Lancaster Regional Medical Center's EHR could not produce a usable summary-of-care document—until it brought in software that generates and tracks referral options. In two years, out-of-network leakage is down 20% and savings exceed $1 million.
When you boil down the care coordination problem at the heart of population health, it's all about the referral workflow.
I would be so bold to say that any population health technology offered to providers which does not manage to insert itself into the referral workflow of those providers is probably doomed to failure.
At Lancaster Regional Medical Center in Lancaster, Pennsylvania, CEO Russell Baxley, who was COO before assuming the CEO role a year ago, understands referral workflow. "The number one complaint I had from our physicians was, 'Our patients go into your hospital, but the information never comes back out,' he says. "You're like a black hole of patient information."
Russell Baxley
Specifically, Lancaster's EHR could not produce a transition-of-care summary document or effectively manage referrals, the outcomes of which could be sent back to Lancaster after a discharge from Lancaster's ER or other acute care.
To which I observed to Baxley, you would think this is something every EHR could produce.
"You would think that it would, and to be honest, I was shocked that our EHRs could not take care of it," Baxley says.
Two years ago, Lancaster, one of the hospitals owned by nationwide provider Community Health Systems, turned to one of the new-generation "post-EHR" products—in fact, to a product which works with EHRs but does not require one—in order to produce a usable summary-of-care document and keep the patient's healthcare team from dropping the care coordination ball.
The biggest source of frustration had been in Lancaster's ED, which uses the Medhost EHR for EDs. Baxley knew one of the Medhost creators when he worked in Texas, and from its creator, he learned of par8o.
It's worth understanding how par8o leverages some previous healthcare IT infrastructure which puts it in a position to help solve Baxley's problem. The par8o platform is itself a 2011 spinoff of Sermo, a leading social network for physicians. The par8o name is a play on the name of Italian economist Vilfredo Pareto, known for the 80/20 rule (aka the Pareto Principle) as well as the economic principle of Pareto optimization, a method of maximum resource allocation.
"We identified the moment of transition of care as a very kind of critical moment in the journey of the patient through their healthcare consumption experience—the moment when there's been a change of diagnosis, an escalation in care, and the patient's in need of a new resource—commonly known as the referral moment," says Adam Sharp, an emergency medicine physician by training and currently CMO of par8o.
Not all referral moments are when one provider refers to another. It could also be when a patient, or her employer, initiates a self-referral.
Sermo client Johnson & Johnson gave Sermo a $3 million grant to build the technology which would become par8o. After the spinoff, par8o's first big customer was an employer, MGM Resorts International in Las Vegas.
"We had just taken the platform live into kind of an open alpha, when the phone rang, and it was MGM asking us if we could help them to build out a high-performance provider network, and then layer a patient-centered medical home model into that network to care for their pool of 35,000 employees in the state of Nevada," Sharp says.
The MGM implementation has been live for three years. Other deployments followed at Brigham and Women's Hospital in Boston and at Mount Sinai Health System in New York. By now, par8o has "also done full integration to some of the larger EMR players, Allscripts and Epic being the two that are currently live," Sharp says.
Stopping Leakage The par8o algorithms consider clinical diagnoses, resources available within that particular health system, and corporate goals to minimize leakage—that phenomenon where patients end up leaving the system to seek care at physicians not affiliated with a particular health system or payer network.
Then, par8o presents a ranked list of referral possibilities to the physician or employer, factoring in all the above considerations. Sharp says that at Brigham and Women's, these measures were able to decrease the hospital's out-of-network leakage by about 20%.
That ranked list also drew upon something Sermo had built: a database of every physician (MDs and DOs) in the U.S, which par8o is able to use to contact the physician being referred to.
After a referral, par8o then tracks those referrals in CRM-like fashion, allowing those referrals to be managed by everyone from a physician to a care coordinator to a large call center, and following up to make sure that patients make it to the referred appointment.
Any results from the referral then make it back to a referring physician. Because software tracks all this, it means drastically reducing the number of phone calls needed to make it all work, Sharp says.
Sharp also notes that par8o is even showing up at imaging centers that don't have an EHR, but still need to manage incoming referrals and followups back to the referring providers.
Bigger players in healthcare are beginning to take notice. United Healthcare invested $3 million in par8o last October. (So far, United is not a par8o client, though Sharp says par8o is in conversations with a variety of commercial payers.)
Eliciting Faster Responses Back at Lancaster Regional Medical Center, Baxley says par8o has made 63,000 referrals so far. About 10,000 of those were simple notifications alerting physicians that patients had presented in the Lancaster ED. The balance were calls to action for those physicians to see patients ASAP as followup to their Lancaster encounters.
"We always monitor time-to-first-action or contact with the patient, and I can tell you that when we first started, our average time-to-contact was probably in or around the 20-hour mark," Baxley says. "Right now our time-to-contact a patient for our entire network—that means employee providers, non-employee providers, affiliates, etc.—we're under 8 hours. A patient will receive a phone call on average within 8 hours of that referral being sent."
Even patients are catching on that Lancaster is using this little-known software. "They actually ask our ED physicians, are you going to send my appointment request through par8o? Now how they know that and why they know that, I'm not entirely sure, but the community is catching on that we are using a system that is getting them to their provider in a timely manner," Baxley says.
As far as other ROI, Lancaster's declining readmission rates, so far, cannot be attributed to par8o, but Baxley says system leakage is down, attributable to par8o, and has saved the system $1.2 million over the past two years.
In the end, that is the kind of metric that will drive technology such as par8o into referral workflow, because every clinician understands the more money squeezed out of waste and inefficiency, the more money can go to actual care. As I've said in the past, it won't necessarily happen by sitting around waiting for the EHR vendors to fix things themselves.
It is no surprise that a growing number of healthcare institutions are seeking partnerships to fund and nourish innovative startups. Massachusetts and New York are at the forefront of fostering such relationships.
This article appeared in the April 2016 issue of HealthLeaders magazine and was based on Scott Mace's online column from January 26.
Joel Vengco
Earlier this month, I attended CES 2016 (formerly known as the Consumer Electronics Show) in Las Vegas, walking aisle upon aisle of digital health technology offerings. I do this every couple of years to take the pulse of a consumer phenomenon that continues to attract millions in venture capital funding: mobile health and wellness trackers, sensors, monitors, appliances, and personal medical devices.
I'm mindful that every time I attend, there will be plenty of new startups, but scant clinical evidence to support the worthiness of their efforts, and often not a trace of the promising startups that made the trek to Vegas just two years prior.
In short, CES is the noise, and healthcare leaders continues to look for the digital health signal.
It is no surprise that a growing number of healthcare institutions are seeking to join forces to apply filters to the noise to tease out the truly innovative startups and nourish them.
When the provider is a large academic medical center, the resources to do this are not difficult to find. But smaller systems are not similarly blessed. While CES was going on (Jan. 6–9), Massachusetts became the latest state to launch an initiative, the Massachusetts eHealth Cluster, to help the smaller healthcare systems and hospitals join forces to get some of that large system innovation mojo.
One CIO who applauds the move is Joel Vengco, vice president and CIO of Baystate Health, nearly a two-hour drive west of Boston. Baystate already operates its own innovation hub, known as TechSpring.
"TechSpring was initially capitalized by the $1B life sciences initiative founded by former Governor Deval Patrick (D)," Vengco told me in an email exchange. "From there, TechSpring set out to connect with private corporations like Dell, IBM, and Cerner. With the support of Baystate Health's administration and clinical staff, we were able to take that public funding and successfully grow it into a broader set of partnerships as well as a technology innovation center within which private, public, and start-up organizations can collaborate.
"The state did ask for our involvement, as they liked our model of connecting with private organizations. But innovation takes seed money and operating dollars to succeed."
Laurence Stuntz
Vengco "loves this idea" of a digital health innovation hub for all of Massachusetts. He wrote:
Filling the Gaps the Private Sector Can't Fill
The Massachusetts statewide initiative announcement, made at Boston Children's Hospital, included present Governor Charlie Baker (R), Boston Mayor Martin J. Walsh (D), Speaker of the House Robert A. DeLeo (D) and corporate support from the Massachusetts Competitive Partnership, a consortium of large employers in the state.
The following day, I spoke with Laurence Stuntz, director of the Massachusetts eHealth Institute at MassTech (MeHI), another of the initiative's sponsors, about the Massachusetts eHealth Cluster. "the goal here in Massachusetts, at least from the public side, is to fill in the gaps that the private sector isn't currently filling," Stuntz says.
"TechSpring was created precisely to solve healthcare problems using digital solutions through a 'crowd-sourcing' innovation framework. Baystate Health is a health system that is representative of many health systems in the U.S. So if it works here, it will likely work at a majority of the health systems in the country. Ultimately, my hope is to enable others beyond Baystate Health to benefit from the tech and analytic innovations that TechSpring delivers in collaboration with its innovation partners and members."
Created by the legislature nearly nine years ago, MeHI is a "quasi-state" agency in that its funding is mostly from the Massachusetts legislature, but it does not report directly to the state administration. MeHI also acted as the federal regional extension center for the state during the push to get healthcare to adopt electronic medical records.
"There are a lot of startup companies out there," Stuntz says. "One of the things that they struggle with a lot is getting opportunities to quickly prove their worth and prove that they've got a clinically valid solution."
The eHealth Cluster will play matchmaker between such startups and health systems, hospitals, payers and public health agencies, but also help such institutions work with entrepreneurs at a time when "they just don't have the bandwidth."
New York's Initiative
Asked to cite examples where this model has worked in the past, Stuntz pointed me to the New York eHealth Collaborative (NYeHC), which four years ago created the New York Digital Health Accelerator program, in partnership with the Partnership Fund for New York City, an effort by the city's largest companies to expand business growth and jobs in the city.
NYeHC operates the Statewide Health Information Exchange of New York (SHIN-NY). "Beyond just moving healthcare data around the state, SHIN-NY now represents a lot of relationships," says Anuj Desai, vice president of market development at NYeHC. "Our board is made up of the CEOs of hospitals, health plans, large employers, and the eight RHIOs around the state."
The New York Digital Health Accelerator is focused on New York state's "massive transformation from fee-for-service to value-based care, and to reduce readmissions by 25% in five years," Desai says.
"What providers around the SHINY table are telling us, [is that] their EHR vendors don't have all the capabilities required to allow them to meet the needs of value-based care," Desai says. They're looking for new solutions primarily in the areas of care coordination, analytics, and patient engagement. Meanwhile, in the New York state ecosystem, there's a number of health tech firms—startups, entrepreneurs, tech companies—that are in the city and around New York state, that are looking to solve these issues."
With providers being called by hundreds of such startups every week, the New York Digital Health Accelerator helps funds the most worthy innovators and match them up with providers and payers for innovative pilots. So far, it has launched 47 pilots over three years within New York state.
Subsequent to being in the program, venture capitalists have funded such startups to the tune of $68 million, and two of the 21 companies have been acquired, Desai says. In addition, these companies have created about 150 jobs in New York.
Questions remain about the effectiveness of such programs. At the Massachusetts announcement, sponsors committed $250,000 to the eHealth Cluster effort, a fairly small amount. And in New York state, Desai as yet has no data on how many of the 47 pilots are now implemented in the workflow of providers and payers.
Still, given the amount of noise in digital health, it is good to see some concerted efforts to create new pathways to connect the most-worthy innovations with the healthcare organizations that need them most. Over time, expect to see such hubs in place widely throughout the country.
Andy Slavitt throttles back his forecast for the end of meaningful use as we know it, disappointing many, and proving that government reform is coming… but at its own excruciating pace.
What are we to make of CMS Acting Administrator Andy Slavitt's pronouncement last week that meaningful use is "effectively over" and that it "will be replaced with something better"?
As of this morning, my take on things is that Slavitt said disappointingly little that was truly new, and various journalists, myself included, jumped to conclusions when we characterized his remarks as a bombshell.
Andy Slavitt
The evidence for this appeared just this morning, as Slavitt himself, in this blog post with Karen DeSalvo, head of the Office of the National Coordinator, basically throttled back his prediction of the end of meaningful use as we know it in 2016. The highlight:
"The approach to meaningful use under MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] won't happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what's next and to continue to give us input. We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations—including meaningful use Stage 3—are still in effect."
Last week, perhaps expecting this walk-back, a spokesman for the College of Information Management Executives (CHIME) had this to say:
"CHIME members need to be focused on meeting the regulations that are currently on the books. While CHIME is encouraged to hear that CMS may be retooling the program, the current regs are still the current regs."
Indeed, Meaningful Use stage 2 regulations remain in effect, and are likely to remain so for some time to come. Final rules adopted in late 2015 make minor adjustments to the program, but it fundamentally remains in place.
Some Relief One bright ray of hope did appear at the end of 2015. On a voice vote, Congress passed legislation offering a blanket hardship exemption to providers from 2015's meaningful use penalties for not attesting successfully for meaningful use requirements.
While this one vote does not in itself end all meaningful use penalties, it provides a path to sustained program penalty relief, which allows providers to look forward, beyond the EHR incentive/penalty program aspects of meaningful use.
In that sense, meaningful use as we knew it has already ceased to exist, to providers' great relief.
Meanwhile, meaningful use stage 3 software certification regulations, also adopted at the end of 2015, continue to act as a starting gun for EHR software developers. They must immediately begin to implement a raft of modifications to their software, with the prospect that some customers could ask for this software by next year, in order to capitalize on 2017 being an optional stage 3 implementation year, while all other providers are expected to implement stage 3 certified software in 2018.
Other CMS requirements that affect implementation of EHR software, namely the Value-Based Modifier and PQRS reporting, are moving forward. In general, these requirements are moving, as meaningful use did, from carrots (incentive payments) to sticks (penalties for non-reporting).
I admit to getting swept up by some of last week's temporary euphoria. After all, this was no mere speech.
Private-sector Sensibilities Slavitt, who was appointed in February 2015 as CMS acting administrator, comes from the private sector, most recently as group executive vice president of United Health Group's Optum unit. He brings more agile private sector sensibilities to a by-the-book regulatory agency, as evidenced by CMS immediately posting the full text of his JP Morgancomments to the CMS blog, and several summary Twitter posts by Slavitt.
This was a full-court press to address criticism of meaningful use in a way his predecessors had not, in a manner that private industry is comfortable doing. And he did it not at HIMSS, not in front of a crowd of physicians or healthcare administrators, but in one of healthcare's most demanding audiences: the bankers who underwrite the industry's debt and issue new stock offerings.
There was no talk of the existing regulations continuing. This was an effort to spin CMS's response to the genuine hatred of the meaningful use program before an influential audience.
It is also worth reflecting that Slavitt did not come alone. Accompanying him was James Madara MD, American Medical Association executive vice president and CEO, at Tuesday's opening JP Morgan conference keynote, "A Discussion with CMS & AMA on the Evolving Healthcare Market."
The AMA has been the most vocal critic of the meaningful use program for the past two years. In Slavitt's words, said while sharing the stage with Madara:
We need to simplify. We have the opportunity to sunset three old programs and align them together in a single new program. That program needs to be streamlined and simple to use so physicians can focus where they need to—on their patients. We are designing from the outside-in. We started by working with front-line physicians, tech companies, and practice managers over a four day session and through an RFI to garner direct feedback on the right measures for each specialty and how to implement the program most simply. Jim and the AMA team were of significant help."
Measurement Continues In their blog post, Slavitt and DeSalvo note MACRA, passed by Congress, considers quality, cost, and clinical practice improvement activities in calculating how Medicare physician payments are determined.
The post notes that MACRA continues to require that physicians be measured on their meaningful use of certified EHR technology for purposes of determining their Medicare payments. We must wait to see just how MACRA's measurement of meaningful use differs from the existing program. The answer to that won't emerge until later this year, when we see the note of proposed rule-making for MACRA.
That just goes to show that not only is hope not a strategy, but neither is reading more into a single speech than is there. Government reform grinds on at much of its customary pace.
MU will be "replaced with something better," says Andy Slavitt. Reaction from healthcare CIOs is largely one of relief.
For the first time, the leader of the Centers for Medicare & Medicaid Services has said publicly that the agency "has the opportunity" to sunset the meaningful use program in 2016.
Andy Slavitt, acting administrator of CMS, made his remarks Tuesday at the J.P. Morgan Healthcare Conference in San Francisco. Slavitt's full remarks were then posted on the CMS blog, and summarized in a series of tweets.
Andy Slavitt
"As any physician will tell you, physician burden and frustration levels are real," Slavitt said. "Programs designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that people who build these programs just don't get it.
"The Meaningful Use program as it has existed, will now be effectively over and replaced with something better."
Slavitt credited feedback and collaboration with front-line physicians and the American Medical Association in moving CMS "from rewarding providers for the use of technology and toward the outcome they achieve with their patients."
One way to aid this, he said, is by leveling the technology playing field for start-ups and new entrants. "We are requiring open APIs in order [that] the physician desktop can be opened up and move away from the lock that early EHR decisions placed on physician organizations. [That will] allow apps, analytic tools, and connected technologies to get data in and out of an EHR securely."
In addition, Slavitt said, "providers will be able to customize their goals so tech companies can build around the individual practice needs, not the needs of the government. Technology must be user-centered and support physicians, not distract them."
Slavitt highlighted recently passed bipartisan legislation as being "squarely on our punch list." The Medicare Access and CHIP Reauthorization Act (MACRA) "brings pay-for-value into the mainstream through something called the merit-based incentive program, which compels us to measure physicians on four categories: quality, cost, the use of technology, and practice improvement."
CIO Reaction Reaction from healthcare CIOs to Slavitt's announcement is largely one of relief.
"I have been an advocate for claiming victory for meaningful use and stopping the program," says Marc Probst, CIO of Intermountain Healthcare. "It doesn't seem to be adding value."
Probst expressed skepticism that CMS can simply halt the meaningful use program. "It's going to be a little more difficult to unravel than just staying we're stopping and moving over to MACRA or whatever."
Another CIO cites a recent precedent for CMS to simply stop enforcing the provisions of such regulations.
"The Sustainable Growth Rate fix has a whole bunch of pages on the fact that you must have radiology decision support systems before you order a complex radiology test," says John Halamka, CIO of Beth Israel Deaconess Medical Center. But "there aren't any products or services in the marketplace to do this yet, so how could it be required? So a few months ago, CMS issued the following statement: 'We will not enforce any of the provisions in the Sustainable Growth Rate fix that require radiology decision support systems.'"
John Halamka, MD
"That isn't to say the meaningful use certification rule [and the] meaningful use attestation rule stay on the books. But if no one enforces them, and no penalties are levied, they could stay on the books for eternity."
Halamka already had no plans to move toward implementing stage 3 of meaningful use within the next six quarters. A bill signed by President Obama late last year provided a path to blanket amnesty for providers from meaningful use stage 2 penalties, and signaled to Halamka "that either legislative or regulatory relief is coming" from the meaningful use program as a whole."
Both Probst and Halamka say Slavitt's remarks further free their health systems to turn to pressing healthcare IT priorities. In Probst's case, it is completing three-fourths of Intermountain's conversion to the Cerner EHR system. Meaningful use is "not our main strategy anymore," he says.
In Halamka's case, priority is given to implementing "numerous innovations" to reduce healthcare cost.
"We're putting bathroom scales and blood pressure cuffs in people's homes connected to iPhones," Halamka says. "We're doing all those things because I have $1.5 billion in risk contracts through the Affordable Care Act and private-payer alternative payment models."
"Certainly Andy suggested that MACRA will provide us with an alternative, to get us back the concept of [a] carrot, if you achieve a remarkable innovation, as opposed to stick if you don't achieve a checklist."
Halamka predicts that CMS's move will free up EHR vendors as well to innovate instead of coding to satisfy regulatory requirements. "It's going to take 150 man-years to achieve full [meaningful use stage 3] certification of everything in the EHR," he says.
"We could either create bold new population health and care management functionality, or spent 150 man-years certifying for meaningful use. I guarantee you, not one customer if the penalty is eliminated will suggest that certification for meaningful use is relevant. So the EHR vendors will go back to what their customers want, as opposed to what the government is mandating."
In a statement released Tuesday, The College of Healthcare Information Management Executives (CHIME) said it is "encouraged that Acting Administrator Slavitt and CMS are open to improving the Meaningful Use program.
Electronic health record software manufacturers have taken early steps into application programming interface publishing, and savvy health informaticians have already created some clever mashups with them.
In late 2013, a study group of scientists released "A Robust Data Infrastructure," more commonly known as the JASON report, commissioned by ONC and AHRQ, which subsequently published the report in 2014.
(JASON is an initiative within the MITRE Corporation, a nonprofit that operates research and development centers sponsored by the federal government. JASON is spelled in all caps, but it is unclear what, if anything, it stands for.)
At any rate, the final rule for meaningful use stage 3, published in October 2015, can be found here (Google searches surprisingly don't rate this link highly, but ONC has yet to format the rules on its own website). That final rule contained language that didn't capture the headlines at the time, but was very much in the spirit of that 2013 JASON report: Electronic health record software should adopt application programming interfaces (APIs).
The use of APIs in stage 3 certified software is somewhat narrowly prescribed to potentially replace an EHR vendor's requirement to provide a patient portal, with APIs that any number of patient engagement technologies could plug into. This would bring a word to healthcare that hasn't really been heard before: mashups.
Mashups have been on the scene for a decade or more in the rest of technology. An early example combined the Chicago crime database with Google Maps. The crime database didn't have to add map functionality, and Google Maps didn't have to learn how to interpret crime data. The mashup just gave users a simple-to-understand combination of the two.
After that proof of concept, mashups took off for several years. Popular Web destinations such as Twitter and Facebook published APIs in sufficient quantity that we saw a flowering of mashups of all imaginable shapes and sizes.
Electronic health record software manufacturers have taken early steps into API publishing, and savvy health informaticians have already created some clever mashups with them. One such expert is Kristen Wilson-Jones of Sutter Health, whose efforts I profiled in May of 2015.
I spoke with Wilson-Jones again in November, and was fascinated to learn of the many tools Sutter is using to extend its IT capabilities. In addition to the hotspotting initiatives I mentioned in the earlier column, to identify frequent emergency department utilizers in a Camden Coalition-style initiative, Wilson-Jones is using tools such as MuleSoft to optimize workflows between Epic and Sutter's call center, which runs Salesforce.com, to track conditions such as COPD.
"Right now they're doing a lot of paper-pushing between the labs and the pulmonologist groups. So we're helping out with streamlining that for them, and gaining insights into what's inside these PFT reports," says Wilson-Jones, chief technical officer of research, development, and dissemination (RD&D) operations at Sutter.
Wilson-Jones finds inspiration all over tech, including a project I had not previously heard of, called IFTTT. "It's consumer-based social media stuff," she says. "I think there's over 360 participants now, where you can actually do these kind of workflow rules engine [integration] between consumer apps. We're doing this kind of stuff, but in healthcare land."
The Camden-like hotspotting project, which leverages Boston University's Project RED and Alfresco's Activiti open source business process management technology, involves non-Sutter providers in the area, and even one public health provider who doesn't run Epic, so much of the work is about the legal agreements that allow data to be shared between the project participants, Wilson-Jones says. Once the hotspotting project goes live—Sutter is targeting February as a go-live date—participants will be able to spot trends including patients who might have narcotics issues, or even those who have a history of posing a security threat to hospital personnel, she says.
Part of what is allowing mashups such as Sutter's to flourish is a temporary moratorium announced by Epic last year on levying fees for API usage. In Epic's case, it's a five-year moratorium. Let's hope the benefits of mashups are so great that when the end of the fifth year rolls around, Epic finds a way to make the moratorium permanent, and to continue to fund its business by other means—or else to make sure that the cost of mashups, on top of the staggering cost of health IT already, doesn't inhibit innovation.
ONC will be watching EHR vendor behavior as these mashups flourish. As Wilson-Jones puts it, "no one thing will ever be all things. There will always be data about a patient somewhere else." Providers "are going to need the kind of integration interoperability that we're putting together. Data about a patient will always be in more than one place, and you will have more than one organization working on it. That's what our stuff addresses. We glue all that together."
Of course, tension between the mashups and the "we do it all" software initiatives isn't going away. After the initial flourishing of mashups on the Web, some of the larger API publishers, such as Twitter and Facebook, cracked down on API usage that the publishers deemed not to be in the business interest of the publisher. So it's not just an issue of the cost of API usage. In certain cases, certain APIs themselves may not be offered forever by a large organization.
As healthcare becomes more dependent on APIs and the mashups they permit, the ongoing healthcare interoperability debate—which until now has been dominated by mere data format issues—will pivot to the more subtle issues that an API-driven healthcare IT world introduce.
The HL7 Argonaut Project, which I wrote about more than a year ago, is one multi-vendor effort to make this pivot. It is my hope for 2016 that many more mashup champions, such as Wilson-Jones, show policy makers just how important it is that the innovation continue in as unfettered a manner as possible. The JASON report laid it all out in 2013. Now it is time for the healthcare industry to build it.
An innovative arrangement means that the provider effectively outsourced data warehousing, analytics, and performance improvement technology, plus content and personnel to the vendor.
This article first appeared in the December 2015 issue of HealthLeaders magazine.
When Allina Health, the $3.7 billion health system headquartered in Minneapolis, signed a $100 million deal with Health Catalyst at the start of this year, the terms of the deal were unusual, to say the least.
As part of the agreement, Health Catalyst—a Salt Lake City–based health IT vendor founded by former Intermountain Healthcare leaders that provides data warehousing, analytics, and outcomes improvement—took dozens of Allina employees onto its payroll, and Allina received a tantalizing potential upside. About 20% of the contract cost is dependent on better outcomes and lower costs at Allina hospitals and clinics. In essence, Allina's vendor partner proposed to share some of the risk that its technology would pay off.
This arrangement differs from and goes beyond the typical healthcare system spinoff, where a technology developed in-house is spun out into a separate company in which the incubating healthcare system retains an investment. In Allina's case, it started out as Health Catalyst's first customer, but Allina did not take a financial investment in Health Catalyst until the two organizations announced the risk-sharing arrangement at the start of 2015.
Health Catalyst builds and operates analytics technology for healthcare organizations. The 10-year agreement will combine technologies, some of which Allina developed since it became the first customer of Health Catalyst technology in 2008. The Health Catalyst data warehousing architecture uses a just-in-time approach to data binding to resolve many of the problems encountered using traditional data warehousing methodologies. The warehouse combines that architecture with a set of sophisticated analytic applications.
In the agreement, the partner organizations established a specific sharing ratio such that for every $8 of savings or revenue enhancement Allina realizes, $2 flows to Health Catalyst. This "shared outcomes improvement bonus" is capped at $2 million per year.
The shared savings does not kick in until calendar year 2016. Year one of the 10-year contract, 2015, is focused on integrating the team members who moved from Allina to Health Catalyst, and deploying a series of analytics applications. Once a year, a governance committee of the Allina–Health Catalyst partnership will identify a prioritized list of improvement projects, each designed to provide measurable care improvement and financial value to Allina. As the partnership achieves each goal, both partners will share in the benefits of that success.
The deal also means that Allina effectively outsourced data warehousing, analytics, and performance improvement technology; content; and personnel to Health Catalyst to accelerate advances.
The $100 million represents the cost of what the staff and tools were costing Allina, says Penny Wheeler, MD, president and CEO of Allina Health, a not-for-profit organization with more than 90 clinics, 12 hospitals, and related healthcare services that provide care for nearly 1.5 million people across Minnesota and western Wisconsin.
"We weren't falling back on hope as a strategy," Wheeler says. "We have a lot of confidence in our partner in Health Catalyst. Eighty percent of that $100 million is standard costing, but 20% of it is at risk, based on how we perform on key indicators—like how well the tools perform, for example, on reducing readmissions or unnecessary admissions for people who can spend nights in their own bed."
Wheeler says use of Health Catalyst technology has permitted Allina clinicians to significantly reduce readmissions, elective inductions of labor, time required to diagnose breast concerns, and sepsis rates.
"Our agreement with Health Catalyst says that if we find a better tool out there, we can use it," she says. "So, for example, if Epic analytics and reporting software Cogito excels at the capabilities that we work with, then we use that. So it's more about what can you use the best to improve care than any exclusivity. That just speaks to the confidence level we both have in our ability to partner and make things better, despite what else is out in the market.
"I'm pretty confident that we're going to have a 10-year agreement and beyond due to that commitment to healthcare," Wheeler says.
"Structuring a relationship with a health system around outcomes improvement, and even being willing to put your money where your mouth is and put a significant portion of your financial upside and your economics at risk, it's further motivation."
For Health Catalyst, which now has multiple other clients, putting so much of its yearly income at risk involved discussion and debate.
"Structuring a relationship with a health system around outcomes improvement, and even being willing to put your money where your mouth is and put a significant portion of your financial upside and your economics at risk—it's further motivation," says Dan Burton, CEO of Health Catalyst.
"We needed to have many discussions about it as a company, with our board of directors, and that includes our major investors," Burton says. "We had a rigorous debate about this business model. One of the things I've appreciated about our company and about Health Catalyst—and this includes the support that we have from our board of directors—is that great strategy is usually about being different. It's about being differentiated, doing something unique that is valuable and that you can do better than anyone else."
Calculating the actual dollar value of outcomes and performance improvement amounts to an exercise in truth-telling between vendor and customer.
"Great strategy is usually about being different. It's about being differentiated, doing something unique that is valuable and that you can do better than anyone else."
"Foundationally, we trust each other," Burton says. "Allina Health is actually one of the most advanced health systems that we have seen, and also it's one of the more enlightened health systems, in terms of being willing to essentially do the right thing from an efficiency perspective, regardless of the current payment model."
The Allina Health finance group will be responsible for measuring these outcomes, and the governance committee will be chaired by Duncan Gallagher, executive vice president, chief administrative officer, and chief financial officer.
Health Catalyst executives also had some convincing to do—of its investors. "When we suggested this model, it was something that our board and our investors really had to think about it and wrap their arms around, because it was new and unfamiliar, and because it involves risk," Burton says. "We had a rigorous debate about this business model."
Health Catalyst is also considering similar at-risk arrangements with many of its other customers, which include Stanford University Medical Center, Indiana University Health, Kaiser Permanente, and it most recently signed at-risk contracts with The Queen's Health Systems in Hawaii and Partners Healthcare.
Wheeler also recently took an unpaid position on the Health Catalyst board of directors, the first provider on the company's board, at least so far.
"It was their idea," Wheeler says. "They wanted a provider on the board. We were basically their first client, so I've seen this organization from its inception."
As for the specific quality goals for the first year, Wheeler says, "We actually start with an assessment of our performance and what the external environment is looking for, and how regulations have changed and other impacts of community measurement. … We'll line that up with the Health Catalyst contract and that 20% that's at risk for them."
The goals toward which Allina and Health Catalyst are striving are in line with those of the healthcare industry's pivot from fee-for-service to value-based care. When asked how much of Allina's payment currently comes from value-based care, Wheeler responds: "Not enough. When you look at our contracts, about 80% of them have some [element of] pay for quality or pay for cost of care, so that seems like that's a lot, right? When you look at what that translates into absolute risk, in terms of revenue, it's about 3%.
"We have a goal to try to work in concert with payers … to disrupt that and move more toward outcomes-based risk. The biggest challenge in healthcare right now is that the waste in the system is somebody's revenue."
Wheeler likens the pivot to a dance with some fancy footwork, aided by Health Catalyst technology. "We say we're willing to shoot ourselves in one foot to try to change the model, but we obviously can't shoot ourselves in both, because we need the margin to reinvest in care," she says. "That said, we're using a lot of the data and information from the Catalyst relationship and things we had developed here to say, 'What things can we even do to decrease internal costs?' "
As one of the CMS Pioneer Accountable Care Organizations, Allina also has dozens of measures in place for such things as optimal diabetes control, optimal vascular control, prevention measures on breast cancer and colorectal cancer screening, and care coordination, Wheeler says.
The innovative partnership with Health Catalyst gives Allina "a way that we can maintain quality or improve quality while reducing internal costs … so you lower somebody's length of stay, because they don't have an untoward complication," she says. "That actually is good for the patients, saves us internal costs with the length of stay, and leverages our data capability to do just that."
How a California physician practice designed a system to catch coder errors without burdening doctors.
Technology continues its climb toward what we would consider intelligence. Your average electronic health record is fairly stupid, being able to sort things in rows and columns, and find character strings. Analytics software adds more sophisticated algorithms that can stratify patients by comparing their symptoms to known risks for developing more serious adverse events.
Jennifer Pereur
In the nearly three years since I wrote about IBM's Watson and its attempt to move health IT into an era of what has become known as cognitive computing, I have seen scattered attempts to further explore its possibilities. Some concepts, such as rules-based engines, expert systems, heuristic algorithms, and other machine learning, have been around in one form or another since the 1970s. More recently, technologists have incorporated these components into the broader knowledge representation systems that cognitive computing encompasses.
I recently spoke with an independent practice association in northern California that seems to be pushing cognitive computing into an area I had not heard about before, this time not strictly to explore clinical research goals, but to achieve real benefits to the group's bottom line.
Jennifer Pereur is director of government programs at San Ramon, California–based Hill Physicians Medical Group, a provider network of more than 3,800 primary care physicians, specialists, sub-specialists, and consultants that manages 300,000 patients lives at risk under contract to Medicare Advantage, managed Medi-Cal, and commercial payers, as well as "some PPO work as well," Pereur says.
The Medicare Advantage dollars that CMS pays the group are risk adjusted, Pereur says. "If somebody has a lot of conditions, they get a higher risk score and, therefore, there is more money to take care of them and provide care for them," she says. "If it's a healthier member, then there are fewer premium dollars."
Therefore, Hill Physicians employs many different mechanisms to make sure it is getting accurate data on the health status of its patients. "Not only does it help us with accurate premiums, but it also helps us to identify members who might be good candidates for different disease management programs," Pereur says.
The difficulty is getting physicians to document data in ways that are easily sharable with other physicians—a challenge facing all of healthcare today. Too often, the data that ends up getting shared is that data that ends up being coded on a billing claim. "We lose data along the way," Pereur says.
For example, one physician might diagnose that a patient is depressed, but that chart note does not find its way into structured data entry. This works against Hill's mission of having an accurate risk adjustment to present to payers, and it also does not help connect dots between medications that patient may have been prescribed for the depression, and how those medications might affect overall patient care.
To address this, Hill Physicians turned to technology from Apixio, whose newly announced cognitive computing platform, Iris, combs through patient chart notes to identify diagnoses. Coders log in to the Iris-powered HCC Profiler application and are presented with a series of its data discoveries, which the coder can then choose to accept or reject. Accepted suggestions create more accurate structured electronic health record data. Suggestions coders end up rejecting give Apixio suggestions on how to fine-tune its cognitive computing algorithms. Out of 100 different documents, Apixio may only present two documents with potential risk-adjusting conditions to be reviewed, Pereur says.
Having seen a demo of how this works, it's possible for me to see how combining the kind of natural language processing that we've seen in many other healthcare IT scenarios with the workflow requirements of coders is a potent union, particularly for an organization such as Hill, where so much is riding on getting the right care to the right patient.
"Now everyone who goes in [can look] at that holistic picture of the member; multiple people can now see that information," Pereur says. "We've taken it out of the chart, and we've put it in a place where we can do our care management."
Because the main action takes place behind the scenes with Hierarchical Condition Category coders entering the Risk Adjustment Factors that CMS and other payers require—not putting the suggestions in front of physicians at the point of care—Apixio's process has had minimal impact on actual clinician workflow since being deployed at Hill Physicians nearly two years ago, Pereur says. Prior to this, the burden of directing people to comb through the charts manually made it cost-prohibitive, she adds.
I asked Pereur if Hill Physicians also has a data warehouse that could achieve the same result. "What's in our data warehouse predominantly is administrative data—payment claim data, lab data, pharmacy data," she says. "We don't have all of that rich data that lives within the electronic health record." Apixio can grab data from any data source, not just the EHR, she adds.
Apixio can also spot codes entered incorrectly into the medical record, Pereur says. "CMS has stiff financial penalties for submitting data that's not backed up in the chart," she says. "So by going in and combing the chart, it also allows us to not only find data that we didn't have, but confirm data we did have, and potentially remove data that's not substantiated."
Hill Physicians says it is seeing an ROI of 7 to 10 times on its expenditure on Apixio technology.
While the unstructured portion of the medical record remains problematic, and smarter processing can't cut down on such information's verbosity, duplication, and possible contradictory elements, we might be seeing a move here toward a kind of machine learning that puts us on the path to clinical documentation done right, or at least better than it has been. And I like the idea of doing so without retraining physicians.
MU stage 3 is so intricate, and the timetable so squeezed, that it could result in the consolidation of the ambulatory EHR healthcare industry.
Chances are, if you're running Epic, Cerner, Allscripts, or one of the bigger EHR technologies, you will get your stage 3-certified software in time to go live by the December 2017 deadline. But if you're running some of the less well-known software out there, it could be a bumpy ride.
Debra Harris
The end of 2015 brings the end of the unusual comment period following the issuance of the final stage 3 rules, but perhaps a more important end-of-comment period arrives next week on December 31, when ONC accepts its final public comment on the test scripts for the software to be certified for stage 3 use. This software certification, known as the 2015 Edition, doesn't actually enter use until 2017 (as an option, if the EHR vendor is ready) or 2018 (in mandatory use by all providers).
Last week I spoke with Debra Harris, clinical product manager for AdvancedMD, an EHR aimed at small physician practices, which has been available for 20 years and garnered some good reviews during that time.
"The timeline CMS has set is still aggressive," Harris says. "Twenty-seven months sounds like a lot of time, but based on the objectives and the requirements, that is still unrealistic." Stage 3's emphasis on interoperability, clinical documentation, APIs, and structured data using SNOMED and LOINC terminology are all requirements.
"Realistically, in order for providers to be prepared to demonstrate meaningful use in 2018, vendors have to be certified in early 2017," Harris says. "That only gives a vendor not even a year to put these changes in place."
Lost in much of this timetable are the mounting pressures on small physician practices to upgrade to stage 3 at a time when they are already struggling, and potentially losing revenue, while trying to continue to deploy increasingly sophisticated EHR technology, Harris says.
In short, stage 3 will likely accelerate the consolidation of the ambulatory EHR healthcare industry. I doubt that was CMS' intent, but it looks increasingly like a continuing major effect.
In addition, numerous small practices, frustrated by meaningful use regulations, will simply shut their doors to Medicare patients, limiting the places to which those patients can seek care.
All of this is a continuation of trends started in stage 2, and it's ironic that physicians accepting Medicaid are exempt from meaningful use non-attestation penalties. Patients in dire economic need will continue to have a wide variety of physicians, but the elderly face a declining choice of physicians.
Focusing on Regulation Rather than Innovation
Technology by itself can do little to affect any of these macro-trends right now. And the longer companies such as AdvancedMD are focused on meeting the objectives of meaningful use stage 3, the less true innovation they will be able to bring to EHRs, a software category widely reviled in healthcare right now.
Another complication for companies such as AdvancedMD is that the accrediting bodies that certify software such as theirs to ensure it complies with the multi-hundred-page stage 3 certification requirements are not yet ready to deploy their testing suites yet.
In AdvancedMD's case, they are expecting such testing suites in the second quarter of 2016. "I went through the proposed rule, knowing that most likely the majority of the information in the proposed rule was going to be final, so we already put in place our development in meeting those requirements," Harris says. "APIs, we're good there, for the most part. We've better prepared this time than we have been in the past."
At the same time, some pieces of stage 3 are so intricate, Harris says AdvancedMD really needs two years to do the job right. Instead, it has less than 12 months.
Slowing down the accrediting bodies is the fact that ONC is taking feedback on test scripts through the end of 2015. That means clarifications on the test scripts will get to those accrediting bodies sometime early in 2016, which puts additional time pressure on accrediting bodies.
The HIMSS Electronic Health Record Association (EHRA) is also closely tracking these test scripts. Sasha TerMaat serves on the EHRA Executive Committee and is chair of the organization's Meaningful Use Workgroup. She is also director of certification and regulatory programs for Epic.
I asked TerMaat if the pressures on smaller EHR vendors might ultimately mean fewer EHR vendors, and a more limited choice than providers have today.
Sasha TerMaat
"I don't know if that's something that the association has really talked about," she says. "We welcome new members to our association."
As a trade association, EHRA offers its members education, conducted by volunteers, to share expertise on some of the intricate issues surrounding software certification and testing, TerMaat says.
"Also we have opportunities to do joint advocacy, so in items like certification test procedures, where it can be really helpful to listen to someone else say, 'here's what I was thinking about this test procedure,' " she says. "One participant might ask, 'Do you think step 2 really makes sense? Others might say, you know, I didn't think about it when I read it, but I see what you're saying.' That is confusing. If people read it two different ways, we definitely will want them to clarify that, so that the certification process can be efficient.
"Ambiguity, and something that two people could read different ways are definitely something we still watch for really closely, and we highlighted a few examples for ONC to consider clarifying in our feedback on the test procedures."
Until the EHR industry sees ONC's final 2015 Edition test scripts, it won't really be possible to know how EHRs will be evaluated, TerMaat says. But technical guides by HL7, referenced by ONC in its draft specifications, provide some help.
While the larger issues about meaningful use continue to fester, the success of ONC's software certification program will play a significant role in the ultimate success or failure of stage 3. I sympathize with AdvancedMD and its users, trying to survive and thrive in a challenging—perhaps even hostile—regulatory environment.
The ideal interoperable electronic health record system will never be as simple to use as an ATM. Healthcare data is just not that simple.
During this past summer's Congressional hearings on healthcare IT interoperability, the CommonWell Health Alliance was held up as a shining example of the kind of industrywide cooperation that should be emulated, and perhaps even given legislative blessing.
It was also compared to the banking industry's interlocking network of ATM networks, which has made getting cash from any ATM so easy, the question practically asks itself: Why can't getting healthcare data be just as simple?
Jitin Asnaani
But while the Alliance has done some laudable work, it remains unable to provide anything like that ATM network-of-networks experience today. I'm here to say that the interoperable EHR will never be just as simple as getting cash from the worldwide banking network, because it's just not that simple.
Today, the CommonWell experience, to the extent that it exists, is allowing a small, but growing number of physicians to query and retrieve some patients' medical records from far-flung healthcare systems and EHRs.
In fact, CommonWell set itself the goal of being live in 5,000 provider sites by the end of this year. If they make their goal, it's certainly progress. "We're still deploying it," says Jitin Asnaani, CommonWell's executive director.
But back to managing those expectations. Asnaani and others have positioned Epic's CareEverywhere network as the equivalent of Bank of America's closed ATM network in the 1990s, while the growing CommonWell network is akin to Cirrus, an ATM network-of-networks of that era. Cirrus did much to get us to where we are today, where pretty much any ATM from any bank can produce cash for an ATM cardholder.
Not So Fast There's a problem with this analogy, however. First, CommonWell proposes to locate patient records anywhere they reside, and even with 5,000 providers online, it's more likely than not that any physician query at this point will not return any records on that patient.
Second, patients themselves have no idea how to choose physicians if one of their criteria is, whether the physician participates in CommonWell? It's as if the Cirrus network never put that familiar logo on the backs of all those ATM cards back in the 1990s.
So, ironically, although Asnaani describes CommonWell as a patient-centric network, patients really do not yet have the ability to use their market power to choose providers who are connecting to CommonWell. No directory of providers yet exists where CommonWell services are live and functioning.
This gives Epic's CareEverywhere a distinct advantage when it comes to the all-important marketing side of HIT interoperability. And Asnaani knows it.
"I actually agree wholeheartedly with your premise on the shortcoming of CommonWell," Asnaani says. He acknowledges that CommonWell has been totally focused on the physician experience. "The physician wants to either get the patient's information, or know there's no information out there, and once he knows one of those two things, in five seconds, he's done," he says.
"If there's no information out there, the moment he has to pull up a directory, the game is over. He's not spending any time on it."
And yet, Asnaani notes that parties who do care about the directory [of Commonwell participants], such as "the physician in an extreme case, but definitely the hospital administrator, definitely a third party who is trying to understand what the CommonWell network is—then I don't have a way of getting the list of places from CommonWell today. I need to go talk to individual vendors, and that's a pain."
This also makes it difficult for healthcare executives to interpret the ongoing stream of announcements of this or that provider—now including HIEs—which CommonWell keeps announcing have joined its alliance. Asnaani concedes there is no strong champion within the alliance to turn those announcements into information the public can use, such as, which providers are actually live on the network right now?
The bigger issue, even within CommonWell, is one of consent for disclosure of patient records across its network. While all providers who sign agreements with EHR vendors who support CommonWell are expected to sign reciprocal use agreements, to share and share alike what patient information they have, there are differences among how the different vendors approach patient consent for release of information.
For instance, as of the middle of 2015, all healthcare providers and practices using the Athenahealth EHR are opted into the CommonWell sharing agreement by default, and must opt out if, for some reason, they wish not to share records, Asnaani says.
In contrast, Cerner chose to approach each of its customers, many of whom are much larger systems and providers than Athenaheath services, and obtain opt-in consent to participate in the CommonWell network.
Despite that hurdle, Asnaani says Cerner has already signed up "thousands of facilities. They'll give their numbers at the end of the year, and it will be impressive, but it will be even bigger next year, because all the clients who have signed up this year are starting to roll out now, but they'll continue rolling out through next year."
Another initial CommonWell Alliance member, CVS Pharmacy, "indicated strong alignment with the vision and they still do, but there was not a use case that applied to the pharmacy at that point," Asnaani says. "Now we have a pharmacy use case that is almost complete, and should get completed in the next month. Then they can incorporate that into their product roadmap. So they'll take a little more time."
One other actor is also waiting in the wings, about to take the stage. Its name is Carequality, a collaborative announced in 2014 and which I mentioned here. A who's who of EHR vendors already belong to this organization, and CommonWell is in regular conversation with Carequality to identify mutual areas of interest. "I'm hopefully going to join Carequality in a more formal way over the next few months," Asnaani says.
So while the ATM network analogy quickly breaks down when healthcare reality intrudes, it could be that a new cadre of empowered patients, not just asking for their "damn data" but also name-dropping CommonWell or Carequality or CareEverywhere while making that request of their providers, might force some interoperability inroads in 2016.
There's been scant progress so far. We shall have to wait and see.
Payers and providers are widening their use of a combination of technologies to simplify patient identification at check-in, spurred in part by progress being made in the credit card industry.
This article first appeared in the December 2015 issue of HealthLeaders magazine.
Craig D. Richardville, MBA
Until recently, most patient ID technology centered on building and maintaining master patient indexes. Enterprise master patient index technology—not a foolproof method of positively identifying someone presenting for treatment—continues to perform foundational work in healthcare.
Now, payers and providers are widening their use of a combination of technologies to simplify patient identification at check-in, spurred in part by progress being made in the credit card industry to adopt smart card technologies, as well as advances in other biometric and cloud technologies.
Providers and payers are expecting a wealth of benefits, including smoother workflow at registration and the same anti-fraud benefits the credit card industry is enjoying.
One of the most successful digital ID programs at a U.S. provider was recently highlighted during a hearing of the U.S. Senate Committee on Health, Education, Labor & Pensions in June 2015.
At the hearing, Craig D. Richardville, MBA, FACHE, senior vice president and chief information officer of Charlotte, North Carolina-based Carolinas HealthCare System and chair of the Premier Healthcare Alliance Member Technology Improvement Committee, described how its patient-matching biometric program, which uses palm-vein scanning, has been voluntarily accepted by 99% of its patient population and has a failure rate of only 0.11%, as compared to a national patient-matching failure rate of 8%-10%.
"When you see some of the new things coming out like meaningful use stage 3 and requiring interoperability, a lot of discussion that's going on has to do with uniquely identifying a patient and trying to get an identifier associated with that patient," Richardville says in an interview with HealthLeaders.
Carolinas' journey began back in the middle of the last decade, when Fujitsu, manufacturer of the PalmSecure system, sought to sell its palm-vein scanning technology to the banking industry, a major hub of which is in the Charlotte area, for its ATM machines.
"We looked at different options," Richardville says. "Fingerprint scanners, which are really common, have a high error rate. It was very inexpensive, but we saw a lot of false positives. You can very easily match somebody's fingerprint if you wanted to, if you wanted to use it for fraudulent reasons. So we ruled out fingerprints."
Carolinas ruled out another biometric option—scanning the unique patterns on a patient's retinal blood vessels—as being too expensive and intrusive, he says.
The palm-vein device captures a person's vein pattern image while radiating it with near-infrared rays, according to Fujitsu. The deoxidized hemoglobin in the palm vein absorbs the rays, reducing the reflection rate and causing the veins to appear as a black pattern. The scanner software stores each registered vein pattern not as a literal image, but as a computer algorithm. Subsequent scans are compared to the stored algorithm. "It's kind of like a snowflake," says Richardville. "Everybody's is unique. So it's not actually your palm print. It's the veins inside the palm."
So far, Carolinas HealthCare has stored algorithms for nearly 2 million unique patients in its system, which includes 900 care locations, 3,000 physicians and advanced clinical practitioners, and 39 hospitals. The actual scanner itself is a 1.5-inch-by-1.5-inch square sensor. The patient places a hand over it, or if the trauma patient arrives at an emergency department in an unconscious state, caregivers can place the patient's palm over the scanner. "It doesn't happen very often, obviously, but when it does happen, it could be a matter of life and death," Richardville says.
From its first deployment in 2007 and its full rollout at Carolinas in 2010, the palm-vein scanning system began to pay for itself and helps to fight insurance fraud. One would-be patient presented for an elective surgery while impersonating his brother in order to use the brother's insurance policy to pay for the surgery, he says. The palm-vein algorithm did not match, and the would-be patient admitted the deception.
Among the benefits, Richardville says, are that the organization can make sure it has the right information on the right patient and can avoid duplication or inappropriately merging information from different patients. "This really helps with all of that tremendously."
Carolinas is now incorporating the palm-vein scanners into its deployment of self-service check-in kiosks, to further streamline revenue cycle workflow and reduce check-in lines, Richardville says. Such kiosks will also be able to accept payment at time of check-in.
Patient ID technology can unify demographic information in a variety of hospital information systems, says John Stoy, chief technology officer at Mid Coast Hospital, a 92-staffed-bed Brunswick, Maine, facility that serves a population of approximately 100,000 residents. Each of Mid Coast's 21 ambulatory clinics maintains its own admissions, discharge, and transfer data, as well as registration information. "We were having issues with that data being in sync across all those systems," Stoy says. "Just because I know you and you walk up to my check-in doesn't mean that I selected you. I could have fat-fingered and picked somebody else up."
To cut down on such errors, in 2014 Mid Coast acquired smart card readers and cards from LifeMed ID. Within seconds of the patient inserting a smart card provided by Mid Coast into a reader, the system displays a photograph of the person associated with that card, and the registration process proceeds.
"The real goal was to streamline our registration and make it one person no matter where they were seen within our organization," Stoy says. "Also it shows the number of days since that patient has visited our hospital or one of our clinics. The reason we did that is because if a patient had just gone to my cardiologist upstairs, and he sends him down to get lab work done, I don't want my registrar asking all the same questions that were just asked upstairs, and I want it to be really a quick registration process for them."
So far, approximately 20,000 Mid Coast patients have acquired patient ID cards. "I won't say all of them pull it out of their wallet when they come, but I'd say a good portion of them do, and it helps our making sure that we have the right patient," Stoy says.
Adding the smart cards has allowed Mid Coast to "streamline" its business processes, and with the system's recent business growth, "we would have had to hire more people than we have now" without the technology, Stoy says. "And the patients like coming in with the card." If they forget to bring it, "we can look them up by date of birth. We have about seven different options. But basically, we don't want to spend the time looking them up."
Another recent boost in the prospects of smart cards is that the standard U.S. credit card is becoming a smart credit card through embedding of the so-called EMV chip. As of October 2015, U.S. merchants who rely on the older, less-secure magnetic strip credit card reader technology assume risk of credit card fraud formerly assumed by the banks that issue credit cards. The technology in LifeMed ID's smart patient ID cards, as well as that of another provider, LifeNexus, is also EMV technology, and technically, the terminals that process all these EMV chip-embedded cards could be a single terminal.
Martin Hickey, MD
"Our billing department will have to have a reader that can read the chip on the credit card," Stoy says. "I'm hoping it can be the same reader."
One of the largest potential uses for smart cards could be in the Medicare program. Despite talk of doing so, the Centers for Medicare & Medicaid Services has yet to launch any serious effort to pilot a smart card or other digital patient-verification system. In part, this may be because a major impetus for smart cards—reducing fraud—appears to be out of scope for CMS. According to a March 2015 report issued by the Government Accountability Office, CMS does not wish to make access to Medicare benefits dependent on beneficiaries having their Medicare card at the point of care. "Because CMS has indicated that it would still process and pay for these claims, providers submitting potentially fraudulent claims could simply not use the cards at the point of care," the report states.
"When Medicare finally says, 'We're going to have a 2% reduction in reimbursements if you don't have this type of technology,' then everybody will move to it," Stoy says.
Payers and providers are also keenly aware that more and more patients are carrying their own technology, which can be utilized in innovative ways to provide new forms of authentication of who a patient is and information only they would know.
Technology from LifeNexus, initially smart card-based and known as iChip, is being tested as software incorporated into smartphone apps by several payers.
New Mexico Health Connections, a health insurance co-op established in 2012, recently learned that despite the state's high level of poverty, more than 80% of its adult population has smartphones.
Like other co-ops, NMHC is a state-based exchange set up through the Patient Protection and Affordable Care Act. It currently includes 35,000 members, says NMHC President and CEO Martin Hickey, MD.
Starting with six ambulatory physicians, NMHC plans to make the iChip app available for download by their patients. When the patients appear for a visit, each physician will have a QR code—a square barcode in common use outside of healthcare—posted at the admissions desk.
Jamisson Fowler
The iChip app will direct arriving patients to capture the QR code image, which uses cloud computing to confirm that the patient carrying that mobile phone has checked in at that particular provider. The phone can also display to provider and patient alike claims data pulled from payers such as NMHC, as well as recent discharge summaries or, potentially, state health information exchange data on that patient.
NMHC plans to make the iChip app available to all its members by January 2017, Hickey says. The phone makes sense, he says, because "the cost of smart card readers is nontrivial, but almost everyone carries their smartphone."
To add another factor of authentication, NMHC members will also be required to establish a four-digit PIN, which they will have to enter at the time of the encounter. In the case of an emergency, Hickey says he hopes that LifeNexus will provide a "break-the-glass" option to allow authentication without someone having to know the PIN.
Larger payers are also taking note of the possibilities of mobile phone authentication of members at check-in.
"We've talked to a number of smart card vendors, and we are willing to participate with any smart card vendor, but we don't have a plan or a specific smart card vendor that we've chosen at this time," says Jamisson Fowler, vice president of digital technologies at Anthem, Inc., an Indianapolis-based payer with more than 38 million total medical members in affiliated health plans. "The main issue there is that the smart card vendors can't solve for the actual identification of the patient in a secure fashion.
"The smart card is designed to identify that this is the actual card. And it has special security capabilities to communicate with the reader, but it's not telling someone that this is Jamisson Fowler."
Instead, Anthem is turning to something more and more patients carry with them, which by its nature is a token authenticating the identity of the patient—a mobile phone.
Fowler says Anthem is in the process of releasing connector technology that providers could use to link their electronic medical records to mobile applications that Anthem members could consume. "Mobile presents the broadest potential that we've seen so far, because of mobile's ubiquitousness. It then allows us to look at pushing patient information, whether it's identity or electronic record information, to the phone and in the patient's care."
Unlike smart cards, mobile phone-based identity systems are extensible to other uses. Anthem is also exploring using Apple's Passbook app as a way to present an Anthem member's ID card to providers, Fowler says.
As requirements of computer security increase, mobile phone users can also be challenged to present additional factors of authentication, such as a personal identification number or a biometric verification such as Apple's Touch ID, a fingerprint recognition feature on the iPhone.
