Of the nation’s $3.5 trillion in annual healthcare spending, 90 percent is for people with chronic and mental health conditions. Can healthcare institutes afford not to engage in the 2020 wave of preventative care healthcare disruption? While healers are not prognosticators, savvy healthcare CEOs have their eye on 2020.
For those riding the disruption wave, the answer is simple. CMS alone is providing more than $80 billion in reimbursements for preventive care initiatives. This calculation alone does not count on complex chronic care conditions and other follow-ups from preventive care engagements.
Also, CMS aims at containing the growth of acute care reimbursement. It has almost the same “carrot and stick” model used for the evolution from paper to electronic. Stay on the paper train and get penalized or get on the preventative care train and receive financial incentives.
Earthquake or Hurricane?
Both natural disasters are simply disasters. We do not use this analogy from a disaster standpoint, but from our ability to monitor the progress towards controlling the impact. Earthquakes cannot be foreseen. A hurricane cannot be monitored to the exact point of where it will hit, but at least it can be monitored to approximately when it will hit and its potential impact.
The paper evolution is like an earthquake to healthcare with its aftershocks still being felt today without the ability to plan much upfront. The preventive care evolution is more like an imminent hurricane. We know it is coming, we know when it lands, but we don’t know where it is going. We need to deal with it and manage where it will take us. Those unprepared will suffer the most negative impacts. Would your healthcare facility take this risk?
Most healthcare institutes have deployed an EHR system, almost completing the evolution from paper to electronic medical records. This was the first wave of healthcare disruption. However, we are now realizing that this was much more of a disruptive process in healthcare than anyone realized, as its impact has gone way beyond how patient medical data is recorded.
Power vs. Paper
It began with requirements for care providers to use an electronic system in place of the traditional paper approach, opening for a potential patient medical information exchange, improving care quality and efficiency. CMS rolled out preventive care reimbursements starting with the Annual Wellness Visit (AWV) in 2015.
CMS then continued to invest in preventive care through additional reimbursements, such as chronic care management, remote patient monitoring, behavioral health integration and transitional care management.
Every year, CMS has either expanding current reimbursements or deployed new preventive care services. This strategy is based on the patient centered medical home with the objective to curb healthcare cost with preventive care measures, a 6:1 ROI versus acute care.
Reimbursements as incentives led to the next wave of healthcare disruption in which care providers’ workflows were impacted on how to record patient medical records. These preventive care initiatives created fundamental changes impacting almost every operational aspect of a care provider’s workflow.
Preventive Care
Today, it is all about preventive care: simply put, the patient is not yet a patient until he or she encounters pain. The patient is not yet sick. The operational model is not reactive. The demand is to anticipate and monitor conditions so care providers can act before the patient encounters a serious medical problem. This causes changes in the operational workflows for healthcare institutes and their workflow.
In the patient engagement model, there is the acute care model in which it is the patient who makes an appointment or visit. For preventive care, it is care providers and healthcare institutes conducting the outreach. However, without the patient outreach model, healthcare institutes cannot realize the full financial incentives offered by CMS.
In non-face-to-face engagements, patients contact their primary care providers for consultation, but that model is different from the preventive care one. In the acute care environment, care providers cannot bill for the engagements, but can bill for visits and appointments. In the preventive care environment, care providers can bill for services, but it is up to care providers (and their staff) to reach out, monitor patient conditions and meet the time required for billing.
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.
The Center of Medicaid and Medicare Service (CMS) continues to increase emphasis on care collaboration, ranging from Chronic Care Management (CCM) to the recent announcement from the US Surgeon General’s landmark report on alcohol, drug and health. Derived from many aspects in healthcare, the authors’ examine the challenges of integrating physical and behavioral healthcare, addressing the Care Collaboration Model outlined by CMS and the Surgeon General.
The author’s, beginning with the interdependency between physical and behavioral health, bring case scenarios supporting the challenges of today’s healthcare, and then introduce an innovative Health Collaborative Ecosystem addressing the many challenges of a care collaboration model.
Interdependency Between Mental and Other Chronic Disorders
Research has demonstrated bidirectional links between mental disorders and chronic conditions. Depression and anxiety are heightening the risks towards hypertension and diabetes. Depression roughly doubles the risk for a new coronary heart disease (CHD) event. We can go further on other mental disorders such as PTSD, drug addiction and alcoholism. Such interdependencies have limited solutions today due to the lack of a collaborative environment. We refer to this as a ‘revolving door care environment’, a vicious cycle compounding the effects of chronic and mental disorders.
A detox center can only retain the patient for detoxification for a limited time. Without collaborating with other behavioral services, the patient will inevitably return to the same habit – either drug addiction or alcoholism. Depression can stem from a social environment or from a recently developed chronic condition such as CHD.
The primary care provider will continue to address the chronic condition without the knowledge of what may actually feed into the patient’s chronic condition. It is yet another ‘revolving door’ for the physical care environment. Such interdependency requires a care collaborative environment between care providers.
Care Collaborative Model and Bidirectional Information Flow
A team-based care collaborative model uses a multidiscipline group of care providers supporting and implementing treatment with the patient at the center. A bidirectional information flow is an absolute must to put the model into realization and operation in healthcare institutes.
Today, healthcare lacks the support of a closed-loop system, one that emphasizes a bi-directional flow of information. Healthcare is muddled with reactive care, instead of preventive, anticipated care. It is that lack of prevention and anticipation that have an adverse impact on the overall healthcare cost and patient outcomes. EHR and EMR systems are the main ‘anchors’ of today’s health IT.
However, there are two EHR components that are non-starters: the boundary of the health institute and unidirectional systems. HIEs (Health Information Exchange) address EHR limitations with their capability to provide support across health institutes, but actually worsen the unidirectional character of the EHR. Neither EHR or HIE can address the requirements for a care collaborative model.
Reaching The State of Homeostasis As A Desired Patient Outcome
The objective is to improve patient outcomes, but how do you define a patient’s outcome?
Homeostasis is a biological term, referring to the stability, balance, or equilibrium within the body. Homeostasis is the process of maintaining a constant internal environment by providing the body with what is needed to survive for the well being of the whole. While disorders (physical or mental) reflect the abnormal condition of the body, homeostasis is the normal, stable and well-being state.
Each disorder is well documented with what would be a normal condition or the state of homeostasis. This state of homeostasis also deviates based on race, demographics, and above all, the relationship with other existing disorders afflicting the patient. It is then noted that each patient outcome requires a personalized state of homeostasis.
From the disorder, the process towards the state of homeostasis consists of genetics, nutrition, physical activity, mental health and an external environment. Genetics is the internal influencer in with medicine’s physical care plays a role in adjusting the disorder toward homeostasis. For healthcare, it is the care plan for a disorder.
The state of homeostasis should be used as the measure of a patient’s outcome, resulting from the care collaborative model addressing the integrated, coordinated care from multiple care providers.
Health Collaborative Ecosystem
The Health Collaborative Ecosystem is the delivery process that supports the care collaborative model, with the objective of bringing the patient to the state of homeostasis. This system would include all providers of health-related services to the chronically ill patient diagnosed with one or more of the designated chronic and debilitating diagnosis that utilize the most significant percentage of health care spending. Such a system would be:
Capable of integrating physical and mental care environments.
An integrated layer complementing (including EHR-agnostic) existing health IT infrastructures, supporting care activities beyond the brick and mortal walls of their facility or clinic.
Consensus among providers to standards of care and bidirectional information flow that encourages innovation, compliance with regulations, secures privacy and adopts a continuous process of improvements to better reach a patient’s state of homeostasis.
Why an Ecosystem?
An Ecosystem is a collective system, including a health IT solution and consulting guidance, and support, for hospital operations in order to maximize the benefits of care collaboration, through efficiency and scalability of a care providers’ bandwidth.
It is an Ecosystem because it must include an auditable compliance component to provide crucial measurements and enforce quality guidelines for the model according to hospital and clinic management.
It is an Ecosystem because it must include the ability to track and monitor progress towards the state of homeostasis for all attributes contributing the patient’s overall well being.
Case scenarios
As noted in one case study, Maria Viera, age 75, takes a dozen medications to treat her diabetes, high blood pressure, mild congestive heart failure, and arthritis. After she begins to have trouble remembering to take her pills, she and her husband visit her primary care physician to discuss this and a list of other worrisome developments, including hip and knee pain, dizziness, low blood sugar, and a recent fall. Maria’s primary care doctor spends as much time with her as he dares, knowing that every extra minute will put him further behind schedule. Yet despite his efforts, there is not enough time to address her myriad ailments. She sees several specialists, but no one talks to all her providers about her care, which means she may now be dealing with conflicting recommendations for treatment, or medications that could interact harmfully. As a result, Maria is at high risk for avoidable complications and potentially preventable emergency department visits and hospital stays.
The care team for the above patient would potentially consists of: a primary care provider (high blood pressure and care coordinator), a cardiologist (congestion heart failure), an endocrinologist (diabetes), dietician (diabetes), a rheumatologist (arthritis), physical and/or occupational therapists (arthritis, falls, hip and knee pain), and a psychologist or a psychiatrist (depression).
The above case brings challenges to the health care system on multiple fronts:
More time from primary care providers with limited result outcomes due to the lack of collaboration with other care providers, specialists and community services.
Potential conflicting recommendations for treatment due to the lack of coordination and bidirectional medical information flows from multiple care providers and specialists.
The patient’s risk for complications, emergency visits and hospital stays significantly increases.
As conditions worsen, the patient develops symptoms for behavioral health conditions.
Today’s solution for the above scenario is based on care management. The care manager would work with all care providers, manually “pulling and pushing” the patient’s medical conditions and updates to all involved care providers. Error prone, high cost, and low efficiency are some of today’s deficiencies for healthcare attempts in implementing the care collaborative model, outlined by CMS.
Net New Revenue Focusing on Preventive Care
This is the challenge of a ‘revolving door care environment’ in addressing the need for integration between physical and behavioral health services. The Health Collaborative Ecosystem is the answer for such a challenge.
However, to support such a revolution, healthcare, as an industry, needs to have the financial incentives. As stated in the introduction of this paper, CMS is not encouraging a transformation through financial incentives.
The authors’ propose a roadmap to roll out the Health Collaborative Ecosystem without upfront risks and budget planning, but to generate new revenue for the institutes. The implementation roadmap leverages these CMS initiatives:
Annual wellness visits
Chronic care management
Integration of physical and behavioral health through the care collaboration model
With the Health Collaborative Ecosystem’s objective is to create a patient state of homeostasis, rural and community hospitals and clinics can accomplish multiple goals – better services to the community, better defined patient outcomes and open new avenues for health services with behavioral health and filling the revenue gap.
Hardly a day goes by without some new revelation of a US IT mess that seems like an endless round of the old radio show joke contest, “Can You Top This”, except increasingly the joke is on us. From nuclear weapons updated with floppy disks to needless medical deaths, many of which are still caused by preventable interoperability communication errors as has been the case for decades.
According to a report released to Congress, the Government Accountability Office (GAO) has found that the US government last year spent 75 percent of its technology budget to maintain aging computers where floppy disks are still used, including one system for US nuclear forces that is more than 50 years old. In a previous GAO report, the news is equally alarming as it impacts the healthcare of millions of American’s and could be the smoking gun in a study from the British Medical Journal citing medical errors as the third leading cause of death in the United States, after heart disease and cancer.
The GAO interoperability report, requested by Congressional leaders, reported on the status of efforts to develop infrastructure that could lead to nationwide interoperability of health information. The report described a variety of efforts being undertaken to facilitate interoperability, but most of the efforts remain “works in progress.” Moreover, in its report, the GAO identified five barriers to interoperability.
Insufficiencies in health data standards
Variation in state privacy rules
Difficulty in accurately matching all the right records to the right patient
The costs involved in achieving the goals
The need for governance and trust among entities to facilitate sharing health information
CMS Pushing for “Plug and Play” Interoperability Tools that Already Exist
Meanwhile in a meeting with the Massachusetts Medical Society, Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services’ (CMS) acknowledges in the CMS interoperability effort “we are not sending a man to the moon.”
“We are actually expecting (healthcare) technology to do the things that it already does for us every day. So there must be other reasons why technology and information aren’t flowing in ways that match patient care,” Slavitt stated. “Partly, I believe some of the reasons are actually due to bad business practices. But, I think some of the technology will improve through the better use of standards and compliance. And I think we’ll make significant progress through the implementation of API’s in the next version of (Electronic Health Records) EHR’s which will spur innovation by allowing for plug and play capability. The private sector has to essentially change or evolve their business practices so that they don’t subvert this intent. If you are a customer of a piece of technology that doesn’t do what you want, it’s time to raise your voice.”
He claims that CMS has “very few higher priorities” other than interoperability. It is also interesting that two different government entities point their fingers at interoperability yet “plug and play” API solutions have been available through middleware integration for years, the same ones that are successfully used in the retail, banking and hospitality industries. As a sign of growing healthcare middleware popularity, Black Book Research, recently named the top ten middleware providers as Zoeticx, HealthMark, Arcadia Healthcare Solutions, Extension Healthcare, Solace Systems, Oracle, Catavolt, Microsoft, SAP and Kidozen.
Medical Errors Third Leading Cause of Death in US
The British Medical Journal recently reported that medical error is the third leading cause of death in the United States, after heart disease and cancer. As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine. However, accurate, transparent information about errors is not captured on death certificates which are the documents the Center for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, but causes such as human and EHR errors are not recorded on them.
According to the World Health Organization (WHO), 117 countries code their mortality statistics using the ICD system. The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it. “Top-ranked causes of death as reported by the CDC form our country’s research funding and public health priorities,” says Makary in a press release. “Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves. It boils down to people dying from the care that they receive rather than the disease for which they are seeking care.”
The Root Cause of Many Patient Errors
Better coding and reporting is a no-brainer and should be required to get to the bottom of the errors so they can be identified and resolved. However, in addition to not reporting the causes of death, there are other roadblocks leading to this frighteningly sad statistic such as lack of EHR interoperability. Unfortunately, the vast majority of medical devices, EHRs and other healthcare IT components lack interoperability, meaning a built-in or integrated platform that can exchange information across vendors, settings, and device types.
Various systems and equipment are typically purchased from different manufacturers. Each comes with its own proprietary interface technology like the days before the client and server ever met. Moreover, hospitals often must invest in separate systems to pull together all these disparate pieces of technology to feed data from bedside devices to EHR systems, data warehouses, and other applications that aid in clinical decision making, research and analytics. Many bedside devices, especially older ones, don’t even connect and require manual reading and data entry.
Healthcare providers are sometimes forced to mentally take notes on various pieces of information to draw conclusions. This is time consuming and error-prone. This cognitive load, especially in high stress situations, increases the risk of error such as accessing information on the wrong patient, performing the wrong action or placing the wrong order. Because information can be entered into various areas of the EHR, the possibility of duplicating or omitting information arises. Through the EHR, physicians can often be presented with a list of documentation located in different folders that can be many computer screens long and information can be missed.
The nation’s largest health systems employ thousands of people dedicated to dealing with “non-interoperability.” The abundance of proprietary protocols and interfaces that restrict healthcare data exchange takes a huge toll on productivity. In addition to EHR’s physical inability, tactics such as data blocking and hospital IT contracts that prevent data sharing by EHR vendors are also used to prevent interoperability. Healthcare overall has experienced negative productivity in this area over the past decade.
The lack of EHR interoperability continues to pose a serious threat to healthcare initiatives, according to a recent report published by the American Hospital Association (AHA). The report discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability.
The report notes that the exchange of health information is critical for the coordination of care. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.
Last year, the ECRI Institute released a survey outlining the Top Ten Safety Concerns for Healthcare Organizations in 2015. The second highest concern was incorrect or missing data in EHRs and other health IT systems caused by interoperability. For the second year in a row, EHR data is identified as a concern.
The Partnership for Health IT Patient Safety, a branch of the ECRI Institute, has released safe practice recommendations for using the copy and paste function in EHRs that can adversely affect patient safety, such as the use of copy and paste that can overpopulate data and make relevant information difficult to locate, according to the partnership’s announcement.
Meanwhile, a survey of 68 accountable care organizations conducted by Premier, Inc. and the eHealth Initiative found that despite steep investments in health information technology, they still face interoperability challenges that make it difficult to integrate data across the healthcare continuum.
The survey found that integrating data from out-of-network providers was the top HIT challenge for ACOs, cited by almost 80 percent of respondents. Nearly 70 percent reported high levels of difficulty integrating data from specialists, particularly those that are out-of-network.
User Frustration Over Lack of HIE and Interoperability Standards
The Office of the National Coordinator for Health Information Technology (ONC) is once again asking the healthcare community for its thoughts on establishing metrics to determine if or to the extent to which electronic health records are interoperable. The push to achieve interoperability is in response to last year’s mandate by Congress, contained in the Medicare Access and CHIP Reauthorization Act (MACRA). Among provisions of that law is a requirement to achieve “widespread” interoperability of health information by the end of 2018.
When it comes to how Health Information Exchanges (HIEs) handle the challenges associated with interoperability, a recent Government Accountability Office (GAO) report cites the following barriers–insufficient health data standards, variations in state privacy rules and difficulty in accurately matching the right records to the right patient. In addition, the costs and resources necessary to achieve interoperability goals, and the need for governance and trust among entities to facilitate sharing health information.
In its annual interoperability survey of hospital and health system executives, physician administrators and payer organization IT leaders released in April 2016, Black Book Research found growing HIE user frustration over the lack of standardization and readiness of unprepared providers and payers.
Of hospitals and hospital systems, 63 percent report they are in the active stages of replacing their current HIE system while nearly 94 percent of payers surveyed intend to totally abandon their involvement with public HIEs. Focused, private HIEs also mitigate the absence of a reliable Master Patient Index (MPI) and the continued lack of trust in the accuracy of current records exchange.
Public HIEs and EHR-dependent HIEs were viewed by 79 percent of providers as disenfranchising payers from data exchange efforts and did not see payers as partners because of their own distinct data needs and revenue models. Progressive payers are moving rapidly into the pay-for-value new world order and require extensive data analytics capabilities and interoperability to launch accountable care initiatives.
Those looking at touted standards such as Fast Healthcare Interoperability Resources (FIHR) point out that it is only capable of connecting one medical facility to another and requiring specific end point interfaces to even do that. For every additional facility, a customized interface must be built. At the end of the day, FIHR is really a point-to-point customized interface requiring extra steps and ties developers to specific hospitals or EHRs and without universal access.
“Progressive FHIR standards can allow EHRs to talk to other EHRs should standard definitions develop on enough actionable data points as we enter a hectic period of HIE replacements, centering on the capabilities of open network alliances, mobile EHR, middleware and population health analytics as possible answers to standard HIE,” said Doug Brown, managing partner of Black Book.
With the yearly bluster and promise of HIMSS, I still find there have been few strides in solving interoperability. Many speakers will extol the next big thing in healthcare system connectivity and large EHR vendors will swear their size fits all and with the wave of video demo, interoperability is declared cured. Long live proprietary solutions, down with system integration and collaboration. Healthcare IT, reborn into the latest vendor initiative, costing billions of dollars and who knows how many thousands of lives.
Physicians’ satisfaction with electronic health record (EHR) systems has declined by nearly 30 percentage points over the last five years, according to a 2015 survey of 940 physicians conducted by the American Medical Association (AMA) and American EHR Partners. The survey found 34 percent of respondents said they were satisfied or very satisfied with their EHR systems, compared with 61 percent of respondents in a similar survey conducted five years ago.
Specifically, the survey found:
42 percent of respondents described their EHR system’s ability to improve efficiency as difficult or very difficult;
43 percent of respondents said they were still addressing productivity challenges related to their EHR system;
54 percent of respondents said their EHR system increased total operating costs; and
72 percent of respondents described their EHR system’s ability to decrease workload as difficult or very difficult.
Whether in the presidential election campaign or at HIMSS, outside of the convention center hype, our abilities are confined by real world facts. Widespread implementation of EHRs have been driven by physician and hospital incentives from the HITECH Act with the laudable goals of improving quality, reducing costs, and engaging patients in their healthcare decisions. All of these goals are dependent on readily available access to patient information.
Whether the access is required by a health professional or a computers’ algorithm generating alerts concerning data, potential adverse events, medication interactions or routine health screenings, healthcare systems have been designed to connect various health data stores. The design and connection of various databases can become the limiting factor for patient safety, efficiency and user experiences in EHR systems.
Healthcare Evolving
Healthcare, and the increasing amount of data being collected to manage the individual, as well as patient populations, is a complex and evolving specialty of medicine. The health information systems used to manage the flow of patient data adds additional complexity with no one system or implementation being the single best solution for any given physician or hospital. Even within the same EHR, implementation decisions impact how healthcare professional workflow and care delivery are restructured to meet the constraints and demands of these data systems.
Physicians and nurses have long uncovered the limitations and barriers EHRs have brought to the trenches of clinical care. Cumbersome interfaces, limited choices for data entry and implementation decisions have increased clinical workloads and added numerous additional warnings which can lead to alert fatigue. Concerns have also been raised for patient safety when critical patient information cannot be located in a timely fashion.
Solving these challenges and developing expansive solutions to improve healthcare delivery, quality and efficiency depends on accessing and connecting data that resides in numerous, often disconnected health data systems located within a single office or spanning across geographically distributed care locations including patients’ homes. With changes in reimbursement from a pay for procedure to a pay for performance model, an understanding of technical solutions and their implementation impacts quality, finances, engagement and patient satisfaction.
The long awaited road to true healthcare IT system interoperability is being implemented at Good Samaritan in Indiana, enabling the 232-bed community healthcare facility to better deliver on its commitment to delivering exceptional patient care. The system will also enable the hospital to substantially increase their practice’s revenue while containing healthcare system integration costs.
“We strive to be the first choice for healthcare in the communities that we serve and to be the regional center of excellence for health and wellness,” said Rob McLin, president and CEO of Good Samaritan. “We are proud to be the first hospital in the country to implement this great integrated health record system that will allow us to provide a much higher level of continuity of care for our patients, as they are our top priority.”
The integration is being made possible with Zoeticx’s Patient-Clarity interoperability platform that will integrate WellTrackONE’s Annual Wellness Visit (AWV) patient reports with Indiana’s Health Information Exchange (IHIE) and the hospital’s Allscripts EHR. IHIE is the largest HIE in the US, serving 30,000 physicians in 90 hospitals serving six million patients in 17 states.
Revenue Generator for the Hospital
WellTrackONE and Zoeticx will enable patient’s AWV data to flow from the application to Allscripts EHR and the IHIE system. With Zoeticx’s Patient-Clarity platform and WellTrackONE’s software, the healthcare IT integration passes on increased revenue from the Centers of Medicare & Medicaid Services (CMS) and decreased IT costs for medical facilities.
Medicare pays medical facilities $164.84 for each initial patient visit under the AWV program and $116.16 for each additional yearly visit. With the AWV integration in place, the hospital is now able to meet CMS’s stringent requirements for patient reimbursements.
It is estimated that the Good Samaritan will be able to generate $500 to $1,200 per AWV patient from follow up appointments for additional testing and referrals for approximately 80 percent of the Medicare patients that are flagged by the AWV for testing, imaging and specialty referrals within the hospital.
This subscriber number is expected to trend upwards into 2050 and will create billions in new healthcare revenue through the US as the population ages. The hospital is not charged any costs for the system until it is reimbursed by CMS.
Overcoming Healthcare System Limitations
The hospital began offering Medicare’s AWV’s a few years ago, but had to develop its own tracking protocols, which impacted its budget and staff resources. The system it had created also operated poorly, allowing hospital staff to only view about 10 percent to 15 percent of patient data.
Good Samaritan medical teams were also constrained by interoperability, having to enter new illness findings and other medical info manually and fax PDFs to other facilities where they would have to again be entered into a different system. The hospital also had all of the data contained in WellTrackONE and Allscripts’ system, but no way to integrate the two, let alone achieve that integration with IHIE. Providers were also spending valuable patient face time trying to find specific patient data buried in the EHR system.
“Our systems were working fine, independently of each other,” said Traci French, director of business development and revenue integrity. “But we could not achieve true interoperability between the two systems. The best we could do was basically reshuffling PDF documents. The next challenge was to integrate that data with the exchange. We needed to get data to providers where they needed it, when they needed it.”
Guest post by Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.
Telemedicine is about reaching out to patients in remote locations, but limited to videoconferencing between patients and health providers. It is similar to a face-to-face service with the exception that the patient and primary care provider are not physically together. Such efficiency is limited in term of scope and only addresses the geographical challenge and scarcity of physician availability, a far cry from what CMS wanted for its Chronic Care Management Services (CMS), which would fundamentally change telemedicine as it is practiced.
CCM services bring the telemedicine definition to the next level – a quiet continuous monitoring and collaboration from all care services to the patient, given the ability to anticipate and engage in care issues. Such ability not only curbs care costs, it would also increase care provider bandwidth, giving them the ability to cover more patients with better efficiency. The challenge is not on the requirements part of CCM services, but the lack of an IT solution to really address all CMS guidelines, including its intent to enforce the concepts through the healthcare industry.
Thanh Tran
The New England Journal of Medicine has covered the major challenges from the new CCM guidelines, touching on all the major shortcomings in today healthcare IT offerings. Healthcare providers recognized that the fee-for-service system, which restricts payments for primary care to office-based visits, is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medication refills, and care provided electronically or by telephone.
The time has come for a paradigm shift to re-engineer how we deliver care and manage our patients. To arrive at a new plateau requires rethinking the needs of our patients and how to meet these needs in an already resource constrained, proprietary, inoperable systems. Unless we develop solutions that both integrate with and enhance the technologies currently available and those yet to be realized, we will not realize a return on health IT investment. That has now changed since one Healthcare 2.0 innovator has been able to connect the CMS guideline dots.
Huge Market Opportunity
According to the 2010 Census, the number of people older than 65 years was 40 million with increasing trends to 56 million in 2020 and not reaching a plateau until 2050 at 83.7 million. With two-thirds of Medicare beneficiaries having two or more chronic conditions while one-third has more than three chronic conditions according to CMS data, putting the number of patients who qualify for CCM services at 15 million. This number is predicted to continue on an upward trend until 2050.
The World Health Organization (WHO) recognized the growing burden this trend in chronic disease places on the healthcare system and addressed the need for innovative solutions in their 2002 report. While the potential market is huge, in the billions of dollars yearly, healthcare organizations have been struggled to address the CMS guidelines with key requirements from CMS. We can no longer afford not to address the needs of patient with chronic medical conditions along with engaging them in their healthcare decisions.
The CMS guidelines are as follows:
24×7 access to clinical staff
Patient care continuum
Collaboration, coordination between primary care providers and other care services
Electronic management of care transition among care providers
Coordination between home and community care services
Patient engagement
Here is how these guidelines are now being addressed:
