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Opening the Care Conversation Through Open Notes

Susan DentzerIt’s a memory aid.

It’s truth serum.

Using it can transform relationships forever.

These may sound like come-ons for the type of product typically hawked on late-night television.  But in fact, they’re some of the things people are saying about OpenNotes.

OpenNotes isn’t a product, but an idea: That the notes doctors and other clinicians write about visits with patients should be available to the patients themselves. Although federal law  gives patients that right, longstanding medical practice has been to reserve those visit notes for clinicians’ eyes only.

But Tom Delbanco and Jan Walker, a physician and nurse at Beth Israel Deaconess Medical Center in Boston, have long seen things differently.

Their personal experiences with patients, and inability to access care records for their own family members, persuaded them that the traditional practice of “closed” visit notes had to change.  So, with primary support from the Robert Wood Johnson Foundation, they launched what has now become a movement.

In 2010, Delbanco, Walker and colleagues led a study in which more than 100 primary care doctors from three health systems began sharing notes online with patients. Patients got secure messages prompting them that the notes were available, and reminders to read notes before their next appointments.

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HIT: Where We Stand and Where We Go From Here

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This post is adapted from DeSalvo’s talk at the annual meeting of the Health and Information Management Systems Society in Chicago last week.

I am optimistic about the bright future we have to leverage health information technology to enable better health for everyone in this country.

One year ago, we called upon the health IT community to move beyond adoption and focus on interoperability, on unlocking the data, so it can be put to the many important uses demanded by consumers, doctors, hospitals, payers, and others who are part of the learning health system.

ONC spent the year listening to the health IT community to understand the challenges and opportunities and developing strategic roadmaps to guide our way. Our goal was to evolve to be best able to lead where appropriate, and partner wherever possible, as we all shift the national strategic focus towards interoperability. I hope you all have felt that shift.

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SGR Appeal: Fixing the Present, Setting a Foundation for the Future

Farzad MostashariLast week, I was riveted to the deliberations on the Senate floor, as the fate of the Medicare Access and CHIP Reauthorization Act (MACRA – so far, more commonly called the “SGR fix”) was decided. One amendment after another failed to pass; the legislation ultimately passed by a vote of 92-8, and was signed into law shortly thereafter.

To date, much of the coverage of MACRA has focused on how it has fixed the “doc pay” problems of the last 18 years – rescuing us from a yearly round of negotiations about how to temporary avoid painful cuts in Medicare’s physician reimbursement rates.

It’s true that MACRA wiped out (and only partially paid for) the accumulated burden of postponed pay cuts. But it also took a huge step in ending the volume-based “fee-for service” payment system that the pay cuts were trying to restrain in the first place. In a volume-based health care world, the only way for the government and other payers to control runaway medical inflation is to make it harder for doctors to get paid (through rejected claims, paperwork, and prior authorizations), and to reduce the price they pay for each office visit, test, or medical procedure. Providers, paid less and less for each visit and service, can try to maintain their income by further increasing volume — seeing more and more patients in less and less time — or routing patients through increasingly questionable services, tests, and procedures. That is the dysfunctional state of US health care today, with patients caught in the middle of the arms race between those who pay the bills, and those who bill them– collateral damage.Continue reading…

Finding the Stars of Hospital Care In the US

Why do star ratings?

Ashish JhaNow we’re giving star ratings to hospitals? Does anyone think this is a good idea? Actually, I do. Hospital ratings schemes have cropped up all over the place, and sorting out what’s important and what isn’t is difficult and time consuming. The Centers for Medicare & Medicaid Services (CMS) runs the best known and most comprehensive hospital rating website, Hospital Compare. But, unlike most “rating” systems, Hospital Compare simply reports data on a large number of performance measures – from processes of care (did the patient get the antibiotics in time) to outcomes (did the patient die) to patient experience (was the patient treated with dignity and respect?). The measures they focus on are important, generally valid, and usually endorsed by the National Quality Forum. The one big problem with Hospital Compare? It isn’t particularly consumer friendly. With the large number of data points, it might take consumers hours to sort through all the information and figure out which hospitals are good and which ones are not on which set of measures.

To address this problem, CMS just released a new star rating system, initially focusing on patient experience measures. It takes a hospital’s scores on a series of validated patient experience measures and converts them into a single star rating (rating each hospital 1 star to 5 stars). I like it. Yes, it’s simplistic – but it is far more useful than the large number of individual measures that are hard to follow. There was no evidence that patients and consumers were using any of the data that were out there. I’m not sure that they will start using this one – but at least there’s a chance. And, with excellent coverage of this rating system from journalists like Jordan Rau of Kaiser Health News, the word is getting out to consumers.

Our analysis

In order to understand the rating system a little bit better, I asked our team’s chief analyst, Jie Zheng, to help us better understand who did well, and who did badly on the star rating systems. We linked the hospital rating data to the American Hospital Association annual survey, which has data on structural characteristics of hospitals. She then ran both bivariate and multivariable analyses looking at a set of hospital characteristics and whether they predict receiving 5 stars. Given that for patients, the bivariate analyses are most straightforward and useful, we only present those data here.

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Will HIMSS Bring About World Peace?

flying cadeuciiI had a HIMSS 2015 hallucination.

Walking through the crowded exhibit halls of the premier health information technology trade show, the Prophet Isaiah’s vision of beating swords into plowshares and the lion lying down with the lamb suddenly unfolded before my eyes. Even if we were in McCormick Place in Chicago, not the Temple Mount in Jerusalem. (Although we were on an upper level.)

There ahead of me, the maker of the A-10 Thunderbolt “tank buster” dwelled in a booth a few steps from a maker of fasteners for tractor engines: sword and plowshare. Elsewhere, the PAC-3 missile manufacturer contentedly cohabitated with a company that sells baby strollers: lion and lamb.

However, what prompted this copacetic condition was not a prophet, but profits. As tens of billions of dollars pour into digital technology to improve the efficiency and effectiveness of U.S. health care, companies large and small all want a cut.

“Swords into plowshares” at HIMSS 2015?

Total U.S. spending on health care is closing in on a staggering $3 trillion.Entrepreneurs from everywhere in the economy are making a pilgrimage to this sector. Venture capital funding in health IT roared to $4.7 billion in 2014, according to the Mercom Capital Group, more than double the $2.2 billion in 2013. Small wonder that more than 42,000 attendees flocked to HIMSS this year, a jump of some 10,000 from as recently as 2011.

Here’s where we come to the part about world peace. The U.S. health care system is by no means the only one needing modernization and rationalization. Several years ago, HIMSS issued awhite paper examining electronic health records from a global perspective. The group now boasts regional offices and puts on events in Europe and Asia. As global capital markets recognize the potential of health IT, it’s not too much to hope that individuals of all religions, races and nationalities can come together in search of the “new, new thing,” the next big deal and the large pot of cash that comes with both.

Ideology is one thing, but, as the saying goes, business is business. Co-existence fostered by capitalism.

Admittedly, this isn’t quite what Isaiah had in mind. Still, if a prominent Middle Eastern country decides to switch from centrifuges to Software As a Service, I’ll be looking for the Iranian booth at HIMSS next year.

Five Years of Failing Patients

Screen Shot 2015-04-17 at 7.59.18 PMAlthough this March marked the fifth anniversary of passage of the Affordable Care Act many of its promises to place patients at the center of care remain elusive. No where is this more evident than in the law’s provision to improve shared decision making.

Oftentimes there is more than one reasonable medical treatment to choose from. Shared decision making helps patients partner with health care providers to make more informed decisions about treatments based on patients’ personal beliefs and values and their informed understanding of their medical choices. Frequently, patients are simply told what course of treatment they are to undergo without considering alternatives.

A well-accepted path towards aligning patients’ preferences with medical care is to use decision aids. These tools include written educational materials, informed face-to face encounters, or videos with instructional images that explore different options for care by providing the risks and benefits of interventions and their alternatives, exploring individual values and preferences, and offering testimonials from other patients who have experienced the various choices.

It is an astounding fact that after five years the Centers for Medicare and Medicaid Services (CMS) has certified only a single decision aid. Even in a city infamous for bureaucracy, this is inefficient at best – especially given that the overwhelming number of studies demonstrate that decision aids align medical care with what patients want, while also saving the health care system billions of dollars.

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Last Chance for Meaningful Use

new adrian gropperI mean: Last chance for patients as first-class citizens in Meaningful Use.

The ghetto is abuzz. As I write this #nomuwithoutme  is just hitting Twitter. The reason the natives are restless in the patient ghetto is a recent proposal  by our Federal regulators to downgrade a Meaningful Use (MU) requirement for Stage 3, in the final stage of a $30B + initiative to advance interoperable digital health records. The focus is on something called View / Download / Transmit (V/D/T) but the real issue and the Last Chance is broader and more important. The bad news is that MU may leave patients as beggars for own data. The good news is that the Office of the National Coordinator (ONC)  and Congress are paying attention and patients still have a chance to shift the terms of the debate to what HIPAA calls “the patient’s right of access” and demand that it apply strictly to MU Stage 3 Appication Programming Interfaces (API).

To find the core of the downgrade, search the Notice of Proposed Rulemaking NPRM  for the word “download”. To experience the ghetto first-hand, search the NPRM for “4 business days”. The issue is plain: patients are to get degraded, delayed information through a “portal” that forces us to take whatever the “providers” are willing to grant us.

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Designing For Good: A Designer’s Hippocratic Oath

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The Designer’s Oath brings together designers from disparate disciplines and backgrounds to create collaborative Oaths that speak across design practices and organizations. The traditional boundaries of design are quickly expanding, and our code of ethics needs to be as flexible and easy to redefine as the process of design itself. The Designer’s Oath must become a tool that is applied to the process of design to ensure that the end result does good.

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Surviving the Affordable Care Act Grace Period

Screen Shot 2015-04-16 at 10.39.10 AMSince the first open enrollment in 2014 more than 11 million people have gotten coverage through the insurance exchanges established through the Affordable Care Act (ACA). While the plans offered through the exchanges are provided by the same insurers you deal with every day, there are some differences.

The biggest one is the 90-day grace period. As we near the end of the grace period for 2015, many practices are still struggling to manage the ins and outs to ensure they get paid. Here’s why.

When a person goes into the exchange to select a policy, they get a 90-day grace period to pay premiums. This grace period is between the insurance company and the policy holder. As with other coverage, when the patient makes an appointment and/or goes to the doctor, he or she shows the insurance card. When the practice verifies eligibility, it shows that the patient is covered. If the patient comes into the office during the grace period, the claim will go out as usual and get paid. However, if the patient did not pay their premium during this grace period, the insurance company will come back to the practice and ask for the money back. Then, the practice has to bill the patient directly. This is difficult for providers for many reasons, not the least of which is that the longer it takes to bill a patient, the lower the chances of getting paid.

As a provider you may feel a strong reaction to this 90-day grace period and want to wait to see patients until the grace period is past. This is probably not realistic. Patients need care, and you need to have a positive relationship with your patients. So, here are a few steps to help manage the grace period and ensure you get paid:

  1. If the patient is in this grace period, ask them to bring proof of payment of their premium (cancelled check or receipt of some kind).

  2. If the patient cannot provide this, have them pay at least 50% of the billed charges at the time of service.

  3. Have patients sign a contract that states that they will pay the charges if the payer denies them or asks for the payment back after services are rendered.

  4. Implement a credit card on file option. Patients provide a credit or debit card and sign a contract that it can be charged up to a specified amount (i.e., $150). If the payer denies the claim or asks for the payment back, the practice can charge the card and send a receipt to the patient.

Over 30% of physicians believe that the largest barrier to good healthcare is inadequate insurance coverage. So it is no wonder that over 40% of physicians also believe that the Affordable Care Act is mostly good and a similar number are accepting exchange plans. However, this doesn’t change the fact that the new plans come with challenges.

As a small business you can’t really afford to wait too long to get paid, or worse, have to return payments and then wait again. By implementing some simple steps now you can help reduce the headaches of exchanges plans in the years to come.

Kathleen Young is the CEO and co-founder of Resolutions Billing & Consulting, Inc., which was founded in 2003. Kathleen is also the owner of Healthcare Chart Audits, which offers auditing to physicians and attorneys. Kathleen has been in healthcare since 1989 and has worked for physicians, large corporations and three billing companies. Kathleen is a CPC and a CPMA with the American Academy of Professional Coders and speaks to many groups on coding, billing, and auditing.

 

The Big Fix. Medicare Doc Pay Enters a New Era

Screen Shot 2015-03-23 at 8.02.41 AMIt’s done.  Congress on April 14 passed and the president signed into law a bill that terminates one of the most egregious and silliest examples of dysfunctional government in recent years—the so-called “sustainable growth rate” (SGR) formula for doctors’ fees under Medicare.

A previous blog explained the background and protracted lead-up to this moment.

Now what?

First, a round of applause for bipartisan agreement—however obvious it was that had to happen in this case.   The vote in the house was 392-37.  In the Senate, it was 92-8.

Praise is also in order for enacting two more years of funding for the Children’s Health Insurance Program and $7.2 billion in new funding over two years for community health centers, a program that was expanded under the Affordable Care Act and serves low-income families.  There’s also welcome help for low-income Medicare beneficiaries and rural hospitals.

But the main thrust of the law is to kill one (failed) program that adjusted doctors’ fees under Medicare and create a new and hopefully better one.

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