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Transition to Value-Based Payments Top Concern for Long-Term and Post-Acute Care

Posted on November 12, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

On 1 October 2019, CMS will flip from a volume-based reimbursement model for Long-Term & Post-Acute Care Organizations (LTPAC) to a value-based one. This looming transformation was the top concern for most of the 2,000 attendees at PointClickCare’s annual user conference – #PCCSummit18.

PointClickCare makes a cloud-based EHR platform for LTPAC and HomeCare Organizations. According to the company, 60% of all Senior Living and Skilled Nursing Facilities (SNFs) in North America use their platform. Each year, PointClickCare hosts a user conference, called PCCSummit, where customers gather to get a preview of new features and to discuss the industry’s most pressing challenges.

Sweeping LTPAC changes by CMS

The top challenge on the minds of #PCCSummit18 attendees was, by far, the sweeping reimbursement changes being implemented by the Centers for Medicare & Medicaid Services (CMS) on 1 October 2019.  Referred to as the Patient Driven Payment Model (PDPM), it contains three significant changes for SNFs:

  1. A new value-based payment model
  2. Adopting ICD-10
  3. New reporting requirements

“The move to PDPM is going to be a challenge for everyone in the industry,” said Dave Wessinger, COO and Co-Founder of PointClickCare. “I think everyone will agree that moving from a volume-based reimbursement model to a value-based one is ultimately better for healthcare and for patients, but getting there is going to take some work. We are investing millions of dollars in product R&D, implementation resources and training to help make this transition as smooth as possible for our customers – who are all worried about PDPM.”

There were several sessions at #PCCSummit18 dedicated to PDPM. Each session was standing-room only.

A new value-based payment model

PDPM is the first step taken by CMS to shift LTPAC from a volume-based reimbursement model to one that is more value-based.

Currently, SNFs are reimbursed based on the minutes of therapy that patients/residents receive. The daily rate is determined by the type of therapy and SNFs are paid for as long as that therapy is administered. SNFs are required to conduct an assessment at pre-determined intervals to determine if further therapy is needed.

Under PDPM, CMS will base payments to SNFs on patient characteristics (diagnosis and comorbidities) rather than the type and duration of therapy being provided. According to CMS, there are several key advantages of this approach:

  • Removes therapy minutes as the basis for therapy payment (which may have encouraged some SNFs to provide unnecessary therapies to patients)
  • Enhances payment accuracy for nursing services by making nursing payment dependent on a wide range of clinical characteristics
  • Introduces payment adjustments that better reflect changes in resource use over a stay

Under PDPM, each patient/resident will be assigned a case-mix classification that drives the daily reimbursement rate for that individual. This classification is based on the diagnosis, acuity and characteristics of the patient/resident. Unlike the current payment model, the daily reimbursement rate is not uniform. It declines over time. This was done because evidence suggests that most therapies have diminishing returns the longer they are administered – unless the condition of the patient/resident changes.

The following slide illustrates the difference. It was presented by Genice Hornberger, RN, Senior Product Advisor at PointClickCare. The column on the left shows the uniform reimbursement for a 30-day SNF stay under the current RUG-IV payment model. The column in the middle shows what it the daily payments would be like under PDPM with accurate documentation.

Notice how the daily rate under PDPM starts off much higher at almost $915/day vs $631/day. This is in recognition of the work required of SNFs when new patients/residents are admitted.

The right-most column is very interesting. It shows the daily reimbursement rate for the case where patient documentation is inaccurate (ie: missing meds or missing patient conditions). This would result in $1,800 less under PDPM vs the current reimbursement model.

Adopting ICD-10

One of the goals CMS had for PDPM was to “promote consistency with other Medicare and post-acute payment settings by basing resident classification on objective clinical information while minimizing the role of service provision in determination of payment”.

To achieve this goal, CMS is mandating the adoption of ICD-10 standard in LTPAC. This will align long-term and post-acute care with their acute-care counterparts and make it easier for CMS to track Medicare patients moving between different parts of the healthcare system.

During the research and development stage of PDPM, found that almost half of SNF claims assigned generic ICD-9-CM codes as the principal diagnosis for residents in their care, which had limited usefulness in classifying residents. It also made it difficult for CMS to perform detailed analysis of LTPAC data.

Under PDPMD, ICD-10 codes will be used to map residents to the clinical categories that represent the primary reason for SNF care and are also sued for resident classification which determine the reimbursement rate.

New Reporting Requirements

Under the current reimbursement mechanism, SNFs are required to file patient/resident assessments with CMS 5 days, 14 days, 30 days, 60 days and 90 days into the stay. For longer stays, only quarterly assessments need to be filed.

Conducting, documenting and electronically transmitting these assessments requires a lot of time and effort by staff. In consultation with industry leaders, CMS is reducing the reporting requirements under PDPM.

Instead of regularly scheduled assessments, SNFs will now only be required to file a report when a patient/resident is admitted, discharged or has a change in condition. CMS expects to save itself $2B over the next 10 years from this reduction in paperwork and calculates SNFs will save on average, 183 hours per facility per year.

CMS tools to help transition

To help make the transition to PDPM, CMS has made several guides and online tools freely available to SNFs. One very useful tool is a customized analysis of each SNF’s current reimbursement vs future reimbursement under PDPM.

CMS used historic claims data from each SNF and corresponding acute-care data for patients transferred to SNFs (because only the hospital data had the requisite ICD-10 coding to determine the new patient/resident classification under PDPMD) to come up with an estimate of that SNF’s reimbursement under PDPM.

The analysis reveals that most SNFs would be at or above current reimbursement levels. A few therapy-heavy SNFs with non-complex patients will see lower reimbursements.

PointClickCare helping with PDPM transition

Given the importance of PDPM and the worries expressed by its customers, PointClickCare has created additional tools to help in the transition.

The team at PointClickCare smartly realized is the key to PDPM is having accurate documentation of each patient/resident. Any diagnosis, condition change or medication that is not documented will have a negative impact on reimbursements. Sandy Herbert, Senior Director of Product Management at PointClickCare explains:

“There is a hidden gap that could significantly impact reimbursements that we want to make our customers aware of. Through the CMS online tool, they can see an estimation of their reimbursement under PDPM, but baked into that estimation is an assumption of perfect documentation. Everything about the patient/resident needs to be captured and documented properly in the system – if anything is missed it means less money. However, with the change in classification method and the new reporting requirements, SNFs will have to be much more diligent in enforcing good documentation habits in order to maintain their level of reimbursement.”

At #PCCSummit18, the company unveiled an online PDPM assessment tool that calculates what a customer’s PDPM reimbursement would be based on the actual documentation in the system. In most cases, this amount is below the amount the CMS estimate.

In her presentation Hornberger showed an example of how significant this gap can be (see slide above). For a typical 30 day stay, PointClickCare found that certain aspects of the record were not coded properly which would result in a smaller claim being submitted to CMS. Their analysis showed that on average, a SNF would only receive $17,100 for that 30 day stay versus $18,900 under the current system and well below the $19,600 that would be possible under PDPM.

PointClickCare has made their assessment tool – PDPM Risk Assessment – freely available to its customers. Their team of consultants are also working with customers to address the gaps that are identified by the free assessment.

“PointClickCare has a history of working well with clients, especially when it comes to data,” said Timothy Carey, Director of Data and Performance Analytics at BaneCare. “Having the right data available to our leadership is critical. It’s what we need to help improve our processes and workflows. As far as I’m concerned, data from the PointClickCare system is like gold. It shows us where things are going wrong and where we can improve.”

Judging from the smiles on the faces of attendees who got a preview of their customized PDPM Risk Assessment at #PCCSummit18, the data is clearly reducing the anxiety around the transition.

Is FHIR Adoption At A Turning Point, Or Is This Just More Hype?

Posted on October 8, 2018 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.

Over the last few years, healthcare industry players have continued to experiment with the use of HL7 FHIR to solve key interoperability problems.

Perhaps the most recent efforts to do so is the Da Vinci Project, which brings together a group of payers, health IT vendors, and providers dedicated to fostering value-based care with FHIR. The group has begun work on two test cases, one addressing 30-day medication reconciliation and the other coverage requirements discovery.

This wasn’t big news, as it doesn’t seem to be doing anything that new. In fact, few if any of these projects — of which there have been many — have come close to establishing FHIR firmly established as a standard, much less fostering major change in the healthcare industry.

Now, a new analysis by the ONC suggests that we may finally be on the verge of a FHIR breakthrough.

According to ONC’s research, which looked at how health IT developers used FHIR to meet 2015 Edition certification requirements, roughly 32% of the health IT developers certified are using FHIR Release 2, and nearly 51% of health IT developers seem to be using a version of FHIR combined with OAuth 2.0.

While this may not sound very impressive (and at first glance, it didn’t to me), the certified products issued by the top 10 certified health IT developers serve about 82% of hospitals and 64% of clinicians.

Not only that, big tech companies staking out an expanded position in healthcare are leveraging FHIR 2, the ONC notes. For example, Apple is using a FHIR-based client app as part of its healthcare deployment.  Amazon, Alphabet, and Microsoft are working to establish themselves in the healthcare industry as well, and it seems likely that FHIR-based interoperability will come to play a part in their efforts.

In addition, CMS has shown faith in FHIR as well, investing in FHIR through its Blue Button 2.0,  a standards-based API allowing Medicare beneficiaries to connect their claims data to applications, services, and research programs.

That being said, after citing this progress, the agency concedes that FHIR still has a way to go, from standards development implementation, before it becomes the lingua franca of the industry. In other words, ONC’s definition of “turning point” may be a little different than yours or mine. Have I missed something here?

Look, I don’t like being “that guy,” but how encouraging is this really? By my standards at least, FHIR uptake is relatively modest for such a hot idea. For example, compare FHIR adoption of AI technology or blockchain. In some ways, interoperability may be a harder “get” than blockchain or AI in some ways, but one would think it would be further along if it were completely practical. Maybe I’m just a cynic.

Can Providers Survive If They Don’t Get Population Health Management Right?

Posted on August 27, 2018 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.

Most providers know that they won’t succeed with population health management unless they get some traction in a few important areas — and that if not, they could face disaster as their volume of value-based payment share grows. The thing is, getting PHM right is proving to be a mindboggling problem for many.

Let’s start with some numbers which give us at least one perspective on the situation.

According to a survey by Health Leaders Media, 87% of respondents said that improving their population health management chops was very important. Though the article summarizing the study doesn’t say this explicitly, we all know that they have to get smart about PHM if they want to have a prayer of prospering under value-based reimbursement.

However, it seems that the respondents aren’t making nearly as much PHM progress as they’d like. For example, just 38% of respondents told Health Leaders that they attributed 25% or more of their organization’s net revenue to risk-based pop health management activities, a share which has fallen two percent from last year’s results.

More than half (51%) said that their top barrier to successfully deploying or expanding pop health programs was up-front funding for care management, IT and infrastructure. They also said that engaging patients in their own care (45%) and getting meaningful data into providers’ hands (33%) weren’t proving to be easy tasks.

At this point it’s time for some discussion.

Obviously, providers grapple with competing priorities every time they try something new, but the internal conflicts are especially clear in this case.

On the one hand, it takes smart care management to make value-based contracts feasible. That could call for a time-consuming and expensive redesign of workflow and processes, patient education and outreach, hiring case managers and more.

Meanwhile, no PHM effort will blossom without the right IT support, and that could mean making some substantial investments, including custom-developed or third-party PHM software, integrating systems into a central data repository, sophisticated data analytics and a whole lot more.

Putting all of this in place is a huge challenge. Usually, providers lay the groundwork for a next-gen strategy in advance, then put infrastructure, people and processes into place over time. But that’s a little tough in this case. We’re talking about a huge problem here!

I get it that vendors began offering off-the-shelf PHM systems or add-on modules years ago, that one can hire consultants to change up workflow and that new staff should be on-board and trained by now. And obviously, no one can say that the advent of value-based care snuck up on them completely unannounced. (In fact, it’s gotten more attention than virtually any other healthcare issue I’ve tracked.) Shouldn’t that have done the trick?

Well, yes and no. Yes, in that in many cases, any decently-run organization will adapt if they see a trend coming at them years in advance. No, in that the shift to value-based payment is such a big shift that it could be decades before everyone can play effectively.

When you think about it, there are few things more disruptive to an organization than changing not just how much it’s paid but when and how along with what they have to do in return. Yes, I too am sick of hearing tech startups beat that term to death, but I think it applies in a fairly material sense this time around.

As readers will probably agree, health IT can certainly do something to ease the transition to value-based care. But HIT leaders won’t get the chance if their organization underestimates the scope of the overall problem.

Do We Sometimes Make Things Too Complicated?

Posted on July 11, 2018 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.

I know it’s not Friday yet (when I usually share fun cartoons), but I saw this cartoon shared by Pete Friesen and I couldn’t help but share it.

This parallels really well with this tweet I saw from ePatientDave as well:

Drugs have done amazing things. Look no further than all the lives saved by penicillin. However, sometimes we need to slow things down and consider all of our options (including drugs).

The problem right now is that there’s nothing really slowing things down for doctors and are care providers. Everything seems to just be speeding up.

I had a doctor today proudly share “I’m an internist can see 40 patients with rapid work on EMR side and also complete my MIPs clicks.”

He was trying to compliment his EHR software for working so effectively. However, you have to wonder what kind of care those 40 patients received and what kind of care they could have received if he only had to see 20. I’m not suggesting he gave them bad care, but I’m suggesting that the care would have been better if he only had to see 20 and not 40 patients. The problem is that doing so will cut his pay in half (literally).

This isn’t doctors fault specifically. They want to get paid for the work they do like anyone else. It’s why so many are excited by things like DPC (Direct Primary Care) and value based care. However, in terms of the later many are still skeptical and for good reason. Value based care could mean creating more of a relationship with a patient, but it could also mean more hoop jumping.

Maybe many of our stressed-out care providers could use some canine stress therapy as well.

New Study Suggests That HIEs Deliver Value by Aggregating Patient Data

Posted on March 5, 2018 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.

Historically, I’ve been pretty skeptical about the benefits that HIEs offer, not because the concept was flawed, but that the execution was uncertain. Toss in the fact that few have figured out how to be self-supporting financially, and you have a very shaky business model on your hands. But maybe, at long last, we’re discovering better uses for the vast amount of data HIEs have been trading.

New research by one exchange suggests that some of the key value they offer is aggregating patient data from multiple providers into a longitudinal view of patients. The research, completed by the Kansas Health Information Network and Diameter Health suggests that the Qualified Clinical Data Registries promoted by MACRA/QPP could be a winning approach.

To conduct the research, the partners extracted data from the KHIN exchange on primary care practices in which more than 50,000 patients visited toward 214 care sites in 2016 and 2017. This is certainly interesting, as most of the multi-site studies I’ve seen on this scale are done within a single provider’s network. It’s also notable that the data is relatively fresh, rather than relying on, say, Medicare data which is often several years older.

According to KHIN, using interoperable interfaces to providers and collecting near real-time clinical data makes prompt quality measure calculation possible. According to KHIN executive director Laura McCrary, Ed.D., this marks a significant change from current methods. “This [approach is in stark contrast to the current model which computes quality measures from only the data in the provider’s EHR,” she notes.

FWIW, the two research partners will be delivering a presentation on the research study at the HIMSS18 conference on Friday, March 9, from 12 to 1 PM. I’m betting it will offer some interesting insights.

But even if you can’t make it to this presentation, it’s still worth noting that it emphasizes the increasing importance of the longitudinal patient record. Eventually, under value-based care, it will become critical to have access not only to a single provider’s EHR data, but rather a fuller data set which also includes connected health/wearables data, data from payer claims, overarching population health data and more. And obviously, HIEs play a major role in making this happen.

Like other pundits, I’d go so far to say that without developing this kind of robust longitudinal patient record, which includes virtually every source of relevant patient data, health systems and providers won’t be able to manage patients well enough to meet their individual patient or population health goals.

If HIEs can help us get there, more power to them.

Some Of The Questions I Plan To Ask At #HIMSS18

Posted on February 23, 2018 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.

As always, this year’s HIMSS event will feature enough noise, sound and color to overwhelm your senses for months afterward. And talk about a big space to tread — I’ve come away with blisters more than once after attending.

Nonetheless, in my book it’s always worth attending the show. While no one vendor or session might blow you away, finding out directly what trends and products generated the most buzz is always good. The key is not only to attend the right educational sessions or meet the right people but to figure out how companies are making decisions.

Below, here are some of the questions that I hope to ask (and hopefully find answers) at the show. If you have other questions to suggest I’d love to bring them with me to the show —  the way I see it, the more the merrier!

-Anne

Blockchain

Vendors:  What functions does blockchain perform in your solution and what are the benefits of these additions? What made that blockchain the best technology choice for getting the job done? What challenges have you faced in developing a platform that integrates blockchain technology, and how are you addressing them? Is blockchain the most cost-efficient way of accomplishing the task you have in mind? What problems is blockchain best suited to address?

Providers: Have you rolled out any blockchain-based systems? If you haven’t currently deployed blockchain technology, do you expect to do so the future? When do you think that will happen? How will you know when it’s time to do so? What benefits do you think it will offer to your organization, and why? Do you think blockchain implementations could generate a significant level of additional server infrastructure overhead?

AI

Vendors: What makes your approach to healthcare AI unique and/or beneficial?  What is involved in integrating your AI product or service with existing provider technology, and how long does it usually take? Do providers have to do this themselves or do you help? Did you develop your own algorithms, license your AI engine or partner with someone else deliver it? Can you share any examples of how your customers have benefited by using AI?

Providers: What potential do you think AI has to change the way you deliver care? What specific benefits can AI offer your organization? Do you think healthcare AI applications are maturing, and if not how will you know when they have? What types of AI applications potentially interest you, and are you pilot-testing any of them?

Interoperability

Vendors:  How does your solution overcome barriers still remaining to full health data sharing between all healthcare industry participants? What do you think are the biggest interoperability challenges the industry faces? Does your solution require providers to make any significant changes to their infrastructure or call for advanced integration with existing systems? How long does it typically take for customers to go live with your interoperability solution, and how much does it cost on average? In an ideal world, what would interoperability between health data partners look like?

Providers: Do you consider yourself to have achieved full, partial or little/no health data interoperability between you and your partners? Are you happy with the results you’ve gotten from your interoperability efforts to date? What are the biggest benefits you’ve seen from achieving full or partial interoperability with other providers? Have you experienced any major failures in rolling out interoperability? If so, what damage did they do if any? Do you think interoperability is a prerequisite to delivering value-based care and/or population health management?

What topics are you looking forward to hearing about at #HIMSS18? What questions would you like asked? Share them in the comments and I’ll see what I can do to find answers.

Key Articles in Health IT from 2017 (Part 2 of 2)

Posted on January 4, 2018 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 first part of this article set a general context for health IT in 2017 and started through the year with a review of interesting articles and studies. We’ll finish the review here.

A thoughtful article suggests a positive approach toward health care quality. The author stresses the value of organic change, although using data for accountability has value too.

An article extolling digital payments actually said more about the out-of-control complexity of the US reimbursement system. It may or not be coincidental that her article appeared one day after the CommonWell Health Alliance announced an API whose main purpose seems to be to facilitate payment and other data exchanges related to law and regulation.

A survey by KLAS asked health care providers what they want in connected apps. Most apps currently just display data from a health record.

A controlled study revived the concept of Health Information Exchanges as stand-alone institutions, examining the effects of emergency departments using one HIE in New York State.

In contrast to many leaders in the new Administration, Dr. Donald Rucker received positive comments upon acceding to the position of National Coordinator. More alarm was raised about the appointment of Scott Gottlieb as head of the FDA, but a later assessment gave him high marks for his first few months.

Before Dr. Gottlieb got there, the FDA was already loosening up. The 21st Century Cures Act instructed it to keep its hands off many health-related digital technologies. After kneecapping consumer access to genetic testing and then allowing it back into the ring in 2015, the FDA advanced consumer genetics another step this year with approval for 23andMe tests about risks for seven diseases. A close look at another DNA site’s privacy policy, meanwhile, warns that their use of data exploits loopholes in the laws and could end up hurting consumers. Another critique of the Genetic Information Nondiscrimination Act has been written by Dr. Deborah Peel of Patient Privacy Rights.

Little noticed was a bill authorizing the FDA to be more flexible in its regulation of digital apps. Shortly after, the FDA announced its principles for approving digital apps, stressing good software development practices over clinical trials.

No improvement has been seen in the regard clinicians have for electronic records. Subjective reports condemned the notorious number of clicks required. A study showed they spend as much time on computer work as they do seeing patients. Another study found the ratio to be even worse. Shoving the job onto scribes may introduce inaccuracies.

The time spent might actually pay off if the resulting data could generate new treatments, increase personalized care, and lower costs. But the analytics that are critical to these advances have stumbled in health care institutions, in large part because of the perennial barrier of interoperability. But analytics are showing scattered successes, being used to:

Deloitte published a guide to implementing health care analytics. And finally, a clarion signal that analytics in health care has arrived: WIRED covers it.

A government cybersecurity report warns that health technology will likely soon contribute to the stream of breaches in health care.

Dr. Joseph Kvedar identified fruitful areas for applying digital technology to clinical research.

The Government Accountability Office, terror of many US bureaucracies, cam out with a report criticizing the sloppiness of quality measures at the VA.

A report by leaders of the SMART platform listed barriers to interoperability and the use of analytics to change health care.

To improve the lower outcomes seen by marginalized communities, the NIH is recruiting people from those populations to trust the government with their health data. A policy analyst calls on digital health companies to diversify their staff as well. Google’s parent company, Alphabet, is also getting into the act.

Specific technologies

Digital apps are part of most modern health efforts, of course. A few articles focused on the apps themselves. One study found that digital apps can improve depression. Another found that an app can improve ADHD.

Lots of intriguing devices are being developed:

Remote monitoring and telehealth have also been in the news.

Natural language processing and voice interfaces are becoming a critical part of spreading health care:

Facial recognition is another potentially useful technology. It can replace passwords or devices to enable quick access to medical records.

Virtual reality and augmented reality seem to have some limited applications to health care. They are useful foremost in education, but also for pain management, physical therapy, and relaxation.

A number of articles hold out the tantalizing promise that interoperability headaches can be cured through blockchain, the newest hot application of cryptography. But one analysis warned that blockchain will be difficult and expensive to adopt.

3D printing can be used to produce models for training purposes as well as surgical tools and implants customized to the patient.

A number of other interesting companies in digital health can be found in a Fortune article.

We’ll end the year with a news item similar to one that began the article: serious good news about the ability of Accountable Care Organizations (ACOs) to save money. I would also like to mention three major articles of my own:

I hope this review of the year’s articles and studies in health IT has helped you recall key advances or challenges, and perhaps flagged some valuable topics for you to follow. 2018 will continue to be a year of adjustment to new reimbursement realities touched off by the tax bill, so health IT may once again languish somewhat.

Key Articles in Health IT from 2017 (Part 1 of 2)

Posted on January 2, 2018 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.

This article provides a retrospective of 2017 in Health It–but a retrospective from an unusual perspective. I will highlight interesting articles I’ve read from the year as pointers to trends we should follow up on in the upcoming years.

Indubitably, 2017 is a unique year due to political events that threw the field of health care into wild uncertainty and speculation, exemplified most recently by the attempts to censor the use of precise and accurate language at the Centers for Disease Control (an act of political interference that could not be disguised even by those who tried to explain it away). Threats to replace the Affordable Care Act (another banned phrase) drove many institutions, which had formerly focused on improving communications or implementing risk sharing health care costs, to fall back into a lower level of Maslow’s hierarchy of needs, obsessing over whether insurance payments would cease and patients would stop coming. News about health IT was also drowned out by more general health topics such as drug pricing, the opiate crisis, and revenue pressures that close hospitals.

Key issues

But let’s start our retrospective on an upbeat note. A brief study summary from January 4 reported lower costs for some surgeries when hospitals participated in a modest bundled payment program sponsored by CMS. This suggests that fee-for-value could be required more widely by payers, even in the absence of sophisticated analytics and care coordination. Because only a small percentage of clinicians choose bold risk-sharing reimbursement models, this news is important.

Next, a note on security. Maybe we should reprioritize clinicians’ defenses against the electronic record breaches we’ve been hearing so much about. An analysis found that the most common reason for an unauthorized release of data was an attack by an insiders (43 percent). This contrasts with 26.8 percent from outside intruders. (The article doesn’t say how many records were compromised by each breach, though–if they had, the importance of outside intruders might have skyrocketed.) In any case, watch your audit logs and don’t trust your employees.

In a bracing and rare moment of candor, President Obama and Vice President Biden (remember them?) sharply criticized current EHRs for lack of interoperability. Other articles during the year showed that the political leaders were on target, as interoperability–an odd health care term for what other industries call “data exchange”–continues to be just as elusive as ever. Only 30% of hospitals were able to exchange data (although the situation has probably improved since the 2015 data used in the study). Advances in interoperability were called “theoretical” and the problem was placed into larger issues of poor communication. The Harvard Business Review weighed in too, chiding doctors for spending so much money on systems that don’t communicate.

The controversy sharpened as fraud charges were brought against a major EHR vendor for gaming the certification for Meaningful Use. A couple months later, strangely, the ONC weakened its certification process and announced it would rely more on the vendors to police themselves.

A long article provided some historical background on the reasons for incompatibility among EHRS.

Patients, as always, are left out of the loop: an ONC report finds improvements but many remaining barriers to attempts by patients to obtain the medical records that are theirs by law. And should the manufacturers of medical devices share the data they collect with patients? One would think it an elementary right of patients, but guidance released this year by the FDA was remarkably timid, pointing out the benefits of sharing but leaving it as merely a recommendation and offering big loopholes.

The continued failure to exchange data–which frustrates all attempts to improve treatments and cut costs–has led to the question: do EHR vendors and clinicians deliberately introduce technical measures for “information blocking”? Many leading health IT experts say no. But a study found that explicit information blocking measures are real.

Failures in interoperability and patient engagement were cited in another paper.

And we can’t leave interoperability without acknowledging the hope provided by FHIR. A paper on the use of FHIR with the older Direct-based interoperability protocols was released.

We’ll make our way through the rest of year and look at some specific technologies in the next part of the article.

The Future Of Telemedicine Doesn’t Depend On Health Plans Anymore

Posted on December 6, 2017 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 as long as I can remember, the growth of telemedicine depended largely on overcoming two obstacles: bandwidth and reimbursement. Now, both are on the verge of melting away.

One, the availability of broadband, has largely been addressed, though there are certainly areas of the US where broadband is harder to get than it should be. Having lived through a time when the very idea of widely available consumer broadband blew our minds, it’s amazing to say this, but we’ve largely solved the problem in the United States.

The other, the willingness of insurers to pay for telemedicine services, is still something of an issue and will be for a while. However, it won’t stay that way for too much longer in my opinion.

Yes, over the short term it still matters whether a telemedicine visit is going to be funded by a payer –after all, if a clinician is going to deliver services somebody has to pay for their time. But there are good reasons why this will not continue to be an issue.

For one thing, as the direct-to-consumer models have demonstrated, patients are increasingly willing to pay for telemedical care out-of-pocket. Customers of sites like HealthTap and Teladoc won’t pay top dollar for such services, but it seems apparent that they’re willing to engage with and stay interested in solving certain problems this way (such as, for example, getting a personal illness triaged and treated without having to skip work the next day).

Another way telemedicine services have changed, from what I can see, is that health systems and hospitals are beginning to integrate it with their other service lines as a routine part of delivering care. Virtual consults are no longer this “weird” thing they do on the side, but a standard approach to addressing common health problems, especially chronic illness.

Then, of course, there’s the most important factor taking control of telemedicine away from health plans: the need to use it to achieve population health management goals. While its use is still a little bit lopsided at present, as healthcare organizations aren’t sure how to optimize telehealth initiatives, eventually they’ll get the formula right, and that will include using it as a way of tying together a seamless value-based delivery network.

In fact, I’d go so far as to say that without the reach, flexibility and low cost of telehealth delivery, building out population health management schemes might be almost impossible in the future. Having specialists available to address urgent matters and say, for example, rural areas will be critical on the one hand, while making specialists need for chronic care (such as endocrinologists) accessible to unwell urban patients with travel concerns.

Despite the growing adoption of telemedicine by providers, it may be 5 to 10 years or so before it has its fullest impact, a period during which health plans gradually accept that the growth of this technology isn’t up to them anymore. But the day will without a doubt arise soon enough that “telemedicine” is just known as medicine.

Health IT Continues To Drive Healthcare Leaders’ Agenda

Posted on October 23, 2017 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 laying out opportunities, challenges and issues in healthcare likely to emerge in 2018 demonstrates that health IT is very much top of mind for healthcare leaders.

The 2018 HCEG Top 10 list, which is published by the Healthcare Executive Group, was created based on feedback from executives at its 2017 Annual Forum in Nashville, TN. Participants included health plans, health systems and provider organizations.

The top item on the list was “Clinical and Data Analytics,” which the list describes as leveraging big data with clinical evidence to segment populations, manage health and drive decisions. The second-place slot was occupied by “Population Health Services Organizations,” which, it says, operationalize population health strategy and chronic care management, drive clinical innovation and integrate social determinants of health.

The list also included “Harnessing Mobile Health Technology,” which included improving disease management and member engagement in data collection/distribution; “The Engaged Digital Consumer,” which by its definition includes HSAs, member/patient portals and health and wellness education materials; and cybersecurity.

Other hot issues named by the group include value-based payments, cost transparency, total consumer health, healthcare reform and addressing pharmacy costs.

So, readers, do you agree with HCEG’s priorities? Has the list left off any important topics?

In my case, I’d probably add a few items to list. For example, I may be getting ahead of the industry, but I’d argue that healthcare AI-related technologies might belong there. While there’s a whole separate article to be written here, in short, I believe that both AI-driven data analytics and consumer-facing technologies like medical chatbots have tremendous potential.

Also, I was surprised to see that care coordination improvements didn’t top respondents’ list of concerns. Admittedly, some of the list items might involve taking coordination to the next level, but the executives apparently didn’t identify it as a top priority.

Finally, as unsexy as the topic is for most, I would have thought that some form of health IT infrastructure spending or broader IT investment concerns might rise to the top of this list. Even if these executives didn’t discuss it, my sense from looking at multiple information sources is that providers are, and will continue to be, hard-pressed to allocate enough funds for IT.

Of course, if the executives involved can address even a few of their existing top 10 items next year, they’ll be doing pretty well. For example, we all know that providers‘ ability to manage value-based contracting is minimal in many cases, so making progress would be worthwhile. Participants like hospitals and clinics still need time to get their act together on value-based care, and many are unlikely to be on top of things by 2018.

There are also problems, like population health management, which involve processes rather than a destination. Providers will be struggling to address it well beyond 2018. That being said, it’d be great if healthcare execs could improve their results next year.

Nit-picking aside, HCEG’s Top 10 list is largely dead-on. The question is whether will be able to step up and address all of these things. Fingers crossed!