Several federal agencies issued a set of final rules based on the No Surprises Act aimed at making it easier for providers to contest payer decisions.

A new No Surprises Act final rule and additional guidance to further implement the independent dispute resolution (IDR) process and require payers to provide additional information to providers about qualifying payment amounts (QPA) was recently released by CMS and other federal agencies.

During the IDR process, an arbiter is directed to consider all information submitted by the physician and insurer, including the median in-network rate, complexity of the case, previously contracted rates, and market power of the physician and insurance company, among other items.

The law states that the QPA could be one of many equally weighted factors considered in payment disputes.

However, until a recent court ruling, the rule made the QPA the primary factor in the IDR process. Organizations have said that since the QPA is "an unverified rate set by insurers," and using it to settle disputes "sets an artificially low benchmark payment, for all care—whether in network or not, which may not support wider access to care—particularly in underserved areas."

In the new rules, CMS references the court decision, saying it will "remove the provisions that the District Court vacated." Now IDR entities may weigh QPA and other factors equally in making their decisions.

This is not a full reversal for the QPA's role, though, according to Part B News.

David McLean, a partner with Hall Booth Smith PC in Atlanta told Part B News that "although the final rules do not require the certified IDR entity to select the offer closest to the QPA, the Departments remain of the opinion that it will often be the case that the QPA represents an appropriate out-of-network rate."

However, there is a win for providers when it comes to downcoded claims.

A major plus for providers is the agencies’ decision to require payers to include both an original and an altered QPA for the claim if the payer has downcoded it by switching a code so that the claim is reimbursed at a lower rate.

Now, the payer must not only admit and describe the downcoding but also explain its reasoning, this will then be considered among the factors in the IDR decision. The new rule should help some downcoded providers on price, but it will also create extra work from the IDR entities, Part B News reported.

Extra work is not ideal for IDR entities.

In fact, a recent IDR process status update showed that between April 15 and August 11, the federal IDR portal has received over 46,000 claims, "which is substantially more than the Departments initially estimated would be submitted for a full year." According to the status update, only 1,200 of those claims have received a payment determination.

Clarification on other important No Surprises Act regulations were not covered in these rules, such good faith estimates, but more guidance is expected in the coming months.

The health system's value-based care model is built around home-grown population health technology.

Crossover Health, a primary care provider catering to self-insured employers, has built its own population health tool to improve patient and clinician experience alike.

The San Clemente, California-based healthcare organization, which counts Amazon among its customers, launched its tool to show clinicians how they were improving the health of their patient populations, says Stephen Ezeji-Okoye, its chief medical officer.

Crossover Health has 42 clinics throughout the United States, a mixture of on-site and near-site clinics, as well as a national virtual medical practice. The organization built its population health tool to overcome what Ezeji-Okoye calls the "tyranny of the visit" that dominates traditional electronic health record software.

"We don't work in a fee-for-service arrangement," he says. "What we're focused on is how do we improve the health and well-being of the population because that's how we show our value."

Such considerations impact Crossover Health's design of its clinics and its exam rooms, he says, so it made sense to extend design considerations to the population health tools utilized by its physicians.

Crossover Health employs traditional primary care providers as well as specialists offering mental health, physical therapy, and chiropractic services -- all augmented by nurse practitioners, health coaches, and care navigators.

"A lot of programs in advanced primary care don't actually include all of the elements I've just described," he says. "We have a very holistic approach. We believe that you've got to go beyond the biomedical model of just treating disease. You've got to get into the things that really affect health."

Ezeji-Okoye says 80% of the factors affecting health are not medical interventions. They might include the behaviors of patients and their living environments.

Stephen Ezeji-Okoye, chief medical officer of Crossover Health. Photo courtesy Crossover Health.

"We brought all of this together in a measurement system that allows us to have a good view of what's going on in the practice and allows providers to understand the impact they're having on the patients they see," Ezeji-Okoye says

An example of that impact: One of Crossover Health's clinics uses the population health dashboard to identify gaps in care among patients undergoing colonoscopies to screen for colorectal cancer.

"The population was one where people were primarily hourly workers," Ezeji-Okoye says. "They needed to be able to be at work as much as possible. Taking a day off for a colonoscopy was actually a huge barrier to care."

To address that gap, the clinic began providing those workers with at-home colonoscopy kits.

"One of the benefits of the tool is it makes these care gaps visible and allows us to work in a proactive fashion to be able to improve the quality of care of the population," Ezeji-Okoye says.

The platform enables clinicians to factor social determinants of health into care management, he says, identifying instances where the root cause of a health concern might not be clinical.

Crossover Health collects data from within its Elation electronic health record system to populate its population health dashboard, he says.

"Then we also use other measurement tools to capture things such as the therapeutic index and the severity index, to help measure how we're doing in those domains," he adds.

For now, Crossover Health's system does not send alerts back to the EHR.

"Certainly, alert fatigue is a real thing," Ezeji-Okoye says. "You'd need to limit the alerts to the ones that are most important. We don't do that at this time, but we're looking at that."

The system helped Crossover Health deal with the pandemic as well.

"Pre-pandemic, we were probably 3% virtual," Ezeji-Okoye says. "During the pandemic, we were probably 90% virtual. Now we're about 70% in person and 30% virtual. Regardless of how members choose to use us, they can expect the same quality of care, and we're going to have the same proactive approach to care."

Over time, he says, Crossover Health will continue to incorporate more data from its patients' visits to other health systems, including claims data.

"We need to make sure that we provide the human intelligence behind the data feeds, to make sure we've got the right treatment plan for each member," Ezeji-Okoye says.

Another feature of the tool allows Crossover Health to measure how quickly patients can get appointments. This drives the company's hiring decisions and helps to avoid overburdening current providers.

When the primary care team must initiate referrals, Crossover Health's care navigators curate lists of medical specialists outside the company who most identify with the company's proactive health values, Ezeji-Okoye says. Health records from such specialist visits then come back into Crossover Health's population health system, to drive further quality of care.

In time, Crossover Health may expand its offerings beyond self-insured employers. It has a commercial offering on a subscription basis, but so far that is a small portion of the company's business.

"Our goal is to be able to make Crossover accessible to anyone who's interested in having a better healthcare experience," Ezeji-Okoye says.

Chris Belmont, vice president and chief information officer for Mississippi's Memorial Health System, says any new program should begin small and focus on the patient.

To Chris Belmont, innovation isn't just a strategy. It's a commitment to improving patient care.

"It's not something you have, but actually something you do," says the veteran healthcare executive who now serves as vice president and chief information officer for the Memorial Health System, a two-hospital network based in Gulfport, Mississippi.

And for innovation to really work, he says, it has to lead back to the patient.

"We're great at creating things, and technology, and processes … but are we really paying as much attention to the patient as we should?" he says.

Belmont has more than 35 years of experience in executive leadership, business development, and consulting, the last two of which have been spent at Memorial Hospital at Gulfport. In the past he's served as vice president and CIO at the University of Texas MD Anderson Cancer Center in Houston and system vice president and CIO for the Ochsner Health System in New Orleans, leading EMR transformation projects at both health systems while helping to revamp their Information Services departments.

At Memorial Health, his strategy for trying out new programs and technologies is to start small, with very specific outcomes, goals, and participants.

"Don't launch these big initiatives," he says. "If we had done that, we would have slowed things down and missed some opportunities."

Chris Belmont, vice president and chief information officer of the Memorial Health System in Gulfport, Mississippi. Photo courtesy Memorial Health System.

In some cases, that might mean starting in a clinical department, rather than IT, to give a program a chance to establish roots before marrying it to a specific technology. Once that base is established, data is gathered, and results are proven, he says. Then, a health system can scale a program out, adding more departments and serving more populations.

"We start with an idea, and we put a program together than can be part of our portfolio," Belmont says. "Once it's in our portfolio, we have the opportunity to put it onto a platform and ask, what can this platform do?"

By taking a tiered approach to innovation, he says, a health system can focus on patient interactions and care. A large project tends to overlook small details, but those details may be what the patient looks at or experiences. As a result, a big program might look good and meet the goals set forth by the health system, but it doesn't necessarily address what the patient wants.

"Don't let the bureaucracy get in the way," he says.

As an example, Memorial Hospital has been working with Emmi digital health technology developed by Wolters Kluwer for patient engagement efforts, with a goal of reducing avoidable ED visits and hospitalizations and improving follow-ups. The hospital had launched a handful of small, concentrated programs and wanted to combine them on one digital health platform.

"It was at a time when we were all distracted by COVID," Belmont says. "Our nurses were busy with screenings and vaccinations, and we wanted to help them. This wasn't a robocall project; we wanted comfortable interactive technology that could improve the experience."

Using interactive voice response calling and multimedia videos to reinforce discharge or care instructions, monitor adherence to care management plans, and remind patients about follow-up appointments, Memorial Health developed a rapport with patients, encouraging them to take a more active role in their care.

"A lot of times [patients] don’t remember what was said [in visits with their doctor]," Belmont says. "We created a more effective messaging platform that engaged with them. It was more comfortable for them than the traditional automated reminders. I was surprised at how quickly patients reacted to the new platform."

According to data supplied by Wolters Kluwer, the program reduced unnecessary ED visits by 26%, which, in turn, reduced ED costs by about $89,000 over 1,000 patient discharges. The 30-day readmission rate also dropped between 27% and 65%, depending on patient adherence to prescribed programs. In addition, patients were 50% more likely to attend follow-up care appointments with their provider within 21 days of discharge.

"This was so much more effective than anything we'd done before in getting patients to [follow their care plan]," Belmont says.

The key to establishing that relationship, he says, is in listening to and understanding what the patient wants, rather than creating some shiny new toy or program and asking the patient to accept it.

"We have to look at this from the patient's point of view," he says. "Just think what would happen if we did too much of this. Would the patient be overwhelmed if we communicate too much? How do we make sure that we're not contacting them [to the point that] they're turning away?"

Belmont calls this a conundrum that every health system will face as it adopts more technology and programs that create more connections with patients outside the health system. All these channels will be great for collaborating on care management and passing information back and forth, but when will it be too much? How do healthcare providers create a conversation with the patient that meets the demands and expectations of both parties?

"Feedback is vital," he says, "both direct and indirect." Aside from asking patients how they want to interact with their care teams, providers need to gather data on how often patients communicate, on what channels, and whether those communications make an impact.

"My metric is if they keep coming back for more," Belmont says. "My role in this is the platform manager. I'm here to connect all the points, to make sure they're secure, and especially to make sure that they are reliable, and that the data we're getting is making a difference."

As Belmont looks to broaden those platforms with new programs and technology, he's focused on creating services that continue, rather than one-time interactions. He wants patients to look at this platform as an ongoing relationship with their care team, as well as a library of resources that they can access whenever they need help.

"We as a health system have to make sure we're taking advantage of all the tools in the toolbox," he says.

With the Cardiac LIFT Clinic, Akron Children's Hospital is giving single-ventricle patients and their families an opportunity to 'survive and thrive' at home, rather than in a hospital or clinic.

Young children with acute care needs don't necessarily have to be in a hospital to get them. Healthcare organizations are now using virtual care platforms and digital health tools to give these patients and their families the care they need at home.

Akron Children's Hospital has gone all-virtual with the Cardiac LIFT (Lifelong Interventions Focused on Thriving) Clinic, reportedly the first program in the country to offer completely virtual care for young single-ventricle patients from prenatal early diagnosis through early adulthood. The program enables families to transition from an NICU to the home and stay there.

"We want [these patients] to survive and thrive," says Kathyrn Wheller, MSN, APRN-CNP, a pediatric nurse practitioner and the clinical lead for the Cardiac LIFT Clinic. "The single-ventricle population is a complex population for cardiology patients in general. This program gives them … that freedom."

Single-ventricle patients are born with one lower chamber of the heart that is smaller, underdeveloped, or missing a valve, and occur roughly in five out of every 100,000 newborns. Three of the most common diagnoses are Hypoplastic Left Heart Syndrome, Pulmonary Atresia/Intact Ventricular Septum, or Tricuspid Atresia.

They start their lives in a neonatal intensive care unit (NICU), and require open-heart surgery at 2-6 weeks, 4-6 months, and 3-5 years to reconstruct their hearts as they grow. These surgeries are called Fontan procedures, and for that reason the patients are often called Fontan patients.

Kathyrn Wheller, MSN, APRN-CNP, clinical lead for the Cardiac LIFT Clinic at Akron Children's Hospital. Photo courtesy Akron Children's Hospital.

The survival rate for all three surgeries used to be low, but improvements in surgical techniques and clinical care have pushed that rate upwards, so that many children can now expect to live into their 40s, if not longer.

Because of the complex nature of these surgeries and care management, single-ventricle patients and their families spend a lot of time in the hospital, clinics, and doctor's offices, meeting with a care team that often consists of several specialists. At Akron Children's, executives had been mapping out a full, multi-disciplinary clinic for these patients.

"Then COVID hit," says Wheller. "We skipped right over the planning and launched our program [on a virtual platform], focusing on the first few months. It's not that easy to do in the cardiac world, but we had to do it."

Wheller said the hospital made plans to go to a hybrid setup once the pandemic waned, "but the virtual visits went great. We didn't need to see them in person when we could do everything we'd need to do with a virtual visit."

The Cardiac LIFT clinic opened in January 2021, and has conducted more than 130 unique visits for about 70 of the estimated 140 patients within Akron Children's Hospital's coverage area (another 35 patients are adults, who receive care separately). Wheller says those numbers will grow in time, because the hospital will be able to serve patients and their families for a broader geographic area.

Wheller says the platform not only allows the patient and family to meet with the care team and specialists from the comfort of their own home, but it gives that care team an opportunity to see more of that patient's home life and environment, which could factor into care management plans. And in a less formal setting than a doctor's office, patients, family members, and the care team could talk about diet and exercise, behavioral health issues, and other factors that affect that patient's health and wellness.

"When you see them in their home environment, you understand better the challenges they face, and just as importantly, the challenges their family faces," Wheller points out. "You can then make more reasonable plans for care."

The platform also helps the care team. Specialists can be brought in virtually, no matter where they're located, and scheduled to meet individually with the patient or as a team. Through an audio-visual link they can arrange to meet weekly or bi-weekly, especially during the first few months, then monthly or as needed.

Wheller says the program is also incorporating remote patient monitoring tools, which allow the care team to keep a daily eye on cardiac function and other vital signs, tracking the trajectory of the heart and the patient in between necessary in-person appointments.

Sara Rush, MD, Akron Children's Hospital's chief medical information officer, says the platform allows the care team to be creative in how it develops a care management plan. They can include physical therapists, nutritionists, behavioral healthcare providers, teachers, and social workers as the need arises.

"This is not the way we learned to practice medicine, so it takes a little time to get used to things," she says. "Then you start to realize that reaching out and pulling in all these resources makes so much sense. You can even bring in community resources."

While the platform is designed with the patient at its center, there are clear benefits for parents and other caregivers as well. Virtual care can help to reduce the stresses on parents and caregivers who struggle with their own health and wellness, cutting down on travel time to and from the doctor's office and missed work, and offering resources for coping with the burden of being a caregiver. Many health systems, in fact, are integrating family and caregiver services and resources into their virtual care programs, with the understanding that a patient's health is directly affected by the health and wellness of those around him or her.

"This is one of those things that can make us better at what we do," says Wheller.

The Centers for Medicare & Medicaid Services has proposed a 12% reduction in reimbursement for CPT codes supporting RPM. Health systems and advocates say that could affect a service that has been known to reduce unnecessary hospitalizations by 50%.

A provider of remote patient monitoring services to several health systems in six states warns that proposed cuts in Medicare reimbursement could endanger those services, which it says are saving thousands of Medicare dollars per patient served.

New York-based Cadence, which partners with health systems in Alabama, Arkansas, North Carolina, Washington, Wisconsin, and Michigan, recently submitted comments to CMS on the proposed cuts (the comment period is slated to end on September 6).

"By driving better patient outcomes, we're reducing emergency room visits by up to 50% for patients who are enrolled in Cadence programs and decreasing their cost of care by $5,000 on average," says Chris Altchek, the company's founder and chief executive officer.

Cadence, which has partnered with LifePoint Health, Community Health Systems, and ScionHealth, is one of dozens of telehealth companies in the rapidly growing RPM space, which saw a surge of interest when the pandemic pushed health systems to curtail in-person services and push more programs onto virtual platforms. Proponents say RPM will continue to grow as healthcare executives see the value in improving care management for patients in their own homes.

Among other stakeholders expressing concern about the cuts so far are the American Telemedicine Association, and Altchek hopes the American Hospital Association, the Alliance for Connected Care, and the Federation of American Hospitals will also file concerns.

Like many others using RPM, Cadence is targeting care management for patient with chronic health conditions, including congestive heart failure, hypertension, and type 2 diabetes. About a quarter of its patient base lives in underserved areas, where RPM programs may be a lifeline for people who face barriers to accessing care.

Chris Altchek, founder and chief executive officer of Cadence. Photo courtesy Cadence.

"CMS has done a lot of good work trying to focus on these chronic conditions," Altchek says.

Under current CMS guidelines, CPT code 99454 specifically reimburses providers for devices and transmission of data to collect vital signs from patients at home. RPM programs typically send digital health devices, such as blood pressure cuffs, weight scales, and blood glucose monitors, home with patients, who monitor their health, send data back to care teams and collaborate on managing their care.

In its proposed 2023 Medicare Physician Free Schedule, CMS is proposing a 12% cut for 99454. It's one of several significant modifications to RPM reimbursement, as outlined in the ATA's August 24 letter, written by Kyle Zebley, executive director of ATA Action.

"These cuts run counter to CMS' stated goals of improving patient outcomes, advancing health equity, and reducing spending through the use of remote patient monitoring technology," states the Cadence letter to CMS.

[See also: CMS Proposes to Cut Audio-Only Telehealth Coverage.]

Altchek is hoping the groundswell of support for RPM programs and criticism of the proposed cut will spur CMS to reconsider.

"CMS is aware and engaged on this topic," he says. "Something could change. They spent a lot of time, almost 10 years, building out a framework to allow these codes to come into play, so they're as motivated as anybody else to make sure they don't limit innovation that they sparked before it can really take hold."

Altchek says accountable care organizations (ACOs) using RPM programs supported by Cadence are seeing a 19% savings on average total cost of care.

"We're sharing everything we have [with CMS] and have offered to update them every six months on the total cost of care savings across our patient population," he says.

CMS has scheduled a 2023 policy review of the cuts affecting 99454 and related CPT codes 99453 (patient onboarding), 99457 (first 20 minutes of monitoring and delivering care to a patient remotely), and 99458 (the next 20 minutes).

"We were not listened to last year, but next year, they've scheduled a real conversation around it," Altchek says.

The policy review will be conducted by the RVS Update Committee, a volunteer group of 32 physicians and other healthcare professionals who advise Medicare on how to value a physician's work.

"My guess is it would go through that process, and then CMS would take it under review as part of its rulemaking," says Meryl Holt, head of legal and chief compliance officer at Cadence.

CMS is also somewhat constrained by existing law. "CMS as the agency is somewhat restricted by the legislative framework that's in place, so they have limited tools with which to actually affect change with particular codes," Holt says.

Should appeals to CMS fail, Altchek says a push for a legislative solution is another option.

"CMS data show that among original Medicare beneficiaries aged 65 years and over, the prevalence of CHF, type 2 diabetes, and hypertension was 13%, 25%, and 58%, respectively," says Cadence's letter to CMS. "This translates into direct medical costs, which for heart disease (excluding stroke) totaled $281 billion in 2015 and $237 billion for diabetes in 2017. Using RPM services to manage these conditions will improve patients’ access to quality care, while also alleviating the burden on clinicians and Medicare spending."

If the CMS reimbursements decline, Altchek says Cadence would withdraw from serving certain regions rather than reducing the quality and quantity of remote patient monitoring.

"We won't deliver the service if we don't think we can do it in a way that's a high-quality way," Altchek says.

Eric Gantwerker, MD, MMSc (MedEd), FACS, a practicing pediatric otolaryngologist and medical director for Level Ex, explains how healthcare organizations can use video games and gamification as an educational tool for clinicians.  

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

Video games aren't just for fun any more.

Healthcare organizations are finding uses for video games that go far beyond entertainment. They're being used to help patients – particularly younger ones – understand healthcare concepts, from chronic disease management to medication adherence, while care providers are using games to track patient outcomes in cases ranging from autism to concussion treatment.

More recently, health systems are using them as educational resources, with the idea that a game can work better than a book or classroom event.

HealthLeaders recently sat down (virtually) with Eric Gantwerker, MD, MMSc (MedEd), FACS, a practicing pediatric otolaryngologist at Northwell Health's Cohen Children's Medical Center and medical director for Level Ex, a video game studio that has designed games for continuing medical education (CME). Gantwerker, who holds degrees from Harvard Medical School and Georgetown University and was recently inducted as an associate member of the American College of Surgeons' Academy of Master Surgeon Educators, shares his thoughts on how the power that practicing through play can improve a clinician's ability to learn and adopt new skills.

Q: What are the benefits to using video games for continuing medical education (CME)?

Gantwerker: While video games are inherently built for entertainment, at their core, they are built on deep knowledge and understanding of how to activate and stimulate the brain to induce learning.

For hundreds of thousands of years, humans have learned through play. Whether playing pretend, turning over a snow globe, or knocking over a maze of dominoes, our minds are constantly developing new mental models to understand the world around us. Expert game designers are well-versed in sociology, psychology, and the cognitive sciences that underlie motivation and behavior. They know how to achieve the perfect balance between challenge and mastery and they develop games deliberately to build reward-driven experiences that capture the attention of billions of people. Games are also intentionally designed to quickly and easily onboard players to the rules and progress swiftly to developing strategy by simply playing the game.  

Eric Gantwerker, MD, MMSc (MedEd), FACS, a pediatric otolaryngologist at Northwell Health's Cohen Medical Center and medical director for Level Ex. Photo courtesy Northwell Health.

Because video games are built for entertainment, they create an intrinsically motivated environment for players where they play for the sheer pleasure of playing. Traditional medical learning and CME are a requirement of medical practice, creating an extrinsically motivated environment for physicians, but they are not fun by design. Lectures, webinars, and thick textbooks are a passive form of learning that often require more time to learn from, but don’t always translate into strong knowledge retention. When games and medicine collide, healthcare professionals are thrust into an entertaining environment that they actively want to engage with - the material just happens to be something they are very familiar with and can learn from. If done well, games can be an extremely powerful tool. 

Q: How are these games introduced or incorporated into an education regimen?

Gantwerker: Oftentimes, the best way to integrate them is to augment formal learning for both knowledge and skills. Games are not intended to replace entire curricula, nor should they. Medical education that is rooted in facts, such as learning the bones in the body, can be easily learned through passive activities like reading or simple matching exercises. For more challenging, experience-based interactions in medicine, such as performing a knee replacement operation or diagnosing a skin disease, the power of video games to create mental models and build 3D spatial skills helps physicians actively make sense of the complexity through play. Imagine the physics that is learned through playing Angry Birds. Players understand mass, velocity, inertia, and all of Newton’s three laws of motion just by playing a game. 

Q: What are the drawbacks or challenges to using video games for CME?

Gantwerker: Perception is the major challenge facing video games for CME. There are 2.6 billion video game players in the world and their average age is 36, yet people still associate games with child-like and brain-numbing entertainment and there continues to be a lack of understanding by educators and faculty that video games aren’t just for kids. In fact, they are a powerful educational tool and often better than reading an article or chapter or sitting in a lecture.

Another challenge is that there are a lot of applications of game elements or 'gamification' that don’t work that well. This gives a bad connotation to game-based learning as the effectiveness studies done may conflate games that are developed with the deep-design principles and psychology of video games and those that just add leaderboards and quizzes to educational contexts. This leads both the public and discerning educators to believe that games aren’t as powerful as traditional learning methods, which is not true. 

Additionally, the technologies that are used to create medical video games are tremendously powerful, but they require expert game designers and engineers to realize their full potential. Because of this, we are now seeing more digital health startups hiring from the ranks of triple-A game studios to advance their work in this area. 

Q: How does a video game improve a healthcare provider's skills that traditional education doesn't?

Gantwerker: Motivation and engagement are some of the biggest challenges named by medical educators today, but they also happen to be the major advantages of playing games. When players are both motivated and engaged they enter a state of mind called the 'flow state.' A well known psychologist named Mihaly Csikszentmihalyi coined this term to describe elite athletes and musicians. This period of intense concentration denotes a maximally efficient period of learning and contributes to better knowledge retention and skill development. The flow state creates a game environment where fun and entertainment are prioritized and education becomes the unintended consequence – it’s why people can lose track of time while playing.

Q: How does one convince a health system's executive leadership to embrace video games for CME?

Gantwerker: It all comes back to perception. There is ample evidence proving the power of games when learning technical and knowledge-based skills. Even consumer games have shown effects on learners with several studies showing that those who played action video games at a young age had better visuospatial skills and performed better on laparoscopic surgery-based tasks than those that did not.

The other critical component in gaining executive leadership’s support is helping them understand the difference between 'gamification' and true video game design. Gamification takes elements devoid of deeper learning and connection to gameplay and applies it to a separate context like leaderboards and badges. You can easily turn a learning activity like watching webinars into a game by slapping a leaderboard on to the video platform so users can see where they fall amongst their peers. It may be motivating at the start, but it does not contribute to a stronger understanding of the skills being taught.

My advice to leadership is to always give games a chance -- the risk is low and the reward can be quite high. Put a well-designed game head-to-head with any other learning modality and you’ll see the advantages of time, enjoyment, and depth of understanding. 

Q: How do healthcare-related video games differ from typical video games?

Gantwerker: This is all about context. Typical video games that use healthcare as the context are often a parody of medical practice. But if you respect the field, design games for entertainment and create a game environment that requires healthcare professionals to apply applicable knowledge to a situation, they are surreptitiously learning something medically relevant. That’s the secret sauce to creating an effective medical video game.

However, healthcare-related video games do have a lot in common with typical video games as they are both built on fundamental core gameplay loops -- the main set of actions undertaken by a player that define the game -- that have been trialed billions of times. These game mechanics and styles are ubiquitous and can easily be applied in healthcare games. They include things like match 3, collection mechanics, puzzle mechanics, first-person shooter, real-time strategy, set and play mechanics, experience points, virtual currency, etc. 

Q: How will this field evolve? What new technologies or strategies do you see on the horizon that might improve video games for CME or make the C-suite more receptive to using them?

Gantwerker: I think perceptions are finally changing and people are realizing the power of game design and technology. As I noted earlier, we are seeing a huge influx of game designers from big name studios coming into the healthcare technology startup world to advance the design of medical video games. We also see the morphing of digital entertainment and the movie industry that is pushing the boundaries of what computers and AI can do in the games industry. This will bleed over into healthcare in meaningful ways, creating much more realistic virtual patients, more natural virtual patient interactions, and more visually appealing virtual healthcare environments.

The metaverse is another concept that comes up a lot when talking about the future of gaming, but it’s important to note that the metaverse is just a platform. It’s software-based, and can be viewed through different hardware, such as a VR headset, but it is still just a platform. Many health tech companies have put their stake down on one platform, say VR or AR, but in doing so have limited themselves to that single platform. Medical video games, however, are platform-agnostic given their software-based modality and can be played on a phone, through a web browser or with the use of external hardware like a VR headset, making them much more accessible. We also see a lot of extended reality (XR) being applied in healthcare and games and this hardware will continue to get better, faster, less bulky and intrusive, and hopefully more intuitive to use as well.

I hope that the studies done on medical video games continue to evolve and not lump games like Jeopardy in with action-adventure games, when trying to draw conclusions about efficacy. Authors in this space need to be better about discerning based on educational levels and outcomes, educational context and game-type, and software vs hardware solutions. Once we have a better understanding and definition of true medical video games, we can start speaking the same language and see the widespread application of these tools in the healthcare space.

The technology cuts log-in times by 70% and leverages other cost-saving cloud efficiencies.

A hybrid cloud architecture is slashing log-in times and optimizing IT costs at a Montage Health.

Led by Tahir Ali, chief technology officer and chief information security officer, the Monterey, California-based health system's virtual desktop infrastructure (VDI) initiative is saving $298,000 yearly in productivity gains by clinicians, as well as other infrastructure costs.

That figure, Ali says, comes from slashing the initial system log-in times of each clinician from 100 seconds to 30 seconds, helping to improve more than 100,000 patient visits annually, and also aiding in rapid response to emergent care situations.

"Some people call it agile infrastructure," he says. "Consumption-based IT is where we set up different infrastructure in a way where we can scale it very quickly."

In the background, the system creates Windows-based virtual machines only when a staff member logs in, with sessions remaining available for up to six hours after initial log-in. After clinicians log out or time out, the system deletes these virtual machines, leaving only the saved data residing in Montage servers. In between log-in and log-out, clinicians' desktops can follow them from workstation to workstation, instantly available with a swipe of their badges.

The system "makes sure [that] if we have ebbs and flows, we have enough capacity on demand to give," Ali says.

Tahir Ali, chief technology officer and chief information security officer at Montage Health. Photo courtesy Montage Health.

Such an arrangement is well-known to retailers dealing with surges in computing demand during peak buying seasons, but is relatively novel in healthcare IT, he says.

"I thought, why not do it for the hospital?" he says. "We have to have people physically in the hospital at a certain time vs. maybe the middle of the night. We can do the same thing in IT."

At the heart of Montage Health's data center is a refrigerator-sized data hardware appliance provided and maintained by Dell, which creates and maintains the APEX Private Cloud that manages the provision and release of computing resources to Montage Health staff.

For further scalability, the private cloud is connected via triply redundant 10 gigabit-per-second links to the internet, where Montage maintains public cloud 'pilot lights' at Amazon Web Services as well as Microsoft Azure clouds.

"I understand that running on the cloud is expensive," Ali says. "The key is running on the cloud pay-per-use. We have [a few] VDI sessions if somebody is working from home. If we need something, we start to build that [public cloud] stack."

In the event of a disaster, Montage Health can quickly scale up those public services to meet unexpected demand, Ali says.

"The pilot light is very cheap, and we are running it inside our data center," he says. "And you have to have a multi-cloud strategy. Each cloud vendor has its strengths and weaknesses."

Montage Health's specialized VDI infrastructure can also tap the private cloud's graphics processing unit (GPU) resources to help radiologists and cardiologists read images.

Beyond the improved clinician productivity, Ali says Montage Health's infrastructure saves money compared to traditional hybrid cloud architectures.

"The traditional way is, you have your VDI infrastructure fully blocked," he says. "You have a replica of at least 70% of the same capacity running on a 'backup data center.' All licensing, hardware, and support is twice as much, because you're running in two different places. We run it in one place."

This hyper-converged infrastructure depends upon the APEX Private Cloud's 80 gigabits-per-second backplane, which eliminates the need for cables to connect the servers operating in the private cloud. Additional FSLogix software from Microsoft, powered by Active Directory, allows individual clinicians' desktop profiles to be delivered to workstations when the clinicians log in, displaying only those applications required for each clinician's work, further boosting system efficiency. If they move to different workstations during their workday, those profiles and applications follow them from workstation to workstation.

A change in how Montage Health conducts video calls internally and externally played a role in the timing of the move to the new infrastructure last November.

"Skype was going to go away, and Microsoft Teams was going to come in, and our traditional hardware was not capable at that time to run Teams with a video," Ali says.

It also was a time of standardizing after employing a variety of video call technology across the enterprise.

"We wanted to converge into a single face of Montage," Ali says. "When patients come to our facility, it doesn't matter if it's ambulatory, the hospital, even our wellness center. It's a single company called Montage Health, and we will take care of them accordingly."

The new architecture also lends itself to a zero-trust data security strategy.

"We have a product that has a full trending of every single packet that goes from one place to another place," Ali says. "If there's any deviation, the flag goes up, and they take [devices] off the network automatically.

"I can bring the technology to a cutting edge. But the security needs to be a little ahead of that."