Mainstream healthcare is seeing returns on virtual care investments. Banner Health, which identifies itself as "one of the top three performers for tele-ICU systems in the country," is just one provider that has reported major gains in quality and lower costs since adopting telemedicine.
If you need any further evidence that the world has gone online, consider this: According to a story in the August 22 issue of the Wall Street Journal, the Home Depot is now selling actual bricks and mortar over the Internet.
So is it any wonder that healthcare, a profession with more than its share of services that are rendered by listening to people and talking to people, is inevitably transitioning into an online experience?
The standard response from providers at this point would be, 'the physical exam can never be duplicated by an online encounter'. But before I address that point, let's consider for a moment all the other ways in which technology has been busily laying the groundwork for telehealth to dominate healthcare.
Hospitals, clinics and the public in all urban areas now have broadband Internet. More and more rural hospitals have broadband, aided by public/private partnerships from Vermont to Nevada and in between. Costs are falling: Expensive leased lines for telehealth can be switched off. Expensive proprietary telehealth gear can be retired and replaced by iPads and other relatively inexpensive mobile devices.
Mobile monitoring devices continue to also shrink in size. For that all-important physical exam, sensitive auscultation devices permit doctors at remote locations to hear heart, lung, and bowel sounds as if they were in the same room as the patient.
Team-based care allows the vast majority of listening and talking tasks to be assumed by nurses, nurse practitioners, and physician assistants, who do not have to be in the same room as the patient.
Scheduling technology permits freer flowing of patients and providers to available exam rooms, arrange for consulting physicians and specialists to join an exam, and even permit family and loved ones to join visits from remote locations, asking all-important questions which can directly benefit with increased patient adherence to medication regimens and other clinician directions.
Silicon Valley retains a deep, abiding interest in building innovations on top of telehealth platforms. Witness Google's latest initiative, Google Helpout, where Google offers video visits to doctors from One Medical Group during a Google user's symptom search.
Mainstream healthcare is also seeing returns on telehealth investments. On September 16, Banner Health reported that participants in its Pioneer ACO program enjoyed major gains in quality and lower costs in the program's second year, at a time when other participants were dropping out of the Pioneer ACO program.
Telehealth is the key enabling technology along with accompanying people and process initiatives, according to Deborah Dahl, vice president of patient care innovation at Banner – also a participant in HealthLeaders Media's HLM Live event on December 5.
Dahl also believes that telehealth enables standardization of care across large systems such as Banner. A preview of the HLM Live event in the October issue of HealthLeaders magazine identifies best practices that a dedicated team of tele-ICU nurses and intensivists can play in standardizing 24-by-7 ICU care.
Dahl elaborates on this in my brief conversation with her. "The ICU RNs have an average 21 years of ICU experience, and what a great opportunity to continue using your brain in a very physically demanding job to bring improvements in patient care to the bedside. Having the intensivists and the nurse practitioners combined with the ICU RNs has made a huge difference."
"We look at the processes within Banner as ways to reduce variability and improve reliability in the care, so whether they're the clinical consensus groups, which get together on a monthly basis and say, if we have a patient with Ebola, for example, this is the treatment protocol we're going to use, this is how we're going to go about doing that care, and that is hardwired into our electronic medical record."
Dahl expands on the report with numbers released in September that prove her point.
"We've been one of the top three performers for tele-ICU systems in the country for 10 out of the last 12 quarters. For ICU length of stay, that's 20,000 fewer ICU days than were predicted, and for patients that come from the ICU into the med/surg environment, that's more than 40,000 fewer med/surg days than were predicted, so on a very conservative model, that's about $68 million cost that was avoided."
"So if you go back to the triple aim, we've improved the clinical outcomes, we've improved the patient satisfaction, and we have seen a significant reduction in the cost for that patient population."
The HealthLeaders story also mentions Banner's partnership with Philips, which used Banner as a proving ground for its eICU technology. Technology alone didn't do it all, and Banner has augmented monitoring with health coaches who determine, for instance, that a patient might skip her congestive heart failure medication because a side effect is swollen ankles, preventing that patient from wearing her dress shoes to church on Sunday.
"When that person would see a physician, either telehealth or in the office, those providers don't have time to get into that conversation," Dahl notes.
Despite Banner's successes, many barriers remain to deploying telehealth everywhere successfully. The importance of the fifth sense—touch—during a physical exam does indeed remain a barrier, one that has contributed to the slowness of telehealth reimbursement policies to catch up with practice. The move from fee for service to value-based care will take care of some of that. But for the reasons outlined above, telehealth and the bigger movement of virtual care will not be stopped.
Telehealth can be a moneymaker and game-changer. Each telehealth success story is different, but like Banner, two other providers seem to have cracked the code that unlocks the value that lies waiting inside other healthcare systems:
Join me on a webcast at 1PM ET today as leaders from Mercy Health System and Nemours reveal how they are using internal telemedicine and remote monitoring to reduce medical errors, improve response times, and alleviate alarm fatigue in frontline healthcare personnel.
A nervous American public wasn't reassured by the absence of a crack team of patient safety experts descending upon the Texas hospital to determine the exact cause and sequence of events leading to the death of a patient with Ebola.
As we enter what may turn into the Ebola era of U.S. healthcare, the long-discussed issue of the effect health IT has on patient safety is suddenly moving from the back burner to the front.
Just last week, HHS awarded a contract to Research Triangle Park, NC-based RTI, a research institute, to create a roadmap for the Office of the National Coordinator's health IT safety center. It's a first step, contingent on ONC receiving funding for the center itself, on ONC's path to providing needed oversight for the variety of medical errors attributed to health IT technology and use.
As part of the HHS award, RTI will create a task force of stakeholders to get input on the roadmap and prepare a report summarizing the evidence on health IT safety since the IOM report was issued in 2011. The report will also evaluate any available interventions and tools that would optimize the safety and safe use of health IT such as electronic health records systems.
But the Ebola outbreak may change all this.
With Texas Health Resources' initial blaming of its EHR software for the inappropriate release of Ebola patient Thomas Eric Duncan (he died days after being readmitted)—and its subsequent retraction—a nervous American public wasn't reassured by the absence of a crack team of patient safety experts descending upon the hospital to determine the exact cause and sequence of events leading to the errors.
Another Federal Agency? Back in 2011, the Institute of Medicine proposed creating just such a mechanism, patterned along the lines of the National Transportation Safety Board, the independent federal agency that descends upon the scenes of transportation accidents to make speedy, impartial assessments after a major transportation calamity.
Why yet another agency? So the argument goes, in Washington, too many agencies, ranging from the Department of Justice to HHS, are too politicized to deliver unbiased assessments of the causes of and remedies for HIT-triggered patient safety misfires.
NTSB, for whatever reason, is run in such a way that it does not become besmirched by politics, and is almost ubiquitously trusted as a source of truth.
Quoting from the IOM report, "Public release of results of investigations could build off the NTSB process, which separates facts discovered by the investigators from opinions and conclusions drawn by the investigators. A feedback loop from the investigatory body back to both the vendors and users is essential to allow groups to rectify any systemic issues that were found to introduce risk into their systems."
The IOM committee that proposed this new agency "envisions an entity that would be similar in structure to the NTSB or the NRC [Nuclear Regulatory Agency), which are both independent federal agencies created by and reporting directly to Congress. Among other responsibilities, these entities conduct investigations, for the purpose of ensuring safety."
Non-regulatory, Non-punitive "The NTSB is a non-regulatory agency that does not establish fault or liability in the legal sense, but investigates incidents. The NRC is a regulatory body that has the ability to issue fines and fees. The committee considered both agencies and concluded the NTSB to be most similar to the needs of health IT-assisted care."
This entity would not have enforcement power and would be non-punitive. Instead, it would have the authority to conduct investigations and, upon their completion, make recommendations.
"The NTSB makes non-binding recommendations to the Secretary of the Department of Transportation, who then must state within 90 days whether the department intends to perform the recommended procedures in total, carry the recommendations out in part, or refuse to adopt the recommendation," the IOM report stated. "In this case, an entity would make similar recommendations to the Secretary of HHS."
Still A Ways to Go Although delivering non-binding recommendations could be described by some as a flaw, the IOM committee believed that the flexibility it provides is a strength, allowing for the healthcare organizations, vendors, and external experts to determine the best course forward collectively.
Since 2011, the IOM's idea hasn't gotten very far. Some would say that in part, this is because one of its primary champions has been Charles Denham, MD, a prominent patient safety advocate accused of taking kickbacks from a product manufacturer.
But a good idea championed by a controversial figure can still be a good idea.
One irony is that improving patient safety overall is dependent upon widespread utilization of health IT throughout healthcare to track adverse events. In testimony on July 17, Ashish K. Jha, MD, professor of health policy and management at the Harvard School of Public Health, stated that most EHR vendors have not yet installed tools that track adverse events.
"If we made automated patient safety monitoring a key part of certification for meaningful use, it would have a dramatic effect," Jha told the Senate Committee on Health, Education, Labor and Pensions.
In the wake of recent events in Dallas, I also contacted the HIMSS EHR Association, the trade group for EHR vendors. A spokesperson referred me to the association's code of conduct, but confirmed that this code is silent on the hot topic of so-called "gag orders" which allegedly prevent some EHR customers from publicly reporting safety-impacting bugs.
Gag Orders and NDAs The EHR spokesperson did note that EHR customers come into possession of a variety of trade secrets and proprietary information when they become customers. For instance, every Epic customer has access to the source code of Epic's EHR.
But customers also sign binding legal agreements not to disclose that source code publicly. So one can imagine that if an Epic customer were to publicly disclose a flaw in the software, it would have to tread carefully so as to not reveal any such source code, or other Epic trade secrets.
Where the public's safety is at issue, we must strike a balance between the vendor's intellectual property rights and the public's right to know. Trying to parse contradictory statements from providers and EHR vendors, or government agencies not representing expert views on health IT, can end up alarming the public, as we have just seen.
I wonder if the ONC can really take this on, given everything on its plate. Far better to consider a comprehensive solution, endorsed by the Institute of Medicine and proven in other industries, which has languished until now.
Policy and technical limitations are pushing providers to choose HIE systems that lack universal integration.
This article first appeared in the September 2014 issue of HealthLeaders magazine.
Providers are taking many paths—some public but, more and more, private—toward electronic health information exchange.
Despite more than $500 million being spent over the past five years by the federal government to promote HIE, many states have no HIE today, forcing providers to turn to regional or private HIE organizations to realize the benefits of such information exchange.
Those organizations include such entities as Healtheway, descendent of the federal government's Nationwide Health Information Network Exchange; NATE, the National Association for Trusted Exchange, which is attempting to link all state-level HIEs across the United States; and the CommonWell Health Alliance, a vendor-based not-for-profit consortium (of which Epic is not a member). There also is a growing number of EHR vendor-specific HIE networks, such as Epic's Care Everywhere.
CommonWell, which began extensive testing of its patient record locator service this year, has received considerable attention. Among the healthcare providers CommonWell approached last fall was Palmetto Health, a 1,138-bed system with more than 8,400 employees and 1,000 physicians, based in Columbia, South Carolina. Palmetto Health uses the Cerner EHR, which has been modified to support health information exchange with other EHRs supporting CommonWell.
Using glycemic management software that integrates with its EHR system, a Virginia hospital system has achieved a 79% improvement over the national average for hyperglycemia rates.
Doctors and nurses following the standard of care in hospitals aren't just paying more attention to analytics. These days, the algorithm can be the cornerstone of superior care.
Consider the tricky process of controlling the glycemic levels of patients with diabetes.
Working out the algorithm on paper that will enable a patient to avoid either hyperglycemia or hypoglycemia, although a time-honored practice, is no match for the speed, efficiency, and accuracy of well-crafted algorithms.
At eight-hospital, Virginia-based Sentara Healthcare, this translates into a 79% improvement over the national average for hyperglycemia rates. These hospitals have achieved an overall hypoglycemia rate of 0.83 percent, which hospital officials says is a remarkable blended rate for IV and subcutaneous insulin therapy.
Through improved glycemic management initiatives, Sentara expects to be able to dramatically reduce readmissions and length of stay, as well as to improve patient safety.
The algorithms, provided in software from Glytec, take inputs such as the patient's weight and type of diabetes, and calculate a target glucose range for the patient as specified by the physician, says Miller Trimble, director of IT at Sentara.
'Prone to error' on paper "We had all those algorithms laid out on paper, and it was complicated, difficult to follow, inefficient, and certainly prone to error," he says.
Complicating the task was understanding how other conditions the patient had dictate the glucose range, and the glucose trend – increasing or decreasing. "A decreasing level for a patient can cause brain damage, require a higher level of care, and can even cause death," says Sentara CIO Bert Reese.
Bert Reese
CIO of Sentara
Of particular note to those who fret over the workflow complications that technology can introduce, Glytec's Glucommander software has successfully been incorporated into the workflow of Epic electronic health record software.
In a prior incarnation of the technology at Sentara, clinicians either had to use an inferior home-grown algorithm incorporated into Sentara's EHR, or had to exit the EHR, launch Glucommander from a separate desktop icon, and key in the patient's information, Miller says.
"We've very tightly integrated the Glucommander software with our electronic medical record application, and it's very seamless for the nurse, while they have the patient's record open in our electronic medical record, to quickly hit an icon and have that same patient's record pulled up in the Glucommander system, get a dose calculated with an input or two, and then know at that point what they need to give, and they can administer it right there back in the EMR," Miller says.
Epic integration Formal training on Glucommander alleviated nurses' fears that the technology would not be used properly, and in four Sentara hospitals running EHR software other than Epic, discussions are underway to implement Glucommander, Miller says.
The Sentara Glucommander story is one of a growing number of stories I am hearing that puts the lie to conventional wisdom that Epic doesn't work well with third-party software.
"We have a lot of these types of extensions that we're talking about here, embedded, where we exit Epic and go back into it, and it's been relatively straightforward for us," Reese says.
Miller adds that Sentara did have to perform a small amount of custom programming to integrate Glucommander with Epic, but "we used the available Epic tools and it wasn't difficult," he says.
"We were starting at a rate of around 25% hyperglycemia, defined as any glucose determination greater than 180, and over the years, we implemented both IV and then subcutaneous Glucommander," says Paul Chidester MD, Sentara vice president of medical affairs. "We've been able to take it down to a rate of around 19%, without a change in hypoglycemia. So we've had some really good results."
It's also worth noting that unlike garden-variety analytics software, the FDA regards Glucommander's algorithms as a medical device, and so Glytec applied for and received FDA approval.
Modifying the order sets Incorporating the Glytec algorithms also required tweaking some newly developed order sets at Sentara, Chidester says.
"We had basically one IV insulin order set for the whole system, with a few variations, whether the patient had a cardiac surgery, or whether they were in OB, where you have even tighter insulin control," he says.
"We basically swapped out that order set for an order set that has Glucommander in its place, and there was a need to make some minor modifications to the order set. Glucommander [is] basically the only way that folks now can treat patients with IV insulin."
"For the subcutaneous module," Chidester continues, "physicians still have the choice to use either our preexisting weight-based order sets in our EMR, or use Glucommander. We didn't want to completely eliminate the preexisting order set, because number one, the subcutaneous module in Glucommander is not FDA approved for nondiabetics, and there are some patients that come in with stress hyperglycemia as a result of their surgery or illness, and they need to be managed on subcutaneous insulin, and again, there's not FDA approval to use Glucommander for that.
"And some of the endocrinologists and other folks still have desire to manage it on their own, Chidester says." We're a teaching institution, and some of the medical school faculty really want the residents to learn how to dose insulin on their own, which is perfectly appropriate, because not every place has this tool."
Adds Chidester: Sentara is in the midst of collecting and analyzing data on the outcomes from using these algorithms, so it will be able to quantify reduced length of stay, readmissions, surgical site infections and mortality.
In their Consensus Statement on Inpatient Glycemic Control, the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) agree, "The complexity of inpatient glycemic management necessitates a systems approach that facilitates safe practices and reduces the risk for errors."
I am certain we will see an ever-increasing number of such joint statements about the advent of more such technology-driven systems approaches across a wider and wider range of specialties in medicine.
Jacob Reider, MD, discusses the usability of electronic health record systems, which was recently lambasted by the AMA. He agrees usability can be improved. At issue is "the progression from where we are to where we need to get to," he says.
The AMA made its latest broadside last week against the appalling state of user interfaces in EHRs. Barely usable EHRs are arguably the biggest impediment to the promised productivity improvements that EHRs were supposed to deliver.
Jacob Reider, MD
In the wake of the AMA's condemnation, I sat down last Friday with Jacob Reider, MD, deputy national coordinator, during his visit to a patient experience hackathon at Stanford University. Although we also spoke at length about interoperability, this week I will share the usability portion of our discussion.
HealthLeaders: Everything seems pivoting towards interoperability. Is this a blind spot in the current ONC strategy, or do you have any particular sage words of reaction to what the AMA has been saying this week about usability?
Reider: I would first direct you to the blog post I wrote about usability. It is a pretty good expression of ONC's position on usability. Is this a blind spot? Absolutely not. It is probably one of the two reasons that I left industry to come to ONC. Usability is the single most important thing that I have worked on in my career. That attention has not faded.
We applaud the AMA. Steve Stack [president elect of the AMA] and I talk frequently about this topic, so we are on the same page as the AMA. Now, [as for] the cause of some of these usability challenges, we may not agree one to one.
We do feel very strongly that it's a problem that needs to be solved. The question is, how should it be solved, and what's the progression from where we are to where we need to get to be with the user experience activities.
I think of user experience as a continuum. It's not something is usable or not usable. It starts out at functional. So the bottom [part of the pyramid] is functional. The Model T Ford was functional. It did it. But it didn't do it every time, because it wasn't reliable.
So the next level is, the system needs to be reliable. The Model T Ford wasn't reliable, but let's say a Chevy Nova is reliable. And yet it wasn't usable in the sense that it anticipated my needs. And there's that little bit of happiness you get when this anticipates your needs, or when something happens that you say, wow, whoever designed this thought about me when they designed it.
Steve Jobs is famous for saying, 'my customers never told me to make an iPhone.' Because good designers give users what they need, which is different from what they ask for. It's a very different thing. And if we really do it well, it's meaningful… It's valuable to my life. It changes my life in some way.
We saw the people on University Avenue standing in line [today for the iPhone 6]. Who's been standing in line to purchase an electronic health record? Nobody, because we're between reliable and usable.
Some of these systems anticipate the user's needs, and we know that clinicians in fact, they expect clinical decisions support to remind them when things that they did are unsafe. So they're now so accustomed to that anticipation of their needs that they rely on clinical decision support to catch their allergies. They're not thinking as hard. So I tie usability to safety.
HealthLeaders: I have heard conversations recorded at a meeting of physicians who made a really good point. They find it so frustrating that they're in an EHR, in this case it happened to be Epic, and they're having to enter a diagnosis before they're ready to enter a diagnosis for some particular encounter, and they can't continue until they put something in, and that's where the safety issue pops up, because the something they put in could be the wrong thing, and bad decisions could be made later if that something isn't corrected, and there's even some issues about the process by which you go back and correct. That's a kind of problem that Steve Jobs never had to deal with.
Reider: I agree that there are anecdotes like that that are evidence of bad implementation of software into the clinical workflow, and when I hear an anecdote like that, I always peel the onion seven times. I always ask the five whys, if we're going to be lean about it. Because what I find is sometimes it's the design of the software. Sometimes it's the customer. It might be the healthcare facility that these doctors work for, that defines a process that then the software instantiates.
HealthLeaders: In the case of Epic, they may customize to please the customer.
Reider: Or the customer may have customized it locally. So we've seen great examples of products that you might not say are usable or easy to use when you look at them at first. It might look like an old, clunky screen. The old character-based screens in many cases didn't look usable, but once you got [in they were] good, man.
HealthLeaders: I remember at the airline counter what those reservation agents could do with those character-based screens.
Reider: They could do things without even looking at it. So usability has lots and lots of factors, and as you know, there's a science to this. There are people who spend their careers studying this and defining it.
To circle back to your question, what we did in Stage 2 was we required that the health IT developers use some of the best practices that other industries have incorporated for decades: user-centered design. We required that they do it, and that they document it, and that they test their products, and that they post the results of those tests on our Web site.
So you can log into our Web site, and you can look at the usability testing that was done on a set of products, so now, as a customer, you can say, gosh, this doesn't make any sense. That was our first step toward bringing this industry to where other industries have been for many years.
It wasn't the last step, and it's not a complete solution. We haven't fixed it yet.
HealthLeaders: I've heard the NIST usability guidelines may be part of the next step. How does that map to addressing the AMA's concerns this week?
Reider: It's the first step. The first step that we took was requiring [developers] to do things the way that other industries do them, so that the products are safer and easier to use… We didn't tell them what their products needed to look like. We didn't say, here's a picture of a usable product. Make it like this. Because obviously, that's not our job.
But we did say, use the right processes. That's what FDA says when you're making sausage or drugs. They say, use the right process. So we said, use the right process. That was our first step.
And I can't talk about our next step, because we're writing our next step. So we applaud what the AMA is doing. We are right on board with them. The industry acknowledges: We know we're not where we need to be, and we need to do better here.
On the issue of interoperability, there is considerable evidence that technology vendors, federal regulators, and healthcare providers are persistently speaking past each other, resulting in the same kind of gridlock we see elsewhere in politics.
Apple last week introduced a glorified fitness trainer for your wrist that fell far short of being a medical device, and with good reason. Washington, of course, is known not as a hotbed of innovation, but as a hotbed of regulation. Medical devices, being but one part of healthcare under regulation's watchful eye, are no exception.
Nothing epitomizes the last few decades of regulatory culture like the usual process for public input into a new regulation, whether from the Food and Drug Administration or the Office of the National Coordinator for Health Information Technology.
Acts of Congress or presidential directives lead to the establishment of task forces, which themselves spawn subcommittees, which report out or back to larger committees, which in turn take public comment before deliberating and then deciding to move forward, or to wait for more information, or to do nothing at all due to factional fighting or lack of leadership.
This is American democracy in action, and you can see a version of it at any local school board or city council meeting.
But the governance process has its idiosyncrasies. Public comment typically is limited to three minutes or less. Even testimony of invited speakers on a typical ONC panel is limited to five minutes. Try to summarize any of the many issues facing healthcare in five minutes. They are too complex. It cannot be done, even with time for Q&A afterward.
The prospect of such a governing process being brought to bear against healthcare IT's biggest challenge —interoperability—is daunting indeed.
Month after month, members of ONC's health IT policy committee, its health IT standards committee, and various designated subcommittees advise ONC and the Centers for Medicare & Medicaid Services how to craft regulations and guidelines to achieve the triple aim through health IT.
But committee members bring their own experiences and biases, as do invited speakers and members of the public. And on the issue of interoperability, there is considerable evidence that participants are speaking past each other in the same kind of gridlock we see elsewhere in politics.
To sum up the conundrum facing those who would mandate health IT interoperability, I would submit that getting participants to truly interoperate requires a spirit of cooperation all too often missing between opposing factions, whether they are providers, payers, or vendors.
In short, no one wants to see the outcome of these interoperability efforts, including ONC's proposed ten-year roadmap, convey a competitive advantage to a rival. And since there are a variety of "siloed" interoperability efforts already underway ranging from Epic's CareEverywhere to the Commonwell Alliance to Healtheway, SureScripts, and DirectTrust—each of these efforts has more or less signaled why it is the demonstrably superior way to tackle interoperability.
Technology is always the joker in the deck. Here is a way to think about this. When the U.S. was a young country and the railroads were just starting, different railroad builders were using different gauges (widths between rails) preventing trains from moving from one company's tracks to another's.
At a certain point, the government mandated a standard width of railroad gauge, and that was that. Trains evolved, but with almost no exception, railway innovation did not require changing the gauge.
Even in the information age, certain standards, such as the method of clearing checks between rival banks, fell into a kind of permanence that allowed innovation without requiring the underlying plumbing to be ripped out. Indeed, the TCP/IP protocol underlying the entire Internet is a shining example of this.
But healthcare technology faces a continuous threat that some new way of doing things—some tech innovation—will appear and sweep aside the "railroad gauge" of a few years ago. This can threaten incumbents and innovators alike.
This is now on the brink of happening on a grand scale, through the emergence of HL7's FHIR standards, by which software programs are connected over the Internet using the most popular modern method of doing so, known as REST. You may not know REST, but you know many Web sites that rely upon it, from Facebook to Google to Twitter and lots more.
The ONC's policy and standards committee is now trying to find a way to implement interoperability in meaningful use Stage 3 with an option to allow FHIR.
It's a stretch for two reasons: FHIR isn't fully defined yet, and the Stage 3 Notice of Proposed Rulemaking is already being written by CMS and will be out for public comment this fall. There seems no way the final Stage 3 rules can be written after FHIR is fully baked and out of the standards oven.
Fortunately, you have a unique opportunity as of this writing to weigh in on this issue and lots more, without being limited to three minutes, and without waiting for CMS to issue its proposed rule.
That is because this week, National Health IT Week, ONC has left open the ability for anyone to leave their thoughts on how best to achieve interoperability at a Wiki which ONC established for public comment on Connecting Health and Care for the Nation, ONC's "concept paper" for its 10-year interoperability roadmap, itself due out in draft form in January 2015.
Although ONC asked for all comments by last Friday, as of Monday evening the Wiki was still allowing comments on variety of aspects of health IT interoperability. Some prominent stakeholders such as the AMA and HL7 have already weighed in.
But this is a golden opportunity for providers, who often have the very tough task of implementing and attesting to meaningful use requirements, to participate in a way that will ripple not only through the ten-year plan but also through the rules being written for Stage 3 of meaningful use.
Throughout this process, again and again you will hear a common refrain: True interoperability will also require an accelerated effort to align incentives away from fee-for-service and toward value-based purchasing or accountable care. I have no doubt that the EHR vendors can be brought into alignment with standards that can work today (Direct, CCDA) or the fast-emerging FHIR standards.
But only when it is in each provider's best interest to share patient data with all other providers, including the hated rival across the street or across town, will true interoperability occur. Until then, stakeholders will continue not to truly listen to each other, or to patients, but will continue talking past each other.
Most hospitals are not ready to face the double-whammy of reductions in Medicare payments and the loss of meaningful use program incentive payments for the fiscal year that begins October 1.
As summer begins to lose its grip, the Meaningful use Stage 2 deadline continues to close in on U.S. hospitals.
Russell P. Branzell
President and CEO of CHIME
Few are prepared.
As of August, only 3.1% of hospitals had cleared the Stage 2 threshold, according to industry analyst Frank Poggio. And yet, a full reporting year begins in less than 30 days, on October 1.
Those hospitals which are not ready face the double-whammy of loss of incentive payments for the fiscal year 2015 that begins that day, as well as reductions in Medicare payments that could be in the range of $200,000 annually for a hospital of 250 beds, according to Kelzon.
After CMS published the final rule on its Stage 2 adjustments late last Friday afternoon, one group, the College of Healthcare Information Management Executives (CHIME), basically hit the panic button on behalf of its members.
"This afternoon the Centers for Medicaid & Medicare Services (CMS) and the Office of the National Coordinator for Health IT (ONC) finalized a regulation granting providers additional flexibility in meeting Meaningful Use (MU) requirements in 2014," said Russell P. Branzell, CHIME president and CEO, in a statement.
The final rule, however, lacked a key provision that would ensure continued EHR adoption and MU participation.
"CHIME is deeply disappointed in the decision made by CMS and ONC to require 365 days of EHR reporting in 2015. This single provision has severely muted the positive impacts of this final rule. Further, it has all but ensured that industry struggles will continue well beyond 2014.
"Roughly 50% of EHs and CAHs were scheduled to meet Stage 2 requirements this year and nearly 85% of EHs and CAHs will be required to meet Stage 2 requirements in 2015. Most hospitals who take advantage of new pathways made possible through this final rule will not be in a position to meet Stage 2 requirements beginning October 1, 2014. This means that penalties avoided in 2014 will come in 2015, and millions of dollars will be lost due to misguided government timelines.
"Nearly every stakeholder group echoed recommendations made by CHIME to give providers the option of reporting any three-month quarter EHR reporting period in 2015. This sensible recommendation, if taken, would have assuaged industry concerns over the pace and trajectory of rulemaking; it would have pushed providers to meet a higher bar, without pushing them off the cliff; and it would have ensured the long-term vitality of the program itself. Now, the very future of Meaningful Use is in question."
EHR Developers Pleased In the hours after Branzell's statement, reaction online was subdued. Here and there, some declared meaningful use dead. Others said they would read CMS's final rule over the holiday weekend and then weigh in.
John Halamka, CIO of Beth Israel Deaconness Medical Center, struck a positive note. "Many CIOs tell me that they will be ready for transition of care and patient view/download/transmit for the full year October 1, 2014–September 30, 2015," he wrote on his blog.
On Sunday, the EHR Association, the trade association for vendors of EHR software, put out its own positive statement. "EHRA is pleased that CMS has released the Final Rule so quickly, as they had indicated they would, to minimize confusion and delays for both EHR developers and providers," stated Mark Segal, EHRA chair and vice president, government and industry affairs, GE Healthcare IT.
"We appreciate that many of our customers will have more flexibility in achieving meaningful use for 2014 given the timing issues created by the Stage 2/2014 regulatory and certification schedule."
Although EHRA offered to put me in touch with a spokesman, none was available through Labor Day evening.
Final for Now My suspicion is we have not heard the last about this final rule by any means. I did reach Branzell, and he added these thoughts.
"We will believe 100% in this program, [but] it hurts no one to change to a 90-day reporting period" for fiscal year 2015, he said. CMS "could have easily done that within the rule structure they had. But now, in theory, if I can't get that [meaningful use] data in the month of October, my entire fiscal year is shot."
I asked Branzell why he had qualified his last statement with "in theory." Did he mean that providers will once again petition for hardship extensions, as they had in fiscal year 2014?
"There may be still some flexibility if enough people raise enough concern," Branzell said. "In theory, they could go back and change it. I don't believe they will now, because they've once again drawn a very clear line in the sand, that reputations and perspectives will be challenged if it wouldn't happen.
In rejecting the call of CHIME and others to reduce the 365-day period to 90 days, CMS in its final rule had stated that it wanted to maintain the momentum of the meaningful use program.
But how much real momentum can Stage 2 have at this point if fewer than 100 hospitals have attested to it as of August?
I recently spoke with a CIO at one hospital which had successfully attested in the April–June quarter, and while its forward-looking leadership clearly had played a role in achieving early attestation, another factor might have been its location. The hospital is in a market–St. Louis–dominated by Epic, where the informal ties that permitted care coordination efforts with competitors to go forward was facilitated through the St. Louis Epic user group.
Plenty of Blame That should send a shudder through regional markets where Epic does not dominate, where the cooperation and coordination do not have such a way for those competitors to interact. For those concerned about Epic's market dominance, this should be another reason for concern.
With more than $24 billion in incentive payments paid out, there is now a natural constituency in place to drown out the concerns of CHIME and others with calls for hospitals to toe the line, attest to Stage 2, or take their lumps.
There are those of the opinion that time is up for those hospitals who would continue to blame their EHR vendors for their inability to attest to Stage 2. According to this line of thought, the blame will now be shouldered by hospital leaders who simply took their eye off the meaningful use ball.
It may be difficult to decide whether the fault is with the meaningful use program or its would-be adopters. Probably some of both. But for now, expect to see the words "in crisis" and "meaningful use" used in close proximity for a while to come.
CIOs and CMIOs around the country would do well to stop imagining that perfect solutions in a decade are worth waiting for, and instead focus on how pretty-good interoperability could serve us all in the near term.
Everyone is talking about interoperability, and at least one fledgling group, spurred by a large healthcare provider, is willing to serve up real demos to prove they mean business.
The Healthcare Services Platform Consortium (HSPC) is an intriguing mix of modern IT thinking, real-world use cases, and (so far) quite modest hype that also has that elusive quality in the interoperability world known as momentum.
While the Commonwell Alliance still spins up basic interoperability work such as harmonizing patient ID information across different providers' systems, HSPC is tackling a broad range of IT challenges, such as allowing decision support or analytics apps to work "out of the box" across different EHR vendors' platforms.
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HSPC's mission is to create "plug-and-play interop, not just interop about data, but sharing of clinical decision support logic, sharing of actual applications, in an executable form, and sharing ultimately more complex processes that include workflows and other kinds of clinical scenarios," said Stan Huff, chief medical informatics officer, during a presentation at this year's HIMSS, a presentation available though little-seen on YouTube and held at the booth of a vendor, Harris Healthcare Solutions.
This type of interoperability could deliver a variety of decision-support applications to clinicians to manage sepsis, or bedside glucose in the ICU, or chronic coagulation, Huff said.
EHRs that support HSPC, and their users, would benefit in innumerable ways. "The magic between these applications and these back ends [the EHRs] are in this middleware part of the structure," Huff said at HIMSS.
He demonstrated three separate applications developed as part of the SMART project, an initiative funded in part by an ONC grant, running on platforms provided by Harris, Intermountain (through its legacy EHR) and HP's "hospital of the future" demonstration at HIMSS.
By next spring's 2015 HIMSS, HSPC plans to show an even broader range of plug and play applications, according to Vishal Agrawal, president of Harris Healthcare Solutions, who I spoke with Monday.
I asked Agrawal whether HSPC would be necessary if, for instance, meaningful use were already successful in its aims.
"The key focus on meaningful use is the exchange of information and getting patient engagement increased," he said. "What we're creating is an App Store that is far beyond the scope of meaningful use. We are creating a set of data virtualization standards, and a reference architecture. We are using FHIR profiles as a technical approach for having that advanced, standardized data format."
Meanwhile, the nonprofit business framework of HSPC would permit collaboration between providers who want to work together on developing an app but resolve intellectual property issues and revenue sharing ahead of time, Huff said at his HIMSS presentation.
"Maybe we want to work with Banner Health or Dignity Health and we want to develop an application," he said. "Certainly there will be tight scrutiny of that framework [of collaboration] by attorneys, but hopefully you can do that up front, and then the actual working together on a piece of software would relate to things that are more like task orders or scope of work type of documents."
As for HSPC itself, "We're just trying to produce enough revenue to be self-sustaining in setting the standards and making them available," Huff said. HSPC will be governed by a board where providers outnumber vendors, "to make sure no single person, organization or block of organizations could prevent [HSPC] from meeting its goals and obligations."
None of this progress has escaped the attention of the ONC, which heard a more recent presentation by Huff at its July 31 JASON Task Force meeting. At this crucial time, when ONC is debating the crafting of a national interoperability strategy, the very real actions of HSPC promise to turn up the heat on ONC to examine and perhaps endorse new ways to get healthcare unstuck from its current set of data and application silos.
CIOs and CMIOs around the country would do well to stop imagining that perfect solutions in a decade are worth waiting for, and instead expend resources to join the efforts of groups such as HSPC to see how some pretty-good interoperability could serve us all in the near term.
Healthcare leaders are finding that consumer-ready technologies can help patients right where they are.
This article first appeared in the July/August 2014 issue of HealthLeaders magazine.
Health technology advances are beginning to reduce hospital readmissions. The smartphone itself is becoming a way of keeping tabs on recently discharged patients. Smartphone apps are engaging patients. Sensors are providing the kind of mobile monitoring that only recently graduated from the ICU to the general hospital bed, and now is able to be used wherever patients resume their normal lives.
Other mobile technology helps patients arrange for rides or reminds them to take their medications, weigh themselves, or perform other necessary daily activities to stay out of the hospital.
"We have one practice that we follow closely" that is applying consumer-ready technologies, such as cell phones, the Internet, and digital cameras, to enhance the patient-physician relationship, says Joseph Kvedar, MD, founder and director of the Center for Connected Health, a division of Partners HealthCare, a Boston-based integrated healthcare system with nearly 60,000 employees and a research budget of $1.4 billion. He is also an associate professor at Harvard Medical School.
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"I call this practice our canary in a coal mine practice, because [the patients] are in a relatively poor town adjacent to Boston, and many of them speak English as a second language, and we survey them for a number of things routinely," he says. "A couple of months ago, we found that 65% of them were carrying smartphones."
Within a year, Partners expects to be routinely asking any patient entering a chronic illness management program if they own a smartphone, know how to download an app, and are able to work with those apps, Kvedar says.
If patients can use their own devices to run these apps or mobile health sensors marketed to consumers, costs could be split between consumers and healthcare systems, and consumers would be partly responsible for the device maintenance, Kvedar says.
"We're looking forward to the time when we can do it that way. This will allow us to spread our resources among many more patients who are in need of this service if the patient can own not just the hub, which is the phone, but the data charges and all of the technology costs that we now pay," he says.
Mobile device management, however, is one challenge. Working with an mHealth startup, the Center for Connected Health gave discharged patients a Withings scale, a blood pressure cuff, and a tablet. The startup's idea was to avoid the potential hassle of a patient having to connect the tablet to a home WiFi network, but instead provide 3G networking in the tablet and a data plan.
"The cheapest data plan is 50 megabytes," Kvedar says. "We convinced them that that was too little, so they went to the 2 gigabytes, and most of these patients ate up the 2 gigabytes watching YouTube videos, and then in the middle of the month they couldn't transmit their data anymore. So little details like that haven't been worked out yet, and it's still viewed as cutting-edge to use consumer mobile devices in the space of managing chronically ill patients."
At Mercy, a St. Louis-based system with 2013 operating revenue of $4.48 billion, smartphones are being paired with special sensor hardware to collect and transmit a variety of vital signs to hospitals.
"It's a medical class 2 device, so I can put it in the chart," says Wendy Deibert, RN, BSN, vice president of telehealth services at the 34-hospital system, which includes 300 outpatient facilities. "It gets heart rate, temperature, respiratory rate, single-line ECG, and then it also shows mobility and motion. If I'm turned right, left, back; if I'm sitting up in a chair; if I'm down on the floor; or if I go from here to here," and it will alert the provider if the patient takes a dramatic change in position—for example, a fall.
"That's real data that I can trust. It can be used as an app on a phone. It's not consumer-grade, but it could be used that way."
Mercy is piloting the reusable BioModule device, made by Zephyr Technology Corp., a division of Covidien. Nicknamed the puck, the device weighs 1-1/8 ounces and mounts on a one-use patch worn on the patient's chest. The device also integrates standard EKG patches already in widespread use in hospitals.
"You come into the ED," Deibert says. "You're fairly healthy. You've got an infection. It might be infection enough that you need antibiotics. Well, let's put you on a puck. Let's send you home and have a nurse monitor you at home where you're comfortable. You never get to the hospital. And now it's a much better outcome. And if you start to get in trouble, we're seeing the data in real time and will act on the early warning signs."
Battery life of the device is 24–36 hours, depending on the number of alerts it sends via Bluetooth or ZigBee to a paired Samsung Galaxy device, which relays data to the hospital, along with data from other paired devices such as weight scales. Each patient gets two of the puck devices, one to wear and one to keep charging.
Part of the process of evaluating the puck involved bringing it into a Mercy ICU during a three-week trial that helped the manufacturer gather data for its FDA approval for the temperature side and confirmed the accuracy of the puck's various measurements, Deibert says.
Also important to Deibert, the puck is completely sealed and easy to clean. "We have found a tool for which nobody has to go around and manually collect vital sign data," Deibert says, noting that the patient simply needs to replace it once a day with the fully charged unit.
While Deibert expects to see substantial corroborating data about the mobile device's efficacy at reducing readmissions, not yet having that data is not stopping Mercy from deploying the puck in more scenarios, such as reducing sepsis.
A big challenge for providers is going to be how to prepare their clinicians for even more information about how patients are doing outside of the clinic, says Linda Reed, RN, MBA, vice president and CIO of Atlantic Health, a Morristown, New Jersey–based system with multiple hospitals and more than 1,300 licensed beds.
"Are you going to leave it as raw transactions?" Reed says. "Are you going to need to feed it into some kind of an analytics engine, and then how do you use it? Do you use it for alerts and reminders? I'm not sure."
With the right permissions, other family caregivers could also be more active participants, Reed says. "Your mom might be in California," she says. "You could be in a different state. If your mom gives you permission, you can have that stuff at your fingertips. How do we keep tabs on our aging parents? You don't want to be on the phone. A mobile app is probably a great way to do that."
Providers still primarily running fee-for-service businesses could trail in their adoption of mHealth for preventing readmissions, but Reed believes that the penalties now being levied by the Centers for Medicare & Medicaid Services "will add up quickly."
Atlantic Health is involved in two CMS Medicare Shared Savings Program accountable care organizations at risk for 75,000 Medicare lives.
mHealth can move providers beyond earlier practices such as interactive voice response calls, Reed says. "What happens if you're not home? You're still playing telephone tag, whereas if you've got this mobile app, you're always connected," she says.
Mobile apps are becoming a remote control for a variety of other applications ranging from automated pillboxes to video communications with providers, Reed says.
Another way mHealth applications can help patients is in preparation prior to surgery, says Bradley P. Graw, MD, an orthopedic surgeon at Sports, Orthopedic and Rehabilitation Medicine Associates in Redwood City, California. For the past two years, Graw has been a beta tester for HealthLoop, a mobile application to prepare patients for joint replacements and follow-up after procedures. Graw has tested the app with more than 100 patients during that time.
"In joint replacements in particular, the name of the game is prevention and planning in terms of decreasing the risk of complications and readmissions," Graw says. "The major complications are infections, lower-extremity blood clots, stiffness, and other medical complications such as cardiac events, so the way I used HealthLoop was with existing protocols that I had been using."
Graw entered the critical portions of those protocols into HealthLoop, so if patients are getting ready for surgery, they go through a checklist of reminders to make sure that they're getting all the appropriate work done, he says.
Postsurgery, the HealthLoop app reminds patients to take medications, get needed physical therapy, and stay in touch if they have any questions, Graw says. The app can catch patients who may be failing to thrive due to uncontrolled pain or inability to move.
"Patients do like the HealthLoop interface so that they can communicate their concerns and get them answered relatively quickly, especially nonurgent ones, because it's when questions start to pile up and people's anxiety level rises that they tend to go to the emergency room as a last resort," Graw says.
Perhaps because Graw practices in Silicon Valley, less than 5% of the patients he sees are uncomfortable using a mobile app. Graw says it is important to remind patients that the mobile app is not a substitute for live patient visits or conversation when needed. "It's an adjunct to these tools to help with patient communication in a world where patients and doctors are busy alike," he says.
Also important is that the entire care team, including medical assistants and nurse practitioners, is comfortable with and actively using the app, Graw says.
In Graw's case, the patients' primary care physicians are not yet part of the care team that uses HealthLoop. "That is certainly a possibility of the interface," he says.
The national rate for joint replacement readmissions is about 5%, but at Redwood City–based Sequoia Hospital, the Dignity Health hospital where Graw practices, that number is already less than 1%, he says.
In 2012, Beth Israel Deaconess Medical Center, a 649-licensed-bed facility in Boston, received $4.9 million from the Centers for Medicare & Medicaid Services to improve patient outcomes within a 30-day discharge window. One component of that program uses iPads, says John Halamka, MD, the CIO.
The program, administered by Julius Yang, MD, medical director of inpatient quality at BIDMC, "has been quite effective identifying patients who are at risk for readmission. These various interventions, especially on patients with congestive heart failure using mobile devices, help to reduce readmissions to the hospital,"
Halamka says.
BIDMC's program, known as PACT, which stands for Post-Acute Care Transitions, deploys nurse care transition specialist care coordinators and dedicated clinical pharmacists dually-sited between the hospital and primary care practice to reliably deliver a "bundle" of postacute care interventions designed to address observed readmission risk.
Halamka says improvements in mobile health will continue to enhance the delivery of care.
"I absolutely believe that in the next two years, as hospitals are paid differently, we will, instead of just providing more care, provide right care, especially gathering data from telemetry and patient homes as part of keeping people continuously well, instead of treating them while they're episodically sick," says Halamka.
The democratization of medicine is as close as the phone in your pocket, says Eric Topol, MD. Healthcare leaders had better be ready for empowered consumers, cost-cutting mobile apps, and genetic sequencing, which promises to be a differentiator.
You're carrying the key to healthcare's salvation in your pocket.
Eric Topol, MD
That was the message from Eric Topol, MD, keynote speaker at last week's HealthLeaders CFO Exchange. In a one-hour tour-de-force session, he made his case for the many virtues of smartphones as constant healthcare companions, patient empowerment, and disruption to the way healthcare has been practiced as far back as ancient Egypt when doctors were also priests.
Topol opened his remarks with photos of taxicab drivers around the world protesting the ride-sharing service Uberen masse. Like many users, Topol loves Uber, particularly UberX, where the driver is more likely not a cabbie. The Uber phone app tells users how many minutes until their ride arrives and "it's a lot cheaper, [the drivers are] friendly, and they want to get the five-star rating," Topol said.
Healthcare is poised to reach consumers through the same portal as Uber—the smartphone, Topol said. As examples, he mentioned the apps Medicast and Pager, which allow consumers to schedule house calls from among nearby doctors.
Even the Mayo Clinic is getting in on the act, with its Better service. "Basically they've taken their nurse practitioner team, which is very strong, and they've put them on the front lines… with the Mayo doctors in the background," Topol told the assembled CFOs. "[Consumers] pay $50 a month for unlimited access."
Long wait times are one of the drivers behind telehealth. To illustrate the point, Topol displayed wait times to see a primary care doctor in various cities. Boston topped the list at 66 days on average. A recent PriceWaterhouseCoopers report suggests that by the end of this year, one in six visits will be virtual.
What Consumers Want. When They Want It.
There's a tongue-tying acronym for this consumer-driven phenomenon – IWWIWWIWI. "I want what I want when I want it." It started in the fashion world and is disrupting many industries besides healthcare. "Everything else is on demand," Topol said. "Your groceries can be delivered to your door within an hour, and so can your healthcare."
Topol is no stranger to readers of HealthLeaders. He's not just a practicing cardiologist, but also holds prestigious positions at the Scripps Research Institute and Scripps Health, and— vested interest alert— took the role of AT&T's chief medical advisor this year. Two years ago, I reviewed his book, The Creative Destruction of Medicine.
Topol's next book, on the democratization of medicine, is in the works. It should arrive just in time to see the next wave of sensors, health-aware smartphones and, not long after, technology to let smartphones X-ray patients, Topol said.
The lion's share of healthcare data, he believes, will be patient-generated. (I'll believe patients taking their own X-rays when I see it, however.)
As another example of the coming democratization of medicine, Topol cited Theranos. It has technology that can perform tests that labs like Labcorp or Quest perform, but using only "a droplet of blood" at a fraction of the current cost. Walgreens is already starting to install the technology at some of its stores.
Recently-released Medicare data showed that Medicare spent $5 billion in 2012 on labs. "That is going to go through a major shakeup," he said. And Theranos is actually intermediatetechnology. In a few short years, it will be possible to perform these lab tests with—you guessed it—the smartphone.
Enter Genetic Sequencing
Someone in the audience suggested that common labs could be done this way, but not more complex tests. Topol conceded the point, but suggested, as he has in the past, that medical centers go upscale, particularly into genomic testing, as a hedge against having today's lab testing revenue eroded by Theranos and all that follow it.
"Health systems have not gotten into sequencing, but they should, because it will differentiate, and it's going to be paid for very soon, or is, in many circumstances, by insurance," Topol said.
Another example: With only 13 out of 1,000 patients benefitting from statins, Topol says genetic screening can make a huge difference in reducing side effects and the cost of drugs by not treating patients who cannot benefit from statins.
But statins are loose change compared to high-cost "drugs like [hepatitis drug] Solvaldi and cancer drugs," he said. "They account for some $120 billion today, but they're projected by the end of the decade to be well over $400 billion, because they all have price tags of about $100,000 or more for a course of therapy.
"We can get personal with sequencing and genomics, and we're going to be increasingly using these to get the right drug, and the right dose of that drug, to the right patient and make this much more efficient," he said.
The next day, I did hear a CFO or two grumble that Topol's smartphone-driven world is still not available to all, nor are adequate networks—cellular or otherwise—in place to drive personalized virtual or real care into all areas. Nothing new there. Technology always seems to be unevenly distributed, even in the U.S.
But even if only a fraction of what Topol expects to happen happens, it's still going to be more intriguing and turbulent in healthcare than ever. He practically dared the assembled healthcare systems to take some bolder steps. We will see if any of them take his advice.