Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
Richard Loomis
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
Guest post by John Squire, president and COO, Amazing Charts.
John Squire
As developers of electronic health record (EHR) software, my company gets into a lot of conversations with providers about their expectations for the future. This information helps us make decisions about what to build next. Here are three trends we’re hearing from our customers right now:
Low-tech beats high-tech in telemedicine
Unlike the way it was imagined decades ago by science fiction writers, telemedicine does not necessarily mean holographic images or live video conferencing with a physician half a continent away. Patients would rather receive “low tech” remote care from their primary care physician who has a full picture of their health status.
This form of telemedicine happens whenever an EHR system adds to a patient’s clinical chart the messages, pictures, or videos sent securely via smartphone. It happens whenever a smartphone connects to a remote health monitoring device for collection of real-time data such as blood pressure, oxygen levels, and heart rate.
The new rules allowing reimbursement of telemedicine and other non-face-to-face services will encourage physicians to bill for these remote care activities. Medicare’s recently expanded set of billing codes for Chronic Care Management (CCM) is a good example of how the future of value-based care goes beyond the office visit to keep patients out of hospitals and emergency rooms. The ability to securely and rapidly receive and answer a patient’s questions via text, and then capture those activities in the patient’s permanent clinical record is a critical step in that direction.
Primary care providers are trying new types of practices
Primary care physicians are frustrated with the hassle and expense of dealing with insurance companies. The new Medicare fee-for-value quality payment program is creating uncertainty about future reimbursement levels and requires additional reporting. Also, there is an acute level of burnout with “corporate medicine,” which has providers booked for dozens of daily appointments, only to spend less than 15 minutes with each patient.
In order to remain independent, a small but growing group of primary care practitioners are becoming more financially creative and experimenting with new models of practice. One example is direct care, in which a financial relationship is established directly between patient and provider, cutting out insurance altogether. This model includes concierge and direct primary care (DPC), where patients become “members” of a practice and pay a fixed monthly fee for unlimited primary care – similar to a gym membership, but for healthcare. Another example of direct care is the cash-only practice that sees walk-in patients for urgent care.
EHR interoperability will catch FHIR
Physicians and their patients are frustrated with the lack of interoperability in health IT. The concept of having a patient’s medical records accessible to any authorized provider at any time is still a rare occurrence. When a patient switches primary care physicians, the first office typically prints out and faxes their medical records to the second office, which introduces the possibility of errors, HIPAA violations, and others.
Guest post Ken Perez, vice president of healthcare policy, Omnicell.
Ken Perez
One of the Affordable Care Act’s overarching goals is to lower cost, and one way it intended to accomplish this was by providing Medicaid coverage to more low-income adults, giving them greater access to and ability to pay for sources of care outside the emergency department (ED), resulting, in theory, in reduced ED use.
ED use is a significant driver of cost, accounting for 5 percent to 6 percent of U.S. health expenditures. Medicaid alone spends $23 billion to $47 billion each year on ED care.
There have been a number of different studies on the impact of providing Medicaid coverage to previously uninsured adults.
Some high-level research suggests that Medicaid coverage does not affect ED use. Pines, et al. analyzed ED use in 36 states—some of which were Medicaid expansion states and some were nonexpansion—for 2014, the first year of expanded Medicaid eligibility. The researchers concluded that there were no significant differences in overall ED use between expansion and nonexpansion states, though Medicaid-paid ED visits rose by 27.1 percent in the expansion states, while uninsured visits dropped by 31.4 percent and privately insured visits fell by 6.7 percent.
Most importantly, the researchers admitted, “…we do not know which visits were by patients who obtained new health insurance (Medicaid) in 2014, as opposed to those who were continuously enrolled, were uninsured, or may have switched insurance type” (Pines, et al., “Medicaid Expansion In 2014 Did Not Increase Emergency Department Use Bud Did Change Insurance Payer Mix,” Health Affairs, Aug. 2016).
In contrast, a randomized, controlled study by Finkelstein, et al. in involving 24,646 lottery-selected uninsured individuals in Oregon who were granted Medicaid coverage in 2008 showed that they increased their ED visits by 40 percent in the first 15 months after receiving coverage. Many observers speculated that the rise in ED use was due to pent-up demand and would therefore dissipate over time as the newly insured found and used other sites of care or as their health needs were met and their health improved. However, the researchers were unable to find any evidence that the increase in ED use due to Medicaid coverage is driven by pent-up demand that decreases over time; in fact, they found that the effect on ED use appears to persist over the first two years of coverage.
In addition, the study determined that Medicaid coverage increased the joint probability of a person’s having both an ED visit and an office visit by 13.2 percentage points, indicating that expanded coverage will not necessarily drive material substitution of office visits for ED use (Finkelstein, et al., “Effect of Medicaid Coverage on ED Use—Further Evidence from Oregon’s Experiment,” New England Journal of Medicine, Oct. 20, 2016).
As the randomized, controlled trial is the gold standard of research, Oregon’s study and its conclusions get the nod in the debate about the impact of Medicaid coverage on ED use.
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.
Guest post by Suzanne Travis, VP, regulatory strategy, McKesson.
Shifting to value-based reimbursement (VBR) is a challenging journey, and trying to proactively manage risk at the same time only makes things more complicated. However, there are simple ways a provider organization can more proactively position their organization for a shift to VBR. While there is no fool-proof method or one-size-fits-all approach, here are four strategies that can help steer providers on the right path, no matter where they are in the VBR transition process.
Start with a program that aligns with organizational goals
Participation in alternative payment and delivery models are on the rise. The American Hospital Association estimates that more than 60,000 providers are participating in a delivery system reform model — and that number is growing. The overarching goal of implementing new health care delivery system models is simple: to provide better, more efficient and coordinated care for patients. However, each model has its own nuances and can sometimes require a different approach. Healthcare organizations should be well-served to take a deliberate path to succeed in their journey to value-based care. First, look at each model to understand how it measures and incentivizes participants and the type of care delivery changes it requires. Select models where you have an alignment on goals, room for improvement, and where you can start with upside-only incentives. It’s better to engage now, when participation can be voluntary and downside risk can be deferred.
Getting started is, of course easier said than done. The American Academy of Family Physicians found that a top barrier to adopting alternative care delivery models is a lack of understanding of the elements and actions for success. There are materials and organizations out there that can help guide the transition. For example, the Global Center for Health Innovation explains the models and provides guidance on questions to ask and tools to consider. The Office of the National Coordinator recently launched the Health IT Playbook that includes a state-by-state listing of federally funded sources of technical assistance to support practice transformation activities. Don’t let a knowledge-gap deter you from achieving your goals.
Be ready to act when new opportunities arise
New payment models continue to be introduced and new cohorts are being added to existing programs. Whether you are impacted by a mandatory model, such as the Episode Payment Model CMS recently proposed, or a new voluntary program is announced, be ready to adapt. Take for example the recently announced Comprehensive Primary Care Plus initiative. Participating practices have a choice of two tracks with the same care delivery requirements, but with different financial risk components. Both tracks aim to provide funding for infrastructure and process transformation. Keeping your finger on the pulse of these opportunities and being prepared to act quickly to engage can help you enter into programs that allow you to learn with less risk. If you know what your goals are, you’ll be able to spot the right opportunity to get started.
Partner with your vendors
As providers adopt new care delivery models and take on more risk, contracted vendors should be expected to engage as partners who can work collaboratively to solve new problems.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
Abhinav Shashank
P.J. Carter in a blog explained how the lack of interoperability resulted in extreme physical pain to his father who had to go into an eye surgery for the repair of a detached retina. His father was told by his eye specialist that and an urgent operation had to carried out. The operation began, but doctors could not access the past medical record of his father. Since doctors were unaware of the medical history, they had to carry out a painful operation of the eye without anesthesia! His father was awake the whole time and had to endure the pain.
Healthcare industry is lagging the most when it comes to advancements. There have been innovations, but equal implementation has been lacking. The cost of care has risen to over $10,000 per person in the US because there is huge expenditure on various digital infrastructures, but not for the meaningful use of them.
Interoperability and Its Types
Interoperability is a term that has no single definition. In broad terms, interoperability is the ability of systems and devices to exchange vital information and interpret it. For healthcare, interoperability is the ability of computer systems in hospitals to communicate, share critical information and put it to use to achieve quality health services delivery.
There are three levels of health information technology interoperability:
1) Foundational: This is the most basic level of interoperability. In this tier, the health information systems are equipped to transmit and receive data, but the HIT system on the receiving end may not be decked up to interpret that information.
2) Structural: The middle level, structural interoperability defines how the data exchange will take place. Structural interoperability is all about how data should be presented in pre-described message standards. This tier is critical to interoperability as it allows a uniform movement of health information from one system to another, avoiding the alteration and promoting the security of data.
3) Semantic: Semantic interoperability is the third tier, and at the top of the communications pyramid. The highest level of interoperability, it provides the systems the ability to exchange data and make use of the information. The message is received in an encoded format and which is later normalized. This normalization of data pushes health IT systems to close in on the technology gaps and create a common platform for secure, uninterrupted machine-to-machine communication.
Scope of Interoperability
There has been a dramatic increase in population, and with that came the need to manage population health. The amount of information increased exponentially with the use of EMRs. They helped in storing the increasing information, but sharing was still doubtful.
In 2005, only about 30 percent of the entire group of office-based physicians and hospitals used basic EHRs which increased to 75 percent for hospitals by the end of 2011. The state of Indiana now connects more than 10 million patients across 80 hospitals, and about 18,000 physicians use this data.
How long until 100 percent interoperability?
It has been accepted that health care, as a single entity, faces challenges in the exchange of information. Even the pioneer EHR vendors admit that although they have some complex connections established, not all of them were successful. According to a report, less than half the providers were satisfied with the way their information exchange was taking place. Stakeholders involved have always been concerned that EHRs, even the ones for Meaningful Use 2, are unable to share data effectively.
In the latest ONC report, it was mentioned that if all the providers were to come down to a common consensus, there happen to be two barriers on the road to complete interoperability. One, discord on how data should be transmitted. Second, a lack of proper infrastructure which is equipped enough to transmit data nationwide. It is very critical that the technology being used is updated and standardized to ease the flow of patients’ vital information to avoid any probable mishap.
Persisting Problems in the Path of Interoperability
1) Inadequate Standards
More often than not even after collecting patients’ data, it cannot be passed on to the members of the healthcare community because of lack of the appropriate standards. Most of the times it happens that two systems trying to exchange data are using a different version of standards. This is because there are varying standards and numerous version for which providers aren’t equipped.
Rohan Kulkarni, vice president of healthcare strategy and portfolio at Conduent,speaks here about Conduent’s healthcare strategy and the company’s move to brand following its separation from Xerox. While doing so, he steps back to look briefly at aspects of healthcare technology’s past then pivots to its future and what he’s most excited about in the space and how he hopes to be part of it. Finally, he describes wheat he would pursue if he were healthcare’s king, and what that would look like and how he would change the sector for the best impact to the patient.
You’re the vice president of healthcare strategy and portfolio at Conduent. Can you explain what the role entails, and how you approach it?
The transformation in healthcare that is occurring is generational and provides for unprecedented opportunities. As the head of healthcare strategy, I am responsible for identifying those opportunities that are relevant to us and help strengthen our portfolio. I then design and develop a strategy in collaboration with our business leaders that will help meet our growth goals.
Tell me how Conduent plays in healthcare and how its solutions specifically impact the point of care.
Conduent has perhaps the broadest solutions portfolio in the healthcare services, allowing us to connect the entire healthcare ecosystem.
Conduent provides solutions that help our clients overcome industry obstacles, including inefficient processes, inaccessible data, regulatory mandates and challenging economics so they can focus on improving patient lives through better, affordable, accessible healthcare. Our solutions are all designed to help our clients manage the health of their patient populations so they can improve healthcare outcomes. We help make the transition to value-based care models a reality, and we work with healthcare professionals to design solutions that meet their specific needs.
Conduent is dedicated to the efficiency of claims accuracy, facilitating bill payments and risk assessments, communicating benefits, driving medication adherence, improving patient engagement and technology education, and delivering on quality and care data across medical systems. Our solutions are designed to reduce preventable readmission rates for defined population sets, control costs by executing proactive engagement and provide ongoing management for patients with chronic conditions.
Conduent just completed its separation from Xerox. What does that mean for your company and for your customers? Why the move and why the rebrand? Why not build on the power of the Xerox brand?
When reviewing the products and services offered across the business, we determined creating two independent, standalone entities – Xerox and Conduent – would give us the ability to create greater shareholder and customer value. The separation is based on a structural view of two of our businesses and with simpler, more focused organizations, we’ll be able to adapt to market demands and ensure we’re positioning the business to deliver tailored solutions based on our clients’ evolving needs.
How has healthcare IT transformed throughout your career? How has Conduent been involved in healthcare’s evolution?
I think most of the healthcare industry expected healthcare IT to be a driving force in improving how providers deliver solutions to their patients, but I don’t think we expected the rate of change to be so dramatic, especially over the last decade or so. We’ve seen vast improvements in how providers use health IT with the advent of electronic health records, mobile health technologies, telemedicine, wearables, analytics, etc., to improve communication with patients, personalize care and drive healthier outcomes. Since our introduction to the healthcare space, we’ve been helping businesses and governments better harness the influx of information to enable transformation. From the back office processes like billing and payments, to using Big Data to drive medication adherence, assessing risk and improving patient engagement, our solutions meet today’s challenges and prepare healthcare organizations to meet tomorrow’s needs.
What are you most concerned about in regard to healthcare’s future?
Healthcare economics continue to be single dimensional in that the focus is on the demand side, i.e., insurance. The Affordable Care Act (ACA), while it has streamlined the demand side, it has not addressed supply side, e.g., hospital charges, cost of medication etc. in any meaningful manner. As such, much of the debate in the public domain about healthcare is unlikely to make progress until both sides of the equation are discussed.
For years, major healthcare and patient safety organizations in both the public and private sectors have discussed how patient identification errors have led to medical emergencies and patient harm in hospitals around the globe. This situation has been mitigated to some degree by the use of barcode print and scan technology.
In this Q&A, David Crist, president of Brother Mobile Solutions, explains how today’s newer and more innovative mobile technology can empower physicians, nurses and technicians to improve patient identification procedures to reduce errors and improve the quality of patient care. Anton Ansalmar, founder and CEO of Rapid Healthcare describes how one application of advanced mobile technology at the actual point of care has successfully identified and prevented potential breast milk misfeed incidents in a U.S. hospital’s busy neonatal intensive care unit (NICU).
First, how do today’s mobile patient ID and verification solutions serve to reduce risk and enhance patient safety and regulatory compliance risk in hospitals and other clinical healthcare environments?
Crist: While most hospitals use barcode scanning and wristband printing systems for incoming patients, many are not leveraging mobile technology to its fullest potential. Today’s next-generation patient identification and authentication solutions use on-demand wristband and label printers help to ensure optimal accuracy and patient safety at all points of care. These wireless mobile systems enable caregivers to administer care whenever and wherever it is needed throughout the facility.
For example, nurses can take samples, infuse blood or administer medications and, at the same time, print out or verify the patient wristband and print a matching label for the samples, blood and medication bags. The matching wristband and labels contain legible human- and machine-readable data (barcode plus text). Following these patient identification validation and authentication procedures at the actual point of care—whether in the ER, operating suite, or at the bedside—not only saves time and improves efficiency, but also significantly reduces the risk of misidentification and human error. It also helps ensure the hospital’s compliance with EHR regulations and the five rights of patients: the right patient, right drug, right dose, right route, and right time.
What are some of the problems created by patient misidentification, and how pervasive are they in today’s healthcare system in which virtually every hospital and ambulatory care center uses patient ID wristbands upon admission?
David Crist
Crist: Even though patient ID wristbands are pretty much universal, at least in the U.S. and other medically advanced nations, incidents of misidentification are still more common than you’d think. For example, a 2016 article in Beckers Hospital Review cites an ECRI Institute report which states: “Failing to associate the right patient with the appropriate action, referred to as wrong-patient errors, is a prevalent occurrence with potentially fatal consequences.” The article notes that ECRI examined more than 7,600 wrong-patient events occurring from January 2013 to July 2015 and found that about nine percent of these had led to temporary or permanent harm or even death.
The study notes that more than half of the wrong-patient events involved either diagnostic procedures or medical treatments. Had these healthcare providers employed mobile patient ID and authentication procedures at the actual point of care, perhaps most of these wrong-patient incidents could have been avoided.
Anton Ansalmar
Ansalmar: Misidentification problems are global in scope as we learned in conducting market research for our Mother’s Milk mobile application for patient identification and authentication. We found numerous international reports of errors related to the misfeeding of bottled breast milk to premature and at-risk newborn infants. For example, in several Australian hospitals where the wrong bottle was given, the error was quickly discovered, but the infant’s stomach had to be pumped to prevent a potentially adverse reaction.
These kinds of incidents clearly show why patient identification and verification is so important. It is especially critical for premature infants and full-term babies born with conditions requiring intensive care, because their delicate systems can be harmed or compromised by being fed the wrong bottle of expressed mother’s breast milk.
What is the Mother’s Milk mobile application and why was it developed? Is the app being used by any hospital here in the U.S.?
