There is an industry-wide surge in providers, payers and post-acute care providers whose needs for transitions-in-care are unmet by their current healthcare IT capabilities. As such, 2016 will likely be the year that referral management comes to the forefront for all stakeholders in the healthcare system.
The moment of referral is an opportune time to engage with patients: with the increase in high-deductible plans and out-of-pocket expenses, patients are extremely motivated to seek care from high-quality, cost-effective, in-network providers. Providing patients with the resources they need, while enabling providers to align their efforts, is a mission-critical need in healthcare today.
There are a few key factors driving improvements in referral management for providers, payers, and post-acute care providers alike:
For providers
With the move to fee-for-value reimbursement, we are seeing a rise in the number of physicians moving to independent physician associations, ACOs, and clinically integrated networks. This is happening for two reasons: first, to negotiate more effectively with payers and second, to equip themselves to take on risk in the future. In order to take on risk effectively, healthcare organizations will need to ensure that patients stay within their systems. In addition, these groups of physicians often have multiple EMRs and are looking for solutions to expand them. Therefore, we have seen an increase in all kinds of provider groups looking for intelligent decision support that guide referrals in a systematic and strategic fashion.
For payers
With the increase in high deductible, narrow network plans, there is a greater need to direct patients to high-quality, low-cost providers. Payers, in partnership with providers, are looking for the ability to navigate patients in this way. Given the cost of specialist visits, payers are also particularly interested in making sure patients get to the most appropriate specialist to receive the care they need.
For example, Carefirst BCBS has pioneered a program, through their PCMH plan, to provide information on specialist costs and quality to inform referrals. They see this as a way to improve quality while, over time, bending the cost curve. This could be the beginning of a broader trend among payers, to acknowledge the importance of referrals and encourage the use of tools designed to implement insightful decision support and a standardized process around transitions-of-care.
For post-acute care providers
As providers have consolidated, so has the post-acute care space. Readmission penalties and bundled payments have further put pressure on post-acute care to ensure a seamless transition from acute care to – and within – different post-acute services.
Patient-centricity , patient centered thinking, and the rise of the “p-suite” in pharma companies continued a trend established over a year ago when Sanofi broke new ground by hiring Dr. Anne Beal, former deputy executive director of the Patient Centered Outcomes Research Institute (PCORI), to the newly created role of chief patient officer. Her new responsibilities included elevating the perspective of the patient within Sanofi and finding better ways to incorporate the unique priorities and needs of patients and caregivers.
Yet as life sciences companies continue the pursuit of a 360-degree view of “customers” typically classified as healthcare professionals (HCPs), a view of patients has been even harder to come by. Partly because of HIPAA and privacy requirements, but also because, unlike healthcare providers and payers who have regular contact with patients, life sciences companies engage primarily at the level of clinical trials and consumer marketing.
Better understanding of the patient is top priority in life sciences for 2016, and executives will continue to push cultural change facilitation, enhanced cross-functional collaboration, and increased employee engagement. But what would a life sciences company consider to be a key patient engagement metric and a measure of ROI?
With data about patients spread across a significant number of sources, including internal, external and social, merely identifying and collating that data can be a challenge – let alone deriving insights that can support patient-centric strategies and programs. Technology exists today to turn patient data into actionable insights for better R&D and commercial efficiency, as well as to deliver better services to the patient. In order to rapidly analyze data and target audience needs with products and services, life sciences will need to close the loop by tracking and monitoring the effectiveness of their offerings. In other words, they have to be both patient-centric and data-driven.
Healthcare Providers and Payers Will Take Data-driven to the Next Level
Healthcare providers and payers have approved access to member and patient data, as compared to life sciences companies, so are able to develop a new breed of data-driven solutions built to serve individuals, employers, providers, brokers and more. These tools, products and services bring value to every stakeholder, and ultimately benefit the patients themselves in the form of better care, lower premiums and improved efficacy.
However, being able to do so requires a significant step up in data management capabilities. Today’s modern data management platforms are not just cloud-based, but include a reliable data foundation that in generations past, used to cost IT teams millions of dollars in hardware, software and implementation resources alone to produce.
Guest post by Joseph Schorr, director of advanced security solutions, Bomgar.
Moving into 2016, healthcare organizations will continue to be one of the most attractive targets for hackers. Last year, attacks against healthcare organizations were up 125 percent from 2010 and cost the industry $6 billion, according to the Ponemon Institute.
As illustrated in the Anthem and Excellus Blue Cross Blue Shield data breaches, hackers are moving beyond phishing attacks and random malware drops, and adopting methods that are more sophisticated. By leveraging third-party access and privileged account credentials (such as those held by IT security professionals, IT managers and database administrators) to exploit IT systems, hackers can gain an unrestricted and unmonitored attack foothold on the network. Once they have this foothold, they are remaining inside the victim’s environment for an incredible span of time – on average more than 200 days.
With this trend continuing, healthcare organizations can expect to see an uptick in these types of attacks within the industry. To combat this rise, healthcare organizations will need to focus on shoring up IT security around vendors and other third parties in the year ahead. The following are areas where they can concentrate attention to aid in this effort:
Reevaluate the legacy
In particular, third parties such as vendors are particularly juicy targets because they often use VPN and other legacy access methods to access systems. Examining and implementing more secure, sophisticated remote access and privileged access solutions is a good place to start strengthening IT security for the new year.
It’s a common misconception that a VPN guide is a secure way to provide third-party vendors with network access. The problem lies in that an organization cannot ensure that third-party vendors’ security policies and practices are as strenuous as internal practices. If a criminal compromises a valid VPN connection, they have an open tunnel to an organization’s network and the sensitive data within.
Be in control
For too many healthcare organizations, vendors have more access than they need or their access can’t be monitored or restricted. It’s a scary question: Does your IT department know who their privileged users are and what level of IT permissions they have? If not, taking stock of those users, the systems to which they need access, and when they must access them is a critical undertaking for 2016. Following that, the organization can set access parameters that allow those privileged users to be productive and gain access to tools, data and systems they need to do their jobs, while limiting risk. Proactively controlling and monitoring access to critical systems can help tighten IT security within healthcare organizations.
Guest post by Scott Jordan, co-founder and chief innovation officer, Central Logic
Scott Jordan
Gone are the days when IT department gurus ran lengthy reports, sifting through numbers and analyzing data until the wee hours of the morning, all in the quest of fancy profit center reports to impress the C-Suite. Especially in hospital settings where lives are on the line, data in 2016 must be delivered in real time, and even more importantly, must be relevant, connected, and able to be understood, interpreted and acted upon immediately by a myriad of users.
Data That’s Right
Today, having the right data intelligence that is actionable is paramount. It’s no longer enough for analytics to only interpret information from the past to make the right predictions and decisions. With the changing healthcare landscape, it’s increasingly important that data intelligence must also be relevant and the tools agile enough to provide an accurate assessment of current events and reliably point to process and behavior changes for improved outcomes … in real time.
All tall order for any IT solution, much less one in healthcare where robust security parameters, patient satisfaction concerns and HIPAA regulations are just the tip of the iceberg a health system must consider.
Data That’s Connected
The good news is data technology tools now exist that offer interoperability features – from inside and outside a hospital’s four walls – this allows providers to exchange and process electronic health information easily, quickly, intuitively and accurately, with reliably replicable solutions.
When users can see the full complement of a patient’s health record, they can more accurately improve care coordination and save lives. Specifically, connected patient records can:
avoid duplication of diagnostic procedures,
properly evaluate test results and treatment outcomes, regardless of where care was delivered,
share basic patient data during referrals and get information after specialist visits,
view medications, regardless of where prescribed, avoiding drug interactions, medication abuse, etc., and
view allergy and pre-existing condition information, especially valuable to Emergency Department transfers.
Guest post by LeRoy E. Jones, chief executive officer, GSI Health, LLC.
The health IT revolution is here and 2016 will be the year that actionable data brings it full circle.
Opportunities to achieve meaningful use with electronic health records (EHRs) are available and many healthcare organizations have already realized elevated care coordination with healthcare IT. However, improved care coordination is only a small piece of HIT’s full potential to produce a higher level synthesis of information that delivers actionable data to clinicians. As the healthcare industry transitions to a value-based model in which organizations are compensated not for services performed but for keeping patients and populations well, achieving a higher level of operational efficiency is what patient care requires and what executives expect to receive from their EHR investment. This approach emphasizes outcomes and value rather than procedures and fees, incentivizing providers to improve efficiency by better managing their populations. Garnering actionable insights for frontline clinicians through an evolved EHR framework is the unified responsibility of EHR providers, IT professionals and care coordination managers – and a task that will monopolize HIT in 2016.
The data void in historical EHR concepts
Traditionally, care has been based on the “inside the four walls” EHR, which means insights are derived from limited data, and next steps are determined by what the patient’s problem is today or what they choose to communicate to their caregiver. If outside information is available from clinical and claims data, it is sparse and often inaccessible to the caregiver. This presents an unavoidable need to make clinical information actionable by readily transforming operational and care data that’s housed in care management tools into usable insights for care delivery and improvement. Likewise, when care management tools are armed with indicators of care gaps, they can do a better job at highlighting those patients during the care process, and feeding care activities to analytics appropriately tagged with metadata or other enhanced information to enrich further analysis.
Filling the gaps to achieve actionable data
To deliver actionable data in a clinical context, HIT platform advancements must integrate and analyze data from across the community—including medical, behavioral, and social information—to provide the big picture of patient and population health. Further, the operational information about moving a patient through the care process (e.g., outreach, education, arranging a ride, etc.) is vital to tuning care delivery as a holistic system rather than just optimizing the points of care alone. This innovative approach consolidates diverse and fragmented data in a single comprehensive care plan, with meaningful insights that empowers the full spectrum of care, from clinical providers (e.g., physicians, nurses, behavioral health professionals, staff) to non-clinical providers (e.g., care managers, case managers, social workers), to patients and their caregivers. Armed with granular patient and population insights that span the continuum, care teams are able to proactively address gaps in patient care, allocate scarce resources, and strategically identify at-risk patients in time for cost-effective interventions. This transition also requires altering the way underlying data concepts are represented by elevating EHR infrastructures and technical standards to accommodate a high-level synthesis of information.
Guest post by Susan Kanvik, healthcare senior director, Point B.
Susan Kanvik
The goals of data governance have long been clear outside of the healthcare industry. Organizations want to enable better decision-making, reduce operational friction, protect the needs of data stakeholders, train management and staff to adopt common approaches to data issues, build standard, repeatable processes, reduce costs and increase effectiveness through coordination of efforts and ensure transparency of processes.
That’s a tall order. And one that’s coming to healthcare this year for several reasons:
Data regulatory mandates will increase the need for data transparency. For example, the requirement for distribution of clinical studies data for public consumption requires pharma and biotech companies to publish clinical study information publicly. This public exposure shines a light on the data, requiring it to be accurate and with consistent definitions.
As patients move toward becoming data consumers, the need for accurate data with consistent definitions becomes even more important. Higher deductible coverage is driving patients to research and buy healthcare services based on published data regarding a healthcare organization’s cost and quality. Additionally, patients are managing their health correspondence via patient portals which, again, requires absolute precision with data accuracy and definition.
The migration to enterprise data solutions and less clear ownership of data is becoming commonplace. While many healthcare organizations were well on their way to implementing enterprise EHRs, moving away from siloed applications, the health IT incentives included in the Patient Protection and Affordable Care Act (PPACA) have pushed a much higher number of healthcare organizations to enterprise solutions. With an enterprise EHR clinical solution, where data is less siloed, data “ownership” is less clear. In the not so distant past, individual departments would manage their own data. The move toward the adoption of enterprise systems requires enterprise level governance, which will increase in importance during the coming year and beyond.
Reporting requirements in healthcare have increased in scope and complexity. Having a data dictionary, a common data governance tool, facilitates common definitions, which is critical in supporting reporting requirements.
Sharing of data across healthcare organizations heightens the need for increased IT security. As healthcare organizations have grown through acquisitions and partnerships, many are finding it hard to share data within their organizations due to a lack of interoperability across different EHRs. This creates a challenge to share data beyond their organization, and healthcare organizations will need to carefully manage both how data is shared and the increased security risks that come with that sharing. Sharing of data and address the increased security risks that accompany it.
Three major trends are driving change in healthcare, and all three will also drive IT demand. First is the movement toward managing population health in various forms. Taking on this financial and clinical risk will require processing and making decisions based on the demographic, clinical and financial data that have been filling warehouses everywhere.
Secondly there is the rise of consumerism. Individuals faced with rising out-of-pocket expenses are doing more self-directed research on their health and doing more comparison-shopping. Providers will continue to respond with medical malls, clinics aligned with retail pharmacies, telemedicine and other innovations to control costs and still deliver care.
Even though more Americans than ever are insured, high-deductible plans can affect providers’ debt and charity care. Patient-friendly point-of-service collections and finance plans will require IT investment, as will more efficient collections processes.
The third trend – the move by government and private payers toward value-based reimbursement – will continue to affect the industry in 2016 and beyond. Even though fee-for-service is still the dominant reimbursement model, the U.S. Department of Health & Human Service’s January 2015 announcement that Medicare would be “tying 50 percent of payments to these {value-based} models by the end of 2018” has seen providers taking a hard look at quality and cost of care.
While payment will increasingly be determined by quality of outcomes rather than quantity of services billed, quality and cost – the components of value – aren’t connected in a straight line. They are affected by every department in a provider system, and no system can manage what it can’t measure. If that data can be accurately collected and analyzed, it can inform decision makers not only on how successful they are at delivering quality care, but also whether the cost of delivery exceeds their reimbursement.
Looking back at 2015, we see significant trends impacting inpatient telemedicine that will gain strength through 2016. Here are the Top Five: How they impacted healthcare, and how they will change hospital medicine moving forward.
More Legislation and Regulation Activity
A recent report from the National Conference of State Legislatures showed there were 200 telemedicine bills introduced in all but eight states in 2015. The federal government also introduced the TELEMedicine for MEDicare Act of 2015 and the Veteran’s E-Health and Telemedicine Support Act of 2015, which are aimed at creating an interstate license for those practicing telemedicine for these patient populations. Last year, 32 states and the District of Columbia enacted telemedicine parity laws, requiring health plans to reimburse telemedicine the same way—and at the same cost—as in-person service. We expect to see more of this activity as telemedicine becomes an increasingly integral part of healthcare in America.
Easier Licensure Across States
Currently, if you have a group of physicians caring for patients in hospitals in four or five states, they must become licensed in each of those states. As noted above, recent legislation (along with new telehealth licensing compacts between states) will make it easier for physicians to get a license across state lines. This will clearly help facilitate the use of telemedicine services
Growing Financial Support
Today, the payer response can best be described as a patchwork. Medicare typically doesn’t reimburse for inpatient telemedicine (except in rural areas as Medicaid), and the commercial payers tend to vary from state to state. There isn’t a uniform basis for reimbursements. Many hospitals end up financing most of the costs of inpatient physician services delivered with telemedicine?and we all know healthcare dollars are tight for everybody. However, the physician reimbursement is moving, albeit slowly. The state parity laws will help. So, too, will having more commercial payers recognize the value of telemedicine services. For example, UnitedHealth Group announced plans to expand coverage for virtual physician visits to employer-sponsored and individual plan participants, increasing those covered from approximately 1 million to well more than 20 million. Better reimbursement structures will help fortify hospitals’ financial underpinnings and alleviate some of the burden they’ve been forced to bear.
The health IT revolution is here and 2016 will be the year that actionable data brings it full circle.
