Readers Write: The Compliance Difficulties of Medical Device Connectivity

The Compliance Difficulties of Medical Device Connectivity
By Abbas Dhilawala

Abbas Dhilawala, MS is CTO of Galen Data of Houston, TX.

There are numerous challenges facing the global healthcare ecosystem today, including aging populations that require more healthcare products and services; rising costs across the industry (shared among consumers, insurance carriers, healthcare providers, and taxpayers); growing wait times for medical services; and a growing demand for convenient and personalized care.

To address these challenges, medical device companies are beginning to produce medical devices with cloud connective capabilities that promote the digitization of healthcare and promote better physician-patient engagement while driving down costs. The global market for connected medical devices is expected to increase from $21 billion in 2018 to $63 billion by 2023, an annual growth rate in excess of 25 percent, according to one report.

Still, the path forward for medical device companies that want to design the connected medical devices of the future and get them to market isn’t always clear and direct. Medical device manufacturers are subject to extensive regulations and compliance requirements for the medical devices that they produce. A recent survey of 237 medical technology employees by Deloitte found something important: 67 percent believe that the current regulatory framework will not catch up with what we can do with medical device technology today for another five years.

Medical device companies today face a fractured compliance landscape that can stifle innovation and lead to heavy expenditures in compliance activities at the expense of research and development. Medical device companies that wish to sell their devices in the United States must comply with the quality regulations set forth by the United States Food and Drug Administration (FDA) in Chapter 21 of the Federal Code of Regulations, Part 820. The regulations include guidelines for ensuring the safety and effectiveness of medical devices, including the establishment of detailed design control documentation, the creation and maintenance of processes for corrective and preventive actions when non-conforming products are discovered, and requirements for document control and approval.

Quality system regulations exist around the world in different forms. Canada uses the Canadian Medical Devices Regulations (CMDR), while medical devices sold in Europe must obtain a CE Marking through compliance with ISO 13485, the international standard for medical device quality. Each time a medical device company enters a new market, it must demonstrate compliance with the corresponding local quality system regulations. Sometimes this means conducting a gap analysis and addressing compliance issues internally, but it could also mean hiring a Notified Body to conduct an expensive and time-consuming third-party compliance audit.

To help ease the path to compliance for medical device companies and reduce the cost burden of compliance activities, regulators worldwide are working towards a Medical Device Single Audit Program (MDSAP) that can establish medical device compliance for global markets based on a single audit. While this measure should reduce compliance costs for medical device companies, it remains to be seen how connected medical devices will be regulated under a new system.

As healthcare innovators continue to develop connected medical devices, privacy is a growing concern for regulators and industry professionals. Imagine a future where in-home care is increasingly common and where patients use wearable and implantable medical devices that deliver patient data electronically in real time to a central repository of electronic medical records.

Such a future might not be far off. The EHR mandate already requires hospitals and medical clinics across the United States to use electronic medical records to track patient data, and connected devices with data transmission capabilities already exist. What doesn’t exist yet is a common framework that promotes interoperability between connected devices and patient databases or any kind of privacy and security regulations that would safeguard such a system against malicious attacks that could compromise patient data.

The final compliance issue faced by manufacturers of connected medical devices has to do with changing payment models throughout the healthcare industry. As the industry shifts towards a model that compensates healthcare providers based on the effectiveness of treatments and patient care outcomes, government regulators and payers are increasingly asking for objective evidence that medical devices are positively impacting patient outcomes. Manufacturers of connected medical devices may face additional compliance obstacles when required to demonstrate that their devices actually improve patient engagement, satisfaction, and outcomes.

Despite the compliance difficulties faced by the industry, medical device manufacturers are meeting the challenge head on by innovating new ways of doing business, including funding models that offer data as a service, the adoption of value-based pricing, and the use of real-world patient data to drive business decisions. The medical device companies of today are ready to advance healthcare into the future. Now it’s up to healthcare providers and regulators to keep up.

Readers Write: Recapturing the Best Part of Best-of-Breed

Recapturing the Best Part of Best-of-Breed
By Meg Aranow

Meg Aranow is CEO of Edaris Health of Boston, MA.

Early on in HIT, departmental systems were the only computer-based clinical and business solutions we had. Often built and sold by teams that came directly out of the operational areas and bringing experiential credibility, these solutions spoke the language of the department leaders who were making the purchasing selections. The more relatable they were, the more significant their market share.

Later, with reputations solidified, these vendors began to capitalize by broadening their horizons into related areas, offering suites of applications to handle adjacent functions, such as all labs sections, not just blood labs, or all finance departments, not just AP/AR.

Then came the perfect storm that really engaged us all in the allure of the enterprise systems. First, computerization became the expected standard and big-budget centralized IT departments took root. Second, the market responded with R&D money and new investment capital. Third, healthcare costs and patient safety became everyday news and the idea of health consumerism grew. As timely, accurate shared data seemed the holy grail for both quality and expense control, the lure of single fully integrated systems became irresistible.

The decisions seemed easier 10 years ago. That was when the primary definition of an enterprise was its physical boundaries. There wasn’t much talk about IDNs and integrating freestanding surgery centers, urgent cares, or SNFs.

Now, even as we seek to integrate the data that ensures quality, safety, and expense control within the walls of our institution, we are simultaneously pushing care outside the walls to be handled in places that have less overhead and are easier for patients to navigate. There’s a tightrope to walk. We can’t trample on the very workflows that have created those higher margins and faster throughput at the lower-cost locations. If we make them behave as the rest of the enterprise does, we may lose the very things that made them attractive business assets and popular care destinations for patients in the first place.

As interoperability standards have become de rigor, there are options of where to draw the perimeter of the enterprise system and where to allow – or even encourage – deep support of site-specific workflows without compromise. That is, workflow support as once delivered by narrowly-focused departmental systems.

Customized workflow support is the new best-of-breed. With mature interoperability standards in place, we do not have to sacrifice tailored, intuitive workflow support for the sake of integrated data, decision support, and analytics. There is no reason not to have it all.

Readers Write: The Key to Population Health Management: The Convergence of Data, Technology, and Social Determinants of Health

The Key to Population Health Management: The Convergence of Data, Technology, and Social Determinants of Health
By Matt Miller, PhD

Matt Miller, PhD is vice president of behavior science at StayWell of Yardley, PA.

Advances in technology are having a significant impact on the healthcare individuals receive. Patient DNA is used to personalize treatments with precision medicine. Artificial intelligence (AI) and machine learning are speeding diagnosis and helping providers determine the best courses of action. The Internet of Things (IoT) is enabling a wide range of remote clinical applications, from medication adherence to monitoring vital functions including glucose, heart rate, and blood pressure to configuring and gathering real-time data from medical devices such as pacemakers and defibrillators.

While these technologies are powerful on their own, the combination of these various patient-specific data streams can produce an exponential impact on improving patient outcomes when merged with behavioral and environmental insights. Integration of this diverse data, through electronic health records (EHRs) and other critical healthcare systems, will play an important role in creating an ecosystem that enables providers and patients to get the information they need, when they need it. In turn, this integration of data will support the larger goals of improving population health.

Modern healthcare is well positioned to reap the rewards of recent advances in technology. Silicon and graphene at the chip level and microelectromechanical systems (MEMS) in semiconductors are in devices used every day for diagnoses and treatment, such as CT scanners, X-ray machines, magnetic imaging, ultrasound, and for monitoring blood pressure, glucose levels, and other vital statistics. These components play critical roles in sensing, data processing, and controlling machines used to monitor and treat patients. Add data science – AI and machine learning – to the mix and the industry can begin to explore new frontiers in healthcare by expanding our ability to detect and interpret patterns.

We are beginning to see this convergence of new technologies emerge in targeted use cases. Computer vision and convolutional neural networks are helping radiologists identify malignant tumors, minimizing the pain, inconvenience, and cost of biopsies. Pharmacogenomics and precision medicine are enabling researchers to identify first-line medications for patients based on their genomes and develop therapeutics based on the unique characteristics of the individual and his or her disease.

These applications are just the beginning of innovations that will redefine healthcare in the 21st century. But there may be a simpler example of how today’s data capture technology can make an equally significant impact in improving population health. This approach involves integrating behavioral, environmental, and social data directly into physician’s workflows, so healthcare professionals can have a more robust understanding of a patient’s risk factors and take proactive steps to help patients remain, or become more, healthy.

Social determinants of health (SDOH) are macro-level factors responsible for influencing health risks and health outcomes. SDOH include economic stability, neighborhood and physical environment, level of education, access to healthy food and quality healthcare, available support systems, and stress. These factors contribute to an individual’s life expectancy, mortality, healthcare expenditures, health status, and functional limitations, according to the Henry J. Kaiser Family Foundation.

Research demonstrates the enormous influence of behavior and SDOH on patient outcomes. Clinical interventions impact only 10 to 20 percent of a person’s health outcomes, while socioeconomic and environmental factors determine 80 to 90 percent, according to The National Academy of Medicine.

Consider the possibilities if a physician had access to social and behavioral information alongside lab tests, imaging results, and other background information about the patient. Not only could the doctor see that his 50-year old female patient’s glucose is high and creatinine and hemoglobin are slightly off, he could also evaluate the impact of her adherence to taking prescription medicine, stress level, and the fact that she lives in an urban food desert and doesn’t have access to regular care.

These types of solutions are already coming to fruition, in a variety of forms and functionality. Consider the offering developed by Proteus Digital Health, which combines ingestible sensors, a small wearable sensor patch, and mobile application to monitor patient health patterns and medication adherence behaviors. The objective information collected by the Proteus system enables doctors to initiate, adjust and measure treatment effectiveness, saving patients and payers money while optimizing care and amplifying outcomes.

Johns Hopkins University School of Medicine was also recently awarded a grant to continue research of the Emocha mHealth app, which tracks medication details and care management for individuals with tuberculosis, a diagnosis where strict medication adherence is essential for positive outcomes. The app connects patients and providers for Directly Observed Therapy (DOT), in which patients record themselves taking prescribed medication. The video is uploaded to a telehealth portal, where providers can confirm the medication was taken correctly and collaborate with patients on care management. Early results show that Emocha app boosted medication adherence rates by 94 percent and saved almost $1,400 per patient in treatment costs.

Using multiple data points to triangulate a patient’s condition enables physicians to deliver healthcare with a more holistic perspective. Understanding the gravitational force SDOH has on health outcomes, physicians not only can address the symptoms of disease, but can also respond to variables known to cause and/or exacerbate illness. With these types of insights, they can make more informed decisions around diagnosis, treatment and the continuum of care.

It can be a challenge for physicians to get insights into social and behavioral factors. But the move to EHRs, plus greater integration and effective data exchange through standardization efforts like Fast Healthcare Interoperability Resources (FHIR), are beginning to make these promises a reality. By capturing more data points through EHRs and having access to complete records regardless of where healthcare services are delivered, physicians will have a more comprehensive picture of patients’ background and health, empowering them to provide the care and resources to meet the unique needs of each patient.

Several device manufacturers are already offering remote monitoring tools capable of capturing patient health data at home and uploading it to an EHR for physicians to track.

For example, Boston Scientific’s Latitude Home Monitoring System enables physicians to monitor implanted devices to manage heart conditions. A five-year study of the system showed that there was a 50 percent relative risk reduction of death as compared to patients who only went to the clinic for device checks. Honeywell’s Genesis Touch collects biometric information, such as oxygen saturation, blood pressure, and weight and shares them with physicians. The related mobile app also enables video visits between patients and physicians and offers an interactive teaching tool to demonstrate techniques to manage various conditions and ensure the patient understands the treatment protocols.

Now take this integration a few steps further. Imagine,that through the power of AI and machine learning, a physician could be proactively alerted to key data points about a patient, in real time, outside of a hospital or office visit. Machine learning would identify certain thresholds that trigger the need for the physician to send a message containing educational materials to the patient, change a prescription based on data trends, or even alert emergency services.

Lessons learned from these types of just-in-time, adaptive interventions can be extrapolated to improve population health services by empowering physicians to offer data-driven recommendations to their patients.

For example, many practices may offer a universal stress reduction program to their patients. However, stress can manifest itself in a myriad of ways for different people at different times in their lives. By using the full scope of data available to understand the stressors – physical, social, and behavioral – and other factors impacting each patient, providers can do more than simply and generically “manage stress.” They can develop an intervention that helps specifically manage that patient’s unique stressors.

The future of each individual patient’s outcome is brighter when you combine the nuance and tailoring of personalized medicine with the reach of population health. Advances in science, technology, and use of SDOH brings this future within reach.

Readers Write: Projects and Costs Out of Control? Take a Low-Dose Aspirin

Readers Write: Projects and Costs Out of Control? Take a Low-Dose Aspirin
By Frank Poggio

Frank Poggio is president and CEO of The Kelzon Group.

A recent announcement in the news about the lack of effectiveness and risk of taking daily low-dose aspirin triggered my re-thinking about the age old question of, “Why is healthcare IT so far behind commercial industry?” or, “Why is healthcare delivery so costly and inefficient?”

“Experts” always say we can improve costs and quality if we practice evidence-based medicine. OK, I can buy that, but what if the evidence keeps changing every few years? I am willing to bet that in about five years some researcher will say that new data shows daily aspirin is good for you, so hope you didn’t stop taking it. How many times have we seen that with other foods like coffee, red wine, etc.?

And what about classic annual diagnostic procedures like Pap smears, mammography, and PSA tests? Or therapies like angioplasty, tonsillectomy, bloodletting, or frontal lobotomy? The list goes on. All deemed good one day in the past, but not so good or maybe deadly soon after.

This obsession with comparing medicine and healthcare to other industries falls apart if you look at a simple example. Say you are washed up and stranded on a large island. As it turns, out there is an abandoned cabin on the island with a motorized boat left at the dock. You also find a set of mechanic’s tools in a storage area, and lucky you, you happen to possess a little mechanical talent from your high school shop class. What you do not have is any documentation covering the boat or engine, but with your cursory experience with cars, you figure out how to start the engine. But alas, it will run only for a few minutes.

You tinker with it for days, but without any owner’s or repair manuals or other specs, everything you do is hit or miss. Of course you take an evidence-based approach, using trial and error and a little creativity. As you fail to make headway and start experiencing severe hunger pains, you take the engine apart to try to get a better understanding of its engineering and how it should function. Put it back together, try again, no luck, apart again, try again, and on and on.

Wouldn’t it easier if you had some documentation, like maybe a troubleshooting guide? Every boat engine that comes off an assembly line has one. If only the original owner had kept it, you could avoid all the time-wasting reverse engineering. And thank heavens the engine isn’t amorphous or biological, which brings us back to the human condition.

When you were born, didn’t the doctor give your mother your owner’s manual, troubleshooting guide, design specs, and of course a warranty? What, you say, you can’t find them, and the frustration is giving you a severe headache? Too bad, maybe try this aromatherapy — it worked for me.

Readers Write: A Person-Centered Approach for Success in Intellectual and Developmental Disability Services

A Person-Centered Approach for Success in Intellectual and Developmental Disability Services
By Andrew Mersman

Andrew Mersman is senior director at Netsmart Technologies of Overland Park, KS.

It’s no secret that limited resources and funding have historically been a challenge for providers of Intellectual or Developmental Disabilities (I/DD) services. That’s why it’s important for healthcare providers to break down information silos and work collaboratively to achieve the best outcomes possible. With the introduction of value-based care payment models, it will be even more important for providers to find effective and efficient ways to manage resources across the healthcare continuum to deliver the right care for every individual’s needs. The continued evolution of Home and Community Based Services (HCBS) waiver plans and emphasis on conflict-free case management also make person-centered care more important than ever before.

To aid organizations in providing the best I/DD services with a person-centered approach, awe’ve narrowed down four key elements to keep at the forefront of managing an individual’s care.

Person-Centered Planning

To deliver the best services possible, it’s important to address it with a holistic, whole-person outlook. Keep the individual at the center of this universe and take in surrounding factors into consideration as you plan and coordinate delivery. Important items to consider in person-centered planning include:

• Taking direction and considering feedback from the individual receiving services, including from their support system
• Integrate the person’s strengths, preferences, and desires – example is integrating pictures into the ISP to help an individual be more active in their services
• Drawing on insight gained from the individual’s relationships within their community
• Enabling individuals to express satisfaction with service delivery through feedback, allowing for course correction as needed

Care Coordination

Care coordination should focus on the health, social, and personal desires of the individual. When approaching care coordination for a person with a developmental or intellectual disability, it’s important to ensure that a person’s service plans are self-directed by the individual and are aimed toward meeting their personal goals, including day-to-day living and other life factors such as independent living or employment goals. Additionally, modern reimbursement models demand more accountability for care coordination between different services and settings.

Comprehensive Assessment and Planning

Person-centered care requires the ability to plan and provide the right type of services that can result in the best outcome possible. To do that, providers need to assess many aspects of a person’s life when determining the best plan for them. This is essential to determine the kind of services that should be provided along with the method in which they are delivered, and account for any potential obstacles that may prevent the individual from being successful. Factors to be assessed can include things like housing, family support, social skills, personal care, communication, financial stability, nutrition, activity level, and more.

When developing a person’s care plan, it’s critical to ensure that all essential elements of the person-centered plan drive the planning process. This is also the time to determine that tasks based on valued outcomes are specific, measurable, achievable, relevant, and timely to make sure that an individual can progress and be successful. Planning should also emphasize community inclusion and participation, independence, and the use of informal community supports when possible.

Data Collection, Measurement, and Reporting

Creating a care plan alone isn’t enough. It’s essential to prove the effectiveness of the support and services your organization provides. The way to tackle that is through collecting, analyzing, and reporting data to demonstrate outcomes. Your organization should be able to look at results and determine if the plan was successful, not just that the tasks were completed.

An integral part of applied behavioral analysis requires the ability to measure an individual’s growth and development. You can’t report progress without any data, so the first step is to gather and collect it throughout their journey. Once they are accessing and receiving the services outlined in their plan, it’s time to record progress. What has been the outcome of the services they’ve been receiving? Are they improving with the method of delivery your organization is providing?

Your EHR should allow your support staff to easily record and track a person’s progress through streamlined, intuitive workflows. And in an age where services are delivered in a variety of settings, mobile functionality is essential for entering important data on a tablet or other portable device. Going mobile is an effortless way to build staff efficiencies and supports the move away from a paper-based system, allowing data to be accessed and retrieved in real time.

Once the data is collected, it’s time to look at what it collectively means in the bigger picture. Here’s where robust reporting and analytics comes in. The ability to display data in a variety of outputs (i.e. raw data counts, compliance or achievement percentage, or graphical representation) is important with respect to who is viewing the data. Also, the ability to provide real-time analysis is important to provide on demand.

No matter what care setting, keeping an individual and their needs at the center of their care plan is essential. Remembering these factors while establishing, assessing, and achieving an individual’s personal goals, care providers across all settings – not just I/DD – are sure to provide the best services to meet the unique needs of everyone.

Readers Write: Capturing Patient-Reported Outcomes for Population Health Management Yields Dividends

Capturing Patient-Reported Outcomes for Population Health Management Yields Dividends
By Gary Hamilton

Gary Hamilton is CEO of InteliChart of Fort Mill, SC.

As the industry pushes towards value-based care, a greater emphasis has been placed on listening to patients, particularly regarding how they view their own health status and quality of life. These patient-reported outcomes (PROs) are essential to help identify obstacles to effectively manage chronic conditions. Patient-reported outcome measures (PROMs), of which there are many across numerous specialties, are also increasingly important to payers under value-based care payment models.

Capturing PRO information can occur in the exam room or hospital, but it is often time-consuming and may be sidetracked if the patient has an acute condition they prefer to discuss. Fortunately, the ubiquity of the Internet, smartphones, and the increasing sophistication of data analytics technology is helping healthcare organizations obtain PRO data and analyze associated measures efficiently so they can improve performance.

PROs are defined by the National Quality Forum (NQF) as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.” These outcomes are, in some cases, more important to the patient than the clinical outcome because it reflects how they are feeling and their ability to pursue daily activities. For example, how many times has a patient told you that they stopped taking a medication due to its perceived side effects and now feel “better than ever?”

Learning about medication side effects and how a patient feels about other elements of their care plan aligns with many value-based care goals. After all, if patients are not achieving their personal health or quality-of-life goals, they may not perceive any value for their care. A treatment then cannot be considered fully effective, even if clinical indicators of health improved along the way.

Listening to patients’ goals is key to designing a care plan that will yield health status improvements or eliminate symptoms, but also improve quality of life. When a patient notices and reports these improvements, they are likely to engage in their care plan or follow through with a recommended procedure recovery regimen.

Capturing PROs can be tedious and not always accurate, especially when the patient is distracted by another condition or other factors, such as being discharged from the hospital. This is where advanced population health management (PHM) technology helps providers save time while improving the patient’s experience.

At discharge, for example, a patient who underwent a procedure may be so concerned about how they will resume their activities at home, they may not be aware a medication prescribed at the hospital is giving them intolerable side effects. After they adjust to the care transition, an automated survey would be sent from the PHM platform to their smartphone to learn about the recovery from the procedure, as well as the new medication. Based on patient preferences, PROs could be captured through an automated interactive voice response (IVR) phone call or a secure electronic message, both initiated through the PHM technology.

Although automated methods are most efficient, a live phone call with a clinician is just as effective at gathering crucial patient information. The PHM technology assists in these situations by automatically reminding the care manager to conduct the interview and offering to create the electronic questionnaire form to be completed. Based on responses from any of the PRO outreach methods, the physician can then decide to adjust the prescribed treatment.

For patients with chronic conditions, here again, a survey can be sent to a mobile device or patient portal periodically to ensure associated care plans are helping them achieve their goals. Electronic surveys or interviews using an IVR or live phone call would include quality-of-life questions concerning physical function, mental health, sleep, or the ability to participate in daily activities. An analytics platform would then flag and compile negative responses for follow-up.

Remote-captured PRO can also support many elderly and rural patients who may have transportation challenges. Instead of these patients coming to the office for routine consultations regarding their chronic conditions, an automated survey, secure portal message, IVR, or live phone call can capture PROs and allow them to avoid unnecessary travel.

The benefit of using a mobile device or a computer to capture PROs is that patients can report their perspective at the right moment, when they have time to reflect away from the distractions of a busy practice, hospital, or workplace. Surveys or automated interviews delivered on a consistent schedule prove to patients the organization is focused on their care, nurturing engagement, and motivating them to improve their outcomes.

For the provider organization, identifying PROM trends among these populations is easier when the PRO module is part of an advanced PHM platform that is integrated with the electronic health record (EHR) system, other information systems, and fed by comprehensive and aggregated data from around the care continuum. When a physician reviews a patient’s chart, they can view PROM trends at a glance to support their decisions.

PRO insight, in conjunction with other data included in the EHR, can help the physician design an effective treatment plan that achieves clinical objectives as well as the patient’s quality-of-life goals. Combined, improving performance on these outcomes can secure greater reimbursement under value-based care payment models while building stronger engagement from patients throughout the year.

Readers Write: A Smart Telehealth Strategy Creates Great Value While Meeting Myriad Needs

A Smart Telehealth Strategy Creates Great Value While Meeting Myriad Needs
By Ray Costantini, MD

Ray Costantini, MD, MBA is co-founder and CEO of Bright.md of Portland, OR.

Friction is the enemy of efficiency, whether it’s an automotive engine clogged with grime or an athlete’s muscles slowed by lactic acid. Our healthcare system is stymied by high levels of friction throughout. Fortunately, for hospitals, doctors, and other healthcare providers seeking an edge in today’s highly competitive healthcare environment, a smart telehealth strategy presents an opportunity to slice through much of this friction and create great value in the process.

Telehealth is a broad category. At one end of the spectrum, it involves managing complex, high-risk conditions such as stroke through remote monitoring and consultation. At the other, it entails providing high quality, on-demand convenience care (or virtual care) for a range of acute, episodic, and non-emergent conditions in an effective, rapid, and cost-effective manner. There are many points across this spectrum to create and capture value for health systems and their patients. Telehealth services hold the promise of unlocking that value and now is an excellent time to think about integrating them into practice.

Several converging trends are contributing to this window of opportunity. One is the shortage of primary care physicians. Did you know that a patient in Boston typically has to wait up to 66 days to see a doctor through a traditional in-clinic visit? If you’re lucky, you’ll get sick in San Diego, where the elapsed time from scheduling to care is just seven days.

Another contributing trend is the consumerization of healthcare. Patients today are increasingly savvy. Empowered by technology, they expect on-demand access to care, and if they don’t get it or don’t like what they get, they’re all too ready to take their business elsewhere. This is one reason we’re seeing a proliferation of independent “retail care” locations, which by the way exacerbate the shortage of providers and add to the friction in the system.

What’s a provider to do to seize the telehealth opportunity? First, you’ll need to come up with a telehealth strategy. There’s no “one size fits all” approach here. For example, one system may be struggling with access issues, while another may face the challenge of serving a specific population group or demographic. The right solution with a tuned operational plan behind it can solve either of those issues. Start by taking an inventory of the pain points you want to solve. Also helpful: stop thinking in terms of return on investment or revenue created and instead begin thinking about the value created by your telehealth strategy and virtual care solutions. There are many different ways to create value, but you’ll have to decide on the right mix for your particular needs.

A smart telehealth strategy entails a comprehensive set of solutions, what I call a “ladder of care.” This could include options such as self-triage, nurse advice, and asynchronous virtual care for common ambulatory conditions. For higher-acuity issues, it could include video visits. In-person visits would be reserved for conditions where multiple comorbidities exist (diabetes and flu, for instance), or when a physical procedure is required (a minor procedure such as wart removal).

How does such an approach unlock value? First, it creates access and capacity in the system. Asynchronous virtual care visits can take less than two minutes of provider time and can be delivered from a smartphone with even a 3G connection from wherever the provider happens to be. One full-time equivalent of physician or Advanced Practice Clinician can deliver more than 20,000 of these virtual visits per year. Compare that with just 2,000 20-minute in-person or video visits for an in-clinic provider. This approach also attracts new patients and retains existing ones, which in turn drives downstream revenue and adds to your brand bank, building loyalty and positive word of mouth through innovation and patient-centered service delivery.

A ladder of care approach also ameliorates provider burnout by giving providers time to focus on higher-acuity patients (and generate associated reimbursement) in clinic and top-of-license practice. If the telehealth solution can automatically generate a chart-ready SOAP note, that dramatically cuts down on clerical work.

The value created pays dividends at the system, clinician, and patient levels of the healthcare ecosystem. At the system level, in a FFS (fee-for-service) world, a smart telehealth strategy can unlock downstream revenue through both patient acquisition and retention. In a capitated model, it helps keep the patient population healthy while preventing minor ailments from becoming major ones due to a lack of treatment or access.

A smart telehealth model can help cut your losses on primary care while also shifting fixed costs to variable costs. Instead of building or leasing and outfitting a two-clinician clinic, you would instead spend a fraction of that cost to provide a far more efficient usage basis. Integrating the staffing of your telehealth with existing retail or urgent care efforts would help fill the more than 30 percent of idle provider time that’s all too common in those settings. The list goes on.

For your patients, there are savings in time, money and more. Patients regain the hours it takes to schedule, wait for, and be evaluated by a physician, also avoiding lost wages, childcare costs if they have to visit the doctor, and so on. Telehealth patients report getting healthier sooner, recovering 1.5 days faster. For clinicians, a tele-visit can turn a 20-minute low-acuity visit into a higher-value visit with a patient who really needs it.

Meanwhile, the barriers to telehealth are quickly coming down. According to a 2016 Medscape study, both patients and physicians have improved their attitudes when it comes to embracing telehealth, with nearly two-thirds of patients surveyed expressing comfort in virtual care, diagnoses, and treatment plans. Add to that an increased availability of telehealth services from providers and a growing sense of patient trust versus privacy and security issues. With so many tech companies turning their focus to healthcare, many of the technology challenges associated with telehealth (bandwidth, availability, etc.) are a thing of the past.

Bottom line: this is no time for hospitals and doctors to retreat into traditional, friction-bound approaches to healthcare delivery. Your patients are already moving to a technology-enabled future of on-demand access to timely, convenient care. A smart, well thought out telehealth strategy is your ticket to join them and ride the next wave of patients and value-creation opportunities.

Readers Write: Augmented Intelligence: Virtual Assistants Come to Healthcare

Augmented Intelligence: Virtual Assistants Come to Healthcare
By Andrew Rebhan

Andrew Rebhan, MBA is a health IT research consultant with Advisory Board of Washington, DC.

Natural language processing (NLP) techniques allow digital systems to streamline user interactions allowing machines to read text, understand meaning, and generate narratives from existing information. Recent advances in artificial intelligence (AI) technologies have accelerated progress in a broad range of NLP applications for healthcare, including digital assistants for clinical staff, concierge services for patients, and digital scribes to streamline documentation processes.

For example, last Fall Nuance Communications released its Dragon Medical Virtual Assistant to help health care providers interact with clinical workflows using NLP and other conversational AI functionality. Nuance announced at HIMSS18 that it will integrate its virtual assistant technology into Epic’s EHR.

According to the news release, the new partnership allows physicians to use the virtual assistant to ask for information from a patient’s chart, retrieve labs, medication lists, and visit summaries using Epic Haiku. Nurses using Epic Rover can use the assistant to conversationally interact with flowsheets to enter and confirm patient info and vitals. Finally, scheduling staff using Epic Cadence can converse with the assistant to check physician schedules and create or modify patient appointments. Vanderbilt University Medical Center recently announced it is leveraging Nuance’s technology to build a prototype voice assistant called “V-EVA” (Vanderbilt EHR Voice Assistant) to help caregivers navigate the hospital’s Epic EHR using natural dialogue.

A number of other healthcare providers have started piloting voice assistants. Northwell Health is testing Amazon’s Alexa across multiple use cases, including one that helps users determine the wait time at nearby emergency rooms and urgent care centers in Northwell’s system. People can ask their Alexa-enabled home devices to either search for the shortest wait time based on their ZIP code, or can ask for the wait time for a specific location. Once the user asks for this information, Alexa queries Northwell’s database of wait times (which analyzes check-in data every 15 minutes) for the best option. The Alexa feature can respond back with the location’s name, address, and wait time.

In another example, the University of Pittsburgh Medical Center (UPMC) is collaborating with Microsoft to create an intelligent scribe called EmpowerMD. The project is part of Microsoft’s Healthcare NExT initiative, which aims to use AI to accelerate healthcare innovation. The virtual scribe listens to conversations doctors have with patients, analyzing speech for clinically relevant concepts to make suggestions in the medical record. The goal is to allow doctors or other staff to engage with patients face to face, without the need to divert their attention to a computer screen. The scribe can make suggestions or take notes for follow up, which the doctor accepts or modifies after the encounter. Staff can also view a transcript of the conversation for greater context on the assistant’s suggestions. Using machine learning, the virtual assistant improves its performance as suggestions are accepted, rejected, or modified by the user.

Patients are also interested in AI-powered virtual assistants. Accenture recently released the findings of its 2018 Consumer Survey on Digital Health, which polled 2,301 US consumers on topics such as wearables, virtual care, and AI. Among the findings, the survey showed that roughly one in five consumers has experienced health-related AI, and in particular, showed an openness to using intelligent virtual assistants:

• 61 percent said they would use “an intelligent virtual health assistant that helps to estimate out-of-pocket costs, schedule healthcare appointments and explain benefit coverage, bills, and payment options”
• 57 percent would use an intelligent virtual coach
• 55 percent would use “an intelligent virtual nurse that monitors your health condition, medications, and vital signs at home”
• 50 percent would use “an intelligent virtual clinician that helps to diagnose health issues and navigate you to the right treatment options”

Is your team interested? Here are some considerations to get you started.

Identify your Goals

Virtual assistants can perform a variety of tasks described above. In addition, they can set reminders, answer basic patient questions, call for a nurse, or even address loneliness. However, virtual assistants may not always be the best solution for a given problem, particularly complex tasks that may benefit from visual displays (such as on a computer or tablet). Make sure your team is specific about how the technology will improve processes and where it fits into existing workflows.

Explore What’s Possible

The major technology companies such as Google and Amazon are trying to make their software development kits and APIs as open and user-friendly as possible – which means your organization can build new skills into these virtual assistants to better suit your needs, assuming you have the right staff skills to code these features. As you evaluate options, ensure that potential solutions are properly evaluated for HIPAA compliance, as natural language interfaces in a healthcare setting may capture sensitive information whether or not that is not part of their intended use.

Expect Change

The healthcare industry is starting to see rapid advancements in NLP, computer vision, and other subsets of AI, but the use of virtual assistants in hospitals is still nascent. The technology will likely continue to evolve as more organizations adopt and test these devices, and the broader industry forms new ways to implement and regulate their use. Early adopters will have an advantage in getting to use and gain experience with these tools, but may also have to update them more often as vendors release new editions with enhanced capabilities.

Readers Write: Why It’s Time to Make Clinical Documentation Clinically Valuable

Why It’s Time to Make Clinical Documentation Clinically Valuable
By Jay Anders, MD, MS

Jay Anders, MD, MS is chief medical officer of Medicomp Systems of Chantilly, VA.

“I love documenting patient encounters,”said no clinician ever.

Clinical documentation is a time-consuming source of frustration for physicians and nurses, yet a necessary evil for any hospital and health system that wants to keep its doors open and its lights on. Clinical documentation drives the billing process, maintains the details for diagnosis and procedure coding, and provides the required justification for reimbursement.

The whole “billing and getting-paid” stuff is obviously important, but what if we could transform the clinical documentation process to make it more valuable to the physician and the patient? In other words, why not “fix” clinical documentation so that it helps clinicians deliver better patient care?

Consider the typical clinical documentation process for a patient encounter. The doctor sees a patient who, for example, is complaining of an irregular heartbeat. The physician pulls up an arrhythmia template in the EHR and begins documenting the patient’s symptoms. Everything moves along smoothly until the patient mentions that he’s recently been having some pain in his right elbow. And, that his A1C levels have been a little elevated.

Suddenly the documentation process gets a lot more complicated as the physician hunts for template options to document the non arrhythmia-related ailments. After a couple of minutes searching unsuccessfully for the right disease templates, the doctor gives up and decides to dictate the rest of the note.

Because of the inefficiencies of most clinical documentation systems, physicians often resort to dictation. The transcription of dictated notes can be expensive and is prone to error. Furthermore, dictated data is stored in a non-structured format that is more difficult to access at the point of care. This means that physicians may overlook critical details hidden within free text, which in turn can impact the delivery of care. In addition, it’s difficult to analyze data in an unstructured format for quality reporting purposes or for any type of analytics.

Physicians and their patients deserve better. Here are my recommended “fixes” to give clinical documentation more clinical substance for the enhanced delivery of patient care.

Clinically-dynamic, patient-specific documentation

More physicians now have access to disease-specific templates, which give clinicians a great head start in the documentation process and help with the capture of structured data for larger quality improvement initiatives. However, because physicians treat whole patients and not a single disease, clinicians also need documentation tools that are patient-specific and clinically-dynamic.

With a clinically-dynamic documentation platform, physicians can easily pull in clinically relevant items without having to call up multiple templates. In the case of the patient complaining of an irregular heartbeat, a doctor can tap in a few keystrokes and quickly add new issues into the existing document. The documentation workflow is not disrupted and the clinician does not need to dictate any details or enter free text. Everything related to the patient, including the elbow pain and A1c concerns, are merged directly into the same note. Each element is logically linked to the relevant section within the note – the problem list or physical exam, for example – so that physicians can quickly access the precise details at any time.

Capturing patient-specific details for quality initiatives

You may never hear a physician say they love documenting patient encounters, but you may be able to convince them that it’s worth the effort if the finished product facilitates better patient care.

When clinical documentation can be leveraged to advance quality initiatives, physicians are less likely to view the charting process as a time-consuming task that turns doctors into overpaid members of the billing staff. With smarter clinical documentation tools, physicians can track more patient data in real time and capture critical information that feeds analytics systems and performance dashboards. Clinicians can then access population-level information or view specific clinical details in a longitudinal format and gain deeper insights into a patient’s medical status.

It’s time to usher in a new era with clinical documentation. With the right technology and a shift in mindset, we have the opportunity to transform clinical documentation so that it’s not just about coding and billing, but instead a vital tool that enhances the delivery of quality patient care.

Readers Write: EHRs Have Not Reduced Paper Usage Yet. Why? And How Do We Change This?

EHRs Have Not Reduced Paper Usage Yet. Why? And How Do We Change This?
By Chris Click

Chris Click is senior healthcare solutions manager of document imaging for Nuance of Burlington, MA.

EHRs have numerous advantages. Foremost among them, patients’ health records are readily available and stored securely. Despite these benefits, hospitals report an 11 percent increase in paper usage, driven by Meaningful Use, the Affordable Care Act, ICD-10, and the adoption of electronic record-keeping. This begs the question — why is paper usage increasing as hospitals adopt EHRs?

According to Health IT Dashboard, in 2016, more than 95 percent of all eligible and critical access hospitals demonstrated Meaningful Use of certified health IT, including EHRs. Unfortunately, doctors are not always happy or comfortable with this widespread adoption of health IT. Physicians Practice’s 2017 Technology Survey found nearly 43 percent of physicians cited issues with their facility’s EHR as the most pressing IT-related concern. In the same survey, about 75 percent of respondents agreed that health IT is failing because doctors generally do not like the technology available to them.

Physicians’ dissatisfaction with their facilities’ EHR systems lead them to print out patient records rather than work from the device’s screen. Evidence points to this being the case; according to one recent US survey, 88 percent of respondents said they understood, retained, and used information better when they read general documents on paper as opposed to on electronic devices.

Things do not have to be this way. Healthcare organizations need to supply their medical staff with tools to make EHRs easier to use and eliminate unnecessary printing and paper-based records in general, while also maintaining a high level of patient convenience and satisfaction.

Paper is still prevalent in healthcare facilities. Not only because doctors seem to prefer it over EHRs, but because patients often arrive with a variety of paperwork: admission forms, consent forms, pharmaceutical records, referrals, and insurance forms. EHRs can store all this information, but manually entering the information can be an onerous task that leaves patients waiting. Therefore, it’s necessary for healthcare facilities to equip their staff with tools to streamline the intake process and automatically input patients’ information into their EHRs. Installing optical character recognition (OCR) technology onto office scanners and integrating the device to the facility’s EHR will enable administrative staff to scan documents and have the information automatically uploaded into the EHR, saving time for both staff and patients.

Doctors are also spending more time with EHRs and less time with patients. A 2016 study in the Annals of Internal Medicine found that nearly 49 percent of doctors’ time was spent on EHRs (updating them, inputting notes, etc.) while just 27 percent was spent with patients in direct clinical engagement. Giving doctors tools to make recordkeeping easier will give them more time to interact with patients.

Hospitals should consider giving their medical staff voice recognition or OCR tools. Both have become practical alternatives to typing and are a much faster, simpler way to transcribe doctors’ notes into EHR systems. A recent study showed that voice recognition software is faster and more accurate than typing, and OCR technology, when paired with document scanners, can convert paper documentation such as patient reports and clinical tests into searchable content for immediate use by the clinician in the EHR.

When EHRs are updated more promptly and accurately, physicians’ confidence levels in them will increase. If physicians know that inputting notes will be significantly easier than in the past, this will encourage them to reduce their reliance on paper and instead leverage more modern, convenient techniques. All of this will help reduce the volume of paper and printing.

Healthcare facilities that do not set parameters at the printer leave open the possibility of staff abusing printing privileges and disregarding resource consumption. Equipping multifunction printers (MFPs) with software that creates an audit trail of print jobs can help healthcare facilities manage costs and resources by allowing them to see who is printing and the associated volumes.

In addition to reducing paper volumes and costs, printers can also ensure a higher level of security for sensitive data residing in paper documents. There is software available that enables including “follow-me printing,” which holds documents in a secure print queue until the user authenticates themselves at any network MFP. This ensures that only privileged users can print certain documents and offers better safeguards PHI residing in paper documents by eliminating the scenario of sensitive documents being left unattended on the printer tray.

The healthcare industry’s paper problem can be solved, but reaching Meaningful Use alone hasn’t done the trick. Transitioning to a paper-light operation will require supporting technologies to augment the benefits of a facility’s EHR while at the same time installing better tools to help both physicians and administrative staff streamline processes and while also keeping sensitive, confidential patient data secure.

Readers Write: Modern Practice: Automation and Lifestyle Management are Key Drivers for Growth

Modern Practice: Automation and Lifestyle Management are Key Drivers for Growth
By Arman Samani

Arman Samani is CTO of AdvancedMD of South Jordan, UT.

At the beginning of 2015, I discussed the technologies that would influence the growth of private practices going forward. Enabled by mobile and cloud computing, integrated practice management (PM), electronic health record (EHR), patient relationship management, and actionable analytics, as well as interoperability were top of mind, with the integration of statistics from patient wearables, benchmarking, and actionable alerts as specific technology solutions for private practices to consider.

Some of these technologies have gained traction while others remain a goal to attain. At the same time, innovations have emerged to help private practices not only compete but thrive in the era of consolidation and healthcare reform. Let’s take a look at how providers are using technology and how they may further engage their patients while thriving as businesses.

Cloud- and mobile-enabled technology as foundation of modern practice

Cloud technology has been around for quite some time now, but I’d estimate that more than 50 percent of private practices still use server-based applications. New entrants into the practice market, particularly those with technology-savvy leadership, are definitely embracing the cloud. These new providers are building their practices around all the technology elements I discussed three years ago. Yet even these modern practices must be vigilant and do their due diligence when identifying cloud-based applications to suit their needs. Some vendors offer so called “fake” cloud: a hosted server solution which is not a true shared environment accessible from any device.

Cloud adoption will absolutely continue for practices that are server-based. Understandably, it’s hard to switch a working practice, but we do see them moving to the cloud when their server applications can no longer keep up with the demand of the new generations of patients.

Workflow automation is a must for successful patient engagement

Given today’s consumer-oriented mentality about healthcare, patients want and need an automated process for all interactions with their medical providers.

As a patient, if I am online searching for a physician, I should be able to look at comments on the doctors in my network, schedule an appointment with the one I select either on a desktop or phone, and receive a reminder of that appointment. I should also be able to provide feedback on my visit and experience. This is where innovations such as Google-interfacing reputation management platforms come in to bring patient engagement closer to how retail, services, and other sectors engage with customers. Private practices can manage their online presence like any other business, obtain feedback from patients, and respond to it in a timely manner.

The physician’s office should also be able to check my benefits, manage my wait time, automatically file claims and receive payments, view day/week/month closings, and send out digital statements. None of it is doable in an efficient and patient- and provider-friendly manner without automation.

Securely automating and interconnecting these processes enables providers to avoid some of the mounting costs of doing business while being responsive to the needs of patients and payers. Ideally, providers should have unified, easy-to-use solutions for all parts of their practice, with one workflow, one database, and one log-in, accessible from all major browsers and on multiple devices.

Continuous engagement for lifestyle management

Everyone is excited about the potential of Fitbits and other wearables to deliver real-time patient data that could both engage patients and help their providers optimize treatment. However, we are far from realizing this integration. Even in the value-based care environment, there are no incentives for private practices to adopt the technologies that would help them proactively manage patient lifestyles. Practices are only reimbursed for managing patients from one visit to the next rather than providing continuous care management that has the potential to significantly reduce care costs.

There is plenty of evidence now that factors such as lifestyle (from exercise to diet to work habits) and social determinants of health (where people are born, live, learn, work, play, and age) account for as great, if not greater, portion of outcomes as clinical factors. This is a tremendous opportunity for the industry to enable providers with appropriate reimbursement and technology to improve the health of our country.

On the lifestyle technology front, think about patient reminders to take medications, fill prescriptions, balance food intake, and check in on both physical and mental health-related issues. Such continuous engagement can be accomplished either by pushing lifestyle applications or sending text messages and responding to communications from the patients.

We are seeing this emerging trend with some employers who are betting on preventative care to keep their employees healthy. They negotiate with payers to offer successful wellness programs that are typically popular with employees. By shifting more funds to lifestyle management, we have more opportunities to reduce costs dedicated to chronic care management. I hope that Medicare will begin to cover lifestyle management medicine, with private health insurance companies following suit.

Future is in technology-enabled continuum of care

Change in healthcare technology does not always occur as quickly as we would like, but it is happening now more rapidly than ever. The consumerism of healthcare will continue to grow and technology will grow with it; ideally, ahead of it. Providers should aim to convert everything that is currently done on paper or that involves a phone call to a digital format that is easily accessible to patients. Private practices are advised to adopt cloud-based systems to optimize the patient experience, including online scheduling, telemedicine, and automated reminders for various purposes, providing options previously unavailable to busy consumers. Technology-savvy patients will be looking for providers who offer this continuum of care and payers will begin to recognize its significance.

The government is also well aware of the consumer-focused technology drivers. I believe we will see a greater consistency in telemedicine rules and reimbursements from state to state and payer to payer. I also truly hope that insurers will begin to support lifestyle management services, helping practices expand beyond chronic care management. Practices can demonstrate the return on investment by measuring results of lifestyle programs through benchmarking and share that data with the insurers.

When we can demonstrate that better-managed lifestyles can reduce or prevent chronic conditions, private practices will have greater leverage in negotiating with payers and be able expand their practices with new, state-of-the-art services and technology supporting the shift. It’s time for payers and providers to move from the visit-to-visit viewpoint to one of long-term wellness.

Readers Write: Creating Clarity from Confusion: The Importance of Healthcare Price Transparency

Creating Clarity from Confusion: The Importance of Healthcare Price Transparency
By Rajesh Voddiraju

Rajesh Voddiraju is founder and CEO of Health IPass of Oak Brook, IL.

Picture this. It’s Saturday night and you’ve decided to try a new restaurant. You pick up the menu, only to discover that there are no prices listed for any of the items. When you flag down a member of the wait staff to inquire about the cost of an item to order , their response is to shrug and say, “I’m sorry, but we aren’t authorized to tell you the prices of our menu items. You will have to have to contact the company that prints the menu to to find out about that.”

You have no idea who to call or what to expect. However, you are hungry, so you order a hamburger, which seems like a safe, economical choice, only to be billed $50 for it weeks later. Of course, had you known the hamburger would cost $50, you might have ordered something else or even found a different restaurant, but now you are stuck paying an unexpected bill. How long would a restaurant with these businesses practices stay open? Not very long, that’s for sure.

Yet this is exactly the situation patients face when they enter most healthcare provider offices. There is no menu of medical procedures with prices clearly labeled. Patients are essentially presented with a choice—face the unknown of paying for healthcare or forgo it altogether.

This lack of price transparency is one of the reasons that people avoid regular preventative care, which in turn leads to a higher incidence of preventable disease. The chain reaction goes on from there. The ultimate effects of uncertain healthcare costs are more far-reaching and devastating than most Americans realize, to the detriment of patients, providers, and the healthcare industry as a whole.

The clear loser in land of opaque healthcare pricing is the patient. Just as the aforementioned diner is left feeling frustrated and helpless by a menu without prices, so too is the uninformed healthcare consumer. The main difference between the restaurant scenario mentioned above and the plight of the healthcare consumer is while a restaurant with such questionable practices would undoubtedly go out of business, the lack of price transparency in healthcare has been considered the status quo.

For years, Americans have grown to accept that medical billing and payment was a mysterious and complex process where prices were kept secret and the ability to review and evaluate the cost of care prior to treatment was non-existent. Fortunately, state policymakers have begun to recognize the urgent need for greater price transparency in healthcare and are beginning to enact legislation that mandates medical providers publish their prices for some of the most common procedures and treatments offered.

For example, at the state level, Colorado Senate Bill 65 went into effect January 1, 2018, requiring hospitals to post self-pay prices for their most common procedures and treatments. Health and Human Services (HHS) Secretary Alex Azar is leading the federal charge toward greater healthcare price transparency as evidenced by his comments at the May 2018 World Health Care Congress, which stressed the importance of lowering drug costs, the consideration of new healthcare models, and free-market forces as a determinant for value-based care. If this trend towards price transparency in healthcare continues to gain momentum, American healthcare consumers will be more informed to make smarter decisions about their care and extract the highest amount of value from out-of-pocket expenditures.

With greater healthcare price transparency, patients go from confused and frustrated to supported and empowered. Informed healthcare consumers are better able to plan and budget for major medical expenses. In addition, when patients are aware of costs, they are more likely to meet their healthcare financial responsibilities, meaning less crippling patient medical debt that burdens the entire system and increased revenue for providers, allowing them to keep their doors open.

As the healthcare industry becomes increasingly consumer-driven, increased price transparency has yet another important function for medical providers – it has become a major piece of the patient retention puzzle. Providers build trust when they are upfront about the cost of care, leading to better, more sustainable positive relationships between patients and provider.

Due to factors such as the 24-hour news cycle and the escalating use of social media, Americans have become more aware of healthcare system deficiencies and weaknesses that inhibit the effective and affordable administration of care. As healthcare costs skyrocket, patients and legislators alike are searching for ways to increase the quality of care. The push for greater price transparency into the cost of care is partly grounded in the move towards value-based care that rewards quality rather than the traditional model of fee-for-service that incentivizes providers to call for tests and procedures that may not be necessary. Price transparency plays a key role in the transition to value-based care because the transition relies on patient access to all care-related data, including medical records and costs.

Price transparency has more than just an educational value for the patient. It has the power to actually lower the cost of healthcare. According to the Robert Woods Johnson Foundation, “Health economists and other experts are convinced that significant cost containment cannot occur without widespread and sustained transparency in provider prices.”

The bottom line is that the modern healthcare consumer refuses to remain captive in an enigmatic healthcare system with a seemingly arbitrary cost structure. Just as the restaurant at the beginning of this article is likely doomed to go out of business due to its suspicious business practices, providers who fail to adapt to changing consumer expectations will suffer negative consequences. Changes are on the horizon for all healthcare providers as healthcare policy begins to catch up to public demand. Savvy healthcare providers will see the writing on the wall and implement healthcare price transparency now, before it becomes a mandate.

Readers Write: Can Appropriate Prescribing Practices Curb the Opioid Crisis?

Can Appropriate Prescribing Practices Curb the Opioid Crisis?
By Victor Lee, MD

Victor Lee, MD is VP of clinical informatics at Clinical Architecture of Carmel, IN.

According to a 2014 report from the National Institute on Drug Abuse, the misuse and abuse of opioids is associated with a staggering number of emergency department visits, hospitalizations, overdose deaths, and many other adverse outcomes. Altarum estimates the economic impact from 2001 to 2017 to be more than $1 trillion, with a projected $500 billion of additional cost through 2020 at current rates. The White House Council of Economic Advisers estimates a burden of $504 billion in 2015, stating that prior estimates of the economic costs of the opioid crisis undervalue overdose fatalities. On October 26, 2017, The United States Department of Health and Human Services declared the opioid crisis to be a nationwide public health emergency.

There are efforts to combat the opioid crisis at many levels, including government (federal, state, and local), professional societies, health systems, health plans, academic institutions, and health IT vendors. Let’s look at a few selected recent events. The President’s Commission on Combating Drug Addiction and the Opioid Crisis provides a multifaceted set of 56 recommendations across categories that address federal funding, prevention, and treatment of opioid addiction. The Centers for Medicare & Medicaid Services issued a final rule which implements the Comprehensive Addiction and Recovery Act of 2016 and states, “a sponsor can limit at-risk beneficiaries’ access to coverage for frequently abused drugs beginning with the 2019 plan year. CMS will designate opioids and benzodiazepines as frequently abused drugs.” The Institute for Healthcare Improvement summarizes four main drivers to reduce opioid use, one of which is to limit the supply of opioids.

The Role of Opioid Prescribing as a Contributor

Why is it necessary to limit the supply of opioids? There is clear evidence that the prescription of opioids for pain management is a major driving force of the opioid crisis in the United States. A case-cohort study by Bohnert et al (2011) links higher opioid doses with opioid overdose death among US veterans. A retrospective cohort study by Brat et al (2018) shows that compared with opioid dosage, opioid prescription duration is even more strongly associated with misuse and overdose in a general surgery population. Findings from a series of structured interviews by Cicero et al (2017) reveal no qualitative differences in the onset and progression of opioid substance use disorder between medically treated patients and recreational opioid users. A review article by Compton et al (2016) provides further discussion of opioid prescriptions resulting in non-medical opioid and heroin use and cites numerous references.

Perhaps the most comprehensive review of risk factors for prescription drug misuse is provided in a 2017 publication by the Substance Abuse and Mental Health Services Administration. In summary, the body of research on prescription opioids shows a consistent link with resultant substance use disorder. This suggests that the demand side of the opioid crisis is critically important to address.

A Potential Solution

Prescribers of opioid medications are in an excellent position to fight the opioid crisis. While there are numerous evidence-based guidelines, a reasonable starting point would be to follow the “CDC Guideline for Prescribing Opioids for Chronic Pain” for appropriately selected patients. Recognizing that other opioid prescribing guidelines exist, the CDC guidelines are most commonly referred to by numerous organizations as part of a multifaceted approach to mitigating the opioid crisis.

While guidelines, clinical trials, reviews, and other literature may be widely available, they are not always translated into practice when applicable. This is where clinical decision support (CDS) may help. Kawamoto et al (2005) systematically reviewed the literature and found that the automatic provision of CDS as part of clinician workflow is 112.1 times more likely to improve clinical practice as compared with control groups (P< 0.00001).

CDS can lower the barrier to adhering to certain CDC recommendations such as:

• Calculating morphine milligram equivalents (MME) dosages and justifying decisions to use ≥ 50 MME/day or ≥ 90 MME/day
• Identifying risk factors for opioid overdose and considering of naloxone as part of an opioid management plan
• Applying other prescribing best practices from the CDC’s 12 recommendations

We’re In This Together

While there are other ways to address the opioid crisis — such as national legislative / regulatory action, statewide technology implementation of prescription drug monitoring programs, and treatment of substance use disorder — there is also an opportunity to prevent opioid overutilization in the first place. If a bathtub is overflowing, the question is not whether to turn off the water, unplug the drain, or to mop up the water—the question is how to do all of these things in the most expedient way to address the problem.

Similarly, lawmakers, administrators, technologists, clinicians, and patients can work together to contribute their efforts in concert with one another to optimize pain management, minimize opioid overutilization, and to effectively treat substance use disorders.

Readers Write: Five Best Practices for Care Programs for Members

Five Best Practices for Care Programs for Members
By Jessica Schiller, RN, BSN

Jessica Schiller, RN, BSN is director of clinical programs at Wellframe of Boston, MA.

What if your members had all of the information they need and wanted? Medication regimen, social / lifestyle support, education for their conditions, access to a care manager — all the critical pieces related to their health and care in one place, right at their fingertips?

In many ways, this vision is becoming a reality as digital member engagement has become a high priority focus for care management. A crucial part of sustained engagement is the information that members receive about their health and that care managers utilize to structure interventions. Embracing a modern approach to engagement demands a new paradigm for care programs altogether — designed for members, delivered digitally, and personalized to meet each individual’s needs through digital and human support.

The application of personalized, interactive, member-facing care programs can amplify the medical risk reduction of care management by putting the right information in members’ hands at the right time, in the right format. With this in mind, let’s examine five best practices for care programs for health plan members.

One of the primary frameworks of care management is the care plan. In parallel to the medical record, the care plan is a collection of each member’s health history, diagnoses, problems, goals, and interventions, which evolves over time. Care plans function as decision support tools designed to help care managers structure interventions and methods for member support, typically delivered over the phone.

While they have been effective to date, the transition to member engagement through mobile and digital channels highlights where care plans are deficient: they are only available to the care team. In the booming digital age, members should be allowed to engage with this information directly.

Multi-channel engagement methods present an opportunity to extend part of the care plan directly and digitally to members in a new format adapted for the audience and the channel. We call this new concept a “care program.”

There are five best practices for effective member-facing care programs. These strategies ensure members receive the information they need to stay on track with their health in a way that aligns with their needs. In addition, well-designed member-facing care programs have proven to dramatically increase care team efficiency by saving clinicians valuable time in relaying information to members.

1. Optimize for mobile

• Create short, interactive content
• Stick to 400 words or less for engaging clinical articles
• Hold attention with under-two-minute video stories from peers or tips from their doctor

2. Meet health literacy standards

• Deliver content at the lowest reading level possible for broad accessibility
• Write in short sentences with basic structure and simple words
• Provide definitions for medical terminology
• Break complex concepts into digestible pieces

3. Be holistic

• Support the whole person, not just the chronic condition
• Give members the support they want for lifestyle factors like weight loss, nutrition and Exercise
• Provide information on key areas of health maintenance like emotional health, safe alcoholuse, and pneumococcal vaccinations, which also relate to HEDIS metrics

4. Deliver content over time

• Start with foundational topics and build on them over time
• Begin with must-know information, like what to do in an emergency, the importance of routine follow-ups, and red flags for the member’s condition
• Progress to education on complications associated with their condition, what their medications do, and psychosocial / lifestyle factors that can impact their day-to-day

5. Enable personalization

• Adjust care programs to meet the unique needs of each member
• Ensure educational components are modular and easy to customize
• Empower care teams to determine what information to send to members

The Outcome of Application

Adhering to these principles for member-facing care programs will generate a positive feedback loop for member engagement that is particularly feasible, cost-effective, and scalable via mobile, particularly when compared to care managers repeating information many times on the phone.

With health education that is personalized, relevant, and accessible, members will engage more often, feel better supported (satisfied), and learn how to self-manage chronic conditions more effectively.

Further, in the context of a therapeutic relationship with their care team, members’ interaction with the care program provides the kernel of insight around which the relationship is able to thrive: everything the member does with the care plan matters and informs better care. In turn, member-facing care programs advance the goals of care management and quality improvement overall, through effective health education to reduce complications, avoid readmissions, and improve outcomes.

Readers Write: HLTH 2018 Recap: A Transformation in Talking about Healthcare Transportation

HLTH 2018 Recap: A Transformation in Talking about Healthcare Transportation
By Travis Good, MD

Travis Good, MD is co-founder, CEO, and chief privacy officer of Datica of Madison, WI.

The premiere, sold-out HLTH conference ended last week in Las Vegas with a generally positive impression on its new style of healthcare conference. I, along with 3,500 attendees, laughed with Jonathan Bush, CEO of Athenahealth, as he entertained us with statements like, “All we do, all of us, is fail… And then we die!” We sat in stunned silence as Harold Paz, MD, executive vice-president and chief medical officer at Aetna shared the disturbing facts of the opioid crisis — facts like 116 people die every day in America, where we consume more opioids than any other country on Earth, and that more Americans will die this year than died through the entire AIDS epidemic or the Vietnam War.

HLTH was different than many healthcare conferences I’ve attended with its rapid-fire panel discussions, where the panelists didn’t waste time explaining high-level concepts like Blockchain, but instead jumped right in to describing the details of the emerging technology details. Numerous announcements and visionary ideas were also presented. The slick nature of the well-orchestrated HLTH event, likely made possible by the $5 million garnered in venture money, left an overwhelming impression for a first-time event.

The HLTH organizers did have one major miss: lack of strong representation of female healthcare leaders. Evidence of that agenda oversight gained audience criticism in social media and questions to panelists (including me) on why they thought few women graced the stage.

Two general themes prevailed throughout the conference. One centered on transforming the current healthcare business model to improve everything from interoperability, costs, and patient outcomes to physician burnout. The second theme that emerged throughout the conference focused on the exploration of entirely new business models that could transform the healthcare industry.

Announcements ranged from the splashy — like former CMS Acting Administrator Andy Slavitt’s launch of Town Hall Ventures, his shift from the government to investing in technologies that facilitate real change in our communities, and Change Healthcare teaming up with Adobe and Microsoft to orchestrate better patient engagement — to the mundane, like Marcus Osborne, VP of healthcare transformation at Walmart announcing, “Walmart isn’t going to stand for this” in describing the poor quality of care their associates have had to endure and Walmart’s push toward an evidence-based approach that ends physician’s entitlements.

Topics around blockchain, genomics, artificial intelligence (AI) and machine learning, cloud, augmented reality, and interoperability prevailed. During a lively panel, the so-called “unicorns of healthcare” shared their predictions of the next generation of unicorns. Anne Wojcicki, CEO and co-founder at 23andMe, predicted that the next unicorn will be in AI or chatbots. Frank Williams, CEO at Evolent Health, says precision medicine. Jonathan Bush thinks they’ll be new reimbursement models or therapeutics.

One theme woven throughout conference presentations is the idea that caring for health needs should extend beyond the walls of a treatment room and out into the community. On the first evening of the conference, David Feinberg, Geisinger president and CEO, described his vision of a new direction for healthcare for the communities Geisinger serves. The vision included not only traditional healthcare, but also feeding and housing people who need it.

Later in the conference, Lauren Steingold, head of strategy at Uber Health, described the company’s innovative new patient transportation offering that could help eliminate the $150B yearly cost to the healthcare industry resulting from 3.6 billion Americans who miss appointments due to transportation issues. Steingold described her vision of expanding that model to encompass telemedicine patients who need a ride to the pharmacy or even surgery patients who need a ride home.

My favorite quote from the conference, which pretty much sums up the current state of healthcare transformation, came from Anne Wojcicki. “What happens in healthcare is you have people who really want to do the right thing, but the ships are pointed in the wrong direction.”

All in all, the conference left attendees more informed and energized. Now HLTH organizers are taking what they learned from the first conference and planning for expansion next year.

Readers Write: Will PDMPs Remain a Vital Tool in the Opioid Response, or a Costly Burden?

Will PDMPs Remain a Vital Tool in the Opioid Response, or a Costly Burden?
By David Finney

David Finney is a partner with Leap Orbit of Columbia, MD.

New battle lines are being drawn in an important corner of the nation’s broad fight to control the opioid epidemic. Health IT professionals should sit up and take notice.

Much quiet maneuvering has been taking place for months, particularly among a number of large and well-connected technology vendors sensing a windfall. But with the recent signing into law of the $1.3 trillion federal omnibus spending package, the debate about what the future should look like for prescription drug monitoring programs (PDMPs) has burst into the open.

PDMPs — which are state-based systems for tracking and analyzing the prescribing and dispensing of controlled substances — have existed in some form for a century. Over the last 10 years, they have become more technologically sophisticated and are frequently pointed to as a critical (and mostly non-controversial) tool in the opioid response. Today, 49 states, the District of Columbia, Puerto Rico, and Guam have established PDMPs, while in Missouri, a PDMP instituted by St. Louis County serves most of the state’s population.

In an increasing number of states—over 30—clinicians and pharmacists are required by law to check their PDMP prior to prescribing or dispensing any controlled substance. Though enforcement is so far minimal, failure to do so could result in suspension or loss of license. Among other emerging techniques, many states now also send unsolicited reports to prescribers, using PDMP data, demonstrating that their prescribing habits are outside the norms for their specialty.

The federal government has encouraged these policies with a steady and increasing stream of grant funding to states to cover software development, licenses, and IT staffing. Not surprisingly, the private sector recognized the opportunity. Appriss, a private equity-owned firm that got its start helping states monitor sex offenders, has been the chief beneficiary of this flow of government dollars achieving a near monopoly in the state PDMP market by, among other things, acquiring its two largest competitors.

With 42 state contracts, Appriss has done what monopolists do, bidding up contract prices and seeking to monetize every aspect of the data it controls. Given the commitment by states and the federal government to “do whatever it takes” to address the opioid epidemic—including supporting PDMPs with ever-increasing grant funds—PDMP administrators may grumble, but otherwise few people have stopped and taken much notice.

Few, that is, except for several large healthcare and technology interests (increasingly those are one and the same) and the Washington lobbyists who work for them. Acting no doubt out of a genuine desire to positively impact the opioid epidemic, and also sensing a business opportunity, these interests have quietly been pushing Congress and the Trump administration to rethink the federal government’s traditional support of PDMPs and “modernize” them.

How to do this? By awarding tens, if not hundreds, of millions of dollars in new federal contracts to one or a small number of firms to facilitate the flow of PDMP data at a national level. This new network would leverage existing prescription data feeds that support e-prescribing and third-party payment. Initially, this network might complement and enhance state PDMPs, but in the longer term, it seems likely to make them redundant.

By all indications, the federal omnibus spending bill and subsequent signals from federal officials and lobbyists seem poised to deliver on this new model. Not surprisingly, Appriss is worried. In recent weeks, it has launched a marketing campaign of its own to highlight the benefits of the current state-based approach to PDMPs and the interstate gateway it developed in collaboration with the National Association of Boards of Pharmacy.

Why should health IT professionals care? Frankly (and functionally), whether the nation continues with a states-based model for PDMPs or a federal one probably won’t make a big difference to end users at hospitals, ambulatory practices, retail pharmacies, or other healthcare facilities. The more timely data offered by the federal model may offer some marginal benefit, but states have already been moving in that direction. In either case, though, the outcome is likely to hit the bottom lines of these organizations in a big way.

Already, as prescribers and dispensers are required by law to consult PDMP data, their IT departments face pressure to deliver the data to them in more workflow-friendly ways. Appriss has gladly obliged by presenting hospitals and health systems across the country with steep per-user, per-month fees to access the data it controls via its state contracts via APIs or single sign-on. These fees can reach seven figures per year for some health systems. A federally facilitated approach is likely to look no different—it would use established e-prescribing networks, whose business models are well known, to deliver PDMP data into the workflow. What all of these businesses likely understand is that the last mile into the prescriber and dispensers’ workflow could be the most lucrative aspect of PDMPs.

A few states are attempting to buck these powerful forces. They take the view that PDMPs are a public utility, and as such, PDMP data should be widely and democratically made available to anyone who has an appropriate use for it. In Maryland, Nebraska, and Washington, this has meant collaborating with a statewide health information exchange to publish open APIs and support a range of standards-based integration techniques for bringing PDMP data into the workflow. California’s PDMP, with support from the legislature, is also in the midst of an ambitious initiative to make open APIs available to all of the state’s healthcare institutions.

These states support a nascent ecosystem of third-party technology providers and system integrators that are inventing new ways to present PDMP data to those who need it, when they need it. Companies—and I count my own among them—are demonstrating real innovation that can make a difference in fighting the opioid epidemic. The earnest competition also keeps us honest and hungry and should ultimately drive down cost. If more take notice, these states may present an alternative to the models being pitched by more powerful interests.

Readers Write: I Am More Than My Specialty: Physician Burnout and Individualism

I Am More Than My Specialty: Physician Burnout and Individualism
By Erin Jospe, MD

Erin Jospe, MD is chief medical officer of Kyruus of Boston, MA.

While physician burnout is garnering more attention with a steady generation of articles and books both academic and lay, we have yet to see improvements despite our awareness of the problem. We have become facile at recognizing the symptoms of exhaustion, detachment, cynicism, and inefficiency as the hallmarks of burnout, but no better at treating the underlying causes.

Per Medscape, no specialty was spared an increase in self-reported burnout symptoms between 2013 and 2017, [1] and the prevalence is unsettling at almost 60 percent in some fields. [2] While there is no silver bullet for burnout, within their professional work environments, recognizing physicians as individuals and giving them the means to convey their unique areas of expertise to patients, fellow providers, and others within the health system can go a long way in paving a path to higher satisfaction and engagement.

We are equally aware of the downstream ramifications of physician burnout as we are of the symptoms, with repeated studies demonstrating the negative impact on patient safety, quality of care, and the patient experience. With the refocusing of the context of care upon the mission to improve patient lives, in 2007 the “Triple Aim” reminded us of the importance of how individual patients experience care. In the 10 years since, there has been a paradigm shift in respecting the individual patient as having unique needs and values that must be addressed to achieve better health.

Physician burnout directly undermines our ability to deliver on this promise and has worsened in the same 10 years. It was innovative to say we needed to acknowledge the humanity of our patients to deliver better care, to recognize the individual and not view them as interchangeable with every other patient. And yet by creating a delivery system that only recognizes the humanity of those needing care and not of the care providers, we sully the sacredness of that patient-provider relationship and create the same negative environment of disrespect that results in so much dissatisfaction among both providers and their patients.

Though we rightly strive to see and address the individual needs of the patient, there is a widespread sense that physicians themselves are interchangeable. This is no less disrespectful than perceiving patients as such. As a physician, I am far more than my specialty,  as are my colleagues. Yes, I have an expertise, and with it comes an expectation of an established skill set and standards of care. But I have a style, manner, and experience that is my own. I have defined niches of interest and excellence that make me better suited to the needs of some patients.

When given no means, no vocabulary, no voice with which to articulate that which is unique to a physician, we do a disservice to the individual physician and to the community of patients and other providers who would seek them out. Our health systems and networks of physicians are growing exponentially larger, but with it, our awareness of individual contributors diminishes. We no longer have connections with one another as physicians and no insight as to where unique strengths and gifts might exist among us.

In the face of an exploding fund of medical knowledge, we cannot deny the necessity of understanding where unique expertise — and not just specialty — lives. It is hard to enough for physicians to acknowledge the deficiencies in our knowledge base. Providing no means by which to uncover who within our community might help only furthers a tendency toward emotional and mental exhaustion.

Addressing burnout at an individual physician level is often too little, too late. Resiliency is important, but in and of itself, resiliency does not change the environment for which it is necessary, and too often will be insufficient to treat or prevent burnout.

Instead, consider the systemic and holistic organizational contributions to the environment which are causal. Rather than address the individual’s propensity to burnout, address the individual. Allow them to be acknowledged and appreciated as uniquely individual contributors. Give them the means to indicate to their networks what their clinical areas of focus are beyond merely specialty / subspecialty. Provide them with teams aligned in their mission to act in concert as exceptional people in the care of exceptional people. Facilitate their understanding of the excellence that exists within the community of providers.

Failure to do so diminishes the joy and satisfaction of relational patient care by converting those interactions into the merely transactional. Though not a panacea for physician burnout, we need to address the anonymity of our providers if we are to do justice to the promise of prioritizing the patient experience.

[1] Medscape Lifestyle Report 2017

[2] AMA, “Report reveals severity of burnout by specialty,” Jan. 31, 2017.