Readers Write: Value-Based Healthcare Drives “Left of Bang” Approach for Risk Management and Compliance

Value-Based Healthcare Drives “Left of Bang” Approach for Risk Management and Compliance
By Mark Crockett, MD

Mark Crockett, MD is CEO of Verge Health of Charleston, SC.

In 2007, the Marine Corps deployed to Iraq and Afghanistan had a problem: how to identify an enemy that blended in with the population. They developed a behavioral approach to helping teams sharpen their tactical awareness skills to remain “left of bang,” or to fend off hostile actions before they culminate in the “bang” of conflict. In 2017, healthcare needs to deploy the same approach to managing risk and improving outcomes.

Healthcare is currently focused on right of bang, or the future correction of adverse events. Too much effort is expended to react to problems that have happened, and aren’t directed to preventing failure. The military (and other industries) expect that more than 80 percent of efforts should be spent left of bang to reliably prevent failure. A shift to a balanced approach is beginning to happen in top health systems for the first time, and it’s critically important for healthcare leaders to understand the how and the why.

How we got to the current right of bang problem is pretty clear. As a physician, I see failure all the time. Kidneys fail, hearts fail, and ultimately people fail. Dealing with that compassionately and professionally is part of the territory. Financial models have not helped at all. Under straight fee-for-service medicine in the past, if I gave someone an infection, it was quite possible I could bill them for a follow-up visit and perhaps even the antibiotics. In that kind of model, preventing failure is working against your economic model, making success in prevention just that much harder.

Times are changing fast. In the last few years, an array of accrediting bodies, regulatory entities, and payment model changes have made failure punishing to a health system’s finances and reputation. It’s now possible to see quality and adverse events on a dozen web sites, and more every day. Readmission prevention, Healthcare-Acquired Conditions, MACRA, MIPS, etc. are all ways of demanding reliable and efficient care. Health systems fail to execute on quality and safety at their risk: competitors across town that are doing it well are looking to expand and acquire patients and even facilities.

For one California-based hospital system, their timeline-oriented thinking – and solutions – needed to become left of bang. One of their hospitals had implemented a Six Sigma plan to reduce central line infections. Six Sigma is a popular methodology that takes a data-driven approach to eliminate defects in any process. The approach aims for six (or fewer) standard deviations between the mean and the nearest specification limit.

Using Six Sigma, the hospital system found a catheter that was superior in their opinion and a skin sterilization technique they knew worked. That single hospital then worked through the purchasing process, the stocking of the catheter, the sterilization procedures, and finally, implemented a process that ensures no one touches the catheter until the surgeon is ready to insert it into the patient. These improvements eradicated central sepsis at that hospital for more than five years. It was an amazing feat compared to industry standard. This completely redefines the concept of “expected complication” to “zero complications,” and unequivocally saved lives.

It’s a great thing when you can eliminate sepsis in central lines. But five years later, the multiple-hospital system still had a small number of hospitals using the technique. They had no means of assessing system-wide compliance with the Six Sigma process design, which at best was being implemented inconsistently. They simply have not organized left of bang. They admitted they lacked the ability to bring about system-wide change from what was learned at one hospital.

“We know how to prevent central line infections,” said one team member. “But without strong leadership, and the technology to implement the safety procedures system-wide, we find ourselves fixing the same problem every three years. We get serious about a problem, design a solution, and implement it. Then institutional inertia takes over. Two years later we are seeing adverse events, or worse, and ask ourselves ‘Where is that folder on the way we prevent catheter infections?’ It’s just not good enough.”

Getting hospitals to look for patterns in identifying adverse events, and working to identify them before they occur, keeps clinicians and staff in perpetual left of bang mode. But process improvement through Six Sigma isn’t going to enable this essential shift to a safety-first culture. Neither will the latest software or the best management training. It’s going to take all of these approaches – and more – for healthcare to truly see the results and outcomes that payers demand from providers.

Readers Write: Why Healthcare Organizations Take So Long to Make Buying Decisions and How We Can Fix It (Part 2 of 4)

Why Healthcare Organizations Take So Long to Make Buying Decisions and How We Can Fix It (Part 2 of 4)
By Bruce Brandes

Bruce Brandes is founder and CEO of Lucro of Nashville, TN.

As any industry observer knows, health systems continue to consolidate in an attempt to ensure their viability given unprecedented financial and operational pressures.  Many organizations struggle to fully leverage their scale post-merger. Most often the difficulty is to align focus, priorities, internal knowledge. and industry experience across the expanded team as they integrate.  

Misalignment is usually the main contributor to the length of the sales and purchasing process. Too often people fall in love with a PRODUCT without first clearly defining the PROBLEM they seek to solve. This challenge is exacerbated by complex purchasing decisions that require collaboration across multiple stakeholders to make the right choices.

My 16 year-old daughter, Lily, recently got her driver’s license and immediately spent lots of time and energy looking to buy a car (product). Much to her chagrin, the head of home operations (my wife) and the economic buyer (me) defined the problem as our daughter needing transportation, and buying a new car was only one of several options for us to address this issue. As we considered how to best solve her transportation problem weighed against other family priorities, we decided to simply get Lily an Uber account and an extra key to use our cars when available.

The same disconnect happens every day in healthcare. So much sales activity and investment are squandered on potential buyers who are only empowered to say no — not yes — to an actual buying decision. With the best of intentions, they may not be aware they are wasting time pursuing deals that will never come to fruition. Just like the sales guy at the car lot with my daughter.

By first defining the problem and enabling appropriate enterprise visibility, we can avoid projects that are misaligned with organizational priorities.  Further, we may also discover that due to poor or fragmented communication, we are pursuing a project where:

• An organizational decision on how to address this problem has already been made.
• Others within the same organization are already pursuing a similar project in parallel.
• The organization already owns existing products, best practices, or internal resources that should be compared as an alternative to buying something new

In working with many health systems to design a solution to this common inefficiency, we borrowed concepts from established solutions we all now use to make buying decisions in our personal lives (Amazon, Airbnb, Yelp, Angie’s List, Pinterest, TrueCar, Zillow, etc.) Healthcare organizations need a better, digital way to define and share the ideas or projects they are considering, to detail objectives, success measures, categories, budgets, timelines, etc. to promote transparency and alignment. 

Additionally, while vendors use a CRM like Salesforce to track their sales activity with prospective and current clients, health systems do not have a similar system to capture and coordinate buying activity with the vendor community (and Salesforce is too complex to serve that purpose for buyers). Gaining visibility into past and current interactions and assessments of vendors and their products is essential to unify knowledge across diverse stakeholders.

As we focus as an industry on important topics like care coordination, healthcare organizations must also apply coordination to implement modern tools and processes that achieve the efficiency and alignment needed to make better decisions faster regarding vendor partners.

Readers Write: The Treatment for BCD (Big Company Disease): How to Streamline EHR Decision-Making

The Treatment for BCD (Big Company Disease): How to Streamline EHR Decision-Making
By David Butler, MD

David Butler, MD is associate CMIO of the Epic/GO project of NYC Health + Hospitals of New York, NY.

I’ll never forget it. I was presenting to a large group of physicians about how we need to implement, adopt, and standardize the EHR to meet quality metrics and decrease total cost of ownership. Before I could finish stating the “S-word” (standardization), a more senior physician looked over his glasses and declared, “Son, I’ve been in healthcare for over 30 years and I can tell you for a fact that this is simply not going to work.”

I had to agree with a portion of his statement. I also had a degree of skepticism about whether this would work or not. However, the former part of his statement caused me to pause and ask, “With all due respect, Doctor, have you been in THIS healthcare for 30 years?”

While I’m not sure he appreciated my Gen X retort, what I said was true. No one has been in today’s healthcare environment for 30 years. A senior executive mentor from McKinsey once told me, “If someone tells you that they understand healthcare today, they’re either lying or just have not been paying close enough attention.”

How We Got into This Mess

The US has wrapped technological advancements in healthcare around an antiquated legal and compliance system that was designed for the long-gone days of paper-based record keeping. We have essentially paved the cow path. Years after these technical infrastructures in healthcare have been hardwired and codified, we are now asking the question, “How can we unwind this and do it the right way?”

Unfortunately, much of the capital dollars and funding that attained the EHR are no longer available to optimize the EHR (understatement of the year). Very few practicing physicians have the time or legal prowess to navigate a fleet of internal compliance, risk, legal, and information technology “experts” who have all agreed that “x should not be turned on.”

All is not lost, though. We have figured out ways to map and execute the transition to digital healthcare, but we must do it together. EHR optimization starts with governance. In this article, I will share three guiding questions that physicians and physician executives can use to assure that their voices are heard and prioritized when EHR decisions are being made. Just as we do not triage a patient with a cough prior to one with chest pain, we must use this same approach when we collectively request changes to the EHR software.

BCD: Big Company Disease

Rule of thumb: The bigger the healthcare system, the slower it is to change.

At one large multi-hospital facility that shared a single instance of the EHR, a physician stated that it took three months for their EHR team to fix a misspelling on the after-visit clinical summary that we give to the patient. The road to EHR optimization is not a straight one, and you need a team to decide what you’re going to do every time you encounter a fork or a bend. Who makes decisions about EHRs in health systems? If you’re like most, this is a staggeringly complex and confusing process (and calling it a process at all might be generous). You’re likely suffering from BCD, or big company disease.

BCD is an epidemic. Hospitals and health systems must implement technology that helps them meet the goals of 2017 healthcare, Value-based purchasing, consumerism, MIPS/MACRA, ACOs … the list goes on. These goals require change in clinical and technology operations and this change must occur rapidly — or at least much more rapidly than the current pace at most organizations — to meet them.

BCD is fraught with complex requirements, departmental silos, poor stakeholder representation, and highly-educated and well-intentioned leaders whose decision-making authority has been stretched much further than their own comfort zones (and pay grades). As we’re working on the cure for BCD, these treatment options will alleviate many of its symptoms.

Three Questions to Establish Governance for EHR Optimization

1. Who makes the decisions about the EHR?

The first step of governance for EHR optimization is determining who the decision-makers are. If you employ a democratic philosophy of governance, then you must first decide what is your constitution (some call it a mission statement). This constitution drives every decision that you make, including who needs to be at the table from the key stakeholder groups: operations, clinical, and IT. These three functional branches of government compose the three-legged stool governance model. If you’re a large system, you’re also going to need three levels of stakeholders: site/local leadership, regional leadership, and corporate/system leadership. No matter how you answer this question, your governance model must be clearly defined and communicated throughout the organization.

2. What are your priorities?

Everything can’t be a priority. All optimization efforts, requests, and enhancements are certainly NOT created equal. After asking the two most critical questions—“can we?” and “should we?”—I often use and recommend adapting an impact effort matrix to determine the clinical impact and resource requirements for EHR project request prioritization:

• Quadrant 1: The “Just do it” quadrant. High clinical impact, minimal resources.
• Quadrant 2: The “Get the geeks, the execs, and the checkbook” quadrant. High clinical impact, high resources.
• Quadrant 3: The “That’s cool” quadrant. Low clinical impact, low resources.
• Quadrant 4: The “Diva” quadrant. Low clinical impact, high resources.

Before you do anything, make sure you know what quadrant you’re working in! Many organizations have found success building upon this simple framework with Lean or other process improvement methodologies.

3. How are we going to make this happen?

You have your governance model established with balanced representation or your three-legged stool. Now, how do you get these people together to actually use the framework to make critical EHR optimization decisions? This is one that plagues virtually every organization I work with. “I didn’t know WE decided that” or “when are the meetings even held?” are common stakeholder grievances.

When the governance group can’t all come together, you end up making decisions based on time constraints instead of thoughtful ones with the right people around the table. Keys to recovering from BCD include:

• Clear roles and responsibilities. What is each committee responsible for accomplishing at the end of the day? (Oh, this is called a charter.) These obligations should be fully defined and every committee member should know this for their committee, as well as the others in their organization.
• Effective meeting management and tools. Before each governance meeting, tackle these items. Determine which decisions, if any, can be made without meeting. Pre-plan the meeting – set the agenda for this meeting by highlighting what was discussed at the last meeting and the action items/decisions to be made at the meeting. Meeting polls — If your governance committee is large, this is a great way to determine consensus quickly. Virtual meeting tools exist that make interaction and measurement much easier.
• Transparent decision-making and prioritization. You have to share information and you have to share it often. Send out a post-meeting debrief to the committee and the other committees within your organization. Make sure everyone knows how the decision was made and how they can escalate an issue. IT should not be the first place to go to get an EHR solution fixed—physician leadership should determine this. Remember: EHR optimization is a clinical project, not a technical project.

Large-scale EHR optimization starts with an effective, mission-aligned, and accountable governance process. Nagging symptoms of BCD may linger longer than you care for, but with the treatment plan I’ve prescribed above, you’ll be in a much better state to move your organization forward.

Readers Write: The Problem List is the Problem

The Problem List is the Problem
By Sam Bierstock, MD

Sam Bierstock, MD is president and founder of Champions in Healthcare, LLC. He developed and trademarked the concept of Thoughtflow.

For years we have heard that the goal is for complete interoperability of electronic health record systems (EHRs). While this must certainly be achieved in the ultimate attainment of confluent data availability, it is important to be sure that exchanged data from differing systems is consistent. In this regard, we have a huge problem – problem lists.

As an interesting exercise, ask any physician the difference between a diagnosis and a problem. It will readily be seen that very few know the difference, and those that offer an explanation of the difference will provide a wide variety of definitions. As a result, problem lists are loaded with a combination of current and inactive complaints, symptoms, and diagnoses, and generally are a mess. They are inconsistent, unmaintained, confusing. and vary between systems for the same patient. A patient who has been admitted to different hospitals using different EHRs will have a different problem list at each hospital, not to mention any problem lists that may exist in EHRs of physicians that they have seen as outpatients.

While I am unaware of any actual studies to assess the cost of inconsistent problem lists to the healthcare system, these costs must be enormous. Medical record departments and coders spend hours sorting out diagnoses since problem lists frequently populate discharge summaries from which billing data is extracted. Active and inactive problems must be identified and separated out. For instance, “Status Post Myocardial Infarction 1999” may be on the list but is not billable. Symptoms frequently appear and may confuse or diminish reimbursement or be entirely non-reimbursable. Productive cough for three days for instance is a symptom, not a diagnosis, and yet is typical of the types of problems currently listed.

In 1970, I was a medical student at the University of Vermont when a dynamic, energetic, brilliant, and visionary physician who had recently joined the university staff brought his radical ideas about computerizing patient histories and findings to the attention of the industry. His name was Larry Weed, MD, and his system, “The Problem-Oriented Medical Record”, was rapidly changing clinical documentation across the country. A level of logic and thinking that had been missing in the assessment, planning, and treatment of patients’ conditions was being recognized for its enormous value. Problems included medical diagnoses as well as social issues and all matters that need to be considered to treat patients in their entirety.

But Dr. Weed’s system got sidetracked in the ensuing years by the introduction of independent electronic record systems designed by corporate vendors. In general, these system designers had a very poor understanding of the Problem-Oriented Medical Record, and as a result, all tended to handle diagnoses and problem lists differently (if they had them at all). As a result, decades later, few physicians can differentiate between “problems” and “diagnoses” and problem lists have degenerated into a morass of confusion.

For more than a decade, I had been advocating an approach to EHR design that differed from the standard approach of existing systems which were based upon reproduction of text-book clinician “workflows.” Although they frequently followed the textbook workflows, these designs were inefficient and had nothing to do with the way physicians think and work and have historically been abysmally received. Most physicians use EHRs today primarily because of legislative mandates and Meaningful Use requirements, but there is almost universal agreement that they are cumbersome and reduce efficiencies.

Since 2003, I have advocated a different approach which I call (and have trademarked) Thoughtflow and which I first described in the literature in 2004 – supporting the way physicians access, assess, prioritize, and act upon data. In other words, how they think and act.

One of the areas that can be addressed using this approach is the Problem List. As a first step, I had to decide what made it to the list in the first place, what constitutes a “problem.” I picked up the phone and I called Larry Weed. Now well into his 90s, Dr. Weed was as brilliant as ever, and I quickly learned the answer to my question about the difference between a problem and a diagnosis.

A problem, Dr. Weed explained, is the highest level of the current diagnosis. Understanding this basic principal provides a path to cleaning up problem lists, keeping them consistent and updated and maintaining active and inactive problems. EHR system designers do not understand this any better than most physicians do, and as a result, each has a different approach to the construction of problem lists in their systems.

Consider the following scenario:

A patient is seen in the emergency room with a five-day history of abdominal pain and constipation of unknown origin, and subsequently admitted for evaluation. The diagnosis is constipation and abdominal pain, which may appear as a combined problem or two separate problems on the admitting history and physical.

Problem #1: Abdominal pain x 5 days
Problem #2: Constipation

The admitting doctor orders a GI consultation and some baseline studies including a flat plate x-ray of the abdomen. On the first day of admission, the x-ray shows an abdominal mass. The Problem List may now look like this:

Problem #1: Abdominal pain x 5 days
Problem #2: Constipation
Problem #3: Abdominal mass

On day 2, the patient has an exploratory laparotomy and is found to have carcinoma of the colon.

Problem #1: Abdominal pain x 5 days
Problem #2: Constipation
Problem #3: Abdominal mass
Problem #4: Carcinoma of the colon

At this point, and at the sole discretion of the attending physician, Problems 1, 2 and 3 may be removed entirely from the Problem List, may be moved to inactive problems, or may stay on the list. They may stay there for some time or be moved by a future physician providing care for a different problem. There are no fixed rules.

However, if Dr. Weed’s dictum is applied, consistency is attained.

On day 1, when the x-ray shows an abdominal mass, “Abdominal mass” becomes the highest level of the current diagnosis, and therefore replaces both “Constipation” and “Abdominal pain X 5 days,” becoming Problem # 1. In my system design, clicking on the updated Problem #1 “Abdominal mass” resulted in a drop-down menu showing, in chronological order, the previous problems leading to the most current and the dates. So clicking on “Problem # 1 Abdominal mass” produced a drop-down that looked like this:

On day 2, after a diagnosis of Carcinoma of the colon, Problem #1 is further updated:

Clicking on each drop-down menu reveals configurable granular data dependent on user preferences.

Consistent with the concept of Thoughtflow as opposed to workflow, the design minimized any requirement for the user to update the problem list. Using vocabulary standards, clinical decision support software, language processing, and automated ICD-10 coding, the Problem Lists can be automatically updated. They can also automatically exported to an evolving discharge summary from which the automated coding provided billing and reimbursement data. The potential savings in time spend scouring charts by coders can be appreciated, as well as the accuracy of coding and assurance of reimbursement.

In addition, updated and current Problem Lists can also populate any medical summary screens which may have displayed overall summary data such as medications, allergies, past surgeries, etc. This assures an accurate, consistent summary of past maximally updated problems, or in other words, the highest level of current diagnoses. Symptom and other extraneous data will then not appear to congest the list and add to assessment and billing confusion.

Rapid maintenance of the list can be attained by simply dragging a problem that was inactive or resolved to the corresponding list. A problem “Myocardial Infarction 1990” could be moved at a physician or coder’s discretion to an Inactive or Resolved Problem list, while “Atherosclerotic Coronary Vascular Disease” remains as an active problem. Problems could be prioritized in order by simply dragging them to the desired position, and numbers changed automatically as the new position was attained or as
problems were added or removed.

The inconsistency of Problem Lists is an inadequately discussed, but universally recognized issue with enormous costs to the healthcare system, both financial and with respect to quality of care. The issue also generates an enormous challenge to EHR design and to the assurance of interoperable, consistent patient information across the spectrum of healthcare systems, physician offices, disparate hospitals, and payers.

Readers Write: Malware Lessons Shared: Seven Key Questions for Health Leaders to Ask About Cyber Preparedness

Malware Lessons Shared: Seven Key Questions for Health Leaders to Ask About Cyber Preparedness
By Joe Petro

Joe Petro is SVP of engineering for the healthcare division of Nuance Communications.

As business leaders, we must confront a new reality: our organizations are facing an unprecedented threat from cybercrime. The number of cyber incidents is growing and the nature of the attacks is evolving. They are becoming faster, more sophisticated, and more potentially destructive. As the severity of incidents increases, the knowledge to address the technical aspects and manage through an attack has become essential to our skill set.

For those reasons, we think it’s important to share some of the lessons we’ve learned since we were affected by a global malware incident on June 27. Cybersecurity experts later identified the malware as NotPetya, highly sophisticated malware written to provide disruption and destruction rather than to demand ransom. It spread quickly, and unlike some malware, patching alone would not have stopped its propagation.

Our first priority was to contain the incident and protect our customers. This meant immediately commencing shut-down procedures across our global network to contain the spread of the malware. These actions affected our ability to communicate with our customers, employees, and other stakeholders, and we immediately sought alternative ways to alert them to the situation. To ensure they had up-to-date information, we hosted daily conference calls and corresponded via email with affected clients. We regularly posted updates to a dedicated Web page in addition to conducting a very large number of one-on-one client calls and meetings.

Importantly, we were able to tell them that NotPetya does not have the ability to copy or extract file contents from affected systems or allow any unauthorized party to view file contents on affected systems. In other words, no Nuance customer information was altered, lost, or removed by the malware.

After containing the spread of the malware, our focus turned to restoring our clients to full functionality. Our dedicated staff—along with third-party experts in cybersecurity and forensics—rapidly initiated restoration efforts. At the same time, we enhanced our security against similar future incidents to ensure we emerge from this incident with an even more secure operating environment.

We are committed to sharing the knowledge we have gained from our own response and recovery process. The more we know about malware like NotPetya, the more powerful we all can be in combatting future cybercrimes. Early lessons include:

• Incident notification protocols should be as simple as possible, with multiple layers of redundancy to ensure stakeholder communication can continue at all times. This is particularly critical in the early days of response, when normal channels may not be viable.
• Increase network segmentation, including adding micro-segmentation.
• Even fully patched Windows machines remain vulnerable to certain exploits and vulnerabilities. We have deployed a hardening process that disables SMBv1, enables additional blocks on host-based firewalls including blocking unnecessary SMB ports, disables unnecessary usage of WMI and PsExec, disables unnecessary admin shares, increases logging levels, and validates that each system meets a minimum baseline of security measures.
• Cyberattacks can occur very quickly, challenging even the best prevention systems. Thus, the best strategy is a combination of prevention, detection, and containment.

Healthcare and IT leaders need to ask the right questions now so that they can be better prepared for a malware incident in the future. Below are seven important security questions every leader should consider:

1. Cybercrime is part of the new reality for every company, organization, and person. What can you be doing now to prepare for this scenario?
2. How comprehensive are your security policies, and do those policies actually translate into deployed security capabilities?
3. Have you developed a crisis and disaster plan and communicated it broadly throughout your organization?
4. How would you communicate to your staff, your board, your customers, and your patients?
5. What are your primary vulnerabilities? What measures are you taking to ensure patient data is protected?
6. Do you understand and align with your vendors’ security policies and do you have the appropriate validation and/or risk assessment programs in place?
7. Have you identified a team of outside experts to help in case of an incident, including cyber security firms?

Readers Write: Response to Webinar, “3 Secrets to Leadership for Women in Healthcare IT”

Response to Webinar, “3 Secrets to Leadership for Women in Healthcare IT”
By Helen Waters

Helen Waters is executive vice president of sales and marketing with Meditech of Westwood, MA.

Recently, I was inspired by a HIStalk webinar, “3 Secrets to Leadership Success for Women in Healthcare IT,” hosted by two female executives of health IT companies, Liz Johnson and Nancy Ham. During the webinar, Ham and Johnson provided valuable advice to women who are interested in progressing in their careers to a leadership position, but who may experience unconscious or conscious gender bias.

I wasn’t surprised to see that organizations experience higher profits when women represent at least 30 percent of their executive leadership teams. I believe when men and women rid themselves of gender biases and come together at the table, great things will happen.

There are thousands of women in high-powered positions making a difference around the world every day. Still, as Ham and Johnson pointed out, the percentage of women in leadership positions — particularly in healthcare IT — remains low. In addition, there are thousands of women who are capable of so much more, who would make great leaders and heads of companies, but who lack confidence.

I wholeheartedly agree with Ham and Johnson’s three secrets  — mastering negotiation, closing the confidence gap, and the networking effect. However, if I could add one more key ingredient to the list, it would be to channel your passion.

Climbing the corporate ladder and breaking the glass ceiling is no easy feat. It takes focus, drive, the belief that you will succeed, and the passion to make it happen. Not only have passion for what you do and your company, but for your customers and the industry you work in. If you don’t love the company you work for or enjoy your day-to-day life at work, then maybe it’s time for a change.

When you love what you do and show up to work excited about what you will tackle and overcome each day, the confidence gap will get smaller and smaller. Why? Because when you’re passionate about something, it will be noticed by others. The enthusiasm and positive energy you bring to work and how you treat and communicate with others will have an impact on your ability to inspire and lead others.

The determination and motivation that passion drives will set you apart, push you to produce your best work, excite others, build awareness, and lead you to your goals, whether it’s a position in management, the C-suite, or on the board.

My passion, commitment, and love for my company and industry runs deep. My love of healthcare and technology has kept me intrigued and stimulated at my company for over 25 years. I believe in my case, knowing that what I do contributes to keeping people safe in one of their most vulnerable times in life (as a patient) is what keeps me going and gives a great sense of fulfillment.

My goal is to help my company continue to grow and flourish, but more importantly, to help staff grow. I strive to develop the next generation of leaders who are as passionate and inspired as I am when it comes to healthcare. Hopefully during my tenure, I will have influenced a substantial number of people and contributed to the future of the company through them.

In my personal life, my family is my passion. I’ve always wanted to show my daughters that anything is possible, to always be open to learning something new, to follow their passion, and do what makes them feel fulfilled.

What are you passionate about?

Readers Write: Why Healthcare Organizations Take So Long to Make Buying Decisions and How We Can Fix It (Part 1 of 4)

Why Healthcare Organizations Take So Long to Make Buying Decisions and How We Can Fix It (Part 1 of 4)
By Bruce Brandes

Bruce Brandes is founder and CEO of Lucro of Nashville, TN.

Over my 28-year career selling to health systems, the most common “competitor” to which my companies would lose a deal was the same: Do Nothing. For decision-makers across the country, there are many reasons that deferring buying decisions was historically a wise choice. 

Rarely was there a compelling reason to make a decision at all. In the past, the economics, competitive pressures, and the underlying business model did not change meaningfully enough to encourage risk-taking. Frequently, if you waited long enough, potential industry changes would often just go away.

Further, vendors that sell “nice to haves” rather than “have to haves,” assume everyone in every hospital must want to hear their pitch. They create noise that is deafening to decision-makers. Plus, most purchases historically have not yielded the promised benefits or ROI and risk-averse buyers that have been burned before are hesitant to make the same mistake again.

As a healthcare vendor, the results of all this doing nothing (while trying desperately to find the person who is going to do something) include unclear value from traditional sales and marketing investments and the consequences of unpredictable business forecasting.

Moreover, there is real concern that the length of healthcare sales cycles discourages bright entrepreneurial minds and innovative investors away from our industry, despite the lure of “disrupting” a three-trillion-dollar annual spend.

In partnering with long-time hospital operator Charlie Martin, I was heartened to learn that he and his peers also found the ridiculousness of the buying / selling process in healthcare equally problematic. In fact, we’ve spent the past two years collaborating with some of the largest and most influential health systems in the country to gain a deep understanding of their challenges related long decision-making cycles.

One specific example was illustrated by the head of strategy for a large regional health system in the Southeast. Their organization had identified the need to be in the direct-to-consumer virtual care business. They followed their normal process to pick a partner — formed a committee, engaged a consultant, did an initial survey of the market landscape, sent out an RFI, had a lot of meetings, sent out an RFP, brought in a short list for demos, had more meetings, called references, and finally made a decision on a vendor partner for the project. The decision was made 24 months after they originally identified their business need.

During the two years of their selection process, the hospital system found that three other healthcare companies (none of which were historically competitive with them) had successfully built and deployed their own direct-to-consumer virtual care platforms in the same market. The incumbent hospital system lost the opportunity to engage, with a modern care alternative, the very community they have traditionally served for decades.

New industry forces (underlying financial models, competitive pressures, reduced volume, consumerism, etc.) in healthcare now dictate that organizations no longer have years, but months to make strategic buying decisions before the market may pass them by.

Together with healthcare organizations that collectively operate 20 percent of all the hospitals in the US, we identified three key areas with opportunity for improvement:

• Alignment
• Trust
• Process

Over the next several weeks, we will detail the learnings that resulted in a new way for healthcare organizations to accelerate and de-risk their buying process.

Readers Write: Moving the Adoption Needle on Electronic Prior Authorization: What Stakeholders Can Do

Moving the Adoption Needle on Electronic Prior Authorization: What Stakeholders Can Do
By Tony Schueth

Tony Schueth is CEO and managing partner of Point-of-Care Partners of Coral Springs, FL.

Prior authorization (PA) is a major pain point for both prescribers and payers (health plans and PBMs). That is because there are significant administrative costs and patient-safety issues associated with today’s antiquated paper-phone-fax PA processes. The number of PAs is increasing, causing stakeholders to look for a solution to keep ahead of the PA curve. The answer is electronic PA (ePA), which is available today. Yet, while headed in the right direction, uptake isn’t where we’d like it to be.

Manual prior authorization and utilization review create burden on providers and payers alike. According to a recent article in Health Affairs, physicians spend $37 billion annually ($83,000 per doctor) thrashing out PA and formulary issues with payers. According to another estimate, doctors spend 868.4 million hours on PA each year, not counting time devoted by other staff members. Payers incur up to costs of $25-$40 per PA, plus risk to downstream CMS rebates and medical cost savings.

Perhaps most importantly, the difficulties inherent in trying to obtain a PA significantly affect the quality of care and patient safety. According to a survey by the American Medical Association (AMA), most physicians experience a delay in excess of a week for their PA request to be processed. Some 70 percent of prescriptions rejected at the pharmacy require PA; of those, 40 percent are eventually abandoned due to the complex, paper-based PA process. The PA process impacts more than 185 million prescriptions each year and results in nearly 75 million abandoned prescriptions.  

These issues will only be exacerbated as demand for PA increases. This is due to several factors. First is the robust pipeline of new specialty medications, the majority of which require PA. Second, the demand for specialty medications is rapidly increasing because, in large part, of the rising number of chronically ill patients who rely on specialty medications.

Because of increased specialty medication utilization — coupled with the reliance on today’s antiquated paper-based processes — prescribers, pharmacies, and payers will be unable to keep pace with the anticipated flood of new specialty prescriptions and related PA requirements. Patients will have delays in obtaining needed therapies or will forego them altogether if prescriptions are abandoned due to administrative delays. Quality and patient safety are at stake.

Now that the need for process improvement and efficiencies is imperative, stakeholders are beginning to coalesce around the promise of electronic prior authorization (ePA). This solution is in keeping with the trend toward automation of healthcare and the wide-spread adoption of electronic prescribing, which is used by 75 percent of ambulatory physicians. Standards to support the ePA transaction are in place. Vendors are emerging that can handle the transaction. States are jumping on the ePA bandwagon, with several requiring use of ePA in the near future and others expected to follow suit. It won’t be long before the federal government is expected to mandate ePA as well.

That said, use of ePA is not to the point of bringing robust value for all stakeholders. Electronic health record (EHRs) can support the ePA process, but not all of them have that capability. Physicians may not know that their EHR supports ePA and it could be integrated into the workflow.

What can be done to move the ePA adoption needle? Here are some things stakeholders can do now.

Prescribers should:

• Ask their EHR vendor about their system’s ePA functionality. If it is not available, push for it as an enhancement request.
• If integrated ePA is available, start using it as a way to improve return on investment (ROI) in the EHR. Electronic PAs get adjudicated much more quickly than prior authorizations submitted on paper via fax. ePA also can reduce costs and improve the quality and safety of patient care. These metrics are increasingly important ingredients of value-based care, alternative payment models, and related reporting requirements.

EHR vendors should:

• Make prescribers aware of their product’s ePA functionality and how it is used. This educational component provides value to the buyer and also could be a differentiator in the market.
• Get ahead of regulatory mandates by either the federal government and the states. Savvy vendors will not wait for the regulatory shoes to drop and then play catch up. This can be costly and affect market share.
• Build competitive advantage. While some of the major EHRs have incorporated ePA, many of the small and medium-sized EHRs have not. Practices and integrated delivery networks are overwhelmed by the growing number of PAs. They are demanding relief, which can only be solved through the availability of ePA. This also is an attractive selling and retention point.

Health plans and PBMs should:

• Adopt ePA functionality that is beyond the basics. Research shows that many PBMs have minimal ePA processing capabilities. Improving ePA processes and question sets will improve efficiency, reduce costs, and add value.
• Push prescribers to adopt and use ePA. A legitimate ROI can be demonstrated, but only if functionality is used.
• Take full advantage of the feature set included in the NCPDP SCRIPT standard for ePA. Supporting more of the features available in the standard will reduce the need for attachments, thus reducing turnaround times and increasing efficiencies. This translate into cost savings.

Advancing ePA requires focused effort by all stakeholders, but the time is right and the technology is ready.

Readers Write: Why Daily Clinical Analysis May Be A Game-changer In Patient Outcomes

Why Daily Clinical Analysis May Be A Game-changer In Patient Outcomes
By Benjamin Yu, MD, PhD

Benjamin Yu, MD, PhD is vice president of medical informatics and genomics at Interpreta of San Diego, CA.

A missing piece in population health is real-time data and its real-time and continuous analysis. It’s a key ingredient that can help streamline health delivery, improve outcomes, and manage a dynamic patient population. Real-time interpretation is a keystone in many service industries, especially finance and e-commerce. However, its value is often overlooked in healthcare.

Instead, the health industry typically relies on monthly or quarterly business reports to spotlight health needs (e.g., gaps in care, medication management, etc.) and to find regional deficiencies. Using this information, groups plan and carry out campaigns to target and improve care through a variety of outreach mechanisms such as care managers, call centers, and provider network contacts.

However, during the laborious process of assessing static reports, millions of conditions change. It’s analogous to using turn-by-turn instructions for driving based on outdated information. Normally, turn-by-turn directions help the driver navigate through unknown roads and emerging traffic conditions in real time. However, if the system is not current, it might alert the driver long after he/she has missed a turn.

Similarly, in healthcare, by the time an outreach takes place, the member’s medications may have changed, a new refill may have been missed, a vaccine or screening may have been completed without the knowledge of the campaign, or a patient could have become ill or hospitalized before discovery of his/her risk. Thus, in addition to being expensive, the discover-and-campaign approach can be disjointed and too slow to adapt to the ever-changing landscape of a patient population.

Despite their potential benefits, real-time clinical solutions have been hampered in population health for several reasons. Many groups fear that real-time clinical data means too many alerts. While this may be true of some clinical information systems, it is not inherently true. In fact, the opposite may be true in that one of the major efficiencies provided by real-time data is reduced noise.

Because data is up to date, resolved issues should quickly disappear from the clinical workflow. For example, when a health plan calls a patient, instead of reviewing a long list of care initiatives — many of which are already complete — the clinician or plan can focus on future needs that are of the highest priority. Using up-to-date information ultimately can reduce alert fatigue and provide a more satisfying and impactful patient experience. In summary, real-time analysis is a noise reducer.

Indeed, the fear of ‘too much information’ often stems from the design of current health information systems, which rely heavily on clinicians and staff to sort through printouts, inboxes, notifications, and data reports to resolve issues in the clinic. Notably, real-time data should not be considered synonymous with an increase in graphs and decisions. Using the driving analogy, data is constantly changing in a turn-by-turn application. However, these applications natively interpret incoming data and only alert the user with upcoming turns or changes to the route. With respect to healthcare, real-time systems also need to be designed to interpret real-time data with actions and prioritizations of the clinician in mind.

The value of real-time data is underestimated. While some inherently accept that real-time clinical information is better than outdated information, real-time data and its immediate interpretation impacts far more than today’s era of business reports. Real-time data and analysis enables feedback interactions and behavioral modifications that cannot be derived from periodic reports.

In the consumer market, real-time responses enable end-to-end services such as ride share, routing, and many financial transactions. In healthcare, real-time clinical information enables better predictive technology and thus an ability to identify trends much earlier. In an increasingly connected world, new clinical services and technologies require instantaneous feedback and timely actions for members and users, enabled by real-time clinical information. If the rapid growth of consumer health devices like wearable monitors is an indicator of upcoming trends, real-time clinical data in population health is just around the corner. Leading healthcare institutions and technology providers need to make sure they don’t miss the turn.

Readers Write: Procuring Sustainable Success with Value-Based Care Models

Procuring Sustainable Success with Value-Based Care Models
By Dustyn Williams, MD

Dustyn Williams, MD is a hospitalist at Baton Rouge General Medical Center (LA) and founder of DoseDr.

All healthcare providers want the same things: better health for their patients and lower costs. Conceptually, value-based care achieves this shared goal by creating the incentives for all involved to provide better care and secure improved outcomes. Yet this approach lacks the appropriate framework and tools that enable and equip clinicians to achieve value-based outcomes.

Adding to this dilemma is the lack of an appropriate definition of “value” that would enable healthcare organizations to truly comprehend what constitutes “value-based care” and how to implement a successful, sustainable value-based model. True value is realized when efforts are focused on reducing costs and achieving enhanced outcomes rather than simply on attaining quality metrics.

Although the utilization and achievement of these metrics is a step in the right direction to positively impact care quality and outcomes, it’s not enough. Checking off boxes indicating that best-practice protocols are being followed does not necessarily equate to better outcomes or improved financials. Closing this gap between incentives and outcomes requires clinical care to evolve to reflect proactive management of chronic disease and promotion of patient wellness. Incentives alone are not enough; clinicians must also have access to the appropriate tools to achieve those quality goals.

The good news is that value-based payment models are providing the necessary impetus for the creation of radical disruptive practice patterns and new models of care. For instance, uptake of Internet-based care delivery that enable more proactive treatments is on the rise, particularly with chronic illness.

Value-based care is also a significant catalyst of advancements in telehealth solutions. These interventions are effectively disrupting traditional care models by providing the necessary best-practice based infrastructures and tools needed to proactively and effectively address chronic health conditions while seamlessly integrating into provider workflows.

Consider diabetes management. Despite the challenges faced with self-management of their condition, diabetic patients spend an average of just two hours per year with their primary care provider. Further, while physicians strive to provide patients with best-practice knowledge for controlling A1c levels, poor retention of medical information and rapidly changing effects of diabetes put patients at risk for serious health conditions and preventable hospitalizations. Clinical and financial impacts stemming from uncontrolled diabetes greatly influences the steep costs of the condition, averaging $176 billion nationwide each year. Patients and providers must have access to tools that enable enhanced collaboration and ongoing care monitoring to improve outcomes and expenditures for diabetes, as well as other chronic conditions.

Telehealth solutions fill this gap. Features such as smartphone-enabled provider feedback loops can now rapidly deliver easily-understandable, actionable information to patients to facilitate engagement, compliance and sustainable improved outcomes. By empowering patients to effectively self-manage their chronic conditions, long-term care costs to health plans and risk based-entities are significantly reduced, along with the steep costs associated with emergency room visits and hospital admissions.

Improvements in the health management of high-risk patient populations secure enhanced Healthcare Effectiveness Data and Information Set (HEDIS) performance measures and Star ratings for health plans, along with improved Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-Based Incentive Payment System (MIPS) outcomes for providers.

Additional issues impacting the efficiency and success of value-based care include resistance to change and slow adoption of innovative care models. Industry laggards continue to stunt the progress made by early adopters of value-based care as they consume more resources than are saved. Ultimately, payers and providers must be willing to accept and adhere to new models, which will be helped along by the evolution of technology and processes, such as telehealth, capable of truly impacting care quality, outcomes and expenditures.

When risk is shared and incentives are aligned, value-based care models can enable providers to ultimately reduce expenditures and enhance patient care. If healthcare facilities provide quality care and cost-effective treatments that yield optimal outcomes, both patients and the healthcare system, as a whole, will benefit. Conversely, if there is no alignment, value-based care will collapse under the weight of a reimbursement structure that continues rewarding utilization. For instance, hospitals may continue to benefit from prolonged lengths of stays, while patients are buried under a mountain of medical bills and struggle with uncontrolled chronic diseases.

By delivering proactive, trusted information directly to patients, disruptive technologies fill a critical gap in population health and care management. The key is ensuring that information has been carefully vetted by a physician capable of making necessary adjustments based on the monitoring of a patient’s health in real time along with additional environmental factors such as food intake. This ensures that these interventions enable improved patient care outcomes while strengthening revenues by avoiding penalties and increasing profitability through performance-based bonuses.

Readers Write: Why Online Provider Search and Referral Management Programs Demand High-Quality Provider Data

Why Online Provider Search and Referral Management Programs Demand High-Quality Provider Data
By Thomas White

Thomas White is CEO of Phynd Technologies of Dallas, TX.

Healthcare systems, like any business, are competing for customers (patients) and referrals. In many respects, this competition has increased as patients are either forced to, or opt to, take more control over their own healthcare. The rise of consumerism is pressing healthcare systems to improve their online presence. Physicians and healthcare systems must fully leverage web tools to grow their customer base by empowering patients with the high-quality information they need to make important healthcare decisions.

The Internet has made it much easier for patients to search beyond their local area for the most qualified providers who meet their needs, participate in their insurance plan, and offer the highest-quality services. As a result of this new paradigm, healthcare systems must prioritize the quality and ongoing maintenance of the provider data that feeds their online “Find A Doctor” search and referral tools. Simply put, a poor search experience is a major turn-off. Patients may go elsewhere, referrals (and revenue) are lost, and reputation is damaged.

Patients and referring physicians alike expect to have the same online experience they would with Google and other search engines: instantly and easily find what they are looking for. Healthcare consumers satisfaction grows (and referrals are gained) when they can quickly find a doctor via a simple process that gives them useful information in easily understood terms. Accuracy is assumed.

Patients expect to see provider demographic, practice, insurance, and contact information with a few keystrokes. That’s a given. And when they are presented with more data than expected — such as the provider’s availability, ratings, languages spoken, clinical focus, research interests, treatments provided, and travel directions — even better.

This search process can be further enhanced if the provider’s data includes videos and other multimedia information. Video profiles personalize information and instructional videos can simplify patient visits and improve customer satisfaction and engagement. It’s kind of like online dating and hoping for the perfect match. In both cases, as they say nowadays, a picture can be worth a thousand words, and a video is worth a thousand pictures.

Patients are more likely to book an appointment if their search results direct them to a provider who meets their needs. High-quality data can seal the deal.

Online providers search tools are not just for patients. Physicians use them to identify the most appropriate in-network referral options for their patients. If the information from a referral management website is inaccurate or out of date, it can result in referral leakage, lost revenue, and wasted time. If there’s a delay in the delivery of urgently-needed care, then patient well-being and satisfaction may suffer. This can hurt reimbursement, particularly in today’s value-based care environment. Value-based payments emphasize evidence-based medicine and efficient delivery of care. These basic tenets should be supported by the information from any “Find A Doctor” search tool by ensuring patients see the most appropriate care giver the first time.

None of this, however, can be achieved without a holistic approach spanning the enterprise (clinical, financial, and marketing systems) to capture, manage, and share high quality provider data. A unified approach to provider data management is critical to meet the rising tide of healthcare consumerism and value-base care initiatives, never mind remaining competitive. Providing effective online provider search tools to healthcare consumers and providers is an investment that can quickly pay for itself through referrals that keep patients in network and improve overall satisfaction.

While online provider search tools are certainly not new, they must serve the demands and expectations of increasingly savvy and demanding online healthcare consumers and harried referring physicians trying to balance conflicting demands on their time and attention. Healthcare system leaders should assess how well their organizations online physician referral and outreach programs are meeting these end-user needs and determine relevant ROI measures to improve their effectiveness with an enterprise provider data management approach.

Readers Write: Top 10 Takeaways From the EClinicalWorks Settlement

Top 10 Takeaways From the EClinicalWorks Settlement
By Colette Matzzie

1. The federal False Claims Act provides an effective way to hold EHR vendors accountable for failing to meet Meaningful Use standards.

Many customers had complained to EClinicalWorks about major problems with its software, but little changed. It took a knowledgeable healthcare IT implementation specialist and the might of the US government to get the software problems fixed. They used a powerful whistleblower law known as the False Claims Act, which encourages whistleblowers to fight fraud by filing “qui tam” lawsuits, to force ECW to take action. Anyone who “causes” false claims to be submitted to the government is liable under the False Claims Act. Customers of ECW relied on representations that ECW’s EHR technology was properly certified and therefore, unknowingly submitted tens of thousands of claims for government incentive payments that falsely attested MU requirements had been met.

2. The federal Anti-Kickback Statute forbids EHR vendors from paying or rewarding users to promote or refer others as customers.

Many healthcare providers, pharmaceutical companies, and medical device manufacturers have been penalized for violating the Anti-Kickback Statute, but the ECW case is the first time it has been applied in the EHR industry. The government cited payments totaling almost $300,000 through ECW’s “referral program,” “site visit program,” and “reference program,” in addition to unknown amounts for consulting and speaker fees paid to influential users, as evidence of alleged violations of the Anti-Kickback Statute. The law prohibits providing money, gifts, or other remuneration intended to get referrals for services or items paid for by federal healthcare dollars except under very limited circumstances.

3. The accuracy of representations made to certifying bodies will be a factor when the DoJ reviews the liability of an EHR vendor under the False Claims Act.

Certification by a government Authorized Testing and Certification Body has been a prerequisite to successful sales because buyers can obtain federal incentive payments only for certified EHR technology. The government cited EClinicalWork’s decision to modify its software to “hard code” the drug codes needed for testing without meeting the certification criteria as evidence that ECW had “falsely obtained” its certification. This gave rise to its liability under the False Claims Act. Accurate and truthful information will remain a requirement for certification, despite the debate over whether the certifications adequately ensure software reliability and patient safety.

4. The Office of Inspector General crafted an innovative Corporate Integrity Agreement requiring ECW to fix deficiencies, notify its customers, provide customers with free upgrades, and permit customers to transfer clinical data without penalty.

As part of the settlement, ECW signed an expansive, state-of-the-art Corporate Integrity Agreement that the OIG put together to ensure that providers and patients are protected going forward. ECW is required to take significant remedial steps, which included sending out a series of notifications and advisories to customers that advise them of patient safety risks with its software, giving customers an opportunity to obtain updated (and presumably remediated) software free of charge; and offering the opportunity to transfer clinical data to another vendor free of onerous penalties or other restrictions. Software vendors should consider the agreement a guide to understand the risks they will face if their software does not meet federal requirements or if other misconduct occurs.

5. The government deems data portability and audit log requirements to be essential to proper EHR functioning.

EHR systems are required by the government to be able to export clinical information on patients electronically, including by batch exports, and reliably and accurately record user actions in an audit log. In its complaint-in-intervention, the government faulted ECW for allegedly misrepresenting these capabilities, and made clear that these omissions from the software were not acceptable.

6. EHR vendors need to respond in a timely and effective manner to customer reports of software defects, usability problems, or other issues that may present a risk to patient safety or that may violate federal law.

The Corporate Integrity Agreement requires ECW to notify OIG of certain reportable events that involve patient safety, certification, or a matter that a reasonable person would consider to be a violation of law. The government wants all EHR vendors to report significant problems or violations of law, especially when patient health or safety may be at issue.

7. EHR vendors should have persons and procedures in place to ensure compliance with federal law, just as healthcare companies do.

ECW’s Corporate Integrity Agreement requires the company to establish a compliance program with a compliance officer and a written code of conduct, similar to what many healthcare companies have. That’s something all EHR vendors should consider doing, as it’s wise to offer employees clear avenues to report concerns internally. Most employees prefer to address concerns internally before blowing the whistle by filing a qui tam lawsuit – unless the company has shown it is not responsive to legitimate concerns or will retaliate against employees who speak up.

8. The government will hold managers personally responsible for activities of the EHR vendor company.

The ECW settlement holds both the company and its three founders (the CEO, CMO, and COO) liable for payment. The settlements reinforce the DoJ’s commitment to individual accountability for corporate decisions in a very tangible way.

9. EHR vendors must ensure that all contracts and agreements with its customers do not restrict disclosures of information about the performance of the software or reporting of patient safety concerns (the “anti-gag” rule).

ECW’s Corporate Integrity Agreement requires that contracts between the company and its customers do not restrict customers from disclosing concerns about the performance of its software. This includes concerns related to patient safety, public health, and product quality. Other vendors should consider adopting similar “anti-gag” practices.

10. Whistleblower rewards may be paid for information that leads to successful resolution of a federal qui tam action against an EHR vendor.

The ECW case shows the government welcomes whistleblowers who have information about significant problems with EHR software. Under the False Claims Act, the government will pay whistleblowers a reward of 15 to 25 percent of the proceeds recovered by the government as damages and civil penalties, if the government joins the “qui tam” case filed by the whistleblower. The government awarded the ECW whistleblower $30 million.

Colette Matzzie is a whistleblower attorney and partner at Phillips & Cohen LLP, which represented the whistleblower in the EClinicalWorks case.

Readers Write: Technology Can Lift the Veil of Secrecy on Drug Prices

Technology Can Lift the Veil of Secrecy on Drug Prices
By Thomas Borzilleri

Thomas Borzilleri is CEO of InteliScript.

The recent story about the rift over prescription drug prices between insurer Anthem and its pharmacy benefits manager Express Scripts should anger — and frankly, befuddle — any physician or electronic health record (EHR) vendor. Providers and IT vendors should be fed up with payers and patients getting ripped off by inflated drug prices, taking a disproportionate share of the healthcare dollar. They also ought to be puzzled about why, with all of our advances, we are still living in a marketplace where no one knows what drugs really cost.

It’s particularly absurd because technology exists that can put an end to the opacity, overpayment, and oligarchy that characterize prescription drug purchasing today. Providers deserve and EHR vendors can offer tools that deliver the prices for any drug at the five cheapest pharmacies nearby. Doctors can have this data at their fingertips, within a few seconds, at the point of care, integrated into their existing workflow. These technology solutions can also track prescriptions to make sure they are picked up and refilled on a regular basis to gain new insight into which patients are at risk for adverse events due to medication non-adherence.

For years, insurers and patients have just accepted that the price they are getting is the best price, or the only price. However, allegations like Anthem’s — that Express Scripts overcharged the insurer by $3 billion — should make everyone in the healthcare ecosystem skeptical about the fairness of drug prices. But truly lifting the veil on drug prices will take a concerted effort by many stakeholders in the provider and IT vendor communities to take on the PBM juggernaut.

Strangely enough, when PBMs gained widespread popularity in the 1980s, there was an understanding that they worked on behalf of payers to lower prices, both by securing discounts and by steering patients towards lower-cost drugs. The truth, however, is that PBM “discounts” have always included heavy padding in the form of ingredient spreads and per-prescription fees. In fact, while PBMs are typically paying manufacturers 96 percent off the Average Wholesale Price (AWP) —the “sticker price” for drugs —the prices they charge insurers and employers are between 70 percent and 85 percent off the AWP. PBMs are skimming 10-25 percent off each prescription.

Insurers and employers have had little recourse, both because they did not know the true price of prescription drugs and because they did not have a way to easily shop around between competing pharmacies to get the best price on every medication. Instead, complex, opaque package deals with PBMs mean the payer might be getting good deals on some drugs and getting raked over the coals on others.

Drug price transparency and shopping tools are essential for payers to rein in costs and keep both premiums and co-pays from spiking. The urgent need for this data has also intensified recently because an increasing share of prescription drug costs are borne by consumers themselves. Patients simply won’t take their drugs properly, or at all, if they are out of reach financially. Affordability is now the number one reason for non-adherence to medications, which leads to poor outcomes, including avoidable hospital readmissions. A lack of medication adherence is estimated to cause approximately 125,000 deaths, at least 10 percent of hospitalizations, and cost between $100 billion and $289 billion a year.

In the past, some patients have looked to Canadian or other foreign mail-order pharmacies to try to lower drug costs. But these transactions are usually outside the doctor-patient relationship and may cause more harm than good to the patient, either by exposing him or her to dangerous drug formulations or by causing rifts in care continuity.

Doctors and patients, together, must come to the best decision about the right drug for their condition and price must be a part of that equation. We need technology solutions that enable doctors to find the best price on any drug, at local pharmacies that are convenient to the patient. Tools exist to address these concerns. The key is to embed these tools into existing EHR systems. By doing so, we can avoid disrupting doctors’ workflow and can ensure that all e-prescribing information is captured in the patient record.

These solutions must achieve savings for both the payer and the consumer. First, the solution must provide the lowest possible retail price while consumers are still paying off their deductibles, and then provide the lowest negotiated payer price to the insurer or employer once they start picking up the tab. These solutions can also be used to circumvent common PBM strategies, such as excluding low-cost brand and generic drugs from formularies to artificially increase co-pays on these cheaper drugs, which costs insurers and self-insured consumers billions of dollars each year.

Typically, consumers don’t realize that the cash price is in many instances lower than their adjusted co-pay, with the excess going right into the pocket of the PBM. Drug price transparency and shopping solutions should crunch the numbers for the doctor and patient, letting them know when it’s better to pay the cash price and when it’s more cost-effective to pay the co-pay.

Health IT solutions are typically geared towards one healthcare user: hospitals, doctors, patients, insurers, or employers. But drug price transparency technology is one of those rare innovations that will benefit each of those audiences. Doctors and patients, together, will be able to make the best decisions about medication management, at the point of care, during the prescribing process. Hospitals will enjoy better population health management through better medication adherence. Insurers and employers will be able to wring more value from each healthcare dollar.

What we need now is a commitment from EHR vendors to adopt this type of technology. The bottom line is that we can’t succeed in bending the cost curve in healthcare if we don’t know what the costs are in the first place. That includes prescription drugs. We in the health IT industry have the insight and ingenuity to draw the curtain back on drug price secrecy and we have a real obligation to do so.

Readers Write: Celebrate the Milestones, But Keep Your Eye on the Road Ahead

Celebrate the Milestones, But Keep Your Eye on the Road Ahead
by Tonguç Yaman

Tonguç Yaman is CIO of Advocate Community Providers of New York, NY.

I will turn 50 this year. A few days after my birthday in May, my daughter will graduate from Yale, the second of my two children to earn that distinction. In October, I will graduate from Columbia University’s Executive Master of Public Health program.

I guess you could say it’s a watershed year for me, one of the biggest of my life so far. We all have them. And once the celebrations are over, I imagine we’re all faced with the same question. What’s next?

Here is what I learned as I looked for answers to that question.

It’s never too late for a new beginning

Some of us might feel inclined to stop and take a breather at 50, especially once the kids are out of school. We may think we have reached a high point that we’ll never exceed in our time on earth. As for me, I’m viewing it as a new beginning.

It’s a simple construct. Fifty is half of my life. Sure, it’s a milestone, but it doesn’t scare me. I’ll admit I am tickled to be at a point in my life where I have no dependents. My son and daughter are well on their way to taking their places in the workforce and the world. While I have strong relationships with my children and see them often, there is a level of excitement, a feeling of freedom now that they are adults.

I don’t want to waste that feeling of freedom. I want to channel it in constructive ways and put it to good use.

The opportunity to focus is a gift

There is an even greater excitement in the fact that I recently began a new phase of my career, a phase that I have envisioned for a very long time. I am no longer simply an IT guy, but a healthcare professional, a CIO for a very exciting organization in NYC brimming with possibilities.

When I was a kid growing up in Turkey, I dreamed of becoming a medical doctor, so this move into healthcare feels as if I have come full circle. Our dreams get tweaked as we get older, but I like the way this one has turned out. Though not an exact match, I am still able to use my skills and experience to effect change in the healthcare sector, and probably on a much larger scale.

The transition wouldn’t mean half as much if I weren’t confident that I did everything I could to prepare myself for its challenges. That’s one of the benefits of maturity. They say good things come to those who wait, but I also believe that good things come to those who are prepared. Now I have the time, the skills, and the experience to give my new healthcare position the total focus it demands. This opportunity is a gift and I am eager to embrace it with all the dedication and energy I have.

Maturity and passion are not mutually exclusive

I’ve attended HIMSS healthcare IT conferences in previous years, but at this year’s event, something was different. Instead of observing from the sidelines, I was involved. I was invited to participate in sessions. I was a contributor. I felt respected and connected and I was able to help others make connections, too. One of these connections resulted in CHIME welcoming a new foundation member.

This ability to find the things two professionals might have in common and make a connection happen for their mutual benefit is probably the thing I am best at. While others are inspirational leaders, effective organizers,or  impeccable planners, I’m a connector.

In my work with colleagues and partners, I can find win-win solutions, shape commitments between parties, challenge others to exercise their own good judgment, and solidify their trust in one another. That is very exciting to me. I heard it time and again at the HIMSS conference this year: people notice my passion. It is gratifying to be able to say that at this point in my career.

Here’s to 50

There’s a saying now that 50 is the new 30. I’m not so sure I agree. Physically, I don’t feel that much different from the way I felt at 30. But in terms of what I have learned about my industry and about myself over the past two decades, I’ll take 50 over 30 any day.

Readers Write: Blockchain’s Missing Link

Blockchain’s Missing Link
By Frank Poggio

Frank Poggio is president and CEO of The Kelzon Group.

The IT concept that you hear most about today is blockchain systems design and technology. If you have not, you will very soon. It’s a concept that relies heavily on core Internet communication tools and shared information.

When you mention blockchain, some people automatically think of bitcoin, but bitcoin is just one application of the block chain concepts and tools — it is not blockchain proper. HIStalk posted a good synopsis of blockchain last year .

Blockchain in its simplest form is a virtual ledger. A ledger that is available to all on an instantaneous basis via the Internet.

Let’s look at an example. Say I borrow $100 from my office buddy Joe. If it’s just the two of us involved and no one else cares, then he notes on his paper ledger an asset of $100, with an offsetting entry of his cash decreasing by $100. On my ledger, I note an increase in my cash balance of $100 and a liability to Joe of $100. If an auditor were to check our ledgers, they would see all four entries and all things would be kosher, or in accounting terminology, in balance.

Now assume everyone in our office cares and we all have electronic ledgers and all our ledgers communicate with one another via the Internet, thereby creating one big virtual ledger. Every time one ledger changes, they all change instantaneously. Everyone in our office would see I owe Joe $100. As I make payments on the loan (or fail to), all ledgers would reflect the subsequent activity.

Blockchain software maintains a universal virtual ledger by maintaining constant communication among all participants. All updates and transactions — whether add, change, or delete — are stored forever. Hence the full provenance of any activity is easily viewable. The number of participants is not limited and could be in the billions, limited only by agreed-to privacy and security constraints.

The implications of blockchain technology are enormous. For example; since the blockchain is always in balance (no single entity entries allowed), goodbye auditors, bookkeepers, accountants, financial intermediaries, clearinghouses, many regulators, and so on.

Some industry pundits are predicting that blockchain will transform healthcare and make the interoperability mountain into a mole hill. A deeper understanding of the healthcare landscape with its many non-technical issues makes me a skeptic.

On the business side of healthcare, the impact should be pretty much the same as in commercial business. You can expect a big impact on finance and supply chain management. Operations such as scheduling and resource management will see significant impacts. Many will happen within the next decade. Legacy systems will have a tough time adapting, more so than their adaptation to the Internet, but slowly they will adjust.

On the clinical / medical side, I predict a much longer runway before we see any real impact. There are two reasons. First, blockchain is highly dependent on definition and structure. Terminology must be consistent and procedures must be standardized. Generally Accepted Accounting Standards (GAAP) have been in place for centuries, and as they have changed over the decades, multiple oversight groups have hashed out agreed-to changes. On the supply side, UPC codes have been around for almost 50 years and go down to almost the molecular level.

Not so in medicine. A practitioner’s understanding and use of terminology and protocols is highly dependent upon where they went to medical school and who they trained under. Studies have shown that even today, after the federal government has paid out over $30 billion in EHR incentives, still over 70 percent of a patient’s medical record is entered into the EHR as free text.

The second reason is that blockchain cannot work without absolute accurate identification about the transaction initiator and the information target. Identifying the initiator is easy. The target is the person / patient and that’s another matter. Still today after decades and trillions of dollars spent on healthcare IT we do not have a unique person / patient identifier.

As I have noted in my past writings on HIStalk and other blogs, this is not a technology problem, but a political one. If blockchain is to be the savior of healthcare interoperability, as the technocrats suggest, then it’s Congress that will have to forge the most critical first link in the chain.

My prediction is that systems developers will continue to jury rig solutions around this missing link. Providers would do well to remember that a chain is only as strong as its weakest link.

Readers Write: The Value Proposition of Optimizing Clinical Communication

The Value Proposition of Optimizing Clinical Communication
By James Jones and Wayne Manuel

James Jones, BSN, MBA, MSN, NEA-BC is VP of patient care services and nursing operations at University of Washington Medicine’s Valley Medical Center. Wayne Manuel is senior VP of strategic services at University of Washington Medicine’s Valley Medical Center.

A few years ago, Wayne was on an airplane when he came across a magazine article about how Texas Children’s Hospital switched to Apple iPhones to improve clinical communication and reduce noise. With some due diligence, he found that Cedars-Sinai Medical Center and several other hospitals had also switched from old ways of communicating to iPhones, and they experienced similar positive results. As our senior VP of strategic services, Wayne recognized the opportunity for UW Medicine’s Valley Medical Center to replace our old, noisy phones with smartphones.

Around the same time, James attended a dinner event for chief nursing officers in Seattle. Again, smartphones were a main topic of the discussion, representing a solution to some common clinical communication challenges.

With both of us having technical backgrounds, we started sharing ideas on how to transition from our disparate communication systems to a more modern solution. We approached our CNO and CMO with research on the value proposition of implementing a mobile communication strategy. It was easy to see how a new way of communicating would bring us additional value. Some of the improvements we hoped to achieve included:

• Improving the clinician and patient experience.
• Reducing interruptions.
• Gaining workflow efficiencies.
• Saving time for clinicians.
• Improving communication between interdisciplinary teams.
• Meeting The Joint Commission’s National Patient Safety Goals for alarm management.

At that time, we had recently deployed a new electronic health record (EHR), which gave us the opportunity to improve many other systems and workflows. Our senior leadership team felt that to get the most out of our EHR, we needed a mobile app to close the gap and provide real-time access to clinical information, allow for mobile documentation, and offer an easy way for nurses and other staff to communicate.

Our staff were already using smartphones in their personal lives and were frustrated with the multiple communication devices they were juggling (two-way radios, legacy phones, pagers, and overhead paging). We met with many of our nurses to get their input, and one said, “Anything you can do to lighten the load would be greatly appreciated.”

We started with a phased approach, rolling out iPhones to one pilot unit, then to all inpatient units and several ancillary departments for calling; secure text messaging; and notification of alarms and alerts from patient monitoring, patient elopement, and the nurse call system. This was done via Voalte and Connexall applications.

We conducted before and after analysis so we could measure the outcomes from the new clinical workflows. One area we looked at was hospital-acquired pressure ulcers and skin integrity events. Using the iPhones, our wound care nurses saw an immediate improvement in workflow by using the Epic Rover application to take a photo of the wound, which uploads the photo for documentation into the patient medical record. The physician or wound care nurses can see it immediately and even show it to the patient and their family when rounding with a physician.

With only two dedicated wound care nurses on our team, their time is extremely limited. Rather than spending time walking around looking for a physician or nurse to discuss a patient, they can now find the appropriate physician in the smartphone directory, send a photo via Rover, and ask the physician to call when he or she is available to discuss treatment. The result has been better communication among our interdisciplinary teams, more efficient use of time for our wound care team, real-time documentation to the medical record, and improved communication with patients and families.

Another area where we have made great headway with the iPhones is in reducing medication errors. Using our new workflow, a nurse changes his or her status in the directory from “available” to “busy” and types in a status message, such as “administering meds.” This lets the rest of the care team know not to interrupt that nurse until their status changes back to “available.” New workflows escalate alerts to a backup while that nurse is busy.

Today, we are using iPhones for communication on all clinical inpatient units for nurses, physicians, respiratory therapists, discharge planners, environmental services managers, and administration. We are communicating more efficiently, with about 70 percent of all communication now taking place via text message versus 30 percent via voice calls. Our very tech-savvy staff loves the new solution and has adapted well to the workflow changes. One nurse said her unit is much quieter and that the hospital “feels like a hotel, so patients can get some rest.”

In our first year using smartphones, we are still learning where we can make adjustments in our workflows to make the most of our new way of communication. Going forward, we will be analyzing workflow efficiencies, adjusting alarm settings, and managing notifications from nurse call, physiological monitors, and the EHR.

The authors presented an HIStalk webinar titled “Improving patient outcomes with smartphones: UW Medicine Valley Medical Center’s story.”

Readers Write: An Uncomfortable Truth About Hospital Revenue and an Overlooked Way to Gain It Back

An Uncomfortable Truth About Hospital Revenue and an Overlooked Way to Gain It Back
By Crystal Ewing

Crystal Ewing is manager of data integrity at ZirMed.

In a video message from last year that he surely never intended for public and regulatory scrutiny, Mayo Clinic CEO John Noseworthy, MD appeared to advise employees to prioritize patients with commercial insurance in order for the famed hospital to remain financially strong.

Months later, Mayo is still explaining exactly what Dr. Noseworthy meant. Many healthcare leaders need no further explanation, even if they personally dislike any suggestion of favoring the commercially insured over Medicare and Medicaid patients. With government reimbursement continuing its decline, most hospitals are straining to hold on to their profitability.

Still, placing hope in commercial insurance to make up the difference is misguided, especially with the rising dominance of health plans that are not only high deductible, but also require high co-payments and high co-insurance. Touted as a means of covering more Americans, these plans often put more of the financial burden on patients than simply paying for healthcare in cash at a discount.

As such, many patients with these plans may claim they have no coverage when it comes time to pay for a procedure or service. It’s hard not to empathize with their motivation for doing so, but it’s a practice that can put the hospital in a precarious position.

With self-pay patients, things become more complicated, especially since there can be a lag of 30 or more days between the time that they are treated and the time the invoice comes due. When faced with a choice between paying for housing, utilities, food for their families, auto repairs, etc. – all of which affect the present and future – or paying a hospital bill for an event that occurred in the past, the decision is easy.

When this thinking is spread across a large patient population, bad debt accumulates quickly. Additionally, patients are unlikely to pay medical bills that are greater than 5 percent of household income, according to the Advisory Board, a consulting firm for hospitals. Median household income in the U.S. is at about $53,000, suggesting that when out-of-pocket charges exceed $2,600 hospitals can forget about collecting, according to Spencer Perlman, an analyst with Height Securities in Washington.

Given the above realities, more hospitals are using automated coverage detection technology, which also finds insurance coverage that patients legitimately aren’t aware of or are unable to communicate. When patients are brought to the hospital in the grips of a heart attack, for example, or while unconscious, they’re hardly able to convey their levels of coverage. Some fully conscious patients even may forget they have coverage, or provide information on secondary rather than primary coverage, or become confused about which carrier covers them. This isn’t uncommon with elderly patients.

No matter the reason it is problematic , it is imperative that coverage verification becomes a more streamlined process at our nation’s hospitals. It can be done in a way that respects the patient and in a timely fashion to protect the hospital’s finances. The most feasible method is to pair automated coverage detection with automated eligibility verification, the latter of which is already in place at many hospitals. However, coverage detection can also be an independent, standalone process. Either way, it makes quick work of checking with thousands of healthcare payers to determine if any are the primary or secondary insurer for a given patient.

Often, as much as 15 percent more instances of billable insurance are uncovered with superior processes and technology. Even just some quick mental calculation can see how this would recoup millions of dollars for many large hospital systems. It’s also significantly over the 1 to 5 percent rate achieved by manual and legacy coverage detection.

Much of this improvement is due to the huge data sets that now power some business intelligence engines, encompassing billions of historical health insurance transactions for millions of Americans. As these insights are tested against a pre-identified set of payers, algorithms can match the key data attributes that confirm coverage and the information needed to file the claim.

What has yet to be quantified but surely exists is the reduction in future collections activity with patients. Despite jargon that describes these patients as “empowered consumers,” the reality is they are struggling to pay their bills and rely on hospitals to help them navigate this uncertain terrain. In turn, hospitals must be fully informed about all of a patient’s sources of payment, including if commercial insurance coverage exists.

There is nothing unethical about seeking such information, only for using it to prioritize patients who it turns out are commercially covered. Clearly hospitals should be setting their sights on treating all patients, regardless of source of payment. The ability to do so is greatly enhanced when hospitals can identify all sources.