Readers Write: Five Emerging Imaging AI Workflows

Five Emerging Imaging AI Workflows
By Stephen Fiehler

Stephen Fiehler is founder and CEO of Interfierce of San Francisco, CA. 

Medical imaging is one area of medicine that could significantly benefit from the implementation of artificial intelligence (AI). Applications that interpret chest x-rays, detect stroke, and identify lung cancer are already available. Many AI solutions have garnered FDA approval for commercial or clinical use.

However, few if any have mastered a “best practice” workflow that seamlessly integrates the application’s output with the hospital’s other clinical applications (i.e. PACS, EHR, dictation system). How should the application’s output be delivered? Who should see it first? The answers to these questions are dependent on the nature of the algorithm (i.e. stroke detection, chest x-ray, pediatric bone age), but five workflows are emerging for imaging AI applications.

Advanced Visualization

Many imaging AI applications are delivering their output to an interpreting radiologist within a separate application. The radiologist is commonly working out of PACS, the dictation system, and the EHR. The Advanced Visualization (or post-processing) workflow introduces an additional application to the radiologist’s workflow. Sending the study to the AI application, launching it, and running the images through the algorithm can add significant time to the interpretation process. The Advanced Visualization workflow sets a high bar for the value of the AI application’s output. If the application does not save the radiologist ample time or provide substantial value, the Advanced Visualization workflow is not viable.

Dictation System Integration

Some imaging AI applications are opting to integrate with the radiologist’s dictation system (i.e. Nuance PowerScribe 360). If an AI application has a discrete output that is independent of the images, it can send that value to the dictation system via Digital Imaging and Communications in Medicine (DICOM) structured reporting (SR). DICOM is the standard way of exchanging images and image related data in healthcare, and DICOM SR is discrete data associated with the imaging (i.e. left ventricle dimension in centimeters).

An example use case is an AI application that analyzes pediatric hand x-rays to determine the patient’s skeletal age can leverage DICOM SR to send its output to the radiologist’s report. The patient’s “Z-score” is conveniently embedded in the radiologist’s report as soon as she opens the study. She can then confirm the value or edit it before finalizing the result. Dictation system integration adds no time to the radiologist’s interpretation process.

PACS Integration

Computer aided detection (CAD) applications have been integrating with PACS for over a decade. CAD applications are designed to annotate images to improve the detection of disease, like breast cancer, and reduce false negative rates. These applications commonly integrate with PACS via DICOM secondary capture (SC), which adds additional annotated images to the study in PACS. Some AI applications use this same type of integration to send annotated images back to PACS to assist with the radiologist’s interpretation. DICOM SC requires the radiologist to navigate to the annotated images within the study, which can be cumbersome depending on the size of the study.

Worklist Prioritization

A popular type of AI integration is worklist prioritization. Many AI applications integrate with a reading worklist to prioritize studies that present signs of time-critical conditions, like stroke, spinal fractures, or pulmonary embolism. Rather than producing a complicated output like annotated imaging or DICOM SR, worklist prioritization simply elevates the priority of the study or flags it as a particular abnormality. This can help radiologists identify time critical studies more quickly in an effort to expedite patient care.

EHR Integration

To my knowledge, no imaging AI applications are sending results directly to the EHR. Yet direct-to-EHR may become the best practice workflow in the future for mature imaging AI applications.

Sending the output of the AI application directly to the patient’s chart in the EHR has many advantages and risks. The information would be immediately visible by other care team members who have the security to view preliminary results. Therefore, the report should adequately warn the viewing user that “THIS IS A PRELMINARY RESULT” and it has not yet been reviewed by a radiologist.

Careful consideration and planning should take place before implementing direct-to-EHR integration, but as AI applications mature in competency, it will become more common. Many hospitals opt to send an EKG machine’s automated interpretation directly to the EHR today. The result is clearly labeled “preliminary” and the inpatient or emergency room providers know it has not been confirmed by a cardiologist. However, the immediate availability of an imperfect result is valuable. I believe many imaging AI applications will eventually send their output directly to the EHR.

Readers Write: Why the Interoperability and Patient Access Proposed Rules Matter for the Future of Healthcare

Why the Interoperability and Patient Access Proposed Rules Matter for the Future of Healthcare
By Russ Thomas

Russ Thomas is CEO of Availity of Jacksonville, FL.

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) have proposed new rules designed to give patients greater control over their own data and advance interoperability across the healthcare industry. Should the rule be finalized in its current form, millions of patients will have unprecedented access to and control over their own health information by 2020.

With some limited exceptions, including several related to privacy and security, the Interoperability and Patient Access Proposed Rule would make patient data exponentially more accessible and portable through open data-sharing technology and patient-facing apps.

Ideally, this would not only provide patients greater ownership of information related to their diagnoses, procedures, and tests, but also would mandate the seamless transfer of information from one healthcare organization to another as patients transition from physician to physician – enabling the promise of coordinated care within a complex healthcare system.

HL7 FHIR will be required as the standard for supporting all APIs under the proposal. Nearly 90% of hospitals and 70% of MIPS-eligible clinicians are using FHIR-enabled EHRs, according to ONC.

On paper, the rules are a logical extension of the Triple Aim—delivering better quality, better population health, and lower costs. Our industry has long advocated for the migration of patients to the center of the healthcare ecosystem.

However, empowering patients as consumers is only as effective as the tools they have to make more informed choices about their care. In this regard, healthcare is woefully behind the curve. Consumers can easily and securely access banking transactions and retail purchases over their smartphones, but not, say, their own clinical information, which is often tangled in a web of data silos, privacy rules, and vendor competition. Implementing and standardizing these rules will not be an easy lift.

In the real world of healthcare, the free flow of data and determining how, where, and when it is routed to the appropriate person is a daunting task with the highest of stakes. Although applying the proposed rules industry-wide will be time-consuming and resource-intensive, I believe the effort is both worth it and long overdue.

These proposed rules are a critical tap on the shoulder, a reminder that achieving healthcare’s future is impossible without first solving the foundational problems rooted in our present moment.

Healthcare technology companies should be at the forefront of supporting industry standards that drive efficiencies and interoperability and reduce costs and administrative burdens for their customers. Tools like FHIR enable healthcare organizations to efficiently exchange well-defined information.

I believe that this standardization is essential to the shift to value-based models of care, where payers and providers are seeking secure ways to better communicate and exchange information.

Standards, however, are only one part of the solution. Creating a more solid foundation for healthcare’s building blocks requires several key ingredients: widespread adoption of automation; more efficient channels for sharing and maintaining healthcare information; and modernization of laws governing healthcare data access and sharing, like HIPAA. It also requires evolution of business models to reward transparency and information sharing and penalize data duplicity.

On the payer side, many health plans still store provider data on legacy systems in multiple disconnected databases. As business requirements have evolved, insurance organizations have implemented incremental stopgap measures to address data limitations, but these don’t address the core challenge, the lack of a single source of truth.

It’s important to hear from all concerned stakeholders in order to get these rules right. However, I believe that at the core of these rules lies an essential truth. Unlocking and harnessing the power of data and providing patients the ability to access it is the truest course to a more sustainable and patient-centric healthcare system.

We have been presented an opportunity to fundamentally transform the American healthcare system for the better. It would be a mistake to miss it.

Readers Write: Three Reasons to Look Beyond the SNF Five-Star Rating When Assessing Potential Hospital Partners

Three Reasons to Look Beyond the SNF Five-Star Rating When Assessing Potential Hospital Partners
By Tom Martin

Tom Martin is director of post-acute analytics for CarePort Health of Boston, MA.

Last month, the SNF Five-Star Rating program underwent major changes in all three domains. As a result, many SNFs saw their ratings drop on Nursing Home Compare, and many hospitals and health systems questioned whether these facilities could continue to meet their high standards for quality.

A close look at the program’s methodology revealed that CMS’s changes in measurement were the root cause of the decline in ratings, as opposed to a true dip in quality. As tempting as it is to use the star ratings as the primary criteria for adding or keeping SNFs in a preferred post-acute network, there are a few compelling reasons for hospitals to look beyond these general statistics and consider alternative strategies.

The first reason is that the quality domain carries the least weight though it includes some of the most important measures.  The survey domain is the most heavily weighted in the calculation of a facility’s overall star rating.

While surveys are certainly an important indicator of quality, they’re not the most relevant or timely markers for hospitals that are assessing SNFs as potential partners. The results are subjective, standard surveys only happen once a year, and the forced distribution of ratings in this domain makes it difficult to know if a provider is truly improving or if other SNFs in their state are just getting worse.

In contrast, CMS is constantly adding new measures to the quality domain, some of which are highly relevant to hospitals. In fact, for a few key measures such as 30-day readmissions, ER visits, and successful discharge to the community that really matter to hospitals, the period of time that patients are followed has been extended beyond discharge from the SNF. These longer measurement windows are especially helpful to hospitals that are part of an ACO or involved in other value-based programming that holds them accountable for patient outcomes across the entire care continuum.

Unfortunately, with a total of 17 quality measures currently included in the quality domain, a SNF’s performance on these critical measures has a limited impact on its quality star rating and minimal impact on its overall star rating.

The second reason to look beyond the star ratings is that the claims-based quality measures are limited to the Medicare fee-for-service population. Even if a hospital or other acute entity such as an ACO focuses on the measures that are most relevant to them, as mentioned above, and ignores the composite star ratings, the data on these measures are confined to a facility’s Medicare fee-for-service population, which may or may not make up a significant portion of its current population. And looking ahead, the percentage of Medicare beneficiaries choosing to receive their benefits under a Medicare Advantage plan will only continue to rise, making these fee-for-service claims-based measures even less representative of the quality of care provided at a SNF—ironic given that they would otherwise have the potential to provide the most valuable information in the program.

The third reason to look beyond the star rating system is that changes in measurements, such as those made this April, have occurred many times over the 10 years the program has been in place and will likely continue to occur. But as we saw in April, they skew the data and can mask true trends in quality, making it hard for hospitals to get a complete and accurate picture of the performance of participating SNFs. What hospitals really need are objective means of measuring performance, and that’s not a given with the Five-Star Rating program. For example, in April CMS changed the cut points for the various star levels in the staffing domain, so even though a provider may have actually increased staffing levels in April, that provider may still have received a lower rating due to these new higher thresholds.

Selecting a few measures from the Five-Star Rating program to focus on when assessing potential SNF partners is a reasonable strategy, but one that doesn’t quite go far enough in the era of value-based care. In today’s climate, where hospitals and health systems are being held responsible for patients long after their inpatient stays are over, these acute entities need to be much more closely connected to their downstream partners. They need access to real-time patient data from SNFs, and not just on their Medicare FFS patients, but on their entire population.

All stakeholders—acutes, post-acutes, and most importantly, patients—benefit when providers break down data siloes and exchange healthcare information freely. Simple alerts stemming from ADT (admissions, discharge, and transfer) data can go a long way toward helping providers stay on top of what’s going on with their patients. The star ratings have their place, but to truly understand the quality of care that is being provided by their post-acute partners and ensure patients are receiving high-quality care at every point in the continuum, hospitals need to get proactive and start collecting their own data.

Readers Write: The Big Fib

The Big Fib
By Weary Healthcare Traveler

On Tuesday, May 7, Don Rucker appeared before the Senate to garner support for ONC’s new rule relating to 21st Century Cures. Although he used complex language and invoked incantations of magic like JASON, Restful Services, APIs, AI, ML, and OAuth2 to US Senators who all just nodded and went back to their scripted questions, this is my summary of what he was really championing in that hearing.

The Baseless Promise that Apps and APIs will revolutionize health and healthcare records. There is no evidence to suggest this at all after almost a decade of patients having the ability to download their own medical records, billions of dollars of venture capital spent on startups, and a wide range of APIs available across all the major healthcare vendors. This includes both standard FHIR and proprietary APIs available through agreements with third parties.

The Big Stick of severe penalties for the new vague crime of data blocking of patients and venture capitalists seeking data perpetrated by doctors, health systems, or technology developers who submit to ONC in support of their ever more ridiculous programs which continue to torture doctors in the name of CMS quality management and payment programs.

Of course, given the lack of any traditional enforcement for such a nebulous crime, ONC’s plan is to invoke False Claims Act laws to create a Sword of Damocles over any vendor or steward of patient data who does not submit fully to the Baseless Promise and the new rule.

The False Flag of claiming patient data rights as the primary rationale for their new rules, as ONC has fully submitted to the venture capitalists of Silicon Valley and other special interests who wish to exploit patient data on a massive scale. The Big Stick is big, but of course specifically designed by ONC to not be big enough to reach the new bread of app developers mentioned in The Baseless Promise who would abuse patient data through complex and intentionally deceitful terms and conditions (they are not covered by HIPAA or ONC Certification.

Rucker misleads the Senate by claiming that OAuth 2, a beautiful standard that works in other industries, will provide protections for patients when in fact he simply means that the patient would retype their passwords and afterwards the same rules that apply to Facebook, Google, Cambridge Analytica and the like would magically protect our most sensitive and personal data. It won’t.

The Big Hero as ONC tries to claim the high ground defending all that is right and just. And,but for the evil forces of vendors, health systems, and wicked data blockers would be able to fix up healthcare in a matter of months if everyone just got behind their new rule. Per Rucker previously, to wait even a month for additional input would have dire consequences to patients.

The Big Villains are said to be EHR vendors, who through their mandated support of ONC, CMS, and other payer requirements, try to help doctors and health systems cope with a fundamentally polluted reimbursement and regulatory system and are cited as the cause of burnout as thanks for their efforts. These vendors will inevitably stand accused under these new regulations for not fully supporting the data broker industry and be subjected to The Big Stick.

And, oh, gag me – this notion that EHR vendors have gag clauses is ridiculous. Asking customers not to publish trade secret intellectual property is not a gag clause. Health systems and provider contracts almost always tip the other way, restricting vendors from sharing any confidential information they may have. That would include basics like fee schedules, business expansion, and acquisition plans, but also observable medical errors that providers and pharmacists make on a routine basis even after overriding a warning to stop and reconsider. That’s where the real gag clauses exist.

If EHR vendors actually had gag clauses, I doubt you’d have the level of ONC- and AMA-sponsored EHR bashing you have today. Let EHR vendors protect their intellectual property and use well-established methods through Patient Safety Organizations for any real EHR safety problems.

The Evil Empire is healthcare providers and systems who themselves hoard data with a fearful eye toward outsiders who seek to exploit it. Fearful because HIPAA will crush them if they make even an innocent mistake in their stewardship of patient data. And now fearful that patients won’t understand how their data, their family history, and their genetic information was permanently released to the Internet and sold many times over when the terms and conditions of an app seemed to assure patients it wouldn’t do so when the patient connected the app to their doctor’s EHR.

All this in spite of health systems now offering online portals and apps that rival any travel, banking, or self-serve app found in any other industry. Going back to the Baseless Promise, only about 35% of patients even sign up to use their apps and portals at the urging of their doctors and health systems which, like airlines, also benefit from patient self service.

So, finally, The Big Fib. Through this new rule and under the flags of innovation and healthcare reform, our government (this administration as well as the previous) is on a path to sell out American patients to a data broker industry that has spent over a decade and countless millions of dollars lobbying for unwitting and uninformed patients to allow their data to be used in ways they can’t even imagine. This False Flag above is in large part sponsored by the a data broker industry worth hundreds of billions of dollars seeking hundreds of more billions.

What should we be focused on instead of ONC’s “Game of Thrones” heroes and villains narrative?

The healthcare industry is largely built on a model of cost shifting from patients without coverage or covered by government-subsidized programs to patients with employer-sponsored commercially insurance. That worked out in a world with more commercial than government subsidized patients. With the Medicaid expansion, there are now more people on subsidized plans and fewer on commercial plans, and thus we have run out of the ability to shift costs. Prices and deductibles are rising fast because neither insurance companies nor healthcare providers want to take a hit to revenue or their bottom lines.

There is not a quick solution here because it is more beneficial for politicians to campaign on the issue of healthcare coverage than to come together to create a bipartisan solution. We need more than a Baseless Promise to fix healthcare. We need to press Washington to unwind this hairball of a reimbursement system.

Healthcare providers seek to enhance and protect their relationships with patients and often do so by using data and services in beneficial ways, leveraging their unique relationship with the patient and their stewardship for the patient data under HIPAA. This can be used for good and as well for evil. Rethinking regulations to protect patients by enforcing rational HIPAA-protected interoperability including both doctor to doctor exchange, but also patient to their chosen apps with full awareness, audit abilities, and responsibilities similar or under HIPAA for those app providers. Force apps to protect patient data in a reasonable and accountable manner similar to health providers.

Get over the fixation on EHR vendors as villains. They have done more to dramatically enhance patient outcomes, reduce medical mistakes, and improve convenience, consistency, and compliance in healthcare over the last decade than any other technical innovation. Spend a moment contemplating this array of regulatory and payer requirements and the explosion of medical knowledge unaided by automation. If enough providers hate their EHR when EHRs are being built to deal with the rules providers choose to submit to, then maybe they’ll stop buying certified EHRs and take the penalties as CMS dictates.

If ONC and DOJ continue to abuse vendors who work in good faith to support these complex and ambiguous programs on ridiculous timeframes, maybe those vendors should simply decide to no longer offer certified EHRs. What would happen in this industry if ECW, Greenway, Allscripts, Epic, and Cerner walked away from the ONC certification program?

Maybe most important of all, stop using exaggerated anecdotes and innuendo to “make your case.” As leaders of ONC, CMS, Congress, and industry, it’s time to put some science and integrity to work in crafting a better-functioning health system for Americans. Many billions of API transactions and hundreds of millions of patient records are being transported across health systems and with apps, also made available directly to patients every year. To hear senators read from their scripts that “we still don’t have interoperability” is embarrassing.

Will it be better 10 years from today than it was 10 years ago? Of course it will, but not if we continue to exaggerate and fool ourselves to the benefit of those who continue to seek to exploit patients and their data. This willful campaign of misinformation will likely lead to a backlash by patients when they realize their government has sold them out to data brokers.

Readers Write: AI and Machine Learning Only Work if You Do

AI and Machine Learning Only Work if You Do
By Brian Robertson

Brian Robertson is CEO of VisiQuate of Santa Rosa, CA.

Do AI and ML represent a game-changing opportunity for revenue cycle management? Absolutely. An annual research report by EMC and IDC indicates that the digital universe will contain 44 trillion gigabytes of data next year, with nearly a third of that data collected and stored by the healthcare industry, according to a Ponemon Institute study.

Within this vast ocean of data, AI and machine learning are well equipped to act as the precision sonar to detect and solve business problems using advanced data-driven methods. Indeed, AI and ML are part of today’s buzzwords du jour, but few now question that it will play a role. We must now advance the conversation: how to get going and laser in on value.

Let’s rewind to a time not long ago when we couldn’t blink without seeing a plethora of white papers on big data. They seemed to all contain the same message: “Big data has the potential to be a game-changer.” As the CEO of a company in the data analytics arena, we sometimes struggled with how to best communicate the power of big data to our clients. Our ultimate answer was to focus less on the intelligentsia and more on “get stuff done” (GSD) thinking.

Using AI and ML as an accelerator

First on deck? Don’t get too caught up in the hype cycle. From a pure technology standpoint, it’s just not that hard. One of the benefits of back-office operations, as opposed to clinical departments, is easy access and availability of structured data.

The harder part? Prioritizing business problems where a return on analytics (ROA) could deliver big value. Back to the ocean. Don’t boil it! Invest more time with your team thinking through what you’re trying to accomplish and what can deliver ROA/ROI.

Let’s take something like denial management. AI and ML can help speed up the discovery of problems that are both acute and systemic.

First, resolve what’s in front of you. Then go upstream where the real potential is. If you’re fixing the same problems repeatedly, solve that problem at its core.

Consider a physician dictation issue where some dictate with great attention to detail the complete services and care provided during a complex surgical case. Coders love that because they rely on substantive information to correctly code. That’s in contrast to physicians with less attention to detail, where denials and/or lost revenue is impacted a la the old adage, “If it wasn’t documented, it wasn’t done.”

Automating variability by physician can help you better solve problems upstream. Maybe it’s a system glitch where a bill editor is not set up correctly. Inaccurate or incomplete payer edits often repeat month after month. Deeper trending insights can automate the illustration of consistent anomalies.

This is where AI and ML become a competitive advantage, particularly when you stay focused on business value vs. the glitter of new tech. Start narrow and allow the algorithms do some of the heavy lifting.

1. Purely repetitive process automation. Take a binary process and drive automation via robotic process automation (RPA) tools and methods.
2. Enhance user or consumer experience. Chatbots can deliver an exceptional user experience. Why not leverage voice automation and have your chatbot send you the daily cash report for your commute home? Or a report showing slow-paying payers? Or the bad debt forecast?
3. Deep data mining. Use anomaly detection on historical claim data to empower upstream decision-making. Leverage ML to see what’s going on with the patterns. Let the decision-making power get smarter every day.

Done right, AI and ML will improve yield, increase velocity, and optimize FTE impact.

Final tips to those looking at AI and ML for back-end optimization

• Fail fast so you don’t lose precious time over-analyzing.
• Avoid the technology hype and focus more on business problems the technology can help enhance or catalyze.
• Train your staff. FTEs in repetitive roles will become obsolete — it’s just the reality of our future. We as leaders have a moral responsibility to train our talent. As Gartner often advocates, create learning pathways to enable your staff to become capable citizen data scientists. Give them a meaningful shot at surviving in the long-term.
• Lastly, pick three business problems. Go narrow and deep. but as deep as you possibly can. Then it’s time to grab a shovel and get after it.

Readers Write: Uniting the Full Continuum of Care for the Individual: Why Digital Technologies Must Embrace Holistic Patient Engagement

Uniting the Full Continuum of Care for the Individual: Why Digital Technologies Must Embrace Holistic Patient Engagement
By Mary Kay Thalken, RN, MBA

Mary Kay Thalken, RN, MBA is chief clinical officer of Ensocare of Omaha, NE.

More than half of healthcare professionals believe digitization is transforming the healthcare industry. Of adults 55+, 85% believe technology will improve healthcare in the next five years by delivering faster and more accurate diagnoses, curing diseases, and predicting and preventing diseases and conditions before they happen. However, 35% of seniors feel their health plans do not use any technology to improve access, information, or care, and they want more tech-enabled solutions.

Though the first two survey findings from 2017-2018 are encouraging, the third speaks loudly to this need: payer organizations as well as provider organizations must examine what is lagging in their technology offerings to better serve our biggest generation of people spanning the birth years of 1946 to 1964. From politics to fiscal projections, it’s reasonable to predict that Baby Boomers will have an outsized influence on the healthcare technology landscape for years to come.

The projected growth of this population has also caught the eye of Washington. In March, the US Task Force on Research and Development for Technology to Support Aging Adults and the Committee on Technology of the Science & Technology Council released the “Emerging Technologies to Support an Aging Population Report.” It identified six primary functional capabilities as being critical to individuals who wish to maintain their independence as they age and for which technology may have a positive impact:

• Key activities of independent living
• Cognition
• Communication and social connectivity
• Personal mobility
• Transportation
• Access to healthcare

Unquestionably, digitization is penetrating healthcare, including the burgeoning post-acute acute marketplace. In my role, I converse with leaders reshaping the patient’s continuing health recovery, from discharge to home health and hospice centers, skilled nursing facilities, rehab facilities, long-term care hospitals, or home. As a former nurse and provider business executive, it’s an exciting time to work in innovation on behalf of end users and patients who will benefit from enabling technology that unites the full continuum of care.

Why holistic patient engagement matters

Still, national survey results that look at the opinions of the senior population are a serious wake-up call, warning us all that a lot more work must be done – particularly in the critical area of patient engagement.

Granted it seems marginally small that only 35% of seniors think their health plans do not use technology to improve access, information, or care and have a desire for more tech solutions. Now consider this survey result in the context of the aging boomer population and their share of national health expenditures, which is expected to reach $6 trillion in less than 10 years. This powerful moment of clarity challenges the status quo, moving us forward in making tech-enabled patient engagement for adults 55+ a top priority.

Connecting digital technologies to the patient starts with a holistic view of that person’s entire care engagement experience. Subsequently, to unify the patient’s entire care experience through the use of technologies, we must zero in on what’s important to that person in terms of social determinants of health at every touch point. In short, we must create a tech-enabled, personalized experience specific to each patient’s individualized care and other needs, starting from within the hospital to discharge post-acute care facility or home.

The patient’s recovery or chronic care journey doesn’t stop there. Providers can address and integrate comprehensively the needs of patients who are spending more time outside instead of inside the brick-and-mortar walls of the hospital. We can effectively manage those patients — coordinate, personalize, individualize, and enrich their care alias tying all the disparate pieces together — to improve overall their experience, the goal of wellness, and outcomes.

Recommended best practices

On October 2, 2018, 48 health IT leaders from provider and vendor organizations gathered outside of Salt Lake City for one day to collaborate with KLAS Research. Participants developed a framework of key patient engagement initiatives and took part in discussions about best practices either observed or used. The following is those most often cited successful practices focused on the individual that healthcare organizations can use as a planning tool.

Technology

• Create easy-to-use apps
• Create cloud-based software solutions
• Adopt telehealth capabilities

Analytics

• Gather and analyze social determinants of health
• Gather and analyze behavioral habits (travel patterns, transportation)

Convenient Care

• Enable 24/7 access to care team
• Enable communication with care team (text, email, phone, video)
• Enable communication with patient (text, email, phone, video)
• Enable families to communicate with care team (text, email, phone, video)
• Allow patients to choose how they want to communicate

Right Care Setting

• Direct patients to the appropriate care setting (nurse practitioner, urgent care, or primary care physician)
• Let patients go to the care setting at which they will be best served
• Bring the right care to the patient (24-hour nurse line, telehealth)

Personalized Care

• Provide patient education and personalized discharge instructions
• Assign health buddy or care manager to patients as they leave
• Include patients in the process of setting goals and choosing interventions
• Enable physicians and nurses to engage with patient during the encounter
• Incent patients to participate in wellness activities and make healthy lifestyle choices

Provider Organization

• Develop a patient engagement vision and road map
• Adopt effective change management when implementing patient engagement strategies

Our industry is facing a colossal transformation over the next 30 years as value-based healthcare solidifies and Baby Boomers dominate the use of healthcare services. Despite their collective differences and perceptions, multi-generations—including the largest groups, the Boomers, Generation X, Millennials and Generation Z—working together creates the potential for creativity, community, coordination, and optimization of enabling technology solutions to enhance quality of life.

No doubt about it, a seismic shift to management and engagement of individuals is underway. To not prepare begets gaps in care that lead to poor outcomes and tremendous waste and spending.

Readers Write: Systems Integration with SMART on FHIR ─ We’ve Come So Far, Yet …

Systems Integration with SMART on FHIR ─ We’ve Come So Far, Yet …
By Dan Fritsch, PhD

Dan Fritsch, PhD is chief applications architect at First Databank of South San Francisco, CA.

When we first launched Meducation in 2009, we realized that we would have to integrate the application with electronic health records if we wanted clinicians to use it with their patients. The good news? Through our efforts, we’ve become industry leaders in such integration. The burst-our-bubble reality? Despite our success, even after 10 years, many integration challenges remain.

Because electronic health record (EHR) systems were not originally designed to accommodate third-party apps, we have found ourselves taking up the integration cause ever since we initially developed our cloud-based solution that enables healthcare providers to dynamically create fully personalized patient medication instructions in more than 20 languages.

While the integration nut is difficult to crack, we’ve experienced quite a bit of success. Case in point: In 2011 we won an Office of the National Coordinator for Health IT contest for our use of Substitutable Medical Apps and Reusable Technology (SMART) – an open, standards-based technology platform – to integrate our product with other systems.

Yet we weren’t able to fully utilize what we had developed. This SMART integration didn’t allow us to leverage real-time data, but instead required data to be transformed and stored in an alternative format. While we had established ourselves as a systems integration trailblazer, we still didn’t experience the live integration needed.

To make integration work, we had to custom-code the product for each EHR, to accommodate each unique data access framework and each underlying data model. This meant starting from scratch with each new integration. Because of this complexity, we often found ourselves relying on outside systems integration specialists for assistance, which is a costly proposition.

When Health Level Seven International (HL7) introduced the Fast Health Interoperability Resources (FHIR) standard, SMART developed code to support it. As such, we were able to run the product in this new SMART on FHIR architecture environment. This integration model made it possible to use the same FHIR resources to implement our product on various EHR platforms without having to significantly modify code. So, if we wanted to integrate our app into 10 EHRs, we didn’t have to reinvent the wheel with each one.

At the most recent American Medical Informatics Association (AMIA) conference in San Francisco, we demonstrated how a mature SMART on FHIR integration enables us to run an app on various EHR systems, something that many other app developers are still striving to accomplish. AMIA members ranked our demonstration as the top presentation at the conference and recognized us with the AMIA/HL7 FHIR App Showcase Award.

Yet, like all app developers, we are still struggling with a variety of integration challenges, such as:

• Optimal workflow placement within the EHR. While some vendors allow our app to be launched in an optimal place – such as at the top of the discharge screen – others bury the app launch in the user interface menu, making it burdensome for an end user to find and use at the right time in workflow. We are constantly working to align with our EHR partners to realize that our application is valuable, not a threat to their autonomy.
• Juggling multiple versions of FHIR. FHIR is a young and rapidly evolving standard. Since its introduction, three versions have been adopted and implemented by various EHR vendors. Each of these standards uses a slightly different data model. As an app developer, we have to know which version each EHR vendor is using so we can modify our code to support that particular iteration.
• Coping with vendors’ interpretations of resources. To function optimally, our app needs to know the patient’s medication list at the point of discharge, which requires specific resources (specific pieces of information). This information is represented in FHIR by either the “Medication Order” resource or the “Medication Request” resource, or sometimes by a combination of both. As such, we often need to query both of those resources and run an algorithm that gives us the discharge medication list that we need. As FHIR becomes more mature, there will be more agreement among the vendors on what the resources mean, but for now, we need to continue to find ways to deal with each vendors’ interpretation.
• Dealing with costs. As a developer, we have to cope with fees to enter developer programs; certification costs; legal fees associated with intellectual property protection; costs that sometimes arise when developers need additional integration assistance from vendors; and royalties paid to EHR vendors. These fees are costly and are prohibitive to many smaller companies.

So while we have been able to establish ourselves as integration leaders, especially around SMART on FHIR, we still, like all other app developers, have our work cut out for us. We look for forward to continuing to pave the way and challenging the status quo.

Readers Write: File-Sharing And HIPAA – How You Can Keep Health Data Secure in an Era of Collaboration

File-Sharing And HIPAA – How You Can Keep Health Data Secure in an Era of Collaboration
By Tim Mullahy

Tim Mullahy is executive vice-president and managing director at Liberty Center One of Royal Oak, MI.

Collaboration is at the heart of modern workflows, and file sharing is at the core of collaboration. That’s as true in the health industry as it is anywhere else. The difference with healthcare, of course, is that the risks of doing file sharing improperly — of distributing files without due attention to security — are higher.

File-sharing and collaboration are necessary for effective patient care. Medical and support staff alike need to be able to openly and readily share patient data with one another, communicating seamlessly both within hospital environments and without. The problem, of course, is enabling such collaboration without violating HIPAA.

After all, Protected Health Information (PHI) is some of the most sensitive data in the world. The penalties, should it fall into the wrong hands, are rightly strict. That isn’t to say that enabling file-sharing is impossible,  just that it needs to be done while keeping a few things in mind.

Encrypt all files

Although HIPAA doesn’t mandate file encryption (it’s recommended, not required), encrypting all data both in-motion and at rest is critical if you’re going to ensure that your files can be shared securely. In the event that a device containing HIPAA is in some way compromised, encryption will ensure that the data it contains remains safe.

I’d advise that you use SSL encryption and use some form of VPN or secure tunnel to keep your files protected when they’re shared across external networks.

Assign unique IDs to all staff

Every user with access to your file-sharing and collaboration platform needs a unique identifier. In addition to being useful for the purposes of authentication, these IDs will allow you to track data access and usage. The idea is that you need to know what data each of them have accessed and what they’ve done with that data at any point in time.

Implement multi-factor authentication

Usernames and passwords are an important component of access control, but they represent only a partial solution. To keep both your files and the platforms through which staff collaborate secure, you’re going to want multiple means of ensuring people are who they say they are. These could include:

• Biometric (fingerprint scanners, facial recognition, voice identification, retinal scanners)
• Behavioral (common login locations, common access and browsing habits, etc.)
• Hardware-based (device recognition, hardware tokens)

Implement auto-logoff

Here’s one directly from the HIPAA guidelines. Any file-sharing or collaboration solution you use needs to have a timeout process built in. After a set period of inactivity (10 to 15 minutes is probably a safe bet), an employee account should be automatically logged out. This protects against unauthorized access via unattended devices.

Ensure that all software is HIPAA-compliant

Last but certainly not least, for each collaboration solution you implement, check with the vendor to ensure that it complies with HIPAA’s regulatory guidelines. Most vendors that support HIPAA compliance will be open about it. Moreover, their solutions will provide full logging and auditing functionality, alongside all the other security controls necessary to stick to HIPAA.

HIPAA need not represent an obstacle to effective collaboration. Provided you incorporate a compliant solution and take all the necessary measures to keep your data safe, you can enable your clinicians, support staff, and everyone else who needs access to collaborate for better, faster patient care.

Readers Write: To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR

To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR
By David Butler, MD

David Butler, MD, is principal at Calyx Partners and interim CMIO at Guthrie Health in Sayre, PA.

There’s no question that physician burnout is one of healthcare’s most pressing problems: Forty-four percent of physicians report feeling burned out. It affects everyone to varying degrees: specialties, employed vs. self-employed, men and women.

The Number 1 contributor? Too many bureaucratic tasks such as charting and paperwork. The bottom line, according to Mayo Clinic Proceedings, is that physicians who aren’t comfortable using EHRs are more likely to reduce their working hours or leave the profession altogether.

We all agree on the challenge, but what’s not as obvious is the solution. Many hospitals are investing in scribes and assistants like they’re a sustainable solution. Individual providers have stated they have higher satisfaction, but the evidence isn’t showing that this is always the case.

Other organizations are placing the burden on other docs, creating physician-led training teams to improve EHR efficiency in their facilities. This can provide some level of peer-to-peer efficiency when thoroughly implemented with the correct support staff, in-room support, and focused curriculum based on user specific metrics. Otherwise, instead of slowing one doc down, you’ve merely doubled your inefficiency.

Mindfulness, yoga, and other self-care strategies are problematic. They take time—of which physicians are already short – but more importantly as this recent whitepaper on burnout points out, they fail to address the root cause and put the responsibility of burnout on individual physicians.

We’re all responsible for burnout. In my experience as a CMIO and EHR implementation and optimization strategic advisor to various healthcare delivery systems, the key to reducing frustration with the EHR and physician burnout is practical tactics that actually give doctors time back in their day.

These are the four biggest time wasters in the EHR and how to address them.

1. Searching for Clinical Data

When you think about search in the consumer world, companies like Netflix and Amazon may come to mind. They use various degrees of artificial intelligence (AI) to serve up what you’re likely to be interested in based on your past searches to streamline what you see.

Unfortunately, EHR search isn’t quite that intuitive yet. Searching for clinical data will happen during every patient visit, making it one of the biggest EHR pain points for physicians. Until the leading vendors incorporate focused AI and machine learning, the average physician should use these tips to filter through the sea of patient data more easily:

• Default to search over navigation. I just described that EHR search is far from perfect. However, it is infinitely better than browsing and clicking your way through the interface. Sure, I know how to navigate to a WebEx site to join the meeting. Do I ever do that? No. Not when typing “Join WebEx Meeting” into Google gets me there much faster. Similarly, I always tell docs to search the chart. Let the system look for you by using the search bar. Once the page loads, typically Ctrl+F will open another more specific search box to find keywords within long patient reports of clinical data. Remember to use quotation marks around words that you want an exact match, i.e. “chest pain” versus just typing chest pain. Most EHRs will not suggest a correction like Google and ask, “Did you mean: chest pain” (correct spelling). So, learn your search tricks like: quotations, NOT, OR, AND, parentheses around multiple terms, etc.
• Save your filters. When you listen to music on your app of choice via your phone or in the car, in order to rapidly get to what you want to listen to, you still have to either download albums, bookmark your favorite playlists, and/or save your top radio stations as presets. If you’re looking for the same type of data over and over again, be certain to treat the EHR in the same manner by saving your most common searches as a filter in chart review (labs, notes, imaging, etc.). Treat the filters like playlists. Create a cardiac playlist for all lipids, cardiac enzymes, and any other labs that brings the patient’s cardiac status into full view for the way you practice medicine based on your specialty and training.
• Create disease- and symptom-specific reports. The majority of physicians in the U.S. are specialists and routinely need to zero in on the same disease, condition, or symptoms. Your EHR teams can easily create elegant patient summary reports that will pull data to you, i.e. all diabetes-related meds, labs, studies, referrals, etc. Most of the time you will have to agree on this with a group of clinicians within the same department, but roughly 20 percent are customizable at the individual level. Remember, just use newly created Maroon 5 “Sugar” playlist for the rest.

2. Managing the Inbox

Have a full Outlook inbox or an IMessage app with a permanent notification icon or badge? The EHR inbox is like that for physicians, but on steroids. InBasket is the name for the inbox for Epic users, but regardless of your EHR vendor, managing the flood of messages can be a struggle, and with greater interoperability, it will only get worse. Here’s what I tell physicians (and IT folks who want to help them) to personalize the InBasket to their workflow and get it under control:

• Rearrange and sort. Many docs don’t realize that there are filters and sort logic available to always keep their most critical messages at the top (for example, abnormal test results, patient calls, refills, etc.). Fight your OCD and move to the top only the folders that you need to address to get the heck out of the office: results, patient messages, billable chart co-signs, refills, etc. Deal with the rest later, as they likely are not important and are just automatically sent to you because they always have been.
• Remove and relocate buttons. Healthcare can take a lesson from the airline industry here. Just like in the cockpit, buttons and alerts should be presented in a logical, easy-to-read, color-coded format. Just like in other programs you use, such as Microsoft Office, you’re able to customize your user interface to increase your focus with no IT team required. Kick the clutter by deleting buttons that are never used and move ones that are frequently used to more convenient locations. Just look for any sort of wrench, bolt, pliers, or other icon on your screen, which typically means you can move things around.
• Maximize your view. Treat your EHR view like you would your physical office and Marie Kondo the heck out of it until it’s most comfortable for you. Adjust the preview panes, sidebar, and the even the order that the report displays in to see as much information as possible at one time. For example, you may have the top half of your screen display your messages and the bottom half display reports about the particular patient to save you time from going to chart review. Maybe the EHR won’t quite spark joy for you, but it will definitely be less painful.
• Create macros / QuickActions. I’ve encountered very few physicians who have created InBasket macros. These are simple, rote tasks / words / clicks that one does over and over based on a specific type of message. These are worth investing in as they offer significant time savings, a 60 to 70 percent time savings per message type for some. For example, you can create a macro that notifies a patient via the patient portal that (1) your labs were abnormal, yet not serious; (2) my office will contact you; (3) route to your nurse/team; (4) add a small note to yourself; and (5) close the lab message–all in ONE CLICK. Spend a few days watching for things that you do over and over, then try one. I suggest refill and normal result labs to start. They’ll give you hours back in your life over time.

3. Entering Orders

Does Amazon have order sets? Sure it does. When you order a new smart TV, it will automatically suggest the recommended HDMI cable, remote keyboard, etc. That’s an order set.

I’ve always wanted an Amazon-oid EHR. When I order the latest back pain (chief complaint) for my patient, I would like for the EHR to then make recommendations based on my patterns, my colleagues’ patterns, and other patients like this one. I’d like to see it display useful information that says something like “other internists like you who have seen patients with similar complaints have done X, Y, and Z.” I’m smart enough to know if I care to follow the pack or click and see what the latest evidence-based data is from the literature.

Until this occurs, here are a few tips you can use today.

• Save your faves. Not saving your favorite orders is like not using bookmarks for your favorite websites when browsing the internet … not cool! Similar to the above macros and filters, these are key to faster ordering common things. Record dosage tapers and save multiple preferences for the same med, lab, or imaging with pre-fills. These are common, especially with chronic diseases, so save yourself from typing it or searching for it an infinite number of times. Some techie docs may already have these saved and may be willing to share with you if you ask nicely. Meds: refills 0, 30, 90 day refills, narcotics. Labs: A1c in three months, A1c in six months, etc. Imaging: CXR – chest pain, CXR – pneumonia.
• Use portions of the name of the order. Google might say, “Did you mean?” when your search isn’t perfect, but the EHR won’t. However, you can use shorthand to look up med, lab, or imaging orders. For example, here’s an Epic trick that’s been around for at least 10 years that many don’t know. When searching for an order or diagnosis, try typing small pieces of the word (in any order), i.e. “CT Abd Con” will return a short list of “CT of Abdomen and Pelvis with Contrast.” Just remember, when it comes to searching for orders in the EHR, less is more! Check with your training team for more tips.

4. Documenting the Encounter

Physicians likely spend the most time here, inputting all of their notes into the EHR. Documentation takes a lot of time, whether it’s documenting visits, sending thank-you notes for referrals, or fielding follow-up questions in the patient portal. If you have to type, then create templates for things you say over and over. There’s no predictive text a la Gmail yet, but we can emulate it until we’re there.

• Leverage SmartText and SmartPhrase templates. These are Epic system-specific names for their tools, but all EHRs I’ve used have the same type of documentation tool. Again, it’s all about making the EHR work for YOU.
• Speak now. In the age of Siri and Alexa, it’s simply bewildering how many physicians don’t leverage speech recognition software like Nuance Dragon or MModal. Add in voice navigation macros and you can rattle off your notes to your computer with incredible speed and accuracy. For example, “Show me last CBC,” or “order amoxicillin 500.” etc. And be concise! Despite what we learned in med school, verbosity doesn’t mean better care.
• Create SmartLinks. One of my favorite tricks to teach is how to pull data into your note for review, then delete (Ctrl+Z is undo). Don’t type values—learn tricks to pull into your note when appropriate (without pulling in too much in creating note bloat). As you look at others‘ notes, you’ll notice that they are pulling these labs, etc. into their note. Just find out from them how they are doing it, get the link, then you do the same yet with no need to leave it in the note. This is faster than search or filters.

Those four areas of the EHR compose about 80 percent of “pajama time.” Anything that you can do in one of those areas that can shave off a little time, you’ll see time come back in the long run—it adds up over many patient visits. Until the EHR vendors incorporate the functionality from consumer technology noted in the above examples, you must do these things to survive and stay optimistic.

By targeting these areas with these tried and true tips and tricks, I guarantee you’ll feel like you have more control over something that once felt like it was uncontrollable. Keep these fire extinguishers handy and you’ll douse some of the flames of burnout and take back your time.

Readers Write: HIMSS, Innovation, and the Infomercial

HIMSS, Innovation, and the Infomercial
By David Lareau

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

Nothing compares to the annual HIMSS conference in terms of providing educational and networking opportunities for health IT professionals. The recent event in Orlando included 300+ educational sessions, dozens of receptions and parties, and multiple days for scheduled and impromptu meet-ups with other attendees.

And then there is the Exhibit Hall. Perhaps I am jaded from my many years in the industry, but I can’t help but feel that the exhibition portion of HIMSS is a bit like a three day-long infomercial, with vendors pitching solutions to problems that many don’t realize they have (the Wearable Towel, anyone?), or for products that sound too good to be true (can you really say goodbye to flab with the ThighMaster?)

Interestingly, many of the “solutions” I saw at HIMSS were designed to fix problems that were created by other “solutions.”

Case in point: EHRs. The inefficiencies and deficiencies of EHRs are well documented. We’ve all seen the surveys about how frustrated doctors are with EHRs, which add to administrative burdens and contribute to physician burnout. Of course, EHRs have long been touted to be time-saving tools that improve patient care and allow physicians to go home earlier. The reality, however, is that few EHR implementations have lived up to all the hype.

But wait, there’s more

Full disclosure: my company was one of the 1,300 exhibitors at HIMSS this year serving up our own brand of infomercial, though I’d like to think we fall more in the Roomba category (innovative and useful) than Chia Pet (just why, people?)

We conducted a non-scientific survey in our booth to better understand providers’ biggest EHR challenges. When asked “Which health IT challenge are you most surprised is still an issue for the industry?” our 361 participants (all of whom were given a chance to win a prize) indicated the following:

• Lack of interoperability between EHRs and between providers: 36.1 percent
• Clinician dissatisfaction with EHRs: 27.7 percent
• Difficulties using data to improve clinical and financial outcomes: 22.6 percent
• Lack of innovation compared to other industry sectors: 13.5 percent

What these results tell me is that despite years of hype, EHRs still need fixing on multiple fronts in order to meet the needs of users and advance clinical and financial incomes.

Money-back guarantee

Providers have spent billions over the last couple of decades implementing EHRs that have failed to adequately deliver the efficiencies that clinicians require. Even if health systems and physicians could take advantage of money-back guarantees, few could afford the time, disruption, and additional investment required to rip out legacy systems and implement new solutions.

What are frustrated providers to do?

Not available in stores (but perhaps as seen on the HIMSS exhibit floor)

Despite the industry’s failure to realize the promise of EHRs, at HIMSS this year I saw increased interest from providers looking to improve the usability of their existing EHRs. More vendors are offering app-based solutions that extend the value of EHRs without the disruption of implementing a brand, new platform.

Some of these technologies are designed to fix inefficient workflows that diminish physician productivity. Others focus on organizing existing data so that clinicians can easily access the right data at the right time for the right patient – even if that data is coming from an outside system. Additional offerings enable more complete and accurate documentation to facilitate quality care, correct reporting, and better clinical and financial outcomes.

You can do it

I am encouraged that despite the plethora of pitchmen hawking products almost as seemingly frivolous as the Snuggie, I saw more signs of innovation at HIMSS19, especially for solutions that consider the needs and desires of clinicians and support better outcomes for patients.

The HIMSS Exhibit Hall may indeed be reminiscent of a marathon infomercial, but consider this: without infomercials, millions might never have enriched their lives with George Foreman Grills, P90X workouts, or the ShamWow.

Readers Write: EMR Direction Changes in the Post-Growth Era

EMR Direction Changes in the Post-Growth Era
By John Kelly

John Kelly is principal business advisor for Edifecs of Bellevue, WA.

Healthcare acquisitions and mergers tend to give the industry an indication of where investors will go in pursuit of new revenue streams to secure growth in future business. The $5.7 billion sale of Athenahealth is no different. This EMR vendor consolidation represents a significant milestone in what might be a segue toward an end state for the major electronic medical record (EMR) vendor market.

What does this mean for the rest of the EMR market? At the highest level, we may anticipate EMR technology to evolve as a commodity, while the services revenue enabled by the technology will emerge as the primary source of long-term sustainability for EMR vendors. The Athenahealth and Veritas Capital move is an indication that venture investors are thinking just that. This will have long-lasting implications for healthcare technology vendors industry-wide.

The Athenahealth acquisition specifically highlights the fact that the path for growth in software sales in the EMR market continues to narrow, as the vast majority of providers with meaningful spending power have already made the transition to electronic records. The rip-and-replace phase by providers dissatisfied by their first-generation EMRs will continue steadily, but will not compensate for the major decline in new sales opportunities for the industry at large.

With the GE / Athenahealth consolidation of assets, the growth outlook for the five major EMR vendors left in the space (Epic, Allscripts, Athenahealth, Meditech, and Cerner) looks a little different.

Though Athenahealth’s high profile as an EMR vendor provides the primary brand recognition, the revenues associated with its revenue cycle management (RCM) line of business still represents the major portion of its value. The future for EMR vendors will mirror other industries, wherein technology is provided at a small margin in order to capture the high value and healthy profits generated by the information and business processing services tied to the use of that technology.

Early evidence of an emerging trend was seen in the $2.7 billion 2016 acquisition of MedAssets by Pamplona Capital Management. There we witnessed how strategic investors are keenly aware that administrative inefficiencies in healthcare still present big opportunities for gain-sharing on significant cost elimination initiatives. Veritas Capital has doubled down on this opportunity by recognizing the value in merging the RCM book of business at Athenahealth with the clinical software footprint from its GE assets acquisition. Further signaling this industry shift to garner new revenue by the top EHR vendors are the recent announcements by Meditech and Allscripts of their intention to implement consolidated managed services across their EMR and practice management software and services stacks.

The fact is, providers are paying billions of dollars to third-party vendors in outsourcing their RCM activities. Bill-and-chase is costing the providers between 6 percent and 13 percent of receivables (varies by practice setting and size). If the industry can bring those costs closer to the 2-3 percent spread, seen in industries like retail, both vendors and providers would be extremely happy. Outside investors see substantial opportunity here. As a result, EMR vendors left scrambling from the sharp decline in new system sales are beginning to consider a very different view of the future.

While there are many business decisions and regulatory changes that will impact revenue streams for payers, providers, and technology vendors alike, success and growth for EMR vendors in particular will be limited if they don’t embrace creative consolidation. The combination of Athenahealth’s medical records and revenue cycle technology with the existing Virence Health assets is not just a venture firm buying a major revenue cycle company with a great brand, but rather an intentional strategic move to change the nature of the EMR market, one that fosters continued growth and furthers technology stability across the industry.

Readers Write: Measuring to Drive Continuous Improvement in Digital Health Management

Measuring to Drive Continuous Improvement in Digital Health Management
By Mohammad Jouni

Mohammad Jouni, MS is is vice-president of engineering for Wellframe of Boston, MA.

As health plans implement digital health management solutions to support the comprehensive needs of people outside the four walls, measurement is an increasing priority in order to quantify every aspect of the business and demonstrate tangible value. But measurement can also enable organizations to continuously identify areas for improvement, implement changes, and measure the effect.

The following examples are tangible ways data-driven improvements can take place from the individual patient level up to the executive board room.

Real-time interventions. A care manager noticed one patient’s falling medication adherence and reached out to ask about the issue. The patient explained she didn’t take her pills when she traveled on the weekends. The care manager mailed a new pill box, and her patient’s medication adherence rebounded to normal.

Daily improvements. Population reports indicated low comprehension of safe acetaminophen dosage. This finding, combined with the risk of misunderstanding medications, prompted a change in health education delivered directly after discharge to focus on safe dosing, resulting in an increase in patient-reported level of understanding.

Weekly staffing optimizations. Supervisors reduced the number of care managers focused solely on outreach for gaps in care when they noticed low patient satisfaction compared to a population in which care managers worked with patients more holistically, closed gaps more effectively, and saw higher satisfaction.

Monthly outreach adjustments. Claims and patient self-reports revealed falling attendance at PCP appointments. Care managers addressed this issue by switching to mobile channels to contact members before appointments and increase the frequency of reminders. Attendance rebounded to a higher rate than the baseline.

Quarterly care team reassignments. With newly-implemented technology, supervisors recognized tech-savvy staff early on and embedded them among less adept peers to share their tactics, bringing the whole group up to speed faster and with more camaraderie.

Yearly reinvestment in health management. After showing thousands of dollars in cost savings per member, executives increased the budget for health management to support increased recruitment efforts and extend health management services to more members in order to double down on those results across a broader population.

When your organization measures rigorously to demonstrate effectiveness and to continuously improve, executives will pay attention. Leadership will be able to not only justify increased investment to grow digital health management programs even further, but also apply the same data models to effectively predict the return on additional funding.

Ultimately, measurement allows health plans to make data-driven decisions that elevate the stature of care management from baseline requirement to strategic value center. In doing so, health plans will be able to amplify the effect of their programs and extend services to more members, doing incrementally and continuously better by each member.

Achieving these goals creates new opportunities to focus on member support by strengthening provider partnerships, differentiating to employers on service and outcomes, and driving retention and new sales. Through rigorous measurement and continuous improvement towards these goals, health plans are poised to quantify impact and capture significant value from the powerful data of digital health management.

Readers Write: Why Integrated Behavioral Healthcare is More Important than Ever

Why Integrated Behavioral Healthcare is More Important than Ever
By Christopher Molaro

Christopher Molaro, MBA is co-founder and CEO of NeuroFlow of Philadelphia, PA.

The pieces are starting to fall into place. Mental health is becoming an integral part of the overall conversation around health. Mental health is discussed in sync with physical health.

It makes sense, too. One affects the outcomes of the other dramatically and the extra costs associated with mental health co-occurrences is staggering.

The question remains: how do we effectively integrate appropriate behavioral healthcare for individual patients when they need it and do so in a cost-effective and time-efficient manner? In other words, how can we align the interests of patients, providers, and payers?

The market is indicating that now is the time to integrate mental and behavioral health into the patient journey. Physical health and mental health are merged into just “health,” patients get the holistic care they need and deserve, and providers are empowered with the tools to improve outcomes and payers save in costs. The triple win is attainable.

Multiple leading commercial payers are reimbursing for certain collaborative care CPT codes released in 2017 and 2018, highlighting the growing awareness around the importance of mental health. As we shift towards a value-based care system, a focus on patient engagement, satisfaction, and outcomes will add visibility to the benefits – and cost savings – of integrated behavioral health.

Also, considering the enormous behavioral health expenses of employees — mental illness costs the US $193.2 billion in lost earnings every year, according the American Journal of Psychiatry — employers are equally willing to find new ways to provide their employees access to tools to address mental health.

The awareness efforts of non-profits, advocacy groups, and healthcare organizations to normalize the conversation around mental health have been invaluable. At the same time, leading athletes and entertainers opening up about their mental health conditions is eroding the historical stigma surrounding those who struggle with behavioral health. Heightened awareness begets healthier, more frequent discussions around treatments and solutions for the one in five Americans experiencing mental illness.

Aetna’s recent “Health Ambitions” study highlights that healthcare consumers recognize the importance of mental health. Over one-third of respondents say digital messaging would make them more likely to communicate with their doctors, and the majority of people ages 18-50 say they would be likely to use a confidential website or app to track health information.

This new narrative around mental health is getting louder, and it will only help to bridge the gap between mental and physical health and the solutions patients need. But numerous studies indicate that we still have a long way to go when it comes to providing digital health technologies that meet the expectations of the modern healthcare consumer.

The digital doctor’s office is no longer a future vision, but a present-day reality. While adoption of these innovative tools can be slow, healthcare providers are rapidly warming up to technologies that can improve patient outcomes while absorbing it into their workflow and existing EMRs.

With behavioral health integration, we’ve arrived at an alignment of incentives and mechanisms among payers, providers, and patients that is rare in the modern healthcare landscape. This is an exciting opportunity for the future of mental health and one that we as a community can’t afford to pass up. The data supports the opportunity as well. Decades of research highlight the effectiveness of collaborative care in psychiatry, and when patients stay engaged with behavioral health treatment, outcomes are improved drastically.

Eighty percent of people with a behavioral health disorder will visit a primary care provider at least once a year, yet we know that treatment and access are still major issues, as nearly 60 percent of adults with a mental illness didn’t receive mental health services in the previous year, according to the National Institute on Mental Illness.

While there is much work ahead, we are encouraged by the progress we’re seeing in hundreds of clinics around the country from pediatric / school settings to geriatric and Medicare populations. Mental health knows no bounds — it can affect anyone. As a health system, our effort in addressing mental health access and engagement should also show no bounds.

Readers Write: Expanding the Horizon of Clinical Surveillance

Expanding the Horizon of Clinical Surveillance
By Janet Dillione

Janet Dillione is CEO of Bernoulli Health of Milford, CT.

Pay-for-performance programs, like the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP), determine provider reimbursement based on a hospital’s ability to meet key patient safety and performance measures. To reap the financial incentives—and avoid the penalties—of HACRP, more hospitals are “investing in clinical surveillance solutions that utilize real-time patient data to reveal deteriorating patient conditions at an early stage,” according to a report released in November by AGC Partners, a multi-vertical research and investment firm.

Continuous surveillance traditionally has been the near-exclusive domain of hospital departments that care for high-acuity patients with the greatest risks for deterioration, such as the ICU. However, the persistence of preventable catastrophic events, such as post-surgical opioid-induced respiratory depression (OIRD) — which accounts for more than half of medication-related deaths in care settings — suggests that the ability to monitor patients continuously and communicate insights to clinical teams in real-time must extend beyond the ICU.

According to a new KLAS report on the subject, “clinical surveillance tools hold the promise of giving caregivers clinically actionable insights that decrease mortality, reduce readmissions, and improve overall patient outcomes, and clinicians expect these alerts to be embedded directly within their workflow.”

However, successfully broadening the utilization of this technology can be complex and disruptive and can bring new uncertainties to the entire organization.

How Scalable is Continuous Surveillance?

For many health systems, continuous surveillance can be broadly used with existing technology infrastructure, especially organizations with critical care units or ICUs. Optimizing that infrastructure’s capabilities and incorporating it into existing clinical workflows is the real heavy lift, but advances in monitoring technology, use of real-time physiological data and smart alarms, and sophisticated analytics and the ability to route that information to remote clinicians show promise for scaling continuous surveillance to a number of patient care departments, including telemetry, maternity, med-surg, and even beyond the walls of the hospital.

Additionally, health systems exploring the viability of continuous surveillance are using their EHRs as a natural starting point. Multivariate, real-time data from medical devices aggregated with retrospective data from EHRs, provides a holistic and complete source of objective information on a patient that can be used for prediction and clinical decision making.

Does It Save Lives—and Costs?

Hospital investments in clinical surveillance and analytics solutions are driven by organizations that are migrating toward value-based care models and are trying to achieve the objectives of value-based care, including improving care quality and outcomes, reducing clinical variation, and reducing healthcare costs.

Similarly, patient safety in the era of value-based care is increasingly defined as preventing adverse events before emergency interventions or costly escalations are required. However, most common monitoring practices are reactive, not proactive –interventions are often applied only after a patient has deteriorated.

A number of hospital-acquired illnesses (HAI) could be prevented by continuous clinical surveillance. Sepsis and respiratory compromise are among the most costly in terms of resources and morbidity and mortality.

• Industry costs. Respiratory failure that requires emergency mechanical ventilation occurs in 44,000 patients per year in the United States. The cost to US hospitals for opioid-induced respiratory depression (OIRD) interventions is estimated at nearly $2 billion per year.
• Hospitalization costs. Respiratory compromise ($22,300), ranks in the top five of 20 conditions that have the highest aggregate costs per stay due to the high frequency of hospitalization.
• Length of stay. Ventilator-associated complications (VAC) can lead to longer stays in the ICU and greater rates of readmission. VAC complications add approximately $40,000 in costs to each case, $1.2 billion in total costs annually.

Will Clinicians Adopt It?

Technology implemented without proper consideration of impacts on workflow and user ability to fulfill their core responsibilities can have deleterious effects on its overall efficacy.

Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made, at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.

According to a clinical surveillance report released this year by Spyglass Consulting Group, “hospitals recognize the importance of real-time capabilities to enhance patient safety and improve care quality.”

Ultimately, the ability to safely manage patient populations across the enterprise, reduce the cost of care, and align with reimbursement and regulatory incentives are driving and accelerating adoption. Clinical surveillance has arrived in healthcare and the future looks bright.

Readers Write: Once Retro, Now Current Again: Why Print is Essential to Your Health Education Program

Once Retro, Now Current Again: Why Print is Essential to Your Health Education Program
By P.J. Bell

P.J. Bell is co-chief content officer at StayWell of Yardley, PA.

Smartphones, tablets, computers. You might think the best way to educate patients about their healthcare is electronically. That’s a fair assumption, considering the average American spends nearly 24 hours a week online. With more than 84 percent of folks accessing the Internet from mobile devices (that’s according to a report from the USC Annenberg Center for the Digital Future), you have good reason to think digital is the way to go. But if your practice is considering going all digital, pause for a moment to rethink that strategy.

While digital experiences are critical for engaging today’s savvy healthcare consumer, printed educational materials remain an important part of the care continuum. People still like to receive printed information at an office visit or during discharge from a hospital stay. Both patients and healthcare providers report that printed brochures or handouts are the most effective means of communication. In fact, more than half of patients say that printed educational material about their diseases or the drugs they’ve been prescribed are more useful than other tools available to them. A similar number of providers also indicate that they rely primarily on print collateral when talking to their patients.

Surprisingly, this majority isn’t just older patients. Even Millennials prefer printed materials. Various surveys have shown that more than three-quarters – and in some cases, 90 percent or more – of Millennials said they preferred reading print materials. In fact, if cost was the same for a print or digital book, they’d pick the paper version.

Paper Rules

Healthcare practices and hospitals are faced with the great challenge of ensuring that their patients fully understand their medical conditions and treatment plans. And just as vital, a patient needs to know what to do after leaving the doctor’s office or being discharged from the hospital. More than $73 billion is spent each year on unnecessary healthcare expenses because patients don’t fully comprehend what their medical providers say to them, according to the Institute for Healthcare Advancement.

The fact is, patients face a number of barriers when trying to follow medical guidance. They can be confused by medical jargon or simply overwhelmed by the amount of information—good or bad—that they can access. Some may be embarrassed to seek additional information or hesitant to ask questions. This alone results in about half of all patients leaving their doctor’s office without a solid understanding of what they were told or what they should do going forward.

However, when printed materials are used as a resource, medical staff can go over the information with patients in the office or at the hospital and get a sense of their understanding. This allows staff to determine any additional resources that could benefit the patient. Just as important, when patients are faced with an unexpected diagnosis or new medicine to take, having something in-hand to take home and re-read later enables them to think more clearly about next steps. That way, they can develop questions they may want to ask of their provider via email, phone, or at a follow-up appointment.

In many cases, given the vast quantity of medical information on the Internet—potentially from questionable sources—patients often believe print materials are more official and trustworthy than electronic documents.

The Prescription for a Well-Rounded Patient Education Plan

If your practice is planning to go all digital, let the evidence showing the importance of printed materials give you pause. Going digital can help you deliver advanced offerings. But ultimately, you need to know your audience and communicate in ways that resonate best with them. This may require a multimedia approach.

To develop a patient education program that will deliver greater value to patients and improve outcomes, consider these tips:

• Don’t re-create the wheel. Your organization probably has a lot of educational content in its archives, whether it is pre-printed brochures or an electronic library from which you can print on demand. Leverage these existing resources to provide customized education that meets individual needs. Give your patients a takeaway that they, as well as family members and caregivers, can refer to later at home.
• Use technology where appropriate. Every patient has a different learning style, so offer educational content in a variety of formats to help enable comprehension. Also, keep in mind that a large part of health literacy is ensuring your patients have repeated access to information. For some, printed material that they can read and keep as a reference is ideal. Others may respond better to watching a video made available online or as a DVD they can borrow from the office. Some patients may be tech savvy and prefer to access their information from a patient portal, while a few others may lack internet access or be uncomfortable using a computer. Also, consider the primary language of your patient base. Do you need to provide educational content in languages other than English?
• Review materials with patient and family members. Sometimes just a few extra minutes can make all the difference. When possible, carve out time to talk through the educational material you’re providing, and use common language that most people will understand. Take cues from your patient. If he or she is impacted by fatigue or the shock of a diagnosis, it can be harder to absorb what you’re saying. It’s also important to consider whether patients have physical, mental, or emotional impairments that may affect their ability to learn. Some may need specialized resources if they are vision- or hearing-impaired. Whenever possible, include family members in the education process, since they often play a critical role in your patient’s healthcare management.

Education is key to ensuring that patients understand what they need to do to address chronic conditions, recover from injury or surgery, or improve their overall health. Digital technologies shouldn’t override your practice’s ability to share healthcare information in a way that enhances patient understanding. As you explore new ways of delivering patient education, don’t miss out on the successful communication available when print materials are part of the process. A winning patient education program is flexible enough to deliver content in the format that works best for each patient.

Readers Write: What’s Good for the Dentist is Good for the Medical Doctor as Well

What’s Good for the Dentist is Good for the Medical Doctor as Well
By Robert Patrick

Robert Patrick is president of dental at Vyne of Dunwoody, GA.

Medical professionals might be tired of the endless requirements of mailing x-rays or other documentation to the insurance company every time they file a claim. Some of them might simply want the ability to add their supporting documentation to claims electronically for easier adjudication.

While medical professionals continue to wait for developments and guidance related to the use of electronic attachment solutions and technologies, their dental colleague counterparts have no such obstacles. Even though there’s no formalized standardization from an organization like the Center for Medicare and Medicaid Services (CMS) for dental, there is a range of solutions that have permeated the sector and enjoy robust use by many thousands of dental practices. Why the disparity?

The simplest reason is that the solutions are readily available in the dental sector, Their use has been embraced despite there being little formal regulation or guidance related to submitting electronic attachments. For example, as long as the solutions are compliant with HIPAA, their use is fair game. Per recent reporting, some on the medical side of healthcare are waiting for a push toward standardization in the way electronic attachments are sent before moving forward with similar solutions.

According to reporting by MedPage Today, Robert Tennant, director of health information technology policy at the Medical Group Management Association — a trade group that represents medical practices — said that HIPAA includes a directive for the federal government to develop standards for electronic attachments. But the HIPAA provision still is not seeing traction or light of day. Even when the Affordable Care Act (ACA) was passed in 2010, it included a provision requiring the federal government to issue a final rule on standardizing electronic attachments, and a deadline of January 1, 2014, for doing so, but nothing yet.

The delay, Tennant speculates, might relate to how CMS can address “solicited” versus “unsolicited” attachments. Maybe the use of a secure attachment protocol or portal for data submission could eliminate this concern. For example, with dental electronic attachment solutions, providers can simply upload their supporting documentation via HIPAA-compliant software services. The respective payer is then notified that attachments are available for claim processing. No muss, no fuss. 

While there’s no requirement or mandate for dental providers to submit attachments, just like there is not one for medical doctors, dental providers are leading the way having embraced the move to electronic attachments years ago, unlike their medical colleagues. Any care professional can (?) make use of the technology, and there is a market on the medical side of the fence, so why the delay in adoption?

One potential issue is that some believe submitting attachments to be “a fairly complex transaction” for health plans to implement. “Since CMS also controls Medicare and Medicaid, they would be required by law to implement this standard, and maybe there is some pushback in terms of the cost to implement this transaction,” said Tennant in the report.

Is regulation on electronic attachments forthcoming for medical providers? The federal electronic attachment conversation continues and was included in the federal government’s unified agenda — a plan of action issued by the Office of Management and Budget — that might not be considered until later this year.

According to regulatory guidance, the electronic attachments rule must contain data formats to be used for the attachments. In 2016, the National Committee for Vital and Health Statistics, a public group that advises the Health and Human Services (HHS) secretary on health data issues, laid out its recommendations for electronic attachments, including suggested formats, in a letter to then-HHS Secretary Sylvia Burwell:

• For the request for attachments, the group recommended using the ASC X12 format
• For the response with a submission of attachment, the HL7 format is recommended
• For the acknowledgement of the response, the ASC X12 format is recommended

For reference, the Accredited Standards Committee X12 (ASC X12) provides standards that can be used for nearly all facets of business-to-business operations conducted electronically. The committee aims to:

• Develop high-quality e-commerce standards that are responsive to the needs of the standards user
• Collaborate with other existing standards to make the standards developed more interoperable
• Avoid any conflict, confusion, and duplication of effort
• Publish and promote the standards along with their education
• Drive the implementation and adoption of the standards developed by the committee

Health Level 7, or HL7, refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is “layer 7” in the OSI model.

The group also recommended that HHS define attachments as the “supplemental documentation needed about a patient(s) to support a specific healthcare-related event (such as a claim, prior authorization, referrals, and others) using a standardized format.”

One thought is that with such guidance and with the backing of CMS, there might be a reduced “provider burden.”

What about the payers? Why not a push by payers for standardized operations? Why don’t payers and providers just decide on standards and implement them without any government help? This hasn’t happened because payers argue that it will cost too much money to implement; no one is going to bother if vendors don’t create products for the providers. Some vendors, of course, are not willing to produce a solution for such without payer’s backing.

In medical care, it seems that everybody’s waiting for somebody else, and no one will do it until the government issues the standard. Perhaps these arguments are valid for physicians, but for dentists, this foundation already is laid. Perhaps infrastructure is the real problem for medical providers. Nevertheless, the technological capabilities exist and have for many years.

If electronic attachments were implemented in medical care, the result could be savings for both health plans and providers, according to the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and other organizations whose goal is to streamline healthcare administration. The 2017 CAQH Index report found that only six percent of medical attachments were submitted electronically that year, but the report also found that providers could it save 51 cents per claim – 30 percent of their current cost — if electronic submission were employed, while health plans could save $1.64 per claim, a 94 percent savings.

CAQH launched a project under its Committee on Operating Rules for Information Exchange (CORE) division — a group of about 130 organizations developing operating rules for healthcare administration — to scan and discover where the healthcare industry stands in relation to electronic attachments, including use of a standard format. The organization is examining the varying types of use cases for documentation and the products available in the marketplace to support an automated approach to move the industry forward.

While the number of electronic attachments exchanged is quite small in volume, at least for medical providers, there is a clear path in place that can be executed with or without the support of an organization like CMS or others, as we have seen on the dental side of the house. While doctors may have been waiting for some guidance since HIPAA’s creation in 1996, dentists have been successfully using electronic attachment solutions since at least 1997, and with great results.

Thus, if more than 60 percent of the dentists in America who need to send supporting documentation to payers to get paid for their service are doing so electronically, why can’t the medical professionals of America do the same? America’s dental payers have agreed to participate in electronic attachments while America’s medical payers seem to be waiting for a mandate.

Readers Write: Our Experience with Epic’s App Orchard

Our Experience with Epic’s App Orchard
By Chinmay Singh

Chinmay Singh, MBA, MSE is co-founder and CEO of SimplifiMed of San Francisco, CA.

SimplifiMed went live last month on App Orchard after several months of work. I believe other startups can benefit from our experience as they pursue integration with Epic.

We integrated with many other EHRs before Epic, including Athenahealth, Centricity, and Drchrono. As I review my experience, there may be a whiff of unavoidable comparison.

1. Epic is the most customer-focused EHR vendor

This became clear to me in my first call with Epic’s App Orchard team. I could vividly imagine a customer in the center of anything App Orchard team discussed — workflow, security, or marketing message. For this reason, I would recommend that startups first integrate with other EHRs, learn from that, and then approach Epic.

2. The App Orchard team knows the customer

Your contact at App Orchard is unlikely to be a mere project manager. He or she will be an active participant and will gently prod and challenge you on your workflows and the selection of APIs. If you don’t have an active Epic customer, this is one of the best resources you have to compensate for the lack of information. Use it.

3. Epic listens to App Orchard members

We all have heard about a certain recalcitrant Midwest company. I was surprised at how receptive the App Orchard team was to my suggestions on the program, pricing, and terms. They listened to my concerns and responded to them in a timely fashion, and I assume that the new program terms were partially influenced by the feedback I provided to them. Reach out to them with your feedback.

4. App Orchard documentation is lacking

The API documentation is very basic, and in some cases, unusable. For example, there is no explanation of the different versions of the same APIs. Or that two different APIs appear to be doing the same thing (they are not) without a good explanation. The advice in #1 and #2 above partially compensates for this. If Epic team needs some inspiration, they should look at Athenahealth’s developer suite. Not only does Athenahealth have more robust documentation, all of their APIs can be tried in the sandbox.

5. No Hyperspace

This is the biggest issue with App Orchard. Without access to Hyperspace, it is difficult to test the product. Moreover, Epic periodically resets the back end, forcing you to re-create your test cases. This is a huge time sink. As we are experiencing now, prospects want to see a demo of SimplifiMed working with Epic. But without access to an Epic instance, we are unable to do so. I would love to hear from other App Orchard partners on how they are overcoming this problem.