NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

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flying cadeuciiDid you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.

Good thing he didn’t say an act of God.

So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?

The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.

First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.

An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.

“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”

“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”

Continue reading “The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.”

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apple storeJe n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. —Blaise Pascal

Translation: I have made this longer than usual because I have not had time to make it shorter.

As Appley as it gets.

A while ago I was challenged to write about what an Apple-like approach to healthcare might look like.

That challenge has been weighing on me.

For starters, we’re all over Appled aren’t we? Maligned anecdotes about Steve Jobs and the iPhone make their way into almost every presentation remotely related to innovation or technology. Triteness aside, I’ve been stalled because Apple is really a philosophy, not a series of steps or lessons learned. (Although, they are nonetheless methodical.)

Instead, what I’ve been kicking around in the ole noggin are three notional predictions, which I’ll assert are inevitabilities which will fundamentally disrupt healthcare delivery as we know it today.

What follows is about as Appley as I’m likely to get. Despite big-bang product launches, Apple actually plays the long game. They introduce small features into products to affect user behavior years before a flagship product takes advantage of those reprogramed behaviors.

That’s how they disrupt.

I believe there are three meaningful, unstoppable trends, in our current world which will significantly alter healthcare. The steps taken towards these inevitabilities, along the way, are what will define the innovators and leaders. They are the ones who see this future and know how to drive towards it.

The three trends are:

  • Tools and culture which favor individual empowerment
  • The commoditization and automation of diagnosis
  • Accelerated globalization of treatment options

But wait, there’s Moore.

Don’t worry, I’m not going to leave you hanging. I’ll attempt to rationalize each of these points and explain why, particularly when considered as a bundle, they are a powerful force for disruption. And to prime that pump, we have to talk about Gordon Moore.

Continue reading “Moore’s Law in Healthcare – Three Predictions”

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Karen DeSalvoDuring National Minority Health Month, we acknowledge the potential for health information technology (health IT) – from electronic and personal health records to online communities to mobile applications – to transform health care and improve the health of racial and ethnic minorities.

Lack of access to quality, preventive health care, cultural and linguistic barriers, and limited patient-provider communication are factors that aggravate health disparities.

By increasing our investment in health IT policies and standards, we can help improve the quality of health care delivery and make it easier for patients and providers to communicate with each other – a huge step toward addressing the persistence of health disparities.

The Pew Research Center’s Internet & American Life Project External Links Disclaimer found in 2012  that African Americans and Latinos are more likely to own a mobile phone than whites and outpace whites in mobile app use, using their phones for a wider range of activities.

The study showed that African Americans and Latinos use their mobile phones more often to look for health information online. This has very important implications for personal management of health and interaction with the health care system.

However, barriers to widespread adoption of health IT remain.

For example, a 2014 consumer engagement report found that minorities were less likely to adopt online patient portals to access their health information than were non-Hispanic whites.

Continue reading “Advancing Health Equity in the Digital Age”

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flying cadeuciiThe American Recovery and Reinvestment Act of 2009 (ARRA), sometimes called the Stimulus Actwas an $831 billion economic stimulus package enacted by the 111th Congress in February 2009 and signed into law on February 17, 2009 by the President.

It included $22 billion as incentives to encourage adoption of certified electronic medical records in hospitals and medical practices. The rationale behind the policy directive was clear: system-wide implementation of electronic medical records enables improvement in diagnostics and treatment coordination, fewer errors, and better coordination of patient care by teams of providers.

Almost immediately, the medical community cried foul.

Their primary beef: the cost to implement these new systems would not be recovered by the incentives.

Similarly, physicians pushed back on the conversion of the U.S. coding system from ICD-9 to ICD-10. They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.

That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.

Last week, physicians won a battle: the Centers for Medicaid and Medicare Services (CMS) announced it was delaying the deadline for implementation of ICD-10 for a year, to October 1, 2015.

Continue reading “Health Information Technology: Sorry, There’s No Turning Back!”

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The American Medical Association (AMA) says the number one issue with recent data releases from HHS is that “there is currently no mechanism for physicians and other providers to review and correct their information.”

We think we have a way to fix that problem over at the DocGraph project!

Over the last two years there have been three major breakthroughs in the analysis of doctors using Open Data. The first was the original teaming and referral database obtained by DocGraph (us) under a FOIA request. The second was the prescribing data set obtained by ProPublica. Both DocGraph and Propublica worked around the 1978 injunction limiting the use of FOIA for doctor data.

The third is the new procedure pattern data set announced as the direct result of the overturning of the 1978 injunction.

We are happy to announce the release of the first “all-in-one” open doctor data browser that we are calling DocGraph Omni. We have created a public tool that allows you to browse the merger of all three major new open data sets about doctors and other healthcare providers that bill Medicare.

Now in one place you can view how a provider prescribes, how they collaborate, and which procedures they work with. Our intention to turn Omni into a browser where you can find any open data about doctors, no matter what the source.

But this is not just about “finding” the data. We have created a system that allows anyone to comment on any given data point in these data sets.

Continue reading “A New Way to Explore and Comment on Doctor Data”

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Since 2000, the government and healthcare industry have sold Americans a bill of goods called workplace wellness, which turns out to have been a colossal waste of billions of dollars.

Most of this money was spent bribing employees to do things that they don’t want to do, such as submit to biometrics, answer intrusive health risk appraisals, and get preventive medical care.

The marketing pitch that wellness makes people healthier and lowers medical care costs, and thus, produces a return on investment for the employer, isn’t true. Wellness also allowed companies to position themselves as employee-friendly, even while wages stagnated and employees morphed into fungible widgets, instead of vital assets in whom employers invested for years or decades.

However, it looks to us as though at least one major US company is treating economic reality seriously, and, consequently, asking its employees to act like adults.

Let’s look at wellness by Amazon.com, which has apparently avoided conventional wellness whole cloth. Despite our best research efforts, we find no evidence that the company makes conventional wellness programming a priority for employees.

It’s a bit ironic that they don’t given the recent spate of tough publicity about the company’s employment practices.

Amazon has been lambasted lately for the plight of the warehouse workers who animate its backroom operation, where constant video surveillance, productivity demands, and getting your bag searched before you go home are the norms. Message boards also detail the pressure-cooker atmosphere of the company’s white collar space, which raises, in our minds, the pointed question of why haven’t they done wellness?

We think it’s because Amazon’s philosophy about work is straightforward: if you work here, expectations are high and relentless. Amazon’s approach to employee well-being seems to be to not have one other than we invite you to grow with us. This is counter-cultural, and it has more to recommend it than first appears obvious.

When you are competing against Walmart and Target, remaining lean and low-cost is critical; wellness drives costs up, not down.

Expecting many staff to work 50, 60, or even 70 hours per week leaves little time for discretionary visits to the doctor that are pointless even before they happen because this superfluous care will save neither lives nor money. When you are not pouring money into coercing employees to join a wellness program, you preserve capital needed to optimize the technologies and product mix that help you grab market share and crush competitors like Best Buy.

Continue reading “Amazon Shows the Way on Wellness — Treat People like Adults”

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Farzad MostashariSeveral of the provisions included within the Affordable Care Act in 2011 designate Accountable Care Organizations (ACOs) as formal, contractual entities.

However, in the real world ACOs come in a variety of shapes and sizes.

When compared to larger, hospital-sponsored ACOs, rural and small physician-led ACOs face a tough challenge, because despite limited resources they need to come up with substantial upfront capital and infrastructure investment to establish a strong ACO foundation.

To help ease this burden, 35 ACOs were selected to participate in the Advanced Payment Model ACO demonstration through a grant program from the Center for Medicare and Medicaid Innovation (CMMI). The grants provided a portion of upfront capital to determine whether or not this financial assistance would help ease the startup burden for smaller ACOs, and increase their success rate.

One of those 35 organizations includes the central Florida-based Physicians Collaborative Trust ACO, LLC (PCT-ACO). They are participants in the January 2013 Medicare Shared Savings Program (MSSP) ACO cohort, along with 106 other ACOs.

Larry Jones, PCT-ACO’s CEO, describes his personal mission as an effort to “preserve and protect the independent practice of medicine.” For over 25 years he has been advocating for physicians through their efforts to organize, negotiate with health plans, and other challenges.

Continue reading “What a Physician-Led ACO Can Teach Us about Getting It Right”

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flying cadeuciiThe Food and Drug Administration has spent decades refining its processes for approving drugs and devices (and is still refining them), so what would happen if they extended their scope to the exploding health software industry?

The FDA, and its parent organization, the Department of Health and Human Services, are facing an unpleasant and politically difficult choice.

Sticking regulatory fences into the fertile plains of software development and low-cost devices will arouse its untamed denizens, who are already lobbying Congress to warn the FDA about overreaching. But to abandon the field is to leave patients and regular consumers unprotected. This is the context in which the Food and Drug Administration, the Office of National Coordinator, after consultation with outside stakeholders, released a recent report on Health IT.

I myself was encouraged by the report. It brings together a number of initiatives that have received little attention and, just by publicizing the issues, places us one step closer to a quality program. Particular aspects that pleased me are:

  • The suggestion that quality programs should start to look at electronic health records (p. 8). EHRs have been certified by various bodies, but usually just to check off boxes and declare that the systems comply with regulations–neither the quality of their user interfaces nor the quality of their implementations have been questioned. Reportedly, the FDA considered “safety and quality standards” for electronic health records in 2010 but couldn’t get them adopted. It also checks certain forms of clinical decision support, but only if they are built into a regulated device. The current HHS report refers back to aspirational documents such as a Health Information Technology Patient Safety Action & Surveillance Plan and a set of guidelines on the safety of EHRs.
  • A call for transparent reporting and sharing of errors, including the removal of “disincentives to transparent reporting”–i.e., legal threats by vendors (p. 25). Error reporting is clearly a part of the “environment of learning and continual improvement” I mentioned earlier. A regulation subgroup stated the need most starkly: “It is essential to improve adverse events reporting, and to enable timely and broader public access to safety and performance data.” Vague talk of a Health IT Safety Center (p. 4, pp. 14-15) unfortunately seems to stop with education, lacking enforcement. I distinctly disagree with the assessment of two commentators who compared the Health IT Safety Center to the National Transportation Safety Board and assigned it some potential power. However, I will ask ONC and FDA for clarification.
  • A recognition that software is part of a larger workflow and social system, that designing it to meet people’s needs is important, and that all stakeholders should have both a say in software development and a responsibility to use it properly.

Don’t imagine that the FDA is unused to regulating software. For quite some time they have instituted practices for the software used in some medical devices , and have tried to keep them up-to-date.

A waterfall-like process of risk assessment and testing called computer system validation has long been required for pharma and devices.

Continue reading “Health IT: The Coming Regulation”

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Figure 1 acaview

With this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth.

2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces.

Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.

With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.

ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients.

athenahealth is a technology and services provider that delivers physicians the tools and support needed to manage the business and clinical aspects of their medical practices. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.

Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics.

We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.

No Meaningful Change to Date in New Patient Volumes

Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether.

If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.

Continue reading “Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice”

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Three related columns in HealthcareITNews caught my attention recently.

The headlines pretty much say it all:

1. Satisfaction with HIE solutions drops.

2.  Vendors missing boat on HIE needs.

3.  CommonWell names 3 biggest HIE hurdles.

Over the years, I’ve written more than a few HealthBlog posts on the topic of health information exchange (HIE) and why I feel so strongly that most of the initiatives currently underway are missing their mark.

As I’ve stated before, during my worldwide travels I haven’t yet come across a country that has accomplished a truly national, interoperable, bi-directional, fully functional HIE.

Those few countries that come close are more like a large American city or small state in size, perhaps mirroring some of the moderately successful regional or state-wide exchanges currently operating in America. Over the years I’ve also watched implosions of national HIE attempts in several countries that have failed miserably despite billions of dollars being spent on the efforts.

Reading each of the articles referenced above, I once again reach the conclusion that what I have been evangelizing as a better model for HIEs still rings true.

Continue reading “Cracking the Code on Health Information Exchange. Is It Time to Wipe the Slate Clean and Start Anew?”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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