Advances in telehealth technology are revolutionizing how healthcare providers respond to the hard knocks and head injuries athletes sustain on the football field, soccer pitch, and ice rink.
It may be baseball season, but I've got football on my mind.
Not the game itself, but the injuries that can result from it, and specifically, how new technology can help detect concussions, those hard knocks that can do so much damage and yet be so difficult to detect.
Sensor technology and telehealth technology are revolutionizing how the healthcare system responds to the football field's hard knocks, and the same technology could apply to other sports such as hockey, soccer, and anywhere else where sharp blows to the noggin are part of the game.
In January at the International CES show in Las Vegas, I got to see technology up close from a firm called MC10, that forms the basis for Reebok's CheckLight, which collected a CES Innovations 2014 Design and Engineering Award.
The soft garment fits over the head, but underneath a player's helmet. Sensors within the garment measure direct accelerations experienced by the head, rather than to the helmet or chin strap. Earlier sensors, attached to these, could provide inaccurate readings.
When CheckLight measures a dangerous acceleration, the technology switches on a yellow or red light, depending on the severity of the acceleration. Coaches and trainers on the sidelines of the playing field can clearly see the light displayed below the bottom edge of the helmet.
Coaches and trainers then can bring the player to the sidelines and run a symptom checklist, which more and more coaches and trainers have been trained to administer.
According to officials at MC10, the sensors measure both linear and rotational acceleration to the head, which together calculate the total energy being delivered to the head.
Players with stronger necks will experience less acceleration than players with weaker necks, says Isaiah Kacyvenksi, director of MC10's sports segment.
With medical device maker Medtronic as one of its investors, MC10 is also pushing forward with even more invisible wearable sensors. At CES it also showed Biostamp, a seamless sensing sticker due out this year that can stretch, flex and move with the body. The company says Biostamp will be able to measure a variety of physiological functions: data from the brain, muscles, heart, body temperature, even hydration levels. (No pulse oxymetry – at least not yet.)
Sensors are fine, but seeking qualified medical assessment quickly is the other technological tool being deployed to treat concussions. As I was researching my story on how telemedicine is expanding for the April issue of HealthLeaders magazine I spoke with Vernon Williams MD, medical director of the Kerlan-Jobe Center for Sports Neurology in Los Angeles. Williams also works with a group called the Sports Concussion Institute. In other words, he's a concussion expert.
"I've always been interested in applying technologies that make sense to medicine and trying to improve my practice, trying to improve access for patients, improve the experience patients have, and the value of the interactions," Williams says.
A common scenario goes like this: An athlete will sustain a blow to the head during a Tuesday practice or a Friday game, but the parent who needs to take him to the doctor cannot take off work for several days, or geography is a barrier, often for the initial appointment, but especially for followup appointments.
So, either the player's symptoms go unchecked and don't get care in a timely fashion, or due to lack of care or followup, patients are told by trainers to sit out for weeks or even skip the rest of the season.
"That's when I came up with this concept of using telemedicine and videoconferencing, and as it turns out, it was great," Williams says.
By sitting the athlete in front of a video session, the neurologist on the other end can ask the athlete to answer some questions or perform some simple exercises that help the neurologist confirm the concussion diagnosis and its severity.
And because injuries from concussions sometimes evolve rapidly, the ability to schedule followup assessments via video chat is a whole lot more convenient than scheduling a succession of doctor's office visits.
Now, more and more trainers are placing telemedicine "towers" (kiosks optimized for a video session) in their training rooms, so that injured athletes, with a trainer and even parents by his side, can be evaluated by the neurologist.
"The communication is far more consistent," Williams says. "We don't have to rely on just sending pieces of paper saying yes he's cleared, or no he's not cleared."
Teams working with doctors also now have a far more consistent approach to their players being returned to play, with consistent evaluation and management, Williams says. It also helps neurologists schedule these followups more efficiently as well.
Of course, once a platform like this is in place, it has benefits that go far beyond concussion treatment. "We can clearly see benefits where an athlete may have a good trainer on the other end where they're actually competing and participating and practicing," Williams says.
"That trainer may have a question about range of motion or an ankle injury or what have you, and they can fire up that videoconference and speak directly with an expert, and say, 'hey here's what's going on, here's what his exam looks like, what do you think? Should he come in? Does he need an X-ray? Does he need an MRI? Should we advance his therapy or his activity level another step?' So it is I think a great tool for improving communication and improving consistent and efficient evaluation and management."
A big enabler of all this has been the plummeting cost of those telemedicine towers, which in the past three years have plunged from a cost of $15,000 to something equivalent to a tablet with its ever-sharper display and built-in camera, and HIPAA-compliant software to ensure privacy, Williams says.
Telemedicine towers still have their place alongside tablets, because cameras on these towers can pan, zoom and tilt. But tablets are still usable as well.
"With the iPad, then they have to either position the iPad or someone else has to be holding it and reposition it so that they can be seen, but it's still achievable, and we still do it, and it works very well," Williams says.
After two full football seasons of use with high schools and colleges, Williams' clinic has conducted hundreds of telemedicine assessments of athletes. With 49 out of 50 states requiring clearance from a licensed healthcare professional prior to returning to play, the access telemedicine affords is making a big difference in treatment.
Add the sensor data to the mix, and you have the kind of analytics that can lift a whole population of at-risk athletes and provide a much larger evidence base to look at concussion and other sports injury trends over time.
Finally, it also provides yet more scenarios where a patient's initial encounter with medical help takes place via technology. Some said it wasn't possible, or advisable. But sports medicine is yet another example of this new reality.
Spurred by new laws and policies that permit online teleconsultations, both payers and providers are exploring ways to enable patients' access to care in ways that also meet growing industry demands.
This article appears in the April 2014 issue of HealthLeaders magazine.
Spurred by interest from insurance companies and employers, physicians are ramping up their ability to make an increasing number of patient encounters online or over the phone.
"We need to meet consumers where they are, knowing that often consumers aren't able to get to the doctor during the workday or on the weekends, and they end up going to the emergency room or the urgent care room for inappropriate use of care, and so we have a service that truly gets to the consumer 24 hours, seven days a week, 365 days of the year, and it's a real doctor every single time," says Matt Marek, vice president of product and marketing at 2.6-million-member BlueCross and BlueShield of Minnesota.
"We believe this is the next generation of retail care that we saw at Target and MinuteClinic years ago, where we're truly trying to serve the consumer beyond normal doctor hours," Marek says.
Using technology from American Well, BCBS offers high-definition video consultation between its members and a physician with an average wait time of less than two minutes, Marek says. The service never costs more than $45, and patients are reimbursed by the health plan like a claim. Some employers are even considering moving to a $0 copay to encourage employees to use online care.
Although BCBS of Minnesota has offered this service since 2010, use of the service is now growing 200% per year, and BCBS expects that growth to accelerate this year. BCBS of Minnesota is also expanding the coverage it offers to employers in its service area. After initially serving only employees in Minnesota, BCBS of Minnesota's Online Care Anywhere service now permits employees of those companies to utilize the service in 46 states and the District of Columbia, Marek says. This makes Online Care Anywhere the fastest-growing service in BCBS of Minnesota's set of service offerings.
Spurring the move are liberalized laws and policies throughout the United States that now permit online teleconsultations. "There are many states today that now allow online care or telemedicine to exist, where three, four years ago we never thought we would get as far as we have," Marek says.
These days, those encounters include video over wireless carriers' networks. "We're able to have a high-definition videoconference consult with the doctor without having the very highest-speed network available without having to be connected into a landline," Marek says.
Online consultation cannot and does not replace many in-office visits, Marek notes. American Well physicians perform necessary triage to advise those who should seek in-person medical help.
"The intent has never been to take services away from the doctors or compete with them," Marek says. "This is not a disruptive strategy. Rather, this is a strategy to better serve consumers, and also it has the potential to allow doctors to be more effective and efficient with their services, especially if you can imagine the emergency room doc who may have some downtime could also log on and serve members and patients, and so that is being explored as well."
At Mount Sinai Health System, a relatively new but fast-growing service called Teladoc became part of the organization's rapid response to Hurricane Sandy in 2012.
"We launched it right after Sandy had hit, and it was a direct-to-consumer service," says Adam Henick, senior vice president of network development for Mount Sinai Health System and Mount Sinai Beth Israel, a 1,083-bed hospital with $1.1 billion in annual revenues, which became part of Mount Sinai Health System last year.
Under the program, New Yorkers who were willing to attest to their residency could access a physician via telephone or video chat for $38.
"Teladoc's model historically has been to either contract with an insurer to provide the service to their beneficiaries, or to contract with an employer to provide the service to their employees," he says. "They had not done a direct-to-consumer offering, and we wanted to try that, and so we launched it."
Despite "great media coverage," however, customer turnout for the service was disappointing. "After about three months, we started doing focus groups to figure out what we were doing wrong, and it turned out that the model was you paid an annual registration fee of $30, and that enabled you to get visits at $38 a visit," Henick says.
Those prospective customers who had no healthcare insurance were very unlikely to prepay anything, and those who were insured wondered why Beth Israel was not participating in their own insurance. "So what intuitively seemed like a logical idea to us met resistance because of barriers, even though they were low-level barriers," he says, adding that even for those with insurance, between copays and deductibles, traditional visits still would have cost more than accessing the service. "But I think it's more a psychological barrier."
Last September, Beth Israel added an option to pay $48 a visit without an annual registration fee, which Henick says is significantly less than the cost of a doctor office visit in New York. "We're not getting a particularly robust response to it," he says, so now Beth Israel is modeling the service with its own employees, who pay $15 per Teladoc consultation.
"Every person that goes on Teladoc, one of the initial questions is, 'Where would you have gone for service had you not chosen this option?' so we're collecting that data and seeing what the cost would have been had they not accessed this service, and then balanced it against our cost of picking up the cost of the visit above $15," Henick says.
This time, Beth Israel's internal usage reflects a return of 7 to 8 times the investment required, and as soon as it has collected a sufficient sample, Henick believes it can return to its payers with this data and its direct-to-consumer product will be able to get insurance company participation and enable the service to take off.
Henick sees it all as an extension of Beth Israel's earlier forays into urgent care centers. And the way Beth Israel Medical Group has arranged its Teladoc partnership, all calls go first to its own tier of doctors who have joined the Teladoc network. If call volume rises such that response times lengthen, other patients would be routed to non– Beth Israel doctors, who are licensed in New York and credentialed by Teladoc, Henick says.
"The Teladoc offering is just basically continuing down that path of saying, there are going to be some young, hip consumers that are going to want to be able to video chat with their doctor at 2 in the morning, because they're working on some computer algorithm and don't want to leave their office or their apartment, and they're going to want to access it that way, and we need to be able to deliver it that way," Henick says.
Some physicians also view services such as Teladoc as their new career path. Timothy Howard, MD, was a family practitioner in Huntsville, Ala., for 20 years. In 2009, to earn additional income, he began working for Teladoc as one of its physicians reachable by telemedicine technology, primarily
via telephone.
This January, after providing several months' notice, the 52-year-old left private practice to work for Teladoc full time. "I want to practice actual medicine and take care of people and not a bunch of administrative things," he says. "You're talking directly to the patient. You don't have a third party or someone else telling you 'Restrictions here, restrictions there, do this, this is preapproved,' this kind of thing. It's really pretty straightforward."
At the top of the list of conditions Howard treats via telemedicine: sinus problems, urinary tract infections, allergies, flu, cough, and ear infections. Video is "exclusively requested by the patient, when they desire to either let you see them or their child," he says.
Due to Teladoc's low overhead, "it's very possible to earn a living with it," Howard says. Out of an average of 180–240 patients per week, four or five a week have problems severe enough that he refers them to seek in-person help.
"The key is that we're episodic," Howard says. "We are not seen as the primary care physician. The urgent may take the place of the important. But that's one of the nuances, and I tell patients all the time, 'I said, the best way to be cared for as a patient by a physician is a hands-on exam.' "
Services such as Teladoc also set and monitor their own quality standards, such as whether doctors are overprescribing antibiotics, Howard says.
One chief medical information officer whose health system is moving into this type of telemedicine is leery of allowing services such as Teladoc to permit health systems to outsource their primary care capability.
"Don't ever outsource your core business," says Shez Partovi, MD, vice president of informatics and CMIO in Dignity Health's Arizona service area. "Our core business is delivering care. I'm not sure if health systems should outsource their core business."
Still, Partovi is just as optimistic about the growth of direct-to-consumer telehealth services. Like many other health systems, Dignity already does thousands of internal physician-to-physician telehealth consults annually. As accountable care and patient-centered medical home efforts expand, the demand for direct-to-consumer telehealth at Dignity is the next big telehealth wave, he says.
So far, Dignity Arizona has started with a small pilot, training three physicians to respond to its own direct-to-consumer telehealth service last fall and launching the service in the fourth quarter of 2013. So far, only about 20 consults are happening monthly, Partovi says.
Part of Dignity's approach is to deeply understand how video encounters change the doctor/patient experience, including on-site testing where doctor and patient are both on site, but in separate rooms, and Dignity studies the interaction, Partovi says. "We have a lot of focus on understanding the user experience," he says.
Still, Dignity plans to have as many as 250 physicians trained in the next phase of the rollout, and Partovi is also chairman of the telehealth committee for all of Dignity. Partovi says there are markets where Dignity will compete with the Teladocs and American Wells of the world for the business of employers seeking direct-to-consumer telehealth options.
Ultimately, such competition may also hinge on health systems providing a broader set of offerings to employers than just telehealth, Partovi says.
"Last year we actually responded to two RFPs where it was broader," he says. "It was about providing a medical community for the employer, and we feel that's a key part of our strategy."
Reprint HLR0414-6
This article appears in the April 2014 issue of HealthLeaders magazine.
Healthcare organizations are at their weakest not necessarily on technical implementations, but in their ability to coordinate and collaborate across organizations, says a security expert.
Healthcare providers, like other industries, are not always very good at sharing cyber-attack intelligence with each other. But according to findings of a first-of-its-kind April 1 simulated drill, improvements are now underway specifically in the healthcare industry.
The industry-wide exercise, CyberRX, presented participants with a series of challenges which "exercised elements within each of the organizations," said Kevin Charest, chief information security officer for the U.S. Department of Health and Human Services.
"We actually started it off with some fraud, where a physician attempted to have some malicious code written that would allow erroneous images to be created and then they could defraud Medicaid and Medicare," Charest explained.
The scenario involved lots of different complexities in incident response, including responding to simulated inquiries from the press, Charest says.
A Wide Range of Players
A big takeaway from the exercise: Healthcare organizations are at their weakest not necessarily on technical implementations, but in their ability to coordinate and collaborate across myriad healthcare entities, says Roy Mellinger, who is vice president, IT security, and chief information security officer at Wellpoint, the largest managed health care, for-profit company in the Blue Cross and Blue Shield Association.
"Unlike financial services, where you're just dealing with primarily banking and loan information, we're dealing with small providers, small doctors' offices and clinics, and diagnostic centers. And we're dealing with medical devices and manufacturers," Mellinger says. "We're dealing with hospital systems. We're dealing with the payer industry. So how do you coordinate intelligence information and expertise across those varying types of entities?"
Not surprisingly, the exercise also pointed out that the ability of similar organizations to respond to a cyberthreat varies based on the maturity and experience of each organization's IT systems and leadership teams.
Early Warning System Needed
Jim Koenig, principal global leader, commercial privacy, cybersecurity and incident response for Booz Allen Hamilton, says "all of the new players present increase opportunities for risk, and systems that haven't become necessarily stable, and all of that happening at once creates a new set of risk profiles." Koenig acted as observer for the CyberRX exercises on behalf of the exercise's organizers, HHS and the Health Information Trust Alliance (HITRUST).
Rapid changes in healthcare technology are all the more reason for an early warning system, because a number of organizations may be subject to the same potential threat and the same potential players, or, a vendor, who may be vulnerable within the chain, Koenig says.
Because all these technologies are increasingly more interconnected, a coordinated threat response across disparate systems is essential, he says.
"Obviously cyberattacks can reach systems that are connected, and increasingly now, there are more and more medical healthcare delivery, radiology, laboratory, and other healthcare delivery and devices that are connected," he says.
An additional finding is that the current model of a generic national cybersecurity framework for critical infrastructure is not sufficient to support healthcare organizations in the current cyber threat landscape, HITRUST officials say.
The exercise left HITRUST with several action items, including linking threat intelligence to HITRUST's Common Security Framework, which provides prescriptive security requirements to ensure clarity. "We will augment CSF with the cyber threat intel to make sure the guidance is more robust, because that is that first line of blocking and tackling," says HITRUST CEO Daniel Nutkis.
Heartbleed and HealthCare.gov The recent Heartbleed vulnerability in the popular OpenSSL cryptographic software library presented a valuable real-world test of the benefits of these exercises, according to HITRUST. More than one CyberRX exercise participant indicated that they leveraged lessons learned from the CyberRX exercise to react quickly and more effectively address the issues brought up by Heartbleed, HITRUST officials stated.
Charest says there is no evidence that the Heartbleed vulnerability has affected networks related to the HealthCare.gov Web site, but that out of an abundance of caution, HHS decided to ask all registered healthcare.gov visitors to reset their passwords by answering their previously set up challenge questions.
The extra caution arose in part due to healthcare.gov's use of the Akamai content delivery network, which had patched its own Heartbleed vulnerability, Charest says.
HITRUST posted a preliminary reportin the wake of the security exercise, with threat preparedness and response recommendations for healthcare organizations. The HITRUST Web site also provides a way for organizations to sign up to participate in future exercises, which HITRUST expects to hold twice a year, according to Nutkis.
Look beyond the EHR incentive program. A national effort to turn CMS's recent release of Medicare physician payment data into useful, actionable data visualizations is the hottest HIT challenge right now.
The days of building electronic medical record software are over.
Oh sure, EHRs will continue to get built, improved, "skinned," perhaps even reimagined.
But with the EHR incentive program beyond its peak, attention is shifting to other important aspects of the healthcare technology spectrum.
Last week in this space, I described how entire communities are engaging in friendly competition to leverage the many digital breadcrumbs that make up today's total population health picture.
The Way to Wellville effort is a five-year marathon. Health Datapalooza's Code-a-Palooza is an opportunity for a variety of stakeholders, healthcare systems included, to step forward and compete in a national one-month sprint to turn CMS's recent burst of Medicare physician payment data into useful, actionable information for patients and payers alike.
While this data gives patients the opportunity to compare and contrast physician-level data on charges, it is a lot of information to sift through.
That is the challenge for Code-a-Palooza entrants. A collaboration among Health Data Consortium, the ONC and CMS, developers are invited to use the newly released data to create a data visualization that improves consumer decision-making when it comes to selecting a physician or procedure, in turn helping to potentially reduce costs and increase value to the patient.
Health Data Consortium will award $35,000 to three top teams at Health Datapalooza on June 3.
To learn more, I spoke with Health Data Consortium CEO Dwayne Spradlin. Last year, Spradlin reminded me, an earlier competition used a specially prepared CMS data set that had not been made public. This year, for the first time, the competition is based on public data. That should drive lots of discussion, and no small amount of controversy.
Last year, the competition winner was a team of doctors who had coding chops. You never know where in healthcare such tech talent may be waiting.
"I would be floored, in fact, if we don't have quite the diversity of individuals and teams registered," Spradlin said.
I responded that there is this conventional wisdom that healthcare is so far behind the technology curve that mere doctors cannot be expected to be the leading technology innovators, but instead must be rescued by the rocket scientists, Wall Street quants and other Brainiacs who populate so many venture-backed healthcare startups, parachuting in as if their ignorance of the healthcare system is some sort of advantage.
There may be some truth in such thinking. "There's an adage in the field of open innovation, which is some problems are too big to leave to the experts," Spradlin said. "Very often, if the expert in a particular field could solve a problem, they would have already." So, will there be contenders from outside of healthcare? You bet.
And yet, Code-a-Palooza may continue to put the lie to this stereotype.
"You do need the people who are the subject masters to really come in and say take this data set from CMS and make it do things that really matter to healthcare," Spradlin said.
But as Spradlin reminded me, last year's winners "did not represent your father's healthcare system. They were fearless, unafraid. They had been brought up in the develop arena as well. They saw a need to do some things differently."
But just to set expectations, remember that the recently released CMS data is all about cost, not quality. The full matching set of quality data is locked up still somewhere in CMS, and since I understand the agency operates at least four separate data warehouses, it could be some time before we see a truly complete coding competition.
That will invite in the controversy, because just looking at cost without the associated quality measures is bound to be taken out of context by someone somewhere. To some extent, because the newly released data hasn't been poured into apps as easy to use as Yelp, some of that controversy hasn't erupted yet. And there's always the possibility that a Yelp-style app won't capture the nuance or the inherent value of a medical encounter. The ensuing outcry could simply be added to all the other perceived outrages of our public healthcare debate.
Still, Spradlin pointed out that in the initial flush of reportage after April 9, reporters and healthcare critics were able to go after apparently inflated costs.
"It took all of about a day for them to start finding which providers had the highest billing numbers," Spradlin said. "But it certainly won't be the last word." Geographic variations, socioeconomic variables and other deep population analysis "may be the most interesting of all. Some of that could come out of this competition. People will be analyzing this data for months and months. I think the least interesting thing is actually what got published on April 10."
Every time more of this data gets released, a network effect will kick in, with new opportunities to correlate previously-released data with the new.
In a world where consumers can spend five hours picking out their latest smartphone, and less than 20 minutes picking a physician, this kind of information will fundamentally change healthcare, Spradlin said.
"The AMA is right, in that there is a lot of context that's important to understand," Spradlin said. "As we get a little bit smarter, and the consumer population gets a little bit smarter about understanding and parsing a lot of this, we'll get better at correlating the quality measures in these cases.
"I also think we could see some unexpected attempts at driving some that, even here. When you look at claims data, you can't help but look at readmission rates. Are readmission rates potentially a strong signal of quality? I think for certain procedures, probably."
Code-a-Palooza visualization proposals are due on April 25. (Don't worry, the coding doesn't all have to be done by then.) As competitors and other healthcare luminaries assemble in Washington June 1–3 and I'll be there again to cover it—then the real fun begins.
A tech investor with a proven track record of attracting innovation and money to a variety of endeavors is looking for a few good communities to compete for the greatest improvement in five measures of health and economic vitality.
Healthcare ladies and gentlemen, start your communities.
That was the call on April 10 from angel investor and tech advisor Esther Dyson, whose population health dream has taken a big step toward reality with the launch of the Way to Wellville competition.
From now until May 23, Dyson's nonprofit startup, HICCup, is inviting communities to apply to be one of five contestants in a five-year-long competition to get healthy using everything from the latest fitness gadgets to reality TV. Dyson is HICCup's founder and chairman of EDventure Holdings.
The 20-page application form is not for the casual applicant. Individuals or consultants need not apply – we're talking community health organizations, other nonprofits or perhaps the local Better Business Bureau.
Why bother? Several reasons. Dyson is an early investor in all sorts of innovative startups, with a proven track record of attracting innovation and money to a variety of endeavors over the past 25 years. She also is a great listener, having convened various listening sessions around the country last fall to get this latest idea off the ground.
Dyson's fledgling organization, HICCup, found its footing in those sessions, and also a CEO, Rick Brush, who spent nearly a decade at Cigna, where he was chief strategy and marketing officer for the national employer segment and launched the payer's Communities of Health venture.
At one of those early scoping sessions, Brush asked the kinds of tough questions about what Way to Wellville should be measuring that landed the answers in HICCup's FAQ and himself in the CEO's chair, Dyson tells me.
A 'Learning Lab for Health' "What we're trying to do is almost create a learning lab for health with subsidiary projects and contests along with the five-year marathon," Dyson says.
Back to that lengthy application, which goes beyond asking about a community's healthcare, straight to the health of a community, seeking such metrics as percentage of temporary residents, household income, poverty levels, and a slew of outcomes data – percentages of a community with diabetes, heart disease, asthma, smoking status, obesity and more.
Applicants also have to describe their top previous successes and failures trying to improve community health, healthcare financing innovations such as ACOs, patient-centered medical homes, population health, bundled payments, and so on.
In other words, it's a lot of the things that HealthLeaders readers are currently embarking on both individually and collectively. And if the prestige of being selected for the first-of-its-kind national competition of sorts doesn't intrigue you, there are a couple of other things to consider.
First is the cash prize at the end of the five years. HICCup itself won't be rewarding such a prize, but hopes to raise $5 million for it. "Honestly, contestants are going to have to spend $15 to $50 million as a community to do this, so you're not doing this for the prize, though of course it matters to some extent," Dyson says.
Second, and more importantly, Way to Wellville contestants will become part of a larger community amongst the five competing communities. They will meet face-to-face in September at an annual conference, Next Step to Wellville, about a month after the five competing communities are selected.
The actual judging of who wins in 2019 has yet to be decided, but it will be a third party for legal and fiduciary reasons. Dyson emphasizes that the organization doesn't have all the answers yet.
Metrics Matter If you believe, like I do, that healthcare is closer than ever to some tectonic shakeups courtesy of technology, then Way to Wellville is likely to be a great observation post. Innovative medical hardware and software companies are already flocking to a variety of competitions such as this. Way to Wellville is just taking a bigger view of what kind of population health solutions will ultimately be necessary.
Expect also a lot of intermediate measurements and competitions.
"We're hoping that some of these quantified self vendors will come in and donate devices to the communities and so we'll have Fitbit and Fuelband contests," Dyson says. "[Add to that] the county health rankings and all of these sorts of official measures, most of which are a year or two old, and we're all going to get a lot more real-time data."
"You can't report transitions to diabetes every month," Dyson says, "so there will be some health measures that are kind of yearly, but then there are, the outcomes measures tend to be slow. The input measures, like the percentage of school lunches that contain no French fries or something, you can measure in more real time."
The $15 to $50 million table stakes per community sounds daunting to me. "It's not the community goes and gets a $50 million grant from somebody," Dyson says. "It's more than they get a $10 million grant for, let's say, heart health. There's a $2 million program for food subsidies for fruits and vegetables. There are accountable care organizations that find an investor to improve the health so that their costs go down. There are social impact bonds."
Philanthropists Wanted "So it's a combination of a large number of different kinds of funding from donors, from social investors, from vendors giving in-kind services or goods, and maybe in outer years, the school board raises a bond to do something with the school lunch. Each community is going to need to get money and support from a variety of courses in a variety of funds.
"We'll be looking for people who want to invest in various ways of producing health. We're also looking for donors [and] philanthropists."
And of course, Dyson is reaching out to her famous set of angel investor friends. The goal, of course, is to go beyond that. Another way to maintain excitement on Dyson's agenda is "a cheesy reality TV show" and perhaps a documentary.
As we see more and more crowdfunded efforts springing up in healthcare technology, Dyson's approach has some similarities – with perhaps a crowd with deeper pockets, or at least one that's been around the startup block a time or two.
Dyson hopes for up to 50 applicants for the five spots, and already has solid interest from several communities. Her population health dream is alive, and by this fall we should start to see some manifestations of it.
"The timelines and the pressures we're putting on the industry need some flexibility and sequencing so that people can be successful," says the CEO of CHIME. He and others are hopeful that Kathleen Sebelius's successor will listen to and understand the needs of the field.
Russ Branzell
President and CEO of CHIME
Burdened by requirements to implement initiatives such as ICD-10 and meaningful use while hospitals face declining revenues, the healthcare CIO community holds hope that the next HHS secretary will have more sympathetic ears.
"I think this entire implementation of all these major initiatives has been on such an aggressive and tight timeline and maybe an inappropriate timeline, that the possibility of more collaboration from the field might have made things a little bit more successful," says Russ Branzell, CHIME president and CEO.
"We're trying to move an industry that is so wrought with error right now that everything we do to try to change it is going to result in some pain and discomfort," Branzell says.
"We truly have said the timelines and the pressures we're putting on the industry need some flexibility and sequencing so that people can be successful, and they've suffered from their own aggressive timelines," Branzell says.
Coming on the heels of the surprise Congressional delay of ICD-10 implementation until at least October 2015, as well as the earlier bumpy rollout of Healthcare.gov, HHS Secretary Kathleen Sebelius's unexpected resignation last week is casting fresh doubt on CMS' ability to execute its own hefty agenda in a timely way, Branzell says.
"You have to wonder if CMS was even ready for ICD-10 themselves, because they were just looking for exchange partners to start testing with, so it's not just the field that feels the pressure of this, but the government entities that have to implement them too," Branzell says.
"So much of what occurs now in Washington is us going there trying to create great relationships and try to foster trust, so we can help influence this process, rather than the opposite of that," Branzell says.
HHS in general and CMS in particular needs to "really reach out to organizations and try to understand what the needs are of the field to be able to be successful in these initiatives. Depending on the person or the leader, some are very good at that.
Former HHS Office of the National Coordinator head Farzad Mostashari "was very good at reaching out to people like myself and other organizational leaders and finding out what can be done to try to improve things," Branzell says. "There were several others. That has just not always been the case."
For now, "we have timelines that are legislated and so we'll continue to march down those legislated timeframes," Branzell says. "If anything, it gives us less of an option at this point, probably, to see any flexibility in that, because they're going to be focused on getting the new secretary nominee through that [nomination] process, so we're probably under more pressure now to get things done in the timeframes that are there."
"In some ways, those of us in IT kind of cringe when we think about the rollout of Healthcare.gov, because it was a great opportunity and it was just completely mismanaged," says David Miller, vice chancellor for IT & CIO at the University of Arkansas for Medical Sciences.
"The person [Sylvia Mathews Burwell] that they've got up for the potential nomination looks really good as well," Miller says. "I think this was probably just a whole lot tougher than people thought it would be, and a whole lot more complex. Those who have been in healthcare—I've been in healthcare 35 years— those of us who have been in healthcare for a long time, know it's a very complex business, and it's very difficult to just make assumptions on what people will and won't do in terms of signing up for insurance or whatever it might be.
"The website itself, that's just project management, so the fact that it didn't go as it should have, it is kind of laid at her feet."
Miller hopes HHS will be more transparent going forward. "You need somebody who understands the complexities of one-sixth of our economy," he says. "There's the old adage that physicians who are honest about their mistakes, even when they make them, get forgiven a lot more often than physicians who aren't. That transparency piece buys you a lot of favor across the industry, so that's what I'd like to see that I didn't think existed at all before."
As for programs such as meaningful use and ICD-10, Miller also believes in staying the course. "We've plowed a lot of money into making this happen," he says. The University of Arkansas for Medical Sciences is scheduled to go live on the Epic EHR on May 3 in its hospital and two thirds of its clinics. Although ICD-10 technology will be ready this October, the Congressional ICD-10 delay provides "a little bit of a breather" for physicians currently immersed in their Epic training, Miller says.
Sylvia Mathews Burwell, the current director of the Office of Management and Budget who President Obama nominated last week to take Sebelius' place, impressed one other physician leader.
"I do like the idea of someone coming in who has what seems to be maybe more experience in running large organizations, and we'll see if things go a little more smoothly in the future," says Lyle Berkowitz, associate chief medical officer of innovation at Northwestern Memorial Hospital in Chicago.
"At this point we can't do everything," Berkowitz says. "They've reached the sort of saturation point of change, and we have done a ton. We've set the groundwork to do a lot, but there's only so much we can do, particularly as reimbursements are going down."
The next HHS secretary has to "step in and evaluate all the programs, figure out where to focus, and listen and understand what people are doing, and then move forward and do it better than we ever have in the past," Berkowitz says. "That's certainly my hope for any new people coming into the system."
Kaiser Permanente Northwest is one of several healthcare providers participating in an effort to roll out open access to clinician notes as a standard of care throughout the Pacific Northwest.
A consortium of nine healthcare provider systems is targeting more than one million residents of Oregon and southwest Washington State in 2014 to provide open access to their physicians' notes in electronic medical records.
The announcement this week marks the first time that OpenNotes, a national movement that urges health-related organizations to adopt open access to clinician notes as a standard of care, has been embraced simultaneously throughout an entire region.
Spurred by the efforts of the nonprofit, nonpartisan health advocacy organization, We Can Do Better, the healthcare providers that have committed to practicing open notes, are Kaiser Permanente Northwest, Legacy Health, Oregon Health & Science University, Providence Medical Group Oregon, The Portland Clinic, The Vancouver Clinic, Portland VA Medical Center, OCHIN and Salem Health.
Each of these groups is already practicing open notes in some form or intends to do so sometime in 2014 or 2015, the group says.
Kaiser Permanente Northwest was scheduled to begin making clinician notes available to its members across the region Tuesday. "Now, nearly 500,000 Kaiser Permanente members will, for the first time ever, be able to easily view the notes charted by their doctor during an office visit," said Michael McNamara, MD, chief medical information officer for Kaiser Permanente Northwest in a statement. "We want patients to feel connected with their providers, and to have the type of tools that will enable them to be more engaged and in control of their care."
Legacy Health will launch its participation on April 12 starting with specific practices, and eventually reaching 85,000 patients, a spokesman said.
OpenNotes was first piloted as part of large-scale research study conducted at Boston's Beth Israel Deaconess Medical Center, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle. All have adopted it. Since January 2013, the U.S. Department of Veterans Affairs, including the Portland VA Medical Center, have also adopted full transparency of clinical note access.
While federal law mandates a patient's right to access their medical records, including clinician notes, obtaining copies of paper records can be time-consuming and in some cases, involve costs for the patient.
"Oregon and Southwest Washington represent the first region in the US to collaborate on implementing open notes as a community," said Amy Fellows, Director of We Can Do Better in a statement. "Local health providers have been very supportive of providing patients here in the Northwest with this increased level of transparency. We look forward to the day when all consumers will be able to access their providers' notes."
The use of open notes by groups in the Northwest extends beyond the region. OCHIN, Inc., an Oregon-based nonprofit health information network that operates in 18 states and serves over 2.5 million patients, has enabled its 78 safety net clinics, nearly half of which are in Oregon, to use OpenNotes since December 2013.
"I've found that OpenNotes is a great way to engage patients in their care," says Tim Burdick, MD, OCHIN's chief medical informatics officer and a practicing family physician at OHSU Family Medicine at Scappoose. "When we flipped the switch nationwide for all OCHIN clinics to use OpenNotes, I was pleased with how excited patients and providers were about this approach."
"With the advent of the electronic health record, it has become much easier to securely share notes among providers and, as a logical extension, with patients," says Homer Chin, MD, chairperson for the We Can Do Better campaign. "In light of the many benefits of doing so, it's time that we engage and empower patients by providing them with easy access to their own medical information."
Based at Harvard Medical School and Beth Israel Deaconess Medical Center, Tom Delbanco, MD, and Jan Walker, RN, MBA, created and continue to lead the OpenNotes initiative.
"This regional collaboration, remarkable both for its nature and the number of patients involved, represents a tremendous step toward engaging patients more actively in their care," Delbanco says. "In fact, it may prove pivotal in establishing full transparency as the national standard of care."
The OpenNotes initiative is funded primarily by the Robert Wood Johnson Foundation. It started with a one-year study that examined the impact of offering clinician notes to more than 13,000 patients cared for by 105 primary care doctors at three pilot sites. The preliminary studies found patients reporting feeling more in control of their care, having greater understanding of their medical conditions, and being more likely to take their medications as prescribed.
At the end of a year, 99 percent of patients asked for the practice to continue, and none of the doctors chose to withdraw.
Since 2012, OpenNotes has been spreading throughout the country in small and large health systems, currently affecting until now some 2 million patients. Non-profit Consumer Reports is working closely with the movement and recently identified OpenNotes as one of the top five innovations in health care in 2013. Major systems implementing this practice now include the Mayo Clinic and the Cleveland Clinic, in addition to Veterans Affairs.
CMS Administrator Marilyn Tavenner firmly vowed only weeks ago that there would be no ICD-10 delay. Now that an undefined delay has been announced, she remains silent on ICD-10's next steps.
The hives-inducing Washington, DC-based drama, ICD-10 Held Hostage, has entered its second week.
This first week has been good news for a variety of FUDbusters and others hawking products meant to cut through the fear, uncertainty and doubt following the stealthy legislative blitz that delayed CMS's requirement for providers to use ICD-10 starting October 1.
One Webinar was subtitled, "What changes? What doesn't?"
The answer is, no one outside of CMS knows yet.
You read that right.
The first thing that needs to change is CMS's ICD-10 landing page, which as of noon Tuesday still stated that the ICD-10 code set would replace ICD-9 "on October 1, 2014." How has this not been updated yet?
It is the height of something or other that CMS Administrator Marilyn Tavenner, who at HIMSS so firmly vowed there would be no ICD-10 delay, remains silent on ICD-10's next steps. Yet somehow, she found time last week to proclaim April National Minority Health Month, a purely ceremonial proclamation.
The fact is that here in week two, providers of all races, creeds and colors are in a bit of a panic about how to proceed on ICD-10. The language of the SGR fix legislation only states that ICD-10 won't commence earlier than October 1, 2015.
That leaves the open-ended possibility, for the moment, that for some inscrutable reason, CMS could opt to select a new cutover date later than October 1, 2015. The mere possibility of this has the entire healthcare IT industry trapped in a kind of limbo.
That is not good for ICD-10 or for healthcare.
For further perspective, last week I spoke with two consultants who advise providers on ICD-10-related matters.
It Gets Worse The first reminded me that healthcare providers have set their upgrade and implementation schedules around the October 2014 schedule. But they are also at the mercy of software vendors who have planned to release upgrades to their programs in bundles.
Software does not respect neat boundaries between things programmed to implement ICD-10 and other enhancements, so the possibility exists that software vendors are prepared to deliver new versions of all sorts of systems this year that have ICD-10 implemented by default.
Those same software vendors are expecting providers to honor contracts they have signed to pay for and accept software that implements ICD-10 this year, not next year.
The news just gets worse. "Every expert in the industry has been advising people to do more than just treat this as a software upgrade, because there were, or there are, potential business benefits to be gained, but only if you actually embed ICD-10 coding into your business processes," says Jordan Battani, who runs a think tank on regulatory changes and trends for Computer Sciences Corporation, a systems integrator.
How long will it take CMS to figure out its part? "I don't know," Battani told me, "and I'm really glad I don't work there this week."
Another consultant, like Battani, is urging his provider clients to pause, take stock of their ICD-10 efforts, and redeploy resources to more pressing tasks if possible, until CMS has weighed in.
"A lot of the clinical documentation in ICD-9 was not all accurate," says Fletcher Lance, national healthcare leader and vice president of global consulting firm North Highland. "There was about a 20, 25 percent error rate there, so we're encouraging clients to go back and work on that, and protect that revenue and get the coding right in this interim period as a very practical step as something to do while we learn more from CMS."
A Silver Lining #JustKidding In the midst of all this uncertainty, on the eve of April Fools' Day, former ONC head Farzad Mostashari tweeted, "Only silver lining to the #ICD10delays? Putting to bed the over-used 'perfect storm' mantra."
But after talking to Battani and Lance, this just looks like an extended hurricane season for healthcare IT.
"I don't know how much experience you have with doing very big projects, but it's very hard to slow them down and stay effective and focused and hit a revised deadline," Battani told me.
"In some ways it's almost easier when you're doing a big project when it's just cancelled. Then you just dismantle all the apparatus and you move on to other things, but the challenge that these organizations will be facing now is how to maintain organizational focus and be ready to ramp up again when the new deadline is disclosed, and that sort of start/stop, continue activity is very, very difficult to optimize."
Battani also threw cold water on a strategy by which some providers would code to ICD-10 in the fall and then back-code to ICD-9 to continue to get paid.
"Here's the thing about payment," Battani said. "There's a lot of reimbursement schemes in ICD-9. When you're forced to use not-very-specific diagnosis information, those claims require additional documentation to be submitted in order to get paid. That's a process that's incompletely automated, so there are problems in the reimbursement process that ICD-10 is a useful tool for helping to fix, streamline, and optimize payment."
In addition, "whenever you're using crosswalks, that creates another opportunity for appeals and disputes about reimbursements, because there's endless argument about did you crosswalk it to the right thing," that's the case even going from ICD-10 back to ICD-9, Battani added.
Small Shops Beware Why do I get the feeling that eventually, the very members of Congress who voted for this delay will be pounding the table demanding to know what HHS is going to do about this newest healthcare crisis, a crisis of their own making that failed to get a single mention on the floor of the House or the Senate, or in the President's statement upon signing?
My final thought this week comes from author Michael Lewis, who has written a book about high frequency trading in the financial markets. Jon Stewart interviewed Lewis about questionable, tech-powered high-speed trading on Wall Street last week. "Larger firms dine off regulation," Lewis noted.
My fear for healthcare is that the extended hurricane season that is now ICD-10 will be only the latest of many threats to community hospitals and small practices. Only the large firms, which have the deepest pockets and the most resources, and are most agile at adapting to changing deadlines, are likely to survive this continued onslaught. Meanwhile, CMS still has a Web site to update.
Another year-long delay in the deadline for implementation of the ICD-10 medical coding set spells frustration for vendors and providers. "This is bad," says CHIME president and CEO Russ Branzell.
Russ Branzell
President and CEO of CHIME
CHIME president and CEO Russ Branzell's mood was one of irritation Monday evening in the wake of the Senate "doc fix" vote which postpones ICD-10 compliance requirements for another year.
"We'll continue to try to push to see with the executive branch and the White House staff [Tuesday] to see if there's any chance at all of doing some education of why this is bad. But at this point, we generally think it's going to go through," Branzell told me.
"Essentially, ICD-10 was being held hostage with the SGR fix and at this point. It had to be voted on tonight and essentially it has to be signed tonight to have an SGR fix effective tomorrow, which is when the original SGR fix sunsets. I would be surprised if it isn't on its way over to the White House to be signed tonight anyway."
I asked Branzell if anybody had identified those groups that had gotten the ICD-10 language inserted.
"I asked the question around today and all I got was that it was predominantly from the specialty and subspecialty medical groups," he said. "We know the AMA wasn't for it, because they put something on their Web site… I would assume that it was more that the specialty groups were pushing for the SGR fix, and this got included in it."
I offered that groups such as the MGMA pretty much supported an ICD-10 delay, but I doubted whether a group like MGMA had sufficient clout to ram through a postponement.
"Most of the physicians now, well over 50 percent, are working within health systems, so you would think the health systems would carry their voice to try to get this where it needs to be. But in the end, if you had to balance payment reform and losing 25 percent of your income versus ICD-10, it sounds like payment is going to take precedence," Branzell says.
During our chat, I mentioned to Branzell that I had had a conversation earlier in the day with an EHR vendor who noted that large, well-capitalized healthcare systems are either continuing on with their ICD-10 plans or have actually gone live with ICD-10 already.
According to this vendor, who asked not to be identified, such large, prepared providers plan to simply "backcode" to ICD-9 for the next year. I wondered, however, if that is an indicator of a widening disparity between those who have the resources to do that and those who do not.
"If you look at the mapping of going from ICD-9 to ICD-10, that's much harder than going from ICD-10 back to ICD-9," Branzell says. "Actually I had a discussion with some people today about that. I'd be surprised if, with some exploration, that isn't part of the toolkits brought out for people and suggestions that come out, whether that be from other associations, or ours, or whatever, as a viable option to stay on track, keep your people trained, and just automate back.
"So, if there are, say, 27 codes for a sprained ankle in ICD-10, and there are only one or two in ICD-9, it's pretty easy to backtrack to ICD-9."
I suggested to Branzell that based on a story I wrote last month about CDI in HealthLeaders magazine, coding for ICD-10 now is also consistent with the kind of coding rigor that SNOMED is striving for. In other words, if you're going to stay on track with SNOMED, you're going to be doing better coding anyway.
But Branzell noted that the extra year of delay will raise the specter again of the entire industry waiting a few extra years to move to ICD-11, which is due to be published in 2015.
On listservs he monitors, which include "quite a few physicians," he's noticed comments like this: "If we're going to delay a year, and ICD-11 really isn't that far away and it's what the doctors want with SNOMED anyway, is this just one delay until the next delay, and then we jump from ICD-9 to ICD-11?"
"It may make sense to just combine it into one effort. I don't know what the wait [for ICD-11] would be and what the trickle effect of issues are. I don't even know if you can go from ICD-9 to ICD-11, [or] if you have to go from nine to 10 and then 10 to 11.
I told Branzell I had looked into this and it seemed like it was much easier to go to ICD-10 first.
"I think it has to do with the documentation requirements. It's much more intuitive for a physician to code and document into a SNOMED environment."
So while the industry fulminates about the underhanded way the newest ICD-10 delay has made its way into the law books, and the cost of delaying the transition are re-tallied, it would be prudent for us to take a moment to also look around and see just how another 12-month delay re-shuffles the deck in the complex game of healthcare IT and payments.
I'm certain that's what U.S. healthcare's CIOs will be doing for the next few days or weeks.
A House bill addressing Medicare reimbursement rates for physicians contains language that would postpone the ICD-10 deadline until October 1, 2015.
Another healthcare reform-related federal deadline may be delayed. This time it's the ICD-10 deadline, which has already been delayed once.
The American Health Information Management Association Wednesday alerted its members that Congress will vote Thursday on a bill, negotiated at the leadership level in the House and Senate, which contains a provision that would delay implementation of ICD-10 for another year, until October 1, 2015.
The main focus of the proposed bill, expected to be voted on Thursday in Congress, would be to patch the Sustainable Growth Rate formula which dictates Medicare reimbursement rates for physicians.
In a statement released late Wednesday, American Medical Association President Ardis Dee Hoven, MD, said her group "and other physician groups are calling on House members to vote no on this legislation. Full repeal of the Sustainable Growth Rate is the answer to strengthening the Medicare program, not another patch."
Section 212 of the proposed bill states that "The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations."
In February, Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner, speaking at the HIMSS 2014 conference in Orlando, stood firm on the October 1, 2014 ICD-10 deadline. "Let's face it guys; it's time to move on," Tavenner said. "There will be no change in the deadline for ICD-10. CMS began installing and testing systems for ICD-10 in 2011. All fee for service systems at CMS are ready."
According to an AHIMA blog post on Wednesday, CMS estimates that a one-year delay could cost between $1 billion to $6.6 billion. "This is approximately 10–30% of what has already been invested by providers, payers, vendors, and academic programs," AHIMA stated. "Without ICD-10, the return on investment in EHRs and health data exchange will be greatly diminished."
AHIMA urged its members to call Congress to oppose the ICD-10 deadline extension. The AMA and other industry groups have been vocal in their desire for a deadline extension.
If the bill passes and ICD-10 is delayed again, it would be another instance of HHS relaxing deadlines and amending policies in response to stakeholder concerns. In February, CMS relented to pressure from physicians, payers, hospitals, and lawmakers and announced it would perform limited end-to-end ICD-10 testing.
Days away from the March 31 deadline to enroll in the federal insurance marketplace, the White House said Tuesday night that it would allow more time for some applicants. HHS Secretary Kathleen Sebelius, in a Congressional hearing March 12, stated that the enrollment deadline would not be delayed.