Included amongst the segments of healthcare such as post-acute care that until recently had been mostly overlooked, specialty pharmacy now is in the spotlight as a key area of healthcare utilization and spend in the U.S. Critical, expensive and often life-sustaining medications for high complexity disease states, as well as care management programs that help patients through their healthcare journey, are at the core, driving nearly $175 billion in drug spend for the 2 percent to 3 percent of the U.S. population considered medically complex. Specialty pharmacy operations typically involve a cross-functional staff of insurance experts, patient care coordinators, nurses and pharmacists that interact with patients and stakeholders to ensure therapeutic success in a historically fragmented, manual process-driven model.
Challenges in specialty pharmacy operations
As with many aspects of the healthcare system, specialty pharmacy operations are fraught with many pragmatic, economic, and clinical care challenges.
Operational, pragmatic challenges include:
Multiple fax and phone communications between prescriber and specialty pharmacy supporting referrals, prescriptions, authorizations and patient care coordination
Challenging and fragmented patient engagement combining traditional phone-based communication with other methods such as texting with mixed results
Overlapping prescriber and patient communications among health plan, pharmaceutical manufacturer patient service hubs, prescribers and specialty pharmacy
These process challenges are creating an economic strain for the pharmaceutical industry, the payer, the provider, and most importantly the patient – where insurance benefit and funding source determinations often create confusion between overall coverage and patient out-of-pocket costs. This is compounded by complex coordination of benefits, billing and payment processing of medical and pharmacy claims, as well as other sponsored funding sources. Increasing patient cost share can make specialty drugs unaffordable for many patients which impacts medication adherence and ultimately patient outcomes.
The resulting clinical challenges make it difficult for critical patient care information to be easily shared (e.g. labs, patient assessments, medication profiles, side-effects, etc.). Additionally, treatment objectives often overlap among specialty pharmacy channel providers, resulting in crossed communications and patient confusion. In the end, key success metrics (both economic and clinical) are not easily measured, and often not operationally and clinically aligned.
The power of data accessibility and real-time analytics
Compressed specialty pharmacy margins require significant technology investment to offset operating costs and increasing service expectations. Technological advances help to address several of these challenges and as a result drive improvement in patient care and satisfaction, lower operating costs and more informed clinical decision-making.
Several of these technological advances that are showing early evidence of changing the historical paradigm include:
Interoperability with EHRs and other critical patient history data sources providing access to holistic views of patient medical records which can improve patient engagement, therapeutic interventions and reduce unnecessary procedures
Sophisticated workflow software driven by data-informed electronic protocols to support overall multi-party process efficiencies
Robust and timely analytics that provide comparative and predictive insights that influence optimal patient care at the lowest cost as well as provide more timely, accurate patient insights that drive patient success, including medication adherence
Integrated patient engagement technologies that improve patient interactions when and how the patient wishes to engage
Impact across the continuum
The application of advanced capabilities in connectivity and analytics in the specialty pharmacy space creates a more efficient system and a better result for all involved. Successful implementation of these technologies accelerates patients onto the most appropriate therapy, optimizes patient treatment plans and improves the overall patient experience which support medication adherence goals. It can also help establish innovative and more productive relationships between health plans, employers, providers, specialty pharmacies, pharmaceutical manufacturers and patients.
By Zachary Blunt, manager of product management population health, Greenway Health
Zachary Blunt
Electronic health records (EHRs) were expected to revolutionize healthcare practices, making them more efficient, reducing costs and enabling them to provide more coordinated care.
But ask healthcare providers about the EHRs they’ve deployed, and the results are far from what was expected.
In fact, more than 60 percent of healthcare professionals rank their return on investment (ROI) for EHR systems as “terrible” or “poor,” according to a recent survey from Health Catalyst. Another study, published in the Journal of the American Medical Association, estimated the costs of billing and insurance-related activities using EHRs ranged from $20 for each primary care visit to $215 for inpatient surgery, totaling 3 percent to 25 percent of professional revenue.
So, why aren’t EHRs living up to the hype and delivering the promised investment? In many cases, it has to do with these systems not being used to their highest potential.
Here’s a look at five steps healthcare practices can take to address challenges resulting from EHR implementation and maximize their ROI.
Get Buy-In Across the Board — from IT to Finance to Front Office Staff
Adopting EHRs to manage clinical activities impacts many revenue cycle-related functions, such as patient registration, insurance eligibility, scheduling and the services/treatments a patient received during each clinical encounter. To achieve ROI, EHRs must be able to improve several operations of a practice and streamline the workflows of different departments. It’s best practice for all clinicians and staff to weigh in before installing new systems or technologies.
Provide Strong Leadership, Communication and Training
Changes in common practices during EHR implementation can result in significant resistance from users or a longer learning curve that hampers efficiency and adds to the cost of the system. To achieve results, healthcare leaders should clearly articulate the EHR implementation plan, prepare themselves for a transition period and develop a training protocol so all users understand their roles in using the system. In addition, users should have a solid background and understanding on how their roles factor into the overall success of the system and the practice at large.
Improve Staffing Efficiency While Improving Operating Margins
Labor costs can account for nearly half of a healthcare provider’s operating costs. But providers often fail to take a strategic look at how adjusting staffing can improve the bottom line. Often, providers use historical averages to determine staffing levels at their practices, resulting in an outlay of overtime pay outside the planned budget when unexpected staffing demands occur. Data from EHR solutions, as well as enterprise resource planning (ERP) sources, can be analyzed to gain a better understanding of historical staffing trends. Accenture estimates that by getting insights from EHR and ERP data, U.S. healthcare providers could save more than $77 billion over the next five years by reducing overtime and overall labor costs.
With the increasingly “on the go” nature of technology and communication, information is accessible from the palm of a user’s hand in the form of mobile devices. Subsequently, the success of modern EHR software lies in the moment accessibility on mobile devices like smartphones and tablets.
The addition of mobile functionality for EHR systems is driving the adoption of electronic health record systems and software in the industry and contributing to meaningful use for patients and physicians alike. Patients benefit from doctors and staff who can make informed decisions by easily accessing their medical records from an easy-to-use mobile interface. Mobile EHRs allow practice staff and physicians to access valuable and crucial patient records, while increasing communication between healthcare facilities in a more efficient, secure manner.
This is incredibly useful in critical care or emergency situations; allowing physicians and other care staff to quickly, securely and accurately view patient information on the fly is a major advantage when emergency surgery or care has to be administered. With the continued scourge of the opioid epidemic requiring investments in patient and physician safety and with continued staffing shortages in the industry leading to further implementation of AI and technology based solutions, mobile EHR will be a critical tool in a healthcare staff’s arsenal, allowing the relaying and accessing of accurate information in a constantly evolving environment.
In addition, the internet, office tools and desktop computers are no longer necessary for effective documentation; mobile EHR allows offline record populating whenever and wherever it’s necessary, increasing the accuracy and timeliness of documentation. By allowing physicians and staff to accurately and conveniently exchange documentation and patient records through a secure, mobile platform, informed decisions can be made 24/7. This drives meaningful use by improving quality, safety, efficiency and care coordination for public health.
By utilizing EHR on mobile platforms, staff and physicians can increase their efficacy and accuracy when updating documentation or accessing patient files. By creating a friendly, innovative platform to access crucial information, EHR software that features mobile functionality is a necessity in modern EHR applications. It will continue to drive meaningful use and accessibility in the healthcare industry going forward as evidenced by the infographic featured below.
Federal healthcare organizations, such as CMS, have spent billions of dollars over the years trying to bridge the gap between medical data and quality patient care with interoperability requirements and data integration, the mesh used to try and bridge the gap. Many government rules have been written to address the type of mesh needed and many EHR companies have claimed to meet these government requirements and claim the throne of the ultimate mesh maker.
However, hospitals and clinics found the mesh contained many holes, such as enabling hospitals to customize EHRs, but only if the EHR customers purchased the EHR systems for the manufacturers for millions of dollars that hospitals could ill afford. Also issues such as proprietary connectivity to their own brands that left the hospitals’ other EHR systems to serve as dead-end data silos. Rules and solutions came and went, but few had any teeth until now.
Anyone for A Slice Of PI?
To end the lack of interoperability morass and data duplication, the Department of Health and Human Services (HHS) issued 1,883 pages of proposed changes to Medicare and Medicaid. The changes rename the Merit-Based Incentive Payment System (MIPS) Advancing Care Information performance category to Promoting Interoperability (PI).
CMS announced the change as part of a proposed rule that will transform the EHR Incentive Programs commonly known as meaningful use under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The proposed policies are part of the MyHealthEData initiative, which prioritizes patient health data access and interoperability improvements.
But this time the name change wasn’t just that. For the first time a new CMS rule specifically requires providers to share data to participate in the life blood of hospital reimbursement—Medicare and Medicaid. The rule also floats the idea of revising Medicare and Medicaid co-pays to require hospitals to share patient records electronically with other hospitals, community providers and patients — a clear-cut demand for interoperability.
PI also reduces hospital interoperability requirements from 16 to six, revamping the program to a points-based scoring system and is requiring that hospitals make patients’ EHRs available to them on the day they leave the hospital beginning in 2019.
Does Your EHR Have the Right Stuff?
While this news from CMS appears to be a step in the right direction to solve a problem that has plagued the healthcare industry for many years, it must first be made a reality by those ultimately responsible for its implementation—hospital HIT organizations. The days of data obstruction and silo logic must end with a focus on new EHR markets built on interoperability.
Interoperability requires multiple layers to demonstrate an EHR system can be accessed. Meanwhile, every EHR system claims to support some form of interoperability, ranging from web interfaces to API protocols or to the lowest and highest cost HL7. However, healthcare systems will have to demonstrate their operability to CMS to abide by PI and therefore allow access of their EHR systems. Hospitals and clinics can encounter many challenges with this, such as HIPAA compliance and support for their infrastructure for open secure access, requiring an HIE and the funds to support data synchronization and IT support.
In January 2015, the Department of Health and Human Services set a goal to tie 50 percent of the Medicare payments to value or quality by 2018. This transition has put physicians on the frontlines of healthcare, as they play a major role in the value-based roadmap of an organization.
However, on the downside, this shift is causing substantial physician burnout — PCPs are spending more than 50 percent of their workday in the EHR doing documentation, order entry, billing, and coding, instead of spending time with their patients. There is a need to reduce physician’s IT usage by giving them easy and quick access to actionable information such as care-, and coding- gaps, thereby allowing physicians to focus on things that matter most – delivery and improvement of care.
Regardless of how many patients physicians see per day, they have to put in an equal, if not more number of hours in front of the EHRs for logging in every single detail. Physicians are likely very interested in quality care and making the care processes efficient; it is important to understand the implications that would be created on their reimbursements with a solution that mitigates IT usage burnout. Physicians should automatically be updated instead of having to inquire about information they need at any given moment as it might be disengaging. It is possible to engage physicians so that they can take forward the quality improvement efforts.
Alternative Physician engagement methodologies and their adoption
Making improvements to the healthcare system are the top of the agenda but how does the current scenario of physician engagement compare to this? Addressing the problem of physician burnout, several methods for engaging physicians have surfaced over the past few years:
Adaptability
Cost
Outcome
Print / Fax PVP
High
Low
Medium
Push data back in EMR
High
High
High
Mobile App
Medium in young physicians
Low in older physicians
Medium
Medium
Another Web Portal
Very Low
Medium
Low
All of these methods are sub-optimal – either they are labor-intensive, or costly to implement, or require physicians to leave the EHR and go to another portal, thus decreasing the physician adoption rates. It is critical to engage physicians in a timely and effective manner to bring information transparency across the network and allow for prompt identification of low-quality care outcomes and unnecessarily high-cost events.
The solution: Engaging physicians with point of support for smarter and holistic care
Addressing above limitations, there is a dire need for a smart point-of-care support for physicians that is automated, easy to implement, and user-friendly. A support system that operates right besides EHR, pinpoints and surfaces only relevant insights, including care gaps and risk factors, which will help physicians right at the point of care without being overloaded with too much information.
Providing precise insights
Physicians require a solution that pops up just the precise insights like care gaps and risk factors to assist them in working with the patient within the EHR at the point of care. Moreover, creating a holistic picture of patients remains highly essential for physicians, however, it is still a challenge because of siloed data storage platforms in healthcare. This lack of a 360-degree view for every patient is a major barrier to collaborative and coordinated care efforts. These challenges can be addressed by integrating various patient-specific datasets, including clinical and claims and surfacing key insights on the physician’s screen in nearly real-time.
Personalizing patient interactions
Almost 80 percent of healthcare data is unstructured, and thus, to create impact at scale, physicians need pioneering analytic capabilities. For example, if a patient has visited the ED three times in the past two months, he needs to be tagged as a ‘frequent ED visitor.’ Giving physicians access to this information will guide them to revisit and optimize their care-programs for this patient such that the patient’s ED visits go down, which would further translate into decreased overall spend for the network.
Sherlock Holmes famously captured the popular imagination with his uncanny ability to make wild, but accurate, leaps of logic to solve mysteries. By observing Dr. Watson’s suit jacket sleeve, upon their first encounter, he was able to deduce that Watson was in fact a surgeon, in the British Army, and had recently returned from Afghanistan, where he had sustained an injury.
When he slowed down to explain his reasoning, it was easy to follow; what made his deductions impressive was how quickly he would skip from observation to conclusion. I’m no Sherlock Holmes, but it seems to me that chatbots are poised to take over much of modern healthcare.
As more data is moved to portals through EHRs and digital documentation, there is increased patient interest in and demand for other digital and remote encounters and health resources. This, along with improving technology and competitive solutions, is helping increase adoption of telehealth. So, patient portals lead to increased telehealth adoption.
Finally, although part of the premise and value of telehealth is enabling face-to-face encounters between caregivers and patients without respect to geography, hospital waiting rooms, or other physical barriers, it changes certain expectations. Like all mobile and web-based services, telehealth feeds a consumer mindset that expects everything on-demand, all but instantaneously, and highly customized at that.
While portable patient records facilitated by EHRs and interoperability can help this, customization and on-demand healthcare doesn’t just put pressure on records and data. Patients want fast and personalized answers. As customer service centers, tech support, banks and virtually every other consumer-facing industry has learned, a lot of the on-demand load can be pushed onto increasingly sophisticated chatbots.
So, telehealth leads to growing expectations for on-demand clinical encounters and chat, which is provided by chatbots.
The Case for Chatbots
Retail has previewed much for healthcare: See how customer service upgrades have turned everyone into “The Most Important Person Here” wherever they go, in person or online. Consumers demand personalization, expedition, authenticity and they want it all exactly when and where they want it. And now, see how AI is not yet taking over the world, but is making FAQs and other routine customer service interactions painless for those answering, and interactive enough for those asking.
Retail is even making inroads to healthcare, as consumer-facing devices promise to measure and track all manner of health metrics. Statistics-loving sports fans witness the increasing digitization and quantification of athletes, games, injuries and training, and they want a similar level of insight and precision for their own care. Mobile technology is redefining and disrupting even the oldest and most stable of markets and industries, bit by literal bit.
So how long until the dry, repetitive questions doctors routinely must answer in check-ups and physicals are ethically and effectively offloaded onto chatbots programmed to triage and educate patients without wasting valuable human resources? How long until using telehealth to keep nonemergency patients out of the emergency room merges with using chat and AI — the basic recipe for chatbots — to keep healthy but curious or concerned patients from wasting time and money going through full encounters simply to get their general questions answered?
It doesn’t take a lot of sophistication to realize the benefits of AI at scale. Google has all but taken over the modern world by connecting searchers with answers to their questions; Wikipedia has all but bankrupted the encyclopedia industry with free, accessible, general knowledge. In a world where health literacy is so lacking in the majority of the population, some interactive resources could go a long way to chipping away at ER overuse and healthcare overconsumption, just by giving people an alternative to seeing the doctor.
Automation of Care, Automation of Crime
As quickly as potential benefits can scale, very real risks and both moral and financial hazards scale even quicker.
The growing popularity and implementation of chatbots has given hackers and cybercriminals a new way to scam, defraud, and generally abuse unwitting consumers. Sometimes that means hackers take over a company’s chat system with their own bot and solicit data. Sometimes fraudsters attract visitors with a spoof website, then use a bot to similarly extract volunteered data at scale from misled visitors. However it is done, it scales almost as well as a more conventional data breach, and can be harder to detect or track.
The start of 2017 provided America’s health system with some global-scale schadenfreude when England’s NHS got caught up in a massive cyber attack. The “WannaCry” ransomware attack, which quickly spread across Europe from an epicenter in Ukraine, seemed to prove beyond any reasonable doubt that American EHRs and health data management systems were not unique in their vulnerability to hackers and thieves leveraging new digital weapons.
In time, this particular attack did manage to spread internationally from Europe over to America, but that only provided further evidence that ransomware, and cyber attacks more broadly, are a threat of seemingly unlimited potential. The failings of American healthcare to get its data safely organized look far less damning when the scale of cyber risk is made explicitly global, and even the NSA is caught off-guard by their own tools being turned into weapons in enemy hands.
Not Alone, but Not Ahead
Of course, that American hospitals weren’t the primary targets for once doesn’t remotely get them off the hook; nor does the jarring impact of this particular incident reflect a growing resilience among health data security in the U.S. American health data may not be alone in its vulnerability or attractiveness to thieves, but neither are our health systems leading the pack in protecting against ransomware, or any other form of cyber attack. Sadly, this wakeup call seems more likely to be heard outside of healthcare than within it; the scale makes it almost universally noteworthy, but otherwise it resembles a new status quo for data leaks in modern health systems.
Credit card data is relatively to protect; thieves are easily and quickly locked out of accounts, if not caught, thanks to everything from increased scrutiny by lenders and processing companies as well as consumer-facing transparency and 24/7 account monitoring via mobile credit card alerts and apps. Health data, by contrast, remains largely vulnerable. Clinics are not particularly good at recognizing fraud when thieves have a person’s medical data; hospitals have proven themselves no better at keeping that data secure in the first place. So compared to traditional identity theft leveraging plastic, digital health data presents a softer and more lucrative target end to end.
T-Mobile recently became the first cell phone carrier to offer free inflight Wi-Fi (in support of Wi-Fi texting, as cellular signals are still not yet allowed) to all its customers. Admittedly, this was technically on the strength of partnering with a third-party platform, Go-Go, but the carrier gets the glory of being first among its big four peers to take even this step.
In-flight Wi-Fi, Wi-Fi calling, and similar services aren’t necessarily new technology, but having support for limited internet browsing and texting, all delivered through one of the top carriers in the nation, makes for a reasonably good elevator pitch—especially if you happen to be a T-Mobile customer. But the importance of the development isn’t just the novelty of the technology or the value of the service on offer; it is planting a shining pink flag in the market and staking that claim of being “first.”
Early Adoption, Arrested Development
Being first hasn’t lost its luster yet, even in a time when consumer expectations are sometimes a generation or two ahead of current technology. Hospitals and their leadership recognize this, and so, despite uncertainty on everything from insurance market regulations to the future of EHR integration, many are taking strides to do as T-Mobile has done — and find a way to get there first on a variety of issues important to consumers. And like T-Mobile, being first doesn’t have to mean getting into the weeds of proprietary innovation and product development—although plenty of larger chains and clinics do take that route; for many hospitals, being first can be accomplished through strategic partnerships with tech-centric companies.
If there is one lesson out of Silicon Valley that has entered the American zeitgeist, it is that being the first out with something can give a company, product or even team of creatives a lot of leeway in terms of going on to iterate, improve, and generally tinker. But on the healthcare front, we see how the drive to be first—or even keep pace with the rest of the industry—can create a “hurry up and wait” situation where meaningful progress sometimes lags fanfare or technology.
That is why the top tech trends in healthcare don’t change much year to year; end users, hospital administrators, and tech developers are all still trying to figure out what works, what works best, and how to integrate new tools into the clinical workflow, the patient experience, and the regulatory environment governing it all.
That is the story of EHRs is a nutshell: a good idea, a rush to adoption (both willing and coerced), and then a lengthy period of reiteration as all stakeholders struggle to recreate or wholistically reconsider the context in which this new system can, and should, operate. But the rush to adopt first and configure later isn’t limited to high-technology in the healthcare sector; it pretty well describes the legal environment surrounding health insurance.
Industry Leadership: Being First or Being Best?
From how it affects patients to what it is still trying to influence in the provider space, the conversation about care and coverage is still shepherded primarily by fear, secondarily by outrage, and in most other respects by confusion. So it looks like we’ll be shopping the exchanges for a while longer, even under President Trump’s watch.
After gazing into the abyss that was Trumpcare, the still-evolving status quo that is Obamacare is more popular than ever. Here again, the power of being first seems to provide some residual sticking power to a law frequently and publicly dragged through the mud by people and organizations with at least as much visibility and influence as one like T-Mobile.
