By Christopher Maiona, M.D., SFHM, chief medical officer, PatientKeeper, Inc.
Christopher Maiona, M.D.
The news on physician burnout lately has been mixed. A 2018 Massachusetts Medical Society/Harvard report received considerable attention – it proclaimed physician burnout has become a crisis, widespread in the medical profession, driven by rapid changes in health care and physicians’ professional environment. Yet last month a study published in Mayo Clinic Proceedings found that physician burnout actually declined more than 10 percentage points from 2014 to 2017, though the rate for doctors was still considerably higher than for U.S. workers at large. And just last week, an American Academy of Family Physicians survey reported that 71 percent of practicing physicians are happy, albeit frustrated by the extent to which administrative and clerical tasks have become part of their daily work.
What to make of all this seemingly contradictory data?
When I began practicing as a hospitalist in the 1990s, the administrative burden on physicians was much less than today, owing in part to the regulations and routine processes of the day and the typical patient caseload. Back then I saw 12 patients per day. With that caseload, you could break even on billing while still having plenty of time to interact with patients and colleagues. While it would not be feasible to return to that volume today, the point is that the hospital afforded a much more professionally rewarding environment. There was time to discuss interesting cases with colleagues. There was time to revisit patients and dig deeper into their records. You had time to sit at a patient’s bedside and hold their hand. The pace today does not afford this opportunity, much to the dissatisfaction of physicians. The resulting isolation from patients and peers is a contributing factor to the burnout seen among physicians.
Then there’s the technology component. EHRs are widely regarded as a significant cause of physician stress and a distraction from patient care. For example, when hospitals installed computerized order entry (CPOE), it eliminated the order clerk and created an additional job for the physician. The evolution of the clinical note is another example of unintended clinical burden, with roots in the evolution of medical practice and the emergence of EHRs.
Take a step back and consider what the original purpose of a physician’s note was: to advance patient care. The note would be updated on a visit-to-visit basis by the same physician or perhaps another physician in the same group covering a weekend. Then shift-based medicine came into play, and the note became a vital mechanism to facilitate care transitions. Then, as malpractice suits became more commonplace, lawyers began requiring physician documentation to support their legal case. From there, we saw the note transform from a clinical and legal document to a billing document and a check for RAC audits.
Given these trends, the pressure on provider organizations (and physicians individually) to document extensively and bill correctly for every service performed has grown over time. Concurrently, the practice of regularly reconciling clinical notes and charges also has grown in importance, both to identify missing charges (for revenue enhancement) and to identify missing notes (for compliance). In order that this process doesn’t become another straw on a physician’s administrative back, many organizations prefer to automate charge-note reconciliation within the revenue cycle management workflow.
For a variety of compelling business reasons, not limited to concerns about physician burnout, healthcare systems must attend to their physician experience with the same level of care and intention as their patient experience. Here are three ways that improving physician experience can help to bolster a hospital’s bottom line:
By Abhinav Shashank, co-founder and CEO, Innovaccer.
Abhinav Shashank
U.S. healthcare is nowhere near what technology made us dream of a decade back. Healthcare technology was meant to act as a means of reducing costs, eliminating burnout, and making care delivery patient-centric. Cut to today, where a broken leg can cost a patient as much as $7,500, seven out of 10 physicians do not recommend their profession to anyone, and we rank poorly among other developed countries in terms of the number of preventable deaths.
Why did technology fail?
While disruptive technology solutions did flood healthcare in the last couple of decades, many of them required physicians to go the extra mile to comprehend those sophisticated systems. Today, physicians are still crunching large data files day in and day out, nurses are doubling up as technical executives, and patients are perplexed by the fact that their providers hardly have time for them.
It’s time for technology to care
If a technology solution is not assisting organizations in improving care quality, reducing costs, and optimizing utilization levels, then its very relevancy is questionable. Healthcare organizations need technologies that can help them actuate their data, realize their strategic goals, and bring patients closer to their providers.
Health IT solutions should make the lives of providers easier. Any health IT solution that puts an additional burden on providers is unjustified and unacceptable. Providers are not data analysts, and expecting them to train tirelessly to understand an IT system and spend a couple of hours each day navigating through complex interfaces can drastically reduce physician-provider time and pave the way for physician burnout.
In with ultimate integration. We need to bring together EHRs, PHMs, payer claims and HIEs and put it all in the palm of the providers’ hands. Whether it’s quality management or data management, it should be simple.
In with relevant insights right at the point of care. Providers are tired of wading through complicated EHRs and excel sheets. What we need now is to seize the nanosecond and realize truly automated care delivery that helps boost the clinical outcomes.
In with 100 percent transparency and bi-directional interoperability. Healthcare providers are often forced to access bits and pieces of electronic healthcare analytics and referrals on disparate applications. Physicians need to capture real-time care gaps, coding opportunities, patient education opportunities, and more; the only problem is that they don’t know how exactly to accomplish this. Providers should be able to capture the gaps in patient care right when they need to and enhance the patient experience of care.
In with true patient-centric care. Healthcare is not just providing episodic care to patients, it is about building relationships with them. In a world where the quality of care directly influences the financial success of an organization, providers should look forward to aligning the needs of their patients to their treatment procedures.
Healthcare of the 2020s needs reliable data activation platforms
“If you can’t explain it simply, you don’t understand it well enough.” — Albert Einstein
Buzzwords like innovation, intelligence, and analytics make sense in today’s time; however, unless the user experience is seamless, the charisma of back-end development does little good for healthcare professionals.
We’re moving into an age of intelligence, and in this age, successful organizations do one thing right- they know the worth of their data. This is the same thing that we need to do in healthcare. Organizations have to switch from a makeshift approach to engage patients and find a concrete strategy that is suited to their advantage, but this needs to be done with the support of data.
By Scott E. Rupp, publisher, Electronic Health Reporter.
Prior authorizations are hurting practices, the American Medical Association contends. According to the organization, prior authorization requirements have increased in the past five years, and 85 percent of physicians say the practice interferes with continuity of care. This is according to a new survey from the organization.
Prior authorization (PA) is a process requiring healthcare providers (physicians, pharmacists, medical groups and hospitals) to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient. While health plans and benefit managers say that PA programs are important to controlling costs, providers often find these programs to be burdensome and barriers to the delivery of necessary patient care.
The AMA’s report was conducted in partnership with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association, releasing the “Consensus Statement on Improving the Prior Authorization Process.” The statement “reflects agreement between healthcare providers and health plans on key reforms needed to reduce PA hassles and enhance patient-centered care.”
According to the 1,000 physicians interviewed, more than two-thirds of these fine folks said it’s difficult for them to determine whether a prescription or service needs prior authorization.
Alternatively, fewer than 10 percent of the physicians said they contract with a health plan that allows programs that can exempt providers from the requirement. Additionally, prior authorizations are primarily obtained by phone or fax, with just a bit more than 20 percent of physicians saying they are able to complete the requests through their electronic health records — which can be most efficient when that capability is allowed.
In a statement released with the survey findings, AMA charged insurance companies with a “year of foot-dragging and opposition” to prior authorization reforms.
According to the study, the AMA is encouraging the use of programs that selectively implement PA requirements based on stratification of healthcare providers’ performance and adherence to evidence-based medicine, but the results from the study show that only 8 percent of physicians report contracting with health plans that offer programs that exempt providers from PA. Likewise, the AMA wants an overall revision of PA requirements, including the list of services subject to PA, based on data analytics and up-to-date clinical criteria. A majority (88 percent) of physicians report that the number of PAs required for prescription medications and medical services has actually increased over the last five years.
From the payer’s point of view, prior authorizations serve as a cost control that limits unnecessary care, and the practice has supporters in high places. For example, a Government Accountability Office report released in 2017 found that prior authorization in Medicare saved as much as $1.9 billion through March 2017. The Trump administration’s proposed budget also includes expanded prior authorization measures for Medicare. The fight over them doesn’t appear head for anything but an ugly stalemate.
Life Image and swyMed announce a new strategic partnership to enhance telestroke capabilities. This engagement will improve the ability for physicians to collaborate and coordinate care while using swyMed’s offering by seamlessly integrating relevant clinical and imaging data into the telemedicine encounter. The agreement also deepens swyMed’s ability to connect to neurologists and primary stroke centers, which are already part of the Life Image network. Life Image is currently supporting more than 140 stroke centers within its U.S. network.
This new partnership will advance swyMed’s telestroke solution by combining the exceptional bandwidth management capabilities in its videoconferencing platforms, which are highly beneficial for rural area hospitals, with access to all relevant medical records, diagnostic imaging, and other critical clinical data.
This data is made available through the Life Image clinical image exchange, which is integrated into the workflows of 80 percent of all large health systems and academic medical centers in the U.S. The engagement will also provide Life Image hospital customers with a value-added telestroke solution as part of the Life Image Interoperability Suite, to extend neurology departments’ reach beyond the walls of the organization and deliver timely, high-quality care for patients affected by stroke.
Evie Jennes
“Despite widespread knowledge that every moment counts when it comes to treating acute ischemic stroke, a majority of stroke patients do not receive adequate treatment in time due to lack of access to primary stroke centers and appropriate specialists,” said Evie Jennes, CCO, swyMed. “We have dedicated extensive efforts to innovating solutions to overcome these challenges and optimize outcomes among stoke patients. By engaging with Life Image, we can now provide immediate access to imaging and clinical data to speed up diagnosis and treatment, as well as connect swyMed users to premier neurology centers and leading research facilities through Life Image’s extensive provider network.”
There are several access-related challenges associated with acute stroke treatment, which are further compounded by the fact that diagnosis and treatment are incredibly time-sensitive and require a specialist. Unfortunately, research shows a severe lack of stroke specialists in the U.S.: only 55 percent of Americans reside within 60 miles of a primary stroke center, and there are only an estimated 1,100 neurologists specializing in stroke nationwide.
This new strategic partnership between swyMed and Life Image will address these data access and specialist shortage issues by offering immediate connectivity, even in the most bandwidth-challenged areas, to stroke specialists across the U.S., and integrating all relevant medical data into the telemedicine encounter to allow diagnosis and treatment to begin before the patient arrives at the hospital.
atthew A. Michela
“Providers have long struggled with interoperability and data-integration issues across systems and locations, and these issues come to a head when caring for a stroke patient. Paramedics and emergency room doctors especially need to immediately reach stroke specialists and provide them with the patient’s neurological exam and other imaging and clinical data in order to achieve the best-possible outcome for the patient,” said Matthew A. Michela, president and CEO, Life Image.
“We see this partnership with swyMed as an important opportunity to advance the clinical practice of telestroke. Whether it’s a rural hospital with poor bandwidth or a hospital without stroke specialists, this new engagement will benefit all providers dealing with stroke management by uniting swyMed’s cutting-edge telemedicine platform with our powerful global network of data and integration into thousands of provider workflows nationwide.”
Life Image’s interoperable solution, which integrates into existing workflows, orchestrates the flow of more than 10 million clinical encounters per month. The network connects 1,500 U.S. facilities, 8,000 affiliated sites, 150,000 U.S. providers and 58,000 global clinics with a broader ecosystem of patients, life sciences, medical device companies and telemedicine companies.
DirectTrust announces that the U.S. Department of Veterans Affairs (VA) Direct Messaging has joined the association’s Accredited Trust Anchor Bundle, allowing VA personnel access to the full national network of 1.8 million Direct endpoints. DirectTrust is a health care industry alliance created by and for participants in the Direct exchange network used for secure, interoperable messaging of protected health information (PHI) between provider organizations, and between provider and patients, for the purpose of improved coordination of care.
Participating in DirectTrust’s trust anchor bundle means VA providers and staff will be able to seamlessly engage in interoperable Direct Messaging and exchange of patient information with thousands of their counterparts in community hospitals and clinics in all 50 states and US territories, through the use of the providers’ electronic health records (EHRs). Use of the DirectTrust trust framework enables a single trusted “on ramp” for providers exchanging health information across a network that currently connects over 1.8 million providers using over 350 certified EHRs nationally.
Scott Stuewe
“Admission to the DirectTrust Accredited Trust Anchor Bundle certifies that an organization has established and upheld a superior level of trust for its stakeholders, which is a significant distinction. Kudos to VA’s commitment to maintaining the highest standards in privacy, security, and trust in identity,” said DirectTrust president and CEO Scott Stuewe.
Margaret Donahue, M.D., Director of VA’s Veterans Health Information Exchange (VHIE) Program said, “VA Direct Messaging’s participation in the DirectTrust Accredited Trust Anchor Bundle will open significant new opportunities for VA personnel to securely share Veterans’ health information through Direct Messaging in every community in the country. This is a major step to increase care coordination with community (non-VA) providers who also provide care for our Veterans.”
DirectTrust Accredited Trust Anchor Bundle has as participants Health Information Service Providers (HISPs), Certificate Authorities (CAs), and Registration Authorities (RAs) that have achieved accreditation either through the DirectTrust HISP Accreditation Program for HISPs or the DirectTrust-EHNAC Trusted Agent Accreditation Program for CA/RAs (DTAAP-CA/RA).
The key value proposition of the DirectTrust Accredited Trust Anchor Bundle is to facilitate interoperable Direct Messaging between HISPs in a uniform and scalable manner that is consistent with industry best practices for security and trust, thereby avoiding the need for further one-off negotiations between relying parties who are participants in the bundle.
Mad*Pow’s Center for Health Experience Design and Health 2.0 Advocates announce a design challenge, funded by the Robert Wood Johnson Foundation, for the health and design communities to envision solutions that would reshape everyday life to be healthier by default. The focus of this Design Challenge is to imagine how, in the near future, technology might be used to make health a part of our daily routines.
Amy Heymans
“Our systems have made it hard to be healthy, and our healthcare system can’t keep up. The United States spends far more on healthcare than any country in the world but achieves disappointing results in comparison,” said Amy Heymans (Cueva), Mad*Pow founder and chief experience officer. “How might we design the systems we use every day so they support us in being as happy and healthy as possible, instead of worn down, stressed out, and sick? This Design Challenge seeks the most creative minds to imagine solutions that improve health, not just by focusing on healthcare and medicine, but also by taking a new look at the fundamentals of our daily lives.”
Design Challenge entries should include ideas that are feasible in five to ten years, change the environment to a healthier default, and incorporate multiple technologies or components. A Q&A webinar is scheduled for May 29, 2019, at Noon ET.
Interested participants should register by May 27, 2019, to receive more information about challenge requirements, criteria, rules, and deadlines. Final submissions will be due on August 31, 2019 by 11:59 PM ET. A panel of judges, including Vanessa Mason from Institute for the Future, Judith Anderson from Mass College of Art & Design, Stacey Chang from Dell Medical School, Allison Arieff from SPUR and the New York Times, Jeff Rison from the Gehl Institute, and Amy Heymans from Mad*Pow, will choose two winning solutions: one design that targets specific healthy behaviors and one design that envisions broad, systemic change. These two winning entries will be announced on Oct. 16, 2019, and will share up to $10,000 in prizes.
“Many of the tech industry’s early attempts to encourage healthy lifestyles rely on prompting people to make healthy decisions in the moment, while doing nothing to address the underlying infrastructure, norms, and culture that guide our behavior,” said Stephen Downs, chief technology and strategy officer, Robert Wood Johnson Foundation. “This Design Challenge will encourage creative thinkers to envision how technology could shape our everyday routines in ways that make healthy lifestyles the default.”
With more than 4 million nurses, the largest segment of the U.S. healthcare sector, nurses have indisputably demonstrated an ability to improve healthcare outcomes. We are just beginning to utilize Healthcare IT data and AI to improve patient outcomes. One of the key benefits of AI will be the ability to leverage the data from nursing care plans and nursing diagnoses to perform work load balancing for nursing staff. This is a key solution to future management of the problem of the shortage of nurses.
Another problem that needs attention is the possible disconnects which can result from nurse to nurse hand offs with the use of virtual nurses who remotely monitor patients. They enter data into their own EHR system – not the same one in use by the hospital where the patient is located. We will discuss here the nature of the data, technologies and frameworks, the nursing information model and the structure of the data elements needed to provide care needed to implement solutions for staffing, interoperability and workflow improvements.
The National Academy of Medicine’s committee background report on the Future of Nursing 2020-2030, Activating Nursing to Address Unmet Needs in the 21st Century, found the worsening health profile in the United States requires “more than a traditional medical response.” As professionals in the care team, nursing documentation requires a standardized framework to achieve consistent data quality in healthcare communications about the work of nurses. This standardized framework recognized for professional nursing documentation is the American Nurses Association (ANA) Nursing Process. This ANA framework is essential to nurses for managing and improving healthcare outcomes, safety and reimbursement as proposed by the Institute for Healthcare Improvement (IHI).
In most electronic health information record systems, the standard nursing data implemented (sometimes called the system terminology, data dictionary, or nomenclature) is proprietary with a pre-existing data structure/framework. The proprietary framework acts as a barrier to nursing documentation by constraining the available concepts for nursing documentation and the nursing care plan fields.
Without interoperable electronic data concepts available for documentation, nursing care notes become unstructured free-text and are not included in coded health information exchanges. Due to the highly structured design of EHR systems, nursing practice is determined by the system’s terminology and ontology framework configuration. If nurses do not select the ANA framework; nursing care data takes on the sedentary shape of the local proprietary data structures, rather than nesting in a flexible, portable and universal tool to enable nurses and other episodic care providers to improve future nursing interventions, practice and care outcomes.
The American Nurses Association (ANA) describes the common nursing framework of the documentation of professional nursing practice as the Nursing Process. The Nursing Process is the foundation for the documentation of nursing care. Yet, in the EHR, nursing documentation is reused during the patient’s stay, over and over, with the documentation being done from the nursing assessment as if the documentation was a template. The Nursing Process is the framework and essential core of practice for the registered nurse to deliver holistic, patient-focused care.”
Producing effective EHR systems for nursing requires a deep understanding of how nurses create and conduct cognitive documentation as well as task-oriented documentation. Most EHR systems dictate rather than adapt to nursing workflows and nursing information is not organized to fit the ANA model of care. The EHRs often assume a nursing care delivery model that is represented as algorithmic sequences of choices, yet nursing care is iterative with reformation of patient goals, revising interventions and actions and updating care sequences with individual patients based on encountered condition changes and constraints. In the dictated workflow of EHRs, nursing data is collected as care assessments with nursing diagnoses, interventions and actions in formats used to create single patient encounters.
To help professionals in skilled nursing facilities (SNF) prepare for the largest payment reimbursement change for their industry in 20 years, the American Health Information Management Association (AHIMA) collaborated with the American Health Care Association (AHCA) to provide in-depth coding and clinical documentation improvement (CDI) training programs.
Beginning Oct. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) will change the reimbursement model for SNFs to a new, value-based Patient Driven Payment Model (PDPM) that will require CDI skillsets and knowledge of ICD-10-CM diagnosis codes in order to accurately support the qualifying stay and demonstrate the need for care and treatment best suited for each patient.
AHCA enlisted AHIMA to help develop in-depth coding and CDI education courses to help prepare SNF providers for the major payment overhaul. The courses include two options: the first provides webinars for coding in ICD-10-CM and requirements in CDI case studies and concludes with a 50-question assessment. The second option is a shorter course for non-coders that includes a webinar with a high-level review and basic information on ICD-10-CM coding guidelines to provide an introduction to the PDPM reimbursement model. Both courses offer AHIMA CEUs and CNE contact hours. In addition, the non-coder course offers NAB continuing education credits.
Wylecia Wiggs Harris
“To stay up-to-date with the ever-changing healthcare industry, it is critical that professionals have the resources they need to continue to provide exceptional care,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “This is why we’re happy to work with AHCA on this important training program, which will equip professionals working in skilled nursing facilities with the knowledge and understanding of ICD-10 needed to thrive under the new payment system, and ultimately improve patient outcomes.”
“ICD-10 is a driving force behind the new PDPM payment system for skilled nursing care,” said Jennifer Shimer, AHCA/NCAL COO and senior vice president, member services. “AHCA partnered with AHIMA to develop the best ICD-10 curriculum possible to prepare our members for this massive Medicare payment change.”
CDI is at the core of every patient encounter and through this collaboration, AHIMA and AHCA will help SNFs understand ICD-10-CM guidelines for coding and reporting and how to apply the guidelines to coding for the PDPM Medicare reimbursement. The courses will also help SNFs assess coding and diagnostic perspectives when identifying high quality clinical documentation and classify SNFs into appropriate clinical categories as defined by the PDPM.
Prior authorizations are hurting practices, the American Medical Association contends. According to the organization, prior authorization requirements have increased in the past five years, and 85 percent of physicians say the practice interferes with continuity of care. This is according to 
