The expansion of e-prescribing and data analytics is leading to improved outcomes, reduced costs, and enhanced patient engagement. And technology is allowing providers to earn hard cash for meeting medication adherence targets.
This article appears in the January/February 2014 issue of HealthLeaders magazine.
Billions of dollars are wasted and thousands of lives lost each year through inefficient or ineffective medication management. It has been estimated that the misuse of prescription drugs in our healthcare system is up to a $300 billion problem annually.
From the doors of the emergency room to the drawers of patients' home nightstands, medications are mixed up, misremembered, overdosed, underdosed, and laboriously documented or misdocumented.
But things are changing: E-prescribing is now the rule, not the exception. Data analytics is red-flagging areas of concern from the doctor's office to the pharmacy and all throughout the chain of care. And technology is allowing providers to earn hard cash for meeting medication adherence targets.
ACO partnerships
Coventry Health Care, a division of the insurer Aetna, is a Bethesda, Md.–based managed healthcare company with 5 million members across the nation. Coventry uses predictive modeling technology from RxAnte to target a population of patients who could most benefit from improving their medication adherence. Then, Coventry offers physicians $50 per medication class per quarter in bonuses to make it happen. The bonuses target three classes of medications and use predictive modeling to narrow the focus.
"Providers are getting bombarded by a bunch of noise, and the worst thing you can do is send them a mile-long list of patients, most of whom are going to be adherent on their own," says Michael Kavouras, vice president for Medicare Stars for Aetna.
"Nothing will frustrate providers more than wasting their time and the time of their office staff and their nurses," he says, "so one of the things we've done is we've used the RxAnte algorithms to skinny down the lists and get to providers and communicate to them that we're not going to do this the old-fashioned way where we're just going to send you every patient that is currently nonadherent."
So far, 570 practices have committed to participating in Coventry's initiative during the third and fourth quarters of 2013, which account for almost 20,000 of Coventry's Medicare Advantage members out of 300,000 total Medicare Advantage beneficiaries.
Medicare Shared Savings Programs are also using analytics technology to manage patients' medication adherence. On January 1, 2013, Baroma Health Partners became the first MSSP-approved ACO in Miami-Dade County, Florida. Baroma Health Partners, a subsidiary of Baroma Inc., consists entirely of independent physician practices.
"Medication therapy is really important for anyone who's discharged from the hospital," says Ricardo Matos, CIO of Baroma Inc. At the time of discharge, Baroma Health Partners and its pharmacy partner, Walgreens, perform a medication reconciliation to make sure patients do not leave with more of a particular medication than they need, or with any medications that may have an adverse effect interacting with other drug therapies, he says.
"It's all independent physician practices down here in south Florida," Matos says. "Trying to help solve this healthcare puzzle down here, we thought that might be some of the low-hanging fruit to help our population coordinate care between the different providers that they see that are not necessarily communicating well, until the ACO provided the avenue to do so."
Such coordination can help hospitals in the area avoid penalties imposed by CMS on those whose 30-day readmission rates are too high, Matos says.
Using Direct encrypted email enabled by technology from Loopback Analytics, Baroma Health Partners is able to transmit personal health information to primary care providers so they can see hospital discharge instructions, be aware of medications the patient has received within three days of discharge, and in return be made aware of patients following up for PCP visits within 14 days of discharge. "That's where it's been successful," Matos says.
Walgreens' role in managing medication has been to give the fledgling Baroma ACO a reputable partner to help convince independent physicians to also partner with the ACO, Matos says.
Although the ACOs under the MSSP are not at risk for Medicare Part D, drugs covered under other parts of Medicare are important to Baroma Health Partners, Matos says. "Although we're not at risk for it, we can't ignore it, because the proper management of medications is going to keep the patient out of high-risk and high-cost settings," he says.
"What we bring is that visibility, that connection, that follow-up, from a community standpoint, that traditionally on its own a hospital wouldn't have," says Joel Wright, group vice president of enterprise specialty at Walgreens.
Walgreens formed three ACOs with physician practices in January 2013: Advocare Walgreens Well Network in Marlton, N.J.; the Diagnostic Clinic Walgreens Well Network in Largo, Fla.; and the Scott & White Healthcare Walgreens Well Network in Temple, Texas.
Walgreens' WellTransitions program, recently endorsed by the American Hospital Association, "really focused around the six core disease states that Medicare has outlined" as highest risk for readmission, Wright says. Those disease states include acute myocardial infarction, coronary artery bypass grafting procedures, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and percutaneous transluminal coronary angioplasty.
Walgreens, using Loopback technology, is able to provide patients' medication history to hospitals at admission to facilitate medication reconciliation, and then to take that reconciled medication list back for use in the community pharmacy postdischarge, Wright says. "Right then we clean up that patient's outpatient profile and close prescriptions the patient should no longer be on," he says. "That way the prescriptions don't get filled in error, and it helps reduce the chance of patients being confused about which medication they should really take or not take."
Within the first six months after the program's implementation at five hospitals, WellTransitions patients had a 9.4% unadjusted rate of 30-day readmission, compared to a 14.3% 30-day readmission rate for patients eligible for but not participating in the program, according to Walgreens.
Mobile apps
At home, patients may find themselves looking at a bottle of pills, wondering if they have taken their medication or not. Many choose to skip a dose because of their uncertainty. Others ignore warnings not to take medicines with other drugs or food that could have an adverse effect.
But one thing has changed in most of those patients' lives: They now have smartphones capable of running medication adherence apps. One such app, MediSafe, is used to provide gentle, simple-to-understand reminders by patients of Barbara Zink-Frederick, a geriatric and internal medicine nurse practitioner in New Freedom, Pa., about 30 miles north of Baltimore.
After trying other apps, Zink-Frederick settled on MediSafe, preferring the app's division of a day into morning, lunchtime, afternoon, and nighttime, visually displaying the medications at the appropriate time of day, and alerting patients it's time to take their meds with the sound of a pill bottle shaking, to distinguish the alert from other smartphone alerts.
Zink-Frederick also likes that MediSafe now allows patients to enter the time a pill is taken when that happens to be later than the originally recommended time, and that it reminds busy workers to take their pills with them before heading off to work.
When patients visit with her, the app reports a medication adherence score with drill-down details, and the bulk of the patient's visit can consist of meaningful interactions, including education addressing ways to obtain medications if the patient is low-income, for example.
"We set up a plan," Zink-Frederick says. "I actually help them put their original drugs in, to make sure that they get them right. They try it for a couple weeks, see if the way they're taking it is okay, or if they have problems, then it gives me the ability to adjust, move this medication to this time, maybe that won't make the patient have an upset stomach, or maybe this medication will help them with their appetite for dinner."
E-prescribing
The boom in e-prescribing is another way that medication management is bridging gaps in care. As many as one-third of prescriptions written in the past never made it to a pharmacy, says Harry Totonis, president and CEO of Surescripts, the e-prescribing network provider owned in part by Walgreens and CVS. If a doctor instead writes an electronic prescription, now that pharmacy knows the patient needs to come in and pick it up, Totonis says.
E-prescribing now accounts for 50% of the prescriptions in the country, Totonis says, and Surescripts is on track to process 6 billion transactions a year. He says that in the next five years, as that figure approaches 80% to 100%, Surescripts will tackle other aspects of adherence, such as whether refills are picked up or not.
Recently, the Drug Enforcement Administration issued a rule that controlled substances could be prescribed electronically. In 2015, starting in New York state, e-prescribing will be mandatory for all controlled substances, and other states will be watching New York's progress, Totonis says. "The minute that every prescription goes electronically, and we take out the paper pad altogether, adherence now just becomes a much stronger case," he says.
Addressing cost
Throughout the healthcare industry, medication management and adherence are sure to dominate much of the discussion about readmissions and other drivers of healthcare costs.
"It really is one of the industry's best opportunities to reach the largest number of consumers and patients and really impact one of the key drivers of healthcare: cost," says Frances Dare, a Dallas-based managing director of connected health services at Accenture, a global management consulting company.
"It's really across all patient populations, from the young to the elderly," Dare says. "It's people who are episodically ill just as much as it is people who are more chronically ill, and includes both over-the-counter medications and prescriptions and multiple medications. I think it's one of the biggest opportunities we have."
Still, as so often is the case, technology alone won't be sufficient, Dare says.
"We are on the journey of figuring out how this works," she says. "I do believe there is a wide range of capabilities—secure text messages that remind folks to take their meds or gamification—there's such a huge range out there that we really do have an opportunity to personalize for folks, or they have an opportunity to find a platform that really does meet their personal needs."
Reprint HLR0214-8
This article appears in the January/February 2014 issue of HealthLeaders magazine.
An electronic health record system provider is offering to equip small physicians practices with cloud-based software on a shoestring. The move is making high-end EHRs that cost tens of millions of dollars to get up and running look like dinosaurs, at least at small health systems.
Samsung Chromebook
One reason physicians have gravitated to mobile devices is the steep discount that phone carriers have passed along to customers to get their hands on the latest hot smartphone. Now that same trend has come to the doctor's office desktop—without the usual two-year commitment.
Practice Fusion, which for several years has given away free, web-based EHR software to small practices of 15 physicians or fewer, upped its game last month by announcing that it would make available one Chromebook per practice to anyone willing to sign up for its cloud EHR.
It's a marketing gimmick, but what a gimmick. Recipients sign no contract, and could basically take the Chromebook and run. Confident officials at Practice Fusion, riding a surge of adoption in 2013, believe recipients will like its cloud EHR enough to stay.
The venture-backed company is one of several big bets that individual practices are not going the way of the dinosaur. From their perspective, the endangered species is more likely to be the high-end EHRs that require tens of millions of dollars to get up and running at large systems.
To an extent, it's a comparison of apples and oranges. Practice Fusion cannot run a hospital. But as the industry moves away from hospitals and toward primary care as the main source of its revenue, equipping a small practice with cloud-based Meaningful Use Stage 2-compliant software on a shoestring budget holds a certain appeal.
Goodnight, XP Adding to this shift is the current sunsetting of Windows XP, that stalwart operating system from the dawn of the millennium, a version of Windows yet unequaled in terms of adoption and acceptance. A lot of small practices are faced with ditching that XP hardware due to the imminent discontinuation of security patches from Microsoft. Although a one-year extension was recently, if begrudgingly, announced.
Chromebooks share a lot in common with zero-client PCs. They're really simple, yet powerful. The computer's browser also has the ability to cache data should there be an interruption in connection to the Internet. During such episodes, don't expect the app to catch every single drug-drug interaction or accept new lab results. But for a small practice, it's just enough technology to get the job done until the connection resumes.
And yes, the desktop and even laptop computers are losing their dominance. A recent study found that more than half of U.S. physicians perform some work-related tasks on a tablet computer. But no one is giving away computers – except, as far as I can tell, Practice Fusion.
Practice Fusion didn't have the best reputation when it was launched. Critics said it lacked features and integration physicians had come to expect on "real" EHRs. But the Meaningful Use program has allowed Practice Fusion, athenahealth and some other interlopers to come a long way in the critics' eyes.
Just last week, athenahealth dethroned Epic for the KLAS award for best practice management software in practices of 75 physicians or less. Like Practice Fusion, athenahealth is cloud-based, which reduces the need, which small physicians never understood anyway, to run their own servers. Meanwhile, Practice Fusion received its Meaningful Use Stage 2 certification in mid-December, while some premise-based EHRs are still struggling to reach that goal.
Fewer Hasslesfor the Well-Wired
The digital divide persists. Many rural communities still lack high-speed Internet, so a Chromebook won't do them much good. Even in the wired communities, outages still happen – Google's Gmail had a hiccup last week that some people swore lasted all day, even though it lasted all of 30 minutes in most places. But these outages are becoming less commonplace.
It's often argued that the true cost of IT is not in the hardware or the software, but in process or workflow redesign, in training, and in the thousand things that can go wrong with PCs—theft, missing backups, viruses, upgrade headaches, and plain old user error.
Some of this persists with the Practice Fusion PC-less model, but it's greatly reduced. Chromebooks don't get viruses. Data gets automatically backed up. Upgrades get automatically pushed to every account with a few days' notice to allow everyone to get used to the latest improvements.
Any EHR carries with it the threat of lock-in. The qualifying step for switching to the Practice Fusion EHR to get the free Chromebook involves converting the physician's e-prescribing credentials over to the Practice Fusion platform, from wherever else the practice has them. Or Practice Fusion can create credentials from scratch if necessary.
Practice Fusion offers standard assurances that all data put into the system can be exported one time, free of charge. (The company also loads data from any EHR at the start free of charge.) Still, no one, small practices least of all, likes to switch EHRs. So likely as not, once they sign up for this cloud-based service, physicians practices are not likely to leave any time soon, unless perhaps they're acquired by a larger practice or healthcare system.
Understanding the Business Model And every time they hear about this something-for-nothing proposition, physicians have to wonder about the underlying business model, and what they're getting themselves into. When I put the question to Practice Fusion co-founder and vice president Matt Douglass, he first noted how the company has raised $150 million from venture capitalists. Now I know some of those VC companies. They're not always in it to make the world a better place. They expect a handsome return on their investment.
So, where are those Practice Fusion revenues? Douglass says the EHR represents "a marketing platform for pharmaceutical companies to advertise to our physicians." Lab companies such as LabCorps, Quest, and 350 other labs in the U.S. pay a premium to Practice Fusion to receive orders electronically from doctors using Practice Fusion, and to send results back electronically. "We repeat that business for imaging centers, for billing companies, for transcription centers, for pretty much any business that needs to interact with physicians."
I'm not sure these revenue sources totally reassure skeptical physicians or make the company worth $150 million in investments. It all has a dot-com whiff about it to me. But we may be at a particular inflection point in the evolution of healthcare IT where giving it away and a getting a big installed base fast works one more time in tech.
So yes, this could portend a big shift in health IT technology. Remember that the dot-com boom left Google and Amazon standing, and look how they're still changing technology more than a dozen years later. So I say to small practitioners: Keep your eyes and your options open. And for larger systems, think about what the tech landscape would look like today if you weren't paying off a $150 million Epic investment.
Electronic health records "are not effective communications tools—not effective at all," says a self-avowed technology optimist who holds a dim view of current EHR capabilities, but has hopes for better systems to come.
Prentice Tom, MD
CMO, CEP America
Prentice Tom, MD, doled out some bitter medicine to a room full of healthcare IT vendors—and, I think, government regulators at the Northern California HIMSS Innovation and Technology Summit this month.
Tom, the lead speaker at the Silicon Valley event and a self-avowed technology optimist, shared his unvarnished assessment of current electronic medical records. They "are not effective communications tools—not effective at all."
I first encountered Tom about two years ago when he rose at a conference to challenge an HHS official about the inefficiency that electronic medical records were creating in his organization, CEP America. One of the largest emergency medicine groups in the country, CEP supplies emergency physicians to hospitals from California to Maryland.
Tom believes that EHRs "are not at all structured how physicians think." He says all such software is built "on a medical student learning platform" and that for the most part, clinical documentation is unnecessary.
"People believe that we have to have this enormous amount of documentation to do what we need to do, and that's not true," Tom told the HIMSS conference attendees. He cited an often-quoted study stating that the average physician waits 18 seconds before interrupting a patient.
"People often say, what can we do to get physicians to listen to their patients for longer? Actually, the question is, why does the average physician interrupt his patient after only 18 seconds? Because most of the information they're providing is not necessary."
Medical Record Documentation 'Primarily for Billing' In his work with 2,000 emergency physicians, Tom has observed that the emergency physician looking at a patient's chief complaint knows 95 percent of the time, within 5 to 10 seconds, "what he is going to do with that patient. The rest of the time is going back and putting in place the documentation and studies that are required for him to do what he actually knew he wanted to do in the first ten seconds."
According to Tom, "medical record documentation is primarily for billing and to have a record in the rare event that there's a risk case." Doctors didn't insist on all this documentation, he says. "We didn't put them in place. The federal government did, and every insurance company copies them."
Fear of litigation is the real driver for all this documentation, Tom insists. But for an emergency physician, the chances of being sued are one in 25,000 cases, he says. "You might not be so willing to spend the time that it takes [documenting] for something that's a pretty rare event," he continued.
Tom even cites a January 2014 study that 40 percent of healthcare dollars spent do nothing to improve patient lives. "Why do people do these types of things? Well, because we're risk-averse, it's a rare event, costs are transferable to the patient, so we practice for the exception. We do a bunch of unnecessary testing. [And] there's a lot of unnecessary documentation that goes along with it."
Yet, particularly in the ED, even if doctors have medical records in front of them, they are not going to pore through them when they can just query the patient and get what they need much more quickly, Tom says.
Billable Hours is Not the Model He contrasts physicians, who get paid more if they see more patients, to attorneys, who bill for the time they spend in any kind of documentation. The more they document the more they can bill. "It's just the opposite for us," he said. "The more time we spend documenting, the less we get paid."
For a significant majority of patients, physicians have no need to spend any significant amounts of time in the medical record. Only relatively few complex patients require such scrutiny, Tom says.
In Tom's ideal world, medical records would be completely mobile and have significant voice recognition capabilities. In a hypothetical scenario, a patient presenting with chest pains would prompt the emergency physician to request a standard chest pain macro, enter appropriate variations, be notified of EKG results, and send those results to the on-call cardiologist.
"That would be it," Tom says. "Now people have developed a system that greatly improves my lifestyle, still has all the documentation, actually improves my ability to communicate with everyone else, and actually allows me to spend more time with patients or seeing more patients or doing the things I need to do, versus going to some fixed station where I have to put in a lot of unnecessary data, except for the fact that I have to bill out."
Too Busy to Innovate CEP America already uses scribes to try to improve physician productivity. The company bills hospitals for its physicians' services, but must eat the cost of the scribes itself, Tom said. "If we can develop systems that allow us to somehow circumvent our need to put in place all this documentation, that's the type of systems that we're looking for," he said.
I did say Tom is a self-avowed optimist. "I don't mean to sound pessimistic," he told the HIMSS chapter. "What I mean to do is provide you with some understanding of why things have taken the length of time that they've taken in the healthcare industry… every physician, every person, every citizen, is in favor of us being able to extract information [in a short period of time]."
As Tom points out, the changes brought about by healthcare information technology can be threatening. Vendors with little knowledge of what physicians actually do can bring ill-advised solutions to healthcare. Busy clinicians simply may be too busy, or too set in their ways, to explore innovation.
One solution Tom offers, for vendors to pay 100 percent of the costs of implementing a pilot technology at a healthcare system, may appeal to too-busy or the too-habituated health systems, and probably plays well to an AMA-type crowd.
But here's where Tom and I part ways. Again and again, I see health systems willing to risk investing time and money in some iffy technology. It may be that the emergency department, with its immediate demands, would naturally be risk-averse. But for the risk-takers, there are payoffs—although not guaranteed ones.
But that isn't stopping innovators within the healthcare system from taking risks, even as the physicians of CEP America go about the business of saving lives. Healthcare technology is multi-faceted, and to simply expect change to be underwritten by Silicon Valley or other tech companies is as unrealistic as expecting Silicon Valley to send every health IT product developer to medical school.
There will be, and are, middle ways of innovating. I hope the next two years of health IT innovation give Tom a reason to have a less scathing assessment by 2016.
At least one critic is calling for the federal health information exchange website to be shut down until a complete security audit can be conducted. Since that's unlikely to happen, let's hope the government is judiciously reinforcing its data breach prevention policies.
For months, Republicans in Congress have been feeding fears of a massive data breach at healthcare.gov. Given the site's many, many shortcomings, healthcare.gov would appear to be a prime target for some sort of data compromise. Its sheer size is reason enough for the bad guys to perpetually keep trying to break in.
And yet, to date, no breaches of any significance have occurred.
In part, that's because at its heart, healthcare.gov isn't one gigantic database. Like Target, which recently sustained a data breach affecting up to 70 million customers, the federal health information exchange is networked to multiple databases, each one housing valuable data.
Therein lies the trouble. By penetrating multiple systems, the Target hackers were able to grab more than just credit card numbers. They got PINs, addresses, email addresses, and other personal information. As one data expert writes, the Target hackers
"…didn't gain access just once. In fact, they kept coming back to harvest data almost daily over the course of several weeks. As we now know, they didn't just stop with the sales data. They roamed across Target's network of servers looking for interesting information..."
At its heart, healthcare.gov is a data "hub" that allows much of the data in seven massive databases to remain at rest between queries, such as whether someone has applied for health insurance on one of the state or federal exchanges, the type of plan they have selected, what the status of that application is, related information about the applicant's income level (as supplied by the IRS) and what tax credits those applicants are eligible for.
Each of those databases has individually been protected by a variety of data security measures for years. To the best of my knowledge, healthcare.gov does not copy all this information into one massive table. In this way, healthcare.gov, in all its buggy glory, still manages to resemble another distributed computing system that seems to continue to survive all manner of cyber-attack—the Internet itself.
Still, voices calling for healthcare.gov to be shut down until a complete risk assessment and security audit can be conducted persist. And they're coming from some startling sources, such as Mac McMillan, the chair of the HIMSS privacy and security task force.
"If that were the standard, they would have to shut down most of the Internet," was the terse comment I elicited from Bruce Schneier, one of the world's foremost data security experts.
McMillan is also chief executive officer of Cynergistek, a security audit and risk assessment firm in Austin, TX. He contends that the American public would be safer with healthcare.gov being taken down for however long is necessary to ensure that not just the hub, but the spokes—the state-associated exchanges plus the databases of the seven participating federal agencies undergo a thorough security assessment.
"There's just a tremendous amount of information about you as an individual in databases that quite frankly, in terms of access, is unprecedented, with this health insurance exchange," McMillan told me in November.
McMillan argues that insider abuse is a huge risk, and he's concerned that operatives in any of these agencies could use the rapidly accumulating information to commit identity theft. But the political cost of taking the site down is one of the big reasons that, HHS refuses to unplug it for an extended period of time.
Where McMillan and I fundamentally disagree is in his contention that the well-documented cases of consumers being unable to log on to healthcare.gov are grounds for an immediate takedown of the site.
"If you don't take it down, and we do have a major event, or a major issue, I think that the harm of that will be ten times worse than if you were to actually take it down and take care of the site and put it back up and have it work properly," McMillan says.
Since healthcare.gov's much-publicized problems began, critics have pointed consistently to Silicon Valley-powered sites such as Amazon and Google as evidence that large sites can scale securely. And yet, Target's very real recent woes point out that healthcare.gov has no monopoly on bad Web site execution.
I pointed out to McMillan that the many articles we've read about bringing high-tech security experts to the rescue rarely, if ever, mention the real possibility that health insurance companies could themselves be great resources to assist healthcare.gov and address its security and performance issues.
"They stand to benefit from this, right?" McMillan replied. "You would think they would want this to work."
Perhaps, and I have no evidence to support this, governments keep the insurers from lending their help for fear that once insurers get their hands on the code running healthcare.gov, they might try to tilt that code to bestow ever-so-subtle preference to that insurer.
"Whichever way this thing goes, they're going to be left standing," McMillan said. However it turns out, McMillan and I agree that poor management, not technology, is the villain here.
"We should stop managing by crisis," he said. "That's how we got into this mess in the first place."
Perhaps, in that sense, the decision to keep healthcare.gov going, and to try to fix its flaws in mid-flight, is the right decision. And yet, if we get through this startup period without a major breach, it could be dumb luck, rather than savvy management, as our saving grace.
Bruce Schneier may be right. You might as well shut down the Internet. But the stakes have never been this high for a mission-critical Internet Web site.
Meanwhile, let's hope the government is judiciously reinforcing its security policies, ranging from employee policies to data-loss prevention infrastructure. Before all is said and done, every bit of those precautions will be necessary.
Healthcare leaders tell Wall Street investors to look at two trends for revenue growth: in the expansion of outpatient care and in clinical integration leading to value-based care.
The annual invitation-only J.P. Morgan Healthcare Conference in San Francisco is where Wall Street meets healthcare to talk business. This year's themes ranged from preparing for the newly insured to continuing the expansion of clinically integrated networks.
For the fourth year, the conference featured big, competitive not-for-profit systems such as Geisinger Health System, Intermountain Healthcare, and The Cleveland Clinic and academic institutions such as Rush University Medical Center.
In 30-minute sessions this week, executives from not-for-profit systems often took the opportunity to thank investors for buying their debt, or in some cases, invited them to buy more. At the not-for-profit sessions, there was no Q&A period, while sessions featuring presentations by for-profit systems such as Humana and Tenet Healthcare were followed by 30 minutes of intense investor grilling.
Investors want to know what's fueling growth. At Chicago-based Advocate Health Care, the answer is non-acute care, said executive vice president Lee B. Sacks MD. "Clinical integration has allowed us to advance in value-based care," he said. "With local leadership and local focus, yet doing things as a system, we've had incredible success."
Sacks says that within 30 to 60 days, Advocate expects to announce "a future clinically integrated entity—not just another PHO [physician-hospital organization], but a hospital that's not owned or managed by Advocate [and] that wants to clinically integrate. It will enhance our geographic coverage, and we anticipate that it will make us more attractive to payers, employers, and to individuals who are purchasing insurance through the exchanges."
A Shift to OutpatientRevenue
In hotly competitive New York City, NYU Hospitals Center chief financial officer Michael Burke made numerous references to "a little challenge called [Hurricane] Sandy" and how the NYU Langone Medical Center has endured during the rebuilding of its emergency department. The ED has been closed since the October 2012 storm and is due to reopen in April.
"I would challenge anybody to take any big academic medical center and survive for 16 months without an emergency room and see how they do," Burke said. "We made a profit despite that."
At the same time, NYU Hospitals Center shifted from a mix of 60 percent inpatient revenues and 40 percent outpatient revenues in 2010, to a mix of 51 percent outpatient and 49 percent inpatient in 2013. "We've achieved that by expanding the amount of clinical space we have dedicated to outpatient care," Burke said.
The Langone emergency department rebuilding project was greatly assisted in December by billionaire financier Ronald O. Perlman, who pledged $50 million to the effort.
Meanwhile, Langone created an urgent care center, which now sees a volume of patients that rivals its old emergency department patient volume. "We might not get as many 911 ambulance calls as we did in the past, but we're making do and we're adapting until the emergency room is completely reconstructed," Burke says.
"Manhattan is probably the most hyper-competitive healthcare environment in the country," he says. "There are a lot of hospitals and a lot of medical groups [and] physician groups within Manhattan. As far as our clinical care delivery, shifting to outpatient has been a large focus of ours, and it really helped us get through Sandy."
HCA Holds Steady Over in the for-profit portion of the JP Morgan conference, HCA, the largest non-governmental hospital system in the U.S. as measured in revenue, EBITDA, and market capitalization, gave a steady-as-she-goes presentation that seemed to reflect little of the turmoil smaller systems are currently facing.
In the past two years, HCA added 900 new beds, and has achieved 22 straight quarters of growth, says Milton Johnson, president and CEO of HCA.
"We've achieved this performance in a tough growth environment," Johnson told investors.
"While we are developing strategies to take full advantage of the newly insured, we are also continuing to build on the strategies that have enabled our strong performance over the past few years," he said. "We see healthcare reform as a net positive for HCA. Some of HCA's most important markets are in states with the highest level of uninsured. This is certainly true in Florida and Texas, which between them represent about 50 percent of HCA's revenue, and when enrollments finally do begin to pick up, we expect to get a lift from reform."
HCA has a good starting point in payer networks as a means to accessing these newly-insured exchange members. "It's worth pointing out that we're just in the first inning with respect to healthcare reform," Johnson says. "No doubt the recent early implementation issues raise the level of uncertainty in the short term, but we remain optimistic that we will see positive impact over the long term."
A new PC being tested in hospital rooms isn't like any PC you know. Sure, it delivers streaming video and gaming, but it can also provide patient monitoring and reporting.
Virtual desktops may be on a trajectory to erase the traditional work PC in hospitals, but at the International CES show last week, Intermountain proved that PCs have a new, somewhat surprising starring role in healthcare.
Last September, I wrote about how Memorial Healthcare in Owosso, Michigan had decided to replace traditional PCs with so-called "zero client" hardware that provided maximum mobility for clinicians and minimum maintenance headaches for IT staff. That trend continues, although some readers noted that antiquated software licensing policies at Microsoft and the PC-based EHR companies are slowing the move to zero-client PCs.
But at last week's International Consumer Electronics Show in Las Vegas, Intermountain Healthcare made the point that the hospital room of the future very much depends on adding a somewhat reimagined PC at the heart of that room, and the software running on that PC won't be a zero client.
That's because the PC would effectively be a set-top box.
Intermountain is pilot-testing a modular PC with up to 350 ICU and ER beds, says Fred Holston, Intermountain's chief information technology officer. He showed off the technology at CES with technology partner Xi3, a company conveniently based in Salt Lake City, like Intermountain.
Xi3's PC probably doesn't look like any PC you have or had. It's a softball-sized, cube-shaped diskless wonder that also captures the fancy of computer gamers looking for an alternative to computer gaming consoles such as Microsoft's Xbox or Sony's PlayStation boxes.
In its first Intermountain incarnation, the Xi3 is becoming the chief enabler of room-to-room telemedicine services I described in the October 2013 issue of HealthLeaders magazine. From any Web browser, an Intermountain physician can establish a videoconference to the patient's room, as well as other room controls and information being generated by sensors in the room, Holston says.
At CES, however, Intermountain demonstrated the Xi3's set-top box capability to enhance the patient experience, providing patients with a rich computing experience of their own, ranging from Internet-based videoconferences with friends and loved ones to the kind of immersive movie watching and video gaming experiences that CES is known for.
Intermountain's Transformation Lab, which Holston runs, is still defining what kind of controller the patient will be using, but the term BYOD could take on new meaning. Holston tells me the healthcare system may give patients the option to bring their own consumer devices, such as tablets or phones, to access the in-room video and Internet services.
If such a scenario comes to pass, for security and simplicity purposes, Intermountain would restrict the patient's device to a specified set of commands and interfaces. Holston doesn't want to have nurses distracted by having to teach patients how to use the system. Or, patients without their own devices might receive a tablet from Intermountain for use while in the room.
Intermountain is starting with ICU and ER scenarios because patients in those rooms are less likely to be using any device during their stay, but I can easily imagine the BYOD phenomenon breaking out once the pilot reaches main hospital beds.
Patient education will get a boost too, since the same infrastructure that delivers movies or games can also deliver interactive content about everything from procedures to patient discharge instructions.
Then there's the continuous monitoring aspect. Like other systems, Intermountain is demonstrating VisiMobile wrist-worn tech from Sotera Wireless that delivers a stream of continuous patient vital sign data to the electronic medical record. I was interested to learn that Sotera just received FDA approval to add the first-of-its-kind cuffless, continuous blood pressure monitoring to its mix of generated data.
That might give patients something beyond value to healing–a good night's sleep.
"in a normal monitoring floor, nurses come around every two hours to wake you up, and then they take vitals with all these things they haul in here, and they run back to a machine and type it all in and document it," Holston says.
"So what if I took all that away? I let you sleep all night. I continuously get the data. I auto-document every 15–20 minutes, into the EMR and do all the alarming from that, and then all of a sudden I've got this beat-to-beat data set that I can learn things about patients and certain things that we discover they have—diseases, situations, whatever, and I discover new things I never knew before, because I've got new data."
All of this new data, however, puts demands on the in-room PC, as do the requirements of streaming live video or delivering a fast-action video game. Hence the Xi3 running Windows 7 initially, because a zero-client PC can't keep up with these processing demands, Holston says.
"You need something closer than the data center, and for us that's a server in the patient room," he says. The responsiveness of the Xi3 hardware will also let the patient control the environment of the room, including light, power, and air.
Although it's also quite possible to run Linux on this kind of hardware, Windows gets the nod because of Intermountain's comfort level with the Microsoft operating system, and because the Transformation Lab is writing the software running on the Xi3 hardware that makes all this work.
Lastly, if Xi3 or something similar takes off in the home – something I think is possible due to the hardware's modular design, simplicity and small physical and energy footprint – Intermountain could be well positioned to be able to take the next step and implement its hospital bed of the future outside of the hospital's walls, in homes or longterm care facilities.
If you want to see just how far information technology can move in transforming healthcare, this latest incarnation of the personal computer is worth watching.
Although electronic health records are known to reduce healthcare costs, concerns about accuracy and usability—and the risk of EHR-caused medical errors—are growing.
This article appears in the December issue of HealthLeaders magazine.
The move away from paper medical records to EHRs has many benefits, but the flip side is that providers need to carefully manage the usability, accuracy, and audit trails of EHRs across the entire care team.
Providers say the day of the doctor carefully controlling and supervising every aspect of a medical record is giving way to an age where the entire medical team and even patients will scrutinize and update a record's accuracy, all while legal and regulatory requirements for maintaining those records are met. At the same time, the complexity of EHR software itself increases the risk of EHR-caused medical errors.
While EHRs have been around for years, the requirements of meaningful use stage 2 for patients to be able to view, download, and transmit their medical records to providers across the care continuum as well as health information exchanges mean it is time for providers to pay special attention to proper record maintenance.
Dealing with errors in the record is coming to the forefront of these concerns. "Traditional practices within the paper record support a single-line strikethrough of the original documentation," according to Amendments in the Electronic Health Record Toolkit, a 2012 paper published by the American Health Information Management Association. "However, these practices will not necessarily transfer to an electronic environment, and new practices should be evaluated against organizational policy and specific system limitations."
AHIMA's paper also advises: "Processes for receiving the patient amendment request identifying PHI affected, determining whether it should be accepted or denied based on the type of request, and notifying the patient of the outcome must be developed."
Further complicating the picture: As physicians move from clinic to clinic or hospital to hospital during their workday, they are using EHRs from multiple vendors, and each EHR may express discrepancies in the medical record differently.
"They may have multiple different interfaces to deal with," says Blackford Middleton, MD, chief informatics officer and professor of biomedical informatics at Vanderbilt University Medical Center, a 626-licensed-bed hospital in Nashville.
Although EHRs improve quality and patient safety and are known to reduce costs, there may be problems associated with their use, and they can even cause medical error, he says.
Middleton likens the abilities of today's EHRs with those of the challenges of using word processing in the late 1980s, when such software ran into usability and interoperability problems.
"Standardizing interoperability means not only the idea of sharing data between system A and system B, but also the idea that the clinician who's rounding at the hospital in the morning, seeing patients all day in [the] clinic, and rounding at a different hospital in the afternoon, can have a calming sort of user experience, if you will," Middleton says.
At the same time, he adds, "We're moving well away from kind of the doctor-on-a-pedestal or omniscient, all-knowing clinician, to someone who, ideally, is collaborating with a patient, designing care goals together, and helping the patient toward those goals in a very effective manner."
Middleton arrived at Vanderbilt in February 2013, having previously been at Boston-based Partners HealthCare and Harvard Medical School. Vanderbilt uses a homegrown EHR, and over time the medical center is showing more of this EHR to patients. "There are reports from operating rooms and procedures and whatnot, but we don't show the full notes yet," he says.
"With docs and nurses and even patients now documenting into electronic tools, what's the quality of the information as documented? For the legal record to evolve to be inclusive of the electronic record and its core components, we have to have the same kind of amending or addending process that is the rule, or the standard of practice, for the paper-based record," Middleton says.
In 2012, Middleton coauthored a paper for the American Medical Informatics Association, Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. The paper recommends that providers give systematic feedback to EHR vendors to improve EHR usability and safety.
Meanwhile, patients are more and more able to suggest annotations for the clinician's record. The Open Notes movement—which began as a Robert Wood Johnson Foundation study at Geisinger Health System and research done at Beth Israel Deaconess Medical Center and Harborview Medical Center—has spread to the Cleveland Clinic. All told, including patients of the Veterans Administration, 1.8 million patients nationwide are able to access their medical records.
In the event of patient feedback, "it's up to the clinician to write something useful in the record to take note of the patient's input," Middleton says. "There has to be an auditable trail of all such changes to the record, as the record becomes increasingly an important point of collaboration and communication between doctor and patient, and nothing should ever be deleted. It may be suppressed and invisible, but one needs to be able to review that through an audit kind of report."
All these changes reflect a groundswell in modern U.S. healthcare toward much more transparency in everything providers do, Middleton says. "There's no point in resisting it. We need to be transparent in the services we deliver, in the cost of care we deliver, and the value, so that employer purchasers, patients, and everybody can make informed choices. Make sure you write your notes with the idea in mind that they will be public."
For that matter, consider that maintaining the quality of an electronic health record is an ongoing responsibility of the entire medical team, says Rachel Chebeleu, corporate director of professional fee abstraction at the 805-licensed-bed Hospital of the University of Pennsylvania in Philadelphia.
"You need people who are concurrently, proactively auditing your records for copy-and-paste issues, for copy-forward issues, and for just general compliance," Chebeleu says. Those tasks should not be relegated to billing specialists or coders but instead be assigned to staff who will audit records for their clinical quality, she adds.
"There might be some nurses who really know clinical content well, are not interested in being on the units anymore, and will just go through records and audit them, the important record-type entry stuff," Chebeleu says. The same audits can examine practice patterns, she says.
EHR audit productivity also needs to be overseen. "You don't want someone who gets so immersed in the record they are able to get through only two a day," Chebeleu says with a laugh. Penn Medicine, the system to which the Hospital of the University of Pennsylvania belongs, uses Allscripts' Sunrise Acute Care (formerly Sunrise Clinical Manager) as its EHR for inpatient computerized physician order entry and discharge summaries, and is now implementing physician notes starting with its rehabilitation facilities.
In its outpatient practices, Penn Medicine uses Epic EHR software, which in the next few years will replace Allscripts on the inpatient side, as well, Chebeleu says.
The governance challenge of achieving quality in EHRs is foremost in Chebeleu's thoughts. "Get the people who care about it" involved, she says. "Get risk management on board, your general counsel on board, your compliance department, your coders, even the quality people," she says. Find the necessary funding and tackle the problem proactively, she suggests.
"This will cut off at the pass a lot of problems you could have if you don't do this," Chebeleu says. "Even if you invest one full-time equivalent, pilot it."
The move to a team-based effort to improve the quality of the medical record "flies a lot in the face of our traditional conception of the medical record as something that belongs to the doctor [and] belongs [only] to the health system," says Jeffrey Linder, MD, a general internist in the division of general medicine and primary care at the 800-bed Brigham and Women's Hospital, part of the seven-hospital Partners HealthCare system.
Until recently, Lindner served on the executive committee of the Longitudinal Medical Record, Brigham and Women's homegrown electronic medical record. Linder still serves on the adult primary care expert panel at the hospital and, like almost all Brigham physicians, has a faculty appointment at Harvard Medical School as an associate professor of medicine.
"It's a big shift to move from that to a more collaborative space where patients can enter data that's useful for their care, that their doctors want to see, but it's also curated and accepted into the record by some clinician," Linder says.
The big flood of nonphysician, nonclinician–entered data that Linder has anticipated for the past five years has yet to arrive, but he fully expects it.
Toward that end, Partners is creating a section in its EHR for patient-entered data. A clinician will need to review the entries and accept them into the chart, but those entries will remain labeled as patient-entered data. Data that is not accepted into the record will also remain, but "my impression is you'd really have to go looking for stuff that wasn't accepted into the record," Linder says.
At the same time that this is planned, Partners is in transition from LMR to Epic, due to be deployed across both inpatient and outpatient systems in 2015, Linder says. "The new healthcare landscape will challenge us to engage in population health management, improve the coordination of healthcare, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges," Linder says. Between now and then, Partners will conduct due diligence to make sure that Epic's capabilities allow the kind of audit trail and other features it requires, he adds.
"We're very interested in having patients enter their own blood sugars and blood pressures and having some mechanism of allowing them to," Linder says. "The only mechanism right now for them to correct their data is via messaging. If they notice a problem that they disagree with, currently it's not really a collaborative space, where the practice and the patient are jointly curating the information in the medical record."
Like the other providers, Partners faces its own governance challenges during this transition. "The other cultural problem we're running up against that we're going to have to work our way through over the next decade is our conception of medical care—the unit of medical care," Linder says. "Right now I work in the ambulatory setting, so we're very focused on visits still, and hospitals are very focused on hospitalization, and so the record is designed around discrete events like that."
Thus, documentation of a medical record today remains largely the story of what was done at a particular visit. "Hopefully we're moving toward a health system that's focused on taking good care of you, whether or not you happen to be in the office at that moment," Linder says. "That shifts the value from visit-based data to the latest instance of the electronic health record as the truth, and that can happen at any time. It's not dependent on a visit."
Of all the stakeholders in healthcare, the ones most concerned about how the medical record evolves are probably the health systems' attorneys. "It's our lawyers who are most interested about keeping a record of everything that happens," Linder says. "Our health information systems department is very focused on keeping a record this way."
Even now, LMR records have a "history" button next to many coded elements, Linder says. "You can kind of delve into the history and see who updated it, and how and when," he says. "But if you think about all the moving pieces in an electronic health record, every single one of those elements has some mechanism for capturing histories behind that element, and it's a lot of data that nobody really has the time or inclination to go through, so it's challenging. It's definitely challenging."
Reprint HLR1213-5
This article appears in the December issue of HealthLeaders magazine.
Our guest columnist recounts the IT-clinical partnership at Sarah Bush Lincoln Health System that reduced ED patient walkouts by 1.2% and increased co-pay collections by 26%.
Guest column by Maggie Ratliff, Vice President & CIO, Sarah Bush Lincoln Health System, with Brian Murphy, IT Technical Director
Maggie Ratliff, Vice President & CIO,
Sarah Bush Lincoln Health System
Sarah Bush Lincoln Health System is going Lean. Our organization, a regional health system in central Illinois, has implemented a very aggressive process improvement strategy based on Lean Six Sigma practices. While the effort necessarily involves many functions within the organization, IT has a particularly important role to play.
In less than two years, the process improvement program has already resulted in hundreds of thousands of dollars in verified savings. We created a new "Performance Excellence" department and trained a number of facilitators to lead the charge. In just a few months, the Performance Excellence group has already conducted dozens of Rapid Improvement Events (RIEs). Further, to ensure that day-to-day Lean thinking is ingrained into our corporate culture, all directors, managers, and supervisors are now required to complete a Lean training course in their first year of employment, where they learn the tools and techniques of Lean and initiate their own improvement projects.
While Lean Six Sigma has many facets, the basic strategy is surprisingly simple. By focusing on driving the waste out of our processes and creating systems for continuous improvement, we reap the benefits not only of cost control but also improved quality of patient care.
By involving all areas of the health system and encouraging improvement at all levels, we have touched on a wide range of processes, from those as simple as reordering supplies to those as complex as a door-to-discharge examination of patient throughput in our emergency department. By involving frontline staff in cross-functional teams, we have been able to improve multiple aspects of shared workflows. In all of these projects, IT support has been essential.
In the example of our deep dive into the emergency department throughput, the Lean teams sought to both reduce patient walkouts and increase collections of co-payments. Once the improvement teams were formed, the teams mapped out the current state of our patient flow, identifying and eliminating those points in the process which did not add value to the patients or caregivers. Envisioning an ideal state and creating a roadmap to achieve it, the teams developed standard work to reduce variation and opportunities for errors. In conjunction with IT, they also identified key points where the judicious application of information technology could save time or add flexibility to work flows.
Our IT group bought a small number of laptops and mounted them on repurposed mobile carts we had in storage. This allowed our registration clerks to leave their stationary desks and meet patients at the bedside, rather than requiring that they spend additional time in the waiting room. We provided headset radios and pocket phones to the now mobile staff. Rich Fanelli, our Director of Patient Services, cites the use of this equipment and the ease of constant communication as critical to the success of the ED throughput project.
As patients enter the emergency department, they are greeted and received into our electronic system with very minimal information. They are quickly triaged and moved to a bed, allowing clinical staff to begin care almost immediately. The registration clerk completes the patient's registration and insurance verification at the bedside. Once treatment is complete, a "pending discharge" status is indicated on a patient tracker board. This prompts the registration clerk to return to the room and speak to the patient about any insurance co-payment.
In the first 90 days following the implementation of these changes, we have reduced patient walkouts by 1.2% and have increased co-pay collections by 26%. Emergency Department and Patient Services management continue to monitor key metrics at various points in the overall workflow to help identify further opportunities for improvement. This is just one example of the many benefits our organization has realized from leveraging appropriate technology in our Lean process improvement initiatives.
Fred Trotter has written a book called Hacking Healthcare, but now he is going to try Hacking HIPAA. That's the name of Trotter's newest venture, a crowdfunded project aimed at circumventing standards bodies and sluggish healthcare giants in order to bring HIPAA into the 21st century.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
At an impromptu lunchtime gathering in Silicon Valley's Computer History Museum, Fred Trotter is drawing lines and boxes on a whiteboard. From around the room, other programmers, healthcare IT experts, and a privacy expert or two toss in suggestions. Trotter excitedly adds to the drawing, challenging some suggestions as he goes, accepting others, and even raising a skeptical eyebrow at his own work.
It's all in a day's work—and play—for the author of Hacking Healthcare, who this May day was helping lay the groundwork for a crowdfunding project known as Hacking HIPAA, which tries to circumvent ponderous standards bodies, sluggish large healthcare giants, and secretive startups to bring HIPAA into the 21st century by clever coding and collaboration.
Trotter will be the first to tell you this work sure beats trying to change things by legislation. If anyone can pull it off through the wisdom of crowds, it's Fred.
"More and more I have been doing things where somebody decides to pay my bills for a little while, and I go and do what I think is the most interesting thing ever," Trotter says.
One of the latter inspirations got its initial crowdsourced funding of $45,000 in 2012. DocGraph, the result of a Freedom of Information Act request, was Trotter's first foray into crowdfunding liberated health data. It started with a set of data from CMS he liberated that contained 60 million referral relationships, nearly 80% of the referrals doctors make to each other in the United States.
He released the data set to attendees of Strata Rx, a healthcare data analytics conference, and reverted to a Creative Commons license. The goal: To create multiple doctor-rating algorithms that patients can use and doctors find fair. "The current credentialing system is abysmal," he says.
DocGraph didn't stop with referrals. Analysts could use Trotter's Freedom of Information Act–obtained data to see which hospitals have poor central line infection rates, and more. A few months later, without further FOIA prompts, CMS stepped up its own release of hospital quality and pricing data—and Trotter's early breakthrough probably shares credit for making that happen faster.
"We are not just building better data systems. We are building a new kind of mind, and that is precisely the place where you need to have ethics deeply embedded," Trotter said at his O'Reilly's Strata Rx 2012 talk.
For all his iconoclastic tilting at medicine's windmills—Hacking HIPAA failed to receive its needed crowdsource funding by its initial August 2013 deadline—it might surprise you to hear that healthcare IT is the Trotter family business, if you will. Trotter's grandfather owned a franchise for Medical Manager, which Trotter says was a very popular practice management system in the 1980s. His aunt and uncle also worked on Medical Manager as well.
But Trotter took a side trip or two before settling into healthcare IT. His first job was doing Internet security for the Air Force Information Warfare Center as a contractor. During a subsequent set of lucrative Internet jobs, he met current collaborator Ashish Patel, an expert at security networking infrastructure of large hospitals.
The return to healthcare was prompted by Trotter's mother being diagnosed with ovarian cancer. "It's almost always progressed too far by the time you even know it's there, which is exactly what happened to my mother," he says. In short order, Trotter made major life changes, getting married, joining the Marine Corps Reserve, and taking over research and development at his family's business.
"The first question I asked of health IT was, what kind of system would need to exist that would be able to make a better guess about my mom's symptoms than what the doctor did?" Trotter says. Now he realizes he was imagining a system similar to IBM's Watson, emerging computer technology that understands natural language and reads vast amounts of healthcare data to generate hypotheses and different probabilities of various outcomes.
"I realized that there were just so many Lego pieces beneath Watson that needed to be built, that I was probably never going to get to that in my career, and I haven't," Trotter says. "I haven't even come close to those kinds of aspirations, but I had a significant impact on all these lower-level Lego blocks."
Then there was the process by which Trotter and coauthor David Uhlman arrived at the title for their book, Hacking Healthcare: A Guide to Standards, Workflows, and Meaningful Use.
"We debated that issue, who was going to be pissed off by this book title," Trotter says. "We spent a lot of time thinking about that, and then we came to the conclusion that all the right people would be pissed off by that title. So we decided that we would move forward under that rubric. So yes, there are people who don't like the title and don't like the thesis, and in general, I find that completely and utterly okay."
Trotter is bullish on the future of crowdsourcing healthcare IT. "I just realized, way back when I was doing my very first systems, that I wasn't the smartest person I knew who was working on the problem I was working on, and that I wanted to collaborate and be ruthless about collaboration," Trotter says. "I always did everything I could do to get my work out there in front of people who I thought were smarter than I was."
Like a lot of open-source advocates, Trotter struggles with IT seesawing between setting standards to promote interoperability and promoting innovation through open-source projects. "It's a curve ball for the whole healthcare system," he says. "MITRE [a not-for-profit organization that operates research and development centers sponsored by the federal government] did an analysis which showed a fairly reasonable correlation between the complexity of the clinical quality measures and the rate at which they were adopted in the EHR developer community. More studies need to be done on that.
"We should be using a method of evaluating quality measures; I became a lot less confident in our system of quality measures because I don't see the evaluation happening."
To understand how Trotter thinks, you have to immerse yourself in what has made open source, with its meritocratic ways, successful in IT. "Collaboration without meritocracy is communism,"
Trotter says. "You have to have a meritocracy, so if you and I were working together, and we get to have equal votes on what ideas get implemented, then we have a problem, because you get a hundred people in a room, the lowest common denominator will always get the vote. If you look at HIMSS and the American Medical Association, any of the big associations, unfortunately, the lowest common denominator is what those organizations very frequently spew out. The exact opposite happens in the open source community."
With all the challenges still ahead for healthcare IT, count on Trotter to be raising those skeptical eyebrows a bunch more, and then getting back to work and urging others to join him.
David Green might be the most disruptive force in medical devices today. Green's startup companies are revolutionizing the high-end hearing-aid market and the intraocular-lens market for correcting the vision of cataract patients.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
David Green might be the most disruptive force in medical devices today.
Green's startup companies are disrupting the high-end hearing-aid market and the intraocular-lens market for correcting the vision of cataract patients.
The truest form of Green's disruptive thinking is the way he proved it could be done profitably with broad implications for making medical devices more affordable for people who cannot afford them.
Green's achievements, featured on National Public Radio and elsewhere, originated in developing countries but are now coming to his native United States.
"I'm helping to set up an eye hospital in San Francisco that will take what we've learned in emerging markets and transfer it here to create a revenue model where the enterprise uses its profit and production capacity to serve uninsured Medi-Cal dual-eligible and undocumented" patients, Green says.
The story begins in 1992 when Green started Aurolab, a company dedicated to making price-busting intraocular lenses, sutures, and pharmaceuticals. The artificial lenses implanted during cataract surgery then cost $300. Countries such as India performed only 800,000 cataract surgeries annually. Working with Aravind Hospital in India, Aurolab initially offered a $10 artificial lens, and India's implant volume skyrocketed to 5 million in 2001. Today, the average price of the same implant is $3 to $4 and can be as low as $2.
"It created a whole price-competitive ophthalmic industry, not just for intraocular lenses, but for all the consumables and equipment used in ophthalmology," Green says. For instance, Aurolab's suture manufacturing lowered the cost of a box of ophthalmic suture from a "monopoly competitor" price of approximately $240 to Aurolab's $23.
Green's next startup, Sound World Solutions, has begun marketing an innovative, aggressively priced hearing aid developed by partner Stavros Basseas. The device will cost a couple hundred dollars, far less than comparable high-end hearing aids.
Now Green is about to market a high-end retinal imaging system, which usually costs around $22,000, for only $5,000 to serve low-income populations. This third company, Brien Holden Vision Diagnostics, will also bring to market a highly affordable device to detect and measure brain concussion, glaucoma, and various neurological disorders.
Although Green's innovations require plenty of inventions and patents, his real strength is in redesigning the supply chains that often add excessive margin at every step of bringing a medical device to market. By analyzing and reimagining these supply chains, Green targets ways to remove "non-value-added-margin" to keep products affordable.
"If you reach the low-income strata in a meaningful way, it increases the volume of people coming who pay the higher-margin prices, and that's what makes these programs viable and sustainable," Green says. "That's what enables them to generate the margin to be profitable and to be able to do cross-subsidization, so it's all kind of like a whole virtuous ecosystem, which is in marked contrast to the present non-virtuous ecosystems that you find in most medical ecosystems where basically you're trying to maximize return on investment at all costs."
Device makers are paying attention. In India, Medtronic is working with consulting firm Innosight to market lower-cost pacemakers through the Healthy Heart for all initiative. "I'm sort of the architect behind that," Green says. "I helped them figure out how to take a Medtronic product with different branding, and how to create a different supply chain pathway to reach lower-income patients who were qualified to be below a certain income with an affordably priced pacemaker."
The lesson Medtronic and others are learning from Green: If you reach the lower economic strata in a meaningful way, it will increase the device maker's volume of higher-margin patients as well.
Unlike the world view of various nonprofit foundations and non-governmental organizations, Green believes in the free market's ability to innovate even among vast populations afflicted by poverty.
"Where I intervene is I address the pricing disparity," Green says "How do you make sight or hearing or life itself affordable and accessible to low-income people? Everything I do, it's using the tools of capitalism. I've learned just by trial and error that the tools of capitalism work to convert need into demand and to be market driving, whereas charity doesn't work."
Green draws upon a degree in health behavior, health education, and a master's degree in public health from the University of Michigan. He has no formal engineering or economics background. "I find people with extreme technical competence in whatever the arena is, and then I work with them," he says. "I assemble teams and craft business models."
Lately, Green also arranges a fair amount of financing for startups following his startup methodologies, financing such as helping Deutsche Bank create a fund that provides debt financing for eye care programs. "The whole thing about self-financing, if you're generating more money than you're spending with the social twist, that means that you're being very efficient and effective in what you're doing," he says. "You're reaching the market with something that they want. You're creating demand. They're marching to your doorstep because of accessibility and quality, and again, that's what changed the competitive landscape."
Both Sound World Solutions and Brien Holden Vision Diagnostics were capitalized in the $10 million to $12.5 million range. "A lot of the social investing funds out there are risk-averse and only put money into revenue-generating entities," he says. "It was a lot of work to capitalize those companies, and I'd like to see funds that are more into early stage risk capital for pre-revenue for companies that can be transformative in the healthcare space. That's a really big issue."
Meanwhile, Green's innovations have touched the lives of millions of people already. "Aurolab has helped 18 million people see, and that's just with the lenses," he says. "The eye care programs that I helped develop, collectively they do something like 800,000 surgeries a year, and treat 6 million people a year."
But Green hastens to add: "It's not just me, but it's all the different groups that I've helped develop and help direct how they scale, which is really an economic model, rather than a donation model."