Sunday, May 5, 2013

Experts call for innovation in healthcare technology

Tampa Bay Touts Itself As Incubator For Healthcare Innovation

The Tampa Bay Partnership has decided to target market four industry sectors identified in the Regional Business Plan as industries that provide high-wage, sustainable job growth opportunities, thus shedding light on the Tampa Bay region as an incubator for healthcare innovation.

The goal is to ensure that Tampa Bay, which accounted for 41 percent of the state’s job growth in 2012, is recognized as one of the nation’s hubs for medical innovation. The industry of applied medicine and human performance leads the region’s target sectors, adding more than 7,000 jobs since 2009.

The applied medicine and human performance industry incorporates core clusters of medical technology and research, including senior health and wellness, personalized medicine, clinical trials, medical instruments and devices, health information technology and bioinformatics.

“Our target sectors have performed better than jobs in Tampa Bay, better than jobs in Florida, and better than jobs in the nation as a whole. The wages in these jobs are higher, and these jobs create more spin-off jobs,” says Dave Sobush, VP of regional business planning and development at the Tampa Bay Partnership.

Tampa Bay not only has the foundation of medical research and the presence of such large medical firms as H. Lee Moffitt Cancer Center and revolutionaries such as M2Gen to create a supply chain for programs, but the region also has great technical training for people to work in laboratory settings.

“Pinellas County is among a handful of communities in the nation with a strong cluster of medical devices,” says Sobush.

Several companies have selected Tampa as a base from which they can conduct ground-breaking medical research.

“We realize that we have something and we want to have one broad message to share with the world. We’re a hotbed for medicine,” says Katie Franco, sr. VP of regional development at the Tampa Bay Partnership.

Tampa Bay is strategically positioning itself as one of the nation’s regions to follow.

“We chose target sectors that are regional in nature, and we present the region purposefully to showcase the strength of the region. There’s no place stronger than the State of Florida,” says Sobush.

For more information on Tampa Bay’s Regional Business Plan, visit Tampa Bay Partnership’s website.

Writer: Kaye Brown
Sources: Dave Sobush and Katie Franco, Tampa Bay Partnership

Seven Choices Medicare Plans Will Need To Make In Order To Survive

May 1st, 2013

by Sundar Subramanian, Joyjit Saha Choudhury, and Hector Rincon

Although the April 1 Call Letter from the Centers for Medicare and Medicaid Services (CMS) seemed to reverse proposed rate cuts to Medicare Advantage (MA) plans, the outlook for insurers still isn’t rosy. The “all-in” impact of the per capita rate increases will be offset by new risk coding intensity adjustments, shifts to fee-for-service parity, and the Health Insurance Tax, actually resulting in an expected 2-3 percent cut for MA plans for 2014.

The Call Letter also limits beneficiary cost sharing, a lever that plans have typically used to offset reductions. Such measures come on top of the potential risk of reductions from sequestration, which may lower fee-for-service (FFS) and health plan capitations by a further 2 percent per year.

The expected impact is lower than the original CMS proposal of 8 – 9 percent for 2014, but the announcement still serves as an urgent reminder of the endgame for Medicare— the rate cuts outlined in the Affordable Care Act (ACA) that will result in approximately 14 percent reductions in MA reimbursements, relative to pre-ACA reimbursements, by 2017. Traditionally MA has enjoyed a rate premium compared with FFS, often justified by the enhanced benefits available to members. These cuts, however, will put the plans roughly at parity. (See Exhibit 1, click to enlarge.)

Clearly, Medicare will not be for the fainthearted. In the short term, MA plans will need to take action in order to survive the initial impact, such as optimizing 2014 plan benefits, reprioritizing star focus areas, and even exiting selected geographies.

In the long term, however, more will be needed as Medicare becomes increasingly consumer-centric. In this market, MA plans must develop a fundamentally different business model that allows them to preserve margins in a future environment of rate parity with Medicare FFS costs while still offering equal or better aggregate benefits.

The winners will be those that make deliberate choices regarding seven key dimensions that build on their strengths and align with the needs of beneficiaries.

1. Select a “Way to Play”

First, Medicare health plans must define a clear value proposition, or “way to play.” The market trends are clear—looming reimbursement cuts and increasing linkages between quality and reimbursements (through the star quality program) will require plans to rethink their value proposition. Taking these trends into account, we believe the market will shift from traditional low-cost models toward one of two options: either a high-quality plan model or a care delivery innovator model that helps manage costs more directly. (See Exhibit 2, click to enlarge.)

Although the two options have some common themes, noteworthy nuances separate them. For example, high-quality health plans have an intense focus on star quality ratings and can develop provider arrangements that closely align incentives to the efficient and timely delivery of care. In addition, these plans possess the analytical tools to continually monitor and refocus quality efforts as needed to maintain high ratings.

Care delivery innovators also aspire to high-quality care, but they focus on managing costs through clinical integration and advanced care management. These plans are known to experiment with care delivery (e.g., through Accountable Care Organizations) and tend to build best-practice capabilities to manage chronic diseases, co-morbidities, and long-term care.

High star ratings can provide a 4 to 5 percent differential in premiums. However, the overall revenue cuts expected by 2017 are on the order of 14 percent, which means that quality performance alone will not be enough. We believe the care delivery innovators that focus on reducing total costs will be the winners in the end.

Plans need to choose their way to play carefully, basing their choice on their own strengths in enabling care delivery, quality management, and care management, and their specific competitive environment.

2. Determine the Right Mix of Products, Segments, and Geographies

With a clear way to play established, plans must determine the best combination of products, segments, and geographies that will enable profitable long-term growth for their particular value proposition. For example, in the choice of segments, individuals with chronic diseases might provide high revenues on a risk-adjusted basis, but costs for these patients may spiral out of control if the right care-management capabilities are not in place.

Similarly, the cost to acquire and serve members can vary considerably across geographies, due to varying demographics and economic fundamentals. As a result, the impact of the expected rate cuts is unequal across counties. With this in mind, plans can choose to exit unprofitable counties by assessing the existing and projected demographic factors, current and pending legislation, and their particular strengths within each market.

3. Optimize Revenue

Once plans have identified the optimal portfolio of products, segments, and geographies for their chosen way to play, the critical next step is revenue optimization. For example, although member cost sharing through co-pays and coinsurance continues to be a means of offsetting the impact of rate cuts, the recent CMS 2014 Call Letter, as noted above, proposes decreasing the amount that members’ costs can change. As a result, plans must look for additional ways to improve revenue.

Plans that misalign benefits with the needs of their customer segments leave money on the table. High-performing plans, by contrast, choose the correct set of benefits by first developing a thorough understanding of their customer segments. This includes determining the unmet needs of specific micro-segments and creating the incentives that can effectively encourage healthy behaviors. For example, plans have historically not designed benefits around value to the customer. As a result, many ancillary benefits that CMS does not require get lumped in, despite providing little to no value for members. Plans can instead offer these ancillary benefits as an upgrade option. A detailed understanding of customers also enables plans to improve their customer-retention strategy.

4. Engage Customers More Effectively

Customers respond differently to different engagement strategies. Over time, plans can improve the experience of their members by stratifying and personalizing their approach, ultimately leading to better health outcomes.

Sales channels are a good example of this. Given the recent proliferation of channels, it is critical that MA plans optimize their mix by focusing on the needs of their customers, instead of looking at what has helped sell various Medicare products in the past. Traditional channel options include direct sales, brokers, groups, and the web; emerging channels include retail stores, payor partnerships, and private exchanges. Each avenue provides a unique experience for the customer, and the right match can determine the eventual buying decision. The range of channels increases complexity, but it also allows leading plans to tailor their engagement strategy by segmenting the customers and personalizing interactions on the basis of segment needs for sales and enrollment, as well as ongoing interactions with the member to improve experience and manage health outcomes.

5. Manage Star Quality Assessments

Star quality bonus payments are a critical revenue stream for Medicare health plans. Such payments provide up to 5 percent in additional reimbursement, or enough to partially offset the expected 14 percent reductions in Medicare Advantage payments set to take effect over the next four years.

Thus far, plans have struggled; 2013 star quality ratings reveal that only 23 percent of plans reached the necessary four-star threshold required to receive bonuses. Improving this performance will entail overcoming several serious challenges, including the disparate data sources used to calculate ratings, the cross-functional nature of measures, and a continually changing methodology.

As result, plans need to focus their efforts on the quality measures with the highest expected impact. Such impact can be measured in many ways, but plans should strive for an unbiased and data-driven approach. For instance, we believe that the expected impact for a specific quality initiative can be objectively measured with a formula that takes several factors into account:

• The relative performance of other plans for each metric

• The relative positions of the star thresholds across plans

• The measure weight

• The current measure distance from the overall summary rating (this takes into account the bonus that CMS provides for low variance)

This calculation allows plans to prioritize their quality initiatives appropriately. Also, statistical methods assigning risk values or likelihood of achieving a particular outcome by metric (based on standard deviations of plan performance data) and using Monte Carlo methods to look for priorities that will maximize overall performance can be very powerful. However, that is only part of the solution. Plans will also need to implement the right governance structure, especially given that many initiatives span functional boundaries. For instance, launching a member engagement campaign requires close collaboration between care management, marketing, and even providers. A governance structure that ensures coordination and establishes accountability is essential if plans are to reach their goals in the established target measures.

6. Manage Medical Costs

Given the long-term pressure on rates, MA plans must learn to operate on a significantly lower total cost structure. The magnitude of change in medical costs requires more than merely tweaking existing network management and care management programs. Plans must fundamentally rethink how they manage members.

To start, such an approach involves eliminating expensive avoidable hospital admissions and readmissions, emergency room visits, unnecessary or duplicative testing, and so on. Related to this, MA plans need to take active steps to keep members healthy. Stratifying their customer segments is one component. By better understanding the needs of members, they can better engage with them on a proactive basis. For example, a benefit question regarding diabetes treatment may trigger outreach to enroll the member in a diabetic care counseling program.

Plans will also need to choose provider partners wisely—based not on unit costs alone but also on the provider’s ability to build close relationships with members (particularly high-risk members), their understanding of the strongest drivers of members’ health, and their ability to manage the patient population. Not all providers are ready to take on such a role. For some MA plans that have operated with broad networks in the past, having closer, more integrated partnerships with a smaller number of providers will be culturally challenging and may require stakeholder management.

In the choice of provider partners, the role of the primary care physician (PCP) and care coordinator will become even more critical as they increasingly become the “quarterback” for the care of Medicare patients. Similarly, the role of home-based and community-based care providers will also increase as MA plans and PCPs strive to keep members healthy and in their homes and communities, instead of in hospitals and long-term care facilities. Finally, the healthcare system will need to tackle the larger—and more sensitive—topic of end-of-life care.

7. Invest in Capabilities

Plans must determine the capabilities needed to support their way to play. For example, plans opting for the emerging two plays, high-quality health plan and care delivery innovator, will need strong capabilities in three key areas. First, plans should build a deep understanding of their interactions with seniors and the resulting customer experience. In addition, the ability to design products to incentivize healthy behaviors by leveraging provider arrangements will be critical to improving quality scores. Last, plans must build the care and network management capabilities needed to design and support new provider partnership models and align incentives to quality indicators.

In addition to these differentiating capabilities, plans must develop and tailor a large set of “table stakes” capabilities (i.e., pre-requisites for all plans) that span the Medicare value chain — activities in the front, middle, and back offices, as well as corporate/shared-services functions (e.g., enrollment processes that are compliant with CMS guidelines).

Next Steps

MA plans are at a crossroads and must conduct an honest assessment of their likely viability in a future environment of rate parity with FFS. If they aim to compete—and succeed—it’s critical that they articulate their chosen way to play. And to support that strategy, they must implement the necessary dimensions discussed here: the right mix of products, segments, and geographies; an improved approach to engaging members; optimized revenue; better management of star quality ratings; stronger cost management; and the right capabilities. The future holds greater challenges for the industry as a whole, but successful MA plans will benefit from inevitable growth in the Medicare market if they take decisive action now in these areas.

Email This Post

Print This Post

This entry was posted on Wednesday, May 1st, 2013 at 1:28 pm and is filed under All Categories,Competition, Consumers, Health Care Costs, Medicare, Payment, Policy, Quality.

Saturday, May 4, 2013

The False Claims Act is Not a Compliance Tool

Philip Betbeze, for HealthLeaders Media , May 3, 2013

If you've not been following the news surrounding the use of the False Claims Act to snare providers for Medicare fraud, let me catch you up. On April 2, the 6th U.S. Circuit Court of Appeals in Cincinnati overturned a lower court's $11 million judgment against MedQuest Associates Inc., a diagnostic imaging company. MedQuest had been accused of a False Claims Act violation—in other words, fraud—for violating Medicare's conditions of payment.

So what's the big deal? What's $11 million to an operator of more than 90 diagnostic imaging centers? Well the decision's importance has little to do with the amount in question. Some attorneys think it will be precedent-setting, in that good faith efforts to comply with the myriad (and that's putting it lightly) regulations involved in Medicare contracting are ultimately worth the effort.

That's because the court ruled that since the regulations MedQuest was accused of violating are not conditions of payment, bringing a suit for violations of the False Claims Act (as the Department of Justice did in this case) is not appropriate.
Instead, said the court, such violations are addressable within the administrative sanctions CMS has available, including suspension and expulsion from the Medicare program.

The suit, which was fueled by information disclosed by a former MedQuest employee whistleblower, asserted that the company used physicians in its employ who were not designated to monitor the procedures. There was no question over whether the work was done or whether the violations occurred.
What MedQuest did, however, isn't fraud. At least in the eyes of the court.
"What's most significant legally is that the 6th Circuit said that the FCA is a powerful and blunt instrument and is not appropriate to police regulatory compliance issues in the complex medical arena," says Ty Howard, a partner in the white collar crime defense and healthcare groups at the Nashville-based law firm of Bradley Arant Boult Cummings.
A former federal prosecutor of white-collar fraud, Howard says the court isn't necessarily saying that what MedQuest did is OK, but that the remedy should not come through the FCA. "That's significant for the industry, because with the use of this powerful tool with its trebling damages—the judgments rack up quickly."
Howard says the MedQuest decision is precedent-setting when viewed in conjunction with another suit filed under the FCA that the same court overturned last fall.
In a case brought against Renal Care Group Inc., a dialysis provider, the 6th Circuit overturned another interpretation of the FCA as overly broad. In that suit, the Sixth Circuit ruled that medical service providers that have established separate corporate entities to maximize corporate profits and take advantage of separate Medicare reimbursement programs do not inherently violate the False Claims Act.

That's especially true since Renal Care sought guidance from regulators regarding Medicare regulations that could be interpreted in different ways—in other words, that are ambiguous.
These decisions are a relief to a wide range of healthcare providers who are promoting a culture of compliance, but who fall short, nonetheless. After all, CMS is still free to suspend or exclude firms that make these kinds of mistakes, and they don't have to clutter up the court system to do so.
It's common sense, and it makes you realize that when you're dealing with an entrenched bureaucracy, common sense isn't so common.
Howard says the rulings and precedent can be boiled down to the difference between two phrases: "condition of payment" and "condition of participation."
"By submitting a claim, you have to be in compliance with a myriad of regulations. If the violation surrounds a condition of payment, that can give rise to FCA," he says. "But if it's a condition of participation, that is not going to rise to FCA liability."
That doesn't mean you can afford to be lax in Medicare billing or oversight. Suspension and exclusion are still options, and, as Howard points out, "those are not insignificant penalties."

But disgruntled workers are out there, and given the fact that they can share in any recovery in fraud cases, whistleblowers will continue to serve as an important tool against fraud. But perhaps the outcomes of these cases will make people who are looking for an easy payday think twice before running to the Department of Justice when an "I" is dotted wrong on a claim.
While an appeal to the Supreme Court is possible, Howard says it is unlikely, and even if appealed, the Supreme Court, of course, picks and chooses the cases on which it will rule judiciously.
Perhaps now the Department of Justice will take a similar approach in deciding which potential fraud cases to pursue.
"Many of these cases never get into court. If you're risk-averse, and face criminal penalties as well, that is huge leverage for the government," says Howard. "It's heartening to know that sanity is being restored in these types of cases. The real hope is that the government will take a more judicious view of these cases and take cases that really merit it."
While it's often claimed that the legal resources of the federal government are unlimited, that only seems true to an individual or company facing the legal might of the U.S. Government.
When you look at the big picture, the department has to make choices. Let's hope they make better ones in the future to catch those who are truly defrauding Medicare, and not through lax oversight of payment rules.

Philip Betbeze is senior leadership editor with HealthLeaders Media.

Adventist Health pays US, CA $14.1M to resolve false claims act allegations

23ABC News - Adventist Health pays US, CA $14.1M to resolve false claims act allegations - News Story - Local News - Bakersfield News, Bakersfield, California News & Bakersfield News Local Headlines - KERO TurnTo23

Friday, May 3, 2013

Cajuncodefest 2.0 positions Lafayette as epicenter of health care innovation | KATC.com | Acadiana-Lafayette, Louisiana

Cajuncodefest 2.0 positions Lafayette as epicenter of health care innovation

Posted: May 3, 2013 11:06 AM by MELISSA CANONE
Updated: May 3, 2013 11:06 AM

Rating:

0.0 (0 votes)

LAFAYETTE, La. - Lafayette was the epicenter of health care technology during the second annual CajunCodeFest, a free, three-day coding competition focused on transforming data into health care solutions. The CajunCodeFest is a signature event for the Center for Business & Information Technologies (CBIT) at the University of Louisiana at Lafayette. Over 400 people from 42 cities, 12 states and 2 countries gathered at the Cajundome to create solutions and discuss the future of healthcare technology. Participants organized themselves into teams before the event, and over a 27-hour period built exciting new prototypes and tools encouraging patients to "Own your Own Health." Last year, the event spawned 6 potential startup companies through team collaborations.

The event also hosted a full day of plenary sessions with keynote guest speakers including Bryan Sivak, Chief Technology Officer, and Dr. Farzad Mostashari, National Coordinator for Health Information Technology of the U.S. Department of Health & Human Services, and Kathy Kliebert, Interim Secretary, Louisiana Department of Health & Hospitals.

The CajunCodeFest competition ended with a local team taking home $25,000 and a qualifying entry in the National Health Data Palooza in Washington DC, in June. Awards were also given for the Best Student Team, The Opportunity Machine Best "Market Ready Team", Best Use of Microsoft HealthVault Technology, and US Ignite Best Software Defined Networking Application. For more information or to view speaker presentations, visit www.cajuncodefest.org.

Recently, CBIT and the CajunCodeFest were recognized with the Innov8 Education award from the Greater Lafayette Chamber of Commerce for bringing innovation in healthcare to the Lafayette community. The CajunCodeFest is a major component of INNOV8, an annual festival of innovation and creativity showcasing talented thinkers and entrepreneurs who make the region a unique place to live and work.

CajunCodeFest Winner's Photos:

"Best in Show" Grand Prize Winner & US Ignite Best Software Defined Application: Team BreakFix

(L-R) Bryan Sivak, CTO, US Dept. of Health & Hospitals, Stacy Crochet, Bill Fentsermaker, Fenstermaker & Associates, Monica Suire, Amy Hanchey, Teri Leblanc, William Zhang, Michael Venable, Trent Poche, Clay Allen, Allen & Gooch.

Best Student Team & Best Student Team Use of Microsoft HealthVault: "Geaux KNEAS"

(L-R) Dr. Joe Savoie, UL Lafayette President, Anh Do, Cory Etheredge, Brian Richmond, Louisiana Health Care Quality Forum.

The Opportunity Machine Best "Market Ready" Team & Best Chronic Disease Application using Microsoft HealthVault: The New Old Schoolers 2.0.

(L-R) Bill Fentsermaker, Fenstermaker & Associates, Luke Ashworth-Sides, Reza Jelvah, Bob Miller, Josh Bain, Kevin Webb, Geoff Daily, Clay Allen, Allen & Gooch.

The Center for Business & Information Technologies (CBIT) supports the University's economic development agenda through research, development and technology transfer in the general area of business and information technologies. In cooperation with private sector, academic, and government partners, the Center conducts basic and applied research aimed at establishing scientific foundations and frameworks for business & information technologies. This research facilitates the development and creation of these products. The Center provides strategic and technical support to Louisiana businesses and government. Visit cbit.louisiana.edu for more information.

The Solution to Risk Adjustment: A Coder’s Perspective

Kameron Gifford, CPC

Over the last twelve years, I have worked with physicians to develop efficient billing practices, implement value added processes and improve the entire experience of care for their patients. What can this knowledge contribute to developing compliant, engaging and transparent risk adjustment programs? What can health plans learn from expert practice managers?

Use a Whole System Approach

In medicine, continuity of care can mean the difference between a positive and a negative outcome. We know that fragmented systems don’t work. So why has this become the standard for Medicare Advantage plans? Initial Health Risk assessments are outsourced to midlevel providers that perform a “home based” assessment or perhaps the patient is instructed to visit a website or to call an 800 number. Then a few months later another company is contracted to “retrieve” medical records from the PCP who then forwards those records to a coder to code any “missing diagnoses”. This does not add any value for the patient. What will?

When patients enroll in a managed Medicare plan they are assigned (or pick) a PCP. This is who should be doing the initial health assessments. CMS encourages FFS providers to perform this type of exam by reimbursing the “Welcome to Medicare” exam with no cost share to the patient. If this is the “standard of care” for some beneficiaries, why not all?

Coding comes from documentation and therefore it is impossible to improve our coding without first improving our documentation. Knowing this, retrospective audits should be used as a tool for identifying deficiencies and a foundation from which specific educational programs can be built to support individual needs and learning styles.

Educate Everyone

In 2011, I began educating medical professionals in compliant HCC Coding and Documentation. My mission was to teach the fundamental purpose and principles behind the methodology. Doctors are trained to take an enormous amount of information and condense all of this into a progress note. This abbreviated summary of events is then interpreted into ICD-9 and CPT Codes (which may or may not risk adjust) which will determine the amount of reimbursement for that particular service.

Currently plans are trying to interject change at the end of a process. Instead, by educating physicians, nurses, coders, administrators, medical assistants, and receptionists change can be implemented at the initial point of contact. If the medical assistant and nurse understand quality measures they will be able to accurately audit the chart before the physician ever walks in. Flags can be raised for patients who have not had their mammogram or who didn’t turn in their hemmoccult cards. Physicians who understand the 10 guiding principles of HCC will document to a higher a degree of specificity and use linking words. A coder with training in HCC Coding will know that you must use a buddy code when coding manifestations. This knowledge allows the coder to query the physician immediately when the case is still fresh on their mind. The ability to audit in “real time” expedites the process of changing one’s behavior and the physician’s ability to adapt under these circumstances are amazing. The end result is a complete an accurate medical record which does add value to the patient.

Return on Investment

Education empowers. One of the greatest dilemmas in managed care is how to get physician buy in? By providing quality educational opportunities to not only physicians but to their office staff as well you will position yourself as a blessing instead of a burden. In the current environment of greater oversight, tighter regulations and changing reimbursement patterns providing something as simple as education builds relationships.

Empirical Risk Management tested this philosophy and the return on investment was incredible. 300 to 1. But, the greatest achievement of all was seeing the hunger for knowledge and the positive impact on human life that was reflected in patient centered whole system change.

For more information please visit our website: www.ermconsultinginc.com or by email: kgifford@ermconsultinginc.com

This is what patient engagement really is

ROB LAMBERTS, MD | PHYSICIAN | MAY 2, 2013

“Patient engagement.”

What is patient engagement? It sounds like a season of The Bachelor where a doctor dates hot patients. It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks. There was a even an entire day at the recent HIMSS conference dedicated to patient engagement. I think the next season of The Bachelor should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define patient engagement:

The Get Well Network calls it: “A national health priority and a core strategy for performance improvement.”
Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to KevinMD.
On the HIMSS Patient Engagement Day, the following topics were discussed:
- How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
- Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
- Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, patient engagement is:

a strategy
a drug
a grail (although I already have a grail)
a “meaningful use” objective
something that requires a business case
something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this? Why make fun of a term used by many people I trust and respect? I was recently discussing my ideas on a communication-centered medical record with a colleague. At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.” I surprised him by disagreeing. Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition. We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement . Patients are not the center of care. Patients are a source of data so doctors can get “meaningful use” checks. Patients are the proof that our organizations are accountable. Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record. We faun over medical records. Companies earn epic profits from medical records. We hold huge conferences to celebrate medical records. We charge patients money to get to see their own medical records. We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice. I want my IT to center on patients, but medical record systems are self-absorbed. They are an end in themselves. They are all about making records, not engaging patients. They are for the storage of ideas, not the transfer of them. Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care. Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas . It did this because we are paid to document, not communicate. Communication takes time and it is not reimbursed. Communication prevents unnecessary care, which is a revenue stream. Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do? I’m not sure. I am still looking for a solution that will meet the central goals of my practice:

Communication – health care is a hassle, with communication relegated to the exam room. I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
Collaboration – the patient should be engaged, but in a two-way relationship. This means they not only should have access to their records, they should contribute to those records.
Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record. I also want a task-management system I share with patients to make sure care gets done.
Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence. Why not do a yearly stress test? There’s evidence for that. Why not use antibiotics for sinus infections? There’s evidence there. Why use an ACE inhibitor to control the blood pressure? I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented. ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham. Engagement is about interaction, listening, and learning in relationship to another person. Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

4 ways to beat time constraints and guide patients to better health

DAVID B. AGUS, MD | PATIENT | MAY 2, 2013

As doctors, we’re typically compensated for the work we do, not the hours we spend. Our jobs are structured so that we’re taxed for time, making even the most routine office visit feel like a race against the clock. Trying to develop a long-term strategy with a patient in this context is not time-efficient. It is, in fact, incredibly frustrating.

Yet medicine is a team effort, and we understand that we’re treating people, not algorithms. We know that when patients are more informed they tend to make better choices at home (eating healthful foods), and in our offices (scheduling things like flu shots). Here, four ways to work within our existing time-constraints to help patients shift the needle toward better health.

Direct patients to good information early. Office visits can be chaotic, and one easy way to offer some focus is to start the conversation beforehand. A page of links to credible articles, a series of posts or downloadable handouts, a few minutes of video content, or even just a list of “frequently asked” questions are all easy to add to your website, for example. Early in the appointment, open the conversation up to questions on these topics. Not all patients will have time to look at or think about them before seeing you. Many won’t. However, for those who do, by introducing common reference points, you’re saving time by creating a shared language and structured dialogue from the very start.

Make intake forms available ahead of time. Another great opportunity to maximize efficiency is to make your intake form available before the appointment. Once in the waiting room, patients can feel harried, nervous, or rushed. By filling the paperwork out at home, they not only have time and additional resources to give more considered answers, but they may develop new, relevant questions to bring to the table.

Monitor. When we weigh our patients or take their blood pressure, we’re relying on single numbers from particular moments to make complex diagnoses. We’re only getting thin slices of what’s going on with their health. However, we know that one of the greatest clues in medicine is change over time, so tap that resource. Ask your patients to monitor a few simple things, such as weight, or how much they’re exercising. Nowadays, there are countless devices that make it easy to track, upload, and even share this kind of data, giving you a much richer picture of what’s going on between checkups.

Re-evaluate. As you and your patients continue your conversation over multiple visits, you’re not just getting updates on their progress, but also a deeper narrative of their long-term wellness. On every return appointment, quickly re-evaluate your own advice to your patients on diet, exercise, medication, and specific actions taken based on their medical history (like early screenings). This gives you repeated chances to ask yourself if there are better ways to deal with any of the problems you’re treating.

There is an old adage that rings true in medicine: With enough data, error goes away. The hope is that this multi-pronged strategy of data collection will enable you and your patients to have the best outcome, time after time.

David B. Agus is a professor of medicine and engineering at the University of Southern California. He is the author of The End of Illness and blogs at ZocDoc’s The Doctor Blog, where this post originally appeared.

Digital Agenda / Heart of the matter: who owns your health data?

EUobserver.com / Digital Agenda / Heart of the matter: who owns your health data?

Heart of the matter: who owns your health data?

03.05.13 @ 09:24

BY NIKOLAJ NIELSEN

BRUSSELS - The titanium metal box implanted inside Hugo Campos' chest keeps him alive.

Some implantable cardioverter-defibrillators (ICD) are remotely monitored by manufacturers (Photo: stuad70)

The size of a wristwatch, the €20,000 gadget houses a generator, circuitry and a battery with thin wires attached directly to the Californian's heart.

"It took me about a year to get used to the idea of having the implant and understanding how things work," he told EUobserver.

The device - or implantable cardioverter defibrillator (ICD), made by US-based firm Medtronic - is designed to treat dangerous accelerations in his heart rate.

It also collects a lot of data.

An accelerometer inside the device can tell when he sleeps, eats or walks around, when he is quiet or speaking, or if fluids are building up inside his chest cavity.

All of the information is transmitted to the manufacturer via a cloud. It does not go to the doctor, the hospital or the patient.

If something goes wrong, his cardiologist will receive an alert from the manufacturer.

If it is serious, the doctor will inform Campos.

There are many others like him in the US and in the EU. A senior director at Medtronic said her company alone remotely monitors some 750,000 ICD patients worldwide.

There are two more ICD-makers in the US - Boston Scientific and St. Jude Medical.

The only other two firms which manufacture them - Sorin and Biotronik - are based in Italy and Germany.

For Campos, there is something fundamentally wrong with the idea that a private company can own and control his most intimate of information.

There is a worry the ICD firms have too much leeway to hide potential problems.

And there is a broader worry on security.

An Australian hacker in October last year reverse-engineered transmitters to deliver killer shocks to anyone with a pacemaker or ICD within 10 metres of his laptop.

But for others, big data - US health organisations generated an estimated 150 billion gigabytes of information on patients in 2011 - is big business.

It is also an opportunity to make breakthroughs in medical research and to cut the costs of healthcare.

For their part, EU institutions are currently trying to legislate on the complex issues involved.

A new European Commission data protection bill would require ICD makers to share patient information more easily.

But there are many questions to answer.

'We are at their mercy'

Campos has for the past four years been trying to get access to the raw information stored on Medtronic's database - CareLink.

He has not got very far.

"To think that a corporation has more rights or better rights [than I have] on data that is collected from my body is actually a little bit scary," he said.

He suspects that one reason for the firms' reluctance to open up is corporate liability.

"That is the biggest threat to companies - liability - and the patient knowing that the device is not working properly and being able to sue a manufacturer," he said.

"We must rely on the manufacturer to recognise such problems and issue a recall. In a way, we are at their mercy," he added.

ICDs are prone to hardware failure.

Campos said the thin wires that attach the device to his heart are "the Achilles heel" of the system.

The wires, he noted "are very pliable and they often fail and there have been some recent problems with St. Jude Medical and Medtronic."

"The patient may be unaware that the lead has failed but the generator connected to the lead knows there is a problem," he added.

Medtronic issued a major product recall in October 2007.

The problem hardware was already in use in the bodies of over 200,000 patients.

In May 2009, the firm issued a statement that 13 patients might have died because of the defect. Related settlements were finalised in January this year.

It was the "Sprint Fidelis" lead which failed.

A fractured lead can kill a patient if it fails to tell the defibrillator to send an electrical jolt when the heart goes into arrest. It can also send repeated and potentially fatal shocks.

Medtronic had received alerts that Sprint-Fidelis-wired patients were experiencing inappropriate shocks due to lead failure and launched an internal investigation.

It looked at data from a clinical trial involving 650 patients at 17 hospitals and did a subsequent review of data collected via remote monitoring for 25,000 patients with the Sprint Fidelis lead.

The findings led it to issue a recall for all its Sprint-Fidelis-wired ICDs.

Most of the patients involved fed their data into CareLink.

But in some cases industry outsourcing - a small fraction of the patients used a generator made by a competing firm - made it more difficult to react.

"In those cases patient management was more challenging because, even when they had a remote system, data were not collected in the same way," a Medtronic spokeswoman said.

Big opportunities

The potential benefits for industry of owning the data are massive.

The size of the data pool and how it is used has implications for healthcare policy makers and healthcare businesses.

Estimates say the US health industry could save $200 billion if more advanced analytics were used on patients' health data in order to see patterns in product recalls.

"There is really a large value for hospitals, doctors, researchers and companies and individuals," Christope Wild, head of information and communication technology at Innsbruck Medical University in Austria, told this website.

He noted that every ICD manufacturer currently has its own data system, making it hard to share and compare data from one system to another, however.

"There isn't a standard to see which data needs to be stored and there isn't a standard to port this data to another manufacturer," Wild explained.

Innsbruck Medical University last year purchased software to trawl manufacturers' websites.

The software logs in with a given doctor's credentials and then pulls raw data from the ICD companies into the given hospital's electronic system.

But it did not work out.

"They had a preliminary agreement with one of the manufacturers last year, but that failed because of the proprietary system of the manufacturer and the hospital. So even if both parties agree they could work something out it still fails because of the different formats," Wild said.

A Dutch cardiologist at the Leiden University Medical Centre also said hospitals struggle to use the different data formats.

The Leiden centre has developed a common standard and is running a pilot programme to implement it at its hospital.

But only four out of the five ICD makers allowed it to run the pilot scheme for free.

Where does the EU come in?

Wild said EU policy makers need a debate on whether collection and storage of data should remain in the hands of ICD firms.

The EU commission's draft regulation would require manufacturers to export data in an easy-to-use and interoperable format.

The bill says data should, where possible, be in an open-sourced electronic format.

But industry insiders say the companies are unlikely to comply.

Meanwhile, European patients have more privacy than American ICD users.

In Europe, the clinic which performed the implant procedure has custody of "personal data" - name, address or anything else which can identify the patient.

The ICD maker has custody of "technical data" - the patient's heart rhythms, how much battery life the ICD has left - and the technical data is "anonymised."

But academic studies have shown that "anonymised" data can in many cases be used to identify people, posing the risk of "profiling."

Profiling is a practice of collecting information about individuals to make assumptions about them and their behaviour.

It is used by private firms who sell data to insurance companies, banks or employers, who can use the information to make commercial decisions which may harm the patient's interests.

The degree of mistrust in Europe is evident in so-called tele-monitoring.

Tele-monitoring allows a doctor to keep an eye on his patient from a distance, for example by checking their ICD rhythms on a website under an agreement with the manufacturer.

Martin Borggrefe - a cardiology professor at University Hospital Mannheim in Germany and vice-president of the France-based European Society of Cardiologists - noted that tele-monitoring can have big advantages.

A patient who consents to it needs to have check-ups at a heart clinic just once a year.

A patient who declines is advised to do them every three to six months.

Borggrefe said: "Medical devices are implanted by a cardiologist or a cardiac surgeon with full consent of the patient. If remote monitoring is offered, the patient signs full consent after discussing all aspects of tele-monitoring."

In the Netherlands, more than 50 percent of people opt in.

But in Germany, privacy worries mean that some 90 percent of people opt out.

Meanwhile, consent standards vary from country to country in the EU.

In some cases, they pose the question of whether a seriously ill person is in a position to make a free, rational and well-informed choice on whether to go ahead.

In Italy, a patient must sign the manufacturer's contract on paper in a doctor's office. But in the Netherlands, a patient simply checks a box on an online privacy disclaimer.

Another question for EU lawmakers is people's "right to be forgotten."

It remains unclear under EU law whether a person who signs a contract with an ICD maker can later exercise their right to have his personal data deleted.

EU law under fire

For Erik Vollebregt of Axon Lawyers, an Amsterdam-based law firm specialising in life sciences, the draft EU regulation has failed to take on board industry's concerns.

He noted that the bill's language on profiling is likely to create even more mistrust.

"If you look at the definition of profiling that is basically a functional description of tele-monitoring," he said.

He also said the EU's "right to be forgotten" conflicts with existing manufacturers' obligations to keep patient data for at least five years after the last device has been placed on the market for quality control purposes.

Vollebregt warned the law as it stands "includes a lot of measures that are not going to work for health policy."

He added: "They don't put enough depth and nuance in the statute to be able to deal with processing of personal data for health care purposes in a rational way."

Other specialists have their own take on the subject.

Annabel Seebohm, a lawyer at the German Medical Association, says people with ICD devices who enter into a contract with a manufacturer become a consumer instead of a patient.

"The patient in this regard is more of a consumer and so the 'right to be forgotten' would apply. It's not a doctor-patient relationship here since it is with the manufacturer," she told EUobserver.

There is equal confusion in the US.

An American privacy law on health information - Hippa - covers service providers who collect data on behalf of doctors or hospitals.

But when contacted by EUobserver, the US consumer protection agency - the Federal Trade Commission - was unable to say whether Medtronic falls under Hippa because it is a manufacturer, not a service provider, a doctor or a hospital.

The federal commission was also unable to say what Hippa means for patient access to health information, such as ICD data.

Amid the uncertainties, Campos' ICD battery has another three years to go.

He told this website he has nothing against tele-monitoring or other leaps forward in medical technology and practice.

But he firmly believes the US and Europe should enshrine patients' access to their data as a "civil right."

"There is nothing more intimate than an implanted electronic device," he said.