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EPtalk by Dr. Jayne 5/18/17

May 18, 2017 Dr. Jayne No Comments

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The National Patient Safety Foundation is holding its annual Patient Safety Congress this week in Orlando. This is the first meeting since NPSF merged with the Institute for Healthcare Improvement at the beginning of this month. I’m a big fan of both organizations, not only because patient safety is such a big deal, but because they both offer accessible and cost-effective training for practices and organizations trying to improve their safety culture.

Awards programs recognized NYC Health + Hospitals/Bellevue for their primary care diabetes program and recognized Christiana Care Health System for a care coordination program aimed at reducing readmissions. For all of us who complain about EHRs, we need to remember how hard it was to pursue these types of initiatives with paper charts. If you missed it, next year’s Congress will be held in Boston from May 23-25.

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Although telehealth continues to be promoted as a way to increase access to patient care and reduce costs, it isn’t being widely adopted in the primary care trenches. Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care queried family physicians to understand their use of telehealth and what barriers exist that prevent expansion. The results were published in the Journal of the American Board of Family Medicine and indicate that although many of us are interested in providing these services, few of us are actually doing it. The survey is somewhat limited by its 2014 data; it would be interesting to see whether adoption has been driven forward given changes in technology and payment policies. At the time, however, only 15percent of respondents had used telehealth services during the year, with many using it only a handful of times throughout the year.

The most common uses of telehealth services included diagnosis/treatment (55 percent), chronic disease management (26 percent), follow up (21 percent), second opinions (20 percent), and emergency care (16 percent). I always shudder when I hear about virtual care of emergency problems, but many of the “emergency care” situations aren’t truly emergent in reality, so perhaps this number isn’t as shocking as I originally found it. Those using telehealth were more likely to be rural, have an EHR, and be in a smaller practice that was less likely to be privately owned. Respondents cited lack of reimbursement and lack of training as obstacles to use – both among those who used and did not use services. The authors recommend that residency training be expanded to include telehealth services and that payers should expand coverage.

Personally, I don’t see the latter happening. As we shift towards value-based care, it’s more likely that physicians will explore telehealth as a relatively low-cost care option, at least compared to office visits. As physicians receive bundled payments and operate under payment systems that are tantamount to capitation, they’re going to look for alternatives to bringing people in.

What remains to be seen is how well telehealth vendors will be able to integrate their solutions into mainstream EHRs and how clunky the arrangements are. I’m working with a third-party care management vendor with one of my clients and the technology itself is a major barrier to use. They actually partner with the primary care office to provide telehealth chronic care management services, which the primary care practice bills for under the Medicare Chronic Care Management codes. The vendor has nurses and care managers who review patient-generated data such as daily weights, blood pressures, blood glucometer logs, and more.

The vendor’s employees meet with patients and document care plans and progress, then send the information back to the EHR. In principle it sounds great, but in practice it’s a tangled mess.

First, the vendor offers a standalone patient portal and wants the patient to submit all their data and conversations that way. This directly competes with the practice’s patient portal and creates confusion for the patient on what kinds of questions should be sent to the office and what should be sent to the care management portal. Although the practice sends data to the vendor discretely, what is pushed back to the office to document the virtual visits and care plans comes back as an image. That means it lives in a separate place in the patient chart from all the other data that physicians are reviewing when they see the patient.

Apparently the root cause of this disconnect is the fact that the third party wanted to quickly partner with multiple EHR vendors to sell its chronic care management services, but the EHR vendors were too busy building certification requirements into their products to be able to build the kind of integration that needs to happen. Unfortunately, my client (the practice) didn’t pick up on this during the slick sales demo, and now is stuck with this hybrid approach, at least until their contractual obligations end.

They’ve stopped enrolling new patients in the service in the meantime and are struggling to stand up their own care management team, which is how I came into the picture. Their EHR has great care management content but just couldn’t handle the billing piece, so we’re working through that gap. They will fully separate from the third party in a few months and I’m confident they’ll be able to ramp up their own program. The practice may not have the same slick videoconferencing capabilities that the third party had, but they can practice telehealth the old fashioned way — via phone. This approach can still help with access issues and cost issues as well as reduction of readmissions. We’ll see how it goes.

As a side note, I’m waiting for the EHR vendors I work with to get through all their regulatory certifications and mandatory releases so they can get back to the business of enhancing usability and coding features that their users actually want. Of course, I’m not delusional enough to think that there won’t be some other burdensome pack of regulations coming right after, but there might be a window of opportunity to do some good work before it hits.

Email Dr. Jayne.

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