Readers Write: Clinical Decision Support: Are We Ready to Invest?

Clinical Decision Support: Are We Ready to Invest?
By Jaffer Traish

Sometimes great ideas are just ahead of their time. Microsoft launched a smart watch in 2004. Digital currency received 100M in venture funding, but collapsed in the dotcom era. Google Glass has come and gone – or has it?

Evidence-based medicine and the marriage with technology is another open playground. Opportunities abound to create interactive, engaging clinician workflows to support real-time decision-making and enhance not just clinical outcomes, but the patient experience and revenue integrity.

The Hearst Corporation’s portfolio includes efforts to improve real-time medication decision support, maintain the currency of order sets and care plans, as well as drive care team and care transition communication. Wolters Kluwer is similarly working on the above, as is Elsevier in their respective product portfolios. The CMS value-based purchasing and other HITECH act incentives provide some soft carrots to push forward.

EHR vendors also provide significant clinical content (sometimes including specialties as well) that provide a very practical head start, though with no assessment of evidentiary integrity. Some startups like Stanson Health are also tackling niche areas of decision support.

The meta-analysis, categorization, and dissemination of evidentiary information is not a hard science. Teams of clinicians and coders together can review hundreds of articles and publish findings relatively quickly. Most healthcare systems have enterprise subscriptions to evidentiary libraries to consume these findings. Even as there is disagreement among communities over studies and trials, that very disagreement is the impetus for further study.

Some EHR vendors support communities of clinicians coming together to bridge the gaps in knowledge and best practice findings, especially in pediatric care.

Healthcare systems aren’t software development shops. Most don’t develop teams to tackle this opportunity. Instead, they hire analysts to manually manage the change (painful and expensive). The evidence subscription vendors have been trying, though they aren’t the EHR experts – the integration approach has been flawed. Groups like OpenCDS are refreshing and bring attention to standards development and process, though still ahead of its time. Last but not least, implementation, rollouts, ICD-10, and other priorities have taken the spotlight.

Clinicians are adjusting to their systems. Are they be ready to do focused collaboration on their (ex.) 200 order sets with evidence depth?

EHRs are maturing their decision support tools. Are they ready to participate more fully in sharing public specifications for standard decision support ingestion?

Evidence vendors have grown revenue streams on non-integrated IT tools. Are they willing to wipe the slate and start fresh with new API models?

Revenue cycle teams have been focused on SBO models, centralization, and patient satisfaction, but there is a strong link to revenue integrity with the reduction of unnecessary tests and improved standards of care. Is the CFO ready to demand this value?

In talking with many CXOs, some truly want to insource this activity while others would prefer to pay –  to have content and evidence managed externally and reap the lessons and value from others. Both models could prove effective. Today, the costs are high dollar subscriptions. Perhaps these costs need to be part of a risk strategy and not paid without successful implementation.

Today, if an African American would have better outcomes with a different antibiotic, the clinician should have this information at his/her fingertips in the workflow.

Today, if a drug is removed from the market, it should be removed from the clinician’s selection in swift manner without much manual intervention.

Today, if the several major children’s hospitals wanted to jump online and compare their pediatric specialty order sets, they should be able to do so with ease and share the best.

Today, if there are 500 opportunities to improve clinical content with evidence supported changes within an organization, the CFO should know what the patient outcomes and related costs/savings may be.

The list goes on, and we can do all of this today – manually.

The challenge is not dissimilar from the interoperability debate. Just as we need a national patient identifier, adopted patient security measures, and implementation cost-sharing that includes practices, hospitals, patients and providers, the same theme can be found here. We need public specifications through collaboration, a change in the way evidentiary information is so proprietary today and closer partnerships with innovation teams.

Organizations each pay $50k-1.2M for decision support systems today in existing budgets. Various market analysis projects decision support to be a market of $550M by 2018, and upwards of $2B in the future. Let us demand more for our healthcare dollars.

 Jaffer Traish is VP of the Epic practice at Culbert Healthcare Solutions of Woburn, MA.

Readers Write: Eight IT Talent Trends to Watch for 2016

Eight IT Talent Trends to Watch for 2016
By Frank Myeroff

What’s in store for the New Year when it comes to IT talent? Here are eight talent trends that are shaping the IT workforce in 2016.

1. Internet of Things (IOT). Talk about a technology revolution! IOT is emerging as the next technology mega-trend across the business spectrum. This means a job boom for developers, coders, and hardware professionals. However, to land a job in IOT, organizations want candidates with specific technology skill sets and experience. Consequently, an IOT talent shortage is expected.
2. New C-level title. Chief privacy officer (CPO) is a senior-level executive title and position that was created as a result of consumer concerns over the use of personal information, including medical data and financial information. Organizations have had to rethink IT security due to recent breaches. According to InfoWorld, while most organizations already have a CSO (chief security officer) and/or a CISO (chief information security officer), there’s a need for a CPO, a dedicated privacy advocate responsible for keeping personal information safe.
3. Gen Z will enter the workforce in greater numbers in May. Generation Z, those born between 1994 and 2004 (although there’s been no general agreement on exact years), are the most digitally connected generation yet. They have no concept about life before the Internet, mobile devices, digital games, or iTunes. Therefore, they are tech savvy and even more entrepreneurial than Millennials. They will choose career opportunities that provide quick advancement and work-life balance over salary and want mentors to help them achieve their goals.
4. Big data becomes even bigger data. Big data is increasing the need for a new breed of engineers who specialize in massive databases. While the skills required aren’t necessarily new, there is a significant amount of knowledge needed in the areas of math and scientific analysis. Typical high-level skills expected for a position in this field include data analysis, data warehousing, data transformation, and data collection.
5. Longer hiring process continues. According to the Wall Street Journal, in the US, the time it takes to fill a job is lengthening. In April 2015, the average job was vacant for 27.3 days before being filled. This nearly doubles the 15.3 days it took prior to 2009. The long hiring process can be attributed to having fewer qualified candidates for job openings as well as the increased number of background screening and drug tests ordered. WSJ also cites that the many portals and databases used to source and find candidates have become more entailed. While better hires are coming out of the process, it’s moving slowly.
6. Hybrid IT talent in demand. The IT hybrid employee is on the rise. They are considered a generalist and a specialist all in one. A generalist tends to be someone who knows quite a few technologies, but only at an average level. A specialist knows only one or two, but at an expert level. A hybrid knows about a great many things at an advanced level and can adapt to any type of project. With a hybrid employee, employers are basically getting two people in one.
7. Project work and consultant roles are abundant. Project work and consulting roles are most likely to remain abundant through 2016 and beyond. Increasing business demands are prompting many companies to invest in new technologies, along with upgrades and migration projects around tools such as enterprise resource planning (ERP) systems. Candidates who have knowledge of both new and legacy business systems are highly sought after by employers.
8. Hottest industries hiring IT. The following industries are the top industries that will be hiring more IT professionals in 2016: healthcare, financial services, managed services, mobile technologies, telecommunications, and hospitality.

Frank Myeroff is president of Direct Consulting Associates of Cleveland, OH.

Readers Write: Sitting In the Shopping Cart: IT Tips for RSNA 2015

Sitting in the Shopping Cart: IT Tips for RSNA 2015
By Michael J. Cannavo

Most IT and C-suite people are about as excited about going to the RSNA as a child is going to the grocery store with their mom. They hope mom buys them some candy to make the trip worthwhile, but often have no choice but to sit in the cart and watch as items are piled in.

That doesn’t need to be the case at RSNA and shouldn’t be, either. IT folks and C-suites have a responsibility to make sure the products and services being purchase make sense from a technical, operational, and financial standpoint. Following these tips should help the trip be more productive and provide a better overall solution for the facility.

1. Ask pointed, directed questions. Don’t be shy. Have questions ready that you will ask of all vendors that require more than a simple yes or no answer. How do you do it, not just do you it.
2. Be consistent. Apples to apples is key, with each vendor getting asked the same questions. If you uncover something that may require further elaboration, go back and ask the others the same question.
3. Lead, don’t follow. It is very easy for a vendor to take you down the path that best projects their products, but that may not necessarily be one that best meet your needs. The Yellow Brick Road was good for Dorothy, but isn’t for you. Take control of the discussion..
4. Interoperability. One of the biggest buzzwords in IT today is interoperability. Don’t just ask where a vendor has connected to an EHR. Find out where and how they have done it and who you can talk to there about it. What resources were required (internal and external as well as financial)? How much time did it take?
5. Support. Does the vendor provide a data dashboard or allow you to integrate to one? How much support can you provide internally and what can and can you not have access to? These are crucial questions.
6. Facts, not fiction. Where have you done it with an EHR like we have in place? Don’t fall for a simple “yes, we can.” Pretend you are from Missouri, the Show Me state. Who can I talk to who has done it?
7. Talk to engineers. If you want the unfiltered truth, talk with a systems engineer. They are easy to spot — the wrinkled shirt that just came out of the Walmart bag and the loose 1980s vintage tie they borrowed from their dad. They are also the ones who also talk nonstop about anything and everything <laugh>.
8. Bail on the demo. RSNA is the absolute worst place to get a full product demo unless you just want a quick and dirty overview. Do the demo at your facility, where you can examine the product in detail, walk it through its paces, and ask the questions to get the answers you want and need.
9. Get contacts. Your IT counterparts are the best source of information. Get names, phone numbers, and e-mails of those who are similar to you.
10. Relax. Consider this a first date, not an “I do” situation. Don’t hesitate to cut your losses early Trust your gut. If it doesn’t feel right, it usually isn’t.

Michael J. Cannavo, aka The PACSMan, is owner of Image Management Consultants of Winter Springs, FL.

Dr. Herzenstube Goes to AMIA–Monday

Dr. Herzenstube is a practicing family physician who can make nothing of it.

The first session I attended today was a panel on ICD-11 given by representatives of WHO, IHTSDO, and academic organizations involved in developing ICD-11. ICD-11 will be the next version of ICD. The general idea behind it is to harmonize ICD with SNOMED to facilitate the use of SNOMED’s polyhierarchy while retaining ICD’s capability to meet the needs of epidemiologic analysis.

Bedirhan Ustun, a psychiatrist who manages terminology work for the WHO, was the first presenter. He explained that, unlike prior versions of ICD, ICD-11 will have an explicit content model. This means that each ICD-11 code will have underlying definitional modeling (as do SNOMED concepts). The work to build this has been initiated in collaboration with IHTSDO. 

Jim Case of NLM and IHTSO came next and explained that the goal of ICD-11 is to link SNOMED CT and ICD so that data can be captured once at the point of care and avoid the need for duplicate coding effort. He explained one important point about ICD, that as classification system, categories are mutually exclusive. This is important to support use cases of epidemiology and statistics, and explains why “other” codes are needed in ICD (something that never really made sense to me until now).

Chris Chute followed with a discussion of the SNOMED-ICD common ontology, which will provide the semantic anchoring of ICD-11.  Jim Campbell from University of Nebraska discussed some of the areas where the SNOMED CT and ICD-11 hierarchies were at odds and need to be reconciled and Harold Solberg discussed the process of building the links between ICD and SNOMED, either through equivalence maps (A = B) or cases where ICD is described as a compositional SNOMED statement, and automated testing for potential disconnects in the respective hierarchies. 

This panel provided a really helpful degree of clarity on ICD-11 from the people at the very center of building it. It will likely be years before this gets used in the US, but it is good to have a sense of where things may be heading.

I also attended a presentation on the Clinical Quality Framework (CQF), an effort to harmonize standards for clinical decision support with those for quality measurement (nope, they’re not already harmonized; yep, they definitely should have been from the beginning, hindsight is 20-20, etc. etc.)

Dr. Julia Skapic from ONC kicked off the presentation by describing a bit of the regulatory context around clinical quality measurement and clinical decision support and the need to develop a unified way of representing the underlying logic that expresses the standard of care involved. The holy grail to which this work strives is that, if a provider organization configures their system to measure quality using a particular quality measure, they can enable clinical decision support functionality based on the same underlying logic without any additional logic editing work. 

Marc Hadley from MITRE described current standards for CQM and CDS and the output of ongoing work under the umbrella of CQF to harmonize them. One such output is Clinical Quality Language”(CQL), which has been issued as an HL7 draft standard for trial use (DSTU). CQL is a Turing-complete, XML-based language designed to be a human-readable way of expressing clinical rules that is also machine-computable and agnostic to data model. 

In addition, Quality Improvement and Clinical Knowledge (QUICK) has been developed as a data model for use along with CQL, automatically derived from FHIR Base Resources and FHIR Quality Improvement Core (QICore) profiles. Kensaku Kawamoto described several pilots of using data artifacts based on these standards, which were able to represent rules for things like chlamydia screening and routine immunization. Tom Oniki discussed the Clinical Information Modelling Initiative (CIMI), a community of interest that has become an HL7 working group.  While this work is not yet ready for prime time, the amount of progress that has been made is really impressive and the momentum seems substantial. The large lecture hall was filled to capacity, an indication of how vital the need is for a solution to this thorny problem.

The first session of the afternoon I attended was on ACOs, moderated by Gil Kuperman of New York Presbyterian. David Bates of Brighan and Women’s Hospital discussed the use of claims data to identify patients at high risk for hospitalization, who then get an assigned care manager. They have seen a significant reduction in hospitalizations in this population since starting their work. 

The most interesting part of his presentation, to me at least, was the use of what he calls Standardized Clinical Assessment And Management Plans (SCAMPs). Basically, SCAMPs consist of a small set of data elements clinicians are asked to document in particular clinical situations. For example, for distal radial fractures, a few details on the fracture type and whether or not the fracture was treated surgically. After a few weeks of data collection, it is shared with the physicians and collection continues. 

What he found was that the practice patterns at the start were highly divergent from one physician to another. After sharing the data, the variances all but disappeared without any attempt to coerce or persuade any of them to change their practice patterns. A remarkable example of the Hawthorne effect. 

David Dorr from OHSU described the state of Oregon’s experiments with developing approaches to coordinate healthcare for vulnerable populations. His research involves figuring out how to help medical practices perform medical home-related activities such as establishing care management plans, ensuring close follow-up from hospitalizations, and doing clinical quality measurement. While he and his colleagues have developed a population management tool, they have observed something that most practicing clinicians will be familiar with — clinicians need point-of-care reminders, care management workflow tools, etc. within the same system they use to manage other patient information (within the EHR, in other words).

David Kaelber of MetroHealth spoke of some of the real-world challenges of meeting payors’ rules around ACO payments, including the fact that different payors often have slightly different requirements around data collection, population definitions, and quality measurement, requiring duplicate work for what amounts to very similar quality measurements. 

David Bates described his work at NYP with the Delivery System Reform Incentive Payment (DSRIP) program, an ACO-like program operated by the New York State Medicaid program. NYP’s programs include everything from patient navigation services in the ED to an HIV chronic care program to a program to deliver palliative care. They did a formal analysis of IT requirements, such as the ability to trigger notifications when key events occur, like a patient being hospitalized or new patient status values in their EHR. Among the lessons learned were that not all of the information flow can be EHR-based since many of the providers they are collaborating with don’t have EHRs.

One of the other highlights of the day was the poster session. The posters were fairly varied, and as is typical for any scientific conference, a bit hit or miss. One that I found amazing was by Matthew Rioth and Jeremy Warner, two physicians at Vanderbilt, titled “Visualizing High Dimensional Clinical and Tumor Genotyping Data.” When understanding data requires looking at it and two dimensions just aren’t enough, innovative data visualization is necessary. While the examples they provided were primarily research-focused, such as generating new hypotheses regarding what genes are important in cancer behavior, some applied directly to clinical practice, like one that showed patterns of ordering of molecular profiling tests across multiple clinics in their organization.

As with earlier days of the conference, the accidental conversations with other attendees were as valuable as the presentations. One memorable such encounter was with Lisa, an epidemiologist working in a reproductive health program at a state health department. She is becoming an informaticist by necessity since to support her research, she needs to figure out how to get more and better data from the clinical practices that her team funds.

To get data to the health department, these clinics currently either complete paper forms (!) or enter data manually through a Web-based portal. A few clinics have set up data entry forms within their EHRs to capture the necessary data, but it still requires duplicate data entry since these forms can’t pull in data from elsewhere in the patient record.  So if the patient has been screened for chlamydia, even if that data is in the EHR, it needs to be entered a second time to into the data element that will be sent to the health department. 

It was a sobering moment, amidst the promise of future progress all around us at AMIA, to realize how pedestrian the current state is in so many ways. It also drove home to me the ever-increasing burden we’re putting on practicing clinicians to engage in data-entry activities that, while they may serve a noble goal, make it harder and harder to focus on the immediate needs of the patient in front of them.

Readers Write: Health Data Security – Who Do You Trust?

Health Data Security – Who Do You Trust?
By Jeff Thomas, MS, CISSP

I don’t know about you, but I certainly don’t want to be associated with the next health data breach in the headlines. But we all likely rely on outside vendors for a variety of services and products, entrusting them with data and information. A recent report by Gartner Inc., “Trust and Resilience – the Future of Digital Business Risk,” lays out the stark reality: “malicious actors and increasing complexity create systemic threats to trust and resilience.”

Like the old 1950s game show “Who do you trust?,” care to roll the dice? Use that old dartboard?

Say you’re looking at new SaaS applications, mission-critical stuff. Naturally vendors are going to tell you that your data is safe with them. That’s what you want. But how can you tell if they are telling you the truth or not? Is there some “truthiness” going on? How can you tell those that are competent from those that are not?

Gartner predicts that IT spending on security and risk will double in the next five to 10 years, going from about 15 percent of overall IT spending to 30 percent. That’s huge. You’ve got to wonder – is your vendor keeping pace with their security needs or are they perhaps cutting a few corners, exposing your data to risk to save a buck?

You’re going to need some help. An important tool to get an insider’s view is a third-party audit report. Has your potential vendor had their data security procedures audited?

Everyone claims to be “HIPAA compliant.” But that gives you no real assurance that your vendor truly knows data security. Let’s look at one of the most widely-used and rigorous audits available, the SOC 2 Type II.

The SOC (Service Organization Controls) series of reports are governed by the American Institute of Certified Public Accountants (AICPA). These reports are designed to build trust and confidence between services organizations that operate information systems and their customers by having their service delivery processes evaluated by an independent auditing organization.

The SOC 2 is relevant for companies handling sensitive data as it reviews controls related to AICPA’s trust principals for Security, Availability, Processing Integrity, Confidentiality, and Privacy. (Controls may range from being technical in nature to manual processes). If those areas are of interest to you when choosing a vendor, reviewing their report is something you will likely wish to do.

A common question I hear is if a SOC 2 is good, isn’t a SOC 1 better? But in reality, it’s an apple-to-orange comparison. SOC 1 revolves around financial reporting and is often used as part of Sarbanes-Oxley compliance. If you’re selecting a vendor to handle your sensitive patient data, it’s not the right fit.

Or how about a SOC 3? A SOC 3 report is a summary report that does not have the detail of a SOC 2 report. It is generally used as a marketing tool, where the SOC 2 is a restricted document. If you want to see what controls are in place and how these controls are tested, the SOC 2 report is what you will want to read. To do so you’ll likely need to sign a non-disclosure agreement.

So you’ve signed the vendor’s NDA and have the report. Now what?

If you’re comparing vendors, it’s important to know that not all SOC 2 reports are the same. For starters, the biggest difference is that there are two types— a Type I and a Type II. A Type I reviews the vendor’s system and the suitability and design of the controls in place. Think of it as a point-in-time review indicating that the design of the controls was deemed to be reasonable on a specific day. A Type II goes further, and tests the operating effectiveness of the controls over a period of time. Accepted testing periods range from six to 12 months.

Once you have the report, what should you look for? First, there will be a summary, in which the auditor will summarize the engagement to include information about the scope of the engagement, as well as their opinion of the controls audited. This is a good place to see if there are any overall concerns.

Another section will be the vendor’s description of their controls. This will be a lengthy description of all the controls in place to meet the SOC 2 principles. After this, you will find a description of the tests for each control and the results for each test. This will map each of the vendor’s controls to the different SOC criteria and list the test performed and if any exceptions were noted. Ideally, you will find controls that meet your needs, along with a report of the tests finding “no exceptions noted.”

A SOC 2 report, especially the Type II, will not be a quick read. The time spent reading it will give you good insight into what measures a vendor uses to protect and process your data. The best part is that you don’t have to take their word for it—it’s coming from a trusted third party.

Don’t roll the dice or use darts when it comes to security. Insist on an industry-accepted, third-party audit or attestation. In this day and age of increasing digital business risk, you’ll be glad you did.

Jeff Thomas, MS, CISSP is chief technology officer of Forward Health Group of Madison, WI.

Readers Write: The Complexity of Maintaining Compliance

The Complexity of Maintaining Compliance
By Megan Tenboer

Clinical research presents a unique challenge when it comes to billing compliance. Often it’s left to clinical staff to understand Medicare and third-party guidelines, Clinical Trial Policies and other internal and external regulations, and to stay current in a fluid regulatory environment. Non-compliance puts the institution’s financial and ethical well-being at risk.

Two timely illustrations of just how complex compliance can be for research institutions came into play earlier this year. One revises the submission process for investigational device exemption (IDE). The other is the introduction of Condition Code 53 (CC-53).

Not satisfied with simply expanding criteria for coverage of IDE studies, the Centers for Medicare and Medicaid Services (CMS) also decided to centralize the review and approval process.

Previously, research institutions were responsible for submitting the require documents to their respective Medicare Administrative Contractor (MAC)[i] for device trials. Now CMS requires the sponsoring organization to secure approval of coverage for IDE device trials that obtained an FDA approval letter dated January 1, 2015 or later.

If this change is overlooked, it could have a devastating financial impact on the study and could delay treatment for patients in critical need. Failure to seek coverage approval through appropriate channels will delay or negate reimbursement for expenses related to the use of an FDA-approved device—even the device itself depending upon whether it is a Category A (Experimental) or Category B (Non-experimental) IDE study (Category A devices are statutorily excluded from coverage[ii]).

Another layer of complexity hit research institutions on July 6, 2015. An updated code details the process/requirements when generating a claim to local MACs, titled, Condition Code 53 (CC-53). This code is designed to identify and track medical devices that are provided to a hospital by the manufacturer at no cost or with full credit due for a clinical trial or a free sample.[iii]

Previously, hospitals used either CC-49 (Product Replacement within Product Lifecycle) or CC-50 (Product Replacement for Known Recall of a Product) along with value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device). However, these codes described only procedures surrounding replacement devices and not a reduced cost for non-replacement devices. The latter may be provided to Medicare beneficiaries as part of medical device trials.

It seems straightforward, and its intent was to fill the void by describing initially implanted medical devices that are not replacements. However, critics have been vocal about the lack of clarity about the new code. This new code adds to an already overflowing cache of device-related services that must be reported.

These two mandates may appear to be obscure regulations that impact only a small fraction of the overall healthcare market, but that’s not the case. According to business intelligence provider Visiongain, the worldwide market for clinical trials over the next five years will experience a cumulative growth of more than 50 percent.

Further, clinical research organization global revenues are expected to reach $32.73 billion in 2015 and to exceed $65 billion in 2021. Add the growing number of strategic alliances between full-service clinical research organizations and big pharma organizations that have outsourced drug development and the impact of errors skyrockets.

The best defense is to assign one individual to become the “regulatory mandate” expert tasked with staying up-to-date on proposed and finalized changes to ensure timely compliance.

Megan Tenboer is director of strategic site operations at PFS Clinical of Middleton, WI.

[i] Centers for Medicare and Medicaid Services: Medicare Coverage Related to Investigational Device Exemption (IDE) Studies. Available at: http://www.cms.gov/Medicare/Coverage/IDE/

[ii] Department of Health and Human Services Health Care Financing Administration: Medicare Carriers Manual Part 3 – Claims Process. Transmittal 1701. May 25, 2001. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1704B3.pdf

[iii] Centers for Medicare and Medicaid Services. “Implementation of New National Uniform Billing Committee (NUBC) Condition Code “53” – “Initial placement of a medical device provided as part of a clinical trial or a free sample.” MLM Matters. Medicare Learning Network. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8961.pdf

Dr. Herzenstube Goes to AMIA–Saturday and Sunday

Dr. Herzenstube is a practicing family physician who can make nothing of it.

Saturday

AMIA is the professional society for health informatics. The AMIA annual symposium is the largest scientific informatics conference in the US. It brings together researchers, policymakers, industry leaders, and practitioners of health informatics from dozens of countries. I have been attending regularly since 2000 and it has been amazing to see the attendees and conference content grow in diversity as clinical information systems become more widespread.

AMIA always offers tutorial learning sessions before the official start of the conference and I have always tried to attend at least one. The chance to take a full day to participate in a structured, deep learning activity, taught by experts in the field, is a rare joy.

In line for coffee, I struck up a conversation with another tutorial attendee, a neonatologist at a major medical center. He also has a degree in informatics and spends “as much time as they’ll let me” on applied informatics projects in his institution, though there is no dedicated informatics department or team. Much of his time is spent working on their Epic system, into which he says they have “shoehorned” their neonatology workflows. 

He is here to attend a CMIO workshop, hoping to learn ways to elevate his level of influence within his organization. It is heartening to see someone dedicated enough to the promise of informatics to push on against the headwind of an organization that doesn’t yet know how to effectively use him, but it is a shame that those headwinds are still so prevalent.

At the tutorial, I found myself sitting next to one of the luminaries of the informatics field, someone who has occupied most of the leadership positions at AMIA and is now a senior executive of a very large academic medical center. To my surprise, he explained that he, too, makes a point of attending at least one tutorial at every AMIA conference. There are few things as impressive to me as someone at the top of their field who still thinks they have something to learn.

At the morning break, I chatted with Jose, another tutorial attendee. Jose is an internist and part of the clinical informatics team at a large East Coast medical system. His interests include population health and chronic care management. One of the projects he’s working on is development of a homegrown application for their health coaches. Among the workflows this application will support is capture of PHQ-9 questionnaire results. 

Jose recognized that there are LOINC codes for both PHQ-9 questions and answers and has been working with his development team to make sure that those codes are stored along with the questionnaire, increasing its ability to be re-used for reporting, decision support, interoperability, etc. Another great example of how informatics knowledge can make a difference in how health care organizations operate.

The NLP tutorial itself was certainly worthwhile, with instructors who were very knowledgeable and well-prepared. At the same time, it illustrated one of the challenges that faces AMIA and the field of informatics in general. Informatics is a “big tent” field whose adherent come from a wide variety of professional backgrounds and are working to solve a wide variety of problems. While this is a tremendous strength, it also creates challenges. In some cases, informaticists assume of each other familiarity with a particular set of knowledge or a shared set of priorities and interests. 

This was evident in the NLP tutorial. The presenters spent much more time describing the steps in using a set of open-source tools to create NLP engines (including the mechanics of setting up the processing queue for new documents in a data repository) than they did describing the logic by which NLP engines work and how that can be optimized. It would have been a great introduction for a grad student considering building an NLP engine for their dissertation. The clinician attendees, hoping to learn how NLP could help manage clinical information and patient care at their organizations, seemed less well served. Still, without AMIA, the “in the trenches” folks and the “in the ivory tower” folks would rarely come into contact. I believe that both benefit from the interaction.

Sunday

AMIA officially opened today with a plenary session with a keynote from Avi Rubin, an information security expert from Johns Hopkins, who gave a widely-viewed TED talk back in 2011 pointing out some serious security vulnerabilities of modern technology, including medical devices. His keynote today expanded on this landscape, which has only worsened. It was a very unsettling talk to hear and a cautionary tale to those who develop IT-enabled implantable devices or take care of people who have them.

After the keynote, the first set of conference sessions began. I attended a paper session on “Deep Phenotyping.” AMIA paper sessions fit four brief presentations into 90 minutes with a few minutes at the end for questions. If you’re not already very familiar with the topic and current research in the area, it’s tricky to keep up. 

Phenotyping refers simply to solving the problem of identifying the phenotype of a person, i.e. classifying them according to some biological or health-related category, such as determining whether they’re diabetic or not diabetic. It’s an important problem if you are trying to do something that requires knowing the phenotype of individuals in a population (for population management, knowledge discovery, etc.) 

The most interesting paper in the session, in my opinion, described “semi-supervised” machine learning for phenotype identification from free-text notes. In traditional (“supervised”) machine learning, a system is given a set of documents and manually-applied labels as to their contents (the “answers”). Based its analysis of the associations between the contents of the documents and the labels, it develops an algorithm that it can use to infer the appropriate labels for an unlabeled document. 

In semi-supervised machine learning, following the supervised process, the system refines its algorithm based on its own inferences on the contents of the data. To my knuckleheaded family physician brain, it’s as if you teach someone that an AMIA attendee with a backpack is more likely to be a grad student than one without a backpack, and then they notice that the AMIA attendees with backpacks are more likely to be wearing sneakers than those without backpacks, and then that person starts inferring that AMIA attendees wearing sneakers are more likely to be grad students. In other words, after learning from being taught explicitly, the computer starts to be able to learn just from what it’s seeing. Intriguing stuff.

Following the session was the welcome reception in the exhibit hall. Among the folks I chatted with was John, the medical director of quality for the Medicaid program of a Midwestern state. It was his first AMIA.  He was excited about the potential of sophisticated data analysis for assessing quality, but also mentioned that at present, the only data he has to work with is claims data — he has no way to get any data from EHRs.  While we’re making great strides in thinking about how we might use healthcare data in positive ways, the options for much of the real world are limited.

Stepping outside the San Francisco Hilton, the realities of human misery are stark and obvious. The Hilton is right in the middle of the Tenderloin district, full of individuals who are clearly mentally ill and/or intoxicated. It is an important reminder of the urgent need to expand knowledge about human health and how to improve it, in which informatics has a critical role to play. As we dive deep into the intellectual challenges of our field, we must never lose sight of whom we’re doing all this for.

Readers Write: Supply Chain Data Meets Clinical Outcomes: The Holy Grail

Supply Chain Data Meets Clinical Outcomes: The Holy Grail
By Andy Cole

The term “Holy Grail” has always been intertwined with stories of epic searches to find the Holy Chalice used at the Last Supper. From Dan Brown’s bestselling novel “The Da Vinci Code” to the always entertaining Spielberg/Lucas film “Indiana Jones and the Last Crusade,” fans have been drawn to the idea of finding something so elusive…so mysterious….so game-changing.

When I think about what it will take to dramatically change the cost, efficiency, and effectiveness of our healthcare system, the solutions too often seem as unattainable as the Grail itself. It dawned upon me that the “search for the Holy Grail” is a perfect metaphor for the ongoing efforts to deliver high-quality, medically-necessary and cost-effective healthcare across this country and beyond.

But as I think even deeper about the dilemma, I realize that the healthcare providers who are charged with solving this crisis already have the tools they need to do so. It’s at the tip of their fingertips. Literally.

For decades, healthcare providers had been in the dark about how much it cost to deliver their services. More importantly, thanks to inefficient reimbursement models, they really didn’t need to know. As long as payers (both private and public) paid them based on how much they charged, there was no incentive to truly understand those costs, and in turn, wrangle them in.

Soon, payers and policy makers realized this model was unsustainable and changes started to happen. Once they understood that reimbursement was driving care, they realized the only way to drive lower cost of care was to reduce reimbursement. With less money coming in the door for their services, healthcare providers had to undergo a paradigm shift. They had to cut costs wherever they could to meet the thin margins that were now in the marketplace. Efficiency was the name of the game, and classic cost-reduction strategies entered the arena.

Cut throat supply competition and Group Purchasing Organizations began playing a huge role in offering the lowest possible prices for supplies and bringing economies of scale to healthcare providers. CFOs began paying attention to how many supplies were being purchased and at what price. With a keen eye on the bottom line, cutting supply expense was usually low-hanging fruit that met their cost-saving objectives. With this need came slick analytic tools that aggregated supply and service spend data and clearly suggested areas for savings, whether that be utilizing a less-expensive vendor or taking advantage of a GPO contract.

We have fallen into our current state of “quality data” as an unintended consequence. Providers had historically focused on collecting data for every service they performed in order to receive maximum reimbursement from various payers. More services =  more money. As a result, claims data was serving only as an excellent vehicle to capture charges and little else was being done with it. As the environment shifted, and reimbursement focus shifted from fee-for-service to pay-for-value, the industry didn’t have to look very far to find the data they needed to analyze.

Since charge data provides a detailed representation of all of the services rendered in a healthcare facility, it was a logical next step to begin analyzing a patient’s data holistically, rather than just from an episode by episode basis. Payers and providers could now longitudinally piece together a patent’s entire health record and use it either increase reimbursement for positive outcomes or decrease it based on negative ones.

When the government bought in and incented providers to use certified EHRs, this only increased the amount of data that was collected. That’s where we find ourselves now — swimming in a sea of healthcare data. The objective now is to harness the power of data and take that next step to uncover new solutions to our cost problem.

With the right tools, we can now take a look at clinical outcomes and supply cost together, whether that’s for an individual patient stay, across many for the life of that patient, or all patients. For the moment, I’ll put myself in the shoes of the CFO of a multi-facility IDN.

Taking a deeper look at a cardiac rhythm management supply analytics reports may suggest that I could get a better deal on my pacemakers if I buy them from a vendor named Jolt instead of my current vendor, KickStart. In fact, with my agreement that I just signed with my GPO, I could save upwards of 20 percent this coming year if I convert to Jolt. A quick review online of Jolt products show no red flags. My chief cardiologist has heard good things and gives me the go ahead. I sign the deal and warm up my calculator to count my savings.

My argument is that there is a crucial step missing in that process, the one that takes into consideration the universal value of making that conversion. Having access to quality and outcomes-based data allows me to cross-analyze the cost of the new pacemakers with the outcomes of patients that use them across my facilities. Perhaps I would save 20 percent on them next year, but I see that patients who have them have higher readmission rates, which would result in Medicare penalties and reduce my reimbursement.

Additionally, I am now taking on risk for my patients because of the Accountable Care Organization arrangement we have negotiated with a major private payer. My goal is to deliver the highest quality care at the lowest cost. The payer gives me a set fee for each “covered life” I take on. If a patient utilizes an over-abundance of services in my network, I will most likely lose money on them. However, if I keep them healthy and can avoid expensive treatments and services, I keep anything left over from my payment. Since data is telling me that patients with Jolt pacemakers are twice as likely to take a costly trip to the ER than those with KickStart’s, I will take a much harder look to determine if that conversion truly makes sense.

With this “Eureka” moment fresh on the minds of healthcare CFOs around the country, they are now tasked with changing the paradigm of purchasing. Marrying clinical outcomes and supply chain costs takes new tools, a new culture, and a new vision. It is an essential shift that will help providers and payers stay financially solvent, and in the end, keep the patient healthier.

Our industry has the information we need to make smarter purchasing decisions. We just need to act on it. We actually have an advantage over Indiana Jones, who traveled the globe searching for his Holy Grail. We already have the Holy Grail we’ve been searching for at our fingertips. All we need is to look closely, smartly, and polish it to a glittering shine. This is a game changer.

Andy Cole is national director of PremierConnect Supply Chain solutions at Premier,Inc.

Readers Write: All Aboard the Analytics Train! Next Stop, ROI!

All Aboard the Analytics Train! Next Stop, ROI!
By Jeff Wu

HIStalk-ers may be familiar with Zubin Damania, MD (aka ZDoggMD), a primary care physician turned health pop star. ZDoggMD has been featured on TED and produces parody videos on YouTube of our dysfunctional healthcare system.

Dr. Damania’s videos are loaded with hilarious and witty lyrics with often deep and powerful commentary on what it’s like to practice medicine in the US. His most recent video pokes fun at EHR implementation and highlights a laundry list of relevant complaints about what EHRs have done to negatively impact many providers’ care of patients. Dr. Damania’s criticisms aren’t so outlandish as to propose going back to paper, but he does make the case that we need a new and better EHR environment.

While he makes a valid argument, we also need to consider that the greatest value that EHRs provide has barely been touched.

As of September 2015, CMS’s Meaningful Use program has doled out approximately $31.6 billion in incentive payments for the adoption of Certified Electronic Health Record Technology (CEHRT). While EHR implementations have proven valuable immediate effects — such as reduction of adverse drug events and medical errors — it would be difficult to make the case that these benefits would provide the magnitude of ROI necessary to justify their costs. CMS’s own projections and several post-MU studies have demonstrated that the types of immediate benefits achieved from CEHRT will recoup only a fraction of the MU program’s cost.

What gives? Why would CMS knowingly implement a program that they knew would not provide the immediate ROI necessary to pay for its implementation?

The intention was never to achieve ROI purely on efficiency gains, optimized billing, or reductions in medical errors. What CEHRT provides is data – to an unprecedented degree.

The real value in CEHRT is the way we are getting insights into how disease and injuries progress and react to treatments. The vast volumes of data mean that we are seeing things in novel ways for the very first time. Advances in both hardware and software means that the old days of manual chart abstraction or fragmented tables in antiquated or siloed databases are being replaced with dynamic analytical platforms that can be leveraged cheaper and more effectively.

Analytics is the way to ROI and the industry is finally moving to embrace this. Several industry reports are already seeing an influx in investments into analytics. Big tech players including Google and Microsoft predict healthcare analytics to be a key area of growth over the next few years.

This is a logical next step in healthcare’s technology maturity that we’ve been talking about a lot, even here on HIStalk. While analytics is a hot topic, who it benefits is surprisingly overlooked.

Our discussions of ROI have to be with our end users in mind. Analytics offers us an important opportunity to re-engage our disenfranchised healthcare workers. Our doctors, nurses, pharmacists, and desk staff all have contributed to the data we now have. They should be the ones to chiefly benefit from the coming data harvest. I have yet to meet a doctor or nurse who didn’t have a dozen questions they knew could be answered from data within the EMR, but did not have the tools to do so. That simple fact should be both a mark of shame and a call to action to every health IT worker.

We are on the verge of shifts in practice that can be truly groundbreaking. The information revolution started by the dot-com boom in the 1990s paved the way for companies like Amazon and Zappos to transform whole industries. These adoptions of technology and analytics are being implemented by other sectors at an even faster rate (Uber, Airbnb, Square). If we in healthcare can embrace the power of analytics and purposefully drive their output to end users, we can start tapping an endless supply of ROI.

The optimism behind analytics does not diminish the challenges the next evolution in healthcare information technology will present. All the “big data” and “data governance” buzzwords are valid, but not insurmountable, and the insights we stand to gain are priceless.

The next buzzword is already circulating—closed-loop analytics. It’s the intentional, purpose-driven effort to get analytics to end users for decision making as near to real time as possible. It’s the attempt to engage end users to a degree that the outputs of our analytics serve purposeful functions in their actual practice rather than a retrospective review of what’s happened.

This progression in healthcare technology is the necessary (and hopefully welcome) change that can make the biggest difference in rejuvenating our staff and demonstrating some much-needed value.

Jeff Wu is a population health researcher with UW Health at the University of Wisconsin-Madison.

Readers Write: Financial Health of Patients Is an Afterthought

Financial Health of Patients Is an Afterthought
By Jonathan Wiik

Most healthcare providers offer exceptional levels of care to their patients. After all, we patients expect it. But what most patients don’t expect is the rising cost of healthcare, and unfortunately, financial health is often an afterthought for both parties.

The average deductible for a single person enrolled in an employer-sponsored health plan reached $1,217 in 2014, just under a 7 percent increase over the previous year, says a 2014 study published in JAMA. What’s more, the Affordable Care Act (ACA) Bronze Plan—the new 2015 HDHP (high-deductible health plan) entry plan for patients—establishes its average annual deductible at $5,203.

By 2019, providers could see a 50 percent increase in the amount of revenue requiring a collection from patients. Of that amount, 30 percent (as much as $200 billion) will be written off as uncollectable, according to estimates from Citi Retail Services, a division of Citigroup. Among households with incomes over 400 percent of the poverty line, almost half cannot afford the higher deductible amounts.

For these reasons, many healthcare consumers are reluctant to pursue adequate and timely medical care. The fact is, they simply cannot afford it.

Consider these facts:

• A recent report issued by the Consumer Financial Protection Bureau (CFPB) found that medical debts account for a majority of debt-collections actions appearing on consumer credit reports.
• An earlier Kaiser Family Foundation report found that one in three Americans struggle to pay medical bills, in spite of 70 percent of them being insured.
• Unpaid medical bills are the highest cause of bankruptcy filings, outranking both credit card and mortgage debt.
• Once in debt, many people may delay or forego other needed care to avoid incurring further unaffordable medical bills.

The number one complaint from patients typically concerns confusion with their medical bills, an issue that could be alleviated with proactive, data-rich discussions on the front end of the cycle. Accordingly, financial clearance—an industry term—is gaining momentum. Screening patients for eligibility under their insurance plan, confirming benefits are payable for the services they are about to receive, and ensuring they can afford to fund their out-of-pocket costs are paramount processes that should occur as early as possible.

Similarly, 501(r), a component of the IRS tax code covering not-for-profits, is garnering a lot of attention. The rule, which takes effect in January 2016, requires that not-for-profit hospitals demonstrate the effectiveness of their financial screening for charity programs, among other initiatives.

Additionally, under certain provisions in the law, providers must offer charity care to qualified patients and refrain from pursuing aggressive collection actions for those who would have otherwise been eligible. Documentation of charity assistance, processing, discounting, and collections must all occur prior to billing.

From a high level, financial clearance helps ensure three important things:

1. That patients are paying within their financial means and are receiving financial assistance where possible.
2. That providers and government programs are maximizing their scarce resources for charity and other programs.
3. That bad debt, bankruptcy, and collection issues are reduced for provider and patient alike.

A patient’s financial health is becoming increasingly important in healthcare. Providers, for their part, must ensure that they have sophisticated tools and workflows to put both parties on the same page from the start.

Jonathan Wiik is principal consultant at TransUnion Healthcare.

Readers Write: ICD-10 is a Win for Patients

ICD-10 is a Win for Patients
By Ken Bradberry

There has been conversation about how the ICD-10 transition will impact unsuspecting patients. Maybe a procedure is delayed due to an inaccurate code or a bill is incorrect. These things will almost certainly happen. While the first days have gone by without significant disruption, it is inevitable that bumps will occur, as with any major technological implementation.

The real story is how much patients have to gain from the transition. ICD-9 was over 30 years old and didn’t keep pace with the dramatic advancements in the healthcare industry. Consider this short list of examples:

• Laser and laparoscopic surgeries were not performed at the time ICD-9 was implemented, but are common medical techniques today.
• Treating a heart attack 30 years ago was generally limited to medications to treat pain and an irregular heartbeat. Today, doctors can quickly evaluate what is causing the attack and treat accordingly – bust clots with new drugs, insert a stent to prop open a narrowed vessel, even sew new vessels into the heart during surgery.
• The first HPV vaccine approved by the FDA in 2006 has significant potential to prevent cervical cancer and is widely recommended by the Centers for Disease Control and Prevention for girls and young women.

This is just the tip of the iceberg in terms of how far medical advancements have come in the last 30 years. There has also been significant change in our health with newly discovered medical conditions and the rate at which diseases are diagnosed. For example, the CDC reports melanoma rates have doubled over the past 30 years, but chickenpox cases in the United States have dropped sharply since the vaccine became available in 1995.

Clearly the healthcare landscape today is almost unrecognizable from where it was 30 years ago. Patients have different healthcare concerns and conditions and have many more options for prevention and treatment.

ICD-10 has about five times as many codes as ICD-9. The codes are much more specific in describing a diagnosis and treatment plan, allowing for providers and payers to have a more detailed and accurate conversation about a patient’s care. This will not only improve accuracy of statements and bills received by a patient, but also improve health safety and outcomes.

Here is an example of ways a patient may benefit from ICD-10 throughout the healthcare experience:

• Diagnosis. During a routine medical exam, a spot is detected on a patient’s lung that requires additional investigation. The healthcare provider orders a series of procedures that require ICD-10 coding to be completed. Because ICD-10 codes are more granular, scheduling the procedure with the right resources is more likely, and therefore a more accurate and timely diagnosis is possible. The precision offered by ICD-10 will not only lead to a more precise diagnosis, it will also provide the provider with more insightful information to guide treatment plans.
• Eligibility determination. This same patient has health insurance which requires testing, procedures, and treatment to be authorized. The ICD-10 codes provide the payer more specific information on the services being provided, which can result in a timelier eligibility determination. This can avoid unplanned cost to the patient and frustration working through a billing issue.
• Quality outcomes. Improved clinical documentation under ICD-10 will help reduce medical errors and also lead to more meaningful discharge data that can help reduce readmissions.

In order to quickly navigate the hiccups caused by the massive transition and quickly get to the point where patients are experiencing real benefits, it’s critical for all stakeholders involved in the delivery of care to choose a partner who can successfully lead them through the complexity of ICD-10.

Ken Bradberry is chief technology officer of Xerox Commercial Healthcare.

Readers Write: The Benefit of Price Discrimination

The Benefit of Price Discrimination
By James Foster

In his Monday Morning Update for 10/12/15, Mr. HIStalk first affirmed the effectiveness of the market in selecting among EHR vendors. Later, in response to a price survey, he expressed frustration with disparate costs of services, saying, "I still don’t understand why providers shouldn’t be required to offer their lowest prices to everybody." His complaint here is with what economists call "price discrimination.”

There are two general justifications for price discrimination: (1) differences in costs to the seller and (2) differences in value to the buyer. Cost differences may explain things like quantity discounts, since even if the widgets cost the same to produce, the marketing and sales costs are less if the seller has to deal with fewer buyers.

Even with the same quantity of what seems to be an identical product or service, there may be hidden costs that can justify a difference in price. For example, the price for a television purchased on credit in a poor neighborhood may be much higher than the price for the same model paid for in cash at a suburban Costco. Here the product is not just the electronics, but also the transaction costs involved in offering credit to poor-risk buyers.

Differences in value to the buyer are no less real and can be justified as a way to ensure that the goods are available at all. Most of us are familiar with the fact that adjacent passengers on the same flight can pay very different prices for the trip. On the one hand, this seems unfair ("I still don’t understand why providers shouldn’t be required to offer their lowest prices to everybody"). On the other hand, it is often the case that if everyone were charged the same price, the product or service could not be supplied at all.

That is, if the airline ticket prices were uniformly high, fewer people would make the purchase and the total revenue would not be sufficient to cover total cost. Likewise, if prices were uniformly low, the planes would be full (aren’t they already?) but the total revenue still would not be sufficient to cover total cost.

In order to provide air travel, airlines must segregate buyers into those that place lower value on the trip (vacationers who could drive or choose a different destination) and those that place a higher value on the trip (business travelers). This discrimination serves to benefit travelers who would not make the trip unless they still have some value over the price.

Healthcare providers face similar challenges as airlines: capital costs are high and marginal costs are low. Yet charging everyone the same (high or low) price would not yield enough revenue to pay for the equipment and staff. Therefore, quantity discounts are offered to large groups (represented by credit-worthy insurance plans) who can take their business across town, while unknown individuals who buy on credit typically face higher prices.

If this still seems unfair, before calling for more government regulation through price controls, we should investigate how government regulation might be contributing to problem. There are a few areas in healthcare where prices are standard, published, and declining over time, such as Lasik eye surgery. These typically are procedures where the consumer is responsible for the full price of the service and takes time to investigate before making a purchase.

Instead of imposing price controls (which have been disastrous in a variety of industries), we should look for policy changes that encouraged more consumer involvement and responsibility.

James Foster is director of operations for GemTalk Systems of Beaverton, OR.

Readers Write: No One Likes the Waiting Game

No One Likes the Waiting Game
By Janie Tremlett

No one likes waiting in line with seemingly no information about when the wait will end, especially when sick or nervous about seeing a doctor. The frustration doesn’t end when you’re called out of the waiting room. Need to get vital signs captured? X-rays taken? Blood drawn? Most likely each of these steps occur in different locations and with different practitioners.

Confusion on the part of the patients about where to go and who to see, combined with staff confusion about where the patient is in the process, can make for a less than optimal experience for both the staff and the patients. In an age where providers’ revenue is contingent upon their patient satisfaction scores, managing patient flow and delivering a superior patient experience is more important than ever. A few ideas …

Intelligent Patient Queuing

Average wait times by provider or facility can be displayed on queuing display monitors and can be updated dynamically when a patient is called off the queue. For added convenience, patients can be summoned off the queue in method that is preferred by them, whether it be via an SMS text, an email, or a phone call. They don’t have to be tethered to a waiting room chair waiting for their names to be called. Instead, they can grab a bite to eat in the hospital cafeteria or take care of any other issues.

Patient and Family Preferences

It sounds simple, but it cannot be emphasized enough: patient demographics need to be understood. Patients in waiting rooms are often anxious and sometimes frustrated if they’ve been waiting there a while. Giving them a way to keep busy while they wait, over and above the typical waiting room magazines, can go far. Providing toys and games to children in a pediatric waiting room setting makes sense, but how many waiting rooms have you been in that provide Wi-Fi for adults? Likewise, offering entertainment infotainment that is pertinent to a certain demographic — like screening live athletic games in a sports medicine office — would resonate with patients.

Patient Communications

We can expect, if you haven’t seen it already, a significant expansion in regards to mobile communication within healthcare. One of the benefits of this expansion is the new ease it brings in communicating with patients. Providers can send reminders about appointment dates and times to patients via SMS as well as give patients insight into expected wait times pre- and during service. Affording patients the ability to communicate to their providers in this same way is key. When a patient can easily and conveniently communicate any delays or early arrivals he or she is experiencing, the hospital staff can then re-route that patient or other patients to accommodate the change in schedule.

Real-Time Dashboards

With real-time reporting and dashboards, staff can track a patient’s whereabouts and status at any point as well as the time spent in each location. With this information, hospitals and other providers can identify any breakdowns in processes or bottlenecks in certain departments so adjustments can be made quickly. If patients routinely spend too much time waiting to get their blood drawn, staff can be reassigned to the lab so more patients can be seen. Likewise, if a patient is waiting to see the doctor but the doctor is running late, the patient can be directed to the lab to get blood work done if there is availability there.

Way-Finding and Patient Tracking

Way-finding, real-time location systems (RTLS) technologies, and Bluetooth beacon technologies are rapidly becoming part of hospital IT infrastructure. Within the hospital, geo-location services hold great promise for patient flow management, such as being able to guide a patient to locations relevant to their appointment, track assets (such as key equipment used to move or discharge patients), and monitor staff actions, such as time spent with patients and how often a patient was seen.

Patient tracking also enables context-specific messaging for visitors, like targeted health promotion campaigns based on a patient’s specific movements and location. For example, offering reminders to patients to get their annual eye exams as they walk by the eye clinic in a hospital.

Early implementations of way-finding and patient tracking solutions have not married patients’ whereabouts to staff workflow. Tethering these two is helpful so staff can mitigate problems and issues as they arise and where they arise. If staff realize they’re running behind, for example, and a patient happens to be waiting in the hospital cafeteria, the staff could capitalize on their knowledge of the patient’s location and send the patient a voucher for a free coffee or something similar to enjoy during their wait.

Pleasing patients isn’t always easy, but ensuring that they move through their hospital or provider’s office quickly and efficiently can help satisfy them. Leveraging patient self-service, intelligent workflows, and reporting can create an information-rich tool for staff to monitor patient flow and an empowering experience for patients.

Janie Tremlett is GM of patient solutions at Vecna Technologies of Cambridge, MA.

Readers Write: The Patient Perspective (aka, Who Just Knocked the Floor Out from Under My Feet?)

The Patient Perspective (aka, Who Just Knocked the Floor Out from Under My Feet?)
By Teri Thomas

On the plane back from a short vacation in the Caribbean, my throat and head began to ache. It worsened until I suspected strep throat. 

After waiting 30 minutes (in a room with other ill people) at the nearest urgent care, I was curtly informed that my insurance no longer covered my care there. Miserably, I drove to the next closest urgent care while I called my insurance company for guidance. They directed me to their web site and asked me for names of individual physicians. However, I just wanted the nearest place to get a strep test. 

I pulled into the next urgent care lot and gave my insurance company their address. Not covered. Third choice was covered, so I waited in the queue and eventually was swabbed. After an hour or so, they informed me it was negative and sent me home with “Tylenol and rest.” I felt a little ashamed to have wasted their time and resolved to toughen up.

Two days later, my sore throat had worsened. I was spiking fevers over 102 and my headache became the worst in my life. My body ached and shook and the pain made light and normal sounds hard to tolerate. I held my head in my hands while my husband drove me to the ER.

The ER nurse gave me a medication. When I asked her what I it was, she said, “la-la.” I found it strange (I had no idea what la-la was), but since it hurt to talk, I let it be. Then the doctor came in and asked me what pain medication I was given. I was embarrassed — all I knew was that the nurse called it la-la. Strangely, he seemed OK with that and he didn’t choose to clarify or comment (it was Dilaudid). They drew blood and did a spinal tap, suspecting meningitis. Things began to move around me, giving me the feeling of being an object instead of a person.

They admitted me to the hospital, bundling me in blankets for chills and medicating the pain, while trying to figure out what my illness was. Each doctor gave me a different diagnosis, often confidently. The epidemiologist said, “It’s dengue.” I had chest x-rays and was told pneumonia. The next doctor said I did not have pneumonia. 

My husband and I wanted the doctors to talk with each other. It didn’t appear that they did, as my husband or I had to inform each doctor about what the others had said. The neurologist asked me questions, but never shared his conclusions. I had to painfully recount the course of my illness to him and the others.

Respiratory therapy was a lifeline because they stayed in the room enough for me to be sure I knew who they were. A curious thing to me was the feeling that I existed “in part” to the various specialists. I was a CNS, or pair of lungs, or a Caribbean vacation. 

Some of the doctors seemed to go as fast as they could in their questions. I felt like a speed bump in their race to their next (maybe more important?) patient. As a patient taking pain medication, it was difficult for me to keep up with them, and since I didn’t have time to prepare for a new visitor (they were a surprise), I gave regretfully jumbled and incomplete information. 

After explaining my history and situation for the third time, I hand wrote the timing, sequence of events, and main symptoms on a piece of paper for new physicians or providers to read. It seemed strange that they didn’t seem to want to read it.

It meant a lot to have someone look me in the eyes.

My attending was a foreign-born hospitalist who directed his dialogue to my husband as if I weren’t there. Being a fairly assertive person, I asked him to please include me. With his mouth, he said, "What can I do for you?" yet his eyes and body language said, "You are wasting my time." 

After being denied by nursing, I asked him for the results of my labs and he said he couldn’t do that. He then asked which ones specifically, and only then verbally answered for those specific tests I could think of the top of my head. A printout or online access would have been much better. Not getting information about my own body was incredibly frustrating. It felt disrespectful, as this was happening to ME.

There was a big sign directly in front of my bed that said, "Medications, always ask– explanation, dosage, side effects." Not once did a doctor or nurse ever offer side effects or dosage information. During times of decent pain control, I found the sign humorous.

In writing this, I struggled to find the best word to sum up how the admission felt. Words that come to mind include humiliating, confusing, and castrating (in the sense of taking away one’s strength). I was a strong, educated, independent woman, used to being on top of things (and directing others) with a solid understanding of healthcare, medical terminology, and hospital operations. Suddenly, I had no control over my schedule, no idea who or what was coming next, was highly vulnerable due to pain and pain medications, and I was afraid — something painful and strange was going on in my body. 

My toilet was set with a plastic catcher to measure my urination, but it sat there overflowing because nobody emptied it. There was a white board in my room with some basic information (e.g. name of my nurse), but it was often incorrect. The pain meds made it hard to track what was going on, yet I seemed to be the owner of communicating my situation to all of the changing players around me. I started taking my own notes in a notebook to ensure I was telling people the correct medications. 

The alarms, blood pressure cuff squeezes, and noise outside my room meant I slept fitfully at best. When I did sleep, I had intense nightmares that caused me to wake in an utter panic. Maybe from my mystery illness, maybe from the medications. Either way, it was intense, and I was grabbing for any sense of control or understanding that I could. 

I was reaching for blocks of reassurances (seeing my labs directly, seeing my problem list or diagnosis notes, being told what or who was coming up and when). Simply hearing my care team collaborate and come to me informed and with a unified hypothesis would have made an enormous difference.

Eventually my blood work showed I was stabilizing. The pain began to subside enough that I — knowing the risks of hospital-acquired infections — asked to go home and recover there. I was told a few weeks after discharge that two blood tests were negative for dengue fever, so I never did find out a definitive diagnosis. I got a copy of my H&P and discharge summary and found it humorous to see how little useful information was included, yet there were numerous references to how pleasant I was (surprising, as I was in terrible pain and struggling to be pleasant, but also not very relevant). 

It certainly could have gone better, and I’m sure for some patients, it does. I can almost hear the comments, “My patients don’t want their lab information; it would just confuse them.” Fair enough. Each patient is different. However what they have in common is a desire to feel respected and listened to. 

If folks are interested, I’m happy to post what happened after that—the experience with post-hospital care coordination, billing, how this relates to HCHAPS, as well as concrete suggestions and lessons learned. Do let me know. Having worked in healthcare for 25 years, this experience has energized me to continue to try to make things better. 

Teri Thomas is vice president of Epic Systems of Verona, Wi.

Readers Write: Mission Impossible: Transitioning to Value-Based Care with Health IT Solutions

Mission Impossible: Transitioning to Value-Based Care with Health IT Solutions
By Victor Lee, MD

Your mission, should you choose to accept it, is to partake in the nation’s efforts to transition our healthcare system from volume-based care and fee-for-service (FFS) reimbursement models to value-based care.

If you are in clinical practice or hospital administration, chances are that you have accepted this mission. Like Ethan Hunt, what choice did you really have?

Earlier this year, the US Department of Health & Human Services (HHS) announced specific goals for shifting Medicare reimbursements from volume to value. Under this plan, 90 percent of all traditional FFS Medicare payments would be tied to quality or value and 50 percent would be tied to alternative payment models by the end of 2018. What does all this mean?

For background information, see this fact sheet which summarizes the payment taxonomy framework that HHS has adopted to categorize its payment reform programs. Briefly, Category 1 is traditional FFS with no link of payment to quality. Category 2 is FFS with a link to quality which includes pay-for-performance programs such as Hospital Value-Based Purchasing, Readmissions Reduction Program, and Hospital-Acquired Condition Reduction Program.

Categories 3 and 4 include alternative payment models, where the difference between them is that category 3 programs are built on top of an FFS architecture (e.g., accountable care organizations, medical homes, bundled payments), while category 4 programs completely move away from FFS and exclusively involve population-based payments (e.g., eligible Pioneer accountable care organizations in years 3-5).

Now that we’ve characterized the impossible mission, let’s look at some tools you can use along your journey. There are no spy trinkets, laser beams, toxin antidotes, or heavy artillery involved. Rather, I am referring to newer, innovative solutions proven to maximize clinical and financial outcomes such as clinical decision support (CDS) and mobile care coordination.

The Office of the National Coordinator for Health Information Technology (ONC) defines CDS as “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.” A classic example of CDS is a pop-up alert that provides guidance to clinicians at the point of care. However, the Centers for Medicare & Medicaid Services asserts that there are many other common forms of CDS in addition to alerts, all of which may be used to satisfy the CDS objective within its EHR Incentive Programs. Which ones have you used on your mission?

Admittedly, many providers have already successfully implemented a variety of CDS interventions in their EHR systems or are somewhere along that journey, so the concept of implementing CDS for quality improvement is not new. However, many organizations struggle with keeping CDS updated over time as new information from clinical trials, guidelines, and performance measures emerges.

Fortunately, there are solutions to help with this part of the impossible mission, including third-party evidence surveillance or software applications that analyze CDS from EHR systems to identify potential deviations from evidence-based best practices.

Care coordination has also been part of a national dialogue, with the Agency for Healthcare Research and Quality (AHRQ) including care coordination as one of its six National Quality Strategy priorities. Care coordination is also explicitly required in certain regulations such as Meaningful Use (mentioned earlier) and the Medicare Shared Savings Program, with the latter specifically requiring the use of “enabling technologies” to support care coordination. So clearly the impossible mission is less likely to be completed in the absence of care coordination, but what solutions are available?

A classic example of a care coordination solution is HIPAA-compliant text messaging. However, newer care coordination solutions take this a step further and incorporate person-centered and evidence-based approaches to ensuring safe and timely transitions of care across providers and venues. Some solutions embrace mobile platforms to ensure accessibility at every point of a person’s care journey.

In summary, our nation’s path toward healthcare reform may appear to be daunting if not nearly impossible. However, the HHS prescription for payment reform and its taxonomy for measuring progress toward its goals includes programs that are dependent on lowering costs, promoting care coordination, and optimizing quality of care. Fortunately, advanced solutions are at your disposal today that transform the mission from one that is seemingly impossible to one that is probable if not inevitable.

This message will self-destruct after we have completed the transition to value-based care.

Victor Lee, MD is vice president of clinical Informatics at Zynx Health of Los Angeles, CA.

Readers Write: HIEs Deliver the Promise of mHealth

HIEs Deliver the Promise of mHealth
By Stuart Hochron, MD, JD

The successful transition from fee-for-service to value-based care will require a high degree of coordination and the sharing of real-time health information among physicians and patients. This article describes how quality and cost incentives are encouraging payers and providers to leverage the information contained within health information exchanges (HIEs) to empower providers and patients.

Patient outcomes improve when timely personal health information (PHI) is shared with and among providers and their patients. Reducing preventable hospital readmissions is an example of the power of this information. As a result of recent successes in the acute care and post-discharge environment, payers and physicians responsible for the care of populations across multiple EHRs are seeking ways to (a) avoid treatment delays and improve care quality by sharing PHI among clinicians, and (b) engage and empower patients. Mobile communications that engage physicians and patients and deliver relevant clinical information can help healthcare organizations coordinate quality care, manage cost, and satisfy physicians and patients.

Until recently, providers seeking PHI from multiple EHRs were required to access and navigate secure HIE websites using personal computers or mobile devices. Web access has generally been less than a user-friendly experience. The fact that many HIE websites are not mobile enabled and rarely push data to user-friendly mobile apps has further limited physician-HIE engagement. Today, however, mobile technology has given rise to an increasing number of user-friendly mobile apps that integrate with HIEs and push the type of information that physicians and patients find most useful.

All sectors involved in value-based care can benefit from mobile delivery of HIE data. Government benefits when the transition to value-based care is facilitated. Payers benefit by more efficiently coordinating care, containing cost, and facilitating quality and member satisfaction. HIEs benefit by expanding their services. Physicians benefit from easy access to critical information and from financial incentives that derive from effective value-based care. Patients benefit from greater security that results from knowing when and why their PHI is being accessed and by whom.

The following case studies represent mobile HIE initiatives that add value in different ways.

Case 1 – Patient Status Notifications to ACO Physicians

An ACO managed by a hospital system is implementing an automated status notification system for primary care physicians. It provides ACO physicians with the opportunity to participate at an early stage in the care of patients presenting to emergency departments or who are hospitalized. In the absence of such information, treating physicians are deprived of the opportunity to discuss details of the patient’s medical history with the patient’s primary care physician. This lack of communication can to lead to otherwise preventable hospital admissions, over-prescribing of diagnostic studies, iatrogenic complications, lower patient satisfaction, poorer outcomes, and increased cost.

Automated patient status notification takes advantage of hospital-HIE data connections, whereby PHI is uploaded in real time to the HIE when a patient presents to a regional emergency department or hospital. ACO-participating physicians are identified by the ACO and HIE using unique numeric codes.

When a patient is registered by an emergency department or is admitted to a hospital, the HIE identifies the patient as part of the ACO, reconciles the physician identifiers, and feeds pre-selected PHI to the patient’s ACO physician(s). This information includes the patient’s name, DOB, diagnoses, emergency facility location and contact information, and the time of ED registration and/or admission. The message is delivered from the HIE to physicians via an HL7 or sFTP (secure fie transfer protocol) data feed that reaches the mobile vender’s server through a VPN (virtual private network).

In this case, all physicians credentialed by the ACO’s hospital are required to participate in the hospital’s mobile communication platform. The time interval between ED registration or admission and ACO physician mobile notification is measured in seconds. Armed with this information, ACO physicians are able to the share key patient information with treating physicians at remote facilities.

Case 2 – Fraud-Protecting Payers and Patients Using HIE Status Notifications

An HIE seeking to expand the scope of its services is developing a mobile patient app that will fraud-protect state Medicaid and its beneficiaries and engage patients. Fraud-protecting Medicaid beneficiaries has the potential to reduce state and federal government annual losses related to fraud. Engaging patients has the potential to improve outcomes, control cost, and improve patient satisfaction. The system will use the HIE’s mobile patient app to authenticate patients and notify patients in real time when a healthcare facility or provider adds, accesses, or requests access to PHI. Patient access to this information requires a paper-based application and considerable time and thus is rarely requested.

Medicaid patients will self-authenticate using the HIE’s secure mobile app. After downloading the app from either the Google Play store or Apple App Store, patients will register by answering a few simple questions including their name, date of birth, and state of residence. The mobile app will connect to Equifax, the HIE’s consumer credit reporting agency, which will ask patients up to five personal financial questions. Questions can be related to a patient’s cable television bill and other commonly purchased product products and services, which broadens the potential applicability of the authentication process. Once authenticated, the patient’s app is activated and protected by a PIN. Patients can present their activated mobile HIE app when accessing Medicaid services at pharmacies, hospitals, and other facilities to document their identity.

Each Medicaid beneficiary has a unique Medicaid and HIE identifier. When a request by a provider for access to a patient’s health record is received by the HIE or when PHI is added, the HIE will store this information, identify the patient as a Medicaid beneficiary, reconcile the patient’s Medicaid and HIE identifiers, and feed pre-formatted notifications specific to each type of status change to the patient’s mobile app. Examples of patient notifications include 

• Radiology results have been delivered to your physician’s office.
• Laboratory results have been delivered to your physician’s office.
• An admission-discharge-transfer summary from a hospital has been delivered through your HIE.

The patient app will also provide patients with relevant health and insurance information and connect patients to network providers and services.

HIEs, like electronic health records in hospitals and physicians’ offices, are repositories of large amounts of PHI. The goal of realizing value from collecting and storing such data is directly related to how quickly and easily relevant PHI is shared with providers and patients. Relevant PHI that is delivered in real time to engaged physicians and patients has the greatest potential to improve outcomes, control cost, and increase physician and patient satisfaction.

Using HIEs to deliver PHI-related information instantly in user-friendly ways to physicians’ and patients’ mobile devices is delivering on mHealth’s promise of adding value through innovation.

Stuart Hochron, MD, JD is co-founder and chief medical officer of Practice Unite of Newark, NJ.

Readers Write: What Do National Patient Identifiers and Donald Trump Have in Common?

What Do National Patient Identifiers and Donald Trump Have in Common?
By Catherine Schulten

Over the past several years (decades?), the call for a national patient ID has moved beyond discontented grumblings by hospital CIOs to a hot button topic that has garnered national attention from the likes of CHIME, HIMSS, the US Congress, and practically everyone with an opinion who is involved in healthcare data exchange.

A HIStalk poll conducted 2/8/15 asked, “Should the federal government issue a national patient identifier?” The overwhelming response was yes, as 79 percent said yes while 21 percent said no.

Interestingly, a poll done by the Wall Street Journal asking, “Should patients have unique electronic identification numbers for their medical records?” revealed that 44 percent said yes while 56 percent said no.

Industry leaders who support the use of a national patient identifier point to the use of universal patient identifiers (UPIs) in the UK, Ireland, Canada, and elsewhere. They tout efficiencies gained, increased patient safety, the ability to easily pull together a longitudinal record across disparate systems, lower administrative costs, accelerated medical discovery, and the ability to preserve patient privacy. They also cite patient privacy advocates and the existing ban on any federal funding to study or promulgate a national patient identifier as the reason why no forward momentum on this issue has occurred.

Those opposed to the national patient identifier typically cite two primary deterrents: patient privacy and the role of the federal government in establishing an agency that has the ultimate authority to create, distribute, and manage these identifiers.

But before we get into the pros and cons of each side in this debate, let’s first agree on a few items that seem to be overlooked when we talk about a national patient ID.

First of all, let’s quit calling it a national patient identifier. In practicality, it is actually a national ID. From the moment we are born until the day we die, we all have the potential to be a patient. In all countries that have adopted this type of system, the ID is assigned to the patient by the government at birth. In some cases, not only is this ID used to identify an individual for healthcare purposes, but it is also used when securing other government benefits.

Secondly, healthcare is a service that applies not only to US citizens born in this country, but others who may be here legally or not. Nationalized citizens, foreign visitors, individuals with work or student visas, and even illegal immigrants would need to use the ID. Otherwise, how does one know for sure whether Jean-Luc Picard with an ID and the one without an ID are the same or different individuals? For this design to work, an ID process must be supported for non-US citizens as well.

Back to the question at hand: what do national patient identifiers and Donald Trump have in common?

Both are light on details and heavy on promises. We hear what we want to hear when told that a national patient identifier is the only option that solves for true data interoperability, that privacy advocates and their concerns stand in the way of this enlightened future, and that an ID, once introduced, will be used consistently and accurately.

We seem to forget that HIT systems, no matter how well they claim to be protected, are vulnerable to sophisticated security hacks and low-tech identity theft schemes. We forget that healthcare is a service that anyone can secure even if you purposefully choose to anonymize yourself or — in the case of an emergent care situation — are simply unable to provide identity credentials.

But here’s another way that a national patient ID is like Donald Trump. We are fed up with the status quo. We struggle for a way to achieve the promise of unencumbered health information exchange. We’ve invested millions, more likely billions of dollars into the systems and exchanges that are supposed to support data liquidity and yet we still stumble over the seemingly simple matter of accurate patient identification and record matching. We are fed up and we aren’t going to take it any more! We demand action!

As a result, the promise of a national patient ID takes the spotlight and many cycles are spent touting this concept as the deliverance we need. If only the federal government would get its act together and those pesky privacy advocates would quit proclaiming doom and gloom.

However, the truth – as is typically the case – lies somewhere in between.

A national strategy and design for health information exchange that considers the unique challenges of patient identity and record matching is required. The ability for a patient to manage his or her own credentials if they wish to promote or even prevent exchange is necessary. Ultimately, we need a design that doesn’t rely solely on a set of individual attributes to properly identify or match the patient (I refer to the oft-cited “Maria Garcia in Harris County, TX” study.)

We need visionaries at the table who understand the nuances and challenges and can chart a new path forward. We need to be looking at the role of existing forms of patient identification such as insurance cards, driver licenses, passports, smart cards, and biometrics to assist in the process. National identity standards and concepts such as OpenID and NIST’s Levels of Assurance are paramount to the design. Finally, peer-reviewed pilot studies that reveal the strengths and weaknesses of different approaches will help ensure the best ideas rise to the top.

Catherine Schulten is director of product management with LifeMedID of Citrus Heights, CA.