Patient data, a longitudinal patient record, and patient identifiers remain valid goals of healthcare reform, despite unhappiness with Meaningful Use.
Last week I spoke with a former CIO who assembled a longitudinal patient record dating back 12 years from seven different healthcare organizations her system didn't own, all of which had agreed to use a single patient ID defined by her system's master-patient index. She made this record accessible via the Web to providers and patients.
This wasn't a recent development. The system went live in 2004 with 700,000 patients.
But then that CIO received a fateful phone call from a patient.
"The patient was crying," says the former CIO, Leslie Kelly Hall. "She said, 'I just read my record, and it said that I'm morbidly obese. I just looked it up…I had no idea I was killing myself with food. So tomorrow, my family and I are meeting with a doctor and we're going to find out how I can live to see my children have children.' "
Even now, years later, Hall gets emotional recalling the story. It was also the moment that Hall realized that patient engagement was a very big thing. After she left the CIO position, she essentially devoted the rest of her career to that belief.
Leslie Kelly Hall
More than a decade later, the U.S. healthcare system is still struggling to provide a longitudinal view of patient data. A common patient identifier is still a dream. Even though Hall and many others have championed patient engagement, today the industry is in a time of retrenchment, when grandiose plans hatched in the meaningful use incentive/penalty program, to verify that patients are being engaged, are on the chopping block.
Hall, now a nationally known expert on patient engagement, understands the pushback from providers on engagement-by-regulation. "For those that want to check the box, it will never be meaningful, and everyone has a choice to do something in a meaningful way, or to check that box," she says.
How important is the health IT component of patient engagement?
After speaking with Hall and other health IT leaders such as CHIME CEO Russ Branzell, I now believe that only when the current push for the longitudinal patient record succeeds will America's healthcare cost curve truly bend.
Getting there will require breaking down the technological and business barriers that prevent interoperability. We shall need more examples such as Hall's, which occurred at Saint Alphonsus Regional Medical Center in Boise, Idaho. She points to more recent efforts at Tenet Healthcare, as well as at Taconic Independent Practice Association in upstate New York. A technology key at both organizations has been the Direct message format, which has had a troubled adoption curve nationally despite being a mandatory part of meaningful use EHR certification, Tenet used Direct messaging to connect long-term post-acute care facilities to its hospitals, Hall says.
These days, Hall is the senior vice president of policy at nonprofit Healthwise, which supplies patient education materials for use by healthcare payers and providers.
The financial foundation for patient engagement
As 10,000 baby boomers per day continue to turn 65, and CMS turns incentives away from fee-for-service and toward value-based care, the business rationale for patient engagement in the Medicare population is efficiency, Hall says. "How do I reduce my rate of growth? How do I reduce my readmissions? How do I reduce my length of stay? And how do I reduce the acuity of the patients presenting, so that I can manage my revenue growth, so that I am making less money slower?"
Patients who participate in decisions with a provider make more conservative choices, which that can mean real savings for providers.
"People talk about coordinating care," she says. "I think that's still transactional. How do we get to the point where we're all 'co-producing' health together with our patients?
"Value-based care totally aligns with that. Population health totally aligns with that by adding certification to long-term post-acute care, to home health agencies, maybe payers."
A hospital of about 300 beds has between 9 and 11 FTEs in the preadmission office, Hall says. "They do testing and they do gathering of information," she says. "Eighty percent of the information they gather is patient-generated. Now if I have 11 FTEs, and 60 percent of my patients coming in my door are Medicare, and I could perhaps get patients to generate that data and present with a fuller and more complete information, and I haven't had to enter it or interview, what would happen if I reduce that from 10 to 11 FTEs to 6 FTEs in the next five years? That's a real savings."
At one of the many hearings Hall has participated in on patient engagement at the national level, a provider speaker spoke of a patient engagement pilot that she did not want to participate in, because she thought adding patient-generated health data would be a waste of time.
"She said, 'What I found out is I'm a better doctor,' " Hall recounts. "She said, 'I have now a really good knowledge of the drugs they're actually taking, not the drugs I prescribed, including over-the-counter. I actually have a better record now, because the patient has found errors. So if I believe information is at all valuable to me, isn't it better to have accurate information?' "
As CMS and ONC struggle to redefine the regulations of patient engagement this summer—and possibly the entire meaningful use program—let Hall's words echo throughout this debate.
A CMIO says 'We've got to do this.' Why ICD-10 is so important, what costs it brings, and why health IT vendors play such a critical role.
Thomas Selva, MD, is chief medical information officer at the University of Missouri Healthcare. Last week we spoke about the last-minute attempt by the American Medical Association to once again halt ICD-10 adoption through Congressional legislation, and about how University of Missouri Health is using new technology to meet the challenge of ICD-10.
HealthLeaders:We've seen this movie before. What do you think?
Thomas Selva, MD
CMIO
University of Missouri Healthcare
Selva: AMA is a political voice for the physicians. They're responding to their constituency and their constituency is saying, We're not ready. Big institutions like ours can bring tremendous amounts of resources to bear, and we're still concerned.
HealthLeaders:You almost make the AMA's case when you say this.
Selva: Yes and no. We've got to do this [ICD-10]. The reality is, we don't have enough specificity in our code. Look at orthopedics, they're crying for more specificity in their codes. There's no room left in ICD-9, and in all honesty, we are very late to the party. Certainly Cerner and Epic both are leveraging [technology from] Intelligent Medical Objects to make it as fast as possible, but at the end of the day, it's still more clicks, and in a busy clinic day, that's a 30-, 40-minute stretch that you're adding to the end of your day by doing all that extra work.
HealthLeaders:CMS says ICD-10 doesn't affect ambulatory, or at least not nearly as much as it does affect hospitals and inpatient.
Selva: On the hospital side, where there's a lot of dollars attached to each patient for each encounter, and way more work, that's true. On the outpatient side, you have lower dollars for each encounter, but you see a lot more patients in a day. We admit and discharge 27,000 patients a year, but we admit and discharge from our clinics 600,000 patients a year, so you could argue that the clinics don't make as much money per patient, but boy oh boy do they do a lot of work.
HealthLeaders:CMS says reimbursement for outpatient and physician office procedures will not be determined by ICD-10 codes, as outpatient and physician office claims are not paid based on ICD-10 diagnosis codes but on CPT and HCPCS, which are not changing.
Selva: It's going to depend on the payers [and] how much pushback they're going to give. Remember, the documentation load on the inpatient side is incredibly high, because it's not just you the treating physician. It's who consulted, who did daily progress notes. If you're the surgeon, it's the follow-up notes. You've got the global fees. So yeah, I would argue that on the outpatient side, not as much. But if you're taught to be specific on the inpatient side, that's going to bleed over into the outpatient side. It's not as much as a payment mechanism. I'm looking more at what physician behavior is going to change.
HealthLeaders:I hear CEO-level executives saying we need ICD-10 to do better diagnoses. When I've written about ICD-10, I've found that it really has been mostly about the billing, and there are other things that are done to deal with diagnoses. There's CPT. There's SNOMED, which is part of meaningful use. I wonder about how it looks to have a CEO stand up there and say, We need ICD-10 to do better diagnosis. I think a lot of people would take issue with that.
Selva: Certainly ICD-10 is more specific than ICD-9. The more specifically you can code something, the better you can go back and look at what you've done. If you're trying to do evidence-based medicine, if you're trying to use protocols, if you're trying to use your electronic medical record to give you clinical decision support, that is all leveraged off a diagnosis. You mention SNOMED. Before meaningful use, physicians didn't know what you were talking about. SNOMED is ICD-10 on a wicked set of steroids. And it's been around forever. It's well-intentioned. I'm assuming that's why the feds chose SNOMED to code problems for meaningful use, but I have got to tell you, that's a different coding scheme, so again, it's created a great market for Intelligent Medical Objects to come up with the Rosetta Stone to somehow convert the two.
HealthLeaders: You're using Cerner, which is creating ICD-9 codes today still for you. Are you actually creating some ICD-10 codes with Cerner?
Selva: We're testing partners with Cerner, so we get new code like every Friday. … [W]e're using something called Physician Transition Early,a product they have that, as you're searching for a diagnosis code today for someone in the office, it's showing you the ICD-9 code and the closest match to an ICD-10 code. It's not asking you to specify yet. However, let's say you need to have labs every three months for the next year. If I draw up that order, one of those lab orders that's in that recurring scheme is going to cross that October 1 threshold, and so immediately we get a pop-up saying, You need to specify that diagnosis, and it gives you what we call a physician diagnosis assistant, which is very fast. It's an incredibly quick filter. In less than five clicks, you can get to the specific code that you need, and you're done. And you're going to find all the larger EMR manufacturers are doing this. They're coming up with ways to try to simplify it as much as they can.
HealthLeaders:You're also doing problem lists in SNOMED already.
Selva: Yes. There was no choice there. We had to do that to meet stage 2 of meaningful use. That was a requirement of the federal government. … We have a 15-year history with Cerner, so our problem lists are pretty large, so we had go through on the back end and run an automated script that would do a best match, and then if it couldn't do a one-to-one match, they have a product that allows you to literally sift through the problem list and it will suggest the kinds of SNOMED codes that are close, but you as a clinician need to make that call.
We allowed free texting back in the old days. Everybody had to go through this cleanup. We had to clean up about 450,000 problems in our problem list. But then moving forward, what [Intelligent Medical Objects] does, which is very cool, is that if you are putting in a diagnosis for today, you can just type in natural language in the search field, and it will give you your diagnosis for today. If you want that to be a problem, we can literally drag the diagnosis from today down to the problem list, and it will convert that to SNOMED, and if it can't, it will pop up a window saying, From the following list, can you pick the one that is the closest match for today's problem? So it's about as close to automatic as I think you can get it.
Advances in telemedicine are redefining who is deciding to form outpatient clinics and how they should run. "If you don't have a virtual model of practice somewhere within a practice, then you're behind the times," says one virtual practice owner.
Forget patients checking in at the receptionists' desk. Maybe forget waiting rooms. Forget brick-and-mortar clinics. Forget leaving home to get to them.
Technology is redefining what it makes to be an outpatient clinic. It's also redefining the requirements to start one. And those things are redefining who is deciding to form clinics, and how they should run, if the old ways of running them are not as friendly as possible to the clientele—or the workforce.
Over the past few months, I've been reminded of this again and again. Before he left to head up Geisinger, UCLA Health psychiatrist-turned-CEO David T. Feinberg, MD, speaking at the twice-annual Vocera Patient Experience Summit last fall, described how the organization went from a patient satisfaction rating of 38% to 99% on survey questions such as, would patients refer UCLA Health to a friend?
But Feinberg said healthcare has a long way to go with patient experience. "They wrote books about us to say we're 99th percentile, and as I tell my team, I think that means we're the cream of the crap." It still means "out of the last 100 people we've taken care of, we've failed 15."
Greater Access; Less Waiting So Feinberg pushed for improvements. Realizing that even the California Department of Motor Vehicles allows online appointment scheduling, Feinberg resolved to improve the appointment system at UCLA Health. "We now offer same-day access for 27 specialties," Feinberg said. "We now answer the phone at UCLA, 'Hello, this is UCLA Health. Would you like to be seen today?'"
The system also opened more clinics in its Los Angeles service area, such that no patient would have to drive more than four miles for primary care "because if it's six miles, it could be a 30-minute drive, depending on traffic." At present, UCLA Health has four hospitals and 150 clinics.
By issuing smartcards to patients, UCLA Health staff are now capable of being alerted when patients arrive in parking lots. "We know it takes about six minutes to get from the parking lot upstairs… We don't want you to wait, so we get the clinic room ready for you," he said.
"We convert our waiting rooms into clinical space so patients don't wait, or we keep them in really small waiting rooms for doctors waiting for patients. The doctor says, 'We've been expecting you. I brought in the other specialists I think we need. Some are here physically. Some are here by telemedicine.'"
"Actually the first thing we like to say is, 'We apologize that you came in. It means our home monitoring didn't work, that you actually had to come in. But now that you're here, we're going to make it effective and take great care of you and you're back in your car in 30 minutes and you're on your way, and we continue to monitor you in between visits.'"
I've heard of other clinics where there is no appointment desk, but instead roaming receptionists checking in visitors via iPad.
Virtual Consultations The truly visionary clinics are moving as quickly as they can to make physical visits unnecessary. As of today [May 19, 2015], One Medical Group now offers free teledermatology consultations to its existing patients, who pay an annual membership fee. Just another feature of the practice, added on as technology allows it, kind of like an app upgrade.
A few months ago, while researching a story on virtual care, for HealthLeaders magazine, I spoke with Mona Counts, PhD and Charlene McFeeley, NP, two co-owners of The River Practice, which they claim is the first virtual nurse practitioner-owned-and-operated clinic in the U.S. Counts told me she came out of retirement when technology enabled her to see patients via telemedicine. "I was kind of hesitant, thinking my older patients, especially the real geriatric ones, would not want to touch the technology," she told me. "Heck, they jumped on board like you wouldn't believe."
The River Practice uses virtual care technology from ExamMed to exchange information with other electronic health records to better serve its patient population in rural Pennsylvania, even reaching out to assist free clinics in the area.
McFeeley is managing partner of The River Practice and also VP of Healthcare Initiatives for ExamMed. She started working with ExamMed in early 2015.
Other nurse practitioners are scattered across southern Pennsylvania. Even though Counts lives in one of the state's poorest counties, she told me, "I will guarantee almost every [patient] has a smartphone of some kind."
Charlene McFeeley, NP
Part of what makes River Practice work well is that patients are, in many instances, continuing relationships they already had with the nurse practitioners—relationships built over years of seeing them in person. "They don't want to go sit in emergency departments," McFeeley told me. "They want to continue to access the providers that they have tremendous relationships with."
Virtual practices are starting to pop up all over. New York-based Maven Clinic, described by Tech Republic as "the first digital health clinic for women" offers services for pregnancy prevention, pregnancy, prenatal, and postpartum care. Women are already using the fledgling online clinic to avoid weekend trips to urgent care centers, and can even obtain second opinions while preserving their anonymity—a level of comfort impossible for women to attain at a bricks-and-mortar clinic.
The takeaway is that this kind of creative thinking in outpatient services is catching on like crazy around the country, taking many different shapes, all touched in one way or another by enabling technology. As McFeeley puts it, "the literature now supports that if you don't have a virtual model of practice somewhere within a practice, then you're behind the times."
Sutter Health brings Silicon Valley to healthcare IT, to speed up development without an army of IT people. The result is applications that improve care processes and benefit patients.
I bristle when I hear that we live in a "post-EHR world" because, of course, EHRs aren't going anywhere. But in one sense, the moniker is coming true.
That is because EHRs are now exhibiting the classic characteristics of technology platforms: assumed infrastructure that allows anyone, including providers, to innovate on top of them to solve clinical problems, workflow problems, and beyond.
Such is the case at Sutter Health, the Sacramento-based health system serving more than 100 communities in northern California. I recently spoke with Sutter's Kristen Wilson-Jones, chief technical officer of research, development and dissemination (RD&D) operations.
Kristen Wilson-Jones
Starting with a technology platform is not the usual springboard for innovation. But if Sutter is any indication, that is changing.
"We have a 'plecosystem'—a platform of ecosystems—that address a lot of the common barriers to innovate in healthcare," Wilson-Jones told me in an interview at the recent HIMSS annual conference in Chicago. Whether by buying or building technologies, Sutter RD&D's role is to pilot and evaluate innovations throughout the health system.
One of Sutter's plecosystem pilots is tackling the effort to lower readmissions rates. Sutter developed a predictive model that generates a list of patients at risk for 30-day readmissions, including demographic data extracted from the Epic EHR, and creates a registry of such patients. Sutter is leveraging Project RED, which stands for Re-Engineered Discharge. Project RED is a research group at Boston Medical Center which develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.
"It's a pure mashup" of data that creates workflows driven by open-source business process management (BPM) software known as Activiti, Wilson-Jones says. Workflows get prioritized by color—red being tasks that are past due, yellow meaning they are upcoming, and blue meaning they are out in the future.
Tying Activiti and Epic EHR together with other platforms, including Salesforce.com call center automation services, falls upon integration platform technology from MuleSoft that spans application integration, service-oriented automation, and API use cases. It is currently in pilot testing at a Sutter hospital in San Francisco.
Most strikingly, Sutter RD&D built this in six weeks, without the army of professional services resources usually required for such a venture.
From May to December of last year, Sutter saw a 41% reduction in 30-day readmissions in the pilot, Wilson-Jones says.
"A lot of times, it all becomes about the HL7 interfaces" between applications, Wilson-Jones says. "The whole effort becomes about how you get the data between the two systems. We're not moving data around like that. We're a pure API strategy."
App developers such as those at Sutter can think in terms of actual data objects, using APIs to create true mashups between applications. Technology vendors have been promising this approach for years, but until now, it's been beyond the easy reach of developers in healthcare—or, for that matter, in many other industries. That's something to truly get excited about as we look for more rapid, cheaper pathways to innovation in healthcare.
Sutter also is applying the plecosystem approach to other use cases. Its RheumShare application lets rheumatoid arthritis patients report data while in the waiting room preparing for a doctor visit. An on-screen avatar of sorts, which Wilson-Jones laughingly nicknamed "Bone Daddy," lets the patient report severity of pain in various body joints. That data goes into Sutter's information systems in time for the visit in the exam room, where the Epic EHR then places a dynamic hyperlink on those particular patients' screens.
When the physician clicks that link, it launches RheumShare on a second screen installed in each exam room. "So it's also used as a patient engagement tool," Wilson-Jones says. "They don't have to log in. They don't have to look the patient up. RheumShare shows pain trends on each RA patient's various points of interest.
"The physicians designed the screen, so it's what they wanted to see and how they wanted to interact with it," Wilson-Jones says. "They actually use it in the conversation with the patient."
Another application for managing chronic care management lets Sutter physicians prepare for a chronic case visit or encounter. "When preparing for these complex chronic cases, it takes them a lot of time to go through Epic and hunt and peck to find all the data," Wilson-Jones says. She referred me to a recent data visualization, "A Day in the Life of Dr. Jones," shown at HIMSS, which describes how during a 16-hour period, with 24 visits, a physician had to make 2,541 clicks in the EHR.
The Sutter chronic care management app, like a number of other EHR overlays I've been learning about lately, greatly reduces this hunt-and-click requirement to conduct the kind of work that physicians have to do every day. At Sutter, it's already moved beyond the pilot stage and is in use with more than 500 physicians.
Such apps also are increasing patient engagement, because physicians are increasingly sharing these screens with patients during encounters. It turns out that dashboards aren't just for staff anymore.
Sutter RD&D also measures what portions of all these apps its clinicians are actually using, and for how long. "Through clickstream analysis, we can find out what in the application is of value, and what's not," Kristen-Jones says.
Measure what you do. Celebrate what's working. Change what doesn't work. Make busy professionals more productive. Technology has no higher calling in healthcare.
In addition to cutting-edge tools and devices, some healthcare leaders are finding that even putting consumer feedback on a website can play a role.
This article appears in the April 2015 issue of HealthLeaders magazine.
All too often, technology manages to get in the way of superior patient experiences in healthcare. Despite the benefits technology brings to healthcare, it also can intrude on doctor-patient communications. Too much gathered information remains locked up, unavailable to the public. But at more and more healthcare organizations, attention is shifting to leveraging technology to make the healthcare experience better and more transparent.
Dignity Health, a San Francisco–based system that employs 56,000, has started using Google Glass, along with technology and services provided by startup Augmedix, in patient encounters. "It was with great delight that I got to bring something to bear that actually had a different experience for our physicians," says Davin Lundquist, MD, CMIO for physician integration at Dignity.
In previous encounters, when a personal computer was in the exam room with doctor and patient, "half the time the doctor has their back to [the patient], typing, and the other half of the time he's cursing at the computer, because he has his back to [the patient] and is typing," Lundquist says.
At its annual meeting, the American Telemedicine Association reports that 24 states now require that healthcare received via telemedicine be paid the same as in-person services.
Over just six months, state regulating bodies show moderate improvement in telemedicine policies and laws, the American Telemedicine Association reports this week.
At its annual meeting in Los Angeles this week, the ATA reported that 24 states and Washington, D.C., now have enacted parity laws requiring comparable coverage of and reimbursement for services delivered via telemedicine as is available for in-person services, by state-approved private insurance plans, state employee medical plans, and Medicaid. Three more states than had such laws in effect last September.
Telemedicine regulation was tracked in a national survey conducted last fall and updated this spring, according to ATA's Coverage and Reimbursement Report.
Health insurers in states still lacking parity laws are pressure, according to a major South Carolina healthcare provider who spoke at this week's ATA conference in Los Angeles.
"Ninety percent of the private insurance [in South Carolina] is Blue Cross Blue Shield," said pediatrician James McElligott, medical director for telehealth at the Medical University of South Carolina (MUSC) Health in an interview. "They have each year taken baby steps [in telemedicine reimbursement]. [That's] the main reason we are not going for parity legislation."
Telemedicine reimbursement is "not as good as we need, but we're working with Blue Cross Blue Shield so that would cover the vast majority of the state," McElligott says. Insurers in states still lacking parity laws hope to avoid passage of such laws by responding to demands for greater coverage of telemedicine, he adds.
Medicare reimbursement of telemedicine services, the only category not covered by the ATA survey, remains a more daunting challenge to states with a particular kind of geography, such as South Carolina. In that state, "44 out of 46 counties are rural by our definitions, but not by [Medicare's]," McElligott says. "It's almost as if telehealth is only acceptable if you're North Dakota, where you have these huge distances."
McElligott also notes that Medicare policy toward telemedicine reimbursement is cumbersome in that much of the policy is dependent on the particular disease being treated.
Despite these difficulties, MUSC, which is owned and operated by the state of South Carolina, was able to obtain more than $31 million over a two-year-period to create a statewide telemedicine system, says Mark Lyles, MD, chief strategic officer of MUSC's clinical enterprise. MUSC then obtained complementary grants from the Duke Endowment and others, Lyles told an ATA audience.
"We are in active discussion with key legislators to get away from the one-time appropriations process, which makes it quite challenging to budget for future years, and so we're asking for some of our future support to be included in the base budget from the [South Carolina] Department of Health and Human Services," he says.
In an interview, Lyles cautioned that "we can create the biggest, the boldest, the most connected program, but if there's no reimbursement model that sustains it, then it will go unused. There still is a high degree of randomness amongst all the ways the various states are addressing this issue. It is good to see South Carolina being somewhat progressive in areas where we have traditionally not been."
Connecticut and Rhode Island rank at the bottom of the ATA Coverage and Reimbursement report.
"Connecticut actually has language that says [they] will not cover clinical encounters that are conducted electronically," said Latoya Thomas, director of ATA's state policy resource center, in an interview. "They're essentially stating that 'We just won't do telemedicine. We're not going to cover it. We're not going to pay for it.' And Rhode Island has been largely silent on that. So you still have those two outliers."
The ATA Coverage and Reimbursement Report compares telemedicine adoption for every state in the U.S. based on 13 indicators. Since the initial report was released in September 2014, five states and the District of Columbia have maintained the highest possible composite score suggesting a supportive policy landscape that encourages telemedicine adoption (Maine, New Hampshire, New Mexico, Tennessee, and Virginia), while Maryland and Mississippi have dropped from an 'A' to 'B' as a result of additional restrictions being placed on telehealth coverage under their Medicaid plans.
Numerous Medicaid agencies that received 'C' grades or poorer last fall "made moderate improvements to expand coverage of services, like rehabilitation, physical therapy, occupational therapy, and speech language pathology and audiology, or they're expanding coverage of services by other healthcare practitioners," Thomas says. "No one wants to fail" at the ATA scorecard, she adds.
The ATA Physician Practice Standards and Licensure Report reviewed state laws and medical board standards in each state. The report revealed some variance from the initial report issued in September. With policy changes made to accommodate out-of-state physician-to-physician consultations via telemedicine, Massachusetts was the only state to improve to an 'A'. Twenty-two states received the highest possible composite score, which suggests that an extremely supportive policy landscape exists in these states for telemedicine adoption and usage.
The District of Columbia, Idaho, and West Virginia dropped from an 'A' to 'B' in ATA scoring due to the creation of new telemedicine clinical practice policies in their states. Texas joins Alabama as the only states with the lowest composite score, 'C,' due to revised telemedicine clinical practice policies.
Telemedicine is removing geographical boundaries and bringing patients and providers together.
This article first appeared in the April 2015 issue of HealthLeaders magazine.
Virtual care is not a new idea. Videoconferencing dates back several decades. Remote monitoring in ICUs began more than a decade ago. Telestroke and remote behavioral health programs have been on the radar in many settings for years.
But two major factors have given virtual care a big boost in the past year. Healthcare's notorious inefficiency is pushing health systems to balance workloads and workflows, erasing distance and time as limiting factors on the provision of care—using virtual care to do much of the balancing. Second, telemonitoring technology is providing improved ease of use and simplicity, while more attractive price points and performance capabilities are driving virtual care innovation into all of healthcare's costly nooks and crannies.
Forty-six states and the District of Columbia offer some form of Medicaid payment for telemedicine services, according to the American Medical Association—though Medicaid payment for more advanced uses, such as remote patient monitoring, is available in only 14 states.
Electronic health records and meaningful use took heat at a recent panel that featured two EHR vendors and a CIO user. But the consensus was that EHRs, despite shortcomings, are shuffling in the right direction.
The electronic health record got a grilling at a session I moderated last week at a national healthcare journalists' conference.
At the Association of Health Care Journalists annual conference, held in Silicon Valley, the most intense interest was reserved for a panel in which the e-cigarette industry defended its products. Meanwhile, I presided over the inquisition of EHRs.
Market leader Epic Systems had declined my invitation to join the panel, but two other EHR vendors were game, as well as the CIO of the highest-acuity children's hospital in the U.S.
The audience came with its best curveballs, and the best of all was thrown by "data journalist" Fred Trotter, no stranger to these pages. During my session, Trotter announced and produced fresh insights from a new joint project between his DocGraph project and his analytics startup, CareSet Systems, to unlock which providers are using which EHRs, and how well each provider is doing at achieving the goals of meaningful use of EHR technology.
On my panel was Kyna Fong, co-founder of Elation EMR, a newer meaningful use-certified EHR company that touts ease of use and focuses on the kind of ambulatory practices that have previously resisted meaningful use. Elation has even managed to convince some practices to switch from rival EHRs, assisted them in doing so, and claimed to make that easy for them, at a relatively low cost.
Such EHR switching costs, or startup costs of any sort for that matter, have been traditionally a pricey affair. For that reason, a lot of the practices that brought in Elation have had their EHR deployments funded by hospitals, either through alliances or outright acquisitions of practices by hospitals. More on that below.
Trotter informed Elation that via his analysis, most of its customers had performed well on the measures that indicate physicians are indeed entering vital signs dutifully, which is one of several dozen metrics that comprise the initial stage of meaningful use.
Trotter even called out a few physicians whose metrics fell short, but he was more interested in asking Fong if she, and the other EHR vendor on the panel, felt his analysis was fair.
The answer I heard from Fong was: sort of. "We spend a lot of time convincing our physicians to actually attest for meaningful use, because their initial reaction is like, 'Well, that's not that much money, and I'm sure it's a terrible process, because it's from the government,' " she said. "So we spend a lot of time talking to them."
Part of what Elation says distinguishes its EHR is the ability for providers at a glance to tell which patients are in compliance with particular measures and which are not. But Fong admitted that some providers were at least partially gaming the meaningful use system. "Some of them are like, 'I'm going to hit the minimum percentage for every measure. The minimum I need to do, I'm going to do. I'm going get my dollars, and then I'm going to ignore it,' " she said.
Fong notes that EHRs, and CMS's meaningful use program, can do only so much to truly generate meaningful use of EHRs. "We can't make [physicians] use it in a particular way or document in a particular way," she said. "We can remind them and make it easier, but ultimately that part's up to them.
Ed Kopetsky
"Could we invest in innovation and functionality and capabilities in our product that move the needle more for patient care than us trying to make meaningful use easy? Absolutely. I could think of so much stuff we could do that's so much more needle-moving and impactful to patients."
Count on the patient perspective being a big part of the debate as we see public comment pour in on the proposed stage 3 rules, as well as the modified stage 2 rules also currently out for comment.
Another EHR vendor on the panel felt that the meaningful use program is "directionally correct" but may fall short of the big goal of the program: total patient record interoperability.
"I think we are going to get to interoperable systems," said Michael Blackman, MD, chief medical officer at EHR vendor McKesson Enterprise Information Solutions. "I'm not sure it's going to be based on the meaningful use arc, however. The meat's really in stage 3. That's all about using the information to really improve health. I think the jury's out."
At which point, the CIO on the panel, Ed Kopetsky of Stanford Children's Health, pointed out that meaningful use has nevertheless laid the groundwork to benefit patient care in the future.
"I see a lot of innovation coming, and it wouldn't have happened without a lot of base infrastructure installed," Kopetsky said.
Kopetsky doesn't see how independent ambulatory practices can go it alone and still meet the various quality measures, value-based incentives, and sheer IT infrastructure that government is demanding. "In the last three years, we bought 40 clinics with 130 providers, and that wasn't the role of a children's inpatient setting anywhere before, but basically the new healthcare reform has pushed us toward this," he said.
On top of integrating this acquisition spree, Kopetsky's marching orders are to innovate. Already he is working with Apple's HealthKit technology to allow families of children with Type 1 diabetes to monitor their status and upload data for inclusion in the Epic EHR. "It is early in adoption and it is difficult," he admitted.
The grilling about EHRs continued, with even the EHR vendors noting some continuing technology challenges. Take alert fatigue. "If I'm a nephrologist, getting an alert that my patients have abnormal kidney function is really annoying, because all of my patients have abnormal kidney functions," Blackman noted. "I'd be more interested for it to tell me the patient had normal kidney function. So how do you balance that?"
A more serious concern is patient safety implications of the EHR. "Because [information] is 'in the system,' there's this sudden belief that [the physician] must have seen it," Blackman said. "The human capacity to absorb that information is no different because it's in a computer than it was in a stack of paper. Now that said, I should be able to find what I'm looking for." All panelists agreed that the best EHR implementations put the truly important patient information front and center, but of course the devil's in the details.
Kopetsky summed up on an optimistic note. "This is not the time to question, Are EHRs correct? It's a question of, How do we make them great, and advance."
At this year's HIMSS conference, the patient engagement provision of Meaningful Use stage 2 was a major casualty. Is that a problem?
Another HIMSS conference has come and gone, and what do we know now that we didn't before?
Without even a hint of a new ICD-10 delay, I will go out on a limb and predict that the transition will occur as scheduled this October 1. Payers will love it. Providers will endure the pain and the vast majority will survive unscathed.
Russ Branzell
President and CEO of CHIME
Meaningful use stage 2 rules will be relaxed, as proposed in the CMS/ONC NPRM released just before HIMSS, to permit 90-day attestation in 2015, avoiding many payment penalties throughout healthcare. Providers will endure the pain of meeting the 90 days of compliance, and the vast majority will survive unscathed.
There has been a major casualty in HIT priorities, however. The patient engagement provision of MU stage 2 is being thrown under the bus by CMS and ONC, aided and abetted by providers.
You may recall that one provision of stage 2, as initially approved, was that providers demonstrate that 5% of their patients had viewed, downloaded, or transmitted some portion of their medical record. The provision was never popular with providers, but no one expected CMS and ONC to relax the requirement to a single patient. That's right—evidence of a single patient doing so will now be sufficient to attest for stage 2 through 2016, and if the provider chooses to, extended through 2017 as well, according to the new NPRM.
Patient advocates are livid, but CHIME CEO Russell Branzell says many patient records will remain inconsistent and incompletely downloaded while meaningful use is still a work in progress.
"I would love for [patient records] to be successful now," Branzell tells me. "With lack of patient matching, with lack of true data quality, some of what is occurring now is you're seeing data corruption and in some cases errors, because we haven't done some of the building blocks."
Thus the act of viewing, downloading, or transmitting a portion of the patient record, by itself, is often of little or no value, Branzell says. "Do I want [view, download, and transmit] now? I want it yesterday."
But what about patients with serious conditions who want to make sure that physicians down the line have the proverbial longitudinal record, which empowered patients or their caregivers strive to carry with them everywhere?
"My daughter had a serious heart condition—she's better now," he says. "Eight specialists, three hospitals, 11 patient portals. Tell me the value [of downloading the data]. It actually made it worse, not better.
"Ask CIOs out there: Is true viewing and downloading working and workable today? There's many challenges still."
What patients have to say
Still, the MU rule change weighs heavily on patient advocates such as Regina Holliday, who often tells a heart-wrenching story of seeing her husband die due to gaps in his medical record that she says could have been averted by an empowered patient or caregiver playing an active role in averting medical errors in care.
Forged by the crucible of her ordeal, Holliday is the patient advocate's advocate now. She was all over the HIMSS conference, expressing her outrage at the gutting of the patient experience requirement in the new NPRM. She certainly played a role in the unprecedented theater of former ONC chief Farzad Mostashari breaking with protocol and criticizing the ONC/CMS decision at a patient engagement HIMSS pre-event.
In a YouTube video, Holliday urges patients to weigh in on the current public comment on the rule relaxation, and also calls for all patients to download their data electronically on July 4—a "day of action" for patient data independence.
There's plenty of blame to go around on why the portal technology strategy in the stage 2 final regulation was dead on arrival—see my HealthLeaders magazine article on how the Direct protocol fell short, for example—but for CHIME and other providers to point to lack of demand doesn't show the kind of leadership I would think providers could muster at this point.
Of course, HIMSS had its usual "just around the corner" technological panaceas. Call it FHIR, call it a public API, or point to various vendor pledges to not charge for this or that download for some period of time; the fact remains that the health IT industry has yet to produce evidence that a workable solution to patient downloading, or interoperability in general, is imminent. As I've written before, the Internet itself displays a continual tug-of-war between companies that embrace standards when it suits their business interests, and large players who suddenly cut off that openness, also when it suits their business interests.
The default referee in all of this is ONC head Karen DeSalvo, who dodged my question about whether the market will resolve these issues, or if more regulation will be necessary later on, perhaps when ICD-10 and the rest of stage 2 are implemented.
"Our commitment to consumers and consumer access to their health information is unwavering. It is thematic and central for me as a doctor and as a person that that control is meaningful," DeSalvo told me. "What's really exciting about the last few days is the dialogue that has ensued, and what's going to be essential is that … consumers sit down and talk to providers and maybe some of the other important developers in the ecosystem to understand where there may be technology and cultural challenges so that we can overcome them."
DeSalvo and her team note that nothing in the proposed regulation takes away the requirement that patients be able to get their data—just that the provider no longer has to prove that a sizable number of patients are actually doing so.
Holliday believes the issue is akin to voting laws in the 1960s that made voting so cumbersome it became a civil rights issue. She may be right. But I would point out that the answer to that issue wasn't necessarily making precincts prove that people of one or another demographic had actually voted. The civil rights struggle was about discrimination against some people. Lack of patient engagement is not a discrimination case. Patients are afflicted everywhere you look. Some analogies can only go so far.
At first I thought CHIME and the patient community were simply going to line up on different sides on the view-download-transmit issue. After talking further with Branzell, it seems clear that everyone wants the patient engagement aspects of meaningful use to succeed. But it will take every trick in the book to pull it off, ranging from Holliday's national day of action to efforts such as CHIME's recent initiative to crowdfund a privately-inspired national patient identifier.
"Will we get to true interoperability and those type of things?" Branzell asks. "I sure hope so. That's our plan. That's the nation's plan, and everybody's calling for it."
Editor's note: The original version of this column was updated to clarify Russell Branzell's statements.
In addition to cutting-edge tools and devices, some healthcare leaders are finding that even putting consumer feedback on a website can play a role.
This article first appeared in the April 2015 issue of HealthLeaders magazine.
All too often, technology manages to get in the way of superior patient experiences in healthcare. Despite the benefits technology brings to healthcare, it also can intrude on doctor-patient communications. Too much gathered information remains locked up, unavailable to the public. But at more and more healthcare organizations, attention is shifting to leveraging technology to make the healthcare experience better and more transparent.
Dignity Health, a San Francisco–based system that employs 56,000, has started using Google Glass, along with technology and services provided by startup Augmedix, in patient encounters. "It was with great delight that I got to bring something to bear that actually had a different experience for our physicians," says Davin Lundquist, MD, CMIO for physician integration at Dignity.
In previous encounters, when a personal computer was in the exam room with doctor and patient, "half the time the doctor has their back to [the patient], typing, and the other half of the time he's cursing at the computer, because he has his back to [the patient] and is typing," Lundquist says.
