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Posts of Note: The 2013 Harvard Business School Cyberposium

Nov 7, 2013

By Grant Ho

This past weekend, I attended Cyberposium at Harvard Business School where I was invited to speak on the Healthcare Technology panel. Cyberposium is one of the largest MBA student-run tech conferences in the country and typically gets around 1,000 attendees — students, industry professionals, press, and VCs. This year was no different.

The atmosphere was buzzing. There’s always a certain energy at these events, and when you’re surrounded by individuals who are passionate about innovation and the curiosity and sense of possibility that come with it, it’s an exciting place to be.

The morning’s keynote featured Bill Clerico, CEO of WePay (a competitor to PayPal in the online payments space). Bill told us about his motivations for starting WePay, their journey to raise $20M, and how he and his team worked relentlessly to scale the organization.

His two big takeaways on what it takes to be a successful entrepreneur, especially if you’re just starting out: 1) you have to be scrappy and 2) you have to have maniacal focus on the customer (both when you acquire and service them). I couldn’t agree more. Personally, it was a reminder that as we grow bigger at CareCloud, we can never lose sight of our entrepreneurial roots.

After the keynote, I headed off to the Healthcare Technology panel. On the panel, I was joined by HCIT folks from Activate Networks, athenahealth, HealthTap, and Operating Analytics. Our panel was moderated by Zen Chu, serial healthcare entrepreneur and founder of MIT’s H@cking Medicine program (who earlier in the day, told me about a startup he recently invested in called Figure1 — think of it as a Pinterest for doctors).

The 50-minute discussion focused on the future of healthcare, from the impact of reform to emerging business models and trends in HCIT investing. As I think back on the panel and dozens of conversations throughout the day, a few things stood out:

1) Big data’s a big deal: Our panel immediately jumped into big data, with one of the more interesting discussions around what’s needed to reach the promised land called population health. For me, it’s about starting with a platform that can easily house both patient and claims data. You can’t have one or the other, you need both – especially as providers take more financial risk for care delivery.

More critically, as you build analytics on top of that, the platform needs to be scalable, have enough horsepower to aggregate and analyze all the information, and is interoperable so you can bring in new data sets from different sources (think genomics or the quantified self). The combination of storing administrative, financial, and clinical data in a powerful, cloud-based system is what we have at CareCloud today and in my view, is a critical enabler for big data going forward.

2) Selling to doctors is hard: During the panel, an audience member (a new HCIT entrepreneur) asked what’s the best way to sell to doctors. As a marketer, we work to connect with practices every day – helping them navigate through the pain of declining reimbursements, while easing their struggle with poorly designed HCIT. In my view, it’s a twofold solution.

First, it’s having a simple, flexible business model like SaaS-based pricing that makes finances easier on practices. Secondly, it’s developing products with “design thinking” from the start. You can build all the Meaningful Use features into your EHR, but if you’re making the doctor’s life harder and she can’t go home to see her family, you’ve failed. Usability has always been an obsession with us at CareCloud, and that’s why I’m so encouraged by the great work of our product teams, led by Edwin Miller, to make the fastest, most user-friendly HCIT solutions out there.

3) Engaging patients is even harder: Throughout the day, there was a lot of buzz about wearable devices like FitBit, mobile health apps like Ginger.io, and physician networks like HealthTap. While the growth of these tools is exciting, it made me realize how siloed all data is and how hard it will be to get patients to take action (I, for one, don’t walk an extra mile when Jawbone Up tells me I’ve hit less than 10,000 steps on any day).

Perhaps it’s linking all this disparate data into a patient portal so it reaches doctors and EHRs, incentivizing doctors on care planning (not just care delivery), or simply having patients pay a greater share of their healthcare spend. However, in my view, a combination of integration and incentives are required to reduce the physician/patient asymmetry.

How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals

Nov 6, 2013• 23

By ASHISH JHA, MD

I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.

He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening. He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs. After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.

That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath: he had a large saddle pulmonary embolus. He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care. He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality. Even after discharge, he received two nursing visits at home to ensure he was doing OK. In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed. Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.

This is the story we all hope for. And when I heard it, I have to say that I wasn’t surprised. There’s something about the BIDMC that’s unusual. Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted mortality rates for all three reported conditions: heart attack, congestive heart failure, and pneumonia. And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.

If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.

So what’s so special about them? What do they do that’s different? I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest. And in a word, it’s leadership. BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care. That commitment translates into real activities that make a big difference. Let me divert us with a story of what this might actually mean.

A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare. As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation. One call is particularly memorable. Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?”

The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better. When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.

Letting the Data Speak: Estimating County Health Care Costs In Washington State

Nov 6, 2013• 1

By Frank de Libero

Besides state and higher-level health care expenditures, county level HCE are useful, integral really. For example, to promote the Triple Aim (the best care for the whole population at the lowest cost) you need per capita HCE. And knowing those costs at the county level would help a lot. However, county estimates generally don’t exist. They didn’t in Washington State until a client needed cost estimates for our 39 counties. To supply those estimates I used a regression approach resulting in this model:

percaphce = +0.1*percapinc + 247*pctage65 + 0.71*percapmedaid + 10.5*pctrural – 1349

Washington State Context
Before discussing model rationale and county HCE estimation, here’s some context about Washington State and its counties. You might view Washington as a microcosm of the nation. It has mountains, forests, deserts, rivers and lakes, vast rural areas, major cities, diverse populations and industries, and a varied climate. It is distinguished by active volcanoes and a coastal border. There is a wide range of political, social and economic clusters. In 2010 King County, where Seattle is located, median annual household income was about $67 thousand (the U.S. median was roughly $50 thousand) yet there are state counties where one in three children live in poverty. The total population is approximately 7 million with half of those people living in just three of the 39 counties.1 At the other end about a third of the counties have populations of 30 thousand or less.

An Aside about Seattle Weather
You may have been told that it rains all the time in Seattle. I live in Seattle and can tell you that’s a myth. Seattle’s average annual rainfall is less than New York City’s. However, during a good part of the non-summer months Seattle, and Puget Sound generally, is grey and cloudy. I once heard a story about the original settlers who landed in November, 1851, at Alki near present-day Seattle. The story is they were there for months before the weather finally cleared and they saw Mt. Rainier for the first time. I don’t know if that story is historically true, but as a Seattleite it’s believable. Regardless, Seattle is a summer paradise. Seattle summers, like most of Puget Sound, are characterized by pleasant sunny days, cool nights and no mosquitoes.

Background for the County HCE Estimates
Last year Empire Health Foundation of Spokane, Washington, asked me to estimate HCE for the 39 counties in the state. The purpose was for an upcoming meeting of policy types such as county commissioners, members of various health organizations, and other stake holders. A theme would be Donald Berwick’s Triple Aim, so cost estimates were wanted for benchmarks and context. The CMS2 Office of the Actuary had recently developed state HCE.3 If I could build a reasonable regression model on state-level data to predict state HCE, and there were similar variables at the county level, I could use the state model to estimate county HCE. That’s the approach I took. A caveat is my understanding was that acceptance—believability and reasonableness of the estimates to a lay audience—were as important as accuracy.

Quality Measurement 2.0

Nov 6, 2013• 3

By John Halamka, MD

I’ve written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification. The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.

There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers. Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.

How do we fix CQMs?

1. Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs. Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations. This is a good start.

2. Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM. The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.

World of Health 2.0 – Interview with Matthew Holt, Co-Chairman

Nov 5, 2013

By Harriet Messenger

The following is an interview of Matthew Holt, Co-Chairman of Health 2.0.

Harriet Messenger – How did Health 2.0 begin?

Matthew Holt – My interest in health began in the early 90s when I found myself doing a study on healthcare in Japan. That then led to getting involved in Japanese versus American comparative health care; which, finally led to me getting a job in health care policy at a place called Institute for the Future. They had a huge technology forecasting component but no one was doing health information technology, so I put the two together.

Around that time the internet got going; there was a sort of E-health stock boom in the late Nineties, so I was involved in looking at that. Some years later I began a blog called The Health Care Blog and as part of that I was spending a lot of time looking at the re-emergence of ‘Web 2.0’, which was the re-emergence of information technology on the web, reaching out to the consumers, doctors, entrepreneurs, etc.

At the same time I met Indu Subaiya, who is my co-founder and my co-chairman. We realised that no one was paying attention to these guys, and that’s when we thought about creating a conference that brought all these great minds together. And that is how Health 2.0 started.

HM – And would you say that Health 2.0 is living up to your initial vision?

MH – Yes, but it takes forever to do anything in health care. Health care has the same problems it’s always had: getting data to the decision maker – whether that is patient or the doctor – and getting the right treatment plans in place for the patient. These are the same problems across the world. However, with the advent of new technology, mostly in the last 20 years, there have been big advances and changes in the way that health care is both consumed and delivered.

I’ve never thought Health 2.0 was going to change the world in three years. I believe that this type of technology is a big deal, but it is going to take time. We are now in the middle of that time – it’s starting now.

Health 2.0 Tools for the Elderly at Health 2.0 Europe

Nov 5, 2013• 13

By Maneesh Juneja

In 2 weeks’ time, at Health 2.0 Europe, I am moderating a pre-conference workshop ‘Health 2.0 Tools for the Elderly’. Dr Leslie Kernisan wrote a blog post after attending the recent Health 2.0 Silicon Valley conference, observing that most Health 2.0 solutions are not designed with the elderly in mind.

That’s why I was very impressed when Health 2.0 invited me to curate and moderate the workshop on Nov 17th in London. We have 11 different technology solutions designed specifically for the elderly being demonstrated at the workshop. Having worked in the pharmaceutical industry, I acknowledge that technology is only one out of the array of solutions available to society.

Looking at the forecasts about the aging population, it’s way too easy to view the elderly as a burden, not a resource. Older people with their talents, wisdom and life experience have much to share with younger members of society. Could technology be used to connect those opposite ends of the age spectrum?
Continue reading…

The Latest Mystery: What Is Happening to All Those Paper Applications?

Nov 5, 2013• 11

By ROBERT LASZEWSKI

Enrollments continue to trickle in. Health plans, with the kind of market share that would have to sign-up 100,000 to 200,000 people for the administration to hit its goal of 7 million people, are generally reporting they have enrolled only about 100 – 200 people over the first 35 days via Healthcare.gov.

Does this mean no one wants to sign-up? No. People can argue about whether we will see the administration hit their goal of seven million or we will end up getting two or three million relatively sicker people for all of the problems Obamacare has faced. But, undoubtedly millions of people, including all of those people who just got cancellation notices, do want to see what they can get for what cost and make a decision about signing up. But they can’t because they aren’t able get through the entire Healthcare.gov website.

As I have said before, Healthcare.gov, because of its many problems, is in de facto shutdown because virtually no one is able to really use it.

Why doesn’t the administration just tell people the site is still too frustrating for people to waste their time on until it is fixed? Instead, the administration says it is getting better and people should keep trying to make it through the gauntlet. More, they are telling them to call the 800 number to fill out a paper application.

If it is better, it is still not better enough for more than a very small trickle to make it through each day.

Many states have literally dozens of complex health plan choices on the federal exchange––each insurance company on the various exchanges is likely offering the four different plans. I find it hard to understand how a consumer can get any real sense of the options over the phone much more be able to understand which plans cover which doctors and hospitals. People really need to see the options on their computer or on the computer of a navigator or an insurance agent to understand what is available and how it fits their needs.

And, as ABC and NBC reported yesterday evening, the paper applications ultimately have to go through the Healthcare.gov system anyway. One thing is crystal clear from the health plans meager enrollment to date; the insurance companies are not getting these “thousands” of paper applications. Where are they sitting?

November is the New October

Nov 4, 2013• 7

By Charles Ornstein

Many health care experts and journalists, including me, felt that the month of October would be the key barometer of the success of Healthcare.gov, the online health insurance marketplace that is a cornerstone of the Affordable Care Act.

But as days became weeks, and the problems plaguing the website stubbornly went unfixed, the question now is whether the administration can make the website work well by the end of this month and salvage the president’s signature achievement. If Healthcare.gov, which handles health insurance enrollment for 36 states, is working well at the end of this month, it will leave consumers just two weeks to choose plans if they want them to take effect on Jan. 1, 2014.

In other words, November is the new October.

The din of partisan accusations and counter-accusations is deafening and only getting louder. But in the interest of finding out what’s really happening on the ground, I consulted Kip Piper, who advises large health care organizations on Medicare, Medicaid, and health reform policy, finance and business strategy.

Piper has served as senior advisor to the administrator of the Centers for Medicare and Medicaid Services (CMS), Wisconsin state health administrator, director of the Wisconsin Medicaid program, a senior Medicare budget officer at the White House Office of Management and Budget, among other roles. He is articulate and clear-headed.

While Healthcare.gov Struggles, A Different Story Plays Out On The Private Exchanges

Nov 3, 2013• 29

By LISA SUENNEN

All eyes are on the hullaballoo created by the challenges at Healthcare.gov and several of the states’ public insurance exchanges. Yet all the while, like in a magic show, attention has been diverted from the real action going on elsewhere. Quietly and in a relatively drama-free way, the private health insurance exchanges are busily taking over the world of insurance and, in my opinion, portend a radical set of changes in how our health insurance system operates.

Several years back, a number of companies began building private health insurance exchanges to initially help companies offload the incredible burden of retiree benefits. Companies such as Extend Health (now owned by Towers Watson), Senior Educators (now owned by Aon), and several others provided a way for large employers to get themselves out of the business (and balance sheet liability) of providing group benefits for retirees, instead providing them with money to purchase their own individual health policies through then small, now large companies. The private exchanges went about the business of building websites that work, call centers that buzz and a wide array of insurance product offerings at various prices. Now, several years later, hundreds of thousands and possibly millions of individuals are out there shopping their little hearts out, choosing their own plans, and dealing with the consequences of high deductibles and the like.

These various private exchanges are now poised and ready to begin serving active employees in 2014 as guaranteed issue (the requirement that all can be insured and no one turned away) goes into effect as a result of the Affordable Care Act. And lest you think this is a small marketplace, you are wrong. In 2008 there were about 120 million total employed workers and just over half of these worked for companies of 500 employees and above (39 million worked for companies with 5000 employees or more). In other words, we are talking about nearly half of American adults and that doesn’t even include the dependents they bring along into their insurance plan.

Interestingly, such large US employers as Walgreens and Petco and DineEquity (parent company of Applebee’s Neighborhood Grill & Bar® and IHOP® restaurants) are all-in on the private exchange program, committing to transfer all of their employees from group plans to the exchange to purchase individual plans come January 2014. The exchanges of Towers, Aon, Mercer, Buck Consultants and a plethora of others are alive and well and open for business at exactly the time when employers are trying to figure out how fast they can reasonably get out of the middle of health insurance administration and run for the hills.

Making Hospital Prices Matter

Nov 3, 2013• 4

By PETER UBEL

I recently learned about a company called OpsCost, which has a very user-friendly website designed to help people figure out how much different hospitals charge for a wide range of treatments and procedures. The company makes use of the data that the Medicare program has recently made available to the general public, and then presents those data more elegantly than many other sites I have seen. You can go here to look at the company website, and you will quickly find yourself looking up prices for hospitals in your region. (Disclosure: I have not received any money from any price transparency companies, nor entered into any business relationships.)

For example, I told the website that I wanted to look at hospital prices near Durham, North Carolina, for “Hip & Femur Procedures Except Major Joint Without Complications And Comorbities/Major Complications And Comorbities,” and the program showed me a list of hospitals and prices, with a Google map on the right-hand side showing where each hospital was located. Pretty nifty.

But is it useful?