Guest post by Justin Sotomayor, pharmacy informatics director, CompleteRx.
Justin Sotomayor, PharmD
The field of health informatics has grown exponentially over the past 50 years. From Robert Ledley’s work paving the way for the use of electronic digital computers in biology and medicine in the 1950s, to the founding of the American Medical Informatics Association in the 1990s, to the launch of the Medicare/Medicaid Electronic Health Record Incentive Program in the 2000s, it continues to mark new milestones at an astounding pace, presenting both challenges and opportunities for the healthcare industry.
Three trends – in particular – will have a marked impact on patients and practitioners, and are certain to define health informatics in the near future, if not for years to come.
The end of Meaningful Use
In 2009, with the passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act, came the launch of the Meaningful Use program – and the related requirement that healthcare providers show “meaningful use” of a certified EHR to qualify for incentive payments. With both Stage 1 (adoption) and Stage 2 (coordination of care and exchange of information) behind them, hospitals are fully responsible for Stage 3 (improved outcomes) by 2018. While, undoubtedly, the program has improved EHR adoption – in many cases, streamlining and enhancing patient care – it has been widely criticized. In a 2015 news release, the American Medical Association regarded Stage 2 as a “widespread failure,” suggesting it monopolized staff attention without commensurate benefit to patients, and hampered innovation.
Most recently, following highly-publicized remarks in January by CMS Acting Administrator Andy Slavitt that Meaningful Use would be replaced, the U.S. Department of Health and Human Services has proposed transitioning Meaningful Use for Medicare physicians to the “Advancing Care Information (ACI)” program under the Medicare Access and CHIP Reauthorization Act (MACRA). According to Mr. Slavitt, this program is designed to be “far simpler, less burdensome, and more flexible,” primarily by loosening the requirements to qualify for extra payments, and incentivizing providers based on treatment merit, known as Merit-based Incentive Payment System (MIPS). While this update doesn’t yet affect hospitals or Medicaid providers, and these groups should continue to prepare for full Meaningful Use implementation, it’s an indication that industry concerns over meaningful use are being heard and responded to, and that additional changes may be forthcoming.
To the average person, holography is the stuff of science fiction. Many people were first exposed to the concept of practical holography in the original “Star Wars” film, released in 1977. Although the apparent 3D images represented in the film were of relatively low resolution, the possibilities were undeniably intriguing — and undoubtedly inspirational to a generation of budding scientists. Subsequent portrayals of the inherent possibilities of this technology were explored on television series, such as “Star Trek: The Next Generation,” in the late 1980s and early 1990s.
Holography: From Science Fiction to Scientific Fact
In that imagined world, holography was vastly superior to the grainy, static-filled images portrayed in “Star Wars.” Entire interactive worlds were recreated in a special space. The unimaginably advanced technology was primarily used for recreation. This fictional technology more closely resembled the 3D interactive “worlds” promised by various recently introduced virtual reality (VR) systems. Although actual VR technology is arguably in its infancy, and interactive content is still largely lacking, these systems come closest to reproducing the experience of entering a “holodeck,” where fully realized, interactive, imagined worlds can be explored at will.
A Brief History
Of course, none of these imagined uses of holographic technology reflect present, real-world applications. That’s not to say holography doesn’t exist. It does, and has done since before the time of the original “Star Trek” series, which debuted in 1966. Although that seminal science fiction series made no mention of holography, the technology already existed in the real world, having begun conceptual development as early as the 1940s. In 1971, a Hungarian-British physicist was awarded the Nobel Prize in Physics for his invention of the holographic method. His success with optical holography was only made possible by the invention of the laser, in 1960.
In essence, a hologram is a photographic recording of a light field. The recording is subsequently projected to create a faithful 3D representation of the holographed subject. Technically speaking, it involves the encoding of a light field as an interference pattern. The pattern diffracts light to create a reproduction of the original light field. Any objects present in that original light field appear to be present, viewable from any angle.
Depth cures — such as parallax and perspective — are retained, changing as expected, depending on the viewpoint of the observer. Holograms have been compared to sound recordings. When a musician performs, the vibrations he produces are encoded, recorded, stored and later reproduced to evoke the original vibrations a listener would have experienced.
Of course, other forms of practical holography have been in common usage for decades. The so-called embossed hologram, which appears on many credit cards and even paper checks, was widely introduced in the mid-1980s. National Geographic magazine, which featured an image of a holographic eagle on its cover in 1984, marks the event among its most notable milestones.
The 2D embossed hologram image retains some of the characteristics of a traditional hologram, in that the image changes somewhat depending on one’s angle of view. It’s primarily used as a security measure, or as a marketing novelty (these mass-produced holograms have even appeared on boxes of children’s cereal). However, these illusions are not true holograms. While the National Geographic eagle was impressive, one could not simply examine the animal from any conceivable angle.
The proposal of the Centers for Medicare & Medicaid Services (CMS) to expand its Recovery Audit Program to Medicare Part C or Medicare Advantage (MA) plans is a new step in its efforts to fight fraud, waste and abuse in the Medicare program. The move is aimed at identifying overpayments and underpayments made on claims for services provided to Medicare beneficiaries. For physicians’ practices, the expanded recovery audit program would mean that they will have to take proactive steps to reduce their risks of falling prey to recovery audits by pay ensuring error-free submission of the claims of MA patients. Outsourcing medical billing and coding is a great option to accomplish this task.
Medicare Advantage (MA) Plans and Allegations of Billing Fraud
MA plans or Medicare Part C are offered by private insurance companies approved by Medicare, which receive payment from Medicare for the coverage provided. There are different types of MA plans which provide all of a Medicare patient’s Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Part C plans are different from standard Medicare in that they are paid a set fee every month for each patient based on a complex formula called a risk score. CMS pays higher rates for sicker MA beneficiaries than for those in good health. CMS scrutinizes the diagnosis information reported by MA organizations and calculates risk scores for each enrollee using the Hierarchical Condition Category risk adjustment model. The risk score is calculated based on the enrollee’s demographic characteristics and health conditions. This practice aims to improve the accuracy of Medicare’s payments to MA organizations and reduces the incentives for plans to select only the healthiest beneficiaries.
Identifying Improper Medicare Payments with Recovery Audits
However, in recent years, there have been various reports of overbilling MA plans, costing taxpayers billions of dollars more than warranted. In Jan. 1, 2010, the government set up the Recovery Audit Program to fight fraud, waste and abuse in the Medicare program. It detects overpayments and underpayments for Medicare claims so that CMS can implement actions to prevent improper payments in all 50 states. Under the program, Recovery Audit Contractors (RACs) — private companies hired by CMS — have the authority to review medical records at short notice. RACs notify health care providers of the outcomes of the reviews via demand letters. An RAC demand letter would contain details of the problem with a claim, such as the coverage, coding or payment policy that was violated, a description of the overpayment made, recommended corrective actions, and explanations on the provider’s right to submit a rebuttal statement prior to recoupment of any overpayment and appeal and more.
Guest post by Ken Perez, vice president of healthcare policy, Omnicell.
Ken Perez
At two recent healthcare conferences run primarily for provider organizations, speakers spent a considerable amount of time highlighting the sharply increased U.S. spending on prescription drugs in 2014 (+12.5 percent versus 2013) and 2015 (+7.8 percent versus 2014)—about double overall healthcare cost inflation for those two years. In 2015, prescription drugs accounted for one-sixth of all the money spent on personal healthcare services. While drug spending growth is expected to moderate in the coming years, the attendees at the conferences were left with the lingering impression that pharmaceutical companies may have gotten away with inappropriate levels of profiteering in recent years.
Of course, that impression was made—and some would say cemented—last year when Martin Shkreli, former CEO of Turing Pharmaceuticals, famously hiked the price of Daraprim, a 62-year-old treatment for parasitic infections, by 5,455 percent overnight from $13.50 a tablet to $750. Similarly, Michael Pearson, outgoing CEO of Valeant Pharmaceuticals, raised by 1,800 percent the prices of two drugs used to treat cancer-related skin conditions: Targretin gel, a topical treatment for cutaneous T-cell lymphoma, and Carac cream, used to treat precancerous skin lesions called actinic keratosis. A 2012 report by Ipsos Public Affairs concluded that the U.S. pharmaceutical sector had a “net negative” favorability score with consumers, and the much-publicized actions of Shkreli and Pearson three years later obviously did not improve the public’s view of pharma.
As expected, the aforementioned price hikes by Turing and Valeant were denounced by numerous presidential candidates, and drug prices became a popular political football. Both former Secretary of State Hillary Clinton and Vermont Senator Bernie Sanders have made lowering prescription drug costs significant planks of their respective policy platforms. They both advocate allowing Medicare to negotiate drug prices with pharmaceutical companies. Sanders goes even further—to the brink of outright drug price controls—pledging to require pharmaceutical companies to publicly disclose information regarding drug pricing and research and development costs—with the obvious implication that there should be some reasonable relationship between the two.
While no one can deny that electronic technology has made giant leaps towards protecting patient information and preventing errors and misuse, you may be surprised to learn that many health care practitioners and facilities are still cutting corners when it comes to medical translations or interpretation.
Inaccurate medical interpreting, or translations carried out incorrectly have the potential to put patients’ lives at risk, and there have been several cases of medical mistranslations documented that have led to severe complications, incorrect diagnosis, and even death.
Check out the following cases that could have had different outcomes had the correctly trained language professionals been used:
Willie Ramirez
In 1980, a young baseball player called Willie Ramirez was taken to a hospital in South Florida, in a comatose state. A medical interpreter was called in to translate the family’s explanation of events; however, the interpreter was not familiar with the Cuban Spanish word “intoxicado,” which was translated as intoxicated, and the doctors assumed that Mr. Ramirez had taken a drug overdose.
This is one of the most famous cases in history of inaccuracy in medical interpretation, as what seems like a fairly small error led to the young baseball player waking up as a quadriplegic. How? Well, in Cuban Spanish, the word “intoxicado” means to be sick after ingesting something, which could be a food, drug, liquid, or anything else that could cause a person to be unwell.
When Ramirez’s doctors dismissed his case as an overdose, they failed to consider other possibilities and overlooked the fact that the patient was actually experiencing bleeding in the brain. By the time the mistake was detected and the proper course of treatment initiated, it was too late. The damage had been done and no amount of neurosurgery could reverse Ramirez’s quadriplegia.
Maria Guevara
If ever there were a more heart-wrenching tale than that of Ms. Guevara’s, it would be hard to imagine, and this tragic example of a medical facility’s negligence has been hotly disputed over the last couple of years. Because of the absence of a medical interpreter, Ms. Guevara was accidentally given a prescription to induce abortion after apparently replying “yes”, to a question she did not understand.
While the doctor was asking her if she wanted to abort the baby, Maria thought the question was whether she wanted to keep the baby, and with no professional medical interpreter to translate between herself and the doctor, the outcome was losing the baby in a Californian hospital where almost half of all patients are Spanish speakers with English as their second language.
Occurring in 2013, the case of Guevara has forced the medical profession to come to terms with the real risk involved in inaccurate or total absence of professional linguists on hand to avoid liable and save lives; especially with the Hispanic population set to outnumber white Caucasians by 2060.
Guest post by Nora Lissy, RN, BSN, MBA, director of healthcare information, Dimensional Insight.
Nora Lissy
A recent report from Research and Markets predicts that the healthcare data analytics sector will grow to more than $34.27 billion by the end of 2022. This is indicative of how hospitals and health systems are realizing the intrinsic value in an analytics capability—which can be leveraged for everything from capturing information to interpreting the data—to make more informed care decisions. From a provider standpoint however, many physicians are still struggling to close the gap between turning data insights into actionable care improvements. For example, looking at a data set of former pharmaceutical plans for patients with asthma and using the information to make a more informed prescribing decisions for a current patient.
So what can healthcare organizations do to help bridge the divide between the clinical staff and the IT department to make it easier for doctors and clinicians to see how analytics can be applied in their day-to-day care routine? To start, they need to identify which members of their clinical staff have a “data mind” and can easily see how data can be turned into care improvement. For example, looking at an analysis of a hospital’s patient care transitions and adjusting patient handoffs to be more streamlined across departments. A person in this role can communicate to both the clinical and IT sides of the house why data needs to be presented in a certain way and where care adjustments and enhancements can be made.
So how can you find this diamond in the rough who has the ability to turn providers’ “Medical Minds” into “Data Docs” of tomorrow? Here are three tips to help determine who the best person at your organization would be to help fill these shoes:
Who is your organization’s “go-to?”
Who is the one person in your organization/department who everyone goes to with questions? It can be anything from a question about a schedule change or process to a new patient’s medication history. In many cases, this doesn’t even need to be someone from the clinical side or from the IT side. It simply should be someone who has a global view of the organization and who is familiar with the clinical side and has an understanding of what needs to happen on the technical side.
Who has good business intuition?
Someone who has a natural knack in the business world also typically has a data-oriented mindset. This is someone who is not afraid to question the reasoning behind certain recommendations and processes. This is not to say that this individual is counterproductive, but instead is the problem solver. Much like the organization’s go-to contact, this person also sees the full organizational picture rather than just through the lens of the department that they work for and are instilled with ability to translate the business and operational needs into the technical needs.
Guest post by Dr. Deborah A. Jeffries, director of sales, Revolve Robotics.
Dr. Deb Jeffries
There are exciting developments with telehealth reimbursement thanks to the progress in moving towards Patient Centered Care, and a focus on Prevention and Wellness. Early in 2016 we saw the introduction of Senate bill 2484 and with it a proposed path to remove many of the obstacles to providing access to patient centered care and telehealth. Now we are seeing the Comprehensive Primary Care Plus model take shape that further supports telehealth adoption and reimbursements. Imagine a connected care team, in collaboration with patient and family members, the relevant data is available as needed, and an empowered healthcare provider who is able to ‘do the right thing’ with respect to each patient.
Wouldn’t it be great if care was accessible independent of the patient’s or doctor’s location, whether they are rural or urban, whether they are in their home or in a clinic? Well, Senate bill 2484 may do just that. It is looking at removing obstacles to delivering telehealth services and opening the door to the delivery of care where and when it is needed.
Additionally, wouldn’t it be great if the primary care practitioner were free to utilize the right delivery of care at the right time?
To date it has been difficult to find a model that empowers the primary care provider and provides the freedom to do what they know is best for their patients including telehealth as appropriate. This year, a change is kicking off that may go a long way toward enabling the primary care practitioner. It comes in the form of the recent announcement from CMS in an interview with Joyce Freidon from Medpage Today published in article on 4-11-16: “The 5-year initiative, known as the Comprehensive Primary Care Plus model, will give doctors the freedom and flexibility to practice medicine the best way they know how, to return to what matters most to doctors and their patients,” said Patrick Conway, MD, CMS chief medical officer, on a phone call with reporters.
And Dr. Conway states “If telehealth makes sense, they can do that.” As the program kicks off this summer and goes into action January 2017, look for more details to unfold.
The article further quotes Dr. Patrick Conway:
“Doctors will be given more freedom to design the type and amount of care that best meets the needs of their patients,” said Conway. “If telehealth makes sense, they can do that … This initiative will also make it easier for doctors to communicate with each other and have all the information they need … to get better support from nurses, specialists, and others on the patient’s care team.”
Guest post by Emily Tyson, director of emerging markets, Curaspan.
Emily Tyson
On the cusp of many important changes currently impacting major healthcare policies, Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), made a striking statement to the audience at the J.P. Morgan Health Care Conference earlier this year: “The meaningful use program as it has existed will now be effectively over and replaced with something better.” This remark created a stir within the healthcare community, which has long lamented the burdensome documentation and lackluster results most often associated with the Meaningful Use (MU) program, and left many providers and healthcare organizations wondering what that really meant for the future of reimbursement, along with healthcare technology and EHR regulation.
What do we know today?
Slavitt’s comments reference a transition – not a replacement – to a new payment program. The government is making a concerted effort to lessen the burden associated with its programs and push the industry toward value-based care. Last year Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). The Act made three notable, high impact changes to Medicare reimbursement:
It ended the Sustainable Growth Rate (SGR) formula for physician reimbursement;
It created a new framework to compensate healthcare providers for better, higher quality care (rather than higher volumes of services); and
It streamlined the process by combining existing quality reporting programs into one new system.
With the recent release of the proposed MACRA ruling, the Act and associated rules may take effect on January 1, 2017 and will offer healthcare providers two options for participating in quality programs: (1) Fee-for-service (FFS) combined with greater incentives through a new Merit-Based Incentive Payment System (MIPS), or (2) Alternative Payment Models (APMs). The current payment adjustments associated with the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and MU will be phased out and replaced with a consolidated approach. MIPS will provide payment adjustments based on four weighted performance categories: Quality (30 percent), Resource Use (30 percent), Meaningful Use of Certified EHR Technology (25 percent), and Clinical Practice Improvement Activities (15 percent). APMs include reimbursement models, such as ACOs, patient centered medical homes, and bundled payments.
