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Will the Disconnected Find Interoperability at HIMSS 2016? Five Scenarios for Action!

Posted on February 28, 2016 I Written By

The following is a guest blog post by Donald Voltz, MD.
Donald Voltz - Zoeticx

With the yearly bluster and promise of HIMSS, I still find there have been few strides in solving interoperability. Many speakers will extol the next big thing in healthcare system connectivity and large EHR vendors will swear their size fits all and with the wave of video demo, interoperability is declared cured.  Long live proprietary solutions, down with system integration and collaboration. Healthcare IT, reborn into the latest vendor initiative, costing billions of dollars and who knows how many thousands of lives.

Physicians’ satisfaction with electronic health record (EHR) systems has declined by nearly 30 percentage points over the last five years, according to a 2015 survey of 940 physicians conducted by the American Medical Association (AMA) and American EHR Partners. The survey found 34% of respondents said they were satisfied or very satisfied with their EHR systems, compared with 61% of respondents in a similar survey conducted five years ago.

Specifically, the survey found:

  • 42% of respondents described their EHR system’s ability to improve efficiency as difficult or very difficult;
  • 43% of respondents said they were still addressing productivity challenges related to their EHR system;
  • 54% of respondents said their EHR system increased total operating costs; and
  • 72% of respondents described their EHR system’s ability to decrease workload as difficult or very difficult.

Whether in the presidential election campaign or at HIMSS, outside of the convention center hype, our abilities are confined by real world facts.  Widespread implementation of EHRs have been driven by physician and hospital incentives from the HITECH Act with the laudable goals of improving quality, reducing costs, and engaging patients in their healthcare decisions. All of these goals are dependent on readily available access to patient information.

Whether the access is required by a health professional or a computers’ algorithm generating alerts concerning data, potential adverse events, medication interactions or routine health screenings, healthcare systems have been designed to connect various health data stores. The design and connection of various databases can become the limiting factor for patient safety, efficiency and user experiences in EHR systems.

Healthcare Evolving

Healthcare, and the increasing amount of data being collected to manage the individual as well as patient populations, is a complex and evolving specialty of medicine. The health information systems used to manage the flow of patient data adds additional complexity with no one system or implementation being the single best solution for any given physician or hospital. Even within the same EHR, implementation decisions impact how healthcare professional workflow and care delivery are restructured to meet the constraints and demands of these data systems.

Physicians and nurses have long uncovered the limitations and barriers EHR’s have brought to the trenches of clinical care. Cumbersome interfaces, limited choices for data entry and implementation decisions have increased clinical workloads and added numerous additional warnings which can lead to alert fatigue. Concerns have also been raised for patient safety when critical patient information cannot be located in a timely fashion.

Solving these challenges and developing expansive solutions to improve healthcare delivery, quality and efficiency depends on accessing and connecting data that resides in numerous, often disconnected health data systems located within a single office or spanning across geographically distributed care locations including patients’ homes. With changes in reimbursement from a pay for procedure to a pay for performance model, an understanding of technical solutions and their implementation impacts quality, finances, engagement and patient satisfaction.

Moving from a closed and static framework to an open and dynamic one holds great potential while requiring an innovative look at how technology is used as a tool to connect the people, processes and data. Successful application and integration of technology will determine future healthcare success. Although the problems with healthcare data exchange have not been solved, numerous concepts have been proposed on how to solve these challenges.

Connecting the Disconnected

Currently, healthcare data flow is disconnected. Understanding the current and future needs of patients and healthcare professionals along with how we utilize the technology tools available to integrate data into a seamless stream can bring about an enhanced, high-quality, efficient care delivery model.  One successful integration example, middleware, has been used for years to integrate data in financial and retail organizations with its simple open technology.

One of the leaders in middleware integration is Zoeticx, a healthcare IT system integrator who integrates the data traffic and addresses, adding the missing components to connect, direct and act upon the healthcare data flow.  This technology helped one hospital struggling with the typical EHR interoperability plaguing most healthcare facilities connect multiple EHR systems.  In addition, the health-care facility used middleware to identify a new revenue stream from CMS reimbursements for patient wellness visits while also improving patient care.

Accessing patient information from EHR’s and other patient health data repositories is critical for patient care. The development of tools and strategies to enhance the patient experience, improve quality and innovation of the care delivery model requires an understanding of how data is accessed and shared.  Current EHR’s have employed numerous ways to extract patient data, each of which brings opportunities and challenges. Here are a few examples to ask about at HIMSS.

The Critical Care Team – Distributed Care

The critical care environment is a challenging one with numerous healthcare professionals teaming up to manage and care for patients. Delays in addressing critical issues, lab values or other studies can negatively impact these patients or lead to redundancy and inefficiencies which increase costs without impacting outcomes. Coordinating care between the various care team members can be a challenge.

The medical record and the nursing flow sheet had traditionally been the platform for communication and understanding the trajectory of care. With the incorporation of the electronic medical record, things have changed. EHR’s bring along new constraints in caring for critical patients while at the same time bring about potential to enhance care delivery through the improvement in communication and management of these patients.

Chronic Care Management

There is a growing prevalence of US adult patients who are managing two or more chronic medical conditions. Governmental and commercial insurance providers have embraced this trend by introducing chronic care management (CCM) programs in an effort to better manage these patients so as to limit costly hospital admissions and improve quality of life.

There are numerous barriers to engaging physicians and patients in the management of chronic health conditions. One of the findings from a recent survey of chronic care management by health plan was how improvement in coordination of care between multiple physicians and other healthcare professionals can positively impact the care received and improve utilization. With commercial and governmental incentives, development and implementation of CCM management tools that interface with EHR’s and connect patients and professionals can enhance care delivery in this expanding population of patients.

Care Transitions

Patients admitted to the hospital for scheduled procedures or the unexpected management of a medical issue are at risk of being readmitted for preventable issues that develop following discharge.  For aging patients with multiple chronic conditions, enhanced communication to limit misunderstandings, conflicts in disease management and compliance with medications are critical as they move from hospitals to intermediate care settings and ultimately back home. Management of these critical care transitions depend on communication of patient data, the meaning ascribed to this data by the primary care physician along with those who managed these patients in the hospital becomes a critical component in care quality, patient satisfaction and to address preventable readmissions.

Healthcare professionals have emerged to manage many aspects of patient care and are dependent on access to patient data which is often spread between EHR’s and other health data systems. Connecting and sharing this information plays a role in how these patients are managed. Development of clinical pathways that integrate and translate evidenced-based medicine into the care delivery model is a critical component to the management of care across transitions.

Patient data, treatment plans and monitoring approaches to chronic conditions and underlying risks must be integrated and communicated between patients and healthcare professionals. The complexity of healthcare and the distributed care-team model makes this more critical now than ever before. Understanding data flow between all members of the care team, including patients and their family, becomes key in the development of strategies to achieve high quality, cost effective and engaging solutions that ultimately impact outcomes.

The Annual Health Screen

Preventative care is an expanding area of medicine with the goal of trying to control US healthcare costs. In 2011, The Affordable Care Act established the Annual Wellness Visit for Medicare beneficiaries. The purpose of this initiative is to perform an annual health risk assessment and identify all of the healthcare professionals caring for a beneficiary. By identifying risks and care professionals, coordination of care and risk mitigation can be put in place.

The Centers for Medicare & Medicaid Services (CMS) is promoting this service in an effort to enhance patient care, reduce unexpected care and reduce healthcare costs. With an expansive list of healthcare professionals who can perform the Annual Wellness Visit, a critical component in implementing this service hinges on communication and the sharing of the information obtained. Understanding and connecting patients, professionals, and their health data into a unified, accessible system must be managed.

Personalized Health

The landscape of patient health data is expanding. Personalized health and wellness trackers, genetic variants influencing risks for chronic conditions and pharmacogenetics, are all revealing new biologic pathways that will impact how care is delivered in the future. Systematically integrating these disparate pieces of data is becoming critical to translate individual disease risk and treatment recommendations. Emerging uses of personalized data will impact how we store, access and use this data for personalized diagnosis and management of disease.

Solving the technical challenge of accessing the data, development of decision-support tools and visually displaying the results to physicians and patients who will ultimately act upon the findings is being actively developed. How these new technologies are integrating into clinical medicine will impact their use and the engagement of all those involved. Exploring the potential ways to integrate emerging technologies into current EHR’s becomes critical to the future of healthcare delivery.

The process of healthcare delivery, use of data to drive decisions and employing various technological tools have become interdependent components that hold great potential for impacting quality of care. Gaining an understanding of the clinical needs, designing processes that meet these patient needs while incorporating evidence-based decision support has become a critical component of healthcare delivery. Understanding the current thinking, available technology and emerging solutions to the challenges we face with data flow and communication is the first step to developing innovative and impactful solutions.

Step up at HIMSS and ask the presenter how they plan to address these needs. Then reach out to the authors at or for a reality check.

About Donald Voltz, MD
Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.

Board-certified in anesthesiology and clinical informatics, Dr. Voltz is a researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.

CMS Redefines Telemedicine by Bringing Better Care to 15 Million Patients and Huge Profitability to Medical Facilities

Posted on September 17, 2015 I Written By

The following is a guest blog post by Donald Voltz, MD.
Donald Voltz - Zoeticx
Telemedicine is about reaching out to patients in remote locations, but limited to videoconferencing between patients and health providers. It is similar to a face-to-face service with the exception that the patient and primary care provider are not physically together. Such efficiency is limited in term of scope and only addresses the geographical challenge and scarcity of physician availability, a far cry from what CMS wanted for its Chronic Care Management Services (CCM) which would fundamentally change telemedicine as it is practiced.

CCM services bring the telemedicine definition to the next level – a quiet continuous monitoring and collaboration from all care services to the patient, given the ability to anticipate and engage in care issues. Such ability not only curbs care costs, it would also increase care provider bandwidth, giving them the ability to cover more patients with better efficiency. The challenge is not on the requirements part of CCM services, but the lack of an IT solution to really address all CMS guidelines, including its intent to enforce the concepts through the healthcare industry.

The New England Journal of Medicine has covered the major challenges from the new CCM guidelines, touching on all the major shortcomings in today healthcare IT offerings.  Healthcare providers recognized that the fee-for-service system, which restricts payments for primary care to office-based visits, is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medication refills, and care provided electronically or by telephone.

The time has come for a paradigm shift to reengineer how we deliver care and manage our patients. To arrive at a new plateau requires rethinking the needs of our patients and how to meet these needs in an already resource constrained system. Unless we develop solutions that both integrate with and enhance the technologies currently available and those yet to be realized, we will not realize a return on health IT investment.  This needs to be an area of focus for hospital CEOs, CIOs and CMOs.

Huge Market Opportunity

According to the 2010 Census, the number of people older than 65 years was 40 million with increasing trends to 56 million in 2020 and not reaching a plateau until 2050 at 83.7 million.  With two-thirds of Medicare beneficiaries having two or more chronic conditions while one-third has more than three chronic conditions according to CMS data, putting the number of patients who qualify for CCM services at 15 million. This number is predicted to continue on an upward trend until 2050.

The World Health Organization (WHO) recognized the growing burden this trend in chronic disease places on the healthcare system and addressed the need for innovative solutions in their 2002 report. While the potential market is huge, in the billions of dollars yearly, healthcare organizations have been struggling to address the CMS guidelines with key requirements from CMS. We can no longer afford not to address the needs of patient with chronic medical conditions along with engaging them in their healthcare decisions.

CMS’ CCM guidelines are as follows:

  • 24×7 access to clinical staff
  • Patient care continuum
  • Collaboration, coordination between primary care providers and other care services
  • Electronic management of care transition among care providers
  • Coordination between home and community care services
  • Patient engagement

Here is how these guidelines are now being addressed:

The Patient-Centric Model

While each patient has a primary care provider who is responsible for CCM service, they are not confined to receiving care in a single practice or institution. The primary care provider assumes the role of care coordinator, but care is likely to be distributed between multiple care providers, often across different care locations. In a patient-centric care model, care services can come from any care providers – geographically and organizationally diverse, necessitating an accountable provider to coordinate and orchestrate high-quality care across multiple chronic conditions.

Secure Electronic Care Transition

CMS clearly states these CCM care plans must be electronically available at all times to all care providers who will be delivering care to these patients, not available by faxing, or scanning as patient data is currently shared. The chronic care management plan must be available to all healthcare providers who might take care of these patients 24×7. In addition, the primary care provider who assumes the care coordinator responsibility for a patient is expected to follow-up on the care delivered, additional needs of the patient and changes in chronic condition that may have been addressed by a healthcare professional remote to the patients’ primary practice.

CMS neither authorizes how such a CCM system is designed nor enforces how efficient the implemented care service is. The monthly reimbursement limits the time and additional resources physicians are able to allocate for the development, implementation and daily operations of a CCM program in their practice. The manual implementation of a system that meets all of the requirements defined by the CMS will far exceed the reimbursement recovered. It is also likely to be inferior to one with some degree of automation coupled with messaging when a patient’s condition changes or their chronic care management plan is accessed by other providers. Efficiency along with automated logging of time spent on care coordination are critical requirements for a service to be effective.

A CCM service solution must meet the requirements defined by CMS while integrating into the current operational structure of primary care practice and integrate with current health IT systems and manage the secure documentation flow.  It must also offer a built-in notification system to alert physicians to changes in patient status and/or access to the care plan while maintaining an efficient operation in clinics with a lower overhead and no need for additional infrastructure.

While CMS does not enforce the efficiency of a CCM care service, the monthly payment must represent an increase of revenue to care providers. Care providers cannot implement a new potential code while increasing its cost due to manual labor increase. So, efficiency must be part of the solution requirements.

The answer to CCM service would be a new healthcare application offering secure documentation flow, built-in notification and collaboration services to support a low cost, efficient operation for clinics.

The CCM application must address the following requirements:

  • No disruption of existing services. The application must operate and integrate seamlessly with any existing EHR so to not change provider workflow or disrupt current processes; defining a very stringent requirement to keep the existing EHR systems untouched and unchanged while allowing for this new service to co-exist.
  • Secure electronic care transition with CCM care plan sharing. Patients can engage with this new care service even when the service may not be contained within the same network as the primary care provider. Patients ultimately maintain control of what information and with whom this information is shared. The primary care provider is responsible for maintaining the CCM care plan, as well as the patient, and should expect any information shared will be used for a single care session and not beyond it. Although the CCM care plan is expected to contain the most up-to-date medication information, primary care providers are not interested in opening up their entire system to others, but instead need to maintain control and secure access while allowing for access to these protected documents.
  • Automation, automation and automation. Efficiency of the whole CCM service must be at the core so that primary care providers can enhance patient care without adding expense and resources to implement it. Consider a patient with Congestive Heart Failure (CHF) where continuous monitoring of weight is critical for early intervention and the avoidance of hospitalizations. To engage patient’s in their care, they must be given a mechanism to report daily weight to their primary care provider. The primary care provider must have a solution where attention is given if the patient’s condition so it not has exceeded a certain threshold. Automation is required so that primary care providers can be efficient and only given attention when attention is required. Automation must be in place so that no activities such as follow-up would be omitted.
  • An EHR-agnostics solution. Implementation of a CCM service must address the constraints of a non-homogeneous environment. Healthcare organizations and physician practices are not able to control the EHR environments when patients receive care outside of their primary practice. The requirement for electronic document exchange along with the expectation of the latest patient health data being contained in the CCM care plan goes beyond a static solution offered by a data duplicated HIE (Health Information Exchange) infrastructure.
  • Visible value to a patient. A critical requirement for CMS reimbursement is a patient’s opting into a CCM management program that includes out-of-pocket monthly co-pay for the service of 8 dollars per month. A patient must see the value for CCM services which can be demonstrated through enhanced engagement, access to providers and the assurance that their condition is being overseen each month by their chronic care coordinator. Anticipation of an early intervention for potential problems along with the ability to inquire and receive feedback on their condition(s) brings added value to patients and their loved ones. This value can only be delivered if such a service can be developed in an efficient manner with a low cost of operating and a limited expansion of personal to bring it about.
  • Documentation of discontinuous time spent on care coordination. CMS requires at least 20 minutes are spent on care coordination activities each month in order to bill for this for patients enrolled in the program. Without a seamless component to log such activity, the efficiency of the overall process comes into question. A comprehensive CCM application must address the practice management side to account for and generate monthly reports of the CCM activities completed.

Future of Healthcare Impacted by Integration, Patient Data and New Modes of Delivery

The future of healthcare will be impacted by the integration of technology, patient collected data, and enhancement of healthcare professionals’ ability to deliver care in modes not yet imaged. With respect to management of chronic medical conditions, leveraging technology to coordinate the care delivered so these patients can lead productive lives at a reduced cost with less time in the hospital for exacerbations of their disease is a goal that is now possible.

Development of tools to coordinate care without additional health IT expense, in either time spent learning a new workflow or cost of such an application, is now available. Finding such an innovate model that works for patients, healthcare professionals and health systems for chronic care management will likely spread into other areas of healthcare. CCM services and care coordination allow remote, discontinuous, non-face-to-face management of patients with complex health conditions when it meets stringent requirements – a quiet, continuous monitor of health status and interventions, collaboration of all care delivered to the patient, an ability to anticipate, engage and alert patients and care professionals of impending issues, along with the administrative side of billing and logging such activity.

This ability not only changes the direction of the chronic care cost curve, it also increases care provider bandwidth, giving them the ability to successfully manage more patient, with better efficiency while delivering high quality, valuable care.

About Donald Voltz, MD
Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.

Board-certified in anesthesiology and clinical informatics, Dr. Voltz is a researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.

Thanh Tran, CEO of Zoeticx, also contributed.