Author: Scott Rupp

Great Expectations: What Health Systems Want from AI Vendors

Andrew Lockhart

By Andrew Lockhart, CEO, Fathom.

Imagine this: physicians spend more time with their patients than with their paperwork. Billing is quick and accurate, with minimal denials. Healthcare workers enjoy a positive work/life balance. Thanks to the rapid advancement of AI, this vision of healthcare is becoming increasingly possible.

Health system leaders are already investing toward this ideal state. From roundtable discussions at Healthcare Financial Management Association and Becker’s Healthcare to Zoom chats every week, I’ve connected with many C-suite executives at health systems about their expectations for AI. There is, across the board, a clear set of priorities for the next one to two years. The overarching vision is not just to integrate new technologies but to do so in a way that delivers tangible improvements in workforce experiences and satisfaction, revenues and costs, and patient care outcomes.

Here are a few resounding themes that I’ve heard.

  1. Proving ROI

Proving ROI on AI investments is crucial: put plainly, you want to ensure you’re getting more than enough bang for your buck. Applications of AI need to map back clearly to measurable cost and revenue impacts. Health system CFOs expect predictable ROI and are screening new technologies closely.

Many AI tools on the administrative side can meet this proof of hard ROI. For example, organizations like ApolloMD have experienced significant improvements in coding efficiency and revenue capture by minimizing coding errors and denials through autonomous coding.

While vendors typically report impressive ROI from their technology, any vendor worth its salt will agree to a proof of concept allowing you to test and validate impact for your organization. For example, an easy way to build confidence in autonomous coding is to compare coding results between your team and the AI system before committing to go-live.

  1. Increasing end-to-end strategies

Many AI tools have surfaced to address a single use case. However, health system leaders are more interested in comprehensive, integrated solutions across departments. Consider the case of ambient documentation and autonomous coding: ambient documentation works as a medical scribe using AI to document clinician-patient encounters, and then autonomous coding steps in as a medical coder to translate and assign the necessary codes for billing.

These types of end-to-end strategies are more compelling and impactful. Health system CEOs increasingly gravitate toward them to ease administrative burdens, speed up visit-related processes, and enhance patient outcomes. The market is supporting this expectation: Abridge, an ambient documentation platform, recently raised $150 million in funding, and Google Cloud added an autonomous medical coding solution to its marketplace earlier this year. Used in conjunction, these technologies offer more integrated – and more valuable – strategies for health systems.

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Battling Physician Burnout with Collaborative Care

Sussan Nwogwugwu

By Sussan Nwogwugwu, DNP, PMHNP, Clinical Leader, Done.

Physician burnout, characterized by exhaustion, compassion fatigue and feelings of inadequacy, not only affects physicians; it also affects their care quality, which ultimately compromises patient well-being.

Collaborative care benefits physicians – and patients – alike.

Primary physician burnout by the numbers

The American Medical Association said that burnout symptoms affected almost 63% of physicians in 2021, a significant increase from the previous year. 

Primary causes of burnout include “the practice of clinical medicine… your specific job… having a life… the conditioning of our medical education… and leadership skills of…immediate supervisors,” according to the AAFPA collaborative care model can remedy burnout.

The benefits of collaborative care

Psychiatry.org says a collaborative care team “is led by a primary care provider and includes behavioral health care managers, psychiatrists and… other mental health professionals… The team implements a measurement-guided care plan based on evidence-based practice guidelines and focuses particular attention on patients not meeting their clinical goals.”

In addition to decreasing clinical workloads, this collaboration also leads to improved feelings of job satisfaction. Further, clinicians experience lower levels of isolation, and a collaborative environment enables knowledge-sharing, ultimately enabling professional growth.

In addition to benefiting clinicians, collaborative care benefits mental health patients by improving access to holistic, specialized care. For patients with chronic conditions, it is especially advantageous.

Components of comprehensive care

Comprehensive care, according to AAFP, is “prevention and management of multiple physical and emotional health problems of a patient over a period of time...”

Its three pillars include impact analysis; evidence-based interventions; and an inclusive patient approach incorporating frequent reviews. Comprehensive care that’s baked into a collaborative care model helps enhance clinician well-being and reduce the burden on primary care providers. It also benefits patients who receive care under this model.

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A HIPAA-Compliant Path to Efficiency and Relief with Telehealth

By Nate MacLeitch, founder and CEO, QuickBlox.

We’ve come a long way since the University of Nebraska pioneered two-way video communication for telemedicine in 1959. Today, telehealth enables healthcare providers to expand access to medical support, improve patient convenience, streamline workflows, and enhance clinical outcomes. But as telehealth has grown, so too have the regulations around it. 

The software behind telehealth — including on laptops, tablets, the cloud, and increasingly AI — requires careful governance and robust security protocols to ensure patient privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA). 

The following explores how telehealth can alleviate administrative burdens and create a more efficient experience, while HIPAA compliance ensures the product is safe for both patients and providers to trust.

HIPAA Compliance Builds Patient and Clinicians’ Trust

While demand for digital health adoption from patients (33%) and providers (36%) is rising, over half of clinicians surveyed are still concerned about data breaches or malware attacks on their healthcare data, global advisor HIMSS (Healthcare Information and Management Systems Society) reports.

Securely communicating sensitive patient information (PHI) within a healthcare organization can be challenging when relying on everyday tools like SMS, Skype, and email. While these platforms offer encryption mechanisms, they fall short in two key areas. 

Firstly, achieving effective encryption requires a uniform environment. Everyone within the organization must use compatible operating systems and the same encryption/decryption software. This uniformity can be difficult and expensive to maintain across a large organization with diverse devices and software versions. 

Secondly, even with encryption, the service providers themselves — like Verizon, Skype, and Google — still have access to the underlying data on their servers. Business associate agreements (BAAs) can be established to address these concerns, but these rely on the providers to maintain the integrity of the encrypted data. Here, Skype’s past actions raise red flags, and it’s fair to question if major communication companies like Verizon or Google would be comfortable with the additional responsibility and potential legal implications of healthcare data breaches.

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Intuity Medical’s POGO Automatic, the First and Only FDA-Cleared Automatic Blood Glucose Monitor, Now Covered by Medicare Part B

Intuity Medical: | PTV Healthcare CapitalIntuity Medical, Inc., a medical technology company committed to making it easier to live with diabetes, announced today that its POGO Automatic® Blood Glucose Monitoring (ABGM) system, featuring one-step testing, is now covered by Medicare Part B. This decision expands access to the innovative monitor for the 16.5 million seniors age 65 and up living with diabetes.

The Centers for Medicare and Medicaid Services (CMS) created two new coverage codes specifically for POGO Automatic, recognizing this new and significantly different technology compared to traditional blood glucose meters (BGMs). POGO Automatic features an all-in-one design that integrates testing supplies into a 10-test cartridge.

As the first and only FDA-cleared automatic blood glucose monitoring (ABGM) system on the market, POGO Automatic revolutionizes diabetes management by allowing people with diabetes (PWD) to easily test their glucose levels without disrupting their daily activities. Its one-step process automates the multiple-step glucose monitoring process associated with traditional BGMs, making it easier for many seniors to check their blood glucose.

Recognized by healthcare professionals for its user-friendly design which can improve testing compliance, POGO Automatic is endorsed as the ideal solution for many diabetes patients by Rosemarie Lajara, MD, an endocrinologist with Southern Endocrinology & Diabetes Associates, P.A. in Plano, Texas:

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Concerns and Uncertainty In the Wake of Sweeping HTI-1 Rule

Stephanie Jamison

By Stephanie Jamison, Executive Committee Chair and Public Policy Leadership Workgroup Vice Chair, EHR Association.

In the months that have passed since the Office of the National Coordinator for Health Information Technology (ONC) issued the final Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-1) rule, the health IT sector has been working diligently to meet the earliest compliance timelines even as it continues an in-depth analysis of the regulatory impact on both developers and the providers who use certified technology.

For the EHR Association, that analysis has given rise to several concerns and ambiguities that need to be addressed to ensure HTI-1, which was published in the Federal Register on Jan. 9, 2024, achieves ONC’s stated goal of advancing patient access, interoperability, and standards.

The new regulations are an important step toward implementing key provisions of the Cures Act and enhancing ONC’s Certification Program. However, there are several aspects of HTI-1 that we believe may have unintended consequences for certified EHR technology (CEHRT) developers and users.

Decision Support Interventions (DSI)

One significant area of concern is with regulations around DSI, which carry the earliest compliance deadlines. While the scope of DSI requirements was narrowed in the final rule, many of the compliance timelines are still insufficient for developing, testing, and implementing the necessary upgrades.

The first deadline is Dec. 31, 2024. That is when CEHRT developers must deliver DSI capabilities to maintain certification. Achieving compliance will necessitate substantial development efforts, including in novel areas for the program like AI/ML for predictive DSIs. Other areas of concern include requirements for:

Meeting these requirements within the 12-month timeframe presents a formidable challenge for CEHRT developers – a challenge amplified by the lack of a certified companion or other resource guide to support developers with compliant updates. Also coming into play are current CMS requirements governing providers’ use of CEHRT that would force developers to deliver updated technology to their customers well in advance of the ONC deadline.

To alleviate these challenges, we are urging ONC to consider implementing an enforcement discretion period of six to 12 months. This would provide much-needed relief for CEHRT developers and healthcare providers alike, while still ensuring that meaningful progress is made toward real-world implementation of DSI provisions by the 2024 deadline.

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Looking Ahead: Precision Medicine Solutions Hold Increasing Promise for Healthcare Businesses

Joe Spinelli

Precision medicine encompasses a broad spectrum of technologies, sciences, and programs that emphasize tailoring medicine to the individual. These capabilities can empower clinicians to optimize treatment pathways and drastically improve patient outcomes, but the healthcare industry’s adoption of precision medicine technology has historically lagged.

Joe Spinelli, chief strategy officer of Aranscia, shares his predictions on how precision medicine tools will become more widely adopted in 2024 and beyond and explains what it takes for organizations to implement these programs successfully.

How is precision medicine evolving and in which areas of healthcare will it be most utilized in 2024?

This is an exciting time for precision medicine, as some of the more foundational work that’s been done over the past several decades in genomics, diagnostics, and artificial intelligence is finding meaningful applications in population health, rare disease treatments, and oncology. The evolutions the healthcare industry is experiencing now are less about the core/novel methodologies and have more to do with the effective practical utilization of those methodologies at scale across the spectrum of care.

What are some of the biggest, most recent healthcare hurdles precision medicine can help mitigate?

The evolution of precision medicine involves two distinct yet equally important initiatives: the development of innovative technologies and therapies to improve care on an individualized basis, as well as the effective utilization of those innovations within clinical care settings. Democratizing access to these types of precision medicine solutions through technology and workflow implementation will be a key factor in the clinical and economic success of these programs.

How will precision medicine solutions benefit providers from a business perspective this year?

As more care cohorts are attached to value-based initiatives and/or care models, multi-step processes of candidate identification, intervention, and outcomes tracking become increasingly important for care organizations and vendors alike to align on. In addition, companion diagnostic and biomarker programs will help providers and payers better align the cost and appropriate therapeutic use of innovative offerings.

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No Surprises Act in 2024: What’s Been Accomplished and Where We’re Headed with Price Transparency

By Derek Reis-Larson, senior vice president, claims pricing services, MultiPlan.

Medical costs continue to vary widely by location, provider, and coverage type, making it difficult for patients to understand the true cost of care and inhibiting their ability to compare pricing. Sweeping bi-partisan healthcare reform was put into action at the beginning of 2022 to help improve the healthcare experience for out-of-network patients with the ultimate goal of alleviating any surprise bills following care delivery.

More specifically, the No Surprises Act (NSA), which was put into effect on Jan. 1, 2022, was implemented to make it easier for consumers to understand how much they will pay, compare costs, make more informed provider selections, and be protected from surprise bills after receiving care. Since then, there have been significant industry hurdles in adopting the new measures, such as the Independent Dispute Resolution (IDR) process and its efficiency.

Current proceedings

On Nov. 3, 2023, the Biden Administration released the Federal Independent Dispute Resolution (IDR) Operations Process Proposed Rules to address backlash and improve the IDR process to ensure timely payment determinations. Pain points these rules attempt to address include the unexpectedly high volume of IDR cases, the high proportion of ineligible claims submitted for IDR, and the inadequate sharing of information between the parties in the initial stages of the process.

None of the proposals included in these Proposed Rules will be effective without a Final Rule being published. The administration requested feedback on these rules should they be adopted, and comments were initially due by January 2, 2024, and were reopened for an additional fourteen-day period in January. On Dec. 15, 2023, the Departments reopened the Federal IDR portal for all dispute types, including previously initiated batched disputes, new batched disputes, and new single disputes involving air ambulance services. With this reopening, parties could access extensions of certain IDR deadlines.

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MDaudit Enhances Billing Compliance And Revenue Integrity Platform with AI Capabilities

MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to minimize billing risk and maximize revenues, announced today it has elevated the artificial intelligence (AI) and automation capabilities of its industry leading billing compliance and revenue integrity platform with the addition of Insights.ai and SmartScan.ai.

A Generative AI tool, Insights.ai democratizes faster insights in response to natural language questions while SmartScan.ai leverages AI to automate key aspects of the external audit workflow process to efficiently manage payer audits. The MDaudit platform is used for compliance and revenue integrity outcomes by more than 70 of the nation’s top 100 health systems with $1 billion in net patient revenue.

The MDaudit enhancements come at a time when federal and commercial payers are ratcheting up audits to identify and claw back billions in improper payments. Consider that the U.S. Department of Justice (DOJ) collected more than $1.7 billion in improper payments in fiscal year 2022. Further, the Office of the Inspector General (OIG) identified more than $200 million in expected audit recoveries and over $277 million in questioned costs in its 2023 Semi-Annual Report to Congress.

The Centers for Medicare & Medicaid Services (CMS) is also expected to claw back $4.7 billion from Medicare Advantage plans over the next decade thanks to recent adjustments to its risk adjustment data validation (RADV) program.

Ritesh Ramesh

“AI has the potential to transform healthcare and drive sustainable outcomes, but only if we maintain a relentless focus on the human experiences and operational processes it impacts rather than amplifying the technology itself. With this principle in mind, MDaudit continues to innovate and deliver AI solutions in the compliance and revenue integrity space,” said Ritesh Ramesh, CEO of MDaudit. “With Insights.ai and SmartScan.ai, our core mission is to enable healthcare organizations to retain their hard-earned revenue and reduce compliance risks by data-driven decision making and automation.”

Insights.ai makes it fast and easy to access the deep insights needed to drive strategic decision making. Whether it’s information about at-risk facilities, providers, coders or which DRG had the highest number of denials for medical necessity in a specific timeframe, Insights.ai democratizes insights across all levels of a healthcare organization – from billing compliance auditors, revenue cycle analysts, operational leadership and to the C-suite – by responding to questions posed in natural language with precisely the insights being sought. Insights delivered are then tightly integrated with actionable workflows to drive outcomes.

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