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Dr Marcie Stoshak-Chavez

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The “Yellow Brick Road” to Value-Based Care

“The Wizard of Oz” is a wonderful movie, full of metaphors that can be applied to real life. As I look at the current state of Healthcare, I can’t help but wonder if there is a true “yellow brick road” from volume based care to value based care. If there is, which stops will we make along the way and what roadblocks will we face?The “Yellow Brick Road” to Value Based Care

Physician engagement is a crucial component on the road to value-based care. As Michael Porter and Thomas Lee mentioned in their article in the Harvard Business Review, “care fragmentation is reinforced by the fee-for-service model in which each doctor, specialist or otherwise, is paid separately, while the hospital receives its own payment.” They go on to mention that crucial services, like care coordination, are often not reimbursed, thus further fragmenting healthcare.

As our population ages, these crucial components will need to be addressed as practices, hospitals and payers will be flooded with patients needing coordinated services. So how do we engage our physicians in this battle? Like the Scarecrow, listening and learning needs to take place. We can allow clinicians to work to the level of their licenses to unburden the physicians by coordinating patient care and documentation which becomes available for the treating physician.   This will then allow the physician to spend quality time diagnosing and treating the patient, patient and physician satisfaction will rise and overall medical costs will decrease. Payers, Accountable Care organizations (ACO’s), Patient Centered Medical Homes (PCMH) and governmental regulators will see the health care value being generated. With value-based care, these services should be included in reimbursement and quality care should be rewarded. Sounds simple, right?! (more…)

A View From the Emergency Department Trenches

The Case for Patient Centered Medical Home, Care Coordination and Population Health Wellness

The Affordable Care Act (ACA) is changing the way patients, physicians and clinicians interact with our healthcare system. At first glance, creating affordable The Case for Patient Centered Medical Home, Care Coordination and Population Health Wellness-A View from the ED Trencheshealthcare for all is an amazing yet daunting initiative. In actuality, however, patients are now finding it difficult to get appointments with their overburdened clinicians, landing them square in the middle of an expensive emergency department (ED) visit. Many of these individuals have primary care clinicians but lack coordinated care management. They have real diseases, diabetes, HIV, congestive heart failure, just to name a few, but make frequent visits to the ER because… Because why? There is no one driving care coordination.

Here’s a real story. Although I only practice emergency medicine part time, I noticed that almost every shift I worked, either I or one of my colleagues would see the same patient repetitively. We are fortunate to have care managers in the ED but they are usually not available in the late evening so this patient was being seen, sometimes had a workup, sometimes not but was usually discharged and told to follow up with his primary care physician. He lives alone, has no social support system and has a real disease. Here is a man who should be part of a patient centered medical home, receiving coordinated care to prevent recurring ER visits. He, and many others like him, have fallen through the cracks. This patient was finally admitted, eventually accepting an assisted living arrangement, thus eliminating unnecessary visits to the ER and providing him a much better health and wellness solution. But could this have been done sooner? (more…)

Two Keys for Population Health Success

Population Health management and success will drive Healthcare for the next several years as mandated by the Affordable Care Act (ACA), Value Based Purchasing (VBP), Accountable Care Organizations (ACO) and multiple other federal and state endorsed programs. Everyone is scrambling to figure out how to achieve the Triple Aim (improved quality, lower costs and better patient satisfaction) which essentially wraps up everything with a nice little bow. But HOW can we enable Population Health and make it a win-win situation for patients, providers and payers alike? There are two key components which have to be addressed to make Population Health management a success. The first one is physician alignment and the second one is geo-specific demographic analytics.

Two Keys for Population Health SuccessLet’s examine the first, physician alignment. As Philip M Oravetz, M.D., Medical Director for Accountable Care, Ochsner Health System, wrote: “In many respects, finding the right information technology solutions is less of a challenge than re-defining the delivery of care. For us, creating a synchronized strategy to align all physicians around population management is the big challenge.”* This is certainly echoed across the country by many provider and payer organizations. Getting buy-in from the physicians who are on the front lines, both in academic and the community settings, is crucial to successful Population Health management.   Effective change management strategies must be established to ensure a positive end result. One of the most important changes should be assuring physicians that all of the additional work associated with Population Health management will not fall into their hands to complete. Teamwork, particularly allowing licensed care providers to practice to the full extent of their licenses, will enable and extend the reach of the physician to a wider population and will help streamline workflow. In addition, providing incentives and empowering these physicians with the appropriate tools and analytics will allow them to visually understand the impact of their efforts to improve care. This, in turn, reaches the center of the circle, the patient, enabling improved care and satisfaction. (more…)

The Three G’s of Mapping….Is Healthcare a Leader?

Ok, it’s true.  I’m a closet geek.   I think no one knows how much I love maps. (Lesli Adams, my colleague at Perficient, often describes herself as a geek so this is homage to her).  There are so many different kinds of maps, so which ones do I favor, you ask?  I think the best maps are the three “G’s”,

  1. geospatial,
  2. genomic and
  3. geocaching.

Let me show you how all of these have relevance to healthcare:

Let’s start with geospatial. 

shutterstock_56289301I am fascinated by the heat maps of disease prevalence, patient engagement and demographics that have started to electrify Healthcare.  Duane Schafer, Director of Microsoft Business Intelligence for Perficient, recently revealed a great demo at HIMSS, based on Population Health statistics from ProHealth in Wisconsin.  Using basic tools from the Microsoft stack, Duane was able to visually map important population health statistics from ProHealth and present that data in a way that entices the viewer to explore deeper.  It allows the organization to see, at a glance, major population demographics in their region.  This can then be combined with additional analytics to determine trending of disease in the area, frequencies of patient visits to the Emergency Departments over time and correlations of missed appointments to care gaps in specific chronic disease management.   Geospatial mapping even hit the news recently when a contamination at Lake Champlain caused concern about the risk of spreading disease and therefore assisted with facilitating a rapid Public Health response in this  situation. Of course, there are many more examples but you get the idea. (more…)

Reframing the ACO Analytics Problem with Malcolm Gladwell

I just finished watching a quick slideshow on the Health Data Management website, “Enterprise Analytics: Moving on Up” and as luck would have it, I also watched several sessions of the live Webcast from the Healthcare Innovation Day Conference 2014 in Washington, DC, sponsored by West Health Institute and the Office of the National Coordinator for Health Information Technology (ONC).

Malcolm Gladwell quoteWhile I was watching these, I was intrigued by the thought of how Accountable Care Organizations (ACO) can leverage existing solutions, combined with point solutions, to accomplish their reporting, analytics and beyond, and use interoperability wisely.  One of the key learning points for me from these sessions was this:  “Reframe the problem”….advice from Malcolm Gladwell’s keynote address.

How do we “reframe the problem” when it comes to ACO reporting and analytics?  There are defined metrics that are required for these organizations, so how can we leverage existing systems to create these reports and analytics?  Do we “build vs. buy”?  Depending upon the organizational size, legacy systems and IT support, the decision can be difficult.  What is good for one system may not work in another.  So where do we start?

A strategic evaluation of current state and desired future state with the development of a road map may be a logical first step.  Data Governance also needs to happen early on in the process to allow an organization to create data standards that will drive reporting and analytics.  Once these steps have occurred, an organization can feel confident that they can make an informed decision to “build or buy.”

(more…)

Two Keys to Success for Healthcare

Healthcare reform, ACA, Business Intelligence, Enterprise Portals, predictive analytics, pay for performance, the Triple Aim, total cost of care, patient safety….these, and many more,  are the buzzwords in healthcare and medicine these days.  Install this system, connect that system, run these reports, use this “intelligent program”… Do you ever wonder if we can solve all of these problems with just technology?

As a clinically oriented physician working in a technology world, I need to take a step back and look at behaviors and workflow.  How can we mentor the next generation of physicians, nurses and allied health professionals, teach them skills and foster their curiosity while encouraging them to be technologically savvy? I believe there are two twisted stethescopecritical keys to success: critical thinking and decision support.  Both are crucial and neither should exist without the other.  Here’s why.

Critical thinking is an essential tool for physicians.  Physicians who have this innate ability are often the most successful at diagnosing and treating their patients well. It is part art and part skill but ultimately, it affects patient safety and wellness.  I was pleased to see that medical school curriculums are now focusing on this as a fundamental skill. According to the recent Wall Street Journal article, “The Biggest Mistake Doctors Make,” the program at Dalhousie University “aims to help trainees step back and examine how biases may affect their thinking. Developed by Pat Croskerry, a physician known for his research on the role of cognitive error in diagnosis, it uses a list of 50 different types of bias that may lead to diagnostic error”.  Couple this with technology driven decision support at the point of care, which assists but never negates clinical judgment, and you have a winning combination.  These basic building blocks allow clinicians to concentrate on their craft: diagnosing and treating patients safely and effectively.

Healthcare reform is necessary but it does not have to undermine the knowledge and experience of our clinicians.  Adding technology, such as Natural Language Processing (NLP), real time decision support, predictive analytics, patient entered data via portals, mobile healthcare management apps and yes, even Watson, can only enhance and advance healthcare, streamline treatment and decrease costs.  Simple?  Let me know your thoughts!

If I Could Learn and Practice Medicine with Watson…

I have to admit that I was jealous when I read that my alma mater and “old training grounds,” Case Western Reserve and the Cleveland Clinic, were engaging IBM’s Watson to further clinical diagnosis, treatment, efficiency and even medical and patient education.  It is the best of all worlds!  Everyone could benefit from this partnership including physicians, nurses, medical students, patients, researchers, allied health professionals, families….the list goes on.  But how “real” is it?

Here’s what I believe.  Watson’s ability to actively “learn” mimics human thought and thus becomes cognitive learning.  “He” can reason brilliantly, synthesize far more than I could ever hope to do, and “his” brain never probably feels like it is going to explode!  For example, “WatsonPaths can use Watson’s question-answering abilities to examine watson_med_school_articlethe scenario from many angles. The system works its way through chains of evidence — pulling from reference materials, clinical guidelines and medical journals in real-time — and draws inferences to support or refute a set of hypotheses. This ability to map medical evidence allows medical professionals to consider new factors that may help them to create additional differential diagnosis and treatment options.”  When you combine this with the human abilities of compassion and empathy, this creates a winning combination.  Now, combine these abilities with Watson EMR, which uses natural language processing (NLP) to mine unstructured data in the EMR to gather all of the “clinical pearls” that often get missed with reporting, and you have the perfect package.

For now, these tools are being tested in a learning environment and have not been rolled out for use in the clinical arena.  I can only hope that one day I will be able to use Watson to help diagnose and treat patients in an efficient, value based, high acuity environment.  Do you think it will happen?  Send me your thoughts!

Social Meets Clinical Meets Research: Big Data in Medicine

I was intrigued immediately when I read that The Mount Sinai Medical Center in New York hired the former data scientist for Facebook, Jeff Hammerbacher, to develop and refine their predictive analytics capabilities.  It seems like a collision of the planets!  Is it possible that this social media data scientist could break the code of predictive analytics in medicine and introduce us to the wonders of big data AND really improve health and wellness in the process?

It is my hope that this collaboration, particularly with Joel Dudley, director of biomedical informatics at Mount Sinai’s medical school, will produce something great.  As a health_iconphysician, I look for the future of medicine to provide insights into the veiled depths of our core being.  Why do some patients respond to treatments while others don’t?  What factors blend together to allow some individuals to achieve wellness when others cannot?  How can we predict who is at risk for becoming “chronically ill” and how can we work to proactively reverse that?  Are these questions based on genomics, demographics, social interaction, environmental factors or something else?

Big Data is everywhere.  From the ever evolving social media space of Facebook, Twitter, LinkedIn and more, to the wealth of Patient Generated Data, to the heat maps of disease outbreaks and millions of patient EMR findings, to the developing genomic data, someone should surely be able to decipher the code and be able to predict wellness.  Maybe it’s a pipe dream, maybe not.  But I do think if great minds combine with great machines, perhaps it CAN happen.

Let me know your thoughts!

Innovative Medical Education…Can it Save Healthcare?

Is there such a thing as “disruptive medical education”?  Can traditional medical education be infused with technology, techniques and individualized learning such that it creates the next generation of enlightened and empowered physicians?  I think so.  Years ago, when I was enrolling in medical school at Case Western Reserve University, I felt like I was a part of just that…exciting, cutting edge education which was “disrupting” the traditional training by allowing students to start interacting with patients immediately.  So I was intrigued when I read about a new program starting at Brown University’s Alpert Medical School in 2015. This program focuses on combining Ausmedschoolpopulation health management and primary care to create physicians who are focused on the principles of the Triple Aim: improved outcomes, better quality healthcare delivery, and decreased cost of care.  But will it work?

As everyone knows, the cost of healthcare is astronomical.  Federal mandates and regulations abound.  To survive in this landscape, physicians need to understand these increasing pressures and begin to embrace the tools which will allow them to provide improved outcomes, better quality of care and do it with less cost.  It seems to me that educating our next generation physicians and arming them with these tools to succeed only makes sense.  Social media, mobile health, telehealth, population wellness, and more are all here to stay.  Patient engagement in healthcare is rapidly evolving and will be an integral part of any health system of the future.  Medical education needs to change and not stagnate.

So my answer is this:  I am hopeful that we choose the right path and decide to disrupt medical education.  I encourage all of the cutting edge, forward thinking, connected educators to lead the charge, just like those at Brown are currently doing.  Just like Case Western Reserve University’s Medical School did several decades ago.  Do you think it will happen?

The Upcoming Health Insurance Conundrum: Does Anyone Win?

Monday morning news often leaves a bit to be desired.  I usually scan several newspapers or websites to see what’s out there.  I was surprised to see that the Wall Street Journal had a very interesting front page article on the upcoming insurance mandates for the uninsured population of the US. This article contends that insurance premiums for a healthy, currently uninsured, forty year old male in Virginia could more than double from the current rates to the suggested rates for the new Health Insurance Exchanges (HIX) for the January, 2014, deadline.  This is incredible, particularly since this is the exact population the insurers WANT to insure to fund the exchanges.

Why is this happening?  As I understand it, new insurance regulations mandate insurers to offer more benefits and require them to spend more money on health expenses.  The law also allows for subsidies, which in turn, provides incentives for consumers to purchase more robust insurance packages. Invariably, these costs will get passed down to consumers.  Also, according to a recent Gallup Poll, 43% of uninsured Americans said they were unaware of the 2010 Affordable Care Act’s (ACA’s) requirement that most Americans must carry health insurance or pay a fine. In addition, premium rates could also increase if not enough consumers sign up for coverage.  This may definitely be the case given the results of a recent survey, conducted by Princeton Survey Research Associates International, which revealed that 64 percent of the uninsured (who are aware of the requirement) say they haven’t decided whether they will buy health insurance by Jan. 1, 2014. Since the fines are relatively low the first year, many people may opt to wait and just pay the penalty.

So does anyone win in this situation?  Perhaps the uninsured, unemployed or low income families who qualify for a subsidy may benefit.  They’ll receive lower premiums and have health coverage.  However, for the majority of healthy, hard-working individuals, who are currently uninsured, is the benefit of insurance worth the price of the premiums?  For many, it might just be a crap shoot.  As a physician, I look forward to the day when all Americans are insured, but at what price?  What are your thoughts?

Personalized Prevention…Will it ever Happen?

Google Search gives way to personalized search, but can personal search be transformed into personal prevention?  That’s the premise of an interesting article written by Dr Joseph Kvedar from the Center for Connected Health, “Is the End of Search the Beginning of Personalized Prevention?”  After reading this article, I have come to the conclusion that I believe it WILL happen but I’m not sure it will happen soon enough.

Take, for instance, the well-publicized case of BRCA 1(breast cancer susceptibility gene 1) positive Angelina Jolie.  Genetic information drove personalized prevention possibilities for her.  It was up to her to make the ultimate decision to have surgery or not AND to what extent.  Because of her celebrity status, she was able to also use this decision as a forum to raise awareness for breast cancer screening.  A win-win situation, any way you look at it.  Personalized prevention meets Population Health improvement.

Other cases are not so clear, as Dr Kvedar points out.  Many people do not want to be accountable for their day to day health let alone have it served up to them predictively by the web.  We are seeing some movement in self tracking, however, from the explosion Quantified Self, Nike Fit Bit and mobile apps.  Can this new movement lead to an enhanced need for health information, predictive prevention and cost savings?  Only time will tell.

I do hope that this movement toward personalized prevention continues.  As my children grow older, I worry about what health hurdles they will face (both are adopted).  Will genetic screening and personalized, predictive preventions allow them to live healthier lives after I’m long gone?  Again, only time will tell.  It is certainly my wish!

Beauty Is In the Portal of the Beholder…Or Is It?

I was intrigued to review the entries for the New York eHealth Collaborative Portal Contest. Why would a physician be interested in patient portal design anyway? There are numerous reasons. First of all, I am fascinated by smart, eye-catching designs. Secondly, I believe that usability is directly related to design and this could significantly further patient engagement, help satisfy Meaningful Use requirements and create a usable personal health record (PHR) for patients as mentioned in my previous blog. So which design will win?

One of the competitors, CEO Christopher Bradley of Mana Health, believes that image based design plays a key role in creating an intuitive, patient centered experience. They have even begun to incorporate patient entered, device entered data (from Fit Bit, for example). This could be a game changer for many patients who want to track their daily fitness and exercise and have it mesh with their PHR. It doesn’t stop here, though. Could we then use predictive analytics to determine whether our activities are actually helping improve our health AND deliver that information to the portal through a series of easy to use icons? I think we can.

There are some drawbacks, however. As Dr. John Halamka, Healthcare CIO of Beth Israel Deaconess Hospital, so elegantly stated in the Wall Street Journal, privacy can be of concern. Our Healthcare IT system is still in its infancy and therefore, we have had difficulty parsing out protected health information (PHI) that many patients do not want to share with others, a process called data segmentation. We may be able to graphically capture, collate, trend, predict and make all of the information usable….but at what expense?

So can we create a beautiful, patient friendly, HIPAA compliant portal that really delivers insight and value to patients? I am curious to see who wins this battle in New York. Whoever can combine simplicity, beauty and ease of use with backend integrity will certainly have my vote!