Article about Emergency Room Experiences

All of us have been to the ER for either our own ailments or those of our families. I read an article here that details some of the unfortunate experiences of some people who seemed to have received the raw end of the stick. This is the article posted today, May 1st, 2018. It’s worth the read. Think about your own Emergency Room experiences. How do we get better over time? How frequent is this experience?

 

Holy MACRA! Patient Engagement rides again!

Regulatory-signage“What was that masked legislation? Why that, my boy was CMS! The greatest regulator in the west!” (Cue The March of the Swiss Soldiers in the William Tell Overture aka, theme song for one of my childhood heroes, The Lone Ranger).

What is MACRA?

MACRA is the abbreviated version of the “Medicare Access and CHIP Reauthorization Act of 2015” which was signed by President Obama on April 16th of this year. (Healthcare and CMS sometimes really can’t help it’s communication to the public when they make these abbreviations something that only so called “healthcare insiders” will understand).

The new law repeals Medicare’s sustainable growth rate (SGR) formula and creates a way to increased Medicare payments. At HIMSS16 this year, there was a focus was on “MIPS” or Merit Based Incentive Payment System which is the program that the SGR will be replaced with.

Physician rates are understood to be increased by 0.5% starting in July and each January through 2019 and then, bonuses could reach 12% and then 27% by 2022 (physicians could also face penalties for not meeting quality targets down the road).

On the CMS site, it asks the question, “How does the Medicare Access & CHIP Reauthorization Act of 22015 (MACRA) reform Medicare payment?”

Apparently, in a couple of ways:

It makes 3 changes to how Medicare pays those who give care to Medicare beneficiaries. The changes create a Quality Payment Program (Abbreviated to ‘QPP’).

  1. Ending the SGR formula for determining Medicare payments for health care providers services.
  2. Making a new framework for rewarding heal care providers for giving better care not just more care.
  3. Combining CMS’ existing quality reporting programs into one system.

The changes have been named QPP and replace other Medicare reporting programs with a flexible system that allows providers to choose from 2 paths that link quality to payments either MIPS or something called Alternative Payment Models (APMs)

MIPS – This combines parts of the PQRS (Physician Quality Reporting System), the Value Modifier (VM or Value Based Payment Modifier) and the Medicare Electronic Health Record (EHR) incentive program in which EPs (Eligible Professionals) will be measured on:

  1. Quality
  2. Resource Use
  3. Clinical Practice Improvement
  4. Meaningful Use of Certified EHR technology.

APMs – Alternative Payment Models give new methods to pay healthcare providers for the care they give to Medicare recipients as from the year 2019 to 2024, CMS will pay some participating healthcare providers an incentive lump sum; increase transparency of physician focused payment models and starting in 2026, offer some participating healthcare providers higher annual payments.

 

 

 

 

 

Interoperability gets a boost! Healthcare 3.0 and Meaningful Use Stage 3

I’ve often talked about Healthcare going through a paradigm shift these past few years. In summarizing the discussion that I had the opportunity to have with students at Miami University last week, when we discussed the what we called Healthcare 3.0. We will review more about MU Stage 3 in the weeks to come in this blog and I’ll also get some feedback in the future from guest bloggers as well. I thought about this as I reviewed the recently released final rules for Meaningful Use Stage 3 by CMS as they said would simplify the requirements and add some flexibilities for providers in order to make, electronic health information available, from what they have mentioned, “when and where it matters most”. The phrase that CMS used which said  that they wanted to shift the paradigm so health IT becomes a tool for care improvement, not an end in itself” really resonated with me and give some impetus to the focus moving forward which would be for healthcare providers and patients to be able to readily, safely, and securely exchange health information.

What CMS said was that they had received feedback from “physicians and other providers” about the challenges they faced in making these technologies work well for their practices and for their patient population so in being able to recognize these concerns, the regulations that they have come up with, apparently make drastic changes to the current requirements by making reporting less of a burden for providers and being able to support interoperability as well as improving patient outcomes. 

CMS has also mentioned that they are “encouraging providers’ to let them know if they are having difficulties with or switching their EHR vendor by applying for exemptions or experienced challenges due to the timing of the rules and EHR implementation. In addition, the new rules will apparently help in the development of new, “user-friendly” technologies, allowing individuals easier access to their healthcare information so they can be better engaged and empowered in their healthcare as we move forward towards, what Victor Simha and I presented last week at Miami University, Healthcare 3.0.

Happy Earth Day – Healthcare’s Green Initiatives

Earth DayCaring for our environment should be everyone’s responsibility. My Grandfather was what he called a ‘Forestry Consultant” and focused on reforestation in the 1970s and the 1980s. He founded a
National Park in the southern Indian city of Bangalore my family’s home town where he was very interested in the cultivation and use of bamboo for use in everyday life. The ability for us to think of ways use less plastic and have more biodegradable products will give future generations an opportunity to live a better life.

When I first heard about Earth Day (and bought a T-Shirt with that on it back in the 90s), it didn’t have as much meaning to me as it does now. As the world’s population grows and we need to think about how we can better utilize our limited resources to nourish and clothe the people of the world, we need to think about better conservation methods. Healthcare is also not immune to this, though going green in Healthcare IT is not a straight forward process. One way that healthcare has been better at conservation is the implementation and use of electronic health records, the biggest Go Green initiative ever by healthcare provider organizations. Tele-Health initiatives means that now, people in rural populations or anywhere for that matter, do not have to drive to a specific location for things such as specialist referrals and can cut gas emissions and improve population health. Data centers have leveraged the concept of server virtualization and reducing the carbon footprint of those data centers and also reducing hardware costs and power consumption. (Don’t forget to join us at our CSO HIMSS Spring Conference focused on mHealth and Tele-Health. Click here to see the agenda and register for the event – Not to be missed)

I’ll take this opportunity again to wish everyone a very Happy Earth Day!

Daylight Savings Time Ended – Did the hospital charge you less?

In the spring of 2014, I wrote a post about possibly getting over-charged for a hospital stay due to synchronizing EMR systems to the correct time. Similarly, this past weekend, when Daylight Savings Time ended, some patients may not have a second bed charge added for the hour that is repeated due to an occurrence in the system.

Many organizations may have the ability to manually update their charges in what is called the hospital billing account after a patient is discharged. This though is a step more than many organizations have the bandwidth to work on these days with all of the regulatory mandates that they are working on.

With Healthcare Payer organizations rejecting claims for even minor defects, this could be a major revenue loss for any provider and would need to have a consistent remediation for Patient Financial Services to be on track with their forecasts. It would be more than likely that they will not unless a patient reviews their charges more carefully. Data for the hour of the double 2am time on Sunday needs to be well documented and validated. Most responsible provider IT Revenue Cycle Management organizations have plans for the time change that have been scheduled far in advance and would be reviewed as I document this post. Is this another reason why we may not need to keep changing back and forth from Daylight Savings Time. Is this one of the reasons why the concept may be moot going into the 21st century? Time will tell.

We don’t “Lobby” in Healthcare IT, we “Advocate”

As someone who grew up in other countries before becoming a naturalized American, there’s always been some kind of fascination when it comes to what is called “lobbying” in the United States. I’ve never been able to understand it as it always seems that it goes against the grain of what I’ve always thought of the United States through history books and the Founding Fathers, whom I so admire for their simple vision that has overcome the tests of time. Yet, hiring professional lobbyists in the United States is perfectly legal and healthcare has been leveraging this legal loophole for sometime now. Just this year as an example, lobbying has come into the news through the change in the regulatory date for ICD-10 from October 1st, 2014 to October 1st, 2015. Most believe that this was the result of pressure from care delivery professionals that wanted more time to get their act together (I for one was against this).

Recently, it was reported in “Modern Healthcare” (September 10th, 2014) that Epic retained a lobbyist and as it was reported the filing said that it was “to educate members of Congress on the interoperability of Epic’s healthcare information technology.”

Last week, HIMSS delegates from across the country had their yearly visit to Washington D.C. for their HIMSS Policy Summit, held during National Health IT week where (as reported by Healthcare IT News) HIMSS had certain asks of the nation’s representatives, which were:

  • Minimize disruption in our nation’s health delivery system emanating from federally mandated health IT program changes.
  • Fund the National Coordinator for Health IT to achieve interoperability, improve clinical quality and ensure patient privacy and safety.
  • Expand telehealth services to improve patient access and outcomes and decrease healthcare costs.

The role of politics and healthcare will remain inextricably tied to one another. As we continue to move through this paradigm shift, these areas will ultimately focus on the future of our country’s care delivery and outcomes and the way that we, the patient, will receive our care.

Advancing Clinical Processes with Meaningful Use Stage 2

As provider organizations work on the completion of stage 1 and think about implementation of stage 2, they will have their hands full with how to implement these initiatives with the constraints on their resources and bandwidth. The CMS site states that:

“Stage 2 uses a core and menu structure for objectives that providers must achieve in order to demonstrate meaningful use.

Core objectives are objectives that all providers must meet. There are also a predetermined number of menu objectives that providers must select from a list and meet in order to demonstrate meaningful use.

To demonstrate meaningful use under Stage 2 criteria—

  • Eligible professionals must meet:
    • 17 core objectives
    • 3 menu objectives that they select from a total list of 6
    • Total of 20 objectives
  • Eligible hospitals and CAHs must meet:
    • 16 core objectives
    • 3 menu objectives that they select from a total list of 6
    • Total of 19 objectives

In a recent article in Healthcare IT News (dated 8/4/14), it stated that only 3% of eligible hospitals and 1% of eligible providers attested to stage 2, which is anything but great as we are in the middle of 2014, when all of the provider organizations were expected to be greatly involved in completing their attestations. Have we reached “MU Fatigue”? I can imagine. I met a nurse earlier today who has now been in IT for sometime and she said that she did not believe CMS anymore after the ICD-10 delay occurred. I think that set off a wave of disinterest in the ecosystem that is still feeling the repercussions of a twice delayed regulatory mandate. “It doesn’t pay to be first!” said one CIO to me a few months ago. Going by the frequent delays in the provider world, one can empathize with that sentiment.

Will CMS give out “Red Cards” to Eligible Hospitals and Providers and penalize them or will there be some relief for the regulatory weary? In the same article, it mentioned that “71% of hospitals plan to attest by the end of 2014 and 22% in 2015”.

What of the HIEs and their ability to give the prospect of intereoperability it’s day?If we are truly to believe the data from the news article, the next 13-14 months will be a busy period for many as ICD-10 comes back around; payer testing, dual coding, physician training and organizational communications will be again an extremely busy period for many provider organizations.

 

Physicians are people too…right?

When it comes to working with physicians,  we’ve seen their involvement in this healthcare technology world at opposite ends of the spectrum.

The younger,  more technologically savvier physicians who have been used to technology from the early 80s to now, seem to somewhat adapt to using EMRs. They are characterized by their comfort with all things digital and their disdain for a paper process and being eco-friendly. While this isn’t always the case, this is mostly attributed to younger, 45/50 and under physicians.

The older,  more experienced physicians who have been around practicing for 3 decades or more have generally been extremely resistant to the current change and have at times,  even retired rather than continue to use EMRs on the grounds that it takes away from their focus on the patient, which can make for an good debate. I’ve also heard that some of the older physicians don’t feel like they need to be “engaged with their patients” as “the way they have been practicing medicine all these years is fine”. Millennial physicians,  early to mid 30s take to technology as if they were born with it. As digital natives,  they have the ability to be the most productive and efficient when it comes to EMR usage.

Also, their has been a divide when it comes to adoption by small and large practices. Smaller practices have had to think about how they can deal with the process of purchasing EMR capabilities and this has not always been easy. During a project in California, we studied how we can get pediatricians to refer patients to the hospital I was working at and how to make sure the referral process was smooth for them; whether it was directly from their PC and their own EMR system or if they needed to login to a portal with their credentials and how it would then go to the correct clinic at the specialty pediatric facility I was working at the time.

For anyone in the care delivery IT arena, this is old news, but really needed to be said. The question is whether if the digital divide has an impact on the quality of your care and if this trend continues, will we lose our senior, experienced physicians to Meaningful Use?

According to an article out by USA Today (dated 6/30/2014), the United States is expected to need 52,000 more primary care physicians by the year 2025 based on research by the Robert Graham Center and funding for teaching hospitals expires in the latter part of 2015. Due to the Affordable Care Act, the need for family physicians to 8000. As a nation, we cannot afford to lose these experienced physicians at a juncture when more physicians are required than ever before.

Interoperability Odyssey: 2024

The final frontier….the search for healthcare utopia where your records follow you seamlessly across the continuum of care without incident. It seems to be fantasy, but that might be what the office of the Office of the National Coordinator for Health Information Technology came out with a paper and a call for collaboration among stakeholders to share with them ideas and suggestions that would help in the achievement of this goal of interoperability over the next decade and the road beyond.

In their vision of the future, they want individuals, healthcare providers, communities, and healthcare researchers to be able to have many healthcare IT products and services that are interoperable and allow the healthcare system to learn on a continuous basis and be able to move the goal of “improved health care.” Patient engagement between care provider and patient would be constant and patients would be well informed as to their care roadmap and be able to be partners in their wellness.

I was excited on the encouraging news in that all 50 US states have a sort of health information exchange and that 50% of hospitals can electronically search for patient information from sources beyond their own organization and over 50% of office-based professionals and more than 80% of hospitals “are meaningfully using electronic health records which will require them to electronically exchange standardized patient information to support safe care transitions.”

In how they envision the nation getting there, they mentioned their focus on certain “Guiding Principles” for the future of the “health ecosystem, namely:

  1. Build upon the existing health IT infrastructure.
  2. One size does not fit all.
  3. Empower individuals.
  4. Leverage the market.
  5. Simplify.
  6. Maintain modularity.
  7. Consider the current environment and support multiple levels of advancement.
  8. Focus on value.
  9. Protect privacy and security in all aspects of interoperability.

The document followed up with a focus on a 3 year agenda with the paragraph titled “Send, Receive, Find, and Use Health Information to Improve Health Care Quality” that discussed  the development of an “interoperability roadmap as articulated in HHS Principles and Strategy for Accelerating Health Information Exchange.” The focus was on ensuring that the population as well as healthcare providers leveraged the basic set of health information across the continuum of care so that care coordination is enhanced and give us the ability to improve the quality of care.

It continued with a 6 year agenda that covered, aside from what was in the 3 year agenda, such things as a “multi-payer claims databases, clinical data registries, and other data aggregators will incrementally become more integrated as part of an interoperable technology ecosystem“.

Finally, in the 10 year agenda to take us to 2024, 4 building blocks are envisioned on how we achieve a state of initial interoperability:

  1. Core Technical Standards and Functions
  2. Certification to support adoption and optimization of Health IT products and services
  3. Privacy and security protections for health information
  4. Supportive business, clinical, cultural, and regulatory environment

In addition, it mentions a focus on data quality and reliability as part of the foundations for interoperability. The ability to engage with stakeholders and focus on operationalizing a common framework in order to grow trust by addressing issues such as privacy, security, business policy and practice challenges to move forward the ability to have secure and authenticated health information exchange through the care continuum.

The plan envisages working with all stakeholders and hone the use of healthcare IT infrastructure that was enabled through the HITECH Act in order to support the paradigm shift in healthcare towards a more patient centric, “less wasteful and higher quality system”.

In closing, they realize that it will take some time to be able to build an interoperable system that will improve the quality of care across the continuum, but say that HHS is committed to the cause of interoperability across all care settings through a roadmap that makes incremental changes that calls upon a collaborative focus to achieve the opportunities presented to all of us to improve the health and well being of our communities.

 

Thought Leadership – Empathy’s involvement in Patient Engagement

 

Earlier this year, I had introduced you to “lifestyle philosopher” and Oxford University Professor, Roman Krznaric and his work on empathy’s role in our world today. He has released a new animation which is an amazing video that is part of this post. Hopefully, it is as insightful for you as it was for me. I interviewed Roman on some of his thoughts about empathy and it’s role in healthcare as well as other areas that were relevant to our world today. Here, below is that interview.

Roman, thanks for your time to answer some of my questions. How did you get involved with the concept of empathy?
I used to be an academic teaching and researching political science. But about a dozen years ago I had an intellectual awakening when I came to realize that societies and politics didn’t simply change through new laws, institutions and policies but through changes in the way people treated each other at the individual level, especially through empathy. I define empathy as the art of stepping imaginatively into the shoes of another person, understanding the feelings and perspectives, and using that understanding to guide your actions. It’s a fundamental skill that almost all of us have, but we rarely fulfill our empathic potential, or work hard enough to harness the power of empathy to create social transformation. 
How do you think that empathy can help healthcare, both there in Britain and here in the US, where healthcare is a very politically charged topic?
It’s interesting to me that the origins of public healthcare in Britain can be traced back to an important empathic shift during the Second World War. Over a million children were evacuated from big cities to rural foster homes to escape the German bombs. And one of the unintended results was that relatively well-off rural folk suddenly had relatively poor city children thrust into their homes, and they could see the extremes of urban poverty with their own eyes: it was a moment of empathic understanding and awakening. There was huge public outcry and the government took immediate action, improving public health care for children, giving free meals in schools, vitamin supplements and other health care. This mass meeting of strangers was, in effect, the beginnings of the British welfare state – and it happened right in the middle of the war when resources were extremely scarce. There is a lesson here: that empathy sensitizes us to health care inequalities, and can spur social and political action to alleviate it.
Of course, healthcare reform is a very politically charged topic in the US, since it is so closely associated with the Obama administration. It was also Obama who started talking about America’s ’empathy deficit’ in the lead up to the 2008 Presidential Election. The American right then started critiquing the concept of empathy because of its links to Obama. Despite all this political complexity, I think empathy remains essential to the issue of healthcare. Why? The historical evidence points to the fact that empathy opens the door of our moral concern for neglected or marginalized social groups, and laws, rights and public policy wedge that door open, helping to universalize that moral concern. Healthcare, like other key areas of public policy, is one where we should be shining the light of empathy, trying to understand how different parts of society experience the public health system (or lack of it), and equally how they are impacted by the structure of private health care. It is only through empathising that we gather enough evidence, from enough points of views of different citizens, to design truly effective and socially just health care systems. Otherwise good healthcare becomes the privilege of a few, rather than the right of the many. 
The US is undergoing a sort of renaissance in healthcare information and technology. What do you see as the role of empathy in this area (more usage of smartphones, tablets and laptops vs. human interaction)?
 
One way to think about this issue is to look at the new wave of ’empathy skills training’ for doctors that has become popular in the last few years. Doctors are often criticized for being too clinical and emotionally detached from their patients. In 2010, doctors at a Boston hospital took part in an empathy skills program in which they were advised to pay greater attention to the changing expressions on their patients’ faces (for instance whether they showed anger, contempt, fear or sadness), to take note of voice modulations, and to make simple changes such as facing the patient rather than their computer screens during a consultation. After just three one-hour training sessions, doctors who went through the program showed vastly improved empathy levels. Their patients said these doctors made them feel more at ease, showed greater care and compassion towards them, and had a better understanding of their concerns. The doctors too could see the benefits. After spending a day putting the program’s methods into practice, one hospital doctor reported that while it was initially difficult to empathize with the patient while simultaneously making her diagnosis, eventually it ‘became fun’ and embodied the kind of personal interaction that had initially drawn her into medicine.
Now, what does this tell us? It would seem to suggest that it is person-to-person interaction that patients are after more than anything, and that this is the key to bringing more empathy into the sphere of healthcare. All the technology in the world doesn’t substitute for having a real human being treat you, look you in the eye, and hear your personal story.
 
That might make me sound pessimistic about the possible role that technology might play in empathic healthcare. Yet I also believe that if we get smart about using technology, it can help bring about an empathy revolution in healthcare. OK, almost everyone would rather have the doctor look at them rather than at their computer screen during a consultation. Yet just imagine if basic video technologies like Skype became a standard way for your doctor to visit you in your home to give post-treatment or post-operation check ups and advice. We need to learn to bring a little more intimacy into the way we use technology, especially social networks.
 
Do you foresee any upcoming empathy deficits?
 
The evidence is pretty clear that the US in a period of long-term empathy decline. A well-known study (Scientific American, December 23rd, 2010) revealed that US empathy levels are down nearly 50% in the last 40 years, with the steepest decline occurring in the past decade. So the empathy deficit is growing. At the same time we see rising levels of narcissism – around 1 in 10 Americans now exhibit narcissistic personality traits. There is also growing evidence that social networking technologies are exacerbating narcissism and contributing to empathy decline. There is a question about whether these trends are going to continue. I’m glad to say that there is a growing movement trying to address these problems by teaching empathy in schools. The most effective program, called Roots of Empathy, began in Canada and has now reached over half a million children worldwide.
 
Will we see more of these animations in the future? I think it is a great tool to get your message  across in a simple, entertaining and informative way.
My animation about empathy, The Power of Outrospection (produced by the Royal Society of the Arts in London) makes the case that empathy can be a powerful tool for social change. It’s fascinating how popular the animation form has become – this particular one has had over half a million views – and is evidence of the shift towards visual learning. I think we need to tap into our multiple intelligences when communicating ideas. For some people books are the most powerful, for others it will be animations, blogs or going to talk with a real live human being! Personally I plan to pursue all these communication routes in the future, including the animations – luckily for the world someone else does the drawing, since my drawing skills are in need of serious work!
Thanks for your time on this interview. Hopefully we see a much more empathetic world as we move forward in the 21st Century.
RomanKrznaricRoman Krznaric, PhD, is a writer on empathy and social change based in the UK. His latest book is Empathy: A Handbook for Revolution (to be published in the US by Penguin in November 2014). He advizes organizations including Oxfam and the United Nations on using empathy as a tool for social transformation and public policy. He is a founding faculty member of The School of Life, and founder of the world’s first digital Empathy Library. Website: www.romankrznaric.com Twitter: @romankrznaric