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The Impact of the 2016 Election on Healthcare IT

Posted on November 9, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today it’s pretty obvious that the Presidential is on everyone’s mind. While I don’t plan to discuss the details of the election and the specific results, it’s worth thinking about what Donald Trump in the white house will mean for healthcare IT.

Let’s start off with the easy one: Meaningful Use/MACRA. One doctor tweeted me that now that Trump is President, MACRA will be gone. I don’t think that’s further from the truth. In fact, I really can’t imagine any scenario where the EHR Incentive program (Meaningful Use, which still applies to hospitals and Medicaid) and the MACRA program would be gone. I think they’re here to stay and won’t be altered at all by this election.

The biggest reason for this belief is that Trump is going to have so many other things on the agenda. Not the least of which is ACA (Obamacare), which we’ll get to later in this post, but also a whole suite of other things that he’ll make a priority. Why would Trump want to take on a relatively bipartisan thing like healthcare IT, EHR and MACRA? I don’t think he’ll waste a second on the subject.

Plus, even if Trump wanted to go after the MACRA and EHR incentive legislation, I can’t imagine the Senate and House passing something to replace those programs either. Remember that Trump can propose all he wants, but the Senate and House have to pass it too and both of those groups seem to be firmly behind both efforts. Add this to the previous point and why would Trump go after health IT when it’s unlikely to pass and isn’t a strategic goal of his? Short Answer: He won’t.

My opinion: we’re unlikely to see any change to MACRA and other healthcare IT initiatives.

The trickier part to assess is the impact a Trump presidency will have on the Affordable Care Act (ACA or Obamacare). I live in Vegas and I wouldn’t even want to offer odds on what’s going to happen there. The rhetoric out there is to “repeal and replace Obamacare.” What’s not clear to me is if this concept is even practical and possible. There are so many issues with the idea of repealing Obamacare, that I can’t imagine it ever happening. I could see parts of it being repealed, but not the whole thing.

I also think it would be seen as very unfavorable for Trump to roll back things like the pre-existing condition exemption that allows those with pre-existing conditions to get insurance. There are probably a dozen other things like this that would likely be hard to take back without some major backlash and so I think they’ll have to preserve many of these things in whatever they do with Obamacare. Maybe that means a full repeal, but then rolling back in some of the popular pieces of the legislation so they can say they repealed it.

All of this said, I think that Trump will evaluate all options to undermine many of the things that were implemented by Obamacare including the insurance mandate and the insurance exchanges. Most people don’t realize that there’s so much more to Obamacare than just the mandate and exchanges. How he’ll undermine Obamacare and the impact it will have is anybody’s guess. I’m not sure anyone really knows and it’s certainly beyond my political punditry.

Long story short on Obamacare, I have no idea. I know that something’s going to happen because of the strict “Rip and Replace” rhetoric. I just think it’s really hard to predict which parts they’ll be able to rip out at this point and what they’ll replace it with going forward.

No doubt this will keep many in healthcare on edge. Unknowns are always a challenge. While I think the Trump Presidency will likely have a big impact on healthcare, I don’t see it having a big impact for good or bad on healthcare IT. I think the path to healthcare IT is happening and he won’t do anything to really stop it.

Side Note: Check out this interesting lessons learned post by Mr. H at Histalk which talks about the challenge of relying on data. As healthcare enters the world of data in a big way, it’s important to make sure we have a good understanding of what the data really tells us and what it doesn’t.

A Look At Nursing Home Readiness For HIE Participation

Posted on October 12, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A newly released study suggests that nursing homes have several steps to go through before they are ready to participate in health information exchanges. The study, which appeared in the AHIMA-backed Perspectives in Health Information Management, was designed to help researchers understand the challenges nursing homes faced in health information sharing, as well as what successes they had achieved to date.

As the study write up notes, the U.S. nursing home population is large — nearly 1.7 million residents spread across 15,600 nursing homes as of 2014. But unlike other settings that care for a high volume of patients, nursing homes haven’t been eligible for EMR incentive programs that might have helped them participate in HIEs.

Not surprisingly, this has left the homes at something of a disadvantage, with very few participating in networked health data sharing. And this is a problem in caring for residents adequately, as their care is complex, involving nurses, physicians, physicians’ offices, pharmacists and diagnostic testing services. So understanding what potential these homes have to connect is a worthwhile topic of study. That’s particularly the case given that little is known about HIE implementation and the value of shared patient records across multiple community-based settings, the study notes.

To conduct the study, researchers conducted interviews with 15 nursing home leaders representing 14 homes in the midwestern United States that participated in the Missouri Quality Improvement Initiative (MOQI) national demonstration project.  Studying MOQI participants helped researchers to achieve their goals, as one of the key technology goals of the CMS-backed project is to develop knowledge of HIE implementations across nursing homes and hospital boundaries and determine the value of such systems to users.

The researchers concluded that incorporating HIE technology into existing work processes would boost use and overall adoption. They also found that participation inside and outside of the facility, and providing employees with appropriate training and retraining, as well as getting others to use the HIE, would have a positive effect on health data sharing projects. Meanwhile, getting the HIE operational and putting policies for technology use were challenges on the table for these institutions.

Ultimately, the study concluded that nursing homes considering HIE adoption should look at three areas of concern before getting started.

  • One area was the home’s readiness to adopt technology. Without the right level of readiness to get started, any HIE project is likely to fail, and nursing home-based data exchanges are no exception. This would be particularly important to a project in a niche like this one, which never enjoyed the outside boost to the emergence of the technology culture which hospitals and doctors enjoyed under Meaningful Use.
  • Another area identified by researchers was the availability of technology resources. While the researchers didn’t specify whether they meant access to technology itself or the internal staff or consultants to execute the project, but both seem like important considerations in light of this study.
  • The final area researchers identified as critical for making a success of HIE adoption in nursing homes was the ability to match new clinical workflows to the work already getting done in the homes. This, of course, is important in any setting where leaders are considering major new technology initiatives.

Too often, discussions of health data sharing leave out major sectors of the healthcare economy like this one. It’s good to take a look at what full participation in health data sharing with nursing homes could mean for healthcare.

MACRA Challenges and Predictions

Posted on October 11, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

On Thursday, October 13, 2016 at 3:00 PM ET (Noon PT) I’ll be hosting a live video interview with three MACRA experts. We’ll be discussing the challenges associated with MACRA and predictions on what will be included in the MACRA final rule. If you’re interested in learning more about MACRA, you’ll really enjoy this discussion.

The great part is that you can join my conversation with this panel of experts live and even add your own comments to the discussion or ask them questions. All you need to do to watch live is visit this blog post on Thursday, October 13, 2016 at 3:00 PM ET (Noon PT) and watch the video embed at the bottom of this post or you can watch on YouTube directly. The conversation will be recorded as well and available on this post after the interview.

Here are a few details about our panelists:

2016-october-macra-challenges-and-predictions

We hope you’ll join us live or enjoy the recorded version of our conversation. The MACRA legislation is an extremely important one for healthcare. Making sure you understand it is going to position you well for all the changes that are coming to healthcare.


(To Ask Questions, visit the YouTube page)

If you’d like to see the archives of Healthcare Scene’s past interviews, you can find and subscribe to all of Healthcare Scene’s interviews on YouTube.

Finally, be sure to check out our MACRA Monday series of blog posts where we dive into the details of the MACRA rules.

As Patient Engagement Advances, It Raises Questions About Usefulness

Posted on September 26, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Reading ONC’s recent summary of patient engagement capabilities at US hospitals left me feeling both hopeful and wistful. The ONC, as usual, is trying to show off how much progress the field of health IT has made since Meaningful Use started, and the statistics in this dashboard meet those goals. On the other hand, I look at the statistics and wonder when real patient empowerment will emerge from these isolated gains.

The ONC dashboard includes information both on raw data exchange–what Meaningful Use called view, download, and transmit (VDT)–and the uses of that data, which ultimately mean much more than exchange.

I considered at first how important I would find it to download hospital information. I certainly would like my doctors to get the results of tests performed there, and other information related to my status upon discharge, but these supposedly are sent to the primary care physician in a Continuity of Care Document (CCD). If I or a close relative of mine had a difficult or chronic condition, I would certainly benefit from VDT because I would have to be an active advocate and would need the documentation. My point here is that our real goal in health reform is coordinated care, rather than data transfer, and while VDT is an important first step, we must always ask who is using that information.

The ONC did not ask the hospitals how much of their data patients can download. God is in the details, and I am not confident that an affirmative answer to the question of downloading data means patients can get everything that is in their records. For instance, my primary care physician has a patient portal running on eClinicalWorks (not his choice, but the choice of the hospital to which he is affiliated). From this portal I can get only a few pieces of information, such as medications (which I happen to know already, since I am taking them) and lab results. Furthermore, I downloaded the CCD and ran it through a checker provided online by the ONC for a lark, and found that it earned D grades for accurate format. This dismal rating suggests that I couldn’t successfully upload the CCD to another doctor’s EHR.

Still, I don’t want to dismiss the successes in the report. VDT is officially enabled in 7 out of 10 hospitals, a 7-fold growth between 2013 and 2015. Although the dashboard laments that “Critical Access, medium, and small hospitals lag,” the lag is not all that bad. And the dashboard also shows advances in the crucial uses of that data, such as submitting amendments to the data

A critical question in evaluating patient engagement is how the Congress and ONC define it. A summary of the new MACRA law lists several aspects of patient engagement measured under the new system:

  • Viewing, downloading, and transmitting, as defined before. As with the later Meaningful Use requirements, MACRO requires EHRs to offer an API, so that downloading can be done automatically.

  • Secure messaging. Many advances in treating chronic conditions depend on regular communications with patients, and messaging is currently the simplest means toward that goal. Some examples of these advances can be found in my article about a health app challenge. Conventional text messaging is all in plain text, and health care messaging must be secure to meet HIPAA requirements.

  • Educational materials. I discount the impact of static educational materials offered to patients with chronic conditions, whether in the form print brochures or online. But educational materials are part of a coordinated care plan.

  • Incorporating patient-generated data. The MACRA requirements “ask providers to incorporate data contributed by the patient from at least one unique patient.” Lucky little bugger. How will he or she leverage this unprecedented advantage?

That last question is really the nub of the patient engagement issue. In Meaningful Use and MACRA, regulators often require a single instance of some important capability, because they know that once the health care provider has gone through the trouble of setting up that capability, extending it to all patients is less difficult. And it’s heartening to see that 37 percent of hospitals allowed patients to submit patient-generated data in 2015.

Before you accept data from a patient, you need extra infrastructure to make the data useful. For instance:

  • You can check for warning signals that call for intervention, such as an elevated glucose level. This capability suggests a background program running through all the data that comes in and flagging such warning signals.

  • You can evaluate device data to see progress or backsliding in the patient’s treatment program. This requires analytics that understand the meaning of the data (and that can handle noise) so as to produce useful reports.

  • You can create a population health program that incorporates the patient-generated data into activities such as monitoring epidemics. This is also a big analytical capability.

Yes, I’m happy we’ve made progress in using data for patient engagement. A lot of other infrastructure also needs to be created so we can benefit from the big investment these advances required.

Doctor Survey Can’t Muster Enthusiasm for Electronic Health Records

Posted on September 14, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Medscape’s annual report on electronic health records (EHRs) is out for 2016. With more than 15,000 physicians over 25 specialties responding, there’s little to celebrate in it. The survey confirms what we know about the Meaningful Use program–it succeeded in getting doctors to use EHRs (slide 2) and to convert their paper charts to EHRs (slide 30). What the Meaningful Use program failed at, apparently, is meaningful use of EHRs.

When doctors were asked about the effects of the EHR on their practice, most reported “no change” (page 18). Yes, they say it has helped them with “documentation”–but how is that an achievement? Maybe you can get your thoughts into the record, but that’s of no value if it doesn’t improve patient service or clinical operations. In fact, the EHR has negative value. The survey confirms what we’ve heard anecdotally for years: the EHR is widely reported to slow down workflow (slide 25) and to dramatically degrade almost every aspect of the doctor-patient interaction: face-to-face time, management of treatment plans, etc. (slide 19). The text in slide 19 pallidly argues that, well, the results aren’t as bad as they were in 2014. Certainly, users will learn over time to compensate for bad systems, but that doesn’t turn them into good systems. If they were good systems, doctor satisfaction would have gone up since 2012–instead, it’s plummeting (slide 22). I have to admit that I don’t quite understand what the term “satisfaction” means in this context (as opposed, say, to the Rolling Stones song). I take the specific observations of slides 18 and 19 more seriously.

We can probably count as a success that 30 percent of patients review their data (slide 20). As a proxy for patient engagement, this doesn’t go far (and it happens during the visit, not online), but I bet hardly anyone used to review their data.

E-prescribing remains the most “helpful” aspect of an EHR (slide 17). This probably reflects the dominance of a single service, SureScripts, in that area. With little to worry about in terms of interconnection, the industry can exchange data relatively easily. Other areas of health care continue to struggle and falter when it comes to basic data exchange–for instance, only 35 percent of doctors found EHRs helpful to provide clinical summaries of visits to patients. When we can’t even get to square one on patient engagement, we have a lot left to demand of EHRs.

There’s a huge gap between hospitals and independent practices in their choice of EHRs. This suggests that the major EHR vendors are aimed at lucrative markets–the kind of enormous practices that run in buildings that tower above their urban landscapes. Epic, of course, is far and away the most popular hospital system (page 6). The market for independent practices looks like the Republican presidential polls early in the primaries–totally fragmented (slide 7). eClinicalWorks takes top spot with 12 percent of the market, and all the other services, many of them well-known, trail with single-digit shares of the market.

Strangely, when independent practices were asked to rate their EHRs (slide 11), the order was quite different. It may be that small samples and close margins make the differences between slide 7 and 11 insignificant.

The nice aspect of this finding (satisfying, one might say) is that independent practices really are independent. Doctors apparently do their research and choose what’s best for them. Large systems, by contrast, force their associated outpatient clinics to use the same system the hospital uses, regardless of its suitability or usability.

Ratings show what users truly think of EHRs. On a scale from 1 to 5, you might think that at least one or two might wander into the 4-to-5 range, but none receives that honor. The Veterans Administrations’ VistA interface (see our recent article on it) comes out on top of the pack (slides 8, 9 10, and 12), which is no surprise because it has been rated highest by doctors for decades. This popularity doesn’t help VistA in the fight for institutional dollars. A widely popular, open source, totally customizable, low-cost solution is no match against aggressive salespeople from vendors that cost a cool billion to install.

But to be fair, several major vendors come very close to VistA in popularity, and I don’t know what the margin of error is (for the survey as a whole, it’s +/-0.8 percent). Epic may well make just as many people happy as VistA. Furthermore, VistA’s rating fell a tiny bit over the past two years (slide 9) and it doesn’t show up at all among independent practices (slides 7 and 11). Vendors are also shuffled around a bit when doctors rate them for particular features, such as ease of use, vendor support, or connectivity. (Connectivity is an odd thing to rate, because it takes two to tango. If doctors rate a vendor well just for exchanging records with other providers using the same vendor, the whole point is lost).

There’s little age difference in doctors’ comfort using EHRs (slide 23). The reported revolt by older physicians doesn’t seem to be real. However, it may be that a truly transformative use of EHRs, with data and clinical decision support intensely integrated into the practice, would appeal more to newer members of the field. Perhaps slide 23 reveals that EHRs aren’t having much effect.

With all the dissatisfaction, 81 percent plan to keep their current EHRs. Perhaps that’s a resigned acceptance of how bad the field is; no alternatives exist. By the way, only 32 percent of the doctors have attested for Stage 2 of Meaningful Use (slide 29). How they’ll meet the requirements of the new MACRA law is beyond me. And unless real EHR competition picks up (in an industry that already has too many vendors), I don’t expect a radical improvement in vendor ratings in the 2017 survey.

Study: Health IT Costs $32K Per Doctor Each Year

Posted on September 9, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new study by the Medical Group Management Association has concluded that that physician-owned multispecialty practices spent roughly $32,500 on health IT last year for each full-time doctor. This number has climbed dramatically over the past seven years, the group’s research finds.

To conduct the study, the MGMA surveyed more than 3,100 physician practices across the U.S. The expense number they generated includes equipment, staff, maintenance and other related costs, according to a press release issued by the group.

The cost of supporting physicians with IT services has climbed, in part, due to rising IT staffing expenses, which shot up 47% between 2009 and 2015. The current cost per physician for health IT support went up 40% during the same interval. The biggest jump in HIT costs for supporting physicians took place between 2010 and 2011, the period during which the HITECH Act was implemented.

Practices are also seeing lower levels of financial incentives to adopt EHRs as Meaningful Use is phased out. While changes under MACRA/MIPS could benefit practices, they aren’t likely to reward physicians directly for investments in health IT.

As MGMA sees it, this is bad news, particularly given that practices still have to keep investing in such infrastructure: “We remain concerned that far too much of a practice’s IT investment is tied directly to complying with the ever-increasing number of federal requirements, rather than to providing patient care,” the group said in a prepared statement. “Unless we see significant changes in the final rule, practice IT costs will continue to rise without a corresponding improvement in the care delivery process.”

But the MGMA’s own analysis offers at least a glimmer of hope that these investments weren’t in vain. For example, while it argues that growing investments in technologies haven’t resulted in greater administrative efficiencies (or better care) for practices, it also notes that more than 50% of responders to a recent MGMA Stat poll reported that their patients could request or make appointments via their practice’s patient portal.

While there doesn’t seem to be any hard and fast evidence that portals improve patient care across the board, studies have emerged to suggest that portals support better outcomes, in areas such as medication adherence. (A Kaiser Permanente study from a couple of years ago, comparing statin adherence for those who chose online refills as their only method of getting the med with those who didn’t, found that those getting refills online saw nonadherence drop 6%.)

Just as importantly – in my view at least – I frequently hear accounts of individual practices which saw the volume of incoming calls drop dramatically. While that may not correlate directly to better patient care, it can’t hurt when patients are engaged enough to manage the petty details of their care on their own. Also, if the volume of phone requests for administrative support falls enough, a practice may be able to cut back on clerical staff and put the money towards say, a nurse case manager for coordination.

I’m not suggesting that every health IT investment practices have made will turn to fulfill its promise. EHRs, in particular, are difficult to look at as a whole and classify as a success across the board. I am, however, arguing that the MGMA has more reason for optimism than its leaders would publicly admit.

Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 2 of 2)

Posted on August 23, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous part of this article ripped apart the use of the words “insurance” and “market” to characterize healthcare. Not let’s turn to another concept even more fundamental to our thinking about care.

Quality

The final element of this three-card Monte is the slippery notion of quality. Health care is often compared to the airlines (when we’re not being compared to the Cheesecake Factory), an exercise guaranteed to make health care look bad. Airlines and restaurants offer relatively homogeneous experiences to all their clients and can easily determine whether their service succeeded or failed. Even at a mechanical level, the airlines have been able to quantify safety.

Endless organizations such as the National Association for Healthcare Quality (NAHQ) and the Agency for Healthcare Research and Quality (AHRQ) collect quality measures, and CMS has tried strenuously to include quality measures in Meaningful Use and the new MACRA program. We actually have not a dearth of quality measures, but a surfeit. Doctors feel overwhelmed with these measures. They are difficult to collect, and we don’t know how to combine them to create easy reports that patients can act on. There is a difference between completing a successful surgery, caring for things such as pain and infection prevention after surgery, and creating a follow-up plan that minimizes the chance of readmission. All those things (and many more) are elements of quality.

Worst of all, despite efforts to rank patients by their conditions and risk, hospitals repeatedly warn that quality measures underestimate risky patients and therefore penalize the hospitals that do the most difficult and important work–caring for the sickest. Many hospitals are throwing away donor organs instead of doing transplants, because the organs are slightly inferior and therefore might contribute to lower quality ratings–even if the patients are desperate to give them a try.

The concept of quality in health care thus needs a fresh look, and probably a different term. The first, simple thing we can do is remove patient ratings from assessments of quality. The patient knows whether the nurse smiled at her or whether she was discharged promptly, but can’t tell how good the actual treatment was after the event. One nurse has suggested that staff turnover is a better indication of hospital quality than patient satisfaction surveys. Given our fascination with airline quality, it’s worth noting that the airline industry separates safety ratings from passenger experience. The health care industry can similarly leverage patient ratings to denote clients’ satisfaction, but that’s separate from quality.

As for the safety and effectiveness of treatment, we could try a fairer rating system, such as one that explicitly balances risk and reward. Agencies would have to take the effort to understand all the elements of differences in patients that contribute to risk, and make sure they are tallied. Perhaps we could learn how to assess the success of each treatment in relation to the condition in which the patient entered the office. Even better, we could try to assess longitudinal results instead evaluating each office visit or hospital admission in isolation.

These are complex activities, but we have lots of data and powerful tools to analyze it. Together with a focus on changing behavior and environments, we should be able to make a real difference in quality–and I mean quality of life. Is there anything an ordinary member of the health professions can do till then? Well, try issuing Bronx cheers and catcalls at any meeting or conference presentation where someone uses one of the three misleading terms.

Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 1 of 2)

Posted on August 22, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Reading the daily papers, I have gotten increasingly frustrated at the misunderstandings that journalists and the public bring to the debates of over health expansion, costs, and reform. But you can’t blame them–our own industry has created the confusion by misusing terms and concepts that work in other places but not in health. Worse still, the health care industry has let policy-makers embed the incorrect impressions into laws and regulations.

So in this article I’ll promote the long process of correcting the public’s impressions of health care–by purging three dangerous words from health care vocabulary.

Insurance

The health care insurance industry looks like no other insurance industry in the world. When we think of insurance, we think of paying semi-annually into a fund we hope we never need to use. But perhaps every twenty years or so, we suffer damage to our car, our house, or our business, and the insurance kicks in. That may have been true for health care 70 years ago, when you wouldn’t see the doctor unless you fell into a pit or came down with some illness they likely couldn’t cure anyway. The insurance model is totally unsuited for health care today.

The Affordable Care Act made some symbolic gestures toward a recognition that modern health care should embrace prevention and wellness. For instance, it eliminated copays for preventative visits. The insurance companies took that wording very literally: if you dare to bring up an actual medical problem during your preventative visit, they charge you a copay. Yet the “preventative” part of the visit usually consists of a lecture to stop smoking and go on the Mediterranean diet.

Effective wellness programs jettison the notion of insurance (although patients need separate insurance for catastrophic problems). They keep in regular contact with clients, provide coaching, and sometimes use intelligent digital interventions such as described by Dr. Joseph Kvedar in The Internet of Healthy Things (which I reviewed shortly after its release). There are scattered indications that these programs do their job. As they spread, the system set up to deal with catastrophic health events will have to adapt and take a modest role within a behavioral health model.

The term “insurance” is so widely applied to our healh funding model that we can’t make it go away. Perhaps we should put the word in quotation marks wherever it must be used.

Market

This term is less ubiquitous than “insurance” but may be even more harmful. Numerous commenters have pointed out the difference between health care and actual markets:

  • In a market, you can walk away and refuse to pay for a good that is too expensive. If the price of beef goes through the roof, you can switch to beans (and probably should, for your own health). So the best time to argue with someone who promotes a health care market may be right after he’s fallen from a ladder and is clutching at his leg in agony. Ask him, “Do you feel you can walk away from an offer of health care?” Cruel, but a lesson he won’t forget.

  • A market serves people who can afford it. It’s hard to find a stylish hair dresser in a poor neighborhood because no one can pay $200 for a cut. But here’s the rub: the people who need health care the most can’t afford it. Someone with serious mental or physical problems is less likely to find work or be able to attend a college with health insurance. Parents of seriously ill children have to take time off from work to care for them. And so on. It’s what economists–who have trouble discarding the market way of thinking–call a market failure.

  • In a market, you know what you’re going to pay for a service and what your options are. Enough said.

  • In a market, you can evaluate the quality of a service and judge (at least in retrospect) whether it was worth the cost. I’ll deal with quality in the next section.

The misconception of health care as a market came to a head in the implementation of the Affordable Care Act. Presumably, millions of “young invincibles” were avoiding health insurance because of the cost. The individual mandate, combined with affordable plans on health care exchanges, would bring them flooding into the insurance system, lowering costs for everyone and balancing the burden created by the many sick people who we knew would join. And yet now we have stubbornly rising health care rates, deductibles, and caps, along with new costs in the states where Medicaid expanded Where did this all fall apart?

Part of the problem is certainly the recession, which caused incomes to decline or stagnate and exacerbated people’s health care needs. Also, there was a pent-up need for treatment among people who had lacked health insurance and avoided treatment for some time. This comes through in a study of prescription medication use. Furthermore, people don’t change habits overnight: many continue to over-rely on the emergency room (perhaps because of a shortage of primary care providers).

But there’s another unanticipated factor: the “young invincibles” actually start using health care once they get access to it. An analysis showed that mental health needs among the young are much higher than expected. In particular, they suffer widely from depression and anxiety, which is entirely reasonable given the state of our world. (I know that these conditions are connected to genetics and biology, but environment must also play a role.)

Ultimately, until we get behavioral health in place for everybody, health care costs will continue to rise and we won’t realize the promise of near-universal coverage. Many health care activists–especially during the recent political primary season–call for a single-payer system, which certainly would introduce many efficiencies. But it doesn’t solve the problems of chronic conditions and unhealthy lifestyles–that will require policy action on levels ranging from improvements in air cleanliness to new opportunities for isolated individuals to socialize. Meanwhile, we still have to look at the notion of quality in tomorrow’s post.

If MACRA Fails, It Will Be a Failure of IT, Not Doctors or Regulators

Posted on August 8, 2016 I Written By

The following is a guest blog by Steve Daniels, president of Able Health.

There has been a whole lot of mudslinging over the last month between regulators and healthcare providers over MACRA, which shifts Medicare payments further toward pay-for-performance starting January 1. On the one hand, CMS Acting Administrator Andy Slavitt is clear that CMS is ready for change. “We need to get out of the mode of paying physicians just to run tests and prescribe medicines,” he told a Senate Finance Committee hearing. Meanwhile, Dr. Thomas Eppes of the American Medical Association has called MACRA a “quantum shift” and pushed for a delay.

Yes, the Medicare Quality Payment Program instituted by MACRA should—and will—evolve based on comments made on the proposed rule. But the reality is the program provides enormous opportunity for providers to increase bonus payments, while streamlining reporting requirements across a patchwork of outdated and duplicative programs. And it’s worth noting that the potential penalties under the Merit-Based Incentive Payment System (MIPS) over the next four years are actually lower than the sum of the penalties of the programs it is replacing.

To meet MACRA goals, it will take a well-prepared team of providers and administrators—empowered by data and well-designed tools. Doctors can’t be solely responsible for achieving patient outcomes, reducing costs and documenting it all for CMS as they go. Unfortunately, the history of health IT has not been kind—or affordable—to doctors. And today, the health IT stack has a new challenge—keeping pace with the proliferation of value-based programs, from accessing data all the way through enabling new clinical practice.

We must move from a mindset of meeting Meaningful Use checkboxes toward supporting a more effective way of operating. And in the modern world of software-as-as-service, there’s no good reason left that IT needs to cost providers millions of dollars. We can do better. As things stand, if MACRA fails, it will be a failure of IT, not doctors or regulators.

Gathering all the data

For value-based care to work, patient data needs to be made available for providers to coordinate with each other, as well as to payers, to properly evaluate performance based on all known information. Those still blocking or jacking up prices for data access are complicit in obstructing the vision of a learning value-based system.

It is time to remove technical barriers through modern and open data standards like FHIR, as well as rules and unreasonable fees that prevent parties from accessing data when they need it. Thankfully, the Advancing Care Information performance category will reflect the emphasis on information exchange set forth in Meaningful Use Stage 3.

Calculating performance flexibly

The new era of performance-based pay requires continuous monitoring of quality and cost, with the ability to track progress across multiple programs on an ongoing basis. To measure quality today, we often use static algorithms hard-coded by EHRs vendors and health system IT departments, conforming to standards set by NCQA or CMS.

But providers need tools that are tailored not just to one or two programs like Meaningful Use and PQRS, but across the organization’s full range of value-based programs as these program continue to expand, evolve, and proliferate. With efforts to standardize IT for quality measures stalling, vendors need to focus less on one-size-fits-all quality measure calculations and more on flexible systems that enable measures to be rapidly constructed and customized to move with the trends. Expect change to be the norm.

Informing new behaviors

With so many health IT professionals focused on gathering and reporting data, it is not surprising that design has taken a back seat so far. But this year, not a single population health vendor earned an “A” rating from Chilmark, due to poor user engagement and clinical workflow. This is no longer acceptable. The challenge of enabling the new clinical and administrative behaviors associated with value-based care is too vast. User experience must be top of mind for any IT implementation, with representative users involved from the start. We have seen the impact of poor user experience in the fee-for-service system, from frustrated clinicians to alarming patient safety issues.

Design is even more important when the challenge is not just documenting billing codes but also achieving health outcomes for patients across a care team. Don’t bombard clinicians with notifications and force clumsy form-filling. Instead, employ best practices from cognitive psychology to inform professionals with lightweight and intelligent touchpoints. Automate documentation and interpretation of data wherever possible.

A new era of health IT

Whether or not it’s delayed, the Quality Payment Program is coming. And the healthcare industry is moving inexorably toward value-based care. Will health IT step up to the challenge of building toward a value-based future that is accessible to all providers? Or will we sit back and wait for the next list of requirements?

About Steve Daniels
Steve Daniels is the President of Able Health, which helps providers succeed under MACRA and value-based programs. Formerly the design lead for IBM Watson for healthcare and a lifelong patient advocate, he is passionate about the role of open data exchange and intuitive experience design in fostering a continuously improving healthcare system. Find him on Twitter and LinkedIn.

ONC Offers Two Interoperability Measures

Posted on July 14, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

For a while now, it’s been unclear how federal regulators would measure whether the U.S. healthcare system was moving toward the “widespread interoperability” MACRA requires. But the wait is over, and after reviewing a bunch of comments, ONC has come through with some proposals that seem fairly reasonable at first glance.

According to a new blog entry from ONC, the agency has gotten almost 100 comments on how to address interoperability. These recommendations, the agency concluded, fell into four broad categories:

  • Don’t create any significant new reporting burdens for providers
  • Broaden the scope of interoperability measurements to include providers and individuals that are not eligible for Medicare and Medicaid EHR incentives
  • Create measures that examine usage and usefulness of exchanged information, as well as the impact on health outcomes, in addition to measuring the exchange itself
  • Recognize that given the complexity of measuring interoperability, it will take multiple data sources, and that more discussions will be necessary to create an effective model for such measurements

In response, ONC has come up with two core measures which address not only the comments, but also its own analysis and MACRA’s specific definitions of “widespread interoperability.”

  • Measure #1: Proportion of healthcare providers electronically engaging in the following core domains of interoperable exchange of health information: sending; receiving; finding (querying); and integrating information received outside sources.
  • Measure #2: Proportion of healthcare providers who report using information electronically received through outside providers and sources for clinical decision-making.

To measure these activities, ONC expects to be able to draw on existing national surveys of hospitals and office-based physicians. These include the American Hospital Association’s AHA Information Technology Supplement Survey and the CDC National Center for Health Statistics’ annual National Electronic Health Record Survey of office-based physicians.

The reasons ONC would like to use these data sources include that they are not limited to Medicare and Medicaid EHR incentive program participants, and that both surveys have relatively high response rates.

I don’t know about you, but I was afraid things would be much worse. Measuring interoperability is quite difficult, given that just about everyone in the healthcare industry seems to have a slightly different take on what true interoperability actually is.

For example, there’s a fairly big gulf between those who feel interoperability only happens when all data flows from provider to provider, and those who feel that sharing a well-defined subset (such as that found in the Continuity of Care Document) would do the trick just fine. There is no way to address both of these models at the same time, much less the thousand shades of gray between the two extremes.

While its measures may not provide the final word on the subject, ONC has done a good job with the problem it was given, creating a model which is likely to be palatable to most of the parties involved. And that’s pretty unusual in the contentious world of health data interoperability. I hope the rollout goes equally well.