Health Information Technology

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

By M2|2018-06-15T19:32:48+00:00June 15th, 2018|Health Care Trends, Health Disparities, Health Information Technology, Health Reform, Innovation, Public Health, Social Determinants of Health, Uncategorized|

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

Here at M2, we spend a lot of time thinking about the social determinants of health (SDH), or the nonmedical factors that can affect a person’s overall health and health outcomes. We have blogged recently about this issue, and . The issue is gaining momentum and we are seeing more articles and studies addressing how to better incorporate SDH into programs and technologies; for example, former CMS administrator Andy Slavitt recently announced his new venture capital firm will focus on companies in this area. Another recent article highlights the opportunities for technology entrepreneurs as adoption rates for SDH technologies are projected to increase over the next ten years. Today we are taking a close look at a recent position paper from the American College of Physicians (ACP).

SDH are defined as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life”. In other words, “where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy,” the ACP notes in its recent paper.

SDH are “responsible for most health inequalities,” the ACP says; the paper examines the complex issues involved and provides recommendations on “better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.”

The paper was drafted by the ACP’s Health and Public Policy Committee, and the ACP notes that it is charged with addressing “issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties.”

“Understanding and addressing social factors that affect health outcomes is a pressing issue for physicians and medical professionals,” the ACP says. The group is issuing a set of recommendations “to empower stakeholders to advocate for policies aimed at eliminating disparities and establishing health equity among all persons.”

The paper features nine policy recommendations. Most notably, these include: integrating SDH into medical education at all levels; adequately funding federal, state, tribal, and local agencies in their efforts to address social determinants of health; developing best practices for utilizing electronic health record (EHR) systems as a tool to improve health without adding to the administrative burden on physicians; and adjusting quality payment models and performance measurement assessments to reflect the “increased risk associated with caring for disadvantaged patient populations.”

Expanding on one of the recommendations above – the importance of EHRs and collecting data – the paper notes that in 2014, a National Academies of Science committee identified 12 social determinants to be included in EHRs as part of meaningful use stage 3, and issued recommendations on standardizing collection of measures of these social determinants. Several behavioral and social domains are currently collected: tobacco use; alcohol use; race/ethnicity; and residential address, which is geocoded.

The report says that in terms of racism and health equity, the ACP’s policy on racial and ethnic health disparities “acknowledges that addressing social determinants of health is a key component to increasing health equity among racial and ethnic populations.”

Social determinants “can exacerbate health care disparities among racial or ethnic groups,” the paper says. “Socioeconomic status, race, and ethnicity are connected in a complex, multidimensional way and may affect a person’s health independently or in combination.” As an example, the ACP notes that Latina women experience a greater incidence of cervical cancer and higher mortality rates than non–Latina women. Access to care for Latina women is also affected, as they are more likely to lack health insurance than white non-Latina women.

SDH has been a bit of a buzzword for a while in public health circles, but it may finally be time for SDH to influence policy, as seen by ACP’s efforts. “Why now?” many are wondering. As proof points pile up, and more people gain an understanding of what SDH are, the concept is gaining momentum and being included in more discussions.

For example, it’s interesting that one of the largest physician groups has developed policy positions on SDH. This may be an indication that physicians in general are realizing the significant role that SDH play in individuals’ health. Incorporating an understanding of SDH into not only the practice of medicine, but also into the tools and incentives that drive patient care, would be welcome steps in helping to reduce the negative health outcomes related to SDH.

Interoperability – all that’s old is new again

By M2|2018-03-08T16:02:41+00:00March 7th, 2018|EHRs, Health Care Trends, Health Information Technology, Hospitals, Uncategorized, What do we pay for and why|

Interoperability – all that’s old is new again

For some of us in health care policy, 2018 so far is the year of testing just how good our filing systems are. All that is old is new again and ideas to “fix the U.S. health care system” from years ago are popping back up. This week “interoperability” is the hot topic, in part because Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), made a big announcement at the Healthcare Information and Management Systems Society (HIMSS) annual conference, saying interoperability would again be a focus of the federal government. She made three big announcements really, but today we are focused on Verma’s announcement that CMS will be overhauling the “Electronic Health Record (EHR) Incentive Programs to refocus the programs on interoperability and to reduce the time and cost required of providers to comply with the programs’ requirements.” Not surprisingly, when she mentioned the burdens on health providers of meeting meaningful use requirements and that CMS would be changing those requirements, the full ballroom broke into applause.

Patients Should Control Their Data. Yes, but…

The CMS administrator also announced a new initiative, “MyHealthEData – to empower patients by giving them control of their healthcare data, and allowing it to follow them through their healthcare journey.” It may seem obvious that patients should have electronic access to, and full control of, their health records, but the government does seem to need to intervene in order to get this information released from government agencies and payers, as well as from private health insurers and providers. Susan Morse (@SusanJMorse), who covered the HIMSS Conference for Healthcare IT News, explains that part of the issue is hospitals involved in data blocking. Verma told conference goers CMS would be strengthening requirements for providers to stop the practice: “It’s not acceptable to limit patient records or prevent them from seeing their complete history outside of (that) health system,” she said.

Data blocking may not be the primary barrier to patient control of their health care data, however. The March 2018 American Hospital Association Trendwatch: Sharing Health Information for Treatment shows hospitals and health systems have rapidly improved electronic sharing of clinical/summary care records over the past several years as the AHA Trendwatch chart below shows.

Can (Will?) Health Providers Use Patient Data?

Interoperability at its core means information can move back and forth between the various entities that have it. That could be from provider to provider, from plan to provider, provider to patient, etc. The fact sheet explaining the Trump Administration MyHealthEData Initiative Putting Patients at the Center of the U.S. Healthcare System mentions one of the goals of the effort is:

“Reducing Duplicative Testing – Provider systems typically do not share patients’ data, which can lead to duplicative tests when a patient goes to see a different provider. This increases costs and can lead to patient inconvenience or even harm. CMS is studying the extent and impact of duplicate testing, and will identify ways to reduce the incidence of unnecessary duplicate testing.”

In a study published in 2010, (all that’s old is new again…) in the Journal of the American Medical Informatics Association titled, “A Preliminary Look at Duplicate Testing Associated With Lack of Electronic Health Record Interoperability For Transferred Patients,” found approximately 20% of patients had non-clinically indicated duplicate testing resulting in added costs to the system. The study authors continued, “The most common setting for duplicate testing identified in the current study happened on admission from an outpatient clinic site. Patients from outpatient clinic transfer to hospital admission via several paths, including entrance via hospital admitting services or directly to the inpatient ward, either escorted or unescorted by hospital clinical staff.”

However, while hospitals and health systems have improved their sharing of clinical summaries with outside entities, the same AHA Trendwatch shows much slower progress in integrating information from outside sources. As the chart (from AHA Trendwatch) below shows, 65% of hospitals and health systems are either not able or not routinely able to integrate external information electronically.

Giving patients access to all of their health care data electronically is no doubt important. However, it is not sufficient to improve care or reduce costs, even for something as simple as avoiding non-clinically indicated duplicate testing. Achieving interoperability will also require payment incentives to change. As this blog has pointed out in other instances, money matters and you avoid what you have to pay for. Electronic health data vendors can still charge providers for building interfaces that help disparate systems “talk” and can charge providers to move data. Keith Aldinger, MD, an internist who practices in Houston, Texas wrote for Medical Economics in late 2017, physicians have “been assessed financial penalties for not attesting to meaningful use and yet the IT industry gets a pass.” His idea for improving interoperability is to put health IT vendors on the hook: “They should not be allowed to charge one cent for transferring information and any attempt to do so should elicit a financial penalty.”

All that’s old is new again. We still have to figure out how to get health care data moving in ways that improve health care for patients. Interoperability, you’re hot again. Let’s hope you do better this time around.

Is there anything about “SINGLE” we could like?

By M2|2017-10-08T11:15:04+00:00October 4th, 2017|Health care spending, Health Care Trends, Health Information Technology, Health Reform, Uncategorized|

Is there anything about “SINGLE” we could like?

As I write this, the latest version of Republican health reform has been halted. The Graham-Cassidy-Heller-Johnson bill (H.R.1628) was officially declared dead and next steps are all guesstimates.

It might be a coincidence that the bill was pulled and Senate Republican leadership decided not to bring the bill the floor for a vote just a day after CNN broadcast a debate between Sen. Bernie Sanders (D-VT), Sen. Amy Klobuchar (D-MN), Sen. Lindsay Graham (R-SC), and Sen. Bill Cassidy (R-LA) on “Obamacare”, CNN Debate Night: The Fight Over Obamacare; and a week after Sen. Sanders introduced the so-called “Medicare for All” bill on September 13.

More than once the CNN debate devolved into an argument over the Graham-Cassidy bill vs. “single payer” health care. But notably, two audience questions (one from a Republican and one from a Democrat) asked the Senate debaters to say what they would do immediately to lower the cost of premiums.

Usually the word “single” in health policy circles makes people think of “single payer.” In my opinion, there is not much possibility with the current Congress to pass a “single payer” bill that would create a nationalized health insurance and health provider system, but I do wonder if there is anything about the concept of “single” that could become policy. Here are two ideas: 1) A “single set of forms” and 2) A “single health IT system.”

“Single Set of Forms”

First, a single set of forms. Could Congress agree to pass a law that would require all insurers, payers, pharmacy benefit managers, etc. to use a standardized set of forms for everything from enrolling in a plan, to requesting a prior authorization for a prescription or medical procedure, to receiving a bill?

The concept isn’t new. Administrative simplification has been a buzzword off and on for more than a decade. Savings from reducing “billing and insurance-related” costs are substantial. A study in 2014 estimated, “A simplified financing system in the U.S. could result in cost savings exceeding $350 billion annually, nearly 15% of health care spending.”

Other studies have attempted to quantify exactly how health care providers waste administrative resources because of the multiple systems they must navigate in order to serve patients. For example, a typical physician might spend 3 to 4 hours per week interacting with health plans, other health care staff (e.g., RN/MA/LPN etc.) might spend 3 to 4 hours per physician per day, and clerical staff might spend 6 to 7 hours per physician per day interacting with health plans. Of the administrative activities involved, the majority of time spent is getting authorizations from health plans to perform services and navigating drug formularies.

A stark and oft-cited example is the Duke University hospital system that has three hospitals with 957 beds, but 1,600 billing clerks. Hard to think that a single set of forms – even if you have multiple payers – wouldn’t be a great way to save money in the U.S. health care system. Seems like “single” when it comes to “single set of forms” is an idea many people could support.

“Single” Health IT System

Second, a “single” health information technology (HIT) system might be a kind of “single” we could like in health care. Recently, the longtime CEO and president of the world-class health care delivery system Cleveland Clinic, Dr. Toby Cosgrove, appeared on Meet the Press Daily to discuss the Graham-Cassidy bill. Most of his comments were focused on ways to improve the current health care system, and one of his top ideas was to make health IT systems interoperable. He would certainly know.

A study from WestHealth Institute in 2013, The Value of Medical Device Interoperability, estimated more than $30 billion could be saved annually by making medical devices “talk to each other.” This seems obvious but the graphic below from WestHealth shows what is typical HIT in a hospital.

Sharing information from one device to another or between devices and the electronic health record (EHR) in a “consistent, predictable and reliable way” that allows clinicians to act upon the information would not only save money, it would also save lives and reduce negative outcomes. Lack of interoperability causes adverse events such as drug errors and diagnostics errors. Keep in mind that about 250,000 people die every year from medical errors. It also impedes clinicians’ abilities to prevent events such as pneumonia caused by ventilators put in at the hospital or postoperative shock.

Why does the word “single” in health care carry such negative connotations? Maybe because most parties—consumers, doctors, hospitals, and plans—don’t think a one-size-fits-all approach will work in this country to address such a wide set of needs when it comes to health care. But the downside to this stigmatization is that the word “single” has become so politically loaded that just uttering the phrase is often enough to stop a conversation that might otherwise turn into useful ideas for reforming our current health care system.

Maybe it’s time to focus on some good ideas for the word “single”—ideas that would truly benefit our large and diverse country. Administrative simplification and interoperability seem like a good place to start.

Spending More, but Getting Less: How Hospitals Can Work Together to Reap the Benefits of Increased Spending on New Technologies

By M2|2017-10-08T11:20:04+00:00September 25th, 2017|Health Information Technology, Uncategorized|

Spending More, but Getting Less: How Hospitals Can Work Together to Reap the Benefits of Increased Spending on New Technologies

Hospitals often buy new technologies without requiring that the technologies communicate with each other, even though this lack of interoperability results in lower physician productivity and an increased likelihood of medical errors occurring. Other hospitals, fearing exactly those inefficiencies, simply avoid buying innovative new technologies. Peter Pronovost and his colleagues at Johns Hopkins Medicine, give some advice on how to avoid these issues in “What Hospitals Can Learn from Airlines About Buying Equipment,” in the Harvard Business Review.

Hospitals’ spending on new technology “has ballooned,” the authors note. “For years, hospitals have invested in sophisticated devices and IT systems that, on their own, can be awe-inspiring,” the authors say. “Yet these technologies rarely share data, let alone leverage it to support better clinical care.”

“Part of the solution must involve hospitals,” the authors state. “If they truly want technologies that save lives and boost productivity, they will need to exert their considerable pressure as purchasers, requiring that manufacturers embrace openness and interoperability, and only purchasing devices that support this.”

“Too often, hospitals treat equipment and IT procurement in a siloed way, focusing on price without looking at how those devices will work as part of a larger system,” the authors say.

“For example, many new hospital beds come with a sophisticated array of sensors that can track such information as whether a patient is at risk of developing a bedsore, based on data about how often they move in bed. Such sensors may be 30% of a bed’s costs. Yet at one of our hospitals [within the Johns Hopkins system], that data is unusable — it’s in a format that our system cannot read.”

The situation is similar for “much of the data that is fed from wireless monitors of patients’ heart rate, blood oxygen levels, blood pressure, and breathing rate: This data doesn’t link to the medical record,” they note.

“The vision of an integrated hospital unit that is much safer and more productive will not be possible without widespread availability of products that share data openly and freely. Just as the U.S. Navy demands that its submarines and ships have interoperable technologies, this change can be driven by those who purchase these technologies,” they say. “Health care leaders that purchase technologies need to do the same.”

However, it is “unrealistic to think that each hospital should go it alone, exerting its purchasing power to move the marketplace,” the article states. “Hospitals could work together, writing specifications and functional requirements for the products that they will purchase and refusing to do business with manufacturers that don’t comply.” There may also be a role here for group purchasing organizations, they say.

As a further step, instead of assembling hospital rooms “one product at a time, hospitals should be able to purchase modules, sets of interoperable products that work together to support an aspect of care,” the authors continue. “This model makes sense, as few if any hospitals have the resources to design and manage all the connections between technologies, or to optimize how the data is used and displayed to support top-quality care. Ultimately, when a hospital is built or renovated, it would have the option to buy modular patient rooms, clinical units or floors — a ‘hospital in a box,’ built to its specifications.”

“We don’t expect airlines to build their own planes. They buy them from experienced system integrators such as Boeing or Airbus,” and hospitals should have a similar model, the authors note. “The question is whether health care leaders will have the resolve to require it.”

On the other hand, “even if digital devices communicate with one another, the lack of standards for health data puts full interoperability and data sharing out of reach,” according to an article in Healthcare Dive highlighting the opinion piece. “While we’ve made progress in the last three to four years and have the promise of FHIR (fast healthcare interoperability resources), the standards in health care from a data exchange standpoint are very weak,” explains Paul Shenenberger, CIO of Summit Health Management.

The lack of interoperability and data standards will be especially challenging as access to health care continues to change in the digital age, as a separate Healthcare Dive article points out. “From alternative care settings to telehealth companies, supply and demand for healthcare services is in flux.”

“Care is actually moving away from the hospitals,” the article quotes Dr. Rasu Shrestha, Chief Innovation Officer at UPMC, as saying during a panel at the National Health Policy Conference (NHPC) earlier this year. “’The brick and mortar hospitals that we know today will not be the focal point of healthcare delivery tomorrow.’ As care moves away from hospitals, whether at large or in part, it will be important to integrate health data from all over the care spectrum to get a full picture of a person’s well-being.”

This points to the persistent challenge related to use of new technologies in health care; in a siloed, non-standardized data world, how do we leverage the massive amounts of data generated in health care every day and facilitate data sharing in a way that actually makes health care more efficient and effective? The Hopkins op-ed authors take a step in the right direction – urging hospitals to leverage their significant purchasing power to demand interoperability. However, in order to do that, the data standards challenges will also need to be resolved. As Healthcare Dive summarizes, “though it may be a painful process, the need for standards and interoperability are desperately needed for innovative care to move forward.”

Health Care Innovation is Hurtling Forward, Despite Policy Uncertainty

By M2|2017-10-08T11:32:37+00:00July 21st, 2017|Health Care Trends, Health Information Technology, Health Reform, Uncategorized|

Health Care Innovation is Hurtling Forward, Despite Policy Uncertainty

Yes, Washington, D.C. has been tied in knots for months over the future of Obamacare. Or more specifically, how and whether the federal government should pay for health insurance for certain consumers. In the meantime, health care innovation is hurtling forward as evidenced by investments and operational commitments by health care companies.

Digital Health Investments

StartUp Health’s 2017 Global Digital Health Funding Mid-Year Report compiles seed, venture, corporate venture, and private equity funding for the period January 1 through June 30, 2017 and shows 2017 investing in digital health “has already surpassed previous years in overall funding.” The second quarter of 2017 was the biggest ever, and that single quarter accounted for more money invested than total annual funding for 2010 and 2011 combined. In the first half of 2017, more than 300 digital health deals were inked, worth more than $6 billion.

CHART: Digital Health Funding 2010-2017 (YTD) from StartUp Health

Many of the digital health funding supports innovative ways of delivering health care.

For example, CareDox is a company focused on helping public school health programs be more efficient. More than 50 million students are served by school health care clinics in the U.S., making it one of the largest medical networks in the country. Innovating this front line of health care for kids could improve both the health care children receive and the coordination of care between schools, medical professionals, and parents.

One of the largest investments has been for GRAIL, a big data/analytics company that has received nearly $1 billion since its inception. GRAIL was started by Jeff Huber, who may not be a household name to health policy wonks, but I can guarantee you use something he’s built. Jeff was a senior engineering leader at Google who spearheaded the harnessing of massive data sets to create Google Ads, Apps, and Maps. After those projects, but just before starting GRAIL, he was working on big data at Google Life Sciences as part of Google X (aka The Moonshot Factory). Jeff’s vision is to combine “science, technology, and clinical studies to reveal cancer at its beginnings. To detect cancer early, when it can be cured.”

Being a glass half-full type of person, I get very excited to read about all the new health care ideas out there being turned into businesses. I’m just covering a few in this blog, but if you want to see a more detailed list, mobihealthnews covered the 81 digital health funding deals for Q2 2017.

Health Insurer Innovation

Several health insurers also announced innovative approaches recently (which we will cover more in upcoming blogs) indicating to me, that while big health policy issues are still up in the air, businesses need to keep providing services and coming up with new products to maintain current customers and win over new ones.

An innovative example of a company combining digital health innovation with health insurance is Bright Health. A Minneapolis-based health insurance company launched in 2016 by former UnitedHealthcare CEO, Bob Sheehy and two partners, Bright Health will be selling plans in the individual market in 2018 in select geographies, including Colorado. The company just landed $160 million in venture capital based on this thinking from one of their investors:

“We’re thrilled to continue our partnership with Bright Health to disrupt a complicated industry where consumers are demanding change and leading health systems are hungry to deliver.”

The innovation Bright Health is offering is the selection of a sole health system as a deep partner in a state, and to use apps and other tech tools to attract consumers. In Colorado, Bright Health has chosen to partner with Centura Health to deliver care to its members. While health policy types might bemoan this type of “ultra-narrow” network, time will tell if consumers prefer to trade less choice for lower premiums.

Watching big picture policy debates, it’s easy to forget that investors and companies across the U.S. are coming up with all kinds of new ways to serve health care customers. The dust will eventually settle (I think!) on whether 2017 is the year to change Obamacare, but in the meantime innovation is hurtling forward which is much better way to see what the future of health care looks like in the U.S.

Health Information Technology: Visioning vs. Planning

By M2|2017-10-08T11:51:55+00:00May 30th, 2017|EHRs, Health Care Trends, Health Information Technology, Hospitals, Uncategorized|

Health Information Technology: Visioning vs. Planning

A recent study in Health Affairs confirmed what health providers and their patients already know: During a typical patient, the health care professional spends more than half of his or her time staring at the computer, not talking face-to-face to the patient. As of 2015, about 96% of health care organizations have a certified electronic health records (EHRs), and by the end of 2013, 66% of physicians were using electronic prescribing. Just ten years ago, those numbers were much lower, with only 9.4% of hospitals using a basic EHR and only 7% of physicians e-prescribing. Behind the push to get hospitals and physicians using health information technology was the promise of using big data.

While there have been volumes written about this has worked well in some ways, and not so well in others, what is undeniable is that health care organizations, and the patients they serve are now digitally intertwined. It is unlikely the system will be going back to paper-only records any time soon, so are there ways to make health information technology (HIT) work better?

One point of view was recently published by Family Medicine for America’s Health (FMAHealth) which focused on what primary care physicians want from HIT. They argue, “in addition to putting up barriers to achieving the Triple Aim, the poor usability and utility is resulting in health IT contributing to the growing problem of physician burnout.”

After a one day Visioning Summit, FMAHealth put forth a vision based on the following design principles: HIT should:

“(1) foster connections among health care professionals, including the individuals and communities they serve, and the environment in which people live;

(2) accumulate and analyze data that can support these connections and address the needs of population health; and

(3) promote appropriate payment for health care.”

The vision is set forth in 1, 3, 5 and 10 year increments. For example, in one year, the group would like to see “Data visualization technologies, which make it easy for the clinician to see patterns and make insight, will emerge to support health-related decisions and actions.” In three years, technology will “provide easy ways to natively support healthy behaviors, such as improved diet and exercise…”. In seven years, the group hopes “We will effectively use technology to deliver meaningful and relevant health-related information at the right time in a way that is “frictionless” and supports bringing the joy back to the practice of medicine.”

In my opinion, HIT is capable of all kinds of things, many of which I am sure we only starting to understand. Bringing joy back to the practice of medicine might be really difficult, but FMAHealth is putting forth a vision, not necessarily a plan.

Leave the plan to the Chief Information Officers (CIOs)!

Considering all of the money, time and human resources invested in HIT, some CIOs argue that hospitals, health systems or large provider groups are essentially health care shops AND software shops. David Chou, CIO at Children’s Mercy Hospital in Kansas City, MO [check it is MO] explained, “the day you made that investment you became a software vendor.”

What are some of the ways to make this technology work better, according to these experts?

· Think like a software vendor (hint: clinicians are your customers!)

· Have a strong focus on the end user

· Use an iterative model to develop, test and get feedback from users

· If you can’t buy it, build it (don’t hesitate create a capability that works for your organization)

No matter our daily work – as policy makers, business owners, health care professionals, or patient advocates, we should all be focused on the end user, and on iterating. As the health care system continues to change, looking to some of the lessons of the fast moving and customer-focused industry of software development could be a great playbook to follow to improve HIT.