relevant provider partners. By automating the data sharing process with FHIR APIs, not just for CMS compliance but for all other interoperability use cases, payers can ‘kill two birds with one stone’ and meet regulatory requirements while also creating internal efficiency and significantly improving access to data, as outlined above.

For providers, using interoperable data for prior authorization can help make patient care decisions more quickly, improving patient, provider, and payer alignment and ultimately improving outcomes.

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Fortifying Healthcare Email Security: Advanced Solutions and Mitigation Strategies

Usman Choudhary

By Usman Choudhary, general manager, VIPRE Security

Email remains a cornerstone communication tool for healthcare entities, yet the communication channel also presents formidable cybersecurity hurdles. The sensitive nature of patient data and the open nature of email renders it susceptible to data exposure and phishing attempts. Thus, as healthcare continues its technology maturation, the imperative to grasp the gravity of email security intensifies. Advanced email security solutions offer a potent means to tackle these challenges head-on.

Why does this matter now? Isn’t email dying? Not based on the numbers. For example:

In a review of just the fourth quarter of 2023, VIPRE reviewed roughly 7.2 billion emails worldwide that were processed through its systems. Of those, more than 950 million malicious or unwanted emails were detected (~13 percent) and blocked. Most of these were detected using classical signature-based detection of bulk email, known malware, and known malicious links, including 20 million emails with malicious attachments and 41 million emails with malicious links. But there were 500,000 malicious emails that were only detected because of advanced, behavioral simulation of a user actually clicking on the link, i.e. detecting true zero-hour malicious sites, which is a feature built into our VIPRE Email Link Isolation. 

It was interesting to note a rise and fall in favored malicious email types each quarter and throughout the year. In 2023, we noticed the following trends:

Regardless of the slight percentage decrease, phishing emails continue to be tied with scam emails in volume, making them a perennial favorite of hackers and a constant threat to inboxes. Healthcare is in the top three targeted industries, representing 14% of the attacks that we observed across all of our customers.

With this data as a reference point, it’s easy to see that healthcare is chronically at risk regarding its vulnerability to cyberattacks driven by phishing and malicious inclusions in email. While writing this piece, one of the nation’s largest healthcare clearinghouses, Change Healthcare, was affected by a massive ransomware attack.

Change Healthcare is a unit of UnitedHealth Group’s Optum subsidiary, and its products are used by a huge variety of healthcare organizations. According to HHS, Change Healthcare “was impacted by a cybersecurity incident in late February. HHS recognizes the impact this attack has had on healthcare operations across the country.” The Russian-speaking cybercriminal gang known as AlphV and Blackcat claimed responsibility and said on its darkweb site that it exfiltrated 6 TB of data in the attack against Change Healthcare.

This specific attack affected healthcare systems, prescription deliveries, and anyone who processes insurance claims. This should raise red flags for all healthcare organizations regardless of size, particularly for smaller organizations with limited budgets. After all, if companies as massive as Change Healthcare—who undoubtedly had advanced cybersecurity measures in place—can be breached, then smaller organizations with fewer resources should take action to protect themselves.

The attack underscores the critical importance of proactive measures to mitigate the risks of sophisticated cyber threats. Although the attack vector in the Change Healthcare breach has not been identified as of this writing, the same group was responsible for the massive MGM Resorts hack in September 2023, which started on LinkedIn with a social engineering-driven exploit. A form of phishing, this foothold was leveraged to gain access within MGM, and this access was then expanded to target many of MGM’s key business systems.

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The Role of Remote Monitoring In Rural Communities: How Can It Provide Better Patient Care?

Jared Lisenby

By Jared Lisenby, chief sales officer, Azalea Health.

Telehealth services have become more popular, particularly after the COVID-19 pandemic highlighted its importance as a necessary solution for rural health clinics (RHCs).

RHCs face distinct business challenges, including serving patients at higher risk of chronic illnesses, limited resources, workforce shortages, and geographical isolation. These challenges require innovative solutions, and telehealth is one such solution.

Also known as telemedicine, telehealth empowers healthcare providers to care for patients without an office visit, saving time and money and allowing providers to see more patients. Care options require internet access and a computer, tablet, or smartphone, including phone or video consultations, secure messaging, email and file exchange.

Telehealth and the adoption of electronic health records (EHRs) have allowed healthcare to extend beyond clinical settings into patients’ homes.

RPM device use is expected to increase

New solutions and offerings make Remote Patient Monitoring (RPM) possible. This technology allows providers to manage acute and chronic conditions, gather vital signs and inform healthcare providers about a patient’s progress while reducing travel costs and infection risk.

Doing so allows providers to make real-time decisions and course-correct care as needed, potentially reducing patient costs in the long run and leading to better healthcare outcomes.

Remote patient monitoring is useful in conjunction with telehealth, particularly for patients who require consistent monitoring for certain health conditions, including high blood pressure, diabetes, and heart conditions. It can also help prevent complications in patients who have difficulty traveling.

RPM devices can include meters and monitors for glucose, heart rate, and blood oxygen levels. Patients with some of these chronic conditions are usually eligible for RPM devices and services.

According to Insider Intelligence, about 30 million Americans will be using one this year.

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