A Primer on Meaningful Use and HISPs

The Massachusetts State government offers low cost HIE services including Direct transport to all the stakeholders of the Commonwealth.    Recently. Micky Tripathi wrote this FAQ which is so good that I wanted to share it on my blog.   Feel free to use it with your stakeholders.

1. What is a HISP?
A Health Information Services Provider (HISP) is an organization that manages security and transport for health information exchange among health care entities or individuals using the Direct standard for transport.  There is no specific legal designation for a HISP, nor are HISPs specifically regulated by Meaningful Use certification rules.  The term HISP was coined to describe specific message transport functions that need to be performed to support scaled deployment of the Direct standard in the market.  HISP functions can be performed by existing organizations (such as EHR vendors or hospitals or HIE organizations) or by standalone organizations specializing in HISP services.

HISPs perform two key functions that support scalability of exchange using the Direct standard. 

a. Issue security certificates.  HISPs establish trust networks by defining policies for network participation and issuing security certificates tied to a HISP anchor certificate to enforce such policies
b. Issue direct addresses.   HISPs issue direct addresses tied to the HISP anchor certificate in accordance with conventions defined by the Direct standard

2. Do I need to use a certified HISP to attest for Meaningful Use Stage 2?
No, because there is no such thing as a certified HISP.  Meaningful Use certification applies to technology, not to organizations.  In order to attest for Meaningful Use Stage 2, you need perform certain activities using certified EHR technology (CEHRT).  For most EHR users, their EHR is certified for all of the functions that they need.  If it is not, you will need to incorporate specific additional certified technology solutions to fill the remaining gaps.  It doesn’t matter whether that additional technology comes from an EHR company or a HISP company – the only thing that matters is that the technology is certified.

3. Doesn’t DirectTrust certify HISPs?
DirectTrust is a private, non-profit organization that voluntarily certifies HISPs through its EHNAC DTAAP program.  This private, voluntary certification often gets confused with Federal Meaningful Use certification.  DirectTrust is NOT a Federal certification entity, and its EHNAC DTAAP certification process is purely private and voluntary and has no relationship with Meaningful Use Stage 2 attestation or certification requirements.

4. What role does a HISP play in Meaningful Use Stage 2?
A HISP provides specialized network services that connect your EHR to other EHRs that are also using the Direct standard for communications.  You don’t need a HISP in order to create Direct-compliant messages, but you do need to be connected to a HISP in order to send and receive Direct messages with other parties.  Using an email analogy, you may have Microsoft Outlook installed on your computer, but if it isn’t connected to an email network, your emails can’t go anywhere and none can get to you.  Similarly, your CEHRT can send and receive Direct-compliant messages, but those messages won’t go anywhere unless you and those who you are communicating with have valid
Direct addresses and are connected to a secure network that can get the messages safely and reliably from one endpoint to another.  These are the message transport functions that HISPs perform.

There are two Meaningful Use Stage 2 attestation requirements that require Direct transport:

• Summary care record for transitions of care (TOC)
• Patient ability to view, download, transmit their medical record (VDT)

Most HISPs (including the Mass HIway) do not yet have the ability to connect directly with patients, so they are not able to assist with the VDT requirement.

For the purposes of attestation, the Meaningful Use Stage 2 TOC requirement specifies that you must electronically send a standardized summary care document to another care setting, and that you must have reasonable assurance that the other care setting actually received the document.  The HISP performs the message transport functions to provide you with the assurance that your messages have been delivered to their intended recipients.

In order to attest for the TOC requirement, you need to send CCDA care summaries containing at least problem lists, medications, and medication allergies.  These summaries must be transmitted with your CEHRT using either the SMTP/SMIME or XDR/SOAP protocol.  There is no Federal certification for HISPs, so you can send your message to its intended recipient using any HISP or any number of HISPs, as long as you have assurance that the message will get delivered.  The only certified system that you need to use is the one that creates the Direct-compliant SMTP or XDR message – after that, your message may take any number of “hops” between your EHR and its final destination, and as long as you’re confident that the message will get delivered, you will have completely fulfilled your Meaningful Use Stage 2 attestation requirement.

5. How do I get assurance that my messages are delivered?
Meaningful use attestation requirements do NOT specify how you get assurance of delivery, they specify only that you have taken reasonable steps to be confident of delivery.  The most robust way for you to be assured of message delivery is for your system to receive message disposition notifications (MDNs) for each message sent by your EHR to the intended recipient.  However, not all receiving systems or HISPs can generate MDNs, and not all EHR systems can consume MDNs even if they are returned. 

Fortunately, you are not required to receive MDNs in order to be assured of delivery.  Other acceptable methods of assurance are through HISP guarantees of delivery after successful setup testing and/or notification of failure of delivery (like emails) and/or HISP central maintenance of delivery logs that can be made available as needed. 

The Mass HIway provides you with assurance of delivery through rigorous setup testing, and maintenance of a central log of delivery successes and failures.  This log is made available to participants as necessary in the event of an audit.  The Mass HIway will also return any MDNs or application-specific responses or acknowledgements generated by receiving endpoints, however, the Mass HIway cannot guarantee that any receiving endpoint will generate notifications, acknowledgements, or responses.

The one exception where delivery notification is available and required is public health.  The Massachusetts Department of Public Health requires that participants receive delivery notifications in order to satisfactorily meet the Meaningful Use Stage 2 public health requirements.  Massachusetts DPH does generate automated acknowledgements, which are sent automatically via the Mass HIway in response to each message successfully received.

6. Is the Mass HIway a HISP?
Yes.  The MA HIway is a trust community that issues security certificates and Direct addresses to eligible participants and provides Direct-compliant message transport services for its participants.

7. Is the Mass HIway certified as an EHR module for Meaningful Use Stage 2?
No, the Mass HIway is not certified as an EHR module for Meaningful Use Stage 2.  Most providers will not require the Mass HIway to be certified in order to use it to help fulfill their Meaningful Use Stage 2 attestation requirements.  (See discussion above in FAQ on HISP roles.)  As long as your CEHRT delivers a Direct-compliant SMTP or XDR message to the Mass HIway (either to the LAND appliance or directly to the central site), you do not need the Mass HIway to be certified.

If your CEHRT does not send a Direct-compliant SMTP or XDR message to the Mass HIway (for example, if you are sending messages to the LAND appliance in a format other than SMTP or XDR), then you will need to change your interface to send Direct-compliant SMTP or XDR to the Mass HIway (including the LAND appliance) in order to count any of these transactions for Meaningful Use Stage 2 TOC requirements.

Even though you do not need the Mass HIway to be certified for Meaningful Stage 2 in most cases, you will still need to have assurance of delivery of messages sent over the Mass HIway to meet your Stage 2 TOC attestation requirements.  The Mass HIway provides this assurance by delivery after successful setup testing.

8. Must I be connected to the Mass HIway in order to attest for Meaningful Use Stage 2?
Yes, you need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 public health requirements for immunization and cancer registries, and syndromic surveillance.  The Massachusetts Department of Public Health will accept public health transactions only through the Mass HIway.  Thus, though there is no Federal requirement that you be connected to the Mass HIway for Meaningful Use Stage 2, you will not be able to meet core public health requirements for Meaningful Use Stage 2 without being connected to the Mass HIway.

You do not need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 TOC requirement.  However, over 100 providers and payers are already live on the Mass HIway HISP.  Thus, connecting to the Mass HIway will likely make it easier for you to meet your TOC requirements because you will be immediately connected with many of the providers you share patients with.

9. The Meaningful Use Stage 2 rules refer to the eHealth Exchange – is that the same as the Mass HIway?

No.  The eHealth Exchange is a health information exchange network comprising federal agencies and other large non-federal organizations.  The Mass HIway is not connected with the eHealth Exchange in any way.

10. Do I have to be connected to the eHealth Exchange in order to meet my Meaningful Use Stage 2 attestation requirements?

Absolutely not.  While the Meaningful Use Stage 2 rules do allow special dispensation for eHealth Exchange members, few providers will attest using this mechanism.  No Massachusetts providers or payers are currently members of the eHealth Exchange.

11. Who are the other HISPs in Massachusetts, and can I join any HISP that I want?
There are a wide variety of HISPs operating in the Commonwealth.  Whether you join any particular HISP depends on a number of factors.  The biggest factor is which HISPs your EHR vendor allows you to join.  Some vendors require that you use a specific HISP (either their own or the one they are integrated with), while other vendors (such as Meditech and Epic) allow the provider to choose which HISP they would like to connect to.  CMS and ONC do not require that you use any particular HISP for meaningful use, but in practice, your EHR vendor will dictate which HISP options are available to you.

If your vendor allows you to choose which HISP to connect to, you can connect directly to the Mass HIway HISP.  If your vendor requires that you use their designated HISP, you will have to connect to the Mass HIway through their HISP, as long as their HISP is connected to the Mass HIway.
Please contact the Mass HIway (http://www.masshiway.net) if you have any questions about your connection options.

12. Is the Mass HIway part of DirectTrust?
No, the Mass HIway is currently not a member of DirectTrust.  DirectTrust is a voluntary private non-profit collaborative that is helping HISPs to connect with each other.  The Mass HIway is connecting directly with the major HISPs operating in the Massachusetts market.  The Mass HIway may join DirectTrust at some point in the future if it provides additional value to participants.  Providers, EHRs, or HISPs do NOT need to be part of DirectTrust in order to meet their Meaningful Use Stage 2 certification and attestation requirements.

13. If I’m in another HISP, can I still be on the Mass HIway?
Yes.  You can connect to the Mass HIway even if you are a member of another HISP.   The Mass HIway is actively connecting with the major HISPs operating in the Massachusetts market so that messages can be sent between HISPs.  You do still have to join the Mass HIway by signing a participation agreement even if you are in another HISP.  As a member of another HISP, you will pay whatever fees are charged by your local HISP and your Mass HIway fees will be waived.  Once you have joined the Mass HIway, your local HISP will configure your system to enable access to the Mass HIway network.  Your local HISP will still provide you with your security certificate and your Direct address, but you will be able to send and receive messages over the Mass HIway network. 

Below is a current list of HISPs that are expected to be connected to the Mass HIway.  The HISP market is evolving rapidly so more HISPs will be added as demand grows.  Please contact the Mass HIway (http://www.masshiway.net) if you would like to discuss your connection options.

HISP Live date
eClinicalWorks April 2014
Surescripts April 2014
eLINC/SES April 2014
Allscripts/MedAllies TBD
Athenahealth TBD
Wellport/Alere TBD

http://geekdoctor.blogspot.com/2014/03/a-primer-on-meaningful-use-and-hisps.html

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HHS FY 2015 budget to reduce Medicare-Medicaid fraud, waste

The Department of Health & Human Services has release its budget for fiscal year 2015, which the department claims is both “fiscally responsible” and aims to strengthen its two most important programs — and doing so by reducing healthcare fraud and waste.

“On the mandatory side, we’ll contribute a net $369 billion toward deficit reduction over the next decade,” Secretary Kathleen Sebelius said in a press conference earlier today. “By incentivizing high-quality and efficient care and by continuing to reduce healthcare cost growth, this budget also strengthens two very important programs — Medicare and Medicaid — with $415 million in net savings over the next decade and extends the solvency of the Hospital Insurance Trust Fund by five years.”

According to Sebelius, a major focus of the FY 2015 budget is to control the year-to-year growth of Medicare over the next ten years. “It will reduce the average annual growth in Medicare over the next decade from 6.3 percent to 5.3 percent. What’s more, by expanding competitive bidding for durable medical equipment, it also produces additional savings for Medicare and its beneficiaries alike,” she added.

An important part of these cost-reduction efforts highlighted in today’s press conference and budget was the work of Health Care Fraud and Abuse Control Program (HCFAC), whose investment is apparently paying off.

“[The budget] invests $428 million in HCFAC and the Medicare Integrity Program, both of which are proven to deliver results in fighting fraud. Every dollar we invest in HCFAC, for example, returns $8.10 of the money we recover. We’ve now announced recovering a record-breaking $4.3 billion,” she explained.

The budget indicates that preventing fraud and reducing improper payments are “top priorities” for the current administration. The investments in HCFAC and Medicaid program integrity funds are expected to yield $13.5 billion in gross savings for Medicare and Medicaid over the next decade.

The budget is also proposing the introduction of new tools via legislative action to increase program integrity oversight. For the Medicare program, these include:

• Allowing prior authorization for Medicare fee-for-service items;

• Allowing civil monetary penalties for providers and suppliers who fail to update enrollment records;

• Allowing the Secretary to create a system to validate practitioners’ orders for high-risk items and services;

• Increasing scrutiny of providers using higher-risk banking arrangements to receive Medicare payments

• Retaining a percentage of incentive reward payment recoveries

For Medicaid, the following proposal are being made:

• Increasing investment in and expanding authority of the Medicaid Integrity Program;

• Supporting Medicaid Fraud Control Unites for the territories;

• Expanding Medicaid Fraud Control Unit review to additional care settings;

• Tracking high prescribers and utilizers of prescription drugs in Medicaid;

• Consolidating redundant error rate measurement programs;

• Preventing use of federal funds to pay state share of Medicaid or CHIP;

• Improving program integrity for Medicaid drug coverage.

Read the complete HHS FY 2015 budget here.

http://ehrintelligence.com/2014/03/05/hhs-fy-2015-budget-to-reduce-medicare-medicaid-fraud-waste/

Florida Health Choices launches state exchange

MIAMI (AP) — The troubled Florida Health Choices program launched an insurance exchange Tuesday, after several delays, that is separate from the Affordable Care Act marketplace.

CEO Rose Naff delayed the launch last month after 10 times higher than anticipated interest in the site prompted technology experts to retool the website. But Naff announced they were open for business with a single vendor, which is offering five different plans, including a prescription discount card and bundled discount products that includes vision, dental, telemedicine and prescriptions.

The program is separate from Obama's federal health law and will not offer tax credits. Consumers seeking to buy insurance on the federal exchange who mistakenly end up on Florida Health Choices' site will be directed to healthcare.gov. For now, major insurers have not signed on to offer plans through Florida Health Choices and coverage under the program will not count as comprehensive health coverage under the Affordable Care Act.

Instead, Florida Health Choices will cater to consumers who don't like the president's law or may be seeking gap coverage, pharmacy discount cards and limited vision or dental plans. The program will add more vendors going forward, which will provide coverage for prepaid health clinics, primary care and outpatient visits. Florida Health Choices also hopes to offer some type of coverage to the roughly 1 million Floridians who make a bit too much money to qualify under stringent Medicaid standards but not enough to qualify for tax credits through the federal exchange.

Naff said she learned from the bungled rollout of the federal health law and delayed the launch several times to ensure the website was ready. Site capacity was increased to handle 30,000 users a day, including 1,000 simultaneous applications, she said.

Critics have complained that Florida Health Choices, the brainchild of former House Speaker Marco Rubio, started in 2008 and still doesn't have a single enrollee more than five years later. But Republicans, many who were eager to an alternative to so-called "Obamacare," have championed the program. Lawmakers have given Florida Health Choices about $1.5 million over the years.

Florida Health Choices hopes to enroll 67,000 consumers in its first year to break even. Naff said she isn't planning to ask lawmakers for additional funds this year.

http://www.naplesnews.com/news/2014/mar/04/fla-health-choices-launches-state-exchange/

FCC Creates Task Force To Boost Wireless Health Adoption

Wednesday, March 5, 2014

TOPIC ALERT:

• Telehealth

Click on topic to receive periodic emails.

On Tuesday, the Federal Communications Commission announcedthat it will create a new task force to examine ways to accelerate health care organizations' adoption of wireless technologies, The Hill's "Hillicon Valley" reports (Hattem, "Hillicon Valley," The Hill, 3/4).

Task Force Details

The task force -- called Connect2HealthFCC -- will be led by Michele Ellison, who has served as chief of FCC's Enforcement Bureau since 2009. Ellison will work with FCC's Director of Health Care Initiatives, the chiefs of the Wireline and Wireless Bureaus and the Office of Engineering and Technology, as well as, public and private health care stakeholders.

In a statement, FCC Chair Tom Wheeler said the task force would work to:

• Identify regulatory barriers and incentives to expand the use of wireless health technologies; and
• Strengthen partnerships with stakeholders in the telehealth and mobile health industries.

He said, "We must leverage all available technologies to ensure that advanced health care solutions are readily accessible to all Americans, from rural and remote areas to underserved inner cities" (Slabodkin, Health Data Management, 3/5).

http://www.ihealthbeat.org/articles/2014/3/5/fcc-creates-task-force-to-boost-wireless-health-technology-adoption

Malcolm Gladwell Keynotes Healthcare Data Interoperability Summit

The global narrative for “digital health” is relatively easy because the opportunities are so enormous. The only real limit is our imagination. Some of the more recent developments have been breathtaking – and include everything from genomics and personalized medicine to 3-D printing to putting healthcare literally in the palm of our hands (or the embedded sensors we will all wear or consume). At the core of it all is a single strategic component – data.

But the challenges are equally enormous – and nowhere is that more evident than data interoperability. This key alignment is at the heart of enormous (often competing) financial interests, true patient engagement and the health (both financial and clinical) of nations – including our own. The lack of this alignment is more than just inconvenient because it often results in gross inefficiencies, fraud, misaligned incentives and errors – all of which result in outcomes that are more expensive and less than desirable (including death).

There were a fair number of healthcare events last month including the largest healthcare IT event of the year – HIMSS. Now in its 53rd year, HIMSS attendance is nearing 40,000 with about 1,000 vendors and hundreds of educational tracks – all of which descended on Orlando, Florida for the better part of last week. As the CEO of Aetna Aetna, Mark Bertolini’s keynote stood out (here) and Hillary Clinton was standing room only.

But HIMSS wasn’t the only significant event last month. There was a second, smaller event that took place in the nation’s O.R. of healthcare policy – Washington, D.C.

Sponsored by West Health Institute (previous coverage by Forbes colleague Zina Moukheiber here), the daylong event – Health Care Innovation Day – was notable for three reasons. First, it had a singular focus on healthcare data interoperability; second because it was co-sponsored by the Office of the National Coordinator (ONC); and third because it included a compelling keynote by master storyteller and serial-bestselling author Malcolm Gladwell.

Gladwell’s latest book – David and Goliath – is the biblical metaphor for many modern endeavors and industries – including, of course, healthcare. In fact, the event itself was a kind of David in the shadows of the HIMSS Goliath.

Gladwell’s healthcare credentials are often overlooked but he did reference them in his opening remarks. From 1987 to 1996 he covered the healthcare industry for the Washington Post and so he openly wondered what his coverage would have been in his former capacity.

He often generates controversy, but whatever else, he is a master storyteller and there were three compelling vignettes for this keynote. They weren’t cut from healthcare cloth, but an opening line helped to frame their relevance.

But I’m only going to spend a little time talking about healthcare proper – both because I think  it’s often more useful to approach some of these issues from an angle by looking at the world outside of the one you’re engaged in – and secondly because I have a rule that I never talk about something my audience knows more about than I do. Malcolm Gladwell – Author

It’s that skewed angle – punctuated with relevant stories – as told by a master storyteller – that really puts Gladwell at the forefront as a speaker. Relative to data interoperability, Gladwell recounted the stories to help “reframe” the data interoperability dialog that continues to gridlock much of the healthcare industry – and the promise of digital health.

The first was The Beqaa Valley Turkey Shoot in reference to the rapid defeat of Syria by Israeli air supremacy in 1982. The swift and decisive victory was orchestrated by bringing different technologies together in a new and far more integrated way.

Using drones, AWAC’s and laser-guided missiles, the Israeli’s were among the first to carefully orchestrate their coordinated use in real time. The Israeli’s didn’t invent any of the component technologies, but they “integrated” their use in a new way that revolutionized military strategy with an exponentially lethal capacity.

The second story was The Shipping Container and recounted the story of Malcolm McLean – who revolutionized the shipping industry. He didn’t invent the shipping container, but he re-framed the problem in a way that transformed both domestic and international shipping.

By standardizing all of the components (containers, trucks, trailers, railways, docks, cranes and ships) in a new way (Lego at an industrialized scale), he effectively reduced the cost of loading and unloading from $5.50 a ton to $0.15 a ton. From his recognition that the problem required a broader systemic solution (not a component solution in isolation), domestic and international trade mushroomed exponentially.

The third story was The MP3 Player and how digitizing music revolutionized every aspect of the music industry. The effect of digitizing music was to make it interchangeable and interoperable. Almost overnight, music was transformed from being an album and episodic experience into one of personal and continuous use. Individual devices like record, cassette and CD “players” artificially constrained the way music was consumed.

Music stores, a dominate part of the retail landscape (and music experience) disappeared entirely within about 5 years. By un-tethering music from a rigid distribution model around proprietary formats, music enjoyment and sales exploded. From 2000 to 2010, growth in live performances and album sales both tripled.

In all three cases, it’s the combined interoperability that has the truly disruptive and exponential effect. The underlying component technology isn’t always a new invention – or exponentially disruptive.

“Sometimes when we look at innovation we make the mistake of thinking that innovation is specific to an individual invention or device. But all of those [individual] views miss the greatest transformation that’s brought about by technology – and that’s when you bring these various pieces and have them work together in combination – it’s the synergies between these tools that bring about the greatest changes in the world that we live in. You are on to something very crucial here – and I wish you all the best.” Malcolm Gladwell – Author

The urgent need for interoperability in healthcare is well understood. It could well be that interoperability isn’t the biggest problem in healthcare today – it’s just the first.

The HCI-DC conference was really designed to emphasize and accelerate the much needed national dialogue on driving medical interoperability to enable a smarter healthcare system across all the different interests. Ultimately, we’re all patients and we all deserve better care than the chaotic, proprietary and unconnected system we experience today. Together, we are working with key stakeholders to transform healthcare delivery in this country to make high-quality healthcare more accessible at a lower cost.” Nick Valeriani – CEO, Gary and Mary West Health Institute

The archived content for the day long event Sponsored by West Health and ONC (including Gladwell’s keynote) is now available in it’s entirety online (free but registration required) here.

http://www.forbes.com/sites/danmunro/2014/03/02/malcolm-gladwell-keynotes-healthcare-data-interoperability-summit/

Telemedicine: Doctor Visits via Video Calls

By Olga Kharif February 27, 2014

---

(Corrects reference to the technology used by Lindsay Kolowich in the sixth paragraph.)

One night last fall, Beth Ferrin’s 9-year-old son came home with a swollen throat and fever. It was after dinner, so she flipped open her laptop and dialed into LiveHealth Online, a service offered by her insurer, WellPoint (WLP), that connects patients with doctors via video calls. Fifteen minutes later, Ferrin says, “we were on with a doctor.”

After a quick diagnosis of an infection (the doctor, Ferrin says, treated it as strep, though couldn’t diagnose that without a test), a prescription for an antibiotic was called in to a pharmacy near Ferrin’s home in Bellbrook, Ohio. “By 10 p.m., I was back home,” she says. “It was quick and easy.” Her other options would have been to see a doctor in the morning or risk a long wait at an urgent care facility. The video call was faster and cheaper—it cost $40 instead of the $100 a pediatrician would charge, she says.

Hundreds of employers of all sizes are contracting directly or through their insurers with telehealth providers to cut medical costs and give workers 24-hour access to doctors and nurse practitioners. WellPoint teamed up with Boston-based American Well to offer telemed services to 3.5 million of its health-plan subscribers last year and intends to extend the service to another 32.5 million over the next 12 to 18 months. UnitedHealth Group (UNH) began a pilot program in January, providing 310,000 subscribers in Nevada with virtual doctors’ visits.

Telemedicine has been spurred in part by the Affordable Care Act, which is funneling more patients into a system plagued by physician shortages. By 2020 the U.S. will have 91,500 fewer doctors than needed, says the Association of American Medical Colleges. Telehealth providers say they help make up for this shortfall by aiding doctors in delivering services more efficiently. WellPoint says users of LiveHealth Online saved an average $71 per visit and most of them saved two to three hours of time.

The widespread use of camera-equipped devices has made remote medical connections easier, and high-definition video often provides enough detail for medical professionals to make diagnoses. “Sometimes if it’s a rash, we can see the rash,” says Katherine Sandstrom, a nurse practitioner in Portland, Ore., who sees a few patients via video each week through health-services provider ZoomCare.

Lindsay Kolowich, a 23-year-old marketer in Boston, recently consulted a doctor through American Well. She wanted to check on how her foot was healing after recent surgery. Her surgeon was far away and only available midday, so she opted for a teleconsult that didn’t require time off from work. “It saved me four or five hours,” Kolowich says. “I had to show him where it hurt and how flexible my foot was, and he gave me easy directions on what to do,” she says.

Telecare works well for treating common conditions such as colds, flu, pink eye, and sprains, providers say. The larger telemedicine companies contract with doctors with an average 15 years’ experience who are certified to practice in the states from which patients call.

The American Telemedicine Association is developing an accreditation program for telehealth providers. A bill introduced in Congress last year by Representatives Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio) would create federal telecare standards.

“I don’t think we know how it works, the risks and benefits at the moment,” says James Perrin, president of the American Academy of Pediatrics. When asked about the throat infection of Ferrin’s son, Richard Rosenfeld, chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y., said: “The only way to diagnose strep is with a test. Best practices say you can’t just throw an antibiotic at somebody.” He says there’s only so much a doctor can tell without an examination performed in-person and telemedicine visits could result in unnecessary medication.

Telehealth companies say they track their doctors’ prescribing practices to ensure they’re in line with the prescription levels of in-clinic doctors. “Reaching out to your primary physician is the best way to be treated,” says Timothy Howard, senior medical director for telemed provider Teladoc. “But if that physician is not available, we would like to be that next level.” Many doctors who provide telehealth services often advise patients to follow up with their doctors.

Most users pay about $40 a visit and receive the services through their insurers. A small number have signed on directly, paying as little as $10 a month for a subscription. About 20 states require private insurers to reimburse doctors for services provided remotely. At least 10 additional states might enact similar laws this year, says Jonathan Linkous, chief executive officer of the American Telemedicine Association.

Telehealth companies are reporting double-digit revenue growth and attracting high-profile investors. MDLive raised $23.6 million in January. Its investors include former Apple (AAPL) CEO John Sculley. “Our service is expected to increase 10 times in the number of patient visits this year,” Sculley says.

“It’s going to be just like urgent care was in the U.S.—it’s now completely acceptable,” MDLive CEO Randy Parker says. “Within the next few years, no consumer will even remember not being able to connect to their providers through telehealth.”

The bottom line: Investors are putting money into telehealth services, used to treat common ailments.

Kharif is a reporter for Bloomberg News and Bloomberg Businessweek in Portland, Ore.

http://www.businessweek.com/printer/articles/186457-telemedicine-doctor-visits-via-video-calls

Smoky Mountain Center introduces mental health literacy program

Press release

From Smoky Mountain Center:

Smoky Mountain Center, in collaboration with the Mountain Area Health Education Center (MAHEC*) and Western North Carolina Health Network, is pleased to add up to thirty new instructors to the Mental Health First Aid team in a training session March 3-7, 2014 at the MAHEC Mary C. Nesbit Biltmore Campus.

The MHFA training course is designed to give members of the public key skills to help someone who is developing a mental health problem or experiencing a mental health crisis. Through this program, conducted by the National Council for Behavioral Health, new instructors will be certified to teach the 8-hour course to a variety of audiences. MHFA is one of several evidence-based programs Smoky Mountain Center provides to the community. The program is intended to identify opportunities for early intervention for individuals experiencing mental health concerns.

“We are thrilled to bring Mental Health First Aid to our Western North Carolina communities,” said Elizabeth Flemming, MA, LPC, Continuing Education Planner at MAHEC. “Most people know how to recognize and appropriately react to medical emergencies, but there is little knowledge in the general public about what to do in a mental health crisis.”

“I’d like to see people as familiar with MHFA as they are with CPR,” states Carolyn Dorner, Quality Coordinator at WNC Health Network. “We need to know how to respond when our friends, family, coworkers and neighbors need help.”

Genny Pugh, Senior Director for Community Collaboration at Smoky, said, “Mental Health First Aid is one of several evidence based programs we provide in our communities. Offering Mental Health First Aid classes to citizens across our 23 county catchment supports wellness for individuals and families through early identification and intervention for mental health concerns.

“We’re enthused to welcome MAHEC as a partner in extending mental health first aid across the country” says Linda Rosenberg, MSW, president and CEO of the National Council. “We anticipate the new instructors will have a great impact on the mental health communities throughout Western North Carolina and will be key players in improving mental health literacy nationwide.”

More than 3,700 U.S. instructors are already certified by Mental Health First Aid USA (MHFA-USA)** as instructors in all 50 states, the District of Columbia, and Puerto Rico. Instructors come from a variety of backgrounds, including behavioral healthcare, law enforcement and public safety, universities, faith communities and primary care. Included on SAMHSA’s National Registry of Evidence Based Programs and Practices, studies show that training in Mental Health First Aid builds confidence in helping an individual experiencing a mental health challenge, reduces negative or distancing attitudes towards individuals with mental illnesses, and increases mental health literacy – being able to identify, understand and respond to signs of mental illnesses and substance use disorders.

Smoky Mountain Center manages mental health, substance abuse, and intellectual/developmental disability services in Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Watauga, Wilkes and Yancey Counties in North Carolina. Access to services is available 24 hours a day, 7 days a week by calling 1-800-849-6127.
*MAHEC was established in 1974 and is a leader in healthcare, education and innovation. Located in Asheville, MAHEC serves a 16-county region in Western North Carolina. It is the largest Area Health Education Center in North Carolina, which evolved to address national and state concerns with the supply, retention and quality of health professionals. MAHEC’s mission is to train the next generation of healthcare professionals for Western North Carolina through quality healthcare, innovative education, and best practice models that can be replicated nationally.

**Mental Health First Aid USA (MHFA-USA) is a collaboration between the National Council for Behavioral Health, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health.

The National Council for Behavioral Health (National Council) is the unifying voice of America’s community mental health and addictions treatment organizations. Together with our 2,000 member organizations, we serve our nation’s most vulnerable citizens — the more than eight million adults and children living with mental illnesses and addiction disorders. We are committed to ensuring all Americans have access to comprehensive, high-quality care that affords every opportunity for recovery and full participation in community life. The National Council pioneered Mental Health First Aid in the U.S. and has trained nearly 100,000 individuals to connect youth and adults in need to mental health and addictions care in their communities.

 http://www.mountainx.com/article/56705/Smoky-Mountain-Center-introduces-mental-health-literacy-program

Mobile health initiative's goal: Cut hospital costs, readmissions

Community EMS, a Southfield-based ambulance and consulting company, has begun pilot testing a mobile health initiative to use paramedics and telemedicine to assess the health of chronic disease patients who develop non-emergency health problems. 

The pilot is viewed as a way to reduce costly hospital readmissions and unnecessary visits to emergency departments. 

"When a patient is discharged from a hospital to home or long-term care facility and they have a chronic illness, many things can trigger a patient being sent back to the hospital," said Greg Beauchemin, CEO of Community EMS. 

"Some symptoms can be addressed by home health agencies. But after hours, they use an ambulance," Beauchemin said. 

Because the average cost of an ambulance run to a hospital is $3,700, Beauchemin said, Community EMS can make a house call for "one-tenth of that cost." He said at least 50 percent of the ambulance runs in the city of Detroit's Detroit EMS are unnecessary.

Under the mobile health initiative, Community EMS and its consulting firm subsidiary, Parastar, will send advanced practice paramedics toBotsford Continuing Care Center in Farmington Hills to test its system on patients who have been screened by nurses and physicians, said Kevin Bersche, Parastar's director of operations.

Bersche said the advanced practice paramedics will be in close contact with emergency physicians at Farmington Hills-based Botsford Hospital, which owns Community EMS and is collaborating on the initiative.

He said similar community paramedicine programs in Texas and Minnesota are showing promise. 

"We want to legitimize that treatment can be done and that it does not jeopardize care," said Bersche, who was deputy chief of the Farmington Hills Fire Department for 32 years before joining Parastar last June.

Sanford Vieder, D.O., Botsford's ER director, said nurses at Botsford Continuing Care have been trained to determine when a patient needs an ambulance or could be served by the mobile health program. 

"Based on our protocol, the nurses call a 1-800 number and a (Botsford) ER physician screens the call," Vieder said. "We go through a series of questions and determine if a patient is a candidate. If we don't think so, 911 is called." 

When paramedics arrive at nursing homes, Vieder said, they will help evaluate the patients and connect them to "VideoDoc" telemedicine devices provided by Wixom-based Health Net Connect Inc., a subsidiary of J&B Medical Supply Co. Inc.

Health Net's VideoDoc, which features high-definition cameras and two-way audio systems, allows physicians to remotely examine patients, talk with them and monitor vital signs. 

"Under the supervision of a physician, paramedics will use VideoDoc to find out why (patients) are wheezing, coughing or having a problem," Vieder said. "They will give antibiotics or steroids and treat them as needed. If they are not improving, they will be transported to the hospital." 

Beauchemin said the mobile health initiative will test the care of about 130 patients to determine if Parastar's system reduces costs and protects patient safety. 

"We will prove to payers (and the Centers for Medicare and Medicaid Services) that from a long-term perspective, patients are better off and costs are lower by treating (patients with non-emergency conditions) at home," Beauchemin said.

Vieder said the problem is that Medicare and private payers don't have a reimbursement code to pay for paramedic house calls or the use of telemedicine. 

"We hope Medicare and payers adopt a shared savings model where the money saved by eliminating transport and treatment costs can be shared" with providers, Beauchemin said. The shared savings model could be a precursor to a formal reimbursement code, he said. 

Bersche said Community EMS has applied for a $3.9 million CMS Innovation Center federal grant to fund the test program. If approved, the funds would help pay for the mobile health initiative, he said.

Vieder said elderly patients at nursing homes and residencies are often unnecessarily sent by ambulance to hospital emergency rooms when they have some sort of medical distress. 

"If they have a medical problem, they frequently get put into a truck, brought to a chaotic ER, treated, then sent back to the nursing home," Vieder said. "The benefit is not pulling them away from a comfortable environment they are in unless they have a real medical emergency." 

Vieder said many 911 ambulance calls are avoidable by assessing patients and providing at-home paramedic or nursing care. 

Besides reducing unnecessary hospital readmissions or admissions, Bersche said, the project also could reduce ER utilization that could lower staffing costs. 

At Botsford Hospital, for example, 26 percent of patients who enter the ER are admitted to the hospital. Of total hospital admissions, 70 percent come through the ER, Vieder said. 

"There is no doubt that if we reduce the number of people coming into the ER, we would have fewer inappropriate hospital admissions and lower costs to the system," he said. 

Gregory Berger, M.D., executive medical director with Detroit Medical Center's Michigan Pioneer ACO, said the Community EMS initiative is a promising method that can save money and improve quality.

"A lot of people end up at the hospital for many reasons," Berger said. "There might be a social problem or a prescription or food program. The idea of getting extra eyes at the home is valuable." 

Jay Greene: (313) 446-0325, jgreene@crain.com. Twitter: @jaybgreene

http://www.crainsdetroit.com/mobile/article/20140302/NEWS/303029985?X-IgnoreUserAgent=1

Phila. area blocked from new Medicare ambulance enrollment

Citing a "significant potential for fraud, waste, and abuse," federal Medicare officials put a moratorium on the enrollment of new ambulance operators in Philadelphia and six surrounding counties.
The Philadelphia moratorium, which took effect Jan. 31, is just the second time officials at the Centers for Medicare and Medicaid Services have exercised this new power under the Affordable Care Act. It is intended to root out fraud.
A similar moratorium, which blocks new ambulance companies from getting paid by Medicare and Medicaid, was ordered in Houston last summer and has been extended for six months, authorities said.
The clampdown on new ambulance companies in the region came after a series of federal indictments since 2011 charged local ambulance operators with more than $15 million in fraudulent Medicare bills.

At issue is the medical necessity for nonemergency ambulance transportation. Medicare is supposed to pay for an ambulance only if a cheaper form of transportation would endanger the patient's health.

In 2011, Medicare paid an average of $289 for a one-way nonemergency trip. By contrast, the payment for a one-way trip in a wheelchair van - which makes up the bulk of business for law-abiding medical-transportation firms - is less than $50.

Most recently, in January, an emergency-medical technician who worked for Brotherly Love Ambulance Inc., of Philadelphia, pleaded guilty to signing up patients for relatively expensive ambulance rides when he knew they could walk or use cheaper transportation.

In addition, the EMT gave riders cash to entice them to keep using Brotherly Love, which fraudulently collected more than $2 million from Medicare from July 2010 through October 2011, the U.S. attorney in Philadelphia said.

An ambulance-industry trade group was in favor of the crackdown on small, fly-by-night ambulance operators that targeted dialysis and other patients for fraudulent rides, and then disappeared before regulators could catch up with them. The ambulance companies would then reinvent themselves with new names and logos.

"This whole moratorium is designed to prevent that reincarnation process," said Dean Bollendorf, president of Ambulance Association of Pennsylvania and vice president of HealthFleet Ambulance Inc., in the Roxborough section of Philadelphia.

Out-of-line costs

To support its moratorium in Philadelphia, federal regulators analyzed ambulance payments for U.S. counties with at least 200,000 Medicare beneficiaries, including Philadelphia. It found that in 2012, ambulance suppliers in Philadelphia were receiving $1,314 per year for the average ambulance patient, compared with $803 in comparable counties.

The analysis also looked at the number of ambulance companies in Philadelphia relative to the number of people receiving Medicare benefits under Medicare Part B, which is voluntary coverage with a premium paid by seniors that covers doctors visits, outpatient care, and other services not covered by basic Medicare Part A.

Philadelphia had 4.8 ambulance companies for every 10,000 Medicare beneficiaries in 2012. That ratio averaged 1.4 in comparable large counties. Only two other counties had more ambulances relative to the Medicare population than Philadelphia.

The regulators did not identify the counties that ranked higher.

Excluded from the analysis were Harris County, Texas, which is home to Houston and where widespread fraud has already been detected, and Manhattan (County of New York), because of its population density.

In the fall, there were about 80 ambulance companies in Philadelphia, including a small number of nonprofits, according to data from the Pennsylvania Department of Health, whose Bureau of Emergency Medical Services oversees licensing.

But nearly half of them had three or fewer ambulances, state data show.

Fraud pays well

The business is attractive to small operators. With just three dialysis patients taking three round-trips a week, an ambulance operator can earn about $250,000 a year, as long as those trips are billed to Medicare, said Daniel Herman, an owner of EMStar Medical Transportation, one of Philadelphia's largest ambulance companies.

"You can do $250,000 in revenue with three patients," Herman said, "and you can be done at 10 in the morning."

However, only 10 percent to 20 percent of dialysis patients actually need ambulance transportation, according to government and industry estimates. Medical necessity is determined on the "honor system," said Herman's partner, Joseph Zupnik.

Transporting the same three patients by wheelchair - which is much more likely to be appropriate - would bring in less than $50,000 annually.

Ambulance fraud involving dialysis patients gets most of the attention, but abuse extends beyond that.

For example, a person who had cancer surgery might go home but still need an ambulance to go for radiation treatments.

"They may not be able to get around for that first week or two. Guess what. We hope everyone's going to get better, and after two weeks," Zupnik said, "they may not need an ambulance."

There could be an approval for 90 days of ambulance rides, but "our nurses will go in and periodically review those cases and transition the person to what we feel is the appropriate level of medical transportation," Zupnik said.

"Other providers," he said, "will run the billing for the whole length of time, and maximize the revenue."

http://www.philly.com/philly/business/20140302_Phila__area_blocked_from_new_Medicare_ambulance_enrollment.html

Incorporate patient-generated health data into the EMR

ISRAEL GREEN-HOPKINS, MD | TECH | MARCH 2, 2014

A few months ago, I spent 15 minutes filling out a detailed health data form at the doctor’s office. The paper form contained multiple questions about my health, family history, medications and basic demographic information. I assumed that an administrative specialist would code it into the practice’s electronic medical record (EMR) to be put to use. So it came as a surprise when I spent another 5 minutes reviewing the form with my physician, who then proceeded to type this information into the EMR herself. I’m confident neither my physician nor I felt enabled by the experience.

Countless people have had a similar experience — or worse, filled out a form with no sign that any clinician ever saw the information. Though the industry has made outstanding progress in adopting EMRs, the practice of data acquisition from patients remains cloudy. Patient-generated health data (PGHD), a term encompassing all forms of data that patients provide on their own, is a relatively new concept in health care. It falls into two broad groups: historical data and biometric data.

Historical data is the type that clinicians are familiar with obtaining from patients: It includes the patient’s medical history, allergies, medications, family history and lifestyle features. Biometric data, little used at present, are health data gathered by consumer medical devices, such as blood glucose meters and fitness trackers.

Scenarios like mine above underscore how ill-prepared the health care infrastructure is for the sharp rise in both opportunities and requirements for PGHD, and the challenges of wrestling these data into the workflow of clinicians. Now, however, an important milestone is on the horizon. A recommendation from the HITSC Meaningful Use Workgroup would require practices with electronic health records (EHRs) to allow 10 percent of patients to report PGHD electronically. If approved in meaningful use stage 3, the final stage of HealthIT.gov’s EHR incentive program, it could push hospitals to incorporate patient-generated data.

This requirement may seem like a relatively simple intervention, but the ramifications are quite significant. If clinical decision-making is made on the basis of data supplied by patients and documented in the EMR, how can clinicians be sure that such data is complete, correct and valid? And will clinicians like me learn to rely on it, or will we disregard it due to concerns about its validity or barriers to integrating it into care flow? Furthermore, if a patient is in control of her health data entry, who is ultimately responsible for its completeness and accuracy — the patient or the clinician?

Incorporating biometric data into the EMR, an exciting prospect, is even more complex. Though clinicians are quite familiar with data entry from FDA-approved medical devices such as blood glucose meters, pacemakers and pulmonary function units, data from a myriad of consumer-driven health devices (Fitbit and others) will soon seek to flex their way into EMRs. Patients clearly value these data; a recent Pew Research report noted that 60 percent of adults claim to track their exercise routine, weight or diet, meaning providers have some catch-up to do in order to meet patients halfway. Some health systems, such as Partners HealthCare, have already been experimenting with the incorporation of PGHD from remote devices into the EMR, and other institutions should follow. Consumer health data devices are moving ahead at a staggering pace, and while the health care system can’t quite keep up, strategic planning should be happening now.

Meanwhile, patients are flocking to sites like PatientsLikeMe and 23andMe to compare and track health data, symptoms and treatment results. Though the connection between clinical medicine and these services is still quite murky, the data show that large contingents of our patients value the notion of comparing and visualizing their health data.

Despite the challenges, incorporating PGHD is a necessary evolutionary step for health care. Intelligently designed, well-executed systems that fully incorporate and display PGHD in a meaningful way will improve shared decision-making and enable patients as active care partners. Keen clinicians and patients will stay closely tuned to the numerous transformations to come.

Israel Green-Hopkins is a pediatric emergency medicine fellow who blogs at Vector, the Boston Children’s Hospital science and clinical innovation blog.

http://www.kevinmd.com/blog/2014/03/incorporate-patientgenerated-health-data-emr.html