What Is Population Health Management, Exactly?
By Steven Merahn, MD
While at HIMSS, I stopped by the KLAS booth and ended up revisiting the October 2013 KLAS report on population health management. I was both impressed and concerned about its findings. Impressed because of the level of market commitment to population health-related solutions, but concerned because I still don’t think the market gets it when it comes to population health management.
The real power of population health is the opportunity it offers those delivering care to disintermediate those we now call payers — removing or disrupting a layer insulating patients from their providers – or at least put physicians and provider networks in a position of strength in negotiations with those contracting for care (unfortunately, it also puts hospitals at risk for similar disruption, like what happened to the railroads when airline travel began to get traction).
HIMSS was full of vendors hawking analytics and care management platforms, but population health is really not at its heart a technology play. In the executive summary of the KLAS report, author Mark Wagner tried to address this issue when he said, “…automation is a misnomer for vendor solutions and PHM remains largely a manual process.”
However, the use of the phrase manual process is itself a misnomer. It presumes that automation is even possible for population health management. Elements of a technology stack can enable (and may be necessary for) population management, but these elements – individually and collectively – are wholly insufficient for successful implementation of a population management infrastructure.
Wagner again alludes to this in his reference to the value of “collaborating with physicians early,” but there’s more to this than simply physician engagement. It’s far more fundamental, as physician leaders, provider networks, and healthcare delivery systems are discovering. In successful population management, the databases, software analytics. and care planning platforms — whether EHR-based or independent but interoperable — are largely subordinate to a more dominant factor: the human factor.
If there’s one thing that has been consistently affirmed to me in the 30+ years since medical school graduation, it is that health and healing is impossible without the human connection. I submit that the value in value-based care – improving quality of care and quality of health based on more efficient use of effective healthcare resources across a cohort or defined population – is more powerfully achieved through reconsideration of the organizational principles and operating relationships among the people, programs, platforms, and partners that comprise healthcare delivery and care management.
Population health management transcends the technological elements that may fulfill some of its specific functional requirements. Product, services, and channels may be necessary, but are insufficient to truly influence the trajectory and quality of a person’s health. That influence occurs at more tactile and emotive levels in people lives, “tactile” referring to the responsiveness, reliability, consistency, and convenience of care; “emotive” referring to the sincerity, authenticity, integrity, and dignity associated with the experience.
I am reminded here of Dr. Lipton, our family physician in the 1950s and 1960s, For him, what we now call population health was just the way he practiced medicine. If my grandfather – who had his first heart attack in his mid-30s – missed his quarterly blood pressure check, we would get a call. After my grandmother’s sigmoidoscopy — then done in an operating room as an inpatient — he stopped by the house.
His technology for this: the work of worry — and a weekly index card tickler file. But despite what would seem to us some technological limitations, time and time again he demonstrated to us that we were very present for him even when we were absent from his waiting room.
He did get paid in cash for services rendered, on a fee schedule and sliding scale, but he also worked to earn our trust. There was no doubt that this was an important form of compensation for him. His value proposition was threefold: mastery of his craft, demonstrable commitment, and genuine consideration. As such, his responsibilities for our health extended beyond the doors of his office.
For our family, he provided comfort and a safe harbor – despite some looming health threats — because there was a person, and not just a person, an expert, who worried along with us and that was in many ways a more powerful influencer of our healthcare quality then the medicines he prescribed. His recommendations were followed, even when there was intellectual resistance, because we could not imagine letting him down.
Our current approach to technology is focused on “managing measureable variables,” but the real challenge is that quality of health is based on a different set of variables than quality of care. Our technology may allow us to identify and attempt to control dozens of evidence-based clinical factors, but is still not powered by factors representing the capacity to influence a patient in ways that truly matter.
Which means that if we truly want transform care delivery with technology, we need to shift our focus from the meaning of the data to what we mean to each other.
Healthcare technologies should be instruments of human expression in service of health and healing, with a fundamental mission to provide the patient and their family the same sense of comfort, safety, and reliability provided by the Dr. Liptons of the world – where professionals are valued for their commitment to mastery and human service and patients are helped to find the meaning of health in the context of their relationship with themselves and others.
This will require us to reconsider what we mean by population health by designing systems of care that amplify the humanness in our care delivery, where technology supports goal-directed collaboration between humans and machines and where we are allowing people to find meaning and value within themselves and from each other.
Steven Merahn, MD is senior vice president and director of the Center for Population Health Management at Clinovations of Washington, DC.
Why a Unique Patient Identifier is Critical to Improve Patient Matching
By Barry Hieb, MD
In a recent HIStalk article entitled “National Patient Identifier: Why Patient Matching Technology May Be a Better Solution,” Vicki Wheatley argues that, “… healthcare organizations should instead focus on strengthening their existing enterprise matching strategies” rather than work to implement a national patient identifier (NPI). The article makes several valid points that contribute to the ongoing debate about an NPI:
In these and several other areas, Ms. Wheatley’s article makes a valid contribution to the ongoing debate concerning a national unique patient identifier.
There were a few areas, however, where we have a somewhat different viewpoint. The first of these is the implied assumption that healthcare organizations must make a choice between having an EMPI and having a national patient identifier. We believe that this is a false dichotomy.
Clearly, healthcare organizations must continue to improve their existing EMPI systems as much as possible. However, years of analysis and experience indicate that this will not allow them to achieve the levels of patient matching accuracy that are being required going forward. Those requirements include identification of individuals across disparate healthcare systems, the need for matching against ever-increasing patient populations, and the fact that patient demographic data has known variability and ambiguities.
These represent just three of the reasons why unassisted EMPI demographic matching cannot represent the sole patient matching strategy. Rather, the EMPI approach will need to be supplemented by techniques such as the use of an NPI, biometrics, digital certificates, and other technologies.
Virtually every EMPI system uses a patient’s Social Security number as a data element to improve the performance of their demographic matching algorithm. I was puzzled by the statement, “… even in theory, every single potential patient in the country would need to be assigned one…” as a condition for an NPI to work. Ms. Wheatley acknowledges that there are many people in the US who require healthcare but do not have an SSN. Despite this deficiency, the use of the SSN clearly adds value in those situations where it is accurately available. Similarly, an NPI would benefit each patient who chooses to use one.
An important point to keep in mind is that there is no mechanism to check for data entry errors in most of the data elements currently used for demographic matching. This includes the SSN, names, and addresses. For example, there is no reliable way to detect transposition of digits when a SSN is manually entered. Nor is there an easy way to automate the capture of a patient’s SSN.
Contrast that with a well-designed national patient identifier system. In most situations, the NPI would be read using automated technology such as a barcode reader or a smart chip that would virtually eliminate errors. Even when the NPI is manually entered, embedded check digits can ensure that any data entry errors are immediately detected and the operator is prompted to re-enter the NPI. When added to a person’s demographic profile, the NPI thus becomes the single demographic element that can lead to accurate patient identification on its own. These proposals represent a major advance from the current situation – i.e., an 8 percent or more error rate in EMPI matches.
It is very clear that healthcare organizations will continue their use of EMPI systems for the foreseeable future. That fact, however, should not blind us to the reality that these EMPI systems need to be augmented by additional capabilities going forward if they are going to meet the patient matching accuracy needs that are emerging in healthcare.
The use of a national patient identifier, even if it is initially only chosen by a subset of providers (or patients, on a voluntary basis), will enhance the patient matching accuracy for those patients and help avoid the medical errors that are associated with patient matching errors.
Barry Hieb, MD is chief scientist with Global Patient Identifiers, Inc. of Tucson, AZ.
The views and opinions expressed in this article are mine personally and are not necessarily representative of current or former employers. Objects in the mirror may be closer than they appear. MSRP excludes tax. Starting at price refers to the base model; a more expensive model may be shown.
Attending HIMSS Made Me Wonder: Does IT Matter?
Flying home from HIMSS after spending a week in Orlando and reflecting on the conference it made me think about Nicholas G. Carr’s book from over 10 years ago that made everyone it IT defensive. Mr. Carr asked, with a provocative title, Does IT Matter?
After spending a few days on the HIMSS show floor, the collective group of exhibitors might have colluded to try to make Mr. Carr’s point.
Before I run the risk of losing my secret CIO decoder ring (which gives me wide, sweeping powers to say “no” to things, an important task of a CIO), let me skip to the end and say, “Heck yes, I think IT matters.” But it sure was hard to see at this year’s show.
Let me add context. Mr. Carr never claimed that IT didn’t matter. People who only read the title of the book argued thinking that, but his main point was that IT yielded diminishing returns as a continuing source of strategic differentiation.
Since I already shared that I don’t agree with his thesis and I think that IT does matter, let me explain more why it was hard to hold my ground at HIMSS.
I believe that real strategic value from IT comes from cumulative and sustained use of our systems.
The show floor at HIMSS is best at being a live shopping catalog. If strategic value comes from health systems hunkering down and “just using what they own,” it really means we should all be at our core vendor’s user group to get focused instead of out shopping. This is not to say that there weren’t some interesting new ideas and companies at the show, but I would contend that most health system should be implementing, optimizing, or perfecting the use of their existing systems.
The problem with not staying focused is that it makes us forget that IT is only a tool, not a panacea. Shopping for the latest technology because it can be installed now does not usually translate to having our problems magically solved.
Especially for those institutions that have achieved MU Stage 1 or HIMSS EMRAM Stage 6 or higher, the goal really needs to be to make use of everything we have by using our systems more deeply. Most big vendors I talk to often complain that they have trouble getting their existing customer base to either stay current on latest versions or to implement and use all of the already-live functionality.
But it is not simple. New technologies will continue to give companies the chance to differentiate and first movers who take risk will gain advantage. But understanding the opportunity and deciding when the right time to make the bet is not for the faint of heart. It is among the toughest choices for CIOs and the rest of the C-suite to make these days, with constrained budgets and scarce ROI from previous large IT projects.
Mr. Carr makes the claim that widespread adoption of best practices through the use of IT software makes advantages disappear. It is obvious to me that Mr. Carr never spend time trying to enforce common content in a large health system. If he saw our slower pace, he would certainly declare we had a long way to go and had a low risk of IT not mattering.
The reality is that a lot of the IT mystique has been eliminated as consumer use of technology continues to grow. IT teams now need to play by the same rules as other business units by having clear objectives before money is spent. The age of technology for technology’s sake is probably in the rear view mirror. As technology infrastructure becomes a commodity (the cloud), how we use our tools or the depth of our use of IT will define and create our advantage.
Adding to the challenges of the CIO will be the realization that just because we find a new innovation, it does not necessarily mean that it will pay to be a pioneer. Our focus might be better spent on hunkering down and optimizing.
If we are going to make IT matter, as a mentor once told me,“Let’s get ‘er done.” Then we can go shopping.
Mark Bakken is CEO of Nordic Consulting and an investor in several healthcare IT startups.
How’s Nordic’s business these days?
Our business is booming, like everybody else in healthcare IT right now. We’re doing a lot with optimization, helping a lot of Epic customers as they figure out how to leverage their investment in Epic and the EMR to not only improve care, but reduce costs at the same time.
It’s been pretty fun to be able to send in experts to quickly do an assessment and say, hey, if you enabled all these features and other things, you could most likely make your co-workers very, very happy by saving them some time, and at the same time, get better results or hone in on a cure a little faster, leverage the technology you have while at the same time get more done with less. It’s like the equivalent of robots for manufacturing. It’s fun to do these.
These organizations are so large. Nobody likes to eliminate positions or let people go if they don’t have to. But since most of them are so big, they can reduce the number of staff they need relative to them growing. If they do acquisitions and mergers, they don’t need to hire as many. The net effect is their efficiency gets better from a cost perspective, or they could do it through attrition if they say we no longer have to do registration, for example. Customers and patients are doing it automatically, so we need a lot of people. That person can then take a new career opportunity within a healthcare organization.
It’s fun to be on the forefront, to see organizations starting to leverage their initial investment into that second wave.
The company just moved to a new headquarters location. Epic is known for some interesting and fun buildings. What’s yours like?
[Laughs] It’s nowhere near as Disney or Google-like as Epic’s, but it’s nice and open and airy. We pride ourselves on transparency. We made it nice and professional looking, but within reason, I would say.
What’s the overall state of healthcare IT innovation and the business climate in Wisconsin?
Obviously with Epic in Madison — and I’m in Madison — there’s a lot going on here. There’s a lot of really sharp people that either come to the University, work at Epic, and then they have some ideas. Epic’s road map isn’t going to get around to building those into their core products for a few years, so they say, hey, maybe I can do it, grab some friends, and give it a shot at the new American dream — starting your own company and making it big some day. There’s a lot of that going on.
There’s a lot of support around that from the investment community here. Madison, Wisconsin was one of the leaders in the whole biotechnology wave that started taking off with stem cell research and everything else. Not to mention all the providers in Wisconsin were some of the early adopters, especially with Epic in our back yard, where they tried some things and are benefitting from some of those early advances with healthcare IT. We’ve got a lot of the good raw ingredients here.
Neither you nor Judy Faulkner would have fit my mental model of what education a founder would have since you both have degrees in computer science. Is there something different about being educated at University of Wisconsin or does Epic just create things that are like Epic?
It is interesting because usually that isn’t the background. We’ve taken different paths. Judy has been at it obviously for a long time. Trying to figure out the right mix and perseverance is a big piece of it and you do find that in computer science people that gravitate towards that. There’s always a problem you’re trying to figure out and there’s many different ways to go about it.
Maybe there’s something to that. Who knows? It might just be coincidence or maybe it is one of those things, as computers and technology are becoming much more relevant in a services-based economy, where you can use computers to automate things. That’s a good question.
What are you doing with your investing and what kinds of things you look for in companies?
What I look for, like most people, is a great management team, leadership, and passion. People that can inspire people, whether it’s people that follow them or just believe in their vision and their dream, whether it’s customers, or potentially investors. Then other employees that have the same desire or vision to do that.
With healthcare and IT and everything going on right now, all the pressure and all the change and everything else, there’s lots of ways you can use technology to not only get the patient more engaged and more accountable and figure out how to do that from the Fitbits, smart scales, to the whole continuum of care that say, it’s all about responsibility. It’s not just the physician, it’s not just the healthcare organization. Let’s all try to leverage technology to be healthier and live longer and find things sooner so we can find a cure.
Learn from each other. I heard a stat that says something like an average 40 percent of physicians’ initial diagnoses are incorrect. If that’s true, we can definitely do better than that by leveraging data. If we can leverage technology, leverage data to find things, to hone in on things sooner before they’re uncurable or unfixable, that ends up being a good thing. That’s basically what you look for.
Epic, Cerner, athena, Meditech, McKesson, AllScripts — the list goes on and on. They’ve got a really good platform and a good foundation, but healthcare and driving down costs and improving care is much more than just the clinical data. You got to take everything into account and there’s lots of different ways to do that. There’s a lot of bolt-ons.
I saw a ton of this with the whole Microsoft wave and revolution in 1990s and early 2000s where Microsoft has a platform, and then there’s lots of other companies out there like, hey, we can build on it and we can make something better for what you specifically need. The thing is, the bigger the companies get, they can’t come out with that specific module or niche. It might take them three to five years, and by the time they come out with it, the market may have moved on. They might have a different need or something else came up.
Young, small startups that are agile and can get things done quickly … it’s fun to be part of that.
What are some companies you’re investing in?
I would probably start with Catalyze.io. They’re creating repeatable platforms for healthcare IT. It’s HIPAA compliant. Instead of reinventing the wheel, there’s a lot of things that we could learn from each other. We can share that framework to do quick custom development stuff.
Forward Health is a great analytics company, population health, medical intelligence organization. Great way to slice and dice information easily. Not just clinical data, but when you look at RX data, claims data, consumer data, or anything else that you need in order to make better decisions faster for actuaries and statisticians as well as physicians.
Wellbe.me is another organization. Patient engagement before they come in for a surgery or when they leave, making sure they do all the things ahead of time and they fill out all the forms and all the checklists. They do it in a very easy way that’s a nice wraparound any of the EMR programs out there. Very affordable, works very, very well. Lots of interest from everybody to say, hey, when you come in, if you do all these things ahead of time, the odds of you not having to be readmitted greatly increase. Then afterwards, make sure you do all the follow-ups. It makes it easier for a healthcare organization to manage tons of people before they come in and after they come in and leverage their social network to do so.
Moxe Health, which is the connection and interfaces. Just think of all the different things you have to connect out there. Instead of paying someone to customize all those at the end of the day, maybe there’s 50 different systems that someone has to connect to, why do you have to custom build all those things over and over and over again? They’re making reusable app store type connectors out there.
Healthfinch is another one that makes a great way to save physician time. That’s their whole goal in life is to reduce the number of clicks. Right now there’s a lot of frustration on the physician side saying, hey, I just want to do what I do. Trying to find the best use of their time, finding that right mix without making them all hire scribes to follow them around. There’s some clever things they’ve done with prescription refills, which is interesting. On average, physicians spend seven percent of their time doing that. They have a way they can get it down to one percent. For every 100 physicians, if you can free up six physicians’ time doing things that could be automated, that’s a good thing for everybody.
What’s your vehicle for investing? Do you just make a personal investment or do you have a fund of some sort?
It’s all new territory for everybody. It’s either go to friends or family, which is tough because you don’t want to mix friends and family. It’s to try to do a round, or do a convertible note is what they would call it, where you can do a loan and then down the road, if they raise money, once they have more customers and more success than the valuation.
The trick is, you want to make sure the people actually doing the work have some substantial stake in the outcome and some motivation to make sure they can create something that’s creating value out there. If they do, they benefit and that would be good for me, too.
I just am a huge, huge fan of entrepreneurs. I know how tough it is to get going. You need the right mix of everything. You need the stars to all align and a little bit of guidance from “don’t do this” or “how do you do that?” Everywhere from how do you work with large organizations, how do you contract with them, how do you get insurance, how much insurance, to payroll, to taxes, to a lot of little things that everybody needed despite what they’re doing. If I can help point them in a direction that will save them a bunch of time so they can focus on what they really are good at, then I think that’s a good thing.
Is there a way the average person can invest now that some of the rules have loosed up, such as for crowd funding, for instance?
Not as easily as you would hope yet. You read all about the crowd funding. Some of the laws in Wisconsin, thankfully, have changed. You can actually get them some equity instead of some kind of token gift or something. It’s going to be easier without having to be accredited and all this other stuff and all these hoops.
There’s some other things I’m looking at personally trying to do. Change the business lending laws to be more in line with America’s economy, which is more of a services-based economy. The business lending laws that were set up 70 years ago were based on America being a manufacturing-based economy. You need inventory, you need all these other things, assets, you need buildings that a bank could repossess in order to get a line of credit or a loan. If we can make that easier for people so they don’t have to spend a bunch of time trying to get people to invest in their idea and everything else, I think that would be a good thing. It would be good for them, good for America.
What do the companies you’re investing in need most, other than money?
They need a mixture of things. You’ve got to have a customer that is willing to work with you, to at least do the pilot, to work out the kinks, to figure out how to price it, how to package it, how to deliver it. That’s one.
They need mentors from every angle, from lawyers, from LLCs or S corp to C corp to some other structure, and then all the other mentor types around like that. In Madison, we have something called 100health, which is geared towards helping people figure out where they can go for different resources and packages to get their idea off the ground in the most efficient manner.
I do have to say, there is a lot of other interest in investment in healthcare IT right now from the venture capital community, even down to the tens or hundreds of thousands of dollars, whether they’re from Chicago or all over the country. I just was in an advisory board meeting where they said that VC funding has more than doubled in the last four years in healthcare IT space. The rest of the world’s starting to take notice, to say, hey, I think there’s something to this whole EMR and healthcare IT technology wave that will be good for everybody.
Money comes at a price and companies give away their equity too early or get taken in a direction that seems to be the quickest path to profitability and not really what their vision was. Do you see that as a challenge?
Yes, absolutely. There are strings attached. Part of it is finding the right way to do that. Typically in Wisconsin and other states around the country, there’s a lot of older money. They don’t quite understand this new world economy; the Silicon Valleys and WhatsApp be worth $18 billion, not to say healthcare IT is going to go that kind of crazy.
It is basically trying to find that right balance. That’s why I think I can, because I know the healthcare IT space. Me personally making some kind of investment of faith at some kind of valuation to at least set the bar that is fair. Then other people can piggyback on that and do things at the same ratio with the entrepreneurs and the people doing all the work feel like, OK, that’s fair, I don’t feel like I’m getting held over a barrel.
What are the start-ups most naive about?
Most of them really, really get excited about their idea and their program or whatever they’re going to do without 100 percent going to the market and knowing are people willing to pay for this, and if so, how much, and is it enough where they can actually make a good living by providing that value to a customer. People can think great thoughts, but if the market isn’t ready, if there isn’t a budget, if it really doesn’t make sense, if it’s a nice to have instead of a need to have, then it’s one of those lessons learned type things.
How do you think healthcare IT will look different than it does today in five years?
It will be hugely different in a very, very good way. There was another study that came out like one in eight hospitals had an EMR back in 2009, five years ago. Five years from now, I think almost everybody will. With that, hopefully we’ll be able to analyze that data to be able to find other Patients Like Me type thing, where physicians, nurses, everybody in the healthcare world can use that data to hone in on a cure faster or to diagnose something before it’s unsolvable. I think we really, really, really will be using data a lot more so to make care better so people can live longer, healthier, happier lives.
Do you have any final thoughts?
It’s pretty fun to be part of it right now, the whole healthcare IT revolution that’s going on. The one thing I look at is saying roughly 18 percent of our economy is spent on healthcare and it’s basically flying blind. We’re using data for everything else, so it would be nice to actually use this data to make care safer and better. It’s fun to be part of it.
The GAO isn’t satisfied with plans the departments of Defense and Veterans Affairs has submitted claiming that separate EMRs will be more affordable and quicker than their original joint plans.
The two agencies had claimed that implementing separate, interoperable EMR systems would be a better choice than developing a joint EMR usable by both agencies. But the GAO says the two have not substantiated their claims that the separate EMRs would save money and time.
The GAO report comes after years of wrangling over how to create a joint, integrated EHR. The two agencies have been discussing creating the joint project, the iEHR, since 2009. The idea behind the iEHR was to allow every service member to maintain a single EHR throughout their career and lifetime.
However, the iEHR project came to a screeching halt in February 2013, when the two agencies announced plans to stop the project and focus instead on making their existing EHR systems more interoperable.
In follow-up, the House and Senate in December 2013 approved the funding bill that required to VA and DOD to create a plan for a single or interoperable electronic health record by January 31.
Since then the GAO has addressed the plans the two agencies made, and concluded that they have not:
In the GAO’s view, the fact that the VA and DOD are taking separate approaches — the VA modernizing its system and the DOD acquiring a new commercially available system — is not going to work out well.
The Health IT Policy Committee approves the Stage 3 Meaningful Use requirements that were recommended by its health policy workgroup, but only after cutting 30 percent of the functionality that was originally proposed.
CMS publishes its revised hardship exemption criteria for EHs and EPs. The new criteria essentially rubber stamps the exemption application for anyone that asks for one so long as they report "2014 Vendor Issues" in their request.
Carolinas HealthCare System is turning to predictive analytics to help identify ED patients that would likely be readmitted so that preventative measures can be taken. The hospital recorded a $5 million loss this year, its first loss in 30 years, and executives hope that analyzing the data from its EHR system will help it recover that loss.
A report from the National Institute of Standards and Technology finds that ambulatory EHR vendors are not doing a good enough job building key clinical workflows into EHR software.
Seeking profits, developers are converting abandoned hospitals in New Jersey into medical malls. This turns out to be a good news, bad news story as described in a recent article (see: Repurposing Closed Hospitals as For-Profit Medical Malls). Below is an excerpt from it:
New Jersey has been losing hospitals for more than two decades....But in recent years, a few developers have purchased some of these abandoned structures, reopening them as private medical complexes that offer many of the services the hospitals once provided. For struggling cities like Paterson, N.J., the new use removes blight from the streets, restores health care services, creates jobs and provides a tax boost when a for-profit company replaces a nonprofit institution. Since 2008, developers have bought hospitals in Paterson, Jersey City, Hammonton and Trenton, converting the buildings into so-called medical malls that house an array of services like urgent care centers, doctors’ offices and dialysis centers. Critics worry that these new medical complexes are no substitute for the hospitals they’ve replaced and may siphon off paying patients from them. Unlike a hospital, individual providers in a private medical complex are not required to provide charity care, nor do these complexes have nonprofit missions to serve a community’s health needs, although some tenants are nonprofits. Nevertheless, these buildings are often ideal for medical uses — an emergency department can be repurposed as an urgent care center. Existing operating rooms can be used for outpatient surgical centers. And an inpatient floor is a natural fit for a subacute care facility. Added to that, the new use is certainly preferable to a deteriorating structure that contributes to urban decay....An urgent care center, for example, is not an emergency room that can admit patients. While a nonprofit hospital is required to serve a community’s health needs, a developer’s primary goal is to fill space with tenants who can pay the rent. So a primary care doctor or a pediatrician might not be as lucrative a tenant as a radiologist....But for communities with a high mix of uninsured patients, the services available at a medical mall are inaccessible to a sizable portion of the population. So the remaining hospitals absorb more uninsured patients, while they lose paying patients to a medical mall.
First of all, the charity care provided by non-profit hospitals as a requirement for their tax-free status turns out often to be a myth (see: Non-Profit Hospitals Drift from Their Mission Despite Subsidies; Can U.S. Hospitals Become More Oriented to Health Outcomes?; Cities Begin to Question Non-Profit Status, Tax Breaks of Their Hospitals). The care provided on this a basis is often minor compared to most of their business and even this percentage is unreliable because it's often accounted for on the basis of the inflated "retail cost" of care. Giant health systems like the the University of Pittsburgh Medical Center are anything but non-profit. Here are a few details about it (see: University of Pittsburgh Medical Center).
The University of Pittsburgh Medical Center (UPMC) is a $10 billion integrated global nonprofit health enterprise that has more than 62,000 employees, 22 hospitals with more than 4,700 licensed beds, 400 clinical locations including outpatient sites and doctors’ offices, a 2.2 million-member health insurance division, as well as commercial and international ventures.
Healthcare is one of the major drivers of the U.S. economy. According to the World Bank, in the U.S. it now comprises 17.9% of the GDP. In many urban centers with large numbers of unemployed and uninsured, the standard business model for hospitals is no longer viable. If developers can convert abandoned hospital buildings to medical malls, this shift should be welcomed. Here's an interesting quote about the cause of many hospital closures and rural "medical deserts" (see: Hospital closures will leave 'medical deserts').
The [hospital] closures are for a variety of reasons, including demographic shifts, politics and the economy,...and reimbursement cuts to hospitals due to healthcare reform....The issue is not just the lack of geographical access, but the fact that residents of "medical deserts" in rural areas are less likely to have good health insurance....
As I reported for MedCity News at HIMSS14 nearly two weeks ago, CMS Administrator Marilyn Tavenner announced plans to provide unspecified flexibility in claims for Meaningful Use Stage 2 hardship exemptions this year. Tavenner then left without speaking to the media.
The news left a lot of people scratching their heads and waiting for some details. Today, CMS issued some clarification, confirming that there would be exemptions for healthcare providers unable to have EHRs certified to 2014 standards in place for the 2014 reporting year. This is particularly important now because Medicare penalties for not achieving Meaningful Use take effect next year, but they are based on the 2014 reporting year (Oct. 1, 2013-Sept. 30, 2014 for hospitals, the 2014 calendar year for physicians and other individual “eligible providers.”)
The guidance confirms that CMS is aware of the problems caused by the slow pace of certification to the new, 2014 standards that Stage 2 requires. As of today, according to the ONC Certified Health IT Products List (CHPL), there are 3,736 ambulatory and 1,200 EHRs and EHR modules certified to 2011 standards, but just 899 total that meet 2014 certification.
The following is a guest blog post by Minnette Terlep from Amphion Medical Solutions.
Often lost in the overarching conversation surrounding the potential negatives of ICD-10 is the very real impact it could have on the selection of physicians and hospitals by health plans, MCOs and shared-risk organizations for participation in provider networks. To succeed, these organizations seek out providers with a strong track record of care that is both high quality and cost-efficient—which is where ICD-10 can hurt or help.
Physicians do not assign codes. They are, however, responsible for documenting at a level of specificity that allows the assignment of codes—the burden of which is exponentially higher under ICD-10. The coder can only assign codes matching the level of specificity supported by the documentation. If the assigned codes reflect a level of severity that is artificially low because of inadequate documentation, it can raise red flags for organizations who profile physicians.
That is because these organizations look not only at severity of illness and mortality rates, but also cost efficiency in providing care. If a physician appears to be over-utilizing resources based on the final assigned codes, it is very likely he or she will be considered a risk and excluded from the network.
For example, if a physician simply documents “pneumonia” as the principal diagnosis and the patient receives standard care for this simple pneumonia, the case will generally and appropriately assign to the lower weighted MS-DRG for community acquired pneumonia. But what if the patient is actually diagnosed with a type of gram negative pneumonia that is fully supported by a positive culture? If the physician fails to document this more resource-intensive type of pneumonia so the significantly higher weighted MS-DRG can be assigned, then the patient’s days in the ICU and on the medical floor for continued care would not appear to be justified.
The difference in cost between the two scenarios is thousands of dollars, which is problematic on its own. However, it also presents ongoing challenges for the physician in the second scenario: Getting improperly tagged as a resource over-utilizer because, based on the codes and MS-DRG assignment, excessive care was provided. This could easily result in exclusion from a plan or participation in shared-risk initiatives.
We’ve been inundated with information on how clinical documentation must be significantly improved in advance of ICD-10 because of the impact under-coding can have on reimbursements and core measures performance. However, as illustrated in the pneumonia scenario, the potential impact on individual physicians runs deeper. When the highly detailed nature of ICD-10 is coupled with the growing emphasis on standardized care and quality over quantity, it spells potential financial and reputational ruin for physicians whose profile raises concerns about mortality rates and ability to provide cost effective care.
It may also impact the hospitals with which the physician is affiliated. Both can quickly find themselves locked out of networks and excluded from potentially lucrative shared-risk models. Exacerbating the potential impact is the growing (albeit slowly) emphasis patients place on identifying physicians and hospitals with high quality and outcomes rankings, both of which can be tainted by the specter of over-utilization.
While protecting a physician’s profile from the over-utilization category isn’t generally at the center of documentation improvement strategies in advance of ICD-10, there are ample reasons why it should be. So much of what we see and hear about the greater specificity required under ICD-10 is geared toward the impact DRG assignments will have on reimbursement, but in reality it can have far greater long-term financial and reputational repercussions.
Thus, identifying and correcting gaps and areas of weakness in clinical documentation will be beneficial not only for ensuring appropriate reimbursement levels and outcomes metrics reflecting true performance, but also to prevent unjust exclusion from provider networks.
Physicians and hospitals taking the time to analyze profiles to ensure they accurately reflect utilization rates, and to identify and correct documentation-related problem areas that may leave managed care and shared-risk organizations with the wrong impression, will find doors to participation will remain open—and benefit the bottom line.
Check out all of our ICD-10 Tuesdays series of ICD-10 related blog posts.
Saturday I had the tremendous (that’s in the sarcasm font in case you missed it) opportunity to do a pediatric walk in visit for my daughter. Everything is fine and my daughter’s doing well. However, while I was waiting in the lobby, I saw the following sign posted on the wall:
For those who can’t see images, here’s what it says:
Mission: Deliver the highest quality of care to tall of our patients.
Promise: HealthCare Partners of Nevada and its team of professionals will not tolerate nor be indifferent to poor quality.
Creed: Live our mission; Keep our promise
Someone recently described my blog focus as covering the business of healthcare. I thought that was a pretty decent description. Certainly we have an IT bend to almost all of our content, but we’re happy to write about anything that relates to the business of healthcare. It just so happens that IT is involved in almost every business aspect of healthcare.
With this focus, I think I sometimes get a little jaded when it comes to healthcare organizations motivations when it comes to the care they provide their patients. I’ve often argued for the importance of the almighty dollar when it comes to influencing doctors in healthcare. This was reinforced just today in Dr. Jayne’s post on HIStalk where she said, “At least all of our physicians were migrated to a common contract in tandem with our EHR project more than half a decade ago because we realized only money would align them with our goals.”
While I still believe that the financial incentives are the best motivator, I think we need to be careful and not take it too far. Healthcare should be and can be more than just the financial incentives alone. In fact, any organization with a long term view will likely have a mission similar to the one espoused by Partners HealthCare.
I strive similarly with my blogs. Certainly I need my blogs to be a viable business and I want to continue building them to be able to reach more people. However, my goal is for my blogs to be about much more than just making a buck. I believe they have, can, and will have an important impact for good on healthcare. I’m sure I’ll overstep on occasion and my good readers will hold me accountable when I do. However, hopefully the Healthcare Scene network can stay focused on providing real value to those who read.
I should maybe consider having my wife do a guest blog post on Partners HealthCare’s above mission as well. She took two of my boys to the same pediatric office today for a scheduled appointment to get some immunizations they said were needed. After waiting an hour in a non-kid friendly exam room with two children, the doctor came in for the visit and noticed my son was acting wild. The doctor then asked if my son was ready for Kindergarten if he couldn’t sit still in the exam room. My wife quickly replied that if he hadn’t kept her waiting in a non-kid friendly exam room for an hour, then our son would have been fine. Not to mention, my son was not looking forward to the shots.
To add insult to injury, the doctor returned to inform my wife that my son didn’t actually need the immunizations. They had finally found the record and he had already had all the required shots. My guess is they couldn’t find the record because they’d had to switch EHR when their EHR vendor sunset their original EHR. This is the same EHR which the doctor had told me two days previously, “He hated even more than the previous one.” That’s almost enough for me to want a PHR for my children. However, it’s not like the school would accept an immunization record from the PHR.
One could argue that my wife’s experience above didn’t compromise the quality of care my children received. That’s true unless you consider the counseling my wife will need for being driven insane while she waited for an appointment she didn’t actually need.
Having worked in clinics, I’m sympathetic to the doctor and practice. We realize things run behind. We realize their are limitations on what child friendly things they can have in exam rooms (although, how about a TV?). We understand that records get lost or that mistakes are made when looking them up. Although, when all those things conspire against my wife, you can understand her frustration.
This discussion reminds me of a topic I’ve been talking a lot about recently. There’s a difference between quality of care and customer service. As patients we have very little understanding of the quality of care we’re being provided. We don’t really know if the quality of care we’re getting is good or not. However, we’re keenly aware of the customer service experience. If you look at any doctor ratings site, it’s all rating customer service. Yet, so many of us equate those ratings with the quality of care.
What’s the moral of the story? We can all do better. That’s the journey we have ahead of us in healthcare. Continue to improve and do the best we can to provide amazing care. This is not a one time battle that you win and move on. It’s an ongoing battle that never ends. That’s what makes it so difficult. It’s also what makes it so important.
Walk-in clinics located in CVS and Walgreens stores offer a wide range of basic services such as vaccinations and the treatment of minor ailments. Some are even some offering lab tests (see: Lab Testing Now Being Offered in Walgreens California Stores). Although there are other players in this business, I think that these two companies dominate the field. They offer the convenience of multiple locations and effective marketing. Since their inception, one of the weaknesses of walk-in clinics in general has been their rudimentary electronic records. This gap now seems to be closing, at least for the CVS MinuteClinics (see: CVS-Epic deal will add EHRs to Minute Clinic in run-up to major expansion). Below is an excerpt from an article on this topic:
Just as CVS Caremark is poised to expand its MinuteClinic system, it’s inked a deal with Epic Systems to provide ambulatory electronic health record support for the clinics. The EHR/EMR giant will replace the homegrown EHR system CVS developed....It reflects a growing maturity of the MinuteClinic concept as it moves beyond flu vaccinations and blood pressure readings to provide more non-emergency care, and it is one of the healthcare industry trends to reduce healthcare costs by providing alternatives to hospitals or the doctor’s office. The clinics are equipped to provide vaccines, do some lab tests and provide several non-emergency care services....Dr. Nancy Gagliano, MinuteClinic’s chief medical officer, said Epic’s support of national interoperability standards, analytics and customization helped cement the deal. CVS currently has more than 800 MinuteClinic locations and expects that to almost double to 1,500 locations....“We need a robust IT system, an EHR that will effectively interconnect with our affiliated partners,” as well as health information exchanges, [Gagliano] said. “We’re going to have over 1,500 clinics in just over a couple of years. We see 4 million patients a year and we’ll see 10 million patients a year in the near future. So we need a big company to support the volume that we’ll have.”
It will be a while before people should expect to see Epic’s EHRs in action. It will take about 12 months to train staff and set up “specialized interfaces” and another year to roll out the EHR network across MinuteClinic locations. A couple of components of the EHR network CVS is installing are Care Everywhere, which works as a health information exchange between Epic customers; and Care Elsewhere, which makes interoperability possible between Epic systems and other non-Epic providers or health information exchanges....CVS just joined the CommonWell Health Alliance — a group of health IT companies to improve the way healthcare data is shared. At the time of its launch last year, the alliance was perceived...as an attempt to better compete with Epic....In the announcement last week at HIMSS, a statement said that CVS is joining CommonWell as a contributing member, and would work with RelayHealth to embed these services natively into its pharmacy system.” It will also help providers securely access prescription information to improve patient safety. “Through the Alliance, pharmacies and health care providers will be able to better connect with the broader health ecosystem.”
These deals and alliances with Epic, RelayHealth, and CommonWell on the part of the CVS MinuteClinics are all about the integration of information and access to prescription data for patients. I suspect that the long-term plan for CVS is to position their clinics as the most basic rung in the U.S. healthcare delivery system. As such, they need to provide clinical and drug information up the line and also get access to the medical records of other providers. This yields both integration and legitimacy.
So what's in this deal for Epic. A huge number of patient records, obviously. Here's a quote from above: [CVS is] going to have over 1,500 clinics in just over a couple of years. We see 4 million patients a year and we’ll see 10 million patients a year in the near future. Although Epic will continue to connect its hospital clients with health information exchanges (HIEs) when available, I also believe that Epic's goal is to become a de facto HIE for their large client base (see: Connectivity and Hospital-Based EMRs; The EMR as an Operating System?; A Reader Comments on Epic Interoperability and Care Everywhere; Surescripts May Capture the Health Information Network (HIN) Business; Sharing Medical Records across Hospitals with Epic's Care Everywhere; Judith Faulkner, EMR Interoperability, and Washington IT Politics). In this context, providing support for the MinuteClinics makes perfect sense.
— Vanessa Ulrich (@vanessulr) March 6, 2014
This is true if the actors are well intentioned. I’ve found that most in healthcare have the right intentions. Although, many don’t have the right data that could help them make better decisions.
— HealthcareNOWradio (@HCNowRadio) March 6, 2014
I’m going to have to chew on the idea of EMR sales being non-linear. An interesting observation by Chandresh. I’m excited to hear Chandresh share more of his experience with EMR sales at the Health IT Marketing and PR conference.
[Infographic] Secure access to patient data is more relevant than data privacy or cost reduction http://t.co/ix38jbuw9W
— EMC Documentum (@EMCdocumentum) March 6, 2014
I’m not sure if this was the exact intent of this tweet, but it reminded me of a discussion I had with some really chronic patients. To a person (and the parents since these were kids), they couldn’t give a rip about privacy. They were more than happy to give up any and all privacy if it would help them find a cure or treatment for their child. This reminds me that context is really important when it comes to privacy.
Since Lipitor has come off patent, Pfizer has been facing very serious competition from the manufacturers of generic copies of its former cash-cow (see: Pfizer Lipitor Sales Are Threatened by Ranbaxy Generic Copy). But the company continues to try to breathe new life into the product by now proposing an OTC version (see: Lipitor Down, But Not Out: Pfizer Plans an OTC Version). Here are some of the details:
I've been following Lipitor's "demise" ever since Pfizer vowed the drug would maintain a 40% share of the total U.S. atorvastatin market. In May 2012, we all thought Pfizer Threw In the Lipitor Marketing Towel when the Lipitor co-pay card/PBM discount plan failed to meet its goal of maintaining the aforementioned 40% share of the combined market for Lipitor and its generic equivalents for at least 6 months after generic brands were launched. At that time Lipitor's U.S. market share was 33%. Guess what Lipitor's U.S. market share versus generic atorvastatin is today. As reported in the WSJ (here), global sales of Lipitor plummeted in 2012 and 2013 to about 20% of what it was in the blockbuster heyday....
...Pfizer is preparing to sell an over-the-counter (OTC) version of Lipitor. According to the WSJ, "Pfizer recently started a 1,200-patient clinical trial to test if consumers taking a nonprescription Lipitor get their own blood tests to see if the medicine is improving their cholesterol and then make the right decisions based on the results." The FDA has to approve the switch to OTC status. Keep in mind that FDA already has "rejected proposals by Merck & Co. to sell an OTC version of the statin Mevacor, amid doubts that consumers could correctly choose to take a statin on their own or sufficiently monitor themselves for changes in cholesterol levels and side effects."
Will consumers "undertreat" their cholesterol because the proposed OTC version of Lipitor will come in a 10 milligram dosage form versus the 40 to 80 milligram Rx dosage forms?...[I]t all depends upon the price consumers will have to pay out of pocket -- medical insurance doesn't cover OTC medicines. Most people would think a little bit of cheap OTC Lipitor...is better than no treatment at all -- and surely better than generics that lack brand "personality." And because it is OTC, consumers will think it is as safe as aspirin and won't cause any problems that require monitoring. Pfizer can then market it like aspirin without mentioning any of the potential problems/side effects.
This is very interesting--a proposal by Pfizer to sell Lipitor OTC with the assumption that consumers will monitor their own cholesterol levels and thus treat themselves effectively and appropriately even with only a low-dose OTC product available. This will be a particular challenge for those with high levels who may not be diligent in seeking medical advices. I agree with the author of this blog note in that consumers frequently consider OTC drugs as "safe as aspirin" which, by the way, is not all that safe.
I am fascinated by the idea that an OTC drug could potentially be accompanied by a recommendation that the consumer should periodically monitor cholesterol levels. I suppose that such an OTC statin could be sold with a test kit for measuring cholesterol levels at home (see: Cholesterol Home Test Kits). However, this involves a finger-stick with a lancet and I suspect that this would be a challenge for many people. Sounds much too complicated so I doubt that it would be approved by the FDA.
::Update on 3/08/2014 at 9:15 a.m.
This year I’m chairing a healthcare IT event series called HealthIMPACT — it’s what I’m hoping will be some of the best places for healthcare technology enthusiasts and buyers to get actionable advice on what’s real, what’s BS, what to buy, what not to buy, and perhaps most importantly, which guidance is worth following. In order to make sure we cover the right topics, we have created a very short survey so that we have some evidence-driven approaches to proving we’re focusing on the right areas.
The survey should only take a couple of minutes to take and includes the following questions:
If you have a few minutes, please take the survey and help us make sure that these events are as filled with actionable advice as possible.
A week after the craziness that is HIMSS (there’s a reason the #HIMSSanity hashtag has done so well), I’m kicking around an idea that came to my mind on my flight home from HIMSS. Overwhelmed by the 5 days of in depth discussions, I closed out my HIMSS talking about healthcare IT with the lovely lady sitting next to me. It just so happened that she was a HIE coordinator at a hospital in California and was heading home from HIMSS as well.
We had a far reaching discussion on the 5 or so hour flight home from Orlando. At one point we started the discussion of personalized medicine. I think I freaked her out a little bit when I mentioned the concept of every organ having an IP address.
Our discussion prompted to me to consider this really interesting an important question:
Can we abolish a disease because we’re so good at predicting that disease that we prevent it from ever happening?
When I considered this idea, it reminded me of Bill Gates (and many others) efforts to literally eradicate Polio from off the face of the earth. They’re doing so using vaccines and I can’t remember the exact timeline, but they’re only a few years out from this goal. It’s so empowering to think about eradicating a disease. Could health IT have a similar impact?
I haven’t thought through all the diseases and all the technology that could benefit from this concept, but I’m quite certain this is the real future of healthcare IT. How wonderful would it be to work on a project that determined the cause of diabetes early enough that we no longer had diabetics? What if we no longer had coughs and colds because we could identify the warning signs early enough that we could stop them from ever happening? We just need to get past the beauracracy and regulation and on to solving these major problems. No doubt this will take an enormous effort and resources and people beyond the traditional health IT.
This is a lofty concept indeed. However, I don’t think these ideas are that far away. What do you think? Could healthcare IT be used to abolish a disease?
A colleague of mine, Dr. Alan Weder, has recently begun to offer his services as a medical navigator to patients and their families for an hourly fee. He is a retired University of Michigan Medical School faculty member. In a previous note, I discussed how so-called "navigators" have begun to crop up as staff members in physician offices (see: Yet Another Type of Healthcare Professional Who Focuses on Patient Support). Dr. Weder is also offering to serve as a navigator but one who is independent of any caregivers and working solely on behalf of the patient. I personally think that such advice can be very useful but, obviously, the quality is highly dependent on the skill set of the physician-navigator. There are also for-profit physician navigator companies advertising on the web but I can't vouch for their quality (see, for example: Your Medical Navigator). In a previous note, I commented about how difficult it was to say "no' to physician recommendations; this is relevant to the emergence of medical navigators (see: Teaching Consumers to Say "No" to Physicians' Recommendations). Here is an quote from it:
It will be extremely difficult for most consumers to say "no" to their physicians. The knowledge and experience in diagnosing and treating disease lies with the physicians we consult for problems. Such a scenario rarely lead to "no". However, try substituting the word "maybe" for "no" in response to a physician's recommendations. This "maybe" approach allows the patient to seek more information to determine whether the recommendation is appropriate. Don't attempt this in the pressure-cooker environment of a doctor's office.
Seeking the services of an independent physician navigator provides another source of information for a patient and family. Here are a number of interesting points I learned during my discussions with Dr. Weder:
Last Spring, after attending an Institute of Medicine meeting on Childhood Obesity, I wrote about fronts and Heroes in the Health Attention War. Arguing that if we were going to do anything about long-term patient engagement around health and influencing healthy decisions, we had to start with habits and getting attention at an early age. Attention is the first step towards long-term behavior change.
At that time, I was happy to see the The Ad Council, who has been so successful in campaigns around littering and drunk driving, was working to get attention around childhood obesity to some specific communities. Advertising, after all, is all about directing attention, the necessary first step towards new behavior change. Meanwhile, some school districts were using the ideas behind behavioral economics to influence healthy food choices in schools, which continue to show success.
Today, I’m happy to report that something – or many things – have been working. Via the Robert Wood Johnson Foundation (RWJF) a JAMA Report “shows that that obesity prevalence among 2 to 5 year olds has dropped by approximately 40 percent in eight years.” This is truly outstanding progress. This is the most important age group to address as habits formed here can remain very hard to break later in life.
RWJF goes on to say “After decades of seemingly endless bad news about obesity, our collective efforts over the last several years show that we as a nation are finally moving in the right direction. Of course we can’t stop now.”
Also encouraging, they mention a report yesterday by “Let’s Move” declaring , “Nine out of ten schools across the country are certified to meet healthier lunch standards, and all schools with 40 percent of students qualifying for free or reduced-price lunch will soon be able to provide healthier, free meals to all of their students.”
Let’s continue to build on this progress, getting attention and enabling smarter choices around the problem that eventually became our nation’s health care crisis.