EPtalk by Dr. Jayne 6/7/18

Quite a few of my clinical informatics colleagues do public health work and the discipline is certainly part of the informatics board exam. I enjoyed this article mentioning the return on investment for public health interventions. As the article notes, funding for public health is low because “the private sector can’t make money on it.” Many of the interventions are long-term plays, such as the return on investment for vaccinations or disease prevention. In many situations, by the time the “savings” happens the patient will be on Medicare, so unless there’s a shorter-term benefit payers might not be willing to spend the money.

Given the current mobility of our work force, employers are challenged to see return on investment for the longer-term conditions as well. Even in this high-tech day and age we still struggle with things like safe drinking water. It’s not just in underdeveloped nations – it’s in places like Flint, Michigan. Even if spending on public health didn’t have demonstrable ROI, it’s something we should simply consider as the right thing to do for the future of humanity.

I just finished reading Atul Gawande’s book “Being Mortal,” which should be required reading for broad segments of the population, such as people who have elderly relatives or anyone who might at some point be elderly, which is (hopefully) most of us. I’m a huge fan of his work and now that I’m at a point in my life where handling affairs for elderly relatives is a reality, it was a timely read. It’s good for those of us who live on the bleeding edge of all kinds of healthcare technology to think about the value of interventions and, as Gawande says, “what matters in the end.”

Speaking of reading, one of my favorite professional journals is Family Practice Management, put out by the American Academy of Family Physicians. Historically, family medicine residency programs have put an emphasis on being able to actually run a successful practice, not just learning the medicine, and the journal cuts to the chase on many of the financial issues that primary care physicians face today. The journal’s online “In Practice” blog addressed quality reporting this week, simplifying some principles that I know many physicians are not thinking about when they consider MIPS quality measures reporting.

Here’s the Cliffs Notes version for those of you who advise physicians in this area. Because they care about their patients, physicians are often tempted to report on measures that have clinical significance to their practice, or on measures that they know they are doing well on. However, this doesn’t take into account the fact that MIPS quality reporting is based on performance to a benchmark and that decile scoring is involved. Even though a provider might do the “right” action 90 percent of the time, which sounds like good performance, if the rest of the world is performing that action 95 percent of the time, the provider may receive fewer points than they expect because they’re actually a low performer relative to benchmark. Some of these measures are also considered “topped out,” where the benchmarks are high enough that it’s extremely difficult to make it into the top decile.

Physicians may also not be aware of bonus points available for high-priority measures or certain reporting strategies. For providers trying to navigate MIPS and other programs on their own, it’s very challenging to understand all the nuances. I would encourage them to reach out to their professional societies to see what guidance is available, whether by specialty, region, or practice type.

The American Academy of Family Physicians does a fair amount of advocacy work for docs in the trenches. I applaud their recent efforts to encourage major national laboratory vendors such as LabCorp and Quest Diagnostics to improve reporting mechanisms so that data is more easily shared among care teams in value-based care paradigms. They’re also encouraging the labs to facilitate data sharing for small practices so they can more easily stay in the game and not be burdened by interface and other costs.

I’d love to see AAFP get into the fray with them (along with many other labs) about reporting LOINC data with results. LOINC codes are critical to strong performance in several reporting arenas, and when codes aren’t sent, it can result in low data quality or large amounts of manual work for practices to try to map results to codes. The latter can be problematic due to many LOINC codes for tests that are similar but not identical, resulting in errors.

I used to provide LOINC mapping for my clients, but there ended up being so much back-and-forth with the performing laboratories and too little information available in their online test directories to the point where I couldn’t make it a cost-effective offering. Ultimately, the performing laboratory is in the best position to know exactly what test they are performing and which methodology is being used, which drives the code. I’d like to see reference labs be mandated to provide the codes in results transmissions so that providers can have solid data.

Failing to require labs to send LOINC codes reminds me of requiring physicians to e-prescribe but not mandating that pharmacies deploy systems that can accept electronic prescriptions. Our patients deserve better and it’s time for non-provider parts of the healthcare system to start ponying up.

It’s never too early to begin shopping for great shoes for HIMSS parties, so I was delighted when a friend sent me a pic of these sparkly numbers. Alas, they’re halfway across the country, so I won’t be getting them, but they give new meaning to the term “reach for the stars.” Speaking of HIMSS, now that it’s summer it’s probably time for me to think about booking my hotel so I don’t get stuck riding the shuttle bus from somewhere in conference Siberia.

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