Relief is welcome, but the challenges that hospital physicians face in complying with MACRA starting in 2017 will be followed by increasing demands in subsequent years.
Hospital CIOs had something to celebrate last week: a relaxation of some reporting requirements for meaningful use stage 2.
It came as a result of the release last week of the final rule for CMS's 2017 Hospital Outpatient Prospective Payment System (OPPS).
At the urging of the College of Information Management Executives (CHIME), CMS reduced reporting periods for 2016 and 2017 from one year to 90 days.
More importantly, the "Modified Stage 2" finalized by last week's rule removed 2017 reporting requirements in the categories of clinical decision support (CDS) and computerized physician order entry (CPOE). In addition, these requirements were also removed from meaningful use stage 3, which hospitals must still comply with in 2018 and beyond.
While the result of Tuesday's presidential and congressional elections could spell further change, even radical change, in the meaningful use program, it has already been replaced in 2017 with the advancing care information provisions of MACRA.
Nevertheless, at CHIME's annual meeting in Phoenix last week, officials were relieved that in the waning days of the Obama Administration, the meaningful use program, often credited with increasing the incidence of physician burnout, won't impose quite as much of a reporting burden in future years.
"That is fabulous for all of us," says Liz Johnson, chief information officer for acute care hospitals and applied clinical informatics at Tenet Health in Dallas. She briefed CHIME attendees.
"CHIME took a lead position reminding ONC and CMS over and over that we need time between attestation periods to do little things," such as making upgrades and stabilizing environments.
Johnson says CHIME members would like to see the 90-day reporting period become a permanent way of attesting to meaningful use, rather than the original CMS vision of 365-day attestation. "We can't seem to get there," she says. "We get [90 days] one year at a time. We got two years this time."
The CDS and CPOE requirements were removed because meaningful use participants are required to certify that they have an EHR certified by CMS and ONC. Every certified EHR has those components, "so they're no longer making us report them separately," Johnson says.
Tenet intends to continue to have its physicians use CPOE and to measure their use of it.
"We were not ever as concerned about how many medication orders you put in, as we were concerned about doctors using a tremendous tool to help deliver care in a safe way," she says. "We believe this is the right thing to do, and it's going to change outcomes if they use the order sets that have been developed by them."
With the CPOE reporting requirement removed from meaningful use, vendors may feel free to take away such reporting functions from the EHRs themselves, according to Johnson.
"So be careful," she says. "If you want to continue to report, and you're dependent on your vendor to do that, often they remove that functionality with new editions, and you no longer have that reporting functionality."
In such cases, providers have two choices: negotiate with their EHR vendors to keep doing that reporting, or create their own reporting, "but be prepared for that," Johnson says.
Of course, looming behind the good meaningful use news is the challenge that hospital physicians face in complying with MACRA starting in 2017, with increasing demands in subsequent years, not to mention the requirements of meaningful use stage 3, which take effect in 2018 and will require EHR software upgrades throughout 2017.
Regarding MACRA, "especially for the quality measures, the payment is not based on meeting a threshold like we're used to with meaningful use," says Mike Martz, vice president and chief integration officer of Ohio Valley Health Services and Education, addressing the same CHIME audience.
"This whole program is keyed around us as providers competing against each other, and how well we get paid depends how much better we are than you or how much better you are than us," says Martz.
"So it's important that all of us change our mentality that we've had with meaningful use of doing just enough, to now doing as much as we possibly can, as best as we can, because we can still do far better than we're doing with meaningful use and lose money. That is a culture change that we have to drive in organizations."
Virtual visit savings are promising but aren't moving the needle yet.
This article first appeared in the November 2016 issue of HealthLeaders magazine.
While some providers are finding a return on investment in telemedicine, measuring such returns involves a multitude of factors.
At the 2016 Healthcare Information and Management Systems Society's annual conference, Kaiser Permanente exhibited its exam room of the future, showing physician-to-physician telemedicine consultations now widely available throughout the Kaiser system.
"It's really personalized, and it builds on our existing relationship with our patients, and it's connected to our electronic medical record," says Angie Stevens, executive director of virtual care IT at the integrated health system and payer, which serves 10.6 million members in eight states and the District of Columbia.
Through this technology, Kaiser physicians can treat a broader range of conditions by conferencing in specialists at other Kaiser facilities, she says.
"In our smaller medical office buildings, such as in the mountains of Colorado, we can't staff all those specialties," Stevens says. Kaiser members can schedule video visits at outlying offices with specialists who join the meeting at the appointed time from wherever they are located in the Kaiser system, she adds.
Members can schedule video visits through traditional means such as the Kaiser call center, and then join the video visits from devices running the app, removing the need for the member to travel to a Kaiser office, she adds.
On the physician or specialist end, within the Epic electronic health record run throughout Kaiser, the clinician's schedule includes a video visit icon at the appropriate time, then turns green to indicate the patient is ready. Then the clinician can join the video visit by clicking on the icon, Stevens says.
All Kaiser regions went live with video visits by the end of 2015, and although Stevens cannot say how many encounters now occur this way, the number is on the rise.
"We also are working on a whole national marketing program so that we can educate our members on the option and what it means and what it's like, and what they can expect from it," Stevens says.
As it expands the range and nature of conditions for which a video visit is appropriate, Kaiser is noting the efforts of a growing number of independent telehealth providers, such as American Well, Teladoc, and Doctor on Demand, Stevens says. "These companies are often limited in the conditions that they can treat, and they often have little background on the patient, unlike our virtual care physicians who have access to their patients' complete electronic medical records," she says. "As the number of video visits at Kaiser Permanente continues to increase, we'll be able to look at a variety of use cases and determine where virtual care adds the most clinical value or personal value for our members."
But like other providers, Kaiser is pursuing hard numbers to justify its investment in telemedicine.
One study published recently in Kaiser's peer-reviewed Permanente Journal quantified how neurologists performing telestroke medicine via Kaiser's infrastructure increased their use of life-saving clot-dissolving medication in patients with ischemic stroke by 73%. The study was a retrospective analysis of all ischemic stroke presentations to 11 emergency departments between 2009 and 2013 in the Kaiser Permanente Southern California region.
By using telestroke, physicians in outlying Kaiser facilities lacking in-house neurology and neurological ICUs are able to contact a neurologist at a remote location, reducing the number of minutes needed to determine whether the patient should receive tissue plasminogen activator (tPA), the FDA-approved treatment for acute ischemic stroke.
"The part I think is unique to Kaiser compared to other versions is the telestroke physicians are able to see the lab values and CT images" during the telestroke session, says Adam L. Sharp, MD, lead author of the study and a research scientist and emergency physician with Kaiser Permanente Southern California's department of research and evaluation in Pasadena. "They're even able to write the order for tPA, and that's unique to our kind of integrated health system." In other institutions, attending physicians on the patient's side of the telestroke session often must write those orders, he notes.
Doctor choice enters the picture
Stevens says Kaiser is also working on developing options for members using telehealth to see their own primary care physicians at a later date, or choose instead to see a different physician on the same day.
This trend attracted major attention at the 2016 American Telemedicine Association conference. A number of providers, including the Cleveland Clinic and Nemours Children's Health System, participated in the launch of the American Well Exchange, a method of offering their services via American Well's LiveHealth Online platform, which offers live video consults with providers for treatment of common urgent care conditions around the clock. LiveHealth Online is operated by Health Management Corporation, a wholly-owned subsidiary of Anthem Blue Cross. American Well partnered with LiveHealth Online in 2012.
In the case of Cleveland Clinic, patients accessing LiveHealth Online in Ohio, West Virginia, and Pennsylvania can connect to Cleveland Clinic nurse practitioners via the Cleveland Clinic Express Care brand.
The alliance between Cleveland Clinic and American Well originated three years ago when Cleveland Clinic President and CEO Toby Cosgrove felt the organization needed a bigger telemedicine focus, according to Peter Rasmussen, MD, a Cleveland Clinic cerebral vascular neurosurgeon who also serves as medical director of distance health at the organization.
Rasmussen now heads up all Cleveland Clinic telemedicine efforts. He started Cleveland Clinic's own telestroke network, now active in more than a dozen sites in western Pennsylvania, Florida, and northeastern Ohio.
"We think that there isn't any aspect of medicine that can't have some component of it practiced via telemedicine or at a distance," Rasmussen says.
In keeping with the American Well LiveHealth Online direction as well as its own, Cleveland Clinic telemedicine customers can choose the provider they wish to see, as well as schedule interactions. Until now, most direct-to-consumer telemedicine services have not given patients the ability to choose which provider will see them.
"That really encompasses a broad range of almost everything that we do at the clinic, with patients being at home using their desktop, tablet, or mobile device," Rasmussen says.
Telemedicine also works well for follow-up patient visits, because many patients travel long distances to be treated at the Cleveland Clinic. "That keeps patients out of the facilities, and is a little bit more convenient for them at a lower cost and a better format for them," Rasmussen says.
Cleveland Clinic's own homegrown e-hospital system "has been a wonderful technology that's afforded us some modest improvements on length of stay, and reduced mortality over time," Rasmussen says. This summer, the organization also began pilot testing virtual chronic disease management, starting with hypertension, COPD, and pediatric asthma patients, he adds.
"It will be a combination of wearables or consumer-grade devices that patients have purchased, or we supply to them, that will generate data at home and will be displayed to us by dashboard, hopefully integrated with the electronic medical record by the end of the calendar year as well," he says.
Although hard financial numbers remain a matter under study, Cleveland Clinic is no stranger to measuring patient experience, and Rasmussen says for follow-up visits with providers, patients are happier doing virtual instead of in-person visits. "We are using this strategy to drive patients with minor complaints away from brick-and-mortar to free up the primary care physicians for more chronic disease management or a way to manage matters that require inpatient visits," he says.
Perhaps nowhere is the bottom line of telemedicine's advent being felt more than at health insurance companies.
"As most people know, health insurance has not been known for being differentiated in the consumer experience side of things," says John Jesser, vice president of Anthem, Inc., and president of LiveHealth Online. "So this is really a great opportunity to create a capability for Anthem that would be remarkable."
Anthem, which currently offers telemedicine as a covered benefit to 18 million Anthem customers, was attracted by the fact that the common retail price of an online visit is $49, Jesser says. "There's a ROI right there, because if you walk into a retail clinic, you're going to spend between $80 and $90. If you walk into urgent care, it will sometimes be over $200, and the emergency room goes up from there. So the ROI for one person is immediate."
FedEx, an Anthem client, knows that at least 20% of the emergency room visits its employees make are unnecessary, Jesser says. "We've been trying to help people with solutions for this for years," he says. In exit surveys after LiveHealth Online encounters, by asking members what they would have done had the telemedicine option not been available, Anthem has determined that telemedicine is generating "considerable savings across the board, every time someone's having an online care visit." Jesser says this cost savings information will find its way into a peer-reviewed journal soon, drawing on Anthem claims data.
A major task ahead for Anthem is educating its members that the telemedicine benefit is available.
"This is such a new way to get care that until you've actually seen it or been exposed to it directly, you don't know that you actually have the ability, that you have a doctor in your pocket."
"Do they all know they have this benefit?" Jesser says. "No. This is such a new way to get care that until you've actually seen it or been exposed to it directly, you don't know that you actually have the ability, that you have a doctor in your pocket."
Anthem is aggressively marketing the telemedicine benefit, "but it's not one of those things like a dental plan or a health insurance copay that you just put on the ID card and everybody understands it. You really need to address people directly through email, sometimes through direct phone calls, and video. We've been working very hard at that. One of the other challenges is just simply obtaining people's email address to let them know they have such a thing," he says.
In addition, Anthem telemedicine services are available to nonmembers as well through the use of a credit card, although they must arrange individual reimbursement for these services, perhaps claiming them as out-of-network services with their own health insurer, Jesser says.
For now, telemedicine represents a small part of Anthem's overall business. "You need millions of visits to even move the needle," Jesser says. "It really wasn't done as an economic growth engine. It was done as a differentiation feature. It's steadily growing, doubling and tripling year over year."
While providers praise flexibility, work is just beginning on which technology will work best, and whether regulations are too little or too much.
As the final days of the Obama administration tick down, a flurry of final rules from CMS and ONC promise to reduce the reporting burden which the meaningful use program imposed on providers.
The final rule on MACRA and Merit-based Incentive Program legislation provide more flexibility on how physicians enter the value-based payment world of CMS' new Quality Payment Program.
John Halamka, MD, chief information officer of Beth Israel Deaconess Medical Center, praised the final outlines of the Merit-based Incentive Payment System and Advanced Alternative Payment Models (APM).
"In the final rule's technology area, called Advancing Care Information (which replaces meaningful use for physicians), CMS reduced the number of [quality] measures from 11 to 5," Halamka wrote in an October 19 blog post.
"CMS recognizes that technology, infrastructure, physician support systems, and clinical practices will change over the next few years, so over reliance on a highly prescriptive and broadly scoped certification rule must be avoided."
A final rule on the Medicare Outpatient Prospective Payment System (OPPS), due within days, may provide some meaningful use relief on the hospital side as well, says Mari Savikis, vice president of federal affairs at the College of Healthcare Information Management Executives (CHIME).
"They did propose to make a 90-day OPPS reporting period for 2016, but they didn't propose it for future years," Savikis says.
"We really want to see them extend that 90-day reporting period for at least 2017 and hopefully later years. That would sync up more nicely with MIPS and MACRA, so hospitals have a little more breathing space."
Hospitals and health systems that employ physicians and thus must report under MACRA will have to install updates from EHR vendors for their clinical quality reporting, while continuing to report meaningful use quality measures for an entire year. "It's a lot," Savikis says.
The ONC final rule gives the office direct oversight and review of information blocking issues, but limits the ONC's role to any blocking that could affect patient safety, Savikis says. "We were pleased to see them walk back some of their pretty big list of items. Focusing on safety is much more reasonable, and we supported that."
The rule requires healthcare providers to attest they did not knowingly and willfully take actions, such as disabling features or functions in its technology, to limit or restrict compatibility or interoperability of certified EHR technology.
Providers also must attest they responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, other healthcare providers, and other persons, regardless of the requester's affiliation or status as a technology vendor.
ONC clarified that it doesn't plan to hold providers accountable for technology pieces that are outside their control, says Savikis. "We're going to have to wait and see how that plays out."
Micky Tripathi, head of the Massachusetts eHealth Collaborative (MAeHC), points out that the MACRA final rule still leaves a great deal of work on the technology side for providers—particularly those connecting information in multiple vendors' EHRs—to achieve the desired outcomes of MACRA.
"There's no standards for the integration of a population health management solution with an EMR or certain types of transactions," Tripathi says.
This leaves a large opening for the panoply of population health vendors and service providers to engineer the necessary bridges between the many EHRs in use across ACOs and the other strange bedfellows thrown together by MACRA.
"Right now we've got a lot of experimentation going on," Tripathi says. For instance, MAeHC provides the data warehouse powering Aledade, a health consultancy focused on helping ACOs succeed in the MACRA era.
"Until we've seen a few months of MACRA and MIPS in action, it will not be possible to pick any emergent technology winners out of these final rules," Tripathi says.
Under MACRA, improvements to meaningful use will continue, as will opportunities for information exchange, predicts the National Coordinator for Health Information Technology.
October 14—the day the MACRA final rule was released—found Vindell Washington, MD, head of the HHS Office of the National Coordinator, in San Francisco briefing the Association of Health Care Journalists.
In between other national briefings, I had 20 minutes to interview Washington one-on-one about the impact of the final rule and the road ahead for healthcare and healthcare IT. This transcript below has been lightly edited.
HLM:What do you say to hospital executives in particular now? They weren't so much addressed by MACRA, but they still face rule upon rule still with meaningful use. Is this going to continue to work for hospitals?
Washington: The meaningful use program I think has been very successful in the adoption space for hospitals.
I had an opportunity look at some of this data a couple of months ago, and if you look at where we were versus where we are now in terms of adoption and deployment, it's just not even close: 96% or 98% of [hospitals] are using electronic health records.
As a former hospital executive, I know that much of that came from the regulation to do this work. To imply otherwise, it doesn't ring true to me.
HLM:Many hospital executives want to declare victory on meaningful use and go home.
Washington: Yes, but the question is what's next. There are opportunities for [health systems] to exchange information better.
There is still more work to be done and as I look at what's happened with MACRA and the physician place and space, there are two things that come to mind.
The first thing is the physician environment is not the same as the hospital environment. If you were to line up the 5,000 hospitals and take out the critical access hospitals, [the remaining facilities] are much more alike than… a pathologist's office versus a family practitioner's office.
Moving to the next phase, there is an opportunity for greater flexibility pieces.
On the hospital side, there are certainly opportunities as we move forward and as the program matures. We're continually making changes to both the framework and the structure, and I presume that those improvements to that program will continue. It's not a static thing.
HLM:Is the technology providers now possess adequate to fulfill the MACRA objectives? Many physicians I talk to feel that the technologies in front of them, the certified EHR technologies, are more geared toward the last war—how do we get paid—and not so much geared toward what MACRA is trying to achieve.
Washington: I think of it more as an arc as opposed to sort of a point in time. We certainly need continued improvements in technology, but that's not different in healthcare than in other areas. The central point of it is that technology is critical for these activities and for this community-centered and population-centered care.
HLM:Prior to HIMSS last March, vendors and providers signed the ONC interoperability pledge. Now it's almost November. Has that pledge yielded results?
Washington: We have a very high percentage of folks now who say that information is being exchanged. Our survey results said that 8 in 10 folks are underscoring enhanced exchange of information.
We had a site visit to San Diego, and a site visit to Tulsa, Oklahoma, where there were competing vendors that had made that pledge. They now have more and more flow of information. Hillcrest and St. John's, I think, were two that we looked at out there. So there are incremental improvements.
We are also engaged in stakeholder listening sessions with some of those pledgees about interoperable medication list exchanges, [and] about moving information using FHIR and APIs, and are now using that information to work on this nationwide effort.
Athenahealth CEO Jonathan Bush says the U.S. healthcare system "created Donald Trump" and reveals his company's efforts to turn Epocrates into "a universal remote for EHRs that you hate to use."
With the 2016 presidential election 34 days away and early voting underway, I decided it was time to check in with Bush.
That's Jonathan Bush, co-founder, chief executive officer and president of athenahealth, who also happens to be a cousin of former president George W. Bush. We spoke one-on-one last week at the Health 2.0 conference about the election, then moved on to MACRA and other pressing topics. The transcript below has been lightly edited.
HealthLeaders: Isn't it ironic that rising healthcare costs, the very thing that's making the economy leading up to this election so agonizing, is the one thing that they haven't talked about so far in the debates?
Bush: I think it's ironic beyond words. I believe that our healthcare system created Donald Trump.
I don't think it's because of healthcare. I think it's because of the checkbook impact of healthcare, and I even think the checkbook impact of healthcare wouldn't have created Donald Trump if people felt power over their healthcare, if they were buying that much healthcare and kind of showing off about it and enjoying it and feeling like they're living longer or their knees work better or something.
HealthLeaders: A high deductible does not power make.
Bush: A high deductible and a kind of a very powerless patient experience. Not even 'thank you' or 'we're glad to see you,' and remember most of us don't do anything with it. Ninety-two percent of us, maybe we have a baby or break an arm here and there, but we're not consuming anywhere near $565 per human per month.
HealthLeaders: We're just paying for it.
Bush: We're paying for 6% of us that are chronically ill and one and a half percent of us that are raging against the dying of the light in ways that we might not want to do ourselves if we could keep the money.
And that wouldn't even matter if it wasn't for the fact that our middle-class paychecks [are declining] and GDP is going up.
Unemployment's low, but the actual deposit into the bank account is declining, and it has been except for a couple years. I don't remember which ones, but the rest of them, those paychecks are smaller after healthcare and required benefits [are paid for put-of-pocket].
HealthLeaders: How do we galvanize healthcare executives to actually do anything differently than what they've been doing, because it seems to me that [whether you] call it meaningful use or call it MACRA or whatever, things kind of just continue as before. The regulators, when pressed, will kick the can down the road as they have now done with MACRA.
Bush: As they did with meaningful use 3.
HealthLeaders: So what is it going to take for our industry to change?
Bush: Innovation has always and will always happen from the outside in. There is such a thing as first movers. Mayo Clinic is the first institution that I know of that has started to detail its clinical decision support guidelines on Epocrates along next to the drug companies. It started in the past three weeks.
We're rewriting all of Epocrates [athenahealth's medical reference app for physicians] to allow every institution to be connected, to even let their charts be visible on ePocrates.
HealthLeaders: So are you turning it into a PHR?
Bush: It's basically a universal remote for EHRs that you hate to use, including athenanet.
How technology eases regulatory burdens, helps providers work smarter, and improves clinical quality.
This article first appeared in the October 2016 issue of HealthLeaders magazine.
Clinical quality measures that are being scrutinized by the Centers for Medicare & Medicaid Services and The Joint Commission are driving providers to work smarter, not just harder, to meet ever-increasing regulatory burdens, and technology is playing its part.
Those regulatory burdens also include reporting data breaches, a category recently clarified by CMS to include ransomware attacks; meaningful use stage 3, which takes effect for some healthcare systems in 2017 and others in 2018; and the Medicare Access and CHIP Reauthorization Act (MACRA), which is also scheduled to commence in 2017 and is CMS' main vehicle for moving healthcare from volume-based to value-based reimbursement.
Quality rules
At Halifax Health, whose main 678-bed medical center is based in Daytona Beach, Florida, director of quality improvement Suzanne Lovelady has turned to technology to automate manual paper rounding, as well as to meet Joint Commission survey readiness objectives.
"We are definitely measuring more," Lovelady says. "When I first went into quality improvement 15 years ago, I could count on one hand the projects that were ongoing. Now it fills up a couple of whiteboards. So the number of projects has grown, and also the scope of those projects is much greater."
Key drivers of these quality reports include patient safety and outcomes. Halifax Health replaced paper-based written observations with software from ReadyPoint to speed preparation of these observation findings and facilitate dissemination of these among its staff through a system replacing numerous, time-consuming meetings or face-to-face conversations.
Technology is a necessary but not sufficient part of making such a transition work, Lovelady says.
"The team that is doing these rounds still has to be familiar enough with the standards to know how to interpret them, any of the regulatory guidelines they're monitoring," she says. "Having some sort of electronic tool that will also allow that team to have those standards at their fingertips as they're rounding is key. If a staff member approaches me [with a question about] how come something isn't compliant—maybe having a cart in a hallway is the issue from a safety perspective—the team can pull up that standard on the spot and show it to them, exactly why we're saying it's not compliant, which is key." The software also utilizes mobile devices carried by the compliance team to capture and present photos documenting noncompliant practices.
Immediately following noncompliant incidents, the software allows Lovelady's team to push out emails to staff leaders, who can then work on corrective action plans even before the compliance team has left the scene, she says. "Once we're done with our rounds, there's no more hours spent on my team's end to come up with our findings, and put it into some sort of understandable format for the rest of the organization. So that's how realtime our compliance efforts and our improvement efforts can be."
Since the initiative has only been in place for three months, it is still too early to tell precisely how much better overall staff compliance is, Lovelady says.
As CMS increases the amount of electronic reporting of clinical quality measures (eCQMs), Lovelady admits that, at times, she and other providers are at the mercy of the electronic health record software vendors to implement this new compliance mandate.
"I believe, and I hear from some of my colleagues in other hospitals that have different platforms, that all EHRs have their shortcomings" in reporting eCQMs, Lovelady says. In addition, EHRs still struggle to pull information from these measurements into clinical decision support workflows, she adds.
Another technology component Halifax uses helps with reporting to The Joint Commission's ongoing professional practice evaluation (OPPE). Since the reporting pulls from four different EHR systems, Halifax recently adopted technology from Acmeware to pull data from data registries in each EHR, Lovelady says.
Clinical decision support and analytics help
"We're being faced with more and more regulatory requirements," says Mary Beth Mitchell, chief nursing informatics officer at Texas Health Resources, a 29-hospital system headquartered in Arlington, Texas. "One of our first challenges is that they don't always align. So you might be reporting the same measure to multiple agencies, but not in the same way. I can think of a couple of agencies that don't always look at things the same way. They try, and they're working at getting more aligned, but still today we're faced with reporting the same data in more than one way."
At Texas Health, a public dashboard shows all key CMS-related quality measures and how they compare to other hospitals across Texas and the United States, Mitchell says. But even here, there may be slight variances in how measures are reported, which could explain why a competitor might score higher or lower than Texas Health, she adds.
"Even more fundamental than that, technology is a critical necessary component to this," Mitchell says. "We absolutely could not keep up with everything if we did not have technology to support it, and if we did not have clinical decision support to help monitor, provide reminders, and to do alerts and comparisons."
A major direction is to enable more and more of these technology-driven processes, and the predictive analytics they can enable, to run in the background and present themselves at appropriate times, yet not force clinicians to constantly read alerts, "though there is still a lot of that," Mitchell says. "When you get a stroke patient in, or a cardiac patient, I believe you need those reminders."
Now, like other providers, Texas Health must also pivot from volume to value. To meet the many new compliance requirements as part of that change, Texas Health created its Reliable Care Blueprinting initiative, "where we are creating standards for different types of care and making sure everything is done the same way for every patient every time," Mitchell says. As part of this initiative, quality efforts must align with compliance mandates such as what we've done with our bundle care program for joint replacement (the Comprehensive Care for Joint Replacement model), she adds.
Leadership remains challenged by the overwhelming amount of change compliance represents to nurses and other clinicians.
"Within the staff nursing area, it's just seen as a lot of change coming at them too fast, and I agree it's becoming a real issue for them," Mitchell says. "I think technology can help, if we can start doing more things that run in the background that take less intervention on the part of the nurse."
For example, Mitchell says she would like to replace nurse requirements to take patient vital signs every four hours with wearable devices that can continuously monitor heart rate and respiratory rate, in order to detect conditions such as sepsis, and bring this to the attention of nurses earlier. "It's something I'm just starting to work on, and it is a challenge and somewhat risky to try unproven technology," she says.
Giving radiologists the compliance value proposition
For far too many clinicians, the many compliance initiatives already in place and those being added to the workload just seem a never-ending grind of checking boxes, even though the original intentions of CMS, The Joint Commission, and others to improve clinical quality seem far removed from that box-checking.
Executives push forward anyway, and realize that communicating the why of compliance is just as important, if not more so, than the what.
"At least for our company, what we're most concerned about is the new legislation that is going to tie our pay to performance, so what we're trying to wrap our heads around is how can we position ourselves so that we can maximize our reimbursement from the Merit-Based Incentive Payment System," says Stephen Holtzman, MD, CEO of the 100-employee Radiology Associates of San Luis Obispo in California, and providing imaging services in two area hospitals and four imaging centers.
"One of the changes we've made recently is for all needle-based procedures—whether it's inpatient or outpatient—we follow a detailed safety checklist," Holtzman says. "The concept is that you really want to prevent even the smallest adverse effects. So The Joint Commission really is out there trying to do things to improve quality and patient safety.
"The disconnect is that it's not explained why this needs to happen. It's just a box that you need to check. It's seen as a waste from the perspective of the provider, and they feel that it's taking them away from doing their care. I think The Joint Commission could do themselves, their patients, and their providers a huge favor if they've really invested upfront in explaining the why."
That said, Holtzman says he is "a huge believer in continuous quality improvement." Using technology from Merge Healthcare, the organization's seven radiologists are able to suggest improvements to quality and safety on a daily basis, he says.
These improvements manifest themselves when radiologists, in the midst of reading a case within Radiology Associates' picture archiving and communication system, make suggestions that find their way into the pop-up templates that guide radiologists through the radiology reporting process, Holtzman says.
"There is no such thing as 100% compliance or 100% security, but prudent organizations and people put forth ongoing good-faith effort to be on top of both. The changing and dynamic threat landscape demands it."
"Our target is to implement 10 improvements on our templates every single day," he says. "One of the current PQRS measures that's going to be converted to MIPS is documenting the number of images you take. It's a surrogate for how much radiation exposure the patient receives. You can't sign off on the report unless you've documented the number of images. The requirement is basically to get people thinking about radiation exposure."
Security compliance remains a challenge
One area where mere compliance with regulations falls short of the ultimate goal of any healthcare organization has to be security and privacy of electronic patient information.
"Oftentimes people feel that if you're compliant, you must be, by definition, secure," says Bob Chaput, founder and CEO of Clearwater Compliance, a Nashville supplier of compliance and cyber-risk services. "It's not true. Similarly, you can be very secure but not compliant with certain regulations. So we encourage organizations to think about not only those two risks, which are inextricably linked, but also about other risks with which they're linked or they may trigger. For example, financial risk or reputational risk, or the risk if you don't have the ability to attract and retain talented people."
"There is no such thing as 100% compliance or 100% security, but prudent organizations and people put forth ongoing good-faith effort to be on top of both," Chaput says. "The changing and dynamic threat landscape demands it."
In Massachusetts, a service used for securely sharing data between physicians and emergency departments is being called a "game changer."
In the battle to reduce hospital admissions and readmissions, the struggle to share information remains on the front lines.
But in Massachusetts, data-sharing arrangements between physicians and emergency departments are making progress. One example is Worcester-based Reliant Medical Group, a multi-specialty group practice with more than 500 providers.
If a patient of one of Reliant's physicians arrives in an emergency department at nearby Saint Vincent Hospital or Milford Regional Medical Center, the EHR systems of those EDs will automatically generate and send a message to the physician.
Within 90 seconds, Reliant's EHR automatically sends a summary of the patient's medical record to the ED via the DirectTrust service.
In this way, ED docs alert these Reliant physicians, and in return gain access to valuable medical history, medication, and allergy lists on the patients they are treating.
"One of the biggest game changers for us is the ability not just to be able to exchange information with other organizations, but to do it in a hassle-free way that doesn't require a lot of effort by the users," says Larry Garber MD, associate director of research and an internist at Reliant.
"Nobody has to do anything other than what they always do, which is registering the patient," he says. "Ninety seconds later," the emergency room doc sees an icon on the bed board "saying this patient has outside records from Reliant Medical Group."
Easy Expansion
By the end of the year, Reliant will extend such relationships to three additional hospitals in central Massachusetts. Expansion within and even outside the Commonwealth, to destinations where Massachusetts "snowbirds" land during the winter months, is relatively easy.
A key enabler of this connectivity is the DirectTrust "trust framework" which securely connects EHRs via health information service providers (HISPs), and sends Direct messages, but which also enables something called its Directory Data Aggregation Service.
This connects some dots: Every certified EHR must be able to send and receive Direct messages, but the government never built a provider directory so that those EHRs or their users could look up the Direct addresses of individual physicians.
Leveraging DirectTrust, participating providers can perform such directory lookups and enable the workflow Reliant and its partners are leveraging.
One Direct messaging shortcoming is that physicians must set up multiple Direct mailboxes, due to the fact they may split their time among their practice offices, hospitals where they may be attending physicians, and other locations throughout the day.
How is a sender supposed to know which of those mailboxes to use? Garber says that within Massachusetts, the state HIE, the Massachusetts Health Information HIway, plays a role in dealing with this problem.
Sending is Not Like Receiving
As mentioned above, all EHR software is capable of sending Direct messages as part of meeting the meaningful use requirements. But configuring an EHR to send Direct messages is different than configuring an EHR to receive Direct messages, Garber says.
"A lot of EHRs, when the message comes in, it goes to some generic pool that some medical records person has to be staffing to figure out which patient is this and who should I send it to, and that really becomes an obstacle," he says.
To solve this, Reliant uses the Mass HIway's Local Adaptor for Network Distribution (LAND) technology, which takes a Direct message and converts it into formatted text ready to be loaded into Reliant's EHR and from where the message can be routed to the appropriate Direct mailbox of the patient's appropriate physician, Garber says.
Ultimately, Garber hopes that EHR software itself becomes smart enough to carry with it the necessary provider directory and associated technology to make all this simple and automatic.
Not all providers belong to DirectTrust, and the lion's share of providers, of course, are not in Massachusetts (think of where those snowbirds may receive emergency care) and don't have LAND to help.
It remains to be seen exactly how and where the remaining dots will be connected to similarly improve patient ER visits everywhere.
Physicians will have learn what the automated systems can and can't do, and recognize their own roles as the developers of the algorithms that smart systems will use, says a proponent of the Internet of Things.
Enough sensor-equipped, collision-detecting, self-braking cars will be on U.S. roads by 2022 to eliminate one third of all traffic highway deaths, the Insurance Institute of Highway Safety predicted last year.
Talk about technology bending the cost curve of healthcare. "That's with today's technology," says James Mault, MD, chief medical officer of Qualcomm Life, who highlighted this prediction at Qualcomm's annual Connect conference in San Diego, CA last month.
"That's 11,000 human beings that within the next five years will not be dying each year. What's going to happen to the trauma centers of the hospitals that are making a ton of money on motor vehicle trauma?
"Your budget is going to change because… people aren't crashing into each other."
Mault is an unabashed champion of the disruptive impact of technology, and his employer sponsors the Tricorder XPrize, a $10 million contest to develop a handheld device that can diagnose 13 health conditions and capture five vital signs in real time, anywhere.
Prize winners will be announced early next year.
Mault also isn't afraid to fire back at critics of some digital technology, such as American Medical Association President James Madara MD, who in June accused the healthcare technology industry of peddling too much digital snake oil.
"From ineffective electronic health records to an explosion of direct-to-consumer digital health products, to apps of mixed quality—it's the digital snake oil of the early 21st century," Madara told the AMA's House of Delegates at its annual meeting.
Ubiquitous sensors and the Internet of things may be poised to reduce the highway body count. They already enable passenger jets to fly themselves with minimal pilot intervention.
The same underlying technology will soon disrupt many other aspects of healthcare, Mault says.
"Let's talk about the intensive care unit in the operating room, where we are still practicing no differently than we did 50 years ago," he says. "We're looking at a patient and, without any real objective information, [thinking,] 'maybe he's ready to wean off the ventilator. I'll dial it down and we'll watch and see.' "
In such a scenario, it's easy to imagine a patient then breathing with difficulty, followed by physicians dialing the ventilator back up.
"Would you consider that to be a smart ventilator, or a not-so-smart ventilator, because you've got a doctor or a nurse who is not able to see what a continuous sensor is going to be able to see and watch, and go, 'well, based on 100,000 sets of data, I know this patient is ready to wean, and here's exactly how we're going to wean this patient based on how he's doing.' All of these systems will become automated."
Failsafe: Human Beings
Of course, as the recent movie Sully demonstrated, pilots still have to take charge of a plane in an improbable crisis. Likewise, in the case of Mault's ventilator example, physicians would still intervene, but only as necessary.
"The failsafe is still going to be the human being," Mault says. "But potentially I could be in a central hall monitoring four different people getting their automated anesthesia, and then it's going to show me this one's gone a little south. I better go in there and make an assessment."
Physicians will have learn what the automated systems can and can't do, and recognize their own role as the developers of the algorithms that smart systems will use, says Mault.
"Machine learning is going to start making these algorithms smarter. When I have ventilator data from a hundred thousand patients and then a million and then ten million patients, that ventilator weaning protocol, that automated system, will get smarter and safer," he says.
Both Madara and Mault criticize the current way medicine is practiced, in that it does not rely enough on the base of available evidence.
Madara points to "digital so-called advancements that don't have an appropriate evidence base, or just don't work that well—or actually impede care, confuse patients and waste our time."
Mault, who will probably end up debating Madara about the pros and cons of digital health somewhere down the road, points out that current care relies too much on "episodic and sporadic" ambulatory patient data, acute-care EMRs which only look at snapshots of data, and a general continued acceptance of trial-and-error care.
Mault serves on the University of Michigan Medical School admissions committee and sees the move to sensors, asynchronous care, remote care, and exception management-based care as essential medical school curriculum going forward.
It's difficult to see how that will also be open to debate.
Since reopening last year, MLK Community Hospital has been a showcase of how a safety net hospital can employ new technology and new thinking to serve a community.
In technology, too many problems often end up being solved by completely restarting a system.
In the hospital world, that's considered the last resort, but a hospital I visited last week suggests there is value in this approach when it's applied on a large scale, too—to an entire hospital.
And so it is that Martin Luther King Jr. Community Hospital, a 131-bed reboot and rethink of the old 400-bed Martin Luther King Jr./Drew Medical Center in south central Los Angeles, has become a blueprint for how to do such a restart.
Following in the wake of a series of terrible quality lapses more than a decade ago, the decision to completely close the old medical center, terminate all its staff, and start fresh was a costly one to the county of Los Angeles.
But since reopening last year, MLK Community Hospital has been a showcase of how a safety net hospital can employ new technology and new thinking to serve a community of 1.3 million people, an area with only one other hospital located within its service area.
I visited MLK Community last week and took away five tips on just how to leverage technology to maximize such a reboot in 2016. My guide was Sajid Ahmed, chief information and innovation officer.
Ahmed is not your average CIO. He was deliberately hired by president and CEO Elaine Batchlor as employee #2 because she valued IT-fueled innovation highly, Ahmed says. His background is in tech, as well as at L.A. Care, the nation's largest public health plan; this is his first gig as a hospital CIO.
1. Outsource IT staffing through a hybrid governance model.
Starting with a blank piece of paper, Ahmed invited competitive bids for a company to staff its IT department, while retaining key IT managers and directors in house.
The winning bidder, CareTech Solutions, provides the other IT workforce, everyone from application analysts to network engineers, at an affordable price to maximize the available skill set for a low-margin safety net hospital.
2. Maximize employee training at restart.
Relatively speaking, choosing and implementing technology is easy, compared to training employees to use that technology to have a smooth licensure and opening day.
Because the technology enables true collaboration between staff, getting the culture right, including freshly crafted policies and procedures to leverage that, is key, Ahmed says.
For instance, from day one, he banned all fax machines at the hospital, to force communications to all-digital. Aside from a few batch uploads involving claims, the fax ban has endured.
3. Start phishing drills early, and repeat monthly.
If technology has an Achilles' heel, it is the sometimes the unfounded trust that employees put in each others' emails.
While two-factor authentication can offer some trust, sophisticated phishing and spear-phishing are probably the root cause of many of today's successful ransomware attacks.
MLK Community recently staged its first internal phishing attack. "We're going to do it again next month in a different way, until employees pick up the habit" to educate themselves about phishing, Ahmed says.
Hospital leadership will also conduct a cybersecurity disaster drill next month, he says.
4. Remote host IT systems where it makes sense, and leverage available discounts.
MLK Community selected Cerner as its EHR, opting for the full Cerner instance instead of a community hospital edition, Ahmed says. Cerner hosts this EHR at its data center in Kansas City, reducing on-site data center needs at MLK, and further enhancing data security.
MLK gets a discount from Cerner because the public partner in the public/private partnership that runs MLK is Los Angeles County, whose health department also chose Cerner as its EHR.
MLK's financial systems, provided by Lawson, are also remotely hosted.
5. Think like a startup.
Because a separate nonprofit corporation runs MLK Community, the new private operators cannot simply turn to taxpayers for operational funds when times get tough.
With responsibility already in place for the top line and the bottom line, MLK Community has to think right now about the world that's coming–value-based reimbursement instead of volume.
So Ahmed has already pushed Cerner and other vendors to adapt their technologies to population health, even though Medi-Cal, California's version of Medicaid, is not yet set up to pay for value. Ahmed knows that day is not far off.
Thus, since last July, every patient at MLK Community has been assigned a care coordinator. The goal: Keep patients out of the ER as much as possible and prevent readmissions, and leverage "e-consults" for more efficient referrals.
As the "Rubik's cube of reimbursement" gets rearranged in the coming years, Ahmed knows he has to be flexible to adapt to changing reimbursement rules. And yet, in the short term, the new hospital has cut costs that the old hospital couldn't afford (too many beds) and increased revenue where it made sense (expanding its OB and maternity services).
It's still early at MLK Community, but Ahmed says internal patient satisfaction scores have been promising, and in February, the hospital achieved HIMSS Level 6 IT certification, a rare thing in a hospital's first year of operation. And Yelp reviewers give it 3-1/2 stars out of five.
As wrenching change continues, more hospitals are bound to close. As some of them are reborn, the lessons MLK Community has to teach shall reverberate.
Healthcare leaders find that one of the benefits of the eHealth Exchange is the single data use and reciprocal support agreement.
This article first appeared in the September 2016 issue of HealthLeaders magazine.
As other health information exchange methods struggle to gain nationwide traction, one method, which originated in the federal government, and replaces lengthy negotiations between providers with a standardized data-sharing agreement, continues to gain adherents.
The eHealth Exchange started its operational life in 2009 as the Nationwide Health Information Network, sponsored by the Office of the National Coordinator. In 2012, NHIN became the eHealth Exchange, and its governance came under the management of the Sequoia Project, formerly known as Healtheway.
By using agreed-upon standards from HL7 and other industry organizations, and support already built into much electronic health record software, the eHealth Exchange provides a way for clinicians to query for records on given patients from around the network, and use the network as a secure way to send and receive Continuity of Care Documents to other nodes on the network.
One benefit of the eHealth Exchange: a single, agreed-on set of rules of the road—a data use and reciprocal support agreement that all participants abide by. Such agreements, when hammered out two health organizations at a time, make for very slow going to advance interoperability at scale.
A major implementation of eHealth Exchange crystallized recently when Intel Corporation, seeking to control its own employees' healthcare costs and increase employee convenience, launched its Connected Care initiative for its employees, and began requiring providers to join eHealth Exchange as a way to move patient records to and from local clinics, including Intel Health for Life clinics available on-site at its company campuses.
Intel Corporation, which self-insures its 50,000 U.S. employees and their 80,000 dependents through several national plans, spends approximately $680 million annually on healthcare benefits.
"That's a very significant amount we could be using in research and development and innovation, and the costs keep going up," says Prashant Shah, director of engineering at Intel Health and Life Sciences, based in Hillsboro, Oregon. "Intel was trying to innovate in this space. How can we get better outcomes at lower cost and increase patient satisfaction? We kept encouraging the national networks to innovate and do a lot more robust care coordination and patient-centered medical home-type models, but progress was very slow."
Intel's impatience with the pace of healthcare transformation helped it decide to self-insure its employees and work directly with providers, and to require providers to join the eHealth Exchange so records could follow patients from primary care offices to specialists and to on-site clinics. Setting up what Shah calls this ACO-like network, initially at a smaller Intel employment site in New Mexico in 2013, "was relatively simple and easy," he says.
When expanding the concept to Intel employment centers in Oregon in 2015, Intel convened local providers, including Kaiser Permanente, Providence Health & Services, the Portland Clinic, and employer on-site care provider Premise Health, to outline how they would meet Intel's ACO-like objectives, describing the clinical processes required.
"Intel has been in healthcare [as a technology supplier] for a long, long time," Shah says. "One of the key barriers to any progress being made in healthcare is the lack of interoperability. Since we hold the purse and we'll be creating these contracts and measuring these health systems, let's bake the interoperability language right into the contracts that we sign with these health systems through HR."
Because Intel employees travel between campuses in Oregon and Arizona, a model built around eHealth Exchange allows for a privacy-preserving interoperability that follows the employees from provider to provider, Shah says, and as use of eHealth Exchange expands nationwide, the potential for further continuity of care grows. In all of 2015, Intel's providers exchanged more than 42,000 Continuity of Care Document Architecture (CCDA) documents as responses to queries, Shah says.
Intel's contracted Arizona healthcare clinics, on-site and off-site, part of the Arizona Care Network, joined the Connected Care effort in 2016.
"Given my background in health IT, I did not want a point-to-point integration" between each healthcare provider, Shah says. "They're really expensive, and they're hard to maintain, and it's a one-off for the health system, and it's not something that the health system likes.
"I wanted to require something that was standards-based that runs on a national network. So we looked at various national networks, and the most mature one from our perspective was eHealth Exchange. Lucky for us, both Kaiser and Providence, at least a large portion of their network was already on eHealth Exchange. They were exchanging CCDA data with the Social Security Administration, and we said, 'Why can't we use the same network for the care coordination between our on-site clinics and the health systems?' We decided to go in for the eHealth Exchange."
Intel made a point of adopting eHealth Exchange and Direct Messaging even though in markets such as the Portland area, the Epic EHR is predominant. However, Intel also was planning to roll out the interoperability model in Arizona, which had a highly heterogeneous EHR ecosystem. This required that the interoperability architecture be completely EHR vendor-agnostic.
"We don't believe this is a one-year effort where we set this whole architecture up and we go live and shake hands and call it done. We are always evolving."
"The thing that fundamentally drives Intel is open data," Shah says. "So let's actually set an example for the industry how this can be done."
In addition, the provider operating Intel's on-site ambulatory clinics, Premise Health of Brentwood, Tennessee, runs not the Epic EHR but one from Greenway Health, which also supports eHealth Exchange, Shah says. "We actually funded Premise Health to have them onboard on the eHealth Exchange and get that going."
Part of Intel's effort is to continually measure how the system is performing. "We don't believe this is a one-year effort where we set this whole architecture up and we go live and shake hands and call it done," Shah says. "We are always evolving. We made it really clear to the health systems that this is a road map, and we have weekly technical meetings and clinical meetings with them evolving this road map."
The Arizona Care Network, a joint venture between Dignity Health and Abrazo Community Health Network and various independent physicians and specialists, presents a new challenge to Kaiser's Arizona use of the eHealth Exchange, Shah says. "There was a long list of different EHRs that were being used by our provider network," he says. "Obviously, our year one goals are going to be significantly different, but part of the reason why we wanted to go with a national network like eHealth Exchange is we can replicate and scale" eventually to expand to Intel's employee base in California as well.
Encouraging Intel's push was Eric Dishman, who recently left his post as vice president and Intel fellow of Intel's health and life sciences group for the National Institutes of Health to take the lead as director of the Precision Medicine Initiative Cohort Program.
Kaiser Permanente's own experience with the Intel initiative has been encouraging, says Kevin Isbell, Kaiser Permanente executive director of data and analytics delivery, based in Oakland. "If I'm an Intel employee, providers treating me at the Intel clinic will want to know my history and my clinical background, and they're able to query that information from Kaiser's electronic clinical medical record in the Northwest, bring over kind of the classic continuity of care document payload, and have an understanding of my allergies, problem lists, and medications," Isbell says.
"Likewise, we maintain a bidirectional relationship with them so that at the time that care is provided and recorded by Premise Health in the Greenway EMR, that information can also be queried back to our Epic electronic medical record through the eHealth Exchange for follow-up by a primary care physician."
As an anchor member of the original NHIN, Kaiser implemented a pilot exchange back in 2009, between its San Diego region and the U.S. Department of Veterans Affairs. Today, Kaiser clinics in eight states and the District of Columbia are all operational on the eHealth Exchange, Isbell says. And the Kaiser connections keep growing. Recently, Kaiser connected to Virginia Hospital Center in Arlington via the eHealth Exchange, Isbell adds.
"We are definitely an Epic shop," Isbell says. "Wherever possible, especially if another organization is also Epic, we will utilize CareEverywhere." Reasons why include the ability to retrieve full lab results and ancillary reports, such as radiology and pathology reports, not yet available via eHealth Exchange, he says. "eHealth Exchange is our definitely No. 2 most active and voluminous exchange, and primarily because of the federal partners that we're able to connect to."
One of those federal partners on the eHealth Exchange is the Social Security Administration, whose presence on the network drives improved revenue to providers such as Kaiser. Through eHealth Exchange, the SSA was able to fully automate the process of verifying disability claim filings by patients being seen by eHealth Exchange–compatible providers such as Kaiser.
Prior to this automation, "it literally was months from the point of a disability claim filing, and many FTEs, humans involved in that process," Isbell says. "For a place lke Kaiser Permanente, we do hundreds of thousands of those a year. We return a CCD to SSA, and they can complete the verification process and make aware the benefit to the person filing in days versus months."
In the mid-Atlantic area, another eHealth Exchange connection point is Envera Health, the new owner of the MedVirginia health information exchange. The newly christened Envera Data Exchange connects the eHealth Exchange with seven Bon Secours hospitals, three Centra Health facilities, and most recently the Virginia Commonwealth University Health System, says Michael Matthews, chief transformation officer of Envera Health.
In addition, Envera Health connects about 1,000 community physicians to eHealth Exchange via its provider portal, Matthews says.
"We're also expanding the services we're providing to those provider connection points," Matthews says. "For example, most of those are receiving results through our platform, so we take the reference labs and the hospital results that a physician has ordered, and we're able to map those directly into the electronic health record."
According to Matthews, the SSA commissioned a study several years ago showing a 35% drop in turnaround time for disability determination due to use of the eHealth Exchange. This study of eHealth Exchange use at Bon Secours showed that its four Richmond hospitals realized a $2.2 million annual revenue enhancement due to the speedup in disability determination, Matthews says.
"In almost all cases across the country, disability claimants also qualify for Medicaid benefits," Matthews says. "Because we reduced the turnaround time for disability determination, we also reduced the time for them to get Medicaid benefits." This in turn drove higher patient revenues at the hospitals, he says.
In essence, eHealth Exchange is poised to prove itself at ever-larger scales nationwide, Matthew says. "We've demonstrated that multiple disparate parties can operate under a single trust agreement with the common rules of the road. We know how to send out data and receive data and render that in a form that physicians can use."
