Innovation Series

This past year I had the opportunity to share my thoughts and insights as to where we need to go in healthcare.  I still firmly believe we need to meet the patients where they want care while maintaining a complete and comprehensive accounting of their medical history and interactions with the health system as well as in their daily lives.  In this short interview I try to offer insights into interoperability, how technology impacts to our movement from volume to value, and efforts to developing a unified consortium of trust partners to safely and securely share medical information.

 

 

2015 Blog Re-launch

I want to welcome you to the relaunch of my blog ChasinChat.  I originally launched this blog in the summer of 2014 after requests from some employees and social network colleagues.  While I started out strong writing about weekly that quickly became much more work than I thought.  I honestly didn’t realize how difficult it was going to be to think up engaging content on a weekly basis but I still had this desire to write about my experiences and engaging content I could share that would spark interest and hopefully discussion.  So, as you can see I am back at it. My goal for this blog is multifactorial.  I want to provide an avenue for any SLHS employee to read, digest the content and engage in discussion with me or their colleagues.  I want to share the fantastic work SLHS IHT is embarking on. Additionally I would like to use this forum to discuss area that I feel are interesting.  As you know HIT is an evolving field and many health systems have become very dependent on our services.  This causes tension and unrealized expectations.  Through sharing my experiences I hope you will learn from my mistakes, learn what I am passionate about and hopefully some leadership lessons along the way.  For those of you that aren’t aware we have recently started our Flourishing Workforce Program (FWP) and my next couple of posts will be about employee and patient engagement and we will transition to some broader topics from there.  So I welcome you to exchange some ideas and contribute to the ongoing dialogue and content.

The Intangibles of Clinical Integration

I had the honor and opportunity to contribute to the NextWaveConnect.com community on the Intangibles of Clinical Integration.  While I don’t portray myself as an expert the fact of the matter is that in order to achieve true integration Information technology needs to be intimately involved from the start.  Here is an excerpt:

 

I often wonder why I decided to go into medicine. I recall countless evenings around a book with my fellow classmates discussing our aspirations of treating the sick and changing the world. Unfortunately that is just a distant memory.

What was once driven by the highest of altruistic endeavour quickly became about volume, E&M codes and dealing with insurance companies with declining reimbursement and dictation of care. At first glance it appeared that I was sold a bit of false advertising. I went through the paces that every young physician endures, building a successful practice, lobbying for my patients best interest and ultimately building a successful relationship with my patients. But there had to be more…….. Please click the link to read the entire article.

The Impact of the FLEX-IT Act

This past week we saw some significant controversy regarding the Meaningful Use Stage 2 Final Rule which was published late August of 2014.  The controversy lies within the reporting period. The final rule requires a full 365 days of reporting.  Many professional organizations feel that this is to arduous.  Earlier this week Congeresswoman Renee Ellmers (R-NC) introduced The Flexibility in Health IT Reporting  (Flex-IT) Act of 2014.  She states:

 

“Health Care providers have faced enormous obstacles while working to meet numerous federal requirements over the past decade. Obamacare has caused many serious problems throughout this industry, yet there are other requirements hampering the industry’s ability to function while threatening their ability to provide excellent, focused care.”

“The Meaningful Use Program has many important provisions that seek to usher our health care providers into the digital age. But instead of working with doctors and hospitals, HHS is imposing rigid mandates that will cause unbearable financial burdens on the men and women who provide care to millions of Americans. Dealing with these inflexible mandates is causing doctors, nurses, and their staff to focus more on avoiding financial penalties and less on their patients.”

“The Flex-IT Act will provide the flexibility providers need while ensuring that the goal of upgrading their technologies is still being managed. I’m excited to introduce this important bill and look forward to it quickly moving on to a vote.”

 

While I applaud Congresswoman Ellmers I personally don’t feel this is the time to ease the pressure of the transformation of healthcare.  As she states only 9 percent of our nation’s hospitals and 1 percent eligible healthcare professionals have demonstrated the ability to meet Meaningful Use Stage 2 requirements.  While I certainly don’t argue the statistics around this issue and agree that the Meaningful Use Stage 2 measures are much more difficult to tackle but most facilities both EP & EH wait until the latter part of the reporting period to attest so I can assume that the 9% number is on the low end.   The fact of the matter is that we should be properly documenting all these pieces of information regardless of an electronic record, it is just good patient care.  By easing up the restrictions on meaningful use sends the message that this pivotal moment on our journey to digitize health and further transform our collective system is not as urgent as it should be.  I just don’t think it is in the best interest of our patients.  By limiting the reporting period to 90 days as opposed to 365 is analogous to only treating the Chest Pain patients you see over a 90 day period correctly while extrapolating that the other patients treated over the next 275 days are treated just as well.  I realize that this may be an overly excessive example but I truly feel that we need to maintain the collective pressure to transform the patient care experience and focus on proper data input so patients can feel we as clinicains and the healthcare system as a whole are able to diagnose our collective patients as accurately and efficiently as possible.

Interoperability- The sub-theme of this years UGM

I had the opportunity this week to attend the Epic user group meeting.  I must tell you that the feel of collaboration around the patient care experience is nothing else I have experienced. One thing many of  the attendees may not have been aware of is the increased focused on interoperability in the next couple of years.  I have  the unique opportunity to serve as chair of the CareEverywhere Council, a group of individuals passionate about the seamless transmission of information.  Additionally I was most recently appointed to chair the CareQuality Trust Framework subgroup.  It is within these two groups I will try to drive toward the three factors that will ultimately facilitate this information transfer so patients can feel just as safe in the healthcare system as they do in their own homes. I have included the The Interoperability Report 2014 Care Everywhere Network here.  In short we must commit to:

  1. The use of industry standards
  2. A nationwide directory of exchange-ready providers
  3. Simple Rules of the Road

These rules establish a universal trust framework that outline the rights and obligations of network participants.  They would give each organization confidence that it can participate in exchange activities while upholding its legal and ethical obligations to maintain the security and privacy of patient records.

Unfortunately that single set of Rules of the Road does not exist across industry, so trust must be established individually.  In order to move beyond the one-to-one connections a framework of mutual trust agreements and standards needs to be in place.

With this in mind I have recently been appointed to chair the CareQuality Trust Framework WorkGroup.  It is here that I will continue to work with all vendors to create a framework that expedites point-to-point patient record exchange basedon mutual trust agreements and national standards

Over the past 2+ years we haven’t done everything right.  In the attached report we detail some of the touching stories of successful information transfer but also some of the issues we have uncovered.  As of August Epic has exchanged over 550,000 patient records with other non-epic vendors per month!!  That is a staggering number and one that is not accounted for in the many news stories on the perceived lack of interoperability.

Presently the CareEverywhere Network includes over 950 hospitals and over 21,000 clinics representing community hospitals. academic medical centers, children’s organizations, FQHC’s, safety net providers and multi-hospital systems all sharing critical patient information with individuals both on Epic and not.

 

Some of our lessons learned

  1. Patients overwhelmingly want to share their data in a secure way
  2. Strict adherence to fewer standards + succinct Rules of the Road + simple patient consent model = SUCCESS
  3. Providers attribute exchange success to integration with clinical workflows
  4. Nationwide exchange is practical even without a national patient identifier, and can be further improved
  5. Successful exchange does not have to be expensive and results in lower cost of care

Recommendations

  1. Simplify consent because the majority of patients want to securely share their data
  2. Simplify exchange: one standard per purpose with a single national phone book of exchange ready organizations and providers
  3. Continue to formally adopt nationally-defined reference terminologies to enhance utility of data incorporated into the local chart.
  4. Standardize how identifying information is captured to further improve patient matching between providers.
  5. Require public health and immunization registries to exchange directly with providers free of charge when using a single, national standard.

 

I look forward to my continued participation on both the CareEverywhere Governing Council as well as the new CareQuality Trust Framework Work Group.

 

Tele-Health Consultation

Beginning this past January there were 4 new CPT codes introduced for the billing of telephone/internet consultations.

  • If the consultation lasts longer than five minutes, and if the primary purpose of the consultation is more than simply arranging a transfer, one of these 4 codes can now be used for billing.

If prior history is any indication, just because a CPT code now exists, this doesn’t necessarily mean that payors will actually pay for the service.

The question I pose is.

  • As we move toward our new world of value and reducing the per member per month (PMPM) cost of care just because you can bill, should you bill?  Will the cost/hassle of collecting demographic and insurance information outweigh the financial benefit?
  • If you don’t bill in this situation, does it constitute some form of kickback?
  • If you do happen to drop a bill, are you disadvantaging your outreach relationship?  This would certainly be the case if the industry norm is “not to bill” and if your system we the only one billing for tele-consults.
  • I wonder if there is any formal legal interpretations on the above that has or will necessarily impact how systems in the United States conduct and bill for telephone and internet consults?

A Trip to Camp

I recently had the opportunity to drive my three girls to sleep-away camp. There had definitely been apprehension mounting in the preceding weeks, and procrastination from me, as this was a new adventure for all of us.

We set out on our 10.5-hour car ride to Arlington, Wash. I kept reinforcing how much fun this was going to be. I even suggested that I could stay at camp while they returned home. I wondered if I was looking forward to it more than they were.

We had to be at camp between 9 and 11 a.m. We chose to be there around 9:30 a.m., so they could feel comfortable that there were other children there and that they weren’t the only ones.

As we pulled into camp, we were greeted by two young women. We rolled down the window and they greeted us, saying, “You three must be Sarah, Rachel, and Leah.” We were impressed that out of 100 children expected, they were able to identify my three kids.

As we parked, we were approached by other counselors and support staff. They introduced themselves and said, “You must be Sarah, Rachel, and Leah. We have been expecting you.” As they loaded the girls’ gear to transport, they started speaking to my oldest, saying, “There are so many unique song birds here” and, “There is a volleyball game later in the afternoon.” As we walked to various registration stations, we were warmly greeted, and each staff person knew a bit more about my kids.

My 8-year-old had been the most skeptical. As we approached her bunk, she was amazed to find that she would be right across from her older sister. By this time, my kids had all but forgotten about leaving home and being at camp for the next two weeks. And I was so pleased with how comfortable they had made my kids feel that it got me to thinking how the camp experience parallels what we are faced with in health care every day.

We treat thousands of people every year, each an individual with a story to tell, a very important story, some fascinating, some heart-wrenching.

This is what makes the relationship between a patient and a physician so valuable. What if we could enhance this experience in a way analogous to the experience my kids had at camp? How can we make the overall experience a comforting one?

I feel that it all starts with a relationship. Understanding who our patients are, their values, and their story all create a “sticky” ecosystem.

Approaching and navigating a healthcare system is daunting, and can be intimidating at times. I have had personal experience of trying to navigate the system. I would say that I am rather well-versed in how the system works, but all that knowledge goes out the window when you or your loved one is ill.

This is where I feel we need to transform. We know our own community, we live in our community, and we treat our teachers and our neighbors. We pride ourselves in being an integral part of the communities we serve.

You may now be wondering why I’m talking about relationships. As a physician and Chief Information Officer, I can appreciate the way technology can improve the way we engage with our community.

As a country we have come a long way.  We have moved past the trough of disillusionment and are on our way toward digitizing our industry.  While we have installed advanced clinical technology we are just starting to see the way we need to integrate and facilitate the movement of data to improve the patient care experience.

The word integrated is very important. In order to build and maintain a fruitful relationship, we need to earn the trust in the care the community entrusts with us. Part of that trust is that we provide clinicians with the most timely information at the most appropriate time.

This integration is a key component to high-quality, efficient health care. This essentially completes the circle (the continuum) of care.  While we have a long way to go we have a path and a plan and I truly believe our patients will benefit from this heavy lifting.  We are in fact transforming a culture.

If you live in East Lansing, Michigan and happen to be visiting family in Savannah, Georgia and you get sick, the physician you see will have complete access to your entire medical record, not a faxed copy.  This is the direction we need to go.  Our mutual patients need to feel just safe anywhere they seek care.

Our patients are slowly demanding this. Medicine and the delivery of care is becoming consumerized.  Some my look at this as the end of the physician patient relationship while I look at it as the best opportunity to truly engage patients in their care.  No other time in the history of modernized medicine has the patient takes such an interest in their own care.  As an industry we would be foolish not to take advantage of this opportunity.

Two weeks later, when I returned to pick up the girls, I sought out the camp director to better understand his system. As it turns out, he asks multiple short questions throughout the year, slowly building out his information on each child (favorite colors, interests, struggles, etc.) for a shared application that the staff reviews prior to camp. Each staff member has a familiarity with each child and can call upon the data to help make the transition as safe and comfortable as possible.

I feel we owe it to our patients and the country provide as comprehensive a care document as possible so we can achieve the triple aim of better health, better care at a lower cost.

 

A MegaTrend in HealthIT

I was reading this fascinating article written by Robert Pearl, MD the CEO of The Permanente Medical Group on the 5 Megatrends that could Transform U.S Health Care. I completely agree with the major trends Cisco chairman and CEO John Chamber sees:

  1. The Formation of Accountable Care Organizations (ACO)
  2. Moving away from Fee-For-Service Payment Models
  3. Rewarding Better Health Outcomes and Quality
  4. Health Information technology (HealthIT) Incentives
  5. A New Generation Of Physicians

I agree that we are at the cusp of a tipping point.  I was rather intrigued regarding the fourth megatrend, Health Information Technology Incentives.  While I agree with the premise there is some inconsistencies within the details.  It is truly unfortunate that healthcare is behind the technology wave that other sectors have adopted decades ago.  I feel that there is good reason for that which goes back to the reason physicians choose to dedicate their lives to treating people.  While that is easily another blog topic the fact is that we need to change and start to change quickly.  Not because of the meaningful use incentives but because it is the right thing to do for our patients.  Our patients are more mobile than before and want to access the healthcare system on their own time.  We are living is a physician centric system evolving to a patient centered system.  That change is going to take a lot of time when the current system has been in existence for almost 50 years. As  Mr. Chambers articulates lack of connectivity is the issue.  This is where the topic goes awry.  There is assumption that every hospital and physician office is on the same system.  That is far from the case. Even if they happen to be on the same system that still doesn’t mean that the two systems will connect.  They could be on 2 different versions of the same system.  Perhaps these two organizations don’t equally value the exchange of clinical information, or are fierce competitors.  Please don’t assume I am a proponent of this as an excuse but just current reality.  And those scenarios are for organizations that have the same system.  The issue compounds when the systems are from  different vendors and you may need a HISP for connectivity not to mention developing Query and Trust Frameworks.  As you can quickly see that the technology is the minor component and the People and Process areas are what make this successful.  While I agree that Meaningful Use Stage 2 will provide the incentives for interoperability I feel that this is just the beginning.  I honestly don’t think that the federal incentives will even cover a fraction of the cost required to connect these systems as we need to develop the appropriate trust framework necessary for complete interoperability.  What I truly feel is that it is in the best interest of the patient and the communities we serve.  A patient should feel safe and well taken care of within the healthcare system whether seeking care in California or New York.  As stated before, this is going to transform the health system and we need to understand that meaningful change takes time.

Seamless Transfer of Information

As I stated in my last post I have been deeply involved with establishing a “Rules of the Road” for the interoperability of patients health information.  I truly believe that in order to aspire toward the triple aim of better health, better care at a lower cost we must provide the most accurate, most timely information for the clinician to make a well informed decision. Only then will be truly understand the cost of care and drive to prevent redundant testing and render care in the most appropriate venue. With that in mind I had the pleasure of sitting down for an interview with Roya Camp of St. Luke’s Health System to discuss my involvement in this national initiative of improving the access of timely health information- interoperability.

Interoperability

Early in my medical career I was already thinking about interoperability and I have devoted much of my career to the seamless transmission of patient data to where it is needed most.  Fortunately there is a national effort to achieving this.  However, the current state of interoperability has been under some scrutiny as of late.  Over the past 2 years I have had the pleasure of serving as the Chair of the CareEverywhere council as well as a board member of the Idaho Health Data Exchange (IHDE).  It is here that I have truly seen the potential for true interoperability as well as where we need to go to make it a reality. Let me rewind the clock for you about 20 years.  I had just been getting ready for college and my parents took me to open a joint bank account.  I was excited as I just received my first ATM card.  The caveat here was that it only ran on the PLUS network of bank machines not the ones with the Cirrus icon on them.  There was no interoperability between networks.  Now 20+ years later both networks are still present but they decided that the convenience of the customer benefitted the industry as a whole so they were able to integrate their directories.  Now we can have the convenience of using any ATM machine we please.  Now, this transformation took more than 20 years.  I wonder why this same type of transformation is it expected for healthcare  in less than 4 years when it took 20 years for the banking industry to reach this type of integration.  Healthcare is very complex.  While we have made significant strides there is still a long road to travel and I know my colleagues and I work on this daily.  I came across an interesting article really criticizing  the current state of healthcare interoperability.

For those of you that work with me know I think of issues in the framework of people, process, and technology.  From my perspective this issue is mostly a people and process issue.  While I agree that there are some technological limitation the crux of this matter revolves around our ability to adopt a standard that will facilitate the transfer of information to any EHR.  Many HIT shops are very complex and have multiple initiative they focus on throughout the year all with the ultimate goal of improving patient care.  So from my perspective there are more issues at play than the blanket statement  “we can’t talk to one another”.

  1. Different versions of the same EHR
  2. Lack of Trust Agreements (Rules of the Road)
  3. Multiple different standards– which means there is essentially no standard
  4. competition between health systems in the same geographic location
  5. competition between vendors
  6. Different strategic focus of the organization (some organizations don’t feel that exchange is high on their list therefore they don’t build out the functionality- this will prohibit the ability to exchange information)
  7. HIE functionality (does the HIE view themselves as a repository or a broker of information exchange)
  8. I know there are others

I guess I feel I have a more positive outlook on the industry.  However, I will make one call to the industry– Please define a single standard that will allow all EHR’s to have the ability to communicate with one another.  I am happy to participate in anyway I can.  I feel that we have made enormous strides this space.  While there is a lot of work to do there are very smart people at the table and I am confident that we will see true interoperability in the near future where patients can feel just as safe in the hospital or doctors office as they do at home.