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Posts Tagged ‘healthcare reform’

ACA and QRS – Shoot for the stars! Part 1

Last month I posted “ACA’s Quality Rating System – An opportunity to gain market share”, which explained how QHP issuers can gain market share in the individual space.  In that blog I mentioned that, as part of the Quality Rating System, plans offered on the Marketplace will receive a “Star” rating based on a 5 star rating system. Over the next few Shoot for the stars!posts, I would like to take a look at what this means from a health plan’s perspective.
As background, there are 43 measures that will need to be tracked. Out of the 43 measures, 31 are derived from data and 12 are derived from the survey. In addition, the draft QRS scoring specifications published by CMS organizes the 43 required measures into composites that roll up into eight domains. These domains are as follows:

  • Clinical Effectiveness
  • Patient Safety
  • Care Coordination
  • Prevention
  • Access
  • Doctor and Care
  • Efficiency and Affordability
  • Plan Services

The eight domains are then rolled up in to three summary indicators: 1) Clinical Quality Management; 2) Member Experience; and 3) Plan Efficiency, Affordability and Management. And of course, the final result is a star rating.

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ACA’s Quality Rating System – An opportunity to gain market share

Starting in 2015 all issuers of Qualified Health Plans (QHPs) on the Healthcare Marketplace will need to provide Quality Rating System (QRS) measurements that will be aggregated and scored to provide consumers with a star rating for each product offered.

How many stars will you have?

How many stars will you have?

Although there are still details to be worked out by CMS, the required measures for the 2015 beta test are in place. All issuers that wish to continue providing QHPs on the Marketplace will need to provide the required measures. There are two different sets of measures included in the beta specifications.

The first is a set of clinical quality measurements that are mostly taken from the current NCQA HEDIS accreditation process. Many issuers already collect the data for these measures; especially, if they are meeting the requirement to be accredited for the Marketplace today and are using NCQA for that process.

The second is set of measures derived from an enrollee satisfaction survey (ESS) that needs to be performed by an accredited third party survey vendor. Most of the questions in the ESS are drawn from CAHPS. The survey processes requires that a sample of data is drawn, audited by a third party and provided to the survey vendor. The vendor then performs the survey and reports the results to CMS. Questions focus on rating an enrollee’s satisfaction with a plan over a six month period.

While the QRS initiative driven by the ACA attempts to provide transparency, it also creates a competitive market that will force issuers to look at ways to increase the quality of care and enrollee satisfaction to deliver better scores. The prize? For consumers, better products. For issuers, a larger share of the market.

Want to participate and win? Then you need a solution that not only provides the required measures, but also provides insight and the ability to drive quality improvements. This can be accomplished with a well thought out solution architecture that provides processes for delivering the measures and the means for analyzing data to drive improvements.

Imagine all the people…without healthcare insurance?

This morning a colleague forwarded a Fast Company article entitled “The Mayo Clinic’s New Doctor is an iPhone.”  The article describes a new Mayo Clinic concierge medicine via mobile device that is subscription based.  For $50 per month (per household) the Mayo Clinic basically offers unlimited access to their nurse’s line powered by iPhone virtual visits.  The service includes:

  • 06FOB-MEDIUM-SPAN-articleLargeReal-time video chats with Mayo Clinic nurses
  • Personally-tailored health information culled from Mayo Clinic databases
  • A “symptom checker” that incorporate’s individual user’s health histories
  • Access to a personal medical concierge who can provide more information or schedule patients’ doctor appointments

Programs like this are becoming increasingly popular.  As I mentioned in the Connected Health trends seriesTime Warner Business Class announced it was venturing into the world of virtual medicine through a partnership with the Cleveland Clinic.  The program is part of Time Warner Cable’s Home Health Monitoring network that was designed to connect healthcare providers to patients in their homes.  It will provide secure, encrypted, two-way video conferencing between patients and Cleveland Clinic providers on a subscription basis. Read the rest of this post »

A Love Letter to Meaningful Use – #HIMSS14

It seems appropriate on Valentine’s Day to write love letters.  This is my letter of adoration to Meaningful Use.  In the past, I have written about how much time and productivity is wasted in the average physician’s office handling phone calls about prescription refills.  My physician’s office has successfully implemented their EMR software, and the patient portal is very, very handy for all of the right reasons.  I could wax poetic about the ease of checking on appointments and reviewing lab results.  The source of my real happiness is the ease of asking for refills and having the ability to route the request to the right pharmacy.  It was love at first click.

A Love Letter toInstead of calling the doctor, waiting on hold to talk to the nurse, fretting about getting the medication name and dosage right for the refill, it was magic.  I signed into the patient portal in a secure fashion, clicked on medication refills, and there was a correct list of my medications!  I selected the ones I needed refilled including a suggested number of days like 30 or 90, selected the pharmacy of my choice and Voila!  Several hours later, I received an email confirmation from the pharmacy that they were processing my order.  Now honestly, I didn’t have to see what went on behind the curtain in the doctor’s office to review my request, but I’m sure they like the elimination of potential communication errors on medications, too.

My doctor has shared with me about the financial burden of casting out his first EMR investment and starting over with a better EMR software.  I have to say that from my point of view, he clearly chose the right one and it actually fulfills the basic tenets of Meaningful Use, particularly from the patient’s point of view.  I plan to share my enthusiasm for the patient portal with him including the secure messaging that allowed me tell him that his changes in my medications worked and improved my quality of life.  This secure messaging was another plus for productivity, and patient satisfaction, because those positive responses got lost in the challenges of telephone communication in the past. Read the rest of this post »

Connected Health Trend Countdown: #8 Sharing Notes with Patients

Top TenOur Countdown of the Top Connected Health Trends of 2014 brings us to:

#8: Sharing Notes with Patients

The more obvious driver of this trend is Meaningful Use.   However, there is a separate market push for patient record access, which is being driven by consumer engagement.  As luck would have it, there was a Healthcare IT News article on this very topic that surfaced yesterday entitled “Consumers now calling for Meaningful Use” by Eric Wicklund.

Where the general trends of the marketplace are concerned, the participatory care movement has been a big catalyst of this trend.  For those not in the know, this movement is being driven by patient advocates through the Society for Participatory Medicine.  This group is driven towards an industry where:

“networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners”.

Quite an admirable cause, indeed.

The Results are In

Back in October, the Journal of Participatory Medicine published a study documenting patient perception of increased data access.  This study surveyed Kaiser Permanente members who had viewed at least one test result online in the last year.  There were a total of 1,546 respondents. The findings showed:

  • Patients that were able to view their lab results online overwhelmingly reacted positively to being able to do so
  • Survey participants reported high levels of satisfaction, appreciation, calm, happiness, and relief
  • Few were confused, upset, or angry at being able to see lab results online
  • After reviewing results online, the most common actions were discussing results with family and friends, looking up information online, or making a graph of results over time

What provider wouldn’t want to own survey results like these?

Opening the Book on Doctor’s Notes

What do you think would happen if doctors handed their notes over to patients in an effort towards patient engagement?  The great thing is, we already know.  OpenNotes is a program that gives patients online access to the notes of their doctors, nurses and other clinicians.  The notes may contain:

  • History of present illness (what the patient told the clinician)
  • Physical exam findings (blood pressure, heartbeat, lung sounds)
  • Lab, radiology, pathology, or other results
  • Assessment or “impressions” (the clinician’s  diagnosis or documentation of symptoms
  • The treatment plan

Patients who read their notes have reported many benefits, which include:

  • Better understanding of health and medical conditions
  • Improved recall of the care plan
  • Feeling more in control of care,
  • Taking better care of themselves
  • Doing better at taking medications as prescribed
  • Strengthening the partnership between patient and physician

Health Plans & the Shared Medical Record

Another, oftentimes unconsidered, source in the drive for demand of record sharing is actually the health plan.  Having a storied history of largely ignoring the B2C relationship, Affordable Care and the drive towards the management of chronic conditions has brought us a health plan that is very interested in helping members gain access to their records.  Understanding that patients typically don’t want their health plan involved in their care, health plans are finding consumer engagement tactics that involve providing members with tools that the provider has been slow in implementing. Access to medical records is one of those tactics.

The Truly Open Book

Driving towards a world where the patient can gain easy access to their medical records is an important trend.  However, what I am most interested in seeing would have to take us another big step forward (don’t blame me, I was born that way).

We will truly have a foundation towards participatory medicine when sharing notes is a two-way street.   Patients have a lot of data to share as well.  The true power of consumer engagement will surface when both the patient and the clinician are able to collaborate over their shared open book.

Positive evidence that Health IT improves patient outcomes

Figure 2: Updated Systematic Review of Effects of Meaningful Use Functionalities on Quality, Safety and Efficiency, By Study Outcome Result (% of Studies) Health IT evaluation studies, 2007-2013 (n=493). Number of studies by meaningful use functionality in parentheses. Positive defined as health IT improved key aspects of care but none worse off; Mixed-positive defined as positive effects of health IT outweighed the negative effects; Neutral defined as health IT not associated with change in outcome; Negative defined as negative effects of health IT on outcome. Citation: Jones SS, Rudin RS, Perry T, Shekelle PG. “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use,” Ann Int Med 2014;160:48-54.

Figure 2: Updated Systematic Review of Effects of Meaningful Use Functionalities on Quality, Safety and Efficiency, By Study Outcome Result (% of Studies)
Health IT evaluation studies, 2007-2013 (n=493). Number of studies by meaningful use functionality in parentheses. Positive defined as health IT improved key aspects of care but none worse off; Mixed-positive defined as positive effects of health IT outweighed the negative effects; Neutral defined as health IT not associated with change in outcome; Negative defined as negative effects of health IT on outcome.
Citation: Jones SS, Rudin RS, Perry T, Shekelle PG. “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use,” Ann Int Med 2014;160:48-54.

This is a fascinating report on a study by RAND researchers about meaningful use. It shows strong evidence that Health IT improves patient outcomes, specifically quality, safety, and efficiency outcomes.

Michael Furukawa Director at the ONC , and Meghan Gabriel, Economist at the ONC, presented the results from this study in a blog post on HealthIT Buzz. They asked RAND to:

…examine recent evidence on the effects of meaningful use functionalities on quality, safety, and efficiency outcomes. The study was the largest and most comprehensive assessment of the health IT literature to date.

Top 5 Technology Trends in Healthcare – November 2013

The healthcare IT field is rapidly developing and changing. Emerging technology and updated regulations put pressure on healthcare providers and health plans to stay ahead of the curve. Perficient creates a monthly list that explores some of the current topics and issues in health IT. This list examines the most talked about issues and technologies that are currently affecting the industry.

HCBlog Top5 Trends

Consolidation and Mergers

Healthcare entities, both payers and providers, have been making an increased effort to capture market share and dominate their geography. Smaller players are being picked up by larger players, consolidating physician practices and health plans. These mergers have driven digital strategy projects and paperless environments, with an increased interest in advertising and public facing websites to try to attract market share. 

Extending Your EMR

Healthcare professionals have been very vocal about the challenges that come along with electronic medical record systems. The workflow in many EMR systems was created by a programmer and works the way it was programmed, not the way healthcare professionals work. Several technology tools were made to extend or approve upon EMRs without ripping the code apart, often by putting it into a browser or allowing it to be mobile.

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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!

Apolitical Tech Lessons from the Meltdown

When launched, it drew an understandably high number of initial users.  Millions poured onto the site, but they weren’t able to sign up for insurance due to technical glitches.  As an impartial observer, it was interesting to watch media outlets struggle to find even one person that was able to sign up successfully.  The Washington Post even went as far as to illustrate this single newly minted healthcare insurance holder as a mythical unicorn.

Late Winter Snowstorm Hits Washington DC

Leave it to clashing political tensions to throw the topics of non-functional requirements, project management, and user experience into the limelight.  Oh, wait.  That’s not what everyone has been talking about since the wake of the Health Insurance Marketplace ribbon cutting…but they should.

There’s lots of finger pointing in the great game of Whodunit.  However, underneath all of the tensions that bely healthcare reform, there are some key takeaways from the case study for anyone looking to build a website as a platform for information dissemination and conversion.  Here they are:

Project Management

It was originally thought that there were only two players involved in the creation of  In reality, there were more than I have fingers to count with.  A project this colossal requires some serious project management, and project management was clearly lacking here.  It has been reported that those in charge were aware of the flaws and were told the site was not ready for launch.  The Washington Post reported that “people were pulling out their hair” and complaining “loudly” about the problems the site was experiencing before being moved over to the live server.  Those in charge still insisted on rolling out the new site on the original timeline.

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Healthcare Reform: Payers – HIXs and Eligibility

In healthcare, it’s a common occurrence to find your organization having to make an investment, unplanned in many cases, in order to comply with a new regulatory requirement due to Health Reform.  When faced with a new compliance need, I have heard many wistfully ponder the question of ROI, yet are already resigned to another initiative to add to an already burdened organization.  What I then help folks understand is that you can get a ROI on this “required” investment, but it won’t be easy and it’s not obvious.  The answer comes from stepping back from the specific requirement, reviewing how the impacted part of the business runs today, analyzing the changes needed and examining how the requirement could be a catalyst for something bigger.  Most of the time, the focus is on the individual activities and tasks performed today and how they need to be tweaked, new steps shoe-horned in, an extra report run, etc.  Our typical response mode is to focus on the micro and don’t rock the boat.  By stepping back and examining the greater context or macro view of business activities and processes which will be impacted by the regulatory change, the organization can do two things.  One, comply and two, by expanding the focus, and yes, investing more, effect a longer term change that improves service levels (customer satisfaction) and reduces the cost to serve, effectively generating a return to offset that dreaded investment.

To help illustrate this, let’s focus on an effort underway by the Payer community to prepare for the forthcoming Healthcare Reform Health Insurance Exchanges (HIXs).  A primary engagement point between the payers and the HIXs deals with eligibility and premium information.  For any payer, a common daily activity is the receipt and handling of eligibility data from their many clients, particularly employer health plans.  While the 834 does exist for this very purpose, the complexity of the transaction, along with the various sources, such as HRIS solutions, HR staff, 3rd parties, etc. have led to a myriad of formats and mechanisms to facilitate this exchange.  Typically, these many feeds will either go directly into the underlying claims systems that support the membership in question or through a conversion process that spits out a proprietary eligibility load file or an 834.  This conversion process is somewhat of a one off with each client/feed, becoming a separate job that must be run, trouble-shooted and maintained.  Many are reacting to the HIX challenge by just setting up new jobs, thankful that the HIXs will be using 834s and trying to figure out the use of the 820 for the premium.

So what’s the broader or macro view and opportunity here?  In most cases, the payers are using a complex and expensive set of services set up years ago that focus on only EDI transactions.  Again, the opportunity that has presented itself is one of being able to step back, look at the broader context and, albeit a greater investment, drive change in how the organizations handle transactions in general.  As many payers wrestle with the need for greater access to, and accuracy of data, they are looking at establishing Data Governance, Master Data Management, ETL platforms, Data Repositories, Data Warehouses and delivery mechanisms.  An enabler to the aforementioned is the deployment of a data and transaction backbone, an Enterprise Service Bus (ESB).  And here’s the link: ESBs can not only support the organizations data consumption, but it can handle the operational transactions, both internal and external.  Furthermore, abstraction can be fully supported, meaning that a standard is developed for introducing eligibility data into the transactional platforms that consume it.  The ESB would accommodate the knowledge needed to interpret the inbound side of the 834 or 820, transforming it per established business rules and pushing it on its way to one or more destinations.  The beauty of such a setup is that it can be done incrementally.  In other words, you don’t need to change everything out at once.  The new and the old can co-exist, while migration occurs.  The organizations commitment up-front is to establish the new foundation and implement first those changes driven by the regulatory requirement.  An added benefit is that you tend to end up with a single interface into the transactional platforms for each core transaction and/or set of master data.  So, when it comes time to upgrading the underlying platforms, you have a minimal number of interfaces to worry about.

Given the multitude of offerings in the market today, any payer organization can do the above.  By multitude, I mean solutions for any budget and varying complexities of environments, along with many of the traditional technology stacks, such as IBM, Microsoft and Oracle.  So, if you’re willing to step back and look at the broader opportunity, a change driven by regulatory requirement can be leveraged in a way that benefits the company, the customers and, over time, provide the return you seek.

Healthcare Delivery Strategy – Goals or Remediation

As healthcare delivery systems are currently engaged in updates and integration of regulations and standards in adherence with Federal and State guidelines, we can begin to address the core perspective of the required strategy. It is common during all relevant discussions of the modeling of the new healthcare delivery system to focus on core strategy and associated methodologies that will enable integration of processes.  It is useful to ponder – what are the foundation of the strategy? Does establishing and reaching pre-determined goals take priority over interim remediation of any gaps in implementation? If it is the latter option, how flexible is an organization in re-establishing goals and their corresponding timeline?

A similar perspective in addressing this concept is the prioritization of preventing challenges before an end-goal assessment is established. There will be inherent variations based on what the determined goals are by organization, provider, and disease diagnosis and treatment. However, there is a core foundation that during the early stages of reorganizing it will be necessary to have assessment loopback methodologies in place to ascertain established goals that are parallel to the process of implementation. If there are nuances that are not in alignment with goals, interested stakeholders can re-evaluate the process prior to key milestones. Based on observed differences, when does this change mandate the discussion of new goals with an appropriate timeline? The entirety of a process is not limited to the initiation and completion, but a comprehensive planning on managing the interim changes and their influence on overall outcomes and expectations.

News Flash: Healthcare Reform Is Working (with some help)

I recently read an article in the NY Times talking about an “unexplainable” sharp and persistent slowdown in the growth of healthcare costs.  It has been followed by others, such as this one from USA Today, that have begun attempting to shed light on the reasons why.  Contrary to the partisanship rhetoric from our lawmakers, change is occurring and we’re heading in the right direction.  Healthcare Reform (HCR) is working.  I’ll talk about the “with some help” later.  The challenge with HCR is that it’s very large, complex and the value the nation derives from it is the sum of all its parts, such as Accountable Care Organizations (ACOs), Meaningful Use, ICD-10, enhancements to HIPAA (not to mention giving it some teeth and putting Business Associates on notice [page 5566, column 3, first bullet]). Also to consider are changing reimbursement schemes that are moving away from the fee-for-service to bundled payments focused on quality and outcomes, Health Information Exchanges (HIEs) requiring providers to share records and avoid duplicative/unnecessary tests, upcoming Health Insurance Exchanges (HIXs) that create a more affordable way to buy health insurance, driving the provider community and EMR/EHR software houses alike to more broadly use technology that not only focuses on each encounter, but looks beyond to the continuum of care for the individual and the population.  With this longitudinal view comes a focus on the quality of care, driven by both the incorporation and reporting of required quality measures, but also through having readily available information.  In addition, with much of the clinical data now in a transactional system and “structured,” it can be leveraged for decision support or business intelligence, both tactically at the point of care and strategically by driving investment and improvements in care.

This positive change is catching many by surprise.  Some have continued down the party path, for example, the  recent decision to not participate in some aspects of HCR by North Carolina, while others, such as Gov. Rick Scott of Florida, have done an about face.  The divisiveness has been around Medicaid Expansion and Health Insurance Exchanges (HIXs).  For the latter, if the state will not establish an HIX, the Federal Government will and they will control the review and “publishing” of Qualified Health Plans (QHPs) to be offered to each state’s population where there isn’t a local or regional HIX.  For Medicaid expansion, the Federal Government will fund the first three years, then revert to 90% for the next seven years.  That’s a great deal of money for the states to leave on the table and 10 years is a long time.  Again, the challenge and arguments against are looking only at the specific components and missing how they fit in with HCR in general.  Each piece has a role to play.  There are so many components to HCR that trying to measure the performance or impact of a specific one is not a good indicator of what’s going on overall.

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