Guest post Ken Perez, vice president of healthcare policy, Omnicell.
Ken Perez
During the 2016 presidential campaign, Democratic candidate Hillary Clinton reiterated the longstanding Democratic pledge to allow Medicare to negotiate drug prices and demand higher rebates for prescription drugs. In response, and aware of the general public’s mounting concern about rising prescription drug prices, Donald Trump shifted to the left and repeatedly called for Medicare to directly negotiate drug prices. For example, at an MSNBC town hall on Feb. 17, 2016, Trump said, “If we negotiated the price of drugs, Joe, we’d save $300 billion a year.”
However, none of Trump’s three most substantive policy statements issued in the fall of 2016—including the healthcare section of the Trump-Pence Campaign website, his “Contract with the American Voter,” and his healthcare plan issued two days after the election—mentioned the challenge of rising drug prices or the idea of Medicare negotiating drug prices with pharmaceutical companies.
On Jan. 31, 2017, President Trump met with a group of pharmaceutical industry executives, including the CEOs of Amgen, Celgene, Eli Lilly, Johnson & Johnson, Merck, and Novartis, as well as Stephen Ubl, head of the Pharmaceutical Research and Manufacturers of America (PhRMA).
While during the meeting Trump called drug prices “astronomical” and said, “We have to get prices down for a lot of reasons … for Medicare and Medicaid,” he stopped short of the aforementioned negotiation of drug prices by the federal government. Trump pressed the pharmaceutical companies to bring drug manufacturing and production back to the United States. In return, Trump pledged to work to reduce corporate taxes, support deregulation, and streamline the FDA to expedite drug approvals. One can interpret those broad statements as a draft outline of the deal with pharma that will be struck by the Trump administration.
Where would such a deal leave the drug pricing issue? While Trump clearly expressed concern about high drug prices, the drug makers can offer him something else that he may want even more: jobs for U.S. workers that come from boosting production at existing plants and opening new plants on U.S. soil. Imagine the photo ops!
The Center of Medicaid and Medicare Service (CMS) continues to increase emphasis on care collaboration, ranging from Chronic Care Management (CCM) to the recent announcement from the US Surgeon General’s landmark report on alcohol, drug and health. Derived from many aspects in healthcare, the authors’ examine the challenges of integrating physical and behavioral healthcare, addressing the Care Collaboration Model outlined by CMS and the Surgeon General.
The author’s, beginning with the interdependency between physical and behavioral health, bring case scenarios supporting the challenges of today’s healthcare, and then introduce an innovative Health Collaborative Ecosystem addressing the many challenges of a care collaboration model.
Interdependency Between Mental and Other Chronic Disorders
Research has demonstrated bidirectional links between mental disorders and chronic conditions. Depression and anxiety are heightening the risks towards hypertension and diabetes. Depression roughly doubles the risk for a new coronary heart disease (CHD) event. We can go further on other mental disorders such as PTSD, drug addiction and alcoholism. Such interdependencies have limited solutions today due to the lack of a collaborative environment. We refer to this as a ‘revolving door care environment’, a vicious cycle compounding the effects of chronic and mental disorders.
A detox center can only retain the patient for detoxification for a limited time. Without collaborating with other behavioral services, the patient will inevitably return to the same habit – either drug addiction or alcoholism. Depression can stem from a social environment or from a recently developed chronic condition such as CHD.
The primary care provider will continue to address the chronic condition without the knowledge of what may actually feed into the patient’s chronic condition. It is yet another ‘revolving door’ for the physical care environment. Such interdependency requires a care collaborative environment between care providers.
Care Collaborative Model and Bidirectional Information Flow
A team-based care collaborative model uses a multidiscipline group of care providers supporting and implementing treatment with the patient at the center. A bidirectional information flow is an absolute must to put the model into realization and operation in healthcare institutes.
Today, healthcare lacks the support of a closed-loop system, one that emphasizes a bi-directional flow of information. Healthcare is muddled with reactive care, instead of preventive, anticipated care. It is that lack of prevention and anticipation that have an adverse impact on the overall healthcare cost and patient outcomes. EHR and EMR systems are the main ‘anchors’ of today’s health IT.
However, there are two EHR components that are non-starters: the boundary of the health institute and unidirectional systems. HIEs (Health Information Exchange) address EHR limitations with their capability to provide support across health institutes, but actually worsen the unidirectional character of the EHR. Neither EHR or HIE can address the requirements for a care collaborative model.
Reaching The State of Homeostasis As A Desired Patient Outcome
The objective is to improve patient outcomes, but how do you define a patient’s outcome?
Homeostasis is a biological term, referring to the stability, balance, or equilibrium within the body. Homeostasis is the process of maintaining a constant internal environment by providing the body with what is needed to survive for the well being of the whole. While disorders (physical or mental) reflect the abnormal condition of the body, homeostasis is the normal, stable and well-being state.
Each disorder is well documented with what would be a normal condition or the state of homeostasis. This state of homeostasis also deviates based on race, demographics, and above all, the relationship with other existing disorders afflicting the patient. It is then noted that each patient outcome requires a personalized state of homeostasis.
From the disorder, the process towards the state of homeostasis consists of genetics, nutrition, physical activity, mental health and an external environment. Genetics is the internal influencer in with medicine’s physical care plays a role in adjusting the disorder toward homeostasis. For healthcare, it is the care plan for a disorder.
The state of homeostasis should be used as the measure of a patient’s outcome, resulting from the care collaborative model addressing the integrated, coordinated care from multiple care providers.
Health Collaborative Ecosystem
The Health Collaborative Ecosystem is the delivery process that supports the care collaborative model, with the objective of bringing the patient to the state of homeostasis. This system would include all providers of health-related services to the chronically ill patient diagnosed with one or more of the designated chronic and debilitating diagnosis that utilize the most significant percentage of health care spending. Such a system would be:
Capable of integrating physical and mental care environments.
An integrated layer complementing (including EHR-agnostic) existing health IT infrastructures, supporting care activities beyond the brick and mortal walls of their facility or clinic.
Consensus among providers to standards of care and bidirectional information flow that encourages innovation, compliance with regulations, secures privacy and adopts a continuous process of improvements to better reach a patient’s state of homeostasis.
Why an Ecosystem?
An Ecosystem is a collective system, including a health IT solution and consulting guidance, and support, for hospital operations in order to maximize the benefits of care collaboration, through efficiency and scalability of a care providers’ bandwidth.
It is an Ecosystem because it must include an auditable compliance component to provide crucial measurements and enforce quality guidelines for the model according to hospital and clinic management.
It is an Ecosystem because it must include the ability to track and monitor progress towards the state of homeostasis for all attributes contributing the patient’s overall well being.
Case scenarios
As noted in one case study, Maria Viera, age 75, takes a dozen medications to treat her diabetes, high blood pressure, mild congestive heart failure, and arthritis. After she begins to have trouble remembering to take her pills, she and her husband visit her primary care physician to discuss this and a list of other worrisome developments, including hip and knee pain, dizziness, low blood sugar, and a recent fall. Maria’s primary care doctor spends as much time with her as he dares, knowing that every extra minute will put him further behind schedule. Yet despite his efforts, there is not enough time to address her myriad ailments. She sees several specialists, but no one talks to all her providers about her care, which means she may now be dealing with conflicting recommendations for treatment, or medications that could interact harmfully. As a result, Maria is at high risk for avoidable complications and potentially preventable emergency department visits and hospital stays.
The care team for the above patient would potentially consists of: a primary care provider (high blood pressure and care coordinator), a cardiologist (congestion heart failure), an endocrinologist (diabetes), dietician (diabetes), a rheumatologist (arthritis), physical and/or occupational therapists (arthritis, falls, hip and knee pain), and a psychologist or a psychiatrist (depression).
The above case brings challenges to the health care system on multiple fronts:
More time from primary care providers with limited result outcomes due to the lack of collaboration with other care providers, specialists and community services.
Potential conflicting recommendations for treatment due to the lack of coordination and bidirectional medical information flows from multiple care providers and specialists.
The patient’s risk for complications, emergency visits and hospital stays significantly increases.
As conditions worsen, the patient develops symptoms for behavioral health conditions.
Today’s solution for the above scenario is based on care management. The care manager would work with all care providers, manually “pulling and pushing” the patient’s medical conditions and updates to all involved care providers. Error prone, high cost, and low efficiency are some of today’s deficiencies for healthcare attempts in implementing the care collaborative model, outlined by CMS.
Net New Revenue Focusing on Preventive Care
This is the challenge of a ‘revolving door care environment’ in addressing the need for integration between physical and behavioral health services. The Health Collaborative Ecosystem is the answer for such a challenge.
However, to support such a revolution, healthcare, as an industry, needs to have the financial incentives. As stated in the introduction of this paper, CMS is not encouraging a transformation through financial incentives.
The authors’ propose a roadmap to roll out the Health Collaborative Ecosystem without upfront risks and budget planning, but to generate new revenue for the institutes. The implementation roadmap leverages these CMS initiatives:
Annual wellness visits
Chronic care management
Integration of physical and behavioral health through the care collaboration model
With the Health Collaborative Ecosystem’s objective is to create a patient state of homeostasis, rural and community hospitals and clinics can accomplish multiple goals – better services to the community, better defined patient outcomes and open new avenues for health services with behavioral health and filling the revenue gap.
Now that electronic health records have become the norm, healthcare providers — as well as healthcare systems and insurers — have access to unprecedented amounts of patient data. As a result, the practice of data mining, or analyzing data sets to identify trends and patterns, has become commonplace in healthcare, with the ultimate intent of improving patient care, improving efficiencies in the delivery of care, and reducing costs. Simply put, data mining has the potential to save lives and save money, but that doesn’t mean that it isn’t without risk.
As you might expect, using patient data for any purpose beyond providing care for the individual patient brings with it some tricky issues regarding privacy, and keeping the information from falling into the wrong hands. There are significant legal issues related to the use of patient data in data mining efforts, specifically related to the de-identification, aggregation, and storage of the data. Failing to take the appropriate steps when using personal health data as a tool for population health could lead to serious consequences, including a violation of HIPAA.
The question, then, is how to protect patient privacy while still gaining the insights that data mining can provide.
Protecting Patient Privacy for Data Mining
One of the major security concerns related to data mining is the fact that many patients don’t even realize that their information is being used in this way. Considering the way in which mined information can be used, this is of concern to many privacy advocates.
For example, in one noted example, Carolinas HealthCare, which runs more than 900 care facilities in the southern U.S., has purchased consumer data on more than two million people, which they use in algorithms to determine the risk for illness. The data includes purchase information collected from credit cards and consumer loyalty programs, as well as public records, to determine which people are at the most risk of getting sick. Providers can potentially use this information to remind patients to visit the gym more often, or encourage them to stop eating so much fast food. Other hospitals have used general demographic information about home and vehicle ownership or family makeup, to gain insight into a patient’s health and well-being, as well as identify potential barriers to care. However, what sets this type of data mining apart from healthcare data mining is that it’s data collected via other sources, and therefore not covered by HIPAA rules.
Still, many patients who have been contacted as a result of this type of data mining have noted that the practice feels intrusive. Even more intrusive is the potential for their personal health data to be used in this way, especially without their permission. Under HIPAA rules, data mining is a secondary, future use of health data, and thus requires the explicit permission of the patient before being used.
By the very definition, data mining is the process of looking for previously unknown patterns in data, so there is no way of knowing from the beginning what data is useful, or what relationships will be uncovered, meaning that there is potential for identifying information to be used or revealed. This highlights an important consideration when it comes to collecting and using personal information for data mining: Permission from the individual. Privacy advocates recommend offering patients the option to opt-in, opt out of specific uses, or opt-out entirely.
Running a healthcare facility is a herculean task even with the most experienced staff. Most studies on the state of healthcare industry decry the high cost of equipment maintenance and it is also the greatest challenge that every hospital administrator deals with. Breakdown of hospital equipment can lead to fatalities and this is why you need to leverage preventive maintenance software to avoid legal issues and costly repairs.
Computerized maintenance management system (CMMS) will help reduce hemorrhage of hospital revenues through unforeseen equipment breakdowns. This system is used to schedule preventive maintenance at the healthcare facility thus avoiding downtime of the machines. With this software, all of the hospital’s assets are tracked and monitored and all of this information is presented on one single dashboard. As the facility manager, you have instantaneous access to information about the condition of all the equipment. With such access to information the maintenance procedures are easier to execute, which saves the institution from financial loss and also improves the quality of patient care provided.
To appreciate why you should invest in such a maintenance system, consider the folowing benefits:
Improved Patient Care
The patients are the top priority in a healthcare facility and as such all efforts should be directed towards providing quality care. By adopting the CMMSsoftware, you will have preventive measures in place in case of equipment failure. The health of patients is in your hands and situations such as power outages and equipment failure must be averted, as they can result in fatalities. You are able to come up with contingency plans in case of emergencies and the system also helps in case of evacuations. By providing for real-time communication between members of staff, this software improves the level of service offered at the facility.
Improved Asset and Inventory Management
A vast healthcare facility receives lots of supplies daily, and these are crucial in offering appropriate health services. Tracking all these supplies manually is very tricky and tedious, but with an automated system you can keep track of what is available and what needs to be replenished, quite easily. You can also monitor which departments are consuming more supplies and make relevant decisions based on such information. This system also helps you keep track of the equipment in the facility. If there are any due repairs, it is easier to alert the concerned parties to avoid downtime.
Risk Assessment
A hospital environment provides unique challenges and risk assessment is crucial to avoid accidents. The best maintenance management software also enables you to assess the potential risks in any project and equipment. By receiving such information beforehand, you are able to preempt any risks and avoid accidents. You can also carry out quality safety inspection to ensure every department is prepared for any unanticipated risks.Continue Reading
Healthcare providers continue to face new and growing challenges across the marketplace. From the release of the MACRA final rule to the consumerization of healthcare, there is a lot to balance and manage. It can be hard to keep up while also trying to provide quality care and get paid. As a result, providers continue to look at alternate payment models according to a new survey from Kareo and the American Academy of Private Physicians (AAPP).
The survey shows that 25 percent of practices are now using some kind of direct pay, concierge, or other membership model in their practice. This number stayed steady from the 2015 study to the 2016 study. Most do not have all their patients on one of these models, but 30 percent have completely transitioned their practice. The results show that many practices are testing these models while still offering patient other options like traditional fee-for-service. This may suggest that physicians want to see how successful the models before shifting their entire practice.
Another 35 percent of providers say they are considering a change in part or in whole to an alternate model like direct pay or concierge. The reasons are consistent with the results from the 2015 survey. The top reason cited was to separate from the insurance payer system, closely followed by spending more time with patients and improving work/life balance.
The survey indicates that those physicians who do switch see improvements in those areas. Physicians using direct pay, concierge or another membership model spend more time with patients, see fewer patients each day at longer visits, and work fewer hours than their fee-for-service counterparts.
This infographic shows the details of both the differences and the similarities when physicians use private pay models versus fee-for-service models.
Mobile technology is impacting every element of American healthcare–from insurance and billing to documentation and caregiving, the impacts are being felt. The truly transformative element of the mobile revolution is not the technology itself, or the way it changes the look and feel of the tasks it affects. Despite complaints of the depersonalizing effect of technology, the ultimate value of mobile in the sector will be how it enhances and encourages communication.
Providers are Going Mobile
Already, flexibility and functionality have already drawn providers to mobile devices and solutions. Voice-to-text technology and similar automated solutions are in the offing to relieve the documentation burden that has dampered some amount of enthusiasm toward digitization. Bolstered by these advancements, caregivers will go from subjects of their EHRs to masters of patient encounters.
One of the huge benefits of mobility — as opposed to simply being networked on desktop computers or having a digital health records solution — is the capacity for greater native customization and app development. Native apps are like the currency of the mobile, smart device world providers are entering. Developers can deliver personal, branded interfaces that allow doctors to choose precisely how they want their dashboards to look, giving their EHRs a custom touch that has been sorely lacking throughout their implementation.
App-centric development will further reduce the friction of adoption and utilization, giving doctors a sense of empowerment and investment, rather than the bland inertia that has carried digitization thus far.
The personalization of the technology through app development will help boost adoption, and return the focus to what the technology enables, rather than how it looks or what it has replaced. Mobile technology’s strength will be in reconnecting doctors and patients, and creating bridges of data and communication across the continuum of care.
Patients are Going Mobile
Patient-facing health apps and mobile point of access to care combine convenience and cost-saving with a learning curve. Increasing the visibility of EHRs through mobile portals gives patients greater reason to develop some basic health literacy, and levels the playing field during doctor encounters. The more providers use mobile solutions, the more incentive patients will have to do the same.
When apps are connected to prescription management and can monitor adherence to treatment plans, mobile devices provide a two-way mirror enabling doctor and patient to remain connected long after the encounter is over. This can allow providers to better anticipate and intervene where drug abuse is at risk, as well as to prevent ED admissions and re-admissions beyond what telehealth has been able to achieve.
Even without connecting providers, mobile health apps will also support personal health management, with an eye to prevention as well as education. From diet-planning to workout tracking and even disease management, patients have more ways than ever to study their bodies and better understand their unique wellness needs. As providers and their EHRs evolve to integrate mobile patient-generated data, the potential for customization will make each encounter more conversation-driven, using data as a platform to educate, engage, and advance communication.
All these personal, data-rich conversations will help push prevention and population health into front of mind for a generation.
Guest post by Joel Rydbeck, director, healthcare technology and strategy, Infor.
Joel Rydbeck
Healthcare is undergoing rapid “digitization” – a move toward an integrated ecosystem of mobile applications and data exchange that integrate consumer data into the enterprise. For healthcare, this could enhance patient engagement and enable care to become more efficient and “real time”.
Nonetheless, moving to a more digital healthcare enterprise presents a series of challenges:
How will the data be transmitted and is it semantically interoperable?
Where and how much should be persisted?
How can the data be made “actionable” for the clinician?
We’ve all visited a doctor and been asked “How are you sleeping?” and “Are you getting exercise?”. If you are among the growing number of people with a fitness tracker, you may think, “Hold on, I have that recorded”. So, you pull out your mobile phone and respond “I am getting six to seven hours of sleep a night and about 11,000 steps a day. Is that good?” While your doctor may understand your quick synopsis of the data, imagine if they were getting the data real-time. Would they know what to do with it? What if it contains disturbing trends? It would be unfortunate if crucial information wasn’t put to good use. But how?
Interactions like these prompted Washington University’s Olin School of Business and Infor Healthcare to collaborate on improving the usability of personal tracker data. This collaboration included conducting a small survey of 39 physicians from a broad spectrum of specialties asking their thoughts about the use of tracker data for clinical care.
The survey uncovered differing views on what information would actually be useful, showing:
56 percent thought active hours would be useful,
46 percent said miles walked or intensity of movement,
36 percent included steps taken as a useful metric,
and 10 percent the said the degree of upward incline during movement would be useful.
The survey also asked providers what factors would enhance their likelihood of using tracker data for patient care. Majority would like to see better integration with their electronic health record (EHR), more patients using the devices, and additional data, such as blood sugar, being collected.
Physicians reported lack of education as a barrier to effectively using the data. About 50 percent believed that education, in the form of a short presentation or discussion, would be useful while 31 percent thought that a short guide would suffice.
While two-thirds of providers were open to discussing personal trackers with their patients, they did express concerns in using the data for care. The data must be proven accurate before physicians will place trust in it. Inconsistent or inaccurate data could lead to unnecessary anxiety and possibly harm. Also noted is that extraneous data can clutter the EHR and complicate patient care. Many of the providers mentioning drawbacks to using device data stated that the devices might work best as motivational tools for patients. More study towards interpreting tracker data for clinical use is needed.
Healthcare is one sector where information technology is yet to be exploited to its fullest. Medical science has gained a lot from computers and information technology but healthcare is still being run mostly without it. The basic healthcare process entail the patient thinking something is wrong with them and going to a doctor. It depends too much on people’s own observances and not enough on science. Our medical equipment has gotten better and we are able to cure and manage more diseases than before but the basic healthcare regimen is still the same. That will not be true for many more years because healthcare is slowly starting to embrace information technology.
The biggest roadblock for technology in healthcare is that failure is unacceptable. In most other areas you can afford some mistakes or errors. Sometimes your Netflix doesn’t load, sometimes your phone may drop a few calls, perfectly acceptable. The same cannot be afforded when it comes to healthcare. So while we are not happy that IT is not being full used in healthcare right, we are happy that we are focusing on ensuring everything works perfectly before implementing it in a medical setting.
Health monitoring will save lives and change how we communicate with doctors
The diseases that most people die of are perfectly curable or manageable. Even most cancers are curable – as long as they are caught in time. That is why so many people still die from cancers. You can have cancerous growths in your body and not show any symptoms. By the time people get in front of an oncologist it is often too late to fully cure their issues. This is also why the deadliest cancers are also the ones that are the hardest to detect. There’s a special type of gallbladder cancer which doesn’t exhibit any symptoms until it metastases. Aside from cancers there are many other diseases which can be reversed in the beginning. Many forms of diabetes as well as heart problems can be reversed if caught early simply through diet and exercise.
Another problem is that people do not know what symptoms to be worried about and often do not go to doctors because they don’t realize what is wrong with them. We can’t blame people either; only doctors know what symptoms to be worried about and it takes them a decade worth of education to reach that level. We cannot expect people who did not pursue a medical education to instantly realize that something is wrong with them. There are many simple things which indicate big problems as well. Things like fatigue and a lack of desire to eat seem like just one of those things that happen to everyone sometimes, but they can be symptoms of serious illnesses as well.
Sensors and trackers will capture medical information in real time
All this is about to be changed thanks to information technology. Medical sensors are already a consumer product but they are limited. Products like Fitbit have been available in the market for years but they only measure basic vital signs such as pulse and the amount of exercise you are getting. As we get better at making sensors smaller we will soon begin seeing similar devices which can monitor many other things in our bodies and let us know if anything is wrong. These devices are proving to be quite popular as well; in this year’s Consumer Electronics Expo there were 32 new health monitoring products unveiled by companies like HTC, Philips, Samsung, and Intel.
Another huge application of such devices is providing vital information to doctors. Doctors need your medical history in order to make the correct diagnoses. Since most of us do not know what is medically significant we aren’t very good at self reporting what is wrong with us. Medical sensors, trackers and mHealth apps will be able to tell doctors exactly what has changed in our bodies and when the changes started. Doctors will have more information about our bodies than ever before which will allow them to make more accurate diagnosis than ever before. The devices will also be connected to the internet and will be able to contact emergency services when needed. Heart attacks, seizures, accidents, anything that requires immediate medical attention will automatically hail an ambulance to your location. This is huge because a big problem is ensuring that people who live alone get the medical help which they need without needing there to be someone else in the room with them to call 911.
Preventive care will get the focus it deserves
There’s a big problem with the way we treat the healthcare system in the world. We focus a lot on curing diseases but do not focus on preventing diseases. We came to this system not because we are stupid – it was just the most viable way to do things. We only begin fighting diseases when people come to the doctor because that was the only way we had to detect a problem. Now, thanks to the developments in information technology, we will soon have the means to focus on preventive care properly. There are already sensors which can tell you if there are any harmful gases or particles in your home.
Such monitoring devices will get more advanced and become a great way to detect diseases earlier and will allow us to prevent them completely. Imagine getting a notification on your phone that goes “You have consumed 10 tablespoons of sugar and 500 grams of fats per day for the past month. Continuing this pattern will cause many diseases and medical problems. Would you like to switch to a healthier diet?”. Information technology will give us the ability to detect problems as they are being formed and fix them. This will also substantially lower our medical expenses. The effects of such monitoring and its aid for preventive care are mind boggling. Ever year more than 3 million skin cancer cases are diagnosed; most of these could be prevented just by ensuring that people do not spend too much time out in the sun. Cardiovascular diseases are the leading cause of death in the developed world, more than all the cancers combined. Yet, most cardiovascular diseases can be prevented entirely through diet and proper exercise.
Now that electronic health records have become the norm, healthcare providers — as well as healthcare systems and insurers — have access to unprecedented amounts of patient data. As a result, the practice of data mining, or analyzing data sets to identify trends and patterns, has become commonplace in healthcare, with the ultimate intent of improving patient care, improving efficiencies in the delivery of care, and reducing costs. Simply put, data mining has the potential to save lives and save money, but that doesn’t mean that it isn’t without risk.
