HIPAA-compliant options are helping healthcare systems relay important information using familiar platforms and devices.
Websites, patient portals, and lower-tech communications such as interactive voice response outreach still dominate the healthcare industry. The industry has been slow to wake up to the societywide tectonic shift to mobile messaging as a preferred communication mode, both from provider to provider and from provider to patient.
Indeed, to turn the old Marshall McLuhan adage on its head, the message is the medium. According to a 2015 study from Juniper Research, instant messages (IM) sent on platforms such as WhatsApp, Facebook Messenger, and Snapchat were poised to overtake email as the most popular digital communication channel.
Physician to Physician
Secure mobile messaging has made its biggest progress so far in connecting physicians to other physicians and healthcare system staff. "It's really about solving workflows for folks who are very busy," says Ed Ricks, MHA, vice president and chief information officer of the acute care, 180-staffed-bed Beaufort Memorial Hospital in Beaufort, South Carolina.
When Beaufort began its mobile messaging initiative four years ago, staff were at the mercy of voice mail and phone tag. "It leads to frustration, and it's just not [an] efficient workflow," Ricks says.
In response, staff had—without management guidance—begun using consumer-grade mobile messaging embedded in the consumer devices they carried. "They went to their devices and were texting each other, because it worked really well," Ricks says. "The challenge is it wasn't secure from a HIPAA perspective. We had protected health information sometimes being texted back and forth.
"A lot of people would say, 'Oh, we've got it solved. We've got a policy that says we prohibit texting of PHI.' For us, that's like sticking your head in the sand. It really doesn't solve the problem."
In response, Beaufort implemented Imprivata's Cortext secure messaging technology. "It's gone well," Ricks says. "We wanted a small pilot of six or eight physicians just to get them going at first, and within about two or three weeks, we had 50 or 60 people in our pilot, because it helped them solve workflow and organizational efficiency."
Shortly thereafter, an executive committee of Beaufort's medical staff, an independent body apart from Beaufort management, decided to ask all physicians on staff to use Cortext. "That really helped grow it for us," Ricks says.
Two other management decisions smoothed adoption. "We used to have a policy that said you could never use your personal cell phone at work," Ricks says.
"We had to change that." In addition, by installing a desktop version of Cortext, Beaufort extended the platform to the hospital’s nonmobile computing resources, he says. "The applications aren't what's mobile. It's the clinicians that are mobile."
Clinicians are also benefitting from an April 2016 partial lifting of a Joint Commission ban on clinicians using mobile texting. However, The Joint Commission stopped short of permitting the use of mobile messaging to transmit physician orders, Ricks notes.
"I think they are still considering going back and forth," he says. "So we only allow clarification of orders via mobile messaging, not orders themselves. We may change that when The Joint Commission changes its stance, and I know it will because there's a lot of people asking for this."
One appealing feature of applications such as Cortext is the ability to create a directory of providers to choose from when sending secure messages. "The directory contains the universe of who can communicate with them through that medium," Ricks says.
Clinicians also like Cortext because it strongly resembles the default consumer-oriented messaging on a mobile device, he says. "It's almost exactly the same look and feel." For added security, Beaufort also requires staff to enter an additional PIN every time they log into the app.
As with physician-to-patient texts, integration with electronic health records means that important alerts can bubble up from the EHR and land on a physician's mobile device. In Beaufort's case, technology from Forward Advantage pulls important data such as critical lab results, or news that one of the physician's patients has been admitted to the ER, out of Beaufort's MEDITECH EHR and presents them as messages in Cortext.
Ricks also sees the return on investment of HIPAA-satisfying secure texting as one of avoiding PHI breaches as well as smoother workflow and time saved. "It is as much cost avoidance and risk mitigation as it is an ROI," he says.
At Beaufort, there is a way to use Cortext to send secure texts to patients, but due to its limitations, most physicians choose not to do so. "You can send a secure message to someone who is not in the directory," Ricks says. "They don't see your phone number. Most physicians don't want that. That may change over time, but we're not seeing a lot of use of that yet."
Mobile Email vs. Mobile Messaging
Despite the rise of mobile messaging, mobile email is still a popular communication medium, according to some providers. These providers note that patients in particular are more open to receiving email than logging in to a patient portal website, if those are the only choices they have. One challenge, though, is that conventional email services generally lack the security and privacy safeguards that HIPAA requires.
Centric Physicians Group is a 18-provider postacute primary care serving 2,400 patients at any one time at skilled nursing facilities, assisted living facilities, and rehab hospitals.
"Because we deal with a lot of patients in and out of the hospital, our providers are all over the place," says Scott Steele, CEO and general counsel of Centric Physicians Group, based in Bourne, Texas, adjacent to San Antonio. "So electronic communication is of huge importance."
A compliance attorney by training, Steele says HIPAA compliance is "really important to all of us" at the company. By turning to a secure subscription-based cloud email service from San Francisco–based Paubox, he was able to avoid the cost of building and hosting an internal email server for the firm, or relying on non-HIPAA-compliant free email services.
"It works very seamlessly across most of our providers," Steele says. "Many are using iOS devices, and some are on Windows devices, whether it's a cell phone, a laptop, a desktop computer, a tablet, whatever. It works very well across all of those platforms."
One advantage of mobile email over text messaging is the ability to attach large documents to those emails, similar to the way Dropbox allows large files to be transferred, Steele notes.
Because Centric physicians use diverse EHR software, Paubox enables them to send exported notes through email attachments. "Our electronic medical record generates a note in a PDF format, and I'm able to use Paubox to email that to the facility that I choose," he says.
These files can range in size from compact patient notes to physician and facility contracting documents between 70 and 250 pages at a time, Steele says.
Because it's still email, Paubox services are available via a secure web portal as well as integrated into the mobile device user's native email, Steele says.
As a trained compliance officer, Steele emphasizes the end-to-end encryption of Paubox email technology, which eliminates the possibility of unencrypted email being stored on a recipient's email server, where PHI could be compromised. Recent moves by the U.S. Department of Health and Human Services Office of Inspector General indicate the office may intend to levy more fines for such breaches, which means securing such PHI is more important than ever, he says.
Still, not all clinicians view email as an acceptable mobile communications medium. A particular physician’s opinion on this matter might depend on how much email he or she sends rather than receives.
"I may get 300 emails today," Ricks says. "Some of them are very important, some of them are not important at all, and some are probably spam messages, and I don't have time to ferret through that while I'm working through my day."
The familiarity of email reduces the amount of time clinicians need to spend learning unfamiliar messaging workflows in EHRs—many of which can only be accessed on mobile devices through cumbersome virtual private network technology, says Ricks.
"Doctors are incredibly busy," Steele says.
"They want to get something done immediately and move on to the next problem. Simply by them using an email client like they always do, it's very easy."
For shorter communications, though, Centric also employs TigerText, a messaging technology alternative to Cortext from TigerText in Santa Monica, California.
"That's the last link in the chain for us," Steele says. "We're able to get out instantaneous information across the continuum so the hospital is aware, the doctor who treats the patient is aware, the nurse practitioner is aware. We all do that on TigerText."
To realize the most benefit for e-prescribing, providers, regulators, and vendors alike must address piecemeal state laws and integrating data from e-prescribing for controlled substances with EHR/EMRs.
Electronic prescribing is now widely used by providers, but it has not yet fulfilled its potential.
Controlled substances can be legally e-prescribed in all 50 states, but use of e-prescribing for controlled substances (EPCS) is not mandatory in 47 states, limiting its benefits at a time when abuse of prescription drugs such as opioids is still grabbing news headlines.
Meanwhile, for e-prescribing in general, physicians who are just beginning to use the electronic system to bypass time-consuming calls to pharmacists when trying to obtain information on the lowest-cost, most-effective drugs for patients are challenged by the lack of transparency of pharmacy pricing and formularies at the point of prescribing any medication.
This could impact patient medication adherence rates if prescription costs are too high.
Despite the challenge that price comparison is not always available when e-prescribing, healthcare leaders are encouraged by the more secure system of e-prescribing.
"E-prescribing provides not only a more secure way of doing things, but a more efficient way of doing things as well, and it's more patient-centric," says Brian Herrick, MD. He is chief medical information officer at Cambridge Health Alliance, a two-hospital safety-net organization that operates three emergency departments and covers about 100,000 lives in the northeast suburbs of Boston.
The number of e-prescriptions written in the U.S. doubled from 2012 to 2015, according to Surescripts, a nationwide health information network connecting providers and pharmacies.
Because practitioners are electronically prescribing, it eliminates the need for patients to carry paper prescriptions to pharmacies, circumventing problems created by illegible handwriting on paper prescriptions.
"An EPCS prescription goes directly to the pharmacy, so there's a lower chance of forgery, as well as clinical alerts to ensure the safety of the prescription," says Peter Kaufman, MD, chief medical officer of DrFirst based in Rockville, Maryland. DrFirst offers providers an EHR-agnostic, web-based secure EPCS connection to Surescripts' network, which, in turn, connects securely to pharmacies.
EPCS finished 2014 with a small portion of the total controlled substance prescription mix, but experienced a surge in 2015, growing from 341,000 prescriptions in 2013 to 1.67 million in 2014 and 12.81 million in 2015, according to Surescripts.
Nationwide, 88% of pharmacies are enabled to accept EPCS, although only 13% of prescribers are enabled, says Paul Uhrig, chief administrative, legal, and privacy officer at Surescripts in Arlington, Virginia.
In 2015, a state law in New York was enacted that required all medications, including all controlled substances, to be prescribed electronically. However, the effective date of the law was pushed back a year, from March 2015 to March 2016. In 2011, Minnesota, and in 2016, Maine, required EPCS as well.
EHR vendors' lack of readiness to integrate EPCS into the prescribing workflow was a major reason for the delay in New York's law. The process also required provider leadership to implement two-factor authentication to verify the identity of prescribing clinicians, according to George Hickman, executive vice president and system chief information officer of the 734-licensed-bed Albany (New York) Medical Center.
The second authentication factor varies, according to technology and healthcare providers. Even within provider groups, prescribers sometimes have a choice of a second factor. For instance, a healthcare provider's IT management/operations department may offer a biometric second factor, or as an alternative, may send a one-time password to the prescriber's mobile phone as the second factor.
"Physicians obviously have a lot going on in terms of providing care, so when you're changing the workflow, that takes a little bit of time and effort," says Uhrig.
The reason EPCS became imperative in New York state had everything to do with the prescription opioid drug abuse epidemic, which had ravaged rural and urban areas of the state. "The New York Bureau of Narcotic Enforcement (BNE) was seeking to utilize technology to forensically discover the providers who are abusing narcotics dispensing," Hickman says.
By implementing e-prescribing and multifactor authentication, the BNE and other state and federal enforcement agencies, such as the U.S. Drug Enforcement Administration, aim to reduce theft of prescriber passwords and prescribing pads intended for controlled substance prescriptions. But first, information systems of prescribers had to be made ready by the vendors and provider organizations.
In Cambridge Health Alliance’s case, EPCS technology provider Imprivata integrated EPCS into Epic, Cambridge Health Alliance’s EHR. "The biggest challenge is really getting the [physicians] in and doing the registration in person so that you can verify their identification," Herrick says.
Healthcare's battle to curtail prescription drug abuse is being fought on multiple fronts. In many states, physicians already have to log into a prescription drug monitoring programs (PDMP) database to review the history of any controlled substances prescribed to a patient.
"The PDMPs have been around for 30 or 40 years depending on the state," says Thomas Sullivan, MD, chief strategic officer at DrFirst. The problem is, "they just weren't adequately funded. They weren't online, and they're completely under the control of each state," Sullivan says.
States have implemented piecemeal mandates for use of PDMP and EPCS. Prior to its 2016 EPCS mandate deadline, New York in 2012 had mandated prescribers use its PDMP website by 2013, known as I-STOP (Internet System for Tracking Over-Prescribing Act). Neighboring state Massachusetts enacted severe penalties beginning in January for prescribers who do not consult its PDMP, says Sullivan.
With the I-STOP PDMP, "the real impact on curbing drug-seeking behaviors really kicked in long before electronic prescribing," says Michael Oppenheim, MD, chief medical information officer at Northwell Health, which operates 21 hospitals and approximately 550 ambulatory sites in metropolitan New York and Florida.
EPCS can build on PDMP use by sending data from EHRs to the PDMP databases, which state agencies such as New York's BNE can query to look for patterns of abuse by prescribers as well as patients.
But at this point, not all EPCS data collected by EHRs makes its way into the PDMP databases, due to the inability of many PDMPs to accept such data from some EHRs.
DrFirst and other companies that seek to integrate EPCS data with EHRs, such as those in use at Northwell, are waiting for the state to publish an application program interface (API) that would permit EPCS data to flow from EHRs to I-STOP, says Kaufman.
As if the variation from state to state wasn't complicated enough, many healthcare organizations use multiple vendors' EHRs or specialty-specific clinical systems across their own enterprises.
Northwell Health is one such organization. It turned to DrFirst's web-based or smartphone-based service to provide an EPCS service for these systems that did not have EPCS functionality as provided by their specialty-specific systems, or for practices that had no EHR, including Allscripts, Oppenheim says.
"I-STOP took us a couple of steps forward," he says. "EPCS is taking us a couple of steps forward. Each bit builds on the previous and helps us tackle this issue a little bit better."
Because DrFirst's service operates independently from a healthcare provider's own EHR, DrFirst also envisions EPCS use within Northwell at community-based programs and school-based clinics where EHRs are not present, Oppenheim says.
Albany Medical Center is also waiting for the I-STOP API to be added to its Cerner-, Allscripts-, and Medent-based EHRs to eliminate the need to log into the I-STOP website before moving back to the EHR to electronically order the prescription, says Azmat Z. Ahmad, vice president at Albany Medical Center.
Any organization where physicians must use multiple EHRs also requires downloading or possession of multiple second factors of authentication, Hickman notes. "Think of even simple inconveniences of workflow to a clinician, a provider that’s doing ordering. One EHR uses a different authentication provider than another, so that means clinicians have to either download more than one token-giving application onto their phone, or carry more than one fob."
Patient convenience is also a benefit of EPCS because patients no longer have to go to their physician for every prescription, Herrick says.
"As long as they're on their treatment plan and have the appropriate tests done and have the appropriate agreement with the providers, they can … go straight to the pharmacy," he says.
At St. Joseph's Hospital in Phoenix, Chief of Nuclear Medicine Frank Schraml, MD, explains how the hospital dealt with a similar shortage several years ago.
"The radiopharmacies in the area essentially give us priority, because we order a lot of isotopes," Schraml says.
During a severe shortage of technetium-99m two years ago, Schraml thought St. Joseph's might have to turn to thallous chloride 201, a suboptimal isotope, but instead decided to make its supply of technetium-99 go a little further.
"We compensated by lowering our doses slightly… you can maintain the same quality by slightly increasing the time of imaging," Schraml says. "We were able to continue business as usual, essentially."
Eventually, the shortage abated, and the hospital resumed its original dosages and dosage times.
Regarding the current shortage reports, "I don't know how dire things will be," Schraml says. "I put a lot of reliance on my technologists and my manager. They seem to always come through, so if the shortage isn't any worse than it was a couple of years ago, then I think we'll be fine."
The PET Alternative
Technetium-99 is used between 70,000 and 80,000 times per day in U.S. healthcare, primarily as a cardiac perfusion imaging agent, says Paul Crowe, chairman and chief executive officer at NuView Life Sciences, based in Dallas.
"It actually shows how well the blood is being moved through the heart, and it is a clinical assessment for the doctor to determine the cardiac output by ability of the muscle, and to help the physician diagnose a patient's condition," Crowe says.
Technetium-99 has been used for decades by clinicians in private offices that have their own nuclear medicine cameras, as well as in hospitals. "Over the last 10 years, there [have] been intermittent shortages of the product that cause cancellations of patient procedures," he says.
One alternative in use is a product of rubidium-82, a PET biomarker. "The difference is that the cameras that utilize the rubidium are larger, they're much more expensive, [and] you have limited facilities in the United States that offer these services for cardiac imaging," says Crowe.
"Most PET imaging cameras are used for staging cancer and observing response to therapy. But there's a growing demand for rubidium as a PET perfusion imaging agent for the heart, because it has higher image quality. It has less artifact that may or may not influence the accuracy of the diagnosis," he says. "Also, the imaging times are lower."
Another reason rubidium-82 could make inroads: MRI and PET cameras are being integrated, aiding earlier detection of heart tumor or plaque, Crowe says.
"If you can diagnose a medical disorder more efficiently, you can treat it more efficiently, and you eliminate a lot of unnecessary tests in between," he says.
NuView plans to reopen a shuttered Texas manufacturing facility to produce both rubidium-82 and technetium-99, Crowe says, and the company aims to have both radioisotopes on the market in 16 to 18 months.
NuView is also working on new radioisotopes, in conjunction with Peter Conti, MD, PhD, professor of radiology and director of the at Keck School of Medicine Molecular Imaging Center at the University of Southern California, utilizing adenosine.
The new products will be available in the next 34 [or] 36 months, providing clinicians with alternatives to technetium-99 or rubidium-82, Crowe says.
A pledge by President Trump to slash regulations at the FDA may run into opposition from health leaders who believe innovation will proceed regardless of the level of FDA regulation, or that too much regulation-cutting could endanger patient safety.
President Trump has promised sweeping rollbacks in regulations across all agencies. But at the Food and Drug Administration, a focus on innovation would be a better way to safeguard patients and get new devices and medicines to market, says Eric Topol, MD.
"There is always a delicate balance between permissiveness and less regulation and oversight, as compared with promoting innovation and getting things out that could help people," he says. Topol is a cardiologist and chief academic officer at Scripps Health in San Diego.
"Setting the tone that we want to see more true innovation accelerated would be a good thing. Often it isn't just the commissioner per se that has the governance" but also those at staff level, he says.
"They approved the drug with 12 people, 12 kids, and no controls," he says. "This was not an example of acceptable, in my view."
If the Trump Administration opts for wholesale deregulation at the FDA without carefully considering the consequences, the approval process for devices and diagnostics will carry some of the same risks, Topol says.
"The FDA has been doing things to turn up the speed [of approval]," he says. "I'm hoping that we'll see consistent means of promoting [and] accelerating meaningful, proven innovation."
Instead of relaxation of FDA standards for new devices and drugs, Topol would prefer to see a revamped process for moving innovations through the FDA's pipeline.
The typical clinical trial process does not track every patient's progress via digital means. "I'd like to see [digital tracking] eventually be the criteria for all approval of everything at FDA related to medicine and healthcare, because we don't track this stuff today," he says.
Post-market surveillance studies, which are intended to monitor the safety of pharmaceutical drugs and medical devices after their release, "don't usually get done, they don't get reviewed, and they're not meaningful because they're not [done for] every single person, and that's where you really learn," he says.
Instead, too many drugs and devices today get pulled off the market in response to unanticipated untoward effects, Topol says. "Typically, they're known in the first year."
Topol suggests the FDA adopt a process in which makers of these devices and therapeutics apply for and receive rapid conditional approvals with a time limitation from the FDA. The process would digitally track all users of the device or therapeutic during the trial period, he says.
If time were to run out before the trial yielded results, the device or drug would come off the market. And it could not be advertised while under conditional approval, Topol adds.
Innovators might object to an advertising ban during the conditional approval period, but "if you give them the choice of a rapid conditional approval in record time, versus… what usually happens, guess which one they would take," Topol says.
This kind of approval process could have prevented the harm caused by the arthritis drug Vioxx after it received FDA approval, he suggests.
"It was the biggest launch in history, at the time, of any pharmaceutical." If Vioxx had been given a conditional approval instead, "the heart attack problem would have been manifest, and you wouldn't have had 20 million people exposed [to the risk] right away."
Because conditional approval already exists but is not used often, the FDA need not enact new regulations, but could simply encourage use of conditional approval, Topol says.
Increasing public pressure for clinicians to use new devices and therapies is one trend that will not slow during the Trump years, he says.
"There's an absolute need to have patient engagement in the design of all therapies, because what researchers think is important versus what patients think are usually quite different," Topol says.
Electronic health record vendors need to modify their products to make it easier for providers to track patients' use of devices and therapeutics, he says. Vendors could add this kind of tracking module to their EHR platforms, Topol suggests.
"Regardless of who's in the driver's seat at the Presidency level, what we need is not incremental innovation but massive dynamic transformational innovation," says Rasu Shrestha, MD, chief innovation officer at Pittsburgh-based UPMC.
When it comes to FDA regulations, "my personal wish is that we finally get to a place where we're actually solving intelligently for decreasing complexity in healthcare overall," says Shrestha, who is also executive vice president of UPMC Enterprises, the payer/provider's medical technology investment arm.
Regulations have to be eased with caution, Shrestha says.
"There are certain forces that historically have tended to drive FDA, and those forces are powerful and they remain firmly in place," Shrestha says. "One is unexpected safety events. You talk to anybody in this area and they'll always go back through the litany of safety issues that have driven the major strands of FDA thinking.
"Now the mind shift is, how do we make intelligent decisions around what works for a single patient, leveraging capabilities with machine learning and artificial intelligence?"
Shrestha believes patients will lead the next wave of innovation. "If we're able to have patients be the arbitrators of their own data, I think interoperability will scale to a level that we've never imagined," he says.
Consumer-led innovation will have its own deregulating effect on the medical device industry. "I believe under the new administration… the transition from volume to value will actually not slow down. It's going to double down," he predicts.
As an incubator and investor in startup technologies, UPMC Enterprises leans toward letting a thousand flowers bloom.
"We need more transparency: price transparency, performance transparency, and letting the best solution win," Shrestha says. "Competition is not a bad thing. It keeps us honest."
Healthcare leaders are looking at their options for making EHRs simpler to use and their data more interoperable, as well as making clinical documentation more useful and meaningful to clinicians. Healthcare leaders have had some success, but solutions aren't coming easily.
This article first appeared in the January/February 2017 issue of HealthLeaders magazine.
Electronic health records, in use at nearly all U.S. hospitals and by more than three-quarters of all physicians, achieve two major objectives for healthcare systems. They facilitate generation of a bill, and they provide documentation of providers' assessments, actions, and plans to treat patients. As the industry pivots from volume to value, the nature of clinical documentation is undergoing unprecedented change, and is driven by the way providers get paid.
This transition is challenging healthcare leadership in ways never before encountered. Changing documentation technology is often cited as a leading cause of physician burnout, in studies such as one by the Mayo Clinic in June 2016, in which 6,560 physicians in active clinical practice were surveyed.
While healthcare leaders and the industry look to evolve EHRs to make them simpler to use and their data more interoperable, and to integrate timely decision support into EHRs to make documentation more useful and meaningful to clinicians, at the same time, patterns of documentation well established under the fee-for-service model persist,confounding these moves toward simplicity.
Lessons from the traditional CDI dynamic
The practice of clinical documentation improvement actually predates the EHR and, when CDI's digital equivalent is used well, has proven to be complementary to a fee-for-service world. Prior to EHRs, physicians would document on paper, and then CDI specialists within a health system would pore over these notes, flagging areas where physicians had not been specific enough. This provided several benefits: alerting the system that a patient's condition was more severe than originally documented and flagging overlooked issues such as comorbidities, but also permitting billing at a higher level, which satisfied management's goal not to leave any money on the table.
"This kind of process was laborious and only partially successful on paper," says Michael Zaroukian, MD, vice president and chief medical information officer of Sparrow Health System, anchored by its 676-licensed-bed teaching hospital in East Lansing, Michigan. The CDI picture brightened when EHRs and accompanying decision support arrived in the form of Claro CDR software for CDI workflow, allowing Zaroukian's team of developers to "make that information available to various health professionals in our organization to decide, for example, which patients might need greater services at discharge to help either prevent readmission or to help them with an improvement in their quality of life," Zaroukian says.
"We did consider it to be part of our approach to making sure we had a better understanding of the total complexity of our care, so that we could then use it to inform other aspects of the tools we use to adhere to best practices, decrease unnecessary variation, and promote improvements in patient care, outcomes, and satisfaction."
In a 2015 HIMSS Analytics Stage 7 case study, Sparrow reported that these CDI efforts yielded $5 million in additional revenue from September 2013 to December 2014, due to increased case-mix index resulting from CDI and computer-assisted coding-supported workflows. Sparrow retired paper CDI queries and replaced them with in-basket EHR messages that made CDI query delivery and physician replies easier and more efficient.
Additionally, physician response rate to CDI queries increased from a baseline of 60% to 92% after implementation of EMR-supported CDI and CAC processes. These processes are now completely electronic, and contributed to Sparrow's CDI specialists being able to move from 80% to 100% review of Sparrow charts, without requiring additional specialists.
Sparrow leadership realized that technology would help with better documentation, so it augmented its Epic EHR with templates, which presented clinicians with cascading text prompts to achieve that greater specificity without a CDI specialist actually looking over their shoulder, Zaroukian says. "As we were getting ready for ICD-10, there was a recognition that just putting an EMR in place and just asking people to document better, using what we've educated them upon in the past and asking them to remember all that and to somehow take time from their busy world in a non-workflow-integrated way to improve their documentation, was not having any significant effect."
The heart of the process is that the text-prompts workflow presents critical information to the clinician at the point of care, but does not overwhelm the clinician.
The Sparrow initiative was facilitated by a physician advisory group, led by physicians who directed the organization's efforts to spearhead the implementation and refined the usability of documentation queries, Zaroukian says.
On the technology side, Sparrow's leadership team also implemented the Optum Enterprise CAC platform for two of its hospitals. This technology reads clinical documents and creates lists of supported diagnoses. These diagnoses contain links to the patient's EHR, highlighting key words and phrases in each document.
Sparrow leadership learned the following from the case study:
Successful implementation with desired results requires understanding and agreement around business processes and how health IT systems can support them. One of the key success factors was identifying and overcoming communication barriers to ensure understanding and promote buy-in.
Executive level support and involvement were critically important to a successful CDI program.
Remember the value of Plan-Do-Check-Act (PDCA) cycles of improvement and continue to get feedback and fine-tune systems and processes after implementation.
Communicating the advantages and expected benefits to affected caregivers throughout the implementation process creates positive engagement, anticipation, and commitment.
Involving frontline caregivers during system build and testing helps ensure successful implementation, improved processes, and high user satisfaction.
ICD-10 falls short
In the year since ICD-10 replaced ICD-9 in the United States, it has taken its place as one tool in the toolbox to help make documentation more consistent, but a tool that has fallen short of its original promise to assist with CDI. "Some people would say it's helping; other people would say it's hurting the documentation," says Dean F. Sittig, PhD, a biomedical informatics professor at University of Texas Science Center at Houston's Health School of Biomedical Informatics and a member of the UT-Memorial Hermann Center for Healthcare Quality and Safety in Houston. "Right now most of the documentation is in free text, so it's not using ICD-10. There's a lot of inconsistencies there and a lot of problems there."
Others studying the clinical documentation inconsistency problem agree physician complaints are real. "It bothers me when physicians say, 'I don't trust the medical record anymore,' " says William R. Hersh, MD, professor and chair of the department of medical informatics and clinical epidemiology in the School of Medicine at Oregon Health & Science University in Portland. "They don't know if this note's been copied and pasted from an earlier medical record or another patient's medical record. They don't know what the patient's story is, because the previous doctor had to click all these boxes to fill in these forms."
"It's not just about the technology. It's about how we communicate. I have physicians that tell me they don't really believe what's in the medical record anymore. I don't think there is turning back the clock, of going back to paper," he says.
The sheer amount of work it takes for physicians to check boxes and fill in structured clinical documentation fields in EHRs is becoming more and more well documented. Researchers from Weill Cornell Medical College and the Medical Group Management Association surveyed 394 physician practices nationwide in 2016 and found physicians and their staff averaged 15.1 hours per physician per week processing quality metrics—the equivalent of 785.2 hours per physician per year.
Hersh says the industry as a whole needs to address cost and burnout from clinical documentation, particularly as it moves to implement new models of care.
"Medicine is fundamentally an information science," Hersh says. "You see some of the news reports [such as in the September 2016 Annals of Internal Medicine that] physicians spend two-thirds of their time away from patients. The reality is that physicians always have spent a minority of their time with patients. Ten years ago it was writing notes in the chart. Today it's dealing with data and information. As we move to things like bundled payments, information becomes more important."
Although much of this does exist today in medicine, Hersh says the healthcare industry can still learn from other professions such as air traffic control and the military, where using precise language reduces variation and ambiguity in practice. "There's never going to be complete elimination of ambiguity," he says. "We do need to try to standardize as best we can, especially if we're going to see any kind of benefit from things like precision medicine."
SNOMED CT, a standard way of exchanging clinical documentation such as problem lists, has proven to be a more precise way of describing the clinical narrative in a structured way than ICD-10, and the good news is software developers are making progress at mapping natural language technology, taking speech or clinical notes as input, into specific SNOMED codes. In addition, ICD-10's eventual successor, ICD-11, will be derived from SNOMED, Hersh says.
"The best attribute of SNOMED is that it's extensible, so you can build more complex terms from simpler ones," Hersh says.
Another provider likens today's CDI to a kind of arms race in which algorithms suggest that more intricate diagnoses replace simpler diagnoses in order to maximize fee-for-service revenue.
"A lot of things that we do around billing, coding, and case-mix index are dependent on how you talk about a situation," says Sameer Badlani, MD, FACP, chief health information officer and vice president at Sutter Health, a 24-hospital system based in Sacramento, California. "If I were to write 'congestive heart failure,' I would get paid less versus if I say 'decompensated systolic heart failure,' which is a technical term for congestive heart failure. To a physician they mean the same thing. I would provide the same level of care, but there is a marked difference in the level of reimbursement that allows you to get paid better. So we're constantly playing this cat-and-mouse game where people are trying to document appropriate care in the best possible sequence of terms to get adequately compensated for the care they provide. And that is not the way we should be practicing medicine. If we were truly in a value-based system, you wouldn't care what I wrote in my documentation. You would care about the patient outcome."
Moreover, a fundamental challenge as clinical documentation pivots from volume to value is the continuing need to code in both old and new styles in order to satisfy requirements of Medicare and other payers, says Alistair Erskine, chief informatics officer at Geisinger Health System, the Danville, Pennsylvania-based system that serves more than 3 million residents throughout 45 counties in central and northeastern Pennsylvania and also in southern New Jersey with AtlantiCare.
"From 1984 on, evaluation and management coding has been a means for CMS and insurance companies to be able to pay doctors," Erskine says. "It's also been an enormous burden."
More and more, EHRs are helping physicians keep up with ever-growing clinical documentation demands, says Erskine. "When I write a note today, the computer really writes 75% of the note for me," he says. "It picks out certain templates, labs, and diagnostic imaging results. It may pull forward information that I had put in a note previously or that somebody else put in a note, and that becomes part of my new note."
While the computer-added information is a boon for analytics driving measures such as clinical quality reporting and population health initiatives, "the problem is we've lost a lot of the narrative in that note," Erskine says.
The ICD-10 transition also fell short of expectations, Erskine says. "It was dramatically overstated that somehow the doctors are going to be picking the right ICD-10-specific diagnoses, and we're going to have a much more robust and revealing medical record system," he says. "It wasn't that much of an issue for them before, and they're not really paying that much attention to it now."
In response, Geisinger has adopted a policy of not forcing its physicians to use a template when they write their notes. "If you want to just open up a [blank document] and start typing text, you're free to do so," Erskine says. "If you want to dictate your note and have that dictation turn into text, you're free to do so as well."
In addition to relying on ever-improving speech-to-text technology, Geisinger, in its role as an academic medical center, encourages its residents and medical students who encounter notes that do not make narrative sense to return the note to the author via the EHR's inbox function and ask the author to restate the note for better clarity, Erskine says.
Another approach that Geisinger and others have taken is to implement OpenNotes, a national movement for sharing the system's existing medical record notes with patients themselves, who are then encouraged to point out errors or additions, Erskine adds.
This refocusing, however, also calls into question the usefulness of some of what an EHR is supposedly measuring, he says. "Over the past couple of decades, we've gotten obsessed with measuring or using process metrics as opposed to outcome metrics," Erskine says. "There's actually a train collision ahead of us in about two years. We're moving away from fee-for-service as quickly as we can, all the while that we're not trying to lose our shirts in the process of doing so. However, the E&M coding and the billing practices, and the law and rules that exist today, are not going away in terms of what fee-for-service expects you to write. So you have this hybrid world where you're expected 100% of the time to do fee-for-service notes with E&M coding and all these different rules in terms of what you put in your clinical note."
Erskine says he has brought these documentation concerns to officials at CMS, but that officials there are reluctant to deemphasize process-oriented documentation in favor of outcomes-oriented documentation, in part because measuring outcomes remains an unfinished task for the industry, and because "CMS is constantly concerned, and rightly so, with fraud and abuse."
While copy-and-paste use in EHRs can serve a valuable function, misuse of copy and paste has also been an issue since EHR use became widespread. Erskine says EHR vendors such as Epic are helping to distinguish when material in the physician's note has been pasted from some other source through use of differently colored or italicized fonts with such text. "It helps illuminate a little bit where people have overused or where there isn't really that much new information, which in the previous iterations you couldn't really tell," he says.
Yet another challenge is getting physicians to impose self-discipline on the length of various aspects of the documentation. "Problem lists get larger but tend not to get smaller," he says. "People have a tendency not to curate it and make sure it's nice and organized in a way that highlights the relevant things. Part of that is because, who really owns the problem list when it has 40 problems on it?"
Chances are difficulties such as this will require the joint efforts of healthcare organizations, physicians, and in particular, technology suppliers such as EHR vendors, Erskine says. "They're really trying to be ambassadors and reconcile and adjudicate those regulatory needs with what the clinicians are really asking for, and trying to do that in as elegant a way as possible, but it's going to be tough to do."
As one example, Erskine says Epic "is going to make at least provenance within their record more front and center, so if I hover over a term in the record that was copied from somewhere else, it will tell me who was the originator of that particular term."
"Presumably, if I'm communicating well because I'm writing good notes and if I'm coordinating well because I'm working with other institutions, and I'm managing the patient well—that's the measure of success, as opposed to what I've actually done and how many times I've ordered something and how many elements I've put into my clinical notes," Erskine says.
"More documentation expected from the physician and more focus on quantitative markers as surrogates for qualitative outcomes is our problem."
Badlani recommends one approach to make sense of the "note bloat" of today's EHRs in the coming value-based, team-based world of care is to rearrange the typical SOAP (subjective information, objective information, assessment, and plan) note into an APSO note, with the assessment and care plan coming first. "When I'm looking at another physician's note, I really want to see their assessment and plan," Badlani says. "And the reason you still maintain the subjective and objective elements at the bottom of the note is because you need them for compliance, for billing, and for coding standards, and then nobody looks at that except whoever is making sure you are billing appropriately."
As much as steps such as these can help, Badlani still sees the same documentation crisis as others do. "More documentation expected from the physician and more focus on quantitative markers as surrogates for qualitative outcomes is our problem," he says.
Sutter is looking to adopt from other healthcare systems in the clinical documentation picture. "In some organizations, they have standardized the way radiologists or pathologists document," Badlani says. "I, as a consumer, know exactly where in the document to expect what." Combining such standardization with a change from SOAP to APSO, would allow physicians to more quickly find what they are looking for within the EHR, he says.
"It's a really critical topic," Badlani says. "A significant portion of physician dissatisfaction comes from steps they have to do in the EHR, which don't really line up to any clinical benefit. The way we do documentation is one of them."
A second technology effort to help with documentation burdens combines the heads-up display found in Google Glass and similar augmented-reality wearables with a notion popularized shortly after the EHR was invented: the scribe. In this regard, in 2015 Sutter began using technology from Augmedix, a company that pairs Google Glass with scribes working from India who help ease the burden of documentation on the wearable-donning physician, presenting relevant information on the heads-up display and allowing the physician to keep their eyes and attention on the patient. "That's an example of innovation trying to leverage what we can in making this better," Badlani says. Sutter has also made a minority equity investment in Augmedix.
Erskine notes that trying to lean too heavily on scribes to help relieve physician documentation burnout has its own risks. "Scribes have tried to help address the issue but they introduced their own problems in terms of potentially overdocumenting what is actually being done," he says.
Still, all these efforts are a reaction to the failings of the meaningful use program to achieve its ultimate objective—improving outcomes, Badlani says.
"It perpetuated the concept that the mere presence of technology, trying to achieve meaningless measures, would make a difference," he says. "For the longest time, EHRs have not been seen as a clinical transaction tool. They have been seen as billing, coding, and documentation tools. We can't get people to do medication reconciliation on a regular basis in almost any organization consistently, because there are so many other tasks that don't add value to their clinical practice."
Erskine also sees a role for an emerging class of what he describes as "text analytics," which can help identify those clinicians doing a good job of writing notes—as opposed to "those who are clearly kind of using the system to just get through and not necessarily communicate the clinical information that's necessary. We've had conversations like that about how could we make it more usable and how could we make it easier.
"I wish I could give you a crisp answer and say we do this, and that way it's all working itself out. But as long as humans are involved, I think we'll still have to learn together in terms of how to make that happen," Erskine says.
There is also a sense that clinical documentation improvement is only one of many imperatives facing physicians. "Clinical documentation improvement for the sake of clinical care becomes one of the 20 things that the healthcare administration has to put in front of the physician," says Badlani.
Overall, U.S. healthcare is still at the beginning of these transitions, says Robert M. Wachter, MD, professor and chairman of the department of medicine at the University of California, San Francisco, and also author of the 2015 book The Digital Doctor: Hope, Hype, and Harmat the Dawn of Medicine's Computer Age, which delved deeply into clinical documentation issues in EHRs.
"My experience would tell me, that the places that do a big CDI initiative are largely thinking about their balance sheet," Wachter says. Instead, they should look for variations, determine costs of care, and ask why their care is more expensive than care elsewhere, he adds. "You need a higher level of documentation. You need to be more confident that these two patients really are requiring the same treatment, and why did it cost twice as much at this hospital we own than that hospital that we own."
"It's easy to copy yesterday's note and make it today's, and critics said you should just ban that. You shouldn't because there's maybe two-thirds of yesterday's note that is today's."
An example Wachter encountered during the writing of his book involved an epidemic Medicare saw four years ago of a rare African diagnosis of kwashiorkor, a severe form of malnutrition not common in the United States. "As soon as you see that, you know what's happened, that some CDI consultant came through and said, 'It looks like this patient has a low albumin, which is a blood protein level,' " Wachter says. "He says, 'Why don't you call that kwashiorkor, because it pays a hell of a lot better than 'malnourished' or 'wasted.' "
While CMS eventually got wise to this type of exaggeration, Wachter is concerned that as machine learning enters the toolbox of CDI specialists and management, such exaggerations could become yet another arms race between cash-starved healthcare systems. "As the money gets tighter, the premium on trying to figure out how can we, within the bounds of legality, get the doctor to write down the words that trigger the highest payment and provide the highest case-mix severity of illness—that's only going to grow," Wachter says. He also shares that he personally has an interest in tackling this, serving on the board of a company—Accuity Delivery Systems—that creates this kind of CDI technology. "It's just an arms race, but it is a race we all have to run," he says.
Meanwhile, at UCSF, Wachter and other executives are "trying to train our house staff on how to write a good note in the electronic era," he says. "It's easy to copy yesterday's note and make it today's, and critics said you should just ban that. You shouldn't because there's maybe two-thirds of yesterday's note that is today's."
Wachter also challenges the notion that ultimately all clinical documentation will be outcome measurement, not process measurement. "We don't understand outcome measurement well enough," he says. "It may be that the outcomes of interest aren't going to happen for a year or two, controlling someone's cholesterol or blood pressure or smoking. The balance here is how do you put some constraints on the number of measures and the amount of time that people have to spend documenting, and then pragmatically ask people to only record so much stuff in that box."
Team care is changing the documentation process
One aspect that seems to get lost in many discussions around the EHR documentation burden is that the nature of physician documentation is itself changing, from the physician documenting solo late into the night, to one where a care team can gradually shoulder more and more of the documentation burden from the physician.
"I really do think that we are going to evolve more rapidly to team-based care," says Darren Dworkin, senior vice president of enterprise information systems and chief information officer at Cedars-Sinai Health System, anchored by its 886-licensed-bed medical center in Los Angeles. "As healthcare systems better adapt to that team-based care, you might see things like individuals that are teeing up orders by protocol, so physicians are just simply reviewing them and approving, based on some clinical decision support or other tools that are presented to them."
When incentives at a provider align more closely, such decision support tools can liberate physicians from some of the EHR's documentation drudgery, says John Mattison, chief medical information officer at Kaiser Permanente, the integrated health system and payer that serves 10.6 million members in eight states and the District of Columbia.
"We put the member first, and that was a complete game changer in terms of what we did with the product," Mattison says.
"To the point about doctors feeling like they're just billing agents, typing in things to get appropriate billing, the second mantra was that billing would be a collateral derivative, but not drive it. And so I built a team of natural language processing folks so we have real-time natural language processing going on with what's being entered, and the principle there was that we right code everything with the automation of the machine learning associated with natural language processing. So our physicians are liberated to document what's in the interest of documenting quality of care and quality outcomes. Then we derive and support the generation of an appropriate code as a secondary collateral benefit, not as the driving force."
Yet another effort underway would make the EHRs and other repositories of information more interoperable not only on a data file exchange level but on the level of semantics or meaning, so that information flowing in from a different care setting could flow more seamlessly into the patient's primary clinical record and narrative.
"Semantic interoperability is, I think, what we need to aim for," Hersh says. "The aim for version three of HL7 was to achieve semantic interoperability to move everything into some lingua franca that anyone can understand. That proved to be more difficult than people anticipated."
As a middle ground, Hersh points to HL7's Fast Healthcare Interoperability Resources, an emerging standard now being incorporated into EHRs.
FHIR is likely to provide that sort of integration in the short term, Hersh says. "It has structures to start to solve the semantic interoperability problem on a simpler level," he says. "If we can get things like prescriptions and documents with standardized names like progress notes, discharge summaries, operative reports, some standard metadata around them, dates, creators, patients, etc., that will actually go a pretty long way."
Test results, patient reminders, and alerts could flow automatically into the EHR if the EHR could recognize the format of the information seeking inclusion, and if governance at healthcare organizations permitted it, or is incentivized by value-based payment structures, according to Thomas H. Payne, MD, FACMI, chairman of the board of the American Medical Informatics Association, which last year produced EHR 2020, a healthcare informatics road map. Payne is also an attending physician at the University of Washington Medical Center and medical director of information technology services at the University of Washington Medicine in Seattle.
"To change the way we reimburse care from E&M to alternatives at a faster rate than we're already undertaking would require substantive changes in government regulation," Payne says.
Payne also says other forms of standardization in the way clinical documentation is created in the United States could help reduce both the burden and the variation in care targeted by value-based care. Considering the oft-repeated scenario of a healthcare system's physicians gathering to define their own order sets for just that system, "in this age of maturity of our system, you wonder why each organization needs to begin with a blank screen, and the answer is they shouldn't have to begin there," Payne says. "That kind of variation is helpful when we are able to incorporate the preferences or special circumstances of the patient, or the strengths and weaknesses of an individual practitioner. That sort of variation fits into usability."
But Payne favors standardization of order sets, problem lists, and other team-oriented care in the same way that he praises the standardized flight deck instruments and displays that have helped the aviation industry achieve a good safety record.
And as in other industries, it seems inevitable that this sort of standardization in healthcare will be achieved, one way or another, through extensive use of computer algorithms.
"The ultimate endgame seems, to me, to be almost unmistakable," Wachter says. "It has to be that as a doctor and a patient have a conversation, voice recognition picks it up, machine learning sifts through it, parses it in the way it needs to be parsed for the note template, and sifts through it to find things it needs to find to measure the things it needs to measure." Then algorithms would prompt clinicians to ask only important questions not otherwise answered. But such a world is likely still a decade away, says Wachter.
For now, healthcare leaders realize that investing in clinical informatics expertise is an essential strategy to driving CDI, Wachter says.
"You can't get this right if you think of this as you're buying a machine, turning it on, and you're done," he says. "The process of getting it right is it's constantly being updated and you need people who are bridges between the IT and the clinical people to make this work."
Lack of clinical informatics resources in healthcare could slow this progress, says Hersh.
"We always need to resist the temptation to just sort of throw technology at things," he says. "People who have knowledge and experience in informatics know that there are things you need to do, and ways you need to look at things, to make the best use of technology."
A mobile app that integrates clinicians' phone with infusion pump alerts is reducing alarm fatigue among staff at a small Wyoming hospital.
Alarm fatigue is a common condition among clinical staff in hospitals. Symptoms of the affliction may include sensory overload, desensitization, and missed alarms.
Now mobile apps that can pre-empt alarms and improve workflow are being tested as possible remedies.
An 88-bed hospital in tiny Sheridan, WY, (population 17,828) is a beta site for one such app.
Sheridan Memorial Hospital has integrated its infusion pump technology with Cerner's CareAware Connect app residing on clinicians' mobile phones. As a result, nurses, physicians, and pharmacists at the hospital can now track the progress of infusions using the same interface they use to securely communicate with each other.
Five years ago, everything at Sheridan was paper-based. But with the recent opening of the hospital's ICU, the ability to connect CareAware Connect to the hospital's infusion systems supplied by Pfizer subsidiary Hospira was an opportunity to move this small hospital toward greater interoperability and technological workflow integration.
Problem: Alarm Fatigue
Alarm fatigue was a concern at Sheridan, as it is at many hospitals. Nurses who could see just how soon those alarms would begin to sound are now able to attend to infusions whose supplies need restocking, or which have run their course.
"We've been on this journey for the last five years, layer upon layer, adding the different clinical components and integration opportunities along the way," says Charlotte Mather, the hospital's chief nursing officer.
"This now allows better teamwork. The alarm is sent electronically to the phone or to the [nursing station] hub, and you get a real good idea about what it is you're needing for that patient before you're making a trip into that patient's room."
The messages on the app are specific: A bag of fluid is depleted; an infusion tube has a kink in it. The app also presents a subset of the kind of data one would find in an EHR, such as an allergy list, as well as telemetry data such as vital signs, all aimed at assisting nurses with knowing more about the patients in the ICU or other hospital beds.
"The big thing with the infusion management is the unit-based dashboard that's in the clinical units as well as in the pharmacy itself," Mather says. Nurses see alarms and know when they need to return to the patient's room; pharmacists know when to start preparing replacement bags of critical fluids.
"It's like air traffic control. So you see a visual picture of all of the infusions that are running either in that unit, or in the pharmacy, in the whole hospital.
A 'Great Visual Tool'
"You have a real good idea from your team perspective in communicating between both departments what is going on, what infusion do I need to pay attention to, especially if I'm the charge nurse, or I'm the nurse manager, I'm the pharmacist. It helps you coordinate care."
From a physician's standpoint, she says, "when they're rounding on a unit, they can just get a real quick look too, or if they're in the intensive care unit, where a lot of those real critical drips and intensity of medications are being used, they can look and see real quick in one visual picture about what infusions are running at what rate and how much has gone in."
Mather calls it "a great visual tool to give you a picture about that medication piece for that patient."
Among the lessons learned, Mather says: "It was really important to test every single medication and then on the actual alerts. I tested all kinds of different ways. You just have to test over and over to make sure you are getting the correct alert at the correct time. So I guess the big thing is just test all the time, or test everything."
The hospital runs Cerner, but its affiliated physicians organization is implementing Epic, so new connections are arriving just in time.
Last month's announcement that Carequality and CommonWell are connecting their networks has apparently caught the imagination of health IT leaders at providers across the country.
Perhaps no organizations stand to benefit more in the immediate term than Boston Children's Hospital and its affiliated Pediatric Physicians Organization at Children's Hospital (PPOC). The hospital is running Cerner's EHR, and PPOC is going live on Epic's EHR at 80 practices representing 400 providers this March.
Moreover, the hospital actually runs Epic as well, to manage its revenue cycle.
Such a mixed bag of EHRs is practically a poster child for the need for CommonWell and Carequality to connect, which will first occur via pilots beginning in the first half of this year.
To round out Boston Children's perfect storm of EHR interoperability needs, the organization faces exponential growth this year in the number of covered lives which will be in the organization's Medicaid ACO operated in conjunction with the commonwealth of Massachusetts, says Dan Nigrin, MD, the hospital's chief information officer.
"You can't provide the optimal care for the patient without knowing fully what's happening to them, so this interoperability is going to be a huge component of our ACO effort," he says.
By sharing patient data gathered by the practices and the hospital, both organizations stand to see a significant reduction in the cost of duplicative imaging studies and other tests. "It will reduce hard costs right away," Nigrin says.
"Don't ask me to put a number to it. I'm sure if I query the literature, I probably could find a number, but I don't know what that is."
Even though it is a Cerner customer, prior to now, Boston Children's had not joined CommonWell. It will now do so, even as the PPOC organization will join CareQuality, in order to enjoy the benefits of membership that will flow from CommonWell members being able to send directed queries to Carequality members, and Carequality members being able to access CommonWell's record locator service.
The integration will also finally quiet the chattering of fax machines currently moving records between the hospital and the independent pediatricians who belong to PPOC.
"Frankly, there's a whole lot of faxing that still occurs, despite having some of the interoperability infrastructure here within the state," Negrin says.
That infrastructure, the Mass Health Information HIway, was of limited value, because providers usually were invited to push patient data to other providers via the Direct protocol, when in fact physicians at the point of care wanted to pull that data from other providers–services delivered by both CommonWell and Carequality.
"From my perspective, the [Mass HIway] health information exchange is nonexistent, even in the context of being able to fax and or send messages through Direct," says Nael Hafez, CIO of PPOC.
"Those faxes are simply not received at the right time by the right person to be able to be of any use to them, and I've heard from many of our providers that they end up having to refax multiple times the documents that they they've sent to organizations including Boston Children's.
In addition, the CommonWell and Carequality integration will relieve PPOC and other providers from having to establish point-to-point or bilateral exchange agreements with other providers, Hafez says.
Progress Will Focus Providers
"When I look at a lot of my list of trading partners, 10 of them are either Meditech or Cerner [EHR] organizations. And we would have had [to have had] conversations with each one of them to establish contractual relationships and trust and figure out technically how to connect."
Both providers liken the new connections to those that built the current network of interconnected automatic teller machines. Like what occurred in banking, this progress will focus providers, including HIEs, on providing more valuable services on top of this network.
"We have to be prepared as organizations to continuously improve obviously on the services that we make available and provide through this architecture," says Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.
Tripathi, who helped facilitate the CommonWell/Carequality agreement, says such networks will allow the best services to compete and win on top of the unified networks. For instance, some customers may opt for or add additional record locator services, such as the one provided by the Surescripts network.
"It opens up a little competition," Tripathi says.
Determining quality over cost, meeting the triple aim, and employing analytics tools are key to success.
As U.S. healthcare pivots from volume to value, spurred on by MACRA and other payer imperatives, participants at a recent HealthLeaders Media Roundtable offered their perspectives on just how to measure value.
"The triple aim objectives are a really great framework for thinking about value," says Mouneer Odeh, vice president of enterprise analytics and chief data scientist at Thomas Jefferson University and Jefferson Health in Philadelphia, Pennsylvania.
"The patient experience is obviously a critical driver of that—the health outcomes and then, obviously, the financial cost."
A key enabler of measuring value is a data-driven culture and analytics tools, Odeh says. "There's such a huge gap between our current capabilities and the potential that exists." Lending perspective to Odeh's opinion are his previous stints directing analytics at firms in other sectors of healthcare, such as pharma, life sciences, and diagnostics.
"If we don't understand the value of what we're providing to our patients, Medicare is going to take back X number of dollars for every patient that we serve," says Stephen Allegretto, vice president of analytic strategy and financial planning at Yale New Haven Health in New Haven, Connecticut.
"We've tried to look at value as quality over cost," Allegretto says. "We can't yet measure the process outcome for every patient population yet … but you have a starting point."
"Value to a patient or to someone who is in a Medicare Advantage plan may not be whether or not I can get the lowest-cost hip or knee replacement and where I can get it, but it may be how to avoid the surgery altogether," says Sam Bagchi, system chief quality and medical officer at Presence Health in Chicago.
"There's nothing magical about a hospital. I am a hospitalist; I spend a lot of time in hospitals. There's very few things that you can't do somewhere else."
Bagchi notes that an inevitable effect of the pivot to value is that "hospitals are closing. You're winding down inpatient utilization."
All participants agreed that healthcare has to continue to find ways to reduce costs, and that analytics technology is a key enabler of this trend.
Revenue cycle software lessens back office strain, increases provider and patient confidence, and reaps monthly savings.
A tiny change to how a small hospital uses technology is resulting in big savings of between $3,000 and $10,000 a month.
Iroquois Memorial Hospital, a 25-bed facility in the eastern Illinois town of Watseka faced a problem. Patients were experiencing high deductibles and copays than in the past, found registering at the hospital to be increasingly nerve-wracking, as they were not able to be ascertain their total out-of-pocket costs until after claims were processed.
Meanwhile, the hospital, which is located 80 miles south of Chicago, had a problem of its own. It faced bumpy claims adjudication and a burdensome post-visit hospital collection process.
"In the past it wasn't so important that money was collected up front," says Rebecca Wright, vice president of strategic planning. "We tried to change that, [and] to change the whole entire revenue cycle. Before, it was always done in the back [office] after the patient left. We are now trying to move things to the front."
In other words, revenue collection at check-in was insignificant.
But by implementing eligibility software, Patient Access from Availity, along with a healthy dose of patient and staff education, Iroquois was able to realize an average monthly savings of $3,000, Wright says.
The savings has spiked to $10,000 when the calculation includes a reduction in eligibility-related issues including claims rework previously required in the business office, as well as collections activity now avoided, she adds.
In the business office, the hospital's billing staff educated the registration staff, on what constitutes a clean claim, how important it is to have the correct information such as the correct insurance plan, and reviewing what it means "if a patient asks what a copay is, or a deductible, or co-insurance," Wright says. "We get a lot of that."
In addition, registration staff became more familiar with what the basic Medicare and Medicaid plans covered, and what the patient responsibilities are.
The Availity software shows hospital and ER registration staff a walk-in patient's eligibility in real time, including how much money is left on each patient's deductible, Wright says.
For scheduled procedures, including outpatient surgeries, the hospital's scheduling department can inform patients before the day of surgery what their estimated copays or percentage of charges will be. "It's no longer [about] the uncertainty of the cost of the procedure," Wright says.
On the check-in staff's screen, the Availity software is connected via an interface to the hospital's CPSI electronic health record software, and runs continuously in the background, popping up only when the staff reaches the eligibility determination stage, Wright says.
The software also provides prompts for staff as they engage in conversation with patients on how to take care of day-of payments, she adds.
Same-day payments afford patients a prompt-pay discount. Or staff can propose other of payment arrangements, or refer patients to speak with someone in patient financial counseling at the hospital, she says. "It's all prompted right in the system."
All of this leads to quicker check-ins and rising confidence of both patients and staff, Wright says.
"If you set that tone up front with our patients, it helps create that confidence for the entire visit for the patient, which is a really positive thing, she says.
As for the estimates the Availity software generates, Wright says they are "for the most part pretty accurate. Obviously you can't always estimate what exact drugs may be used during a procedure, or additional supplies that may be used. [But] for most common procedures, they're pretty close."
The software also leverages demographic data, combined with household income, net worth, and other financial indicators to predict a patient's capacity to pay.
For EHR clients who lack this sort of estimating and workflow capability, the solution Iroquois chose seems like a win-win technology proposition.
Implementation of one such system resulted in reductions in health care costs of $1.36 million over a 12-month period in 2010 and 2011.
Learning health systems, long-predicted to lead to lower costs, better care, and improved clinical research, have in one instance, shown their value.
A team from Nationwide Children's Hospital and The Ohio State University found that over a 12-month period, combining tailored electronic health records system entry, care coordinators, and evidence-based clinical data and research resulted in a 43% reduction in total inpatient days, 27% reduction in inpatient admission, 30% reduction in ER visits, and 29% reduction in urgent care visits.
The study was conducted with 131 children treated through the hospital's Cerebral Palsy (CP) program via its Learn From Every Patient (LFEP) initiative, which resulted in reductions in health care costs of $1.36 million over a 12-month period in 2010 and 2011.
The LFEP program leveraged special data entered into the patients' EHRs to coordinate care, reducing treatment duplication and errors. LFEP data were extracted into an Epic Clarity enterprise data warehouse, which also housed billing information.
Using clinical documentation templates created in Epic, providers were presented with a prioritized list of research questions designed to drive specific improvements in clinical care.
A Savings Ratio of 6:1
The cost of implementing the pilot program, including care coordination expenses, totaled about $225,000 over the first year. But these costs were only 16% of the reduced total health expenditures during the first year of the program, a savings of about $6 for every $1 invested.
Ten of 11 providers participating in the study also reported that use of LFEP made documentation easier and faster.
Since the chronic conditions of the children with CP resemble those of chronic multi-symptom conditions in adults, the study authors believe programs such as LFEP may yield greater potential healthcare system savings in adult patients.