Category: Editorial

The Outlook for ACA Healthcare Delivery Reforms

Guest post by Ken Perez, vice president of healthcare policy, Omnicell, Inc.

Ken Perez
Ken Perez

The Patient Protection and Affordable Care Act (ACA) mandated five major healthcare delivery reforms that collectively aim to improve care quality and slow the growth of healthcare spending. In the five years since passage of the ACA, each of these delivery reforms has been implemented, revised and broadened.

What is the outlook for these changes? Clearly, the long-term strategic intent of the Obama administration is to shift Medicare payments from fee for service to fee for value. On Jan. 26, 2015, Health and Human Services Secretary Sylvia Burwell set forth quantified goals and an aggressive timeline for directing an increasing share of Medicare payments through alternative payment models (APMs) such as accountable care organizations (ACOs) and bundled payments, from 20 percent in 2014 to 50 percent in 2018. Let’s consider each of the major healthcare delivery reforms.

Accountable Care Organizations

On January 11, the Centers for Medicare & Medicaid Services (CMS) announced that 477 organizations are participating in one of Medicare’s four accountable care programs.

With 434 current participants, the Medicare Shared Savings Program (MSSP) accounts for the vast majority (91 percent) of the total. Although the total number of MSSP ACOs has grown steadily each year since the program’s inception in 2012, cumulatively about 100 ACOs (19 percent) have dropped out of the program.

Medicare’s first ACO program, the higher-risk, higher-reward Pioneer ACO Model, suffered numerous departures during the second half of 2015, as the number of Pioneers has dropped from 32 original participants announced in December 2011 to a current total of nine, a 72 percent decline. However, some of the departing Pioneers have transferred to the MSSP or the even higher-risk, higher-reward Next Generation ACO Model, which was launched in March 2015.

CMS also disclosed that 21 organizations are participating in the Next Generation ACO Model, including five former Pioneers. The remaining 13 of the 477 ACOs are the initial participants in the first disease-specific Medicare ACO program, the Comprehensive ESRD Care Model, which was announced in October 2015.

Despite these seemingly impressive numbers, to achieve the aforementioned goal of flowing half of Medicare payments through APMs by 2018, CMS needs even more growth in the number of Medicare ACOs coming onboard in the next couple of years, perhaps 150-200 net new ACOs per year in 2017 and 2018.

Bundled Payments

In 2013, CMS launched the Bundled Payments for Care Improvement Initiative (BPCI), a voluntary program which offers providers four episode-based payment models. In three of the models, implementation is divided into two phases. During Phase 1, “the preparation period,” CMS shares data and helps the participating providers learn in preparation for Phase 2, “risk-bearing implementation,” in which the providers begin bearing financial risk with CMS for some or all of their episodes. CMS required all participants to transition at least one episode (e.g., Acute Myocardial Infarction) into Phase 2 by July 1, 2015, to continue participating in the BPCI.

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6 Healthcare Predictions for 2016

Guest post by Torben Nielsen, senior vice president product and strategy, HealthSparq.

Torben Nielsen
Torben Nielsen

The past few years have seen record investments in digital health. More than $12 billion have been poured into digital health companies in 2014 and 2015 alone, according to Rock Health, and there’s no indication of any slowing in 2016.  Here are my predictions for what’s in store for health care in the New Year:

#1: Fragmented and disparate data sets turning into relevant and comprehensive information sets

Healthcare data sources have been siloed and fragmented for years. Data in electronic health records (EHRs) have worked within the hospital setting (to some degree), but not across systems, or for the consumer. Patient portals have attempted to bring data together, but with limited adoption due to sporadic data, old interfaces and no clear use model. With new data standards, APIs, and open source developments, data will become more fluid and accessible. We will finally start to see data portability and data integration in ways not witnessed before. This will be to the benefit of the consumer, who will be able to share and embed data from different sources into their preferred view. This will ultimately create a more relevant and engaged experience for the healthcare consumer.

#2 Continuous and team-based care on the rise

Along with a deeper and more portable experience of one’s own healthcare information (both from the healthcare system and via patient-driven data) comes a more continuous and streamlined patient-doctor experience. Interaction between the patient and the system will happen via Wi-Fi enabled technology and smart devices allowing for a continuous stream of data and information. This will benefit the doctor, who will be able to interact and react much faster. It will also do away with the “information black-outs” that often occurs between the time a patient visits their physician, all the way until their next scheduled visit. The patient will also be able to better track their condition. Furthermore, much of this information can be shared with the patient’s broader care team such as significant others, children, specialists, etc. This will ultimately benefit the care provider, the patient and the overall system.

#3 Millennials will be the catalysts for the healthcare consumer revolution

One of the most over-used buzzwords in the healthcare industry today is “consumer/patient engagement.” Everyone seems to have a solution for driving up engagement for the masses. However, it’s a fallacy to believe that anyone or everyone will engage in a particular system, process or technology. As is the case with most products, an early-adopter segment needs to be identified to successfully scale and ramp up sales. For healthcare, millennials will be a great catalyst for change and the movement towards consumerism. This generation has grown up with Uber, Amazon, Instagram and Facetime. They will demand a much more efficient and technology driven healthcare experience. They will push for a seamless and personalized experience, and their voice will become stronger and stronger over the years as they start consuming healthcare to a greater extent.

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Health IT’s Responsibility to Produce Actionable Data in 2016

Guest post by LeRoy E. Jones, CEO, GSI Health, LLC.

LeRoy Jones
LeRoy Jones

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.

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Healthcare IT: The One Trend to Rule Them All

Guest post by Paddy Padmanabhan, CEO, Damo Consulting.

Paddy Padmanabhan
Paddy Padmanabhan

After years of underinvestment, CIO’s in healthcare may have something to cheer about this year. The biggest trend seems to be the increased focus and investment in IT in healthcare enterprises. With more than $30 billion invested in electronic health record (EHR) systems, and meaningful use (MU) requirements out of the way, we are seeing enterprises turn toward the more strategic aspects of IT in the ongoing transformation of the healthcare sector.

These investments, however, will follow the money. In other words, funding will focus on initiatives that have the biggest impact in terms of revenues, cost avoidance, and transformative potential. A recent survey by technology provider Healthedge suggests that investments among payers will be targeted at selective enhancements to the most critical systems that support business development, and not a wholesale upgrade of IT. Here are a few of the top investment areas across healthcare:

Population Health Management (PHM): Everybody is on board with the concept of PHM as the defining principle in an outcomes-based business model. However, PHM has eluded a consistent definition, other than that its desired impact is to reduce overall costs of patient populations, and improve clinical outcomes. Analytics has been an important aspect of this discussion, however standalone analytics solutions have struggled to demonstrate value, and progress on advanced analytics involving predictive models and cognitive sciences has been slow. This year may change all of that. Many standalone analytics companies are likely to be acquired, and IBM Watson will gain more traction. M & A in healthcare will drive PHM as well.

Information Security: With healthcare data breaches at over 112 million in 2015, including high-profile breaches at Anthem, Premera, and Excellus, IT security is now a CEO level issue. There is no doubt what this means – investments in data security technologies are going to increase. However, there is no guarantee that data breaches will not increase.

Healthcare Consumerism: Changing demographics and unexpected increases in the costs of health insurance are driving the consumerization of healthcare today. Silicon Valley startups, flush with VC money, are coming up with direct-to-consumer approaches that are making traditional healthcare firms sit up and take notice. At the same time, the newly awakened healthcare consumer is also demanding information and price transparency. New York Presbyterian has launched a patient-first marketing strategy aimed at improving engagement with patients through information sharing, and is revamping its website completely. BCBS of NC has already released the cat among the pigeons by publishing price data (and is facing pushback from its provider network). IT investments will now be focused on maximizing the reach and value of the information to empower consumers to make the right choices.

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The Year of the Consumer: Health IT Trends for 2016

Guest post by Jason W. Buckner, senior vice president, informatics, The Health Collaborative.

Jason Buckner
Jason Buckner

Last year, 2015, was a year of buildup, anticipation, and finally some bold moves to propel healthcare technologies forward, specifically regarding interoperability of data. The Office of the National Coordination, under the auspices of the department of Health and Human Services, released the long-awaited and much-debated meaningful use Stage 3 requirements in October. All the players in the health tech space were awaiting the final verdict on how Application Programming Interface (API) technology was placed into the regulations, and the wait was worth it, regardless of which side of the fence you were on. Before we get into the predictions, though, a little background knowledge about these technologies, and their benefits, will be helpful.

API Overview

An API is a programmatic method that allows for the exchange of data with an application. Modern APIs are typically web-based and usually take advantage of XML or JSON formats. If you are reading this article, you almost inevitably have used apps that exchange data using an API. For example, an application for your smartphone that collects data from your Facebook account will use an API to obtain this data. Weather apps on phones also utilize an API to collect data.

HL7 Overview

Next let’s take a look at the history of interoperability of healthcare data. HL7 2.x is a long standing method to exchange healthcare data in a transactional model. The system is based on TCP/IP principles and typically operates with Lower Layer Protocol (LLP) which allows for rapid communication of small delimited messages. The standard defines both the communications protocol and the message content format. No doubt about it, HL7 2.x is incredibly effective for transactional processing of data, but it has been limited in two key areas:

  1. A pioneering developer of a successful HL7 interface engine once said: “Once you have developed one HL7 interface … you have developed one HL7 interface.” The standard exists, but there is nowhere near enough conformity to allow this to be plug-and-play. For example, a patient’s ethnicity is supposed to be in a specific location and there is a defined industry standard list of values (code set) to represent ethnicity. In reality, the ethnicity field is not always populated and if it is, it rarely follows the defined code set.
  2. HL7 is an unsolicited push method, which means when a connection is made, messages simply flow from one system to another. If you are attempting to build a collection of cumulative data over time, this is a mostly sufficient method, but what you cannot do is ask a question and receive a response. Although some query/response methods have existed for years, their adoption has been very sparse in the industry.

2016: Year of the Healthcare API

If you are a physician with an electronic health record (EHR) system and you accept Medicare patients, you likely have gone through the process of becoming meaningful use (MU) certified, which means you have purchased an EHR software solution certified by the ONC. This EHR must follow guidelines of technical features, and physicians must ensure they utilize those features in some manner. In October 2015, the ONC released MU Stage 3 criteria (optional requirement in 2017, mandatory in 2018) which includes this game changer: A patient has a right to their electronic health information via an API.

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Gazing Into the Crystal Ball: What 2016 Will Look Like for Health IT Consultants

Guest post by Ben Weber, managing director, Greythorn.

Ben Weber
Ben Weber

This is the time of year when people are looking into their crystal ball, and telling all of us what they see happening in the next 12 months. Some of these predictions will be wild (aliens will cure cancer!) and some will be obvious (more health apps in 2016!). But how many will be helpful?

As I gaze into my own crystal ball, I have to admit I’m also peeking at my email (I like to multi-task). I can’t really say if it’s inspired by the swirling lights of the magic orb on my desk, or if it’s because of the inquiries from clients, messages from my management team and RFPs from various hospital systems … but I also have a prediction for the New Year: 2016 will be the year of migration for Epic and Cerner consultants.

The United States healthcare industry has made great progress in EHR implementation—to the point where implementation is no longer the primary conversation we’re having. Now we’re discussing interoperability, if we’re using ICD-10 codes correctly, how and if we should integrate the data collected from wearable fitness technology, and more. Those discussions—and the decisions made as a result—will continue to require human intelligence and power, but in 2016 there will be a decreased demand for consultants on these projects. Healthcare IT professionals who have grown accustomed to this kind of work will either have to settle into full-time employment—or turn their nomadic hearts north to Canada.

Our neighbors on the other side of the 49th parallel are ramping up their EHR implementations, which is good news for consultants interested in using their passports. Implementations in the US are slowing down, and while there is still work available, it is not as constant and may not command the same hourly rates as in years past. Meanwhile, several leading Canadian healthcare IT organizations have already warned of a looming talent shortage in their country (source), the effects of which are beginning to be felt.

Epic and Cerner specialists are particularly in demand, as there is a dearth of experienced talent. Out of the Canadian healthcare IT professionals who have worked with an EMR, 28 percent report familiarity with MEDITECH, 13 percent with Cerner, and 7 percent with McKesson. Only 4 percent have worked with Epic, according to the 2015 Canadian Healthcare HI & IT Market Report.

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Interoperability for Real; It’s Finally Here

Guest post by Sanjeev Agrawal, president, LeanTaaS Healthcare.  

Sanjeev Agrawal
Sanjeev Agrawal

Interoperability will be healthcare IT’s biggest trend in 2016 as the industry finally sees momentous forward movement.

In fact, interoperability is not a new trend. It has been an important mission (and a challenge) for healthcare administrators for decades, but the past couple of years have been game-changing:

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Healthcare IT Predictions for 2016

Guest post by James Carder, CISO of LogRhythm, VP of LogRhythm Labs.

James Carder
James Carder

This year’s biggest health data breach victims include insurers Premera and Anthem, where incidents affected nearly 100 million patients combined. It’s clear that healthcare organizations must strengthen their cyber security programs to protect themselves and their patients, or they’ll be targeted again and again. Strategically, healthcare organizations must change the way they have operated for the past 30+ years with regard to their behaviors and their use of IT. Cyber security is now a key business differentiator as both patient care and safety are paramount to a hospital’s ability to remain a trusted provider. The hospital of the future is one that incorporates these protection measures into its business brand, thereby recruiting, retaining and reinvesting in patients.

As we start out 2016, here’s what I think we’ll see going forward:

Healthcare IT security will continue to fall further and further behind the rest of the industry verticals

Healthcare IT security will continue to fall further behind the rest of the industry verticals. Healthcare organizations are focusing on functionality for patient care (rightfully so), and security is an afterthought. Many organizations are overly dependent on antiquated hardware and software, with inherent vulnerabilities, that could inadvertently put patients in danger. There has never been a real investment in information security, so the cost to catch up to industry standards and shed the label of being the hackers’ “low hanging fruit” is that much more expensive. The industry will continue to be targeted by sophisticated and organized attackers until a serious investment is made in both technological and human capital.

The medical record is a relative goldmine of information and, as such, a highly valuable target for all classes of attackers, ranging from financial crime groups to nation state threat actors. The number of items a hacker has access to and the way in which the information can be used is more extensive. Stolen data can be re-used by a hacker over and over again. So, in addition to this general prediction, I also think that at least one of the U.S. News and World Report top 10 hospitals will go public with a breach through outside channels.

Healthcare IT (security) spend will be the highest it has ever been, doubling the spend of 2015

Despite my first prediction, healthcare organizations will invest a lot of money in IT security technology and human resources, doubling the spend of 2015. Although the executives may fund the security department, a security culture might not trickle down to the rest of the organization. The person in charge of security might be accountable for security, but the buy-in must come from the board of directors down through every level of the organization. Staff and the clinicians must understand what they are doing is making the organization a safer place for them and their patients–their effective security behaviors allow clinicians to do their job in treating patients better.

At least one major medical device manufacturer will have to go public with a vulnerability that could fatally affect patients

Medical device vendors and manufacturers have never taken security seriously. They are primarily looking for functionality for patient care and ease of administration and maintenance. A medical device is a computer system with one end attached to the patient, providing critical patient care, and the other end attached to the corporate network or Internet. Just like most devices on the network, a medical device runs a known operating system; vulnerable to the myriad exploits that effect any computer. Based on the risk profile of a medical device, it should be subject to the highest security standards in the industry but unfortunately they are not. If someone can hack into a Windows XP box that is unpatched with exploitable vulnerabilities, someone can hack into an XP-based medical device. I predict that another medical device manufacturer will disclose an easily exploitable vulnerability that could patients at direct risk. I also predict that an attacker will exploit a medical device and use it as a bridge into a company’s corporate network to facilitate a breach.

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