McKinley County, New Mexico, is the namesake of the assassinated 25 U.S. President William McKinley. Many locals, particularly those Native Americans of Navajo decent living on reservations, have also been the victim of assassination, but in character in addition to physical attacks. Three decades ago Gallup, New Mexico, which borders on the Navajo Reservation, was known as “Drunk Town, USA.”
For many years Northwest New Mexico’s Gallup ranked number one nationally in the number of alcohol-related deaths. This reputation also killed many resident’s spirits, contributing to addiction, joblessness and homelessness, further highlighting the need for behavioral health care in this region. Native American youth have the highest rates of alcoholism of any racial group in the country, according to the National Institutes of Health.
McKinley County Is One of Poorest in U.S.
There are many stories like this. Addiction’s partner is the adjunct poverty of McKinley County, one of the poorest counties in the U.S. In Gallup there is a large population of Navajo and Na’nizhoozhi Indians. It is the most populous city in the county with 22,670 residents and is situated between Albuquerque and Flagstaff with 61 percent living below the federal poverty line and unemployment at 8.4 percent.
The Indian Health Service (IHS), an operating division within the U.S. Department of Health and Human Services (HHS) is the principal federal health care provider for Indians. Its mission is to raise their health status to the highest possible level. However, there are still issues such as the life expectancy for Indians being approximately 4.5 years less than the general population of the United States, 73.7 years versus 78.1 years.
Data from a 2014 National Emergency Department Inventory survey also showed that only 85% of the 34 IHS respondents had continuous physician coverage. Of these 34 sites surveyed, only four sites utilized telemedicine while a median of just 13 percent of physicians were board certified in emergency medicine. Another behavioral health related disease afflicting the territory is diabetes. In 2016, diabetes was the sixth leading cause of death for New Mexicans and the seventh leading cause in the U.S.
RMCHCS Hospital Fights Addiction with Behavioral Health Apps
Despite the drumbeat of bad news and discouraging statistics, organizations such as Gallup’s Na’ Nihzhoozhi Center Inc.’s (NCI) has 26,000 admissions every year and is the nation’s busiest treatment center with many repeat customers. The detox center was the result of an effort 30 years ago which began when more than 5,000 people marched from Gallup to Santa Fe to demand assistance from state lawmakers and received a $400,000 for a study to build a detoxification center. The hospital then received two-million-dollar ongoing yearly federal grant out of which NCI was born.
When he became CEO of RMCHS a few years ago, he took a financially failing hospital and turned it around with the help of William Kiefer, Ph. D who is the hospital’s chief operating officer. Recognizing the root cause of the region’s health problem was addiction, Conejo revitalized a former rehab building on the hospital’s grounds and with some fundraising he launched the Behavioral Health Treatment Center.
The center is operated by Ophelia Reeder, a long-time healthcare advocate for the Navajo Nation and a board member of the Gallup Indian Medical Center. Bill Camorata, a former addict, is the behavioral special projects director. He opened “Bill’s Place,” an outdoor facility where he and hospital volunteers treated the homeless with meals, clothing and medical triage as part of Gallup’s Immediate Action Group that he founded and serves as president. The center has treated more than 200 addicted residents since the center opened in 2015 and has a staff of 30 who manage resident’s case work, provide behavioral health services and are certified in peer support.
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.
One ageless trend emerging for 2018 is the quest of hospitals, larger carriers and clinics to identify new revenue streams; not just managing revenue cycles, but creating them. The healthcare industry is now looking at revenue which can be generated through the interoperability of annual wellness visits (AWV), chronic care and service care transitions between physical and behavioral health services. Hospital systems and other healthcare facilities that can connect these services with technologies such as bi-directional information flow will benefit by offering these services and creating a new profit centers of revenue through reimbursements by CMS and private insurers.
These types of market drivers are noted in The Global Healthcare Revenue Cycle Management (RCM) Software Market report for 2017-2021, issued a few months ago. The report predicts that the global healthcare revenue cycle management (RCM) software market will grow at a CAGR of 4.50 percent during the period through 2021.
Healthcare service providers deploy automated systems to address RCM processes and to fill the payment gap that arises from the processes of medical billing and collections. However, the report points out IT applications such as hospital information system and EHR have outdated technology platforms that lack advanced functionalities needed to address RCM issues, causing hospitals and health systems to prefer to outsource these services due to the lack of interoperability between revenue cycle processes and workflows. This type of outsourcing drains hospital revenue.
Meanwhile, global business researcher Radiant Insights issued a study in November reporting that the healthcare information technology market will have growth through 2022 of close to $50 billion. Factors such as increasing focus on improving quality of care and clinical outcomes, rising need to reduce healthcare costs and minimize errors in medical facilities, along with government support for healthcare IT solutions will drive the market. Increasing adoption of technologically advanced software solutions including EHR and EHR connectivity systems, e-prescribing and clinical trial management software and clinical decision support systems is helping to improve healthcare productivity.
The study also cited the growth of cloud computing in the healthcare industry is improving real-time communication and data exchange. Interoperable systems and cloud computing are integrating healthcare systems at a rapid pace and are identifying infectious diseases and tracking the incidence as well as occurrence rates of chronic diseases.
Radiant Insights points to up-and-coming organizations such as Zoeticx, Inc., a provider of medical software, that has introduced a cloud app called ProVizion Wellness. This software can be beneficial for streamlining data integration for annual wellness visits by offering interoperability through bi-directional data flow. Hospitals and other healthcare facilities are benefiting by providing this service through private and government insurers. This system provides management capabilities for supporting tracking ability on population progress for AWVs. The report also mentioned prominent players operating in the healthcare information technology (IT) market include 3M Health Information Systems, Lexmark Healthcare, Conifer Health Solutions, and CSI Healthcare.
The Chemistry of Linking Unrelated Hospital IT Landscapes to Revenue
As the hospital revenue trend for 2018 looks promising, we are still facing the same old interoperability issues despite the advances in technology pointed out in the previously mentioned research. What can hospitals and clinics do to be a revenue leader? As we move into 2018, it might be a good time to examine what is necessary to solve a complex problem like the ability of hospitals to link interoperability and the benefits that arise from adopting tools, technologies and concepts from unrelated landscapes.
When we look at the value generated in healthcare, we remain enamored with acute care administration to address patients’ concerns with a new illness or exacerbation of a chronic condition. One of the stated goals of widespread EHR adoption was to assist in this aspect of care. EHRs are being used to capture patient data, as well as to label and extract detailed metrics in an attempt to quantify the amount and quality of the care delivered, irrespective of the geographic and temporal boundaries of where the data was captured. The design of EHR’s is to allow for capture and subsequent analysis and billing for the care delivered.
However, the value of health IT lies in the robustness of applications. This might seem obvious since most of the technology we have direct experience with relies on the applications which drive value such as cloud based assets. For hospitals, investing in an application seems more prudent then investing in a protocol. However, by looking at the problems faced in healthcare, changing the perspective of the problem from an application-centric one to that of a protocol-centric view brings new revenue possibilities.
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.
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 M. 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; and Thanh Tran, CEO, Zoeticx, Inc.
The ECRI Institute released in May a survey outlining the top 10 safety concerns for healthcare organizations in 2015. The second highest concern is incorrect or missing data in EHRs and other health IT systems.
HIEs? The latest Black Book survey in the U.S. finds that 90 percent of hospitals and 94 percent of independent physicians don’t trust the business model of public HIEs and have concerns over how much of the cost payers will be fronting, causing a contraction in the HIE market. Even the ONC and medical industry are at odds on how to address the interoperability issue. The ONC does not even mention middleware in any of its plans.
Even HL7 does not provide the seamless connection of middleware and is only capable of connecting one medical facility to another, 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, HL7 is really a point-to-point customized interface requiring extra steps. A middleware platform does not tie developers to specific hospitals or EMRs and allows universal access.
Meanwhile, yet another survey cites the tragedy of a lack of interoperability. A new survey of nurses nationwide, taken by the Gary and Mary West Health Institute, find that some 60 percent of registered nurses say medical errors could significantly decrease if hospital medical devices were coordinated and interoperable. Also, 74 percent of these nurses agreed that it is burdensome to coordinate the data collected by medical devices and 93 percent agreed that medical devices should be able to seamlessly share data with one another automatically.
Half of them claim they actually witness medical mistakes because of lack of interoperability of these devices. Some 46 percent of RN respondents also noted that when it comes to manual transcription from one device to another, an error is “extremely” or “very likely to occur.”
From a cost perspective, West Health Institute officials estimate that a connected, fully interoperable health system could save a potential $30 billion each year by reducing transcription errors, manual data entry and redundant tests. Meanwhile physicians and surgeons struggle with interoperability on a daily basis.
According to data published on HealthIT.gov, 173 health IT vendors are supplying certified EHR products to more than 4,500 hospitals. Despite wide penetration of EHR’s in hospitals, clinics and physician offices, access to patient information between systems continues to plaque our healthcare system.