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Can Mobile Health Apps Improve Oral-Chemotherapy Adherence? The Benefit of Gamification.

 

A report on how gamification mobile applications, like CyberDoctor’s PatientPartner, may improve patient adherence to oral chemotherapy.

(includes interviews with CyberDoctor’s CEO Akhila Satish and various oncologists)

 

Writer/Curator: Stephen J. Williams, Ph.D.

UPDATE 5/15/2019

Please see below for an UPDATE on this post including results from the poll conducted here on the value of a gamification strategy for oral chemotherapy patient adherence as well as a paper describing a well designed development of an application specifically to address this clinical problem.

Studies have pointed to a growing need to monitor and improve medical adherence, especially with outpatient prescription drugs across many diseases, including cancer.

The trend to develop oral chemotherapies, so patients can take their medications in the convenience of their home, has introduced produced a unique problem concerning cancer patient-medication adherence. Traditionally, chemotherapies were administered by a parental (for example intravenous) route by clinic staff, however, as noted by Jennifer M Gangloff in her article Troubling Trend: Medication Adherence:

 

with the trend of cancer patients taking their oral medication at home, the burden of adherence has shifted from clinicians to the patients and their families.

 

A few highlights from Jennifer Gangloff’s article highlight the degree and scope of the problem:

 

  1. There is a wide range of adherence for oral chemo– as low as 16% up to 100% adherence rates have been seen in multiple studies
  2. High cost in lives and money: estimates in US of 125,000 deaths and $300 billion in healthcare costs due to nonadherence to oral anticancer medications
  3. Factors not related to the patient can contribute to nonadherence including lack of information provided by the healthcare system and socioeconomic factors
  4. Numerous methods to improve adherence issues (hospital informative seminars, talking pill bottles, reminder phone calls etc.) have met with mixed results.

 

A review by Steve D`Amato of published literature also highlights the extent of problems with highly variable adherence rates including

  • 17-27% for hematologic malignancies
  • 53-98% for breast cancer
  • 97% for ovarian cancer

More strikingly, patient adherence rates can drastically decline over treatment, with one study showing an adherence rate drop from 87% to 50% over 4 years of adjuvant tamoxifen therapy.

 

Tackling The Oral Chemotherapy-Patient Adherence Problem

 

Documented factors leading to non-adherence to oral oncology medications include

  1. Patient feels better so stop taking the drug
  2. Patient feels worse so stops taking the drug
  3. Confusing and complicated dosing regimen
  4. Inability to afford medications
  5. Poor provider-patient relationships
  6. Adverse effects of medication
  7. Cognitive impairment (“chemo fog”; mental impairment due to chemotherapy
  8. Inadequate education/instruction of discharge

There are many examples of each reason why a patient stopped taking medication. One patient was prescribed capecitabine for her metastatic breast cancer and, upon feeling nausea, started to use antacids, which precipitated toxicities as a result of increased plasma levels of capecitabine.

In a white paper entitled Oral Oncology Treatment Regimens and the Role of Medication Therapy Management on Patient Adherence and Compliance, David Reese, Vice President Oncology at Tx Care Advantage discus how Medication Therapy Management (MTM) programs could intervene to improve medical adherence in both the oncology and non-oncology setting.

This review also documented the difficulties in accurately measuring patient adherence including:

  • Inaccuracy of self-reporting
  • Lack of applicability of external measurements such as pill counts
  • Hawthorne effect: i.e. patient pill documentation reminds them to take next dose

The group suggests that using MTM programs, especially telephony systems involving oncology nurses and pharmacists and utilizing:

  • Therapy support (dosing reminders)
  • Education
  • Side effect management

 

may be a cost-efficient methodology to improve medical adherence.

 

Although nurses are important intermediary educating patients about their oral chemotherapies, it does not appear that solely relying on nurses to monitor patient adherence will be sufficient, as indicated in a survey-based Japanese study.

As reported in May 12, 2014 | Oncology Nursing By Leah Lawrence

 

Systematic Nurse Involvement Key as Oral Chemotherapy Use Grows– at: http://www.cancernetwork.com/oncology-nursing/systematic-nurse-involvement-key-oral-chemotherapy-use-grows

 

Survey results indicated that 90% of nurses reported asking patients on oral chemotherapy about emergency contacts, side effects, and family/friend support. Nurses also provided patients with education materials on their assigned medication.

However, less than one-third of nurses asked if their patients felt confident about managing their oral chemotherapy.

“Nurses were less likely to ask adherence-related questions of patients with refilled prescriptions than of new patients,” the researchers wrote. “Regarding unused doses of anticancer agents, 35.5% of nurses reported that they did not confirm the number of unused doses when patients had refilled prescriptions.”

From the Roswell Park Cancer Institute blog post Making Mobile Health Work

https://www.roswellpark.org/partners-practice/white-papers/making-mobile-health-work

US physicians are recognizing the need for the adoption of mobile in their practice but choice of apps and mobile strategies must be carefully examined before implementation. In addition, most physicians are using mobile communications as a free-complementary service and these physicians are not being reimbursed for their time.

 

Some companies are providing their own oncology-related mobile app services:

CollabRx Announces Oncology-Specific Mobile App with Leading Site for Healthcare Professionals, MedPage Today

(http://www.collabrx.com/collabrx-announces-oncology-specific-mobile-app-with-leading-site-for-healthcare-professionals-medpage-today/)

San Francisco, August 13, 2013CollabRx, Inc. (NASDAQ: CLRX), a healthcare information technology company focused on informing clinical decision making in molecular medicine, today announced a multi-year agreement with Everyday Health’s MedPage Today. The forthcoming app, which will target oncologists and pathologists, will focus on the molecular aspects of laboratory testing and therapy development. Over time, the expectation is that this app will serve as a comprehensive point of care resource for physicians and patients to obtain highly credible, expert-vetted and dynamically updated information to guide cancer treatment planning.

The McKesson Foundation’s Mobilizing for Health initiative

has awarded a grant to Partners HealthCare’s Center for Connected Health to develop a mobile health program that uses a smartphone application to help patients with cancer adhere to oral chemotherapy treatments and monitor their symptoms, FierceMobileHealthcare reports.

 

CancerNet announces mobile application (from cancer.net)

http://www.cancer.net/navigating-cancer-care/managing-your-care/mobile-applications

 

However, there is little evidence that the plethora of cancer-based apps is providing any benefit with regard to patient outcome or adherence, as reported in to an article in the Journal of Medical Internet Research, reported at FierceMobileHealthcare (Read more: Cancer smartphone apps for consumers lack effectiveness – FierceMobileHealthcare http://www.fiercemobilehealthcare.com/story/cancer-smartphone-apps-consumers-lack-effectiveness/2013-12-26#ixzz34ucdxVcU )

The report suggests that there are too many apps either offering information, suggesting behavior/lifestyle changes, or measuring compliance data but little evidence to suggest any of these are working the way they intended. The article suggests the plethora of apps may just be adding to the confusion.

Johnson&Johnson’s Wellness & Prevention unit has launched a health-tracking app Track Your Health. Although the company considers it a “gamification“ app, Track Your Health© operates to either feed data from other health tracking apps or allow the user to manually input data.
Read more: J&J launches ‘quantified self’ app to game patients into better behavior – FiercePharmaMarketing http://www.fiercepharmamarketing.com/story/jj-launches-quantified-self-app-game-patients-better-behavior/2014-05-28#ixzz34uhFDJr2

Even ASCO has a list of some oncology-related apps (http://connection.asco.org/commentary/article/id/3123/favorite-hematology-oncology-apps.aspx) and

NIH is offering grants for oncology-related app development (https://www.linkedin.com/groupItem?view=&gid=72923&type=member&item=5870221695683424259&qid=dbf53031-dd21-443c-9152-fad87f85d200&trk=groups_most_popular-0-b-ttl&goback=.gmp_72923)
As reports and clinicians have stated, we need health outcome data and clinical trials to determine the effective of these apps.

MyCyberDoctor™, a True Gamification App, Shows Great Results in Improving Diabetics Medical Adherence and Health Outcome

 

Most of the mobile health apps discussed above, would be classified as tracking apps, because the applications simply record a patient’s actions, whether filling a prescription, interacting with a doctor, nurse, pharmacist, or going to a website to gain information. However, as discussed before, there is no hard evidence this is really impacting health outcomes.

 

Another type of application, termed gamification apps, rely on role-playing by the patient to affect patient learning and ultimately behavior.

An interested twist on this method was designed by Akhila Satish, CEO and developer of CyberDoctor and a complementary application PatientPartner.

Akhila Satish Picture

 

 

Ms. Akhila Satish, CEO CyberDoctor

 

 

 

 

 

 

 

Please watch video of interview with Akhila Satish, CEO of CyberDoctor at the Health 2.0 conference http://vimeo.com/51695558

 

And a video of the results of the PatientPartner clinical trial here: http://vimeo.com/79537738

 

As reported here, the PatientPartner application was used in the first IRB-approved mhealth clinical-trial to see if the gamification app could improve medical adherence and outcomes in diabetic patients. PatientPartner is a story-driven game in changing health behavior and biomarkers (blood glucose levels in this trial). In the clinical trial, 100 non-adherent patients with diabetes played the PatientPartner game for 15 minutes. Results were amazing, as the trial demonstrated an increase in patient adherence, with only 15 minutes of game playing.

Results from the study

Patients with diabetes who used PatientPartner showed significant improvement in three key areas – medication, diet, and exercise:

  • Medication adherence increased by 37%, from 58% to 95% – equivalent to three additional days of medication adherence per week.
  • Diet adherence increased by 24% – equivalent to two days of additional adherence a week.
  • Exercise adherence increased by 14% – equivalent to one additional day of adherence per week.
  • HbA1c (a blood sugar measure) decreased from 10.7% to 9.7%.

As mentioned in the article:

The unique, universal, non-disease specific approach allows PatientPartner to be effective in improving adherence in all patient populations.

PatientPartner is available in the iTunes store and works on the iPhone and iPod Touch. For information on PatientPartner, visit www.mypatientpartner.com.

Ms. Satish, who was named one of the top female CEO’s at the Health Conference, gratuitously offered to answer a few questions for Leaders in Pharmaceutical Business Intelligence (LPBI) on the feasibility of using such a game (role-playing) application to improve medical adherence in the oncology field.

LPBI: The results you had obtained with patient-compliance in the area of diabetes are compelling and the clinical trial well-designed.  In the oncology field, due to the increase in use of oral chemotherapeutics, patient-compliance has become a huge issue. Other than diabetes, are there plans for MyCyberDoctor and PatientPartner to be used in other therapeutic areas to assist with patient-compliance and patient-physician relations?

Ms. Satish: Absolutely! We tested the application in diabetes because we wanted to measure adherence from an objective blood marker (hbA1c). However, the method behind PatientPartner- teaching patients how to make healthy choices- is universal and applicable across therapeutic areas. 

LPBI: Recently, there have been a plethora of apps developed which claim to impact patient-compliance and provide information. Some of these apps have been niche (for example only providing prescription information but tied to pharmacy records and company databases). Your app seems to be the only one with robust clinical data behind it and approaches from a different angle, namely adjusting behavior using a gamefying experience and teaching the patient the importance of compliance. How do you feel this approach geared more toward patient education sets PatientPartner apart from other compliance-based apps?

Ms. Satish: PatientPartner really focuses on the how of patient decision making, rather than the specifics of each decision that is made. It’s a unique approach, and part of the reason PatientPartner works so effectively with such a short initial intervention! We are able to achieve more with less “app” time as a result of this method.  

LPBI: There have been multiple studies attempting to correlate patient adherence, decision-making, and health outcome to socioeconomic status. In some circumstances there is a socioeconomic correlation while other cases such as patient-decision to undergo genetic testing or compliance to breast cancer treatment in rural areas, level of patient education may play a bigger role. Do you have data from your diabetes trial which would suggest any differences in patient adherence, outcome to any socioeconomic status? Do you feel use of PatientPartner would break any socioeconomic barriers to full patient adherence?

Ms. Satish: Within our trial, we had several different clinical sites. This helped us test the product out in a broad, socioeconomically diverse population. It is our hope that with a tool as easy to scale and use as PatientPartner we have the opportunity to see the product used widely, even in populations that are traditionally harder to reach.  

LPBI: There has been a big push for the development of individual, personalized physician networks which use the internet as the primary point of contact between a primary physician and the patient. Individuals may sign up to these networks bypassing the traditional insurance-based networks. How would your application assist in these types of personalized networks?

Ms. Satish: PatientPartner can easily be plugged into any existing framework of communication between patient and provider. We facilitate patient awareness, engagement and accountability- all of which are important regardless of the network structure.

LBPI: Thank you Akhila!

A debate has begun about regulating mobile health applications, and although will be another post, I would just like to summarize a nice article in May, 2014 Oncology Times by Sarah Digiulo “Mobile Health Apps: Should They be Regulated?

In general, in the US there are HIPAA regulations about the dissemination of health related information between a patient and physician. Most of the concerns are related to personal health information made public in an open-access platform such as Twitter or Facebook.

In addition, according to Dr. Don Dizon M.D., Director of the Oncology Sexual Health Clinic at Massachusetts General Hospital, it may be more difficult to design applications directed against a vast, complex disease like cancer with its multiple subtypes than for diabetes.

 

Mobile Health Applications on Rise in Developing World: Worldwide Opportunity

 

According to International Telecommunication Union (ITU) statistics, world-wide mobile phone use has expanded tremendously in the past 5 years, reaching almost 6 billion subscriptions. By the end of this year it is estimated that over 95% of the world’s population will have access to mobile phones/devices, including smartphones.

This presents a tremendous and cost-effective opportunity in developing countries, and especially rural areas, for physicians to reach patients using mHealth platforms.

Drs. Clara Aranda-Jan Neo Mohutsiwa and Svetla Loukanova had conducted a systematic review of the literature on mHealth projects conducted in Africa[1] to assess the reliability of mobile phone and applications to assist in patient-physician relationships and health outcomes. The authors reviewed forty four studies on mHealth projects in Africa, determining their:

  • strengths
  • weaknesses
  • opportunities
  • threats

to patient outcomes using these mHealth projects. In general, the authors found that mHealth projects were beneficial for health-related outcomes and their success related to

  • accessibility
  • acceptance and low-cost
  • adaptation to local culture
  • government involvement

while threats to such projects could include

  • lack of funding
  • unreliable infrastructure
  • unclear healthcare system responsibilities

Dr.Sreedhar Tirunagari, an oncologist in India, agrees that mHealth, especially gamification applications could greatly foster better patient education and adherencealthough he notes that mHealth applications are not really used in India and may not be of much use for those oncology patients living in rural areas, as  cell phone use is not as prevalent as in the bigger inner cities such as Delhi and Calcutta.

 

Dr. Louis Bretes, an oncologist from Portugal, when asked

1) do you see a use for such apps which either track drug compliance or use gamification systems to teach patients the importance of continuing their full schedule of drug therapy

2) do you feel patient- drug compliance issues in the oncology practice is due to lack of information available to the patient or issues related to drug side effects?

“I think that Apps could help in this setting, we are in
Informatics era but..
The main question is that chronic patients are special ones.
Cancer patients have to deal with prognosis, even in therapies
with curative intent such as aromatase inhibitors are potent
Drugs that can cure; only in the future the patients know.
But meanwhile he or she has to deal with side-effects every day. A PC can help but suffer this symptoms…it. Is a real problem believe me!”

“The main app is his/her doctor”

I would like to invite all oncologists to answer the poll question ABOVE about the use of such gamification apps, like PatientPartner, for improving medical adherence to oral chemotherapy.

UPDATE 5/15/2019

The results of the above poll, although limited, revealed some interesting insights.  Although only five oncologists answered the poll whether they felt gamification applications could help with oral chemotherapy patient adherence, all agreed it would be worthwhile to develop apps based on gamification to assist in the outpatient setting.  In addition, one oncologist felt that the success of mobile patient adherence application would depend on the type of cancer.  None of the oncologist who answered the survey thought that gamification apps would have no positive effect on patient adherence to their chemotherapy.  With this in light, a recent paper by Joel Fishbein of University of Colorado and Joseph Greer from Massachusetts General Hospital, describes the development of a mobile application, in clinical trial, to promote patient adherence to their oral chemotherapy. 

 

Mobile Applications to Promote Adherence to Oral Chemotherapy and Symptom Management: A Protocol for Design and Development 

 

Mobile Application to Promote Adherence to Oral Chemotherapy and Symptom Management: A Protocol for Design and Development. Fishbein JNNisotel LEMacDonald JJAmoyal Pensak NJacobs JMFlanagan CJethwani K Greer JA. JMIR Res Protoc. 2017 Apr 20;6(4):e62. doi: 10.2196/resprot.6198. 

 

Abstract 

BACKGROUND: 

Oral chemotherapy is increasingly used in place of traditional intravenous chemotherapy to treat patients with cancer. While oral chemotherapy includes benefits such as ease of administration, convenience, and minimization of invasive infusions, patients receive less oversight, support, and symptom monitoring from clinicians. Additionally, adherence is a well-documented challenge for patients with cancer prescribed oral chemotherapy regimens. With the ever-growing presence of smartphones and potential for efficacious behavioral intervention technology, we created a mobile health intervention for medication and symptom management. 

OBJECTIVE: 

The objective of this study was to develop and evaluate the usability and acceptability of a smartphone app to support adherence to oral chemotherapy and symptom management in patients with cancer. 

METHODS: 

We used a 5-step development model to create a comprehensive mobile app with theoretically informed content. The research and technical development team worked together to develop and iteratively test the app. In addition to the research team, key stakeholders including patients and family members, oncology clinicians, health care representatives, and practice administrators contributed to the content refinement of the intervention. Patient and family members also participated in alpha and beta testing of the final prototype to assess usability and acceptability before we began the randomized controlled trial. 

RESULTS: 

We incorporated app components based on the stakeholder feedback we received in focus groups and alpha and beta testing. App components included medication reminders, self-reporting of medication adherence and symptoms, an education library including nutritional information, Fitbit integration, social networking resources, and individually tailored symptom management feedback. We are conducting a randomized controlled trial to determine the effectiveness of the app in improving adherence to oral chemotherapy, quality of life, and burden of symptoms and side effects. At every stage in this trial, we are engaging stakeholders to solicit feedback on our progress and next steps. 

CONCLUSIONS: 

To our knowledge, we are the first to describe the development of an app designed for people taking oral chemotherapy. The app addresses many concerns with oral chemotherapy, such as medication adherence and symptom management. Soliciting feedback from stakeholders with broad perspectives and expertise ensured that the app was acceptable and potentially beneficial for patients, caregivers, and clinicians. In our development process, we instantiated 7 of the 8 best practices proposed in a recent review of mobile health app development. Our process demonstrated the importance of effective communication between research groups and technical teams, as well as meticulous planning of technical specifications before development begins. Future efforts should consider incorporating other proven strategies in software, such as gamification, to bolster the impact of mobile health apps. Forthcoming results from our randomized controlled trial will provide key data on the effectiveness of this app in improving medication adherence and symptom management. 

TRIAL REGISTRATION: 

ClinicalTrials.gov NCT02157519; https://clinicaltrials.gov/ct2/show/NCT02157519 (Archived by WebCite at http://www.webcitation.org/6prj3xfKA). 

 In this paper, Fishbein et al. describe the  methodology of the developoment of a mobile application to promote oral chemotherapy adherence.   This mobile app intervention was named CORA or ChemOtheRapy Assistant. 

 

 Of the approximately 325,000 health related apps on the market (as of 2017), the US Food and Drug Administration (FDA) have only reviewed approximately 20 per year and as of 2016 cleared only about 36 health related apps. 

According to industry estimates, 500 million smartphone users worldwide will be using a health care application by 2015, and by 2018, 50 percent of the more than 3.4 billion smartphone and tablet users will have downloaded mobile health applications.  However, there is not much scientific literature providing a framework for design and creation of quality health related mobile applications. 

Methods 

The investigators separated the app development into two phases: Phase 1 consisted of the mobile application development process and initial results of alpha and beta testing to determine acceptability among the major stakeholders including patients, caregivers, oncologists, nurses, pharmacists, pharmacologists, health payers, and patient advocates.  Phase 1 methodology and results were the main focus of this paper.  Phase 2 consists of an ongoing clinical trial to determine efficacy and reliability of the application in a larger number of patients at different treatment sites and among differing tumor types. 

The 5 step development process in phase 1 consisted of identifying features, content, and functionality of a mobile app in an iterative process, including expert collaboration and theoretical framework to guide initial development.   

There were two distinct teams: a research team and a technical team. The multidisciplinary research team consisted of the principal investigator, co-investigators (experts in oncology, psychology and psychiatry), a project director, and 3 research assistants. 

The technical team consisted of programmers and project managers at Partners HealthCare Connected Health.  Stakeholders served as expert consultants including oncologists, health care representatives, practice administrators, patients, and family members (care givers).  All were given questionaires (HIPAA compliant) and all involved in alpha and beta testing of the product. 

There were 5 steps in the development process 

  1. Implementing a theoretical framework: Patients and their family caregivers now bear the primary responsibility for their medical adherence especially to oral chemotherapy which is now more frequently administered in the home setting not in the clinical setting.  Four factors were identified as the most important barriers to oral chemotherapy adherence: complexity of medication regimessymptom burdenpoor self-management of side effects, and low clinical support.  These four factors were integral in the design of the mobile app and made up a conceptual framework in its design. 
  1. Conducting Initial Focus Group Interviews with key stakeholders: Stakeholders were taken from within and outside the local community.  In all 32 stakeholders served as study collaborators including 8 patient/families, 8 oncologists/clinicians, 8 cancer practice administrators, and 8 representatives of the health system, community, and overall society.   The goal of these focus groups were to obtain feedback on the proposed study and design included perceived importance of monitoring of adherence to oral chemotherapy, barriers to communication between patients and oncology teams regarding side effects and medication adherence, potential role of mobile apps to address barriers of quality of cancer care, potential feasibility, acceptability, and usage and feedback on the overall study design. 
  1. Creation of Wireframes (like storyboards or page designs) and Collecting Initial Feedback:  The research and design team, in conjunction with stakeholder input, created content wireframes, or screen blueprints) to provide a visual guide as to what the app would look like.  These wireframes also served as basis for what the patient interviews would look like on the application.  A total of 10 MGH (Massachusetts General Hospital) patients (6 female, 4 male) and most with higher education (BS or higher) participated in the interviews and design of wireframes.  Eight MGH clinicians participated in this phase of wireframe design. 
  1. Developing, Programming, and Refining the App:  CORA was designed to be supported by PHP/MySQL databases and run on LAMP hosts (Linux, Apache, MySQL, Perl/PHP/Python) and fully HIPAA compliant.  Alpha testing was conducted with various stakeholders and the app refined by the development team (technical team) after feedback. 
  1. Final beta testing and App prototype for clinical trial: The research team considered the first 5 participants enrolled in the subsequent clinical trial for finalization of the app prototype. 

There were 7 updated versions of the app during the initial clinical trial phase and 4 updates addressed technical issues related to smartphone operating system upgrades. 

Finally, the investigators list a few limitations in their design and study of this application.  First the patient population was homogenous as all were from an academic hospital setting.   Second most of the patients were of Caucasian ethnic background and most were highly educated, all of which may introduce study bias.  In addition, CORA was available on smartphone and tablet only, so a larger patient population who either have no access to these devices or are not technically savvy may experience issues related to this limitation. 

In addition other articles on this site related to Mobile Health applications and Health Outcomes include

Medical Applications and FDA regulation of Sensor-enabled Mobile Devices: Apple and the Digital Health Devices Market

How Social Media, Mobile Are Playing a Bigger Part in Healthcare

E-Medical Records Get A Mobile, Open-Sourced Overhaul By White House Health Design Challenge Winners

Qualcomm Ventures Qprize Regional Competition: MediSafe, an Israeli start-up in the personal health field, is the 2014 Winner of a $100,000 Prize

Friday, April 4 8:30 am- 9:30 am Science Track: Mobile Technology and 3D Printing: Technologies Gaining Traction in Biotech and Pharma – MassBio Annual Meeting 2014, Royal Sonesta Hotel, Cambridge, MA

Information Security and Privacy in Healthcare is part of the 2nd Annual Medical Informatics World, April 28-29, 2014, World Trade Center, Boston, MA

Post Acute Care – Driver of Variation in Healthcare Costs

Kaiser data network aims to improve cancer, heart disease outcomes

 

Additional references

  1. Aranda-Jan CB, Mohutsiwa-Dibe N, Loukanova S: Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa. BMC public health 2014, 14:188.

 

 

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The Affordable Care Act: A Considered Evaluation.
Part III. Final Implementation of the Affordable Care Act and a Patient and Community Outcomes Focus

Author and Curator: Larry H Bernstein, MD, FCAP

 

UPDATED on 3/2/2018

Physicians’ Broader Vision For The Center For Medicare And Medicaid Innovation’s Future: Look Upstream

MARCH 2, 2018

https://www.healthaffairs.org/do/10.1377/hblog20180227.703418/full/

 

Introduction

This is the third discussion of a three part series on the Affordable Care Act, which is enacted and has passed review by the US Supreme Court with respect to Constitutional Legality. As a result, there is a requirement for States to implement the ACA by forming Accountable Care Organizations as a major mandate to provide an insurance safety net for the unemployed, the indigent children of unemployed or underemployed, and the highest risk population of our citizens.  The implementation of the law will take time, will need tweaking, and is already accompanied by significant reorganization of the insurance industry, which has been dominated by for-profit-organizations with a label ‘managed-care’, by the alignment of hospitals into large networks to gain leverage in negotiation of annual budget allocations, and reorganization of physicians either into very large ‘institutional providers’, or into groups of independent physicians into a ‘contract managed’ concierge group, or the persistent independent practice with assigned privileges in a department on the Medical Staff.  In any case, these arrangements are clearly matters of managing risk.  The current sequestration is an unneeded confounding factor is the matter of managing financial risk.

There are at least three issues that have surfaced:

[1] The formation of alliances of hospitals, not necessarily within one state, and the provision of care by maybe two hospitals in a community.  One interesting case is the existence of two hospitals in Erie, PA.  The Catholic Hospital has an assigned medical staff, and the other hospital is managed by University of Pittsburgh Healthcare Alliance, which is also a health insurance entity on its own.  The consequence of this arrangement is that there is no crossover of medical staff and patient choice of a physician is no longer an issue for choice.

[2] I have already mentioned where the physician is in this reorganization.  Young physicians coming into practice will choose an established group, or they might become an employee of the hospital with the ‘Part B’ payment coming through the organization’s finance (to the Medical Practice Organization), and the facilities and equipment costs taken care of by the organization.

[3] The hospital’s negotiate the insurance rates as a large network of organizations.  One risk for some members of the organization is the siphoning of cases to the strongest members of the group.  This would mean that smaller, non-metropolitan hospitals would have to refer any cases with moderate-high complexity.   That could present a problem of fairness in allocation of resources, and possibly a problem of access over large distances.

infographic The healthcare and life sciences industry is experiencing unparalleled disruption and consolidation while converging on new business models

mHealth: Managing Data on the Go

Follow the Connecting the Continuum series
By John Morrissey   Hospitals & Health News

The continuum of care requires continual communication and information sharing to tie it together, and that involves computerized equipment that clinicians and patients understand, are familiar with and will gladly use. The proliferation of cellphones, their morphing into miniature computers and the addition of wireless tablet computers have become a ready base for health-related information interchange.

The challenge for health care CEOs is to bring that potential into the particular realm of care delivery, surrounding it with reliable infrastructure and fostering policies on IT support and data security that keep a beneficial but strongly decentralizing force from getting out of corporate control, experts say.
http://www.hhnmag.com/hhnmag/images/pdf/ATTgate_july2013.pdf

A smartphone or tablet is engaging to clinicians “because it’s intuitive, it’s got the good battery life, it’s got the accessibility, fairly good speed; it brings everything to your fingertips,” says David Collins, who heads up mobile health activities with the Healthcare Information and Management Systems Society.

In contrast to interfaces for electronic record systems, which take some time to get to know and love, the intrinsic enthusiasm for mobile devices has required reining in physicians’ ambitions to use them beyond what may be practical or supportable.

An interdisciplinary committee for mobile-health policy — deciding not just device issues, but also the clinical issues of working them into health care operations — is the first step in developing a sensible rather than haphazard approach, says Collins.

Being HIPAA Compliant is a Journey

By Mike Semel

Here are a few simple things you can do to maintain a HIPAA compliant environment.

1.      HIPAA Compliant Human Resource Department

Make sure HIPAA stays on the radar of your HR staff. Be sure that HIPAA training is on the checklist for all employees. The next time a new employee is hired, ask to see the evidence that the person was trained prior to being given access to patient data. If it was done, document it as part of your internal auditing program to stay HIPAA compliant.

2.      HIPAA Compliant Employees

Audit your employees to make sure they are HIPAA compliant. Check work areas to ensure that passwords are not visible. Check the documentation for the tasks they perform. Observe them while they do their jobs. Let everyone know you are looking and conduct random HIPAA audits regularly.

3.      HIPAA Compliant Risk Analysis

Being HIPAA compliant means you will review it at least once a year. Immediately document any significant changes, like moving to a new location, relocating IT equipment to a new data center; or implementing a new EHR system. If nothing changes in a year, just make a note, and sign and date it.

4.      HIPAA Compliant Business Associates

A bigger challenge to being HIPAA compliant than your employees are your vendors. They can cause a data breach that could cost you millions of dollars. Demand evidence that they are HIPAA compliant, and their subcontractors are HIPAA compliant.

5.      Scheduling HIPAA Compliant Management

How can you remember everything needed to be HIPAA compliant?  Use your computer to schedule reminders to audit HR, your employees, and schedule reviews of the biggest threat to you staying HIPAA compliant— usually your IT company, cloud software vendor, data center, or online backup company.

ACP Concerns with Meaningful Use Program

Letter to: Sebelius, Ms. Tavenner, and Dr. Mostashari    Sep 12, 2013

On behalf of the American College of Physicians, I am writing to share our views on what has been released for Stage 2 and what we have been told to expect for Stage 3 of Meaningful Use.

ACP applauds ONC and CMS, as well as the Health IT Policy Committee and Standards Committee for their diligence and hard work in developing Stage 2 of the EHR Incentive Program. However, we are concerned that the very aggressive timeline combined with overly ambitious objectives may unnecessarily limit the success of the entire EHR Incentive program. Further, the reliance on evolving and draft standards, technologies for which integration is not yet completely tested, developing infrastructure, and upcoming regulatory requirements (i.e., ICD-10) add complexity and uncertainty to the situations faced by physicians and their teams.

As you work to transform the recommendations for Stage 3 into ambitious yet broadly achievable measures, we urge you to keep in mind the original guiding principles of the program – to position physicians and other healthcare providers to deliver excellent, patient-centered care focused on improving clinical outcomes.

While we support the goals represented by the Meaningful Use (MU) objectives, we are concerned about the appropriateness, focus and feasibility of some of the proposed measures, as well as the potential unintended consequences and additional costs to the practices of these well-intended efforts.

Return on Investment in EHRs

Meaningful Use Is Only the Beginning: Efficiency and More-Appropriate Coding Bring Savings and Increase Revenues

Today, the hope of receiving “Meaningful Use” rewards is motivating some physicians to begin using electronic health records sooner rather than later. But the government incentives will not cover all of their EHR-related costs, and there are many other reasons to get an EHR now.

Properly implemented, an EHR system with supe-rior features can:

•            Improve practice efficiency. By replacing paper records with EHRs, for example, practices can reduce record handling and access data more quickly for both clinical and billing purposes.

•            Help improve quality of care. Decision-support features can help avoid medical errors, while reporting and registry functions allow practices to track and reach out to patients who need preventive or chronic care.

•            Be a building block for a medical home. Many payers are now giving incentives to encourage physicians to create patient-centered medical homes, which require EHRs.

•            Prepare practices for accountable care: EHRs in interoperable networks are essential to accountable care organizations (ACOs).

•            Help recruit new physicians. Young doctors who trained on EHRs in residency want to work in computerized practices.

Sources Of Return On Investment (ROI)

According to experts, the incentives for Meaningful Use — up to $44,000 per provider through Medicare or nearly $64,000 through Medicaid — will cover only a portion of the long-term cost of an EHR system. Estimates of the five-year cost of EHR hardware and software range from $30,000 to $80,000 per physician, depend¬ing partly on practice size. And that doesn’t include the cost of training, interfaces, patient portals and conversions from other systems.

So a business plan for an EHR system acquisition must include sources of ROI that go beyond Meaningful Use rewards. A short list of these would include:

•            Tax write-offs (in 2011 and 2012)

•            Savings in labor and supplies

•            More accurate and complete coding, which usually results in higher revenue

•            Improved accounts receivable (A/R) manage-ment

•            Conversion of space currently used for chart storage

•            Rewards from Medicare’s Physician Quality Reporting Initiative (PQRI)

•            Pay for performance and medical home incen-tives

Except for depreciation, all of these ROI sources can be facilitated by the use of an integrated EHR and practice management (PM) system with a single database. The government’s regulations also allow physicians to show Meaningful Use by employing a combination of certified EHR modules — for example, electronic prescribing, document management, and charting systems. But if these systems are from unrelated vendors, it will be very difficult and expensive to con¬nect them with a single interface so they can work together. So, even though these modules may enable some practices to meet the Stage 1 Meaningful Use requirements, they will slow physicians down and make practices less, rather than more, efficient.

Government Incentives

To obtain financial incentives, physicians must demonstrate Meaningful Use of an EHR system certified by a government-approved certification body. In Stage 1 of Meaningful Use, a physician or other eligible professional (EP) may attest to Meaningful Use for a 90-day period in either 2011 or 2012. That attestation will entitle the EP to a payment of $18,000. Further payments fol¬low over the next four years if the EP meets the Stage 2 and 3 criteria for Meaningful Use.

EHR as a Powerful Tool in ICD-10 Conversion

The U.S. Department of Health and Human Services has mandated all health care providers begin use of ICD-10 on October 1, 2014. The conversion to the new coding set will demand incredible effort from the medical community and, if not proactively addressed, could cause major disruptions for health organizations. To complicate matters, the conversion comes at a time of other significant changes including the implementation of EHR (electronic health records). Although EHR and ICD-10 may seem like separate issues, adopting the right EHR system will help you prepare for the ICD-10 conversion. AdvancedMD EHR and integrated billing are powerful tools in the ICD-10 conversion. With over 60 years of experience, ADP is a trusted company with the knowledge and resources to give your practice the advantage in ICD-10 conversion and EHR implementation.

Getting ready for ICD-10

The conversion to ICD-10 has caused uneasiness in the health care community. The coding changes come at a time when healthcare providers are already grappling with other reforms, including the implementation of electronic health records (EHR). Recent regulations to implement ICD-10 and EHR are intended to streamline information sharing and create a more efficient national healthcare system. However, the changes can seem overwhelming for a busy private practice. Physicians are scrambling to purchase software and make upgrades before the quickly-approaching deadlines. You can’t afford to wait any longer to develop your EHR and ICD-10 implementation plans.

Although ICD-10 and EHRs may seem like separate issues, carefully designing a plan that address both your needs will save you time, money and energy. Selecting the right EHR system can aid in your conversion to ICD-10.

Today’s EHR systems are more powerful than ever. They have been designed to reflect regulatory changes to record-keeping, documentation, and coding. But not all systems are created equal— choosing an EHR system may be one of the biggest decisions you make for your practice’s financial health. EHR software should reduce the disruptions of ICD-10 conversion, not compound them.

Five things you should consider when selecting an EHR system

1. Invest in an EHR system that will be fully utilized by staff.

When you are selecting an EHR system, be sure that it will meet the specific needs of your practice. In order to reach Meaningful Use (MU) requirements and facilitate the ICD-10 conversion, your EHR system must be accessible to both clinical and administrative staff. An EHR system should meet the following standards:

•            Simple chart note creation
•            Minimal steps to access information
•            Easy-to-learn and easy-to-use interface
•            Intuitive workflow
•            Interoperability with internal and external systems

2. Choose an EHR designed to reduce ICD-10 transition challenges.

ICD-10 requires physicians and clinical staff to capture more specific patient data. With nearly nine times as many codes as ICD-9, the new coding set aims to record a higher level of medical data to use in patient care, billing, and reporting.

Additionally, EHR should aid in creating complete, detailed patient documentation. Physicians have always strove to create accurate patient charts, but the task may seem daunting with new ICD-10 codes and an expectation of increased specificity. EHR systems should provide point-and-click options to apply treatment codes and make chart notes.

3.           Ensure EHR software facilitates clinical information exchange.

When the federal government passed legislation to reform health care information technology, the reporting and exchange of patient information was a primary focus. An important consideration is how EHR technology will manage the data from other providers and health information exchanges (HIE).

Powerful EHR software makes this data an invaluable asset to patient care by intelligently organizing shared information. A private practice’s technology should present clinicians with applicable information in an easy-to-use format.

4.           Check for intelligent mapping and prompting.

An EHR system should enhance the patience experience, not complicate it. Systems that provide intelligent mapping and prompting will allow the provider to easily code and chart. Based on a patient’s history, current findings, and documentation, EHR software should suggest proposed ICD-10 codes.

Physicians can focus on engaging with the patients rather than worrying about coding proficiency or manually hunting through data screens. Intelligent mapping and prompting will reduce the time spent manually updating a patient’s chart or charge slip.

5.           Select an EHR system that will support future requirement updates.

An EHR system can be a powerful tool during the ICD-10 conversion; it can also be a hindrance. Selecting an EHR system that is capable of supporting the ICD-10 transition may be one of the most important decisions you make—but that is just a start. Be sure it will accommodate future regulatory changes.

EHR systems must be adaptable to new requirements through simple upgrades. A powerful EHR system can be updated without causing major disruption to your daily operations or to patient care. When evaluating a new system, be sure it can be modified to address future needs.

Expect more from your EHR. The EHR must provide tools that meet Meaningful Use requirements, maximize practice efficiency, and aid you in the ICD-10 conversion.

Closing Points:

•            Smoothly migrate to ICD-10 compliance with minimal disruption
•            Eliminate the costs and hassles of server-based software and hardware
•            Provide high-quality of care with access to shared health information
•            Increase proficiency and accuracy with an easy-to-learn, easy-to-use interface

Lower Health Insurance Premiums to Come at Cost of Fewer Choices

By         New York Times  Sep 22, 2013

From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.WASHINGTON — Federal officials often say that health insurance will cost consumers less than expected under President Obama’s health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers.

When insurance marketplaces open on Oct. 1, most of those shopping for coverage will be low- and moderate-income people for whom price is paramount. To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.

Some consumer advocates and health care providers are increasingly concerned. Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.

Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group.

“That can be positive for consumers if it holds down premiums and drives people to higher-quality providers,” Mr. Linker said. “But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network
.

ED Use Could Surge Under ACA, Study Suggests

Sep 17, 2013  By Cole Petrochko,    MedPage Today

Action Points

[1] Note that this study of California registry data suggested an increase in ED visits among those insured by Medicaid from 2005-2010.

[2] Be aware that the authors speculate that the high use of the ED by Medicaid participants is due to poor access to primary care.

[3] Increases in California emergency department (ED) use were driven in large part by Medicaid patients, presaging increased burdens after the Affordable Care Act kicks in completely, researchers found.

From 2005 to 2010, the number of visits to California emergency departments rose by 13.2% from 5.4 million to 6.1 million annually, with a significant 35% increase in the number of patients insured through Medi-Cal (as Medicaid is known in California) driving this rise (P<0.001), according to Renee Hsia, MD, MSc, of the University of California San Francisco, and colleagues.

Medicaid patients also had the highest usage burden for ambulatory-care-sensitive conditions (54.76 per 1,000 patients on average) compared with those who had private insurance (10.93 per 1,000 patients) or none at all (16.6 per 1,000 patients), they wrote online in a research letter in the Journal of the American Medical Association.

According to previous research, many patients who will soon be insured under the ACA will be enrolled in Medicaid. While these people are generally healthier than current Medicaid enrollees, they may introduce a new and vast additional burden to treat undiagnosed and uncontrolled conditions.

The largest increase in visits occurred in 2009, most likely because of the “H1N1 pandemic and the influence of the economic downturn on coverage transitions and access to care,” the authors explained. Total visits per 1,000 adults living in California increased by 8.3% from 252 to 274 between 2005 and 2010.

Will healthcare reform drive up ED use?

By Alicia Caramenico
Medicaid patients use the emergency department more frequently than uninsured patients, as they still have trouble accessing primary care, according to a research letter in today’s issue of JAMA.

Researchers conducted a retrospective analysis of California ED visits by adults 19 to 64 years of age from 2005 to 2010, and found the number of visits to EDs increased by 13.2 percent to 6.1 million per year.

The largest increase in ED visit rates occurred among adult Medicaid beneficiaries, who had higher rates than both uninsured and privately insured patients.

Moreover, Medicaid patients’ high and growing ED use for ambulatory care sensitive conditions suggests the trend will continue with Medicaid expansion under healthcare reform, according to the research announcement.

Echoing those concerns, James McCarthy, M.D., of the University of Texas Health Science Center at Houston told MedPage Today the Affordable Care Act’s expansions to Medicaid “will certainly increase [ED visits] as Medicaid beneficiaries will have the most difficulty getting into primary care clinics.”

To prevent Medicaid patients from making frequent visits to the ED, hospitals could replicate efforts in Washington state that improve communication and care coordination between the ED and primary care providers, the article noted. The program in Washington educates Medicaid patients about appropriate care settings and involves case managers identifying and tracking frequent ED users, Michael Lee, M.D. of the Alpert Medical School at Brown University in Providence, R.I., told MedPage.

Hospitals should target Medicaid “super-utilizers,” using early intervention and primary care, to save money while improving the health outcomes of these complex patients, according to The Center for Medicaid and CHIP Services.

But despite concerns that high ED use by Medicaid patients stems from poor access to primary care, previous research has found most Medicaid patients go to the ED because they have to, seeking emergency or urgent care for serious medical problems, FierceHealthcare previously reported.

State Politics and the Fate of the Safety Net

K Neuhausen, M Spivey, and AL Kellermann
Sep 18, 2013       http://dx.doi.org/10.1056/NEJMp1310572             http://www.nejm.org/doi/full/10.1056/NEJMp1310572

Only 2% of acute care hospitals nationwide are safety-net facilities, but they provide 20% of uncompensated care to the uninsured. Because most are in low-income communities, they typically generate scant revenue from privately insured patients. The Medicaid Disproportionate Share Hospital (DSH) program was established to help defray their costs for uncompensated care.

Currently, Medicaid DSH disburses $11.5 billion annually to the states, which have considerable latitude in allocating these funds. Some states carefully target their DSH payments to hospitals providing large volumes of uncompensated care, but others, such as Ohio and Georgia, spread their payments broadly, transforming the program into a de facto subsidy of their hospital industry.

Because the Affordable Care Act (ACA) was expected to dramatically expand insurance coverage, safety-net hospitals were expected to need less DSH money. Therefore, to reduce the cost of expanding Medicaid, the ACA reduced Medicaid DSH funding by $18.1 billion between fiscal years 2014 and 2020. To allow time for coverage expansion to take effect, the cuts are back-loaded — starting at $500 million (4% of current national DSH spending) in 2014 but reaching $5.6 billion (49% of current spending) in 2019.

The DSH cuts are so deep in part because Congress assumed that all states would expand Medicaid, providing coverage for 17 million low-income people and sharply reducing uncompensated care. The anticipated increased revenue from Medicaid was considered sufficient to compensate hospitals for lost DSH funds. The fiscal math changed when the Supreme Court ruled that states could opt out of Medicaid expansion. Now, only 24 states and the District of Columbia plan to expand Medicaid in 2014; 22 states, including Texas and Florida, will not, and the rest are undecided. Thus, at least 6 million Americans who were expected to obtain coverage will remain uninsured. Because many states that won’t expand Medicaid currently receive large DSH payments, their safety-net hospitals will be hit hard when the DSH cuts kick in.

Even states that expand Medicaid will need some DSH support. After Massachusetts implemented its health care reform law, uncompensated-care costs at its hospitals dropped by 40% but soon climbed again. In 2011, Massachusetts hospitals required $440 million to offset their costs for uncompensated care.

Recently, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule allocating reductions in DSH payments across states for the first 2 years, on the basis of three equally weighted factors:

  1. the percentage of uninsured people in the state,
  2. how well the state targets its DSH payments to hospitals with high percentages of Medicaid inpatients,
  3. how well it targets DSH payments to hospitals with high levels of uncompensated care.

If the rule is adopted as written, states with lower percentages of uninsured citizens will receive steeper cuts, but the biggest reductions will hit states that don’t target DSH payments to hospitals providing large amounts of Medicaid and uncompensated care.

We believe the proposed rule moves DSH policy in the right direction by providing incentives to states to focus their remaining DSH funds on the hospitals that need it most. The proposed rule does not change states’ authority to use DSH funds for a broad hospital subsidy, but those that do will get less money.

States that refuse to expand Medicaid and to target DSH payments more carefully will not only forfeit billions of dollars for covering their poorest residents; they will also forgo hundreds of millions more when DSH cuts are ramped up in 2017. If politics continue to trump economic self-interest in these states, the consequences for their safety-net hospitals could be dire.

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/0/nejm.ahead-of-print/nejmp1310572/20130918/images/small/nejmp1310572_t1.gif

If properly enforced, the proposed rule will help sustain the safety net. But if the state governments that refused to expand Medicaid also refuse to rethink their approach to allocating DSH funds, there will be little money left to sustain their safety-net hospitals when the cuts deepen in 2017. The cascade of service reductions and facility closures that this could trigger would have sweeping consequences.

Total Patient Engagement

AT Brooks, L Silverman and GR Wallen
Shared Decision Making: A Fundamental Tenet in a Conceptual Framework of Integrative Healthcare Delivery
Integrative Medicine Insights 2013:8 29–36   http://dx.doi.org/10.4137/IMI.S12783

With the increased usage of complementary and alternative medicine (CAM) in the US comes a need for evidence-based and integrated care systems which encourage open communication between patients and providers. This paper introduces a conceptual framework for integrative care delivery, with shared decision making being the “connecting force” between holistic treatment and improved health outcomes for patients.

The use of complementary and alternative medicine (CAM) is increasing. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as “a group of diverse medical and health care … practices and products that are not generally considered part of conventional medicine” (referring to Western medicine). “Conventional” medicine is oft-referred to as allopathic, or biology-based medicine, which has emerged as the Western medical model. However, CAM is utilized by nearly half of all industrialized countries and similar or higher rates exist in many developing countries.2 These practices can be implemented together with conventional medicine, known as “complementary,” or in place of conventional medicine, known as “alternative”. Particularly in the United States, we are experiencing a shift toward combining the physiologic and technologic dimensions of curing with the spiritual dimensions of healing. The World Health Organization (WHO) recently launched a global strategy on traditional and alternative medicine, focusing on policy, safety, efficacy, and quality.4 Standardization across these dimensions has the potential to increase both access to and knowledge about CAM.

Potential barriers to CAM use and implications.

Despite developments in the field of CAM, certain barriers may inhibit its widespread adoption and integration. These potential barriers are engendered by lack of knowledge about CAM therapies, and difficulty incorporating CAM into daily routines. For treatments which require accessing a health care provider (as opposed to self-care), lack of accessibility may be an issue. Among younger individuals, the approval of family members and significant others can be important factors in individuals’ decision to use CAM.

Despite advances in technology and the power of emerging genetic and genomic discov¬eries, patients around the world are still seeking holistic, individualized care that is focused on health of both the mind and the body. Despite advances in technology and the power of emerging genetic and genomic discoveries, patients around the world are still seeking holistic, individualized care that is focused on health of both the mind and the body. Currently in the US, most patients who present to a primary care provider are scheduled into fifteen-minute visits, even though varying levels in acuity and complexity of conditions may require more intensive attention and longer visits. Expressing concern about patient needs and teaching patients how to control their symptoms are important and necessary in caring for patients in a holistic manner and require focused time and attention on the part of the health care provider. Ben-Arye and colleagues (2012) conducted a study in northern Israel and identified that patients expect that their primary care providers refer them to CAM treatments and participate in building a CAM treatment plan. Some studies suggest that making provider visits more patient-centered should be focused on “improving dialogue quality” and “efficient use of time” instead of lengthening the visits.

Patients have expressed concern about quality of care in general both in the US and internationally. Satisfaction with the care and performance delivered by our health care system is lower in the US than many other countries internationally, and health disparities within the US remain cause for concern because our current model of health care delivery is not adequate.  Experts in the field propose training more integrative health care providers to ensure that healthcare is both “high tech and high touch”.

Shared Decision-Making and CAM

The paradigm shift from “CAM” to integrative medicine reflects a need for open dialogue between patients and their providers, both conventional and CAM. Shared decision-making (SDM) between patients and providers is ethical, can preserve patient autonomy, considers patient values and preferences, and may lead to improved health outcomes. The conceptual framework introduced in this paper suggests that SDM is a vehicle that can help achieve implementation of integrative health care delivery. In a shared decision making model of care, the patient-provider relationship is interactional in nature, in that both the patient and provider are invested and actively involved in treatment decisions. Incorporating patient desires through shared decision-making (SDM) is considered to be ethical by promoting truthfulness and openness while encouraging patient autonomy. Most importantly, SDM has been associated with improved health outcomes across a range of illnesses.

The Challenge and Opportunity of ACOs: Insights from ACO Pioneers

By D Gentile, and T Samo

  1. What is an ACO?
  2. What is Clinical Integration?
  3. What is the role of Information Technology in an ACO?

How can healthcare organizations that were built on volume adapt to the arrival of a value-based reimbursement system? American providers, as well as payers, are struggling to find an answer to that critical question. When it comes to the Accountable Care Organization (ACO), the struggle generally takes two forms: either to jump in with both feet via a model such as the Medicare Pioneer ACO program, or to sit back and take a wait-and-see approach.

1.  What is an ACO?

Accountable Care Organizations are groups of physicians, hospitals and other healthcare providers in a specific geographic area who come together voluntarily to provide coordinated high quality care to their patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, its members share in the savings achieved for payers, whether Medicare or commercial insurers.

Medicare offers three ACO programs:

•            Medicare Shared Savings Program—a program that helps Medicare fee-for-service providers become an ACO

•            Advance Payment Initiative—a supplementary incentive program for selected participants in the Shared Savings Program

•            Pioneer ACO Model—a program designed for early adopters of coordinated care who already contract for defined populations on a risk basis

Many commercial payers have also entered into ACOs with providers, expanding on the long-standing concept of capitated reimbursement, a per-member, per-month advance payment model. In commercial ACO programs, capitated or value-based reimbursement is typically overlaid with targets for overall costs and incentive provisions for meeting cost goals and various quality metrics. Yet many commercial models are more tentative, providing arrangements such as traditional fee-for-service overlaid with shared savings and a care management fee.

2. What is Clinical Integration?

A concept that has been around for many years, clinical integration is the foundation of any ACO. Clinical integration is the means by which ACOs foster collaboration among independent physicians and hospitals to increase the quality and efficiency of patient care. Providers will need to achieve a significant level of clinical integration before they can contract with health plans, or participate in a shared savings incentives program, whether it is funded by Medicare or by commercial payers.

There are three key components of clinical integration: 1) an active, ongoing collaboration between hospitals and physicians; 2) a coordinated effort, informed by information technology, to improve the quality and efficiency of care through the use of evidence-based practices and data-driven performance improvement; and 3) an agreement with a payer that aligns the financial incentives of physicians and hospitals to accomplish these goals. In the Medicare ACO program, as well as a small but growing number of commercial programs, #3 is achieved using the shared savings approach.

3. What is the role of Information Technology in an ACO?

Successful ACOs will be those that best coordinate treatment of chronic diseases, which can, if left unchecked, balloon into expensive hospital stays. Accomplishing this requires all caregivers who treat these conditions to be in the same information loop. For most provider organizations, that means making a significant investment in information technology.

A robust IT infrastructure is required to plug the many gaps that impede the coordination of care across inpatient, outpatient and home care settings. Four basic IT components are needed: 1) a health information exchange to ensure providers across the community have access to the same patient information; 2) an interoperable Electronic Health Record (EHR) that can be accessed in multiple settings, both inpatient and outpatient, to coordinate care; 3) personal health records to help engage patients in their own health; and 4) data analytics tools to profile physicians and at-risk patients alike. Each of these technologies are now in use, but not often in a coordinated manner.

Besides these core technologies, important IT contributors to the success of an ACO include advanced utilization management functions, such as disease management, complex case management, preauthorization services, specialty referral management and other analytic tools, as well as the financial and actuarial modeling typically performed by health plans.

Four categories mirror the key constituents of an ACO: physicians, payers, hospitals and health systems and patients. A fifth category describes an ACO’s organizational imperative – helping these groups to work together by building a shared identity.

Physician:
•            Physician leadership is critical
•            Local governance advances shared goals
•            Equip physicians with infrastructure to succeed
•            Work to engage independent physicians
•            Use both local and global incentives
•            Educate and train on a schedule
•            Monitor physician performance

The ACO flips the traditional adversarial relationship between hospitals and physicians on its head. To be successful, an ACO requires shared, consensual leadership between hospitals and physicians, who come to the table as fully equal partners in the new organization.

Use of Clinical Analytics in the World of Meaningful Use

Feb 2011  Sponsored by Anvita Health

In June 2010, HIMSS Analytics released a white paper that addressed the use of clinical analytics in the marketplace. At that time, most of the respondents participating in this research indicated that they were actively engaged in collecting and/or leveraging both clinical and claims data to enhance patient care cost, safety, efficiency and reducing healthcare costs. It was noted that none of the applications in the EMR suite had reached market saturation. And, while utilization of each of these applications has increased in the past year, that is still the case.

It is this growth in EMR adoption which is one of the principal drivers of the increased use of clinical analytics, since it is the patient data captured by these applications that is the primary source of the information that healthcare organizations analyze using clinical analytics tools. Spurred by Title XIII of the American Recovery and Reinvestment Act (ARRA) adoption of these technologies is expected to continue to accelerate in the future. In July 2010, the Centers for Medicare and Medicaid Services (CMS) published the final rules on the Electronic Health Record Incentive Program. According to the Federal Register, “The HITECH Act statutorily requires the use of health information technology in improving the quality of care, reducing medical errors, reducing health disparities, increasing prevention and improving the continuity of care among health settings”. In order to meet the goals of this statement and receive incentive payments, CMS identified a core set of 14 meaningful use objectives on which eligible hospitals need to focus to qualify for incentive funds provided through the new CMS Medicare and Medicaid incentive program. Additionally, eligible hospitals must achieve five of 10 menu set objectives to qualify for incentive funds.

In addition to a focus on meaningful use measures, the industry’s shift to the use of ICD-10 (International Statistical Classification of Diseases and Related Health Problems-10th revision), mandated for the coding of all inpatient and outpatient claims beginning in October 20132, will also impact the use of clinical analytics.

1 HIMSS http://www.himss.org/content/files/MU Final Rule.pdf 
2 Centers for Medicare & Medicaid Services https://www.cms.gov/ICD10/

The increased granularity from ICD-10, combined with the increased electronic capture of clinical data will yield volumes of new data for which healthcare organizations will have the opportunity to translate into information that can be used to improve the delivery of healthcare in the United States. However, for this to be successful, healthcare organizations will need both the tools to review and analyze data and an environment, such as a data warehouse in which to store and stage the data for efficient analysis.

Drivers for Using Clinical Analytics

In the research conducted in 2010, two key drivers for using clinical analytics to translate data into information were identified. These were achieving a high quality of care and patient safety and increasing awareness about the costs associated with the provision of care. These two factors continue to be the principal drivers in the market, as respondents indicated that they are continuing to try to provide a high level of care to individuals in their service area, while carefully monitoring and managing costs.

One way in which organizations are framing the quality of care issues is within the context of meaningful use, which has become a powerful industry driver. Because of the financial carrot of incentives when meaningful use criteria are met, many healthcare organizations (HCOs) are evaluating how they are capturing and analyzing data. All of the respondents noted that they are carefully analyzing the data that is being generated during the care delivery process and mapping that data against the process measures, such as capturing flow sheet data and changes in vital signs that have been identified in the meaningful use criteria or entering orders using computerized practitioner order entry (CPOE). And, because organizations will be required to report on multiple measures to achieve the meaningful use incentives, they are driven to find ways to be able to capture and report successfully on all measures rather than focusing on only a handful of measures.

Cost control also continues to be a key driver for these organizations, and has become an area of heightened concern over the course of the past year. Healthcare organizations are under pressure to meet increased demands for services, while at the same time containing costs. Additionally, as HCOs shift to an environment in which Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) are being touted as key solutions for the future, HCOs are looking for ways to limit their financial risk and provide care in a smarter, more efficient and more cost-effective fashion. As such, both payer and provider respondents in this research suggested that they look at data that had the potential to allow them to improve the financial bottom line at their organizations.

Current Use of Clinical Analytics

Most of the respondents participating in the June 2010 research reported that they are collecting and/or leveraging clinical and/or claims data to enhance patient care cost, safety and efficiency. The respondents from the current research cited similar approaches. To ensure that they are able to understand trends emerging within their patient population, respondents from the HCOs represented in this study reported analyzing data from wide variety of departments within their organizations. Some of the data sources identified by the respondents from provider organizations included OR, other procedural suites and the emergency department (ED). They also noted that medication, laboratory, billing and claims data were also analyzed. A number of respondents are also looking at data captured in ambulatory environments. The payer respondents in this research are also analyzing data from a wide variety of sources, including laboratory data, pharmacy data and claims (i.e. UB92) data.

Data Sharing

In addition to patient data that is captured at the HCO that is providing care, respondents reported sharing data with other organizations such as Midas, United Hospital Consortium (UHC), Premier and Health Plan Employer Data and Information Set (HEDIS). In conjunction with their own data, these external data sources allow HCOs to create a series of benchmarking reports that help them identify and analyze variances on their performance compared to other organizations of similar size and composition on key metrics such as length of stay, case costs and outcomes measures. Respondents from payer organizations are also relying on external metrics such as HEDIS and CAHPS (Consumer Assessment of Healthplan Providers and Systems) to direct their analysis.

A 3-Year M.D. — Accelerating Careers, Diminishing Debt

SB Abramson, D Jacob, M Rosenfeld, et al.
It’s been more than 100 years since Abraham Flexner proposed the current model for medical education in North America: 2 years of basic science instruction followed by 2 years of clinical experience.1 Over the past several decades, major changes have caused the medical community to reconsider current educational models. These changes include increasing education costs, shifts in health care needs, the demographics of the applicant pool, and many scientific, pharmacologic, and technological advances resulting in increased specialization of physicians.

Oversight of U.S. medical education is compartmentalized, with standards independently set for undergraduate and graduate accreditation by the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME), respectively. This system results in rigid, time-based, non–learner-centered training. Recognizing this limitation, the Carnegie Foundation recently recommended that education should “provide options for individualizing the learning process for students and residents, such as offering the possibility of fast tracking within and across levels.”

In the past 30 years, the required training period after medical school has increased substantially,2 but the time spent in medical school has not been shortened. The average age of physicians entering practice has therefore increased. Since 1975, the percentage of physicians who are younger than 35 years of age has decreased from 28% to 15% (see graph), as the prolongation of specialty training has delayed entry into the workforce, reducing the productive years of clinicians and physician scientists. Compounding the effect of the increased duration of training is the growing number of entering medical students who have taken “gap” years between college and medical school. National data indicate that the average age of first-year medical students is 24. At the New York University School of Medicine (NYUSOM), 55% of this year’s entering medical students have taken 1 or more gap years.

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2013/nejm_2013.369.issue-12/nejmp1304681/20130918/images/small/nejmp1304681_f1.gif

Percentage of Physicians in the United States Who Are Younger Than 35 Years of Age, 1975–2011.

The Challenge and Opportunity of ACOs: Insights from ACO Pioneers

Djen Linji    http://bit.ly/acochallenges
How can healthcare organizations that were built on volume adapt to the arrival of a value-based reimbursement system? American providers, as well as payers, are struggling to find an answer to that critical question. When it comes to the Accountable Care Organization (ACO), the struggle generally takes two forms: either to jump in with both feet via a model such as the Medicare Pioneer ACO program, or to sit back and take a wait-and-see approach.

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hhs_medicare_docs participating in and billing Medicare

healthprices time price of HC over 50 years

NHEbyDCforHS1 NHE annual growth rate of 4%

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