An interoperability update: Do we need more carrots and sticks?

Earlier this year, the ONC released the Trusted Exchange Framework and Common Agreement (TEFCA), which responds to a mandate included in 2016’s 21st Century Cures Act and lays out principles, terms and conditions on which to base an interoperability framework that healthcare organizations can embrace.

 “This means patients who have received care from multiple doctors and hospitals should have their medical history electronically accessible on demand by any other treating provider in a network that signed the Common Agreement,” said National Coordinator for Health IT Donald Rucker in a recent blog post.

To achieve that goal, TEFCA is divided into parts A, the principles, and B, the terms and conditions, which is also where the rubber meets the road for many who live in the healthcare IT world.

“Part A good, Part B not so much,” John Halamka, MD, CIO of Beth Israel Deaconess Hospital in Boston, said in recent comments.

The departure between A and B, per Halamka and others, is that TEFCA has the temerity to spell out both the how (A) and the what (B). Describing the what as “old, very cumbersome standards,’ Massachusetts E-Health Collaborative CEO Micky Tripathi said, “Developers won’t touch those things with a 10-foot pole.”

I have no quarrel with Halamka and Tripathi on their evaluation of standards, but ONC and Congress are right to feel that this whole healthcare IT ubiquity thing is taking too long.  

Sure, the proposal and the responses illustrate well that the ongoing project to make healthcare IT systems communicate is long and arduous. But the real issue is that it’s also fraught with complexity, as Tripathi points out, and that insufficient incentives, misplaced priorities and narrow perspectives leave some tasks without any identifiable advocate.

The short list of remaining interoperability obstacles is significant.

Incomplete EHR Adoption: For starters, while incentives to adopt electronic health records have worked well, they’ve really only been applied to hospitals and clinics. Left out of the deal were skilled nursing facilities, behavioral health facilities, long-term and post-acute facilities and other providers. It will be difficult to have comprehensive records to share if only certain segments of the overall healthcare complex have the necessary tools.

Uneven Network Availability: To this point, rural hospitals and clinics, ironically the most essential of all facilities, have fared the worst in adopting EHRs. Funds are in short supply and trained personnel are often scarce outside urban areas, so it doesn’t help that internet service providers have often not built secure, reliable networks in these areas either. How will these facilities exchange patient records if there is no method of exchange?

Lack of an Accepted Exchange Standard: Part B in TEFCA designates HL-7’s FHIR standard moving forward, and while FHIR certainly has the early lead and a lot of support, the specific naming of it as a standard makes Halamka and others uncomfortable.

“Maybe a better way to say it is that FHIR enables many new possibilities, rendering a number of historical approaches obsolete,” he said.

No National Directory: There is currently no comprehensive way for providers to find each other should they need to. What’s needed is a “national phone book” that connects providers electronically when they need to exchange patient data.

So, where is the push to close these remaining holes going to come from? Let’s think about who has sufficient incentive to make them happen. Ideally, each of these concerns can be addressed by creative business ideas. Realistically, the free market probably can’t get us across the finish line by itself.

The solution, then, has to be some kind of collaboration between ONC, healthcare and IT vendors that offers proper incentives for facilitating patient data sharing and overcomes industry concerns, which remain. Healthcare IT vendors fear they’ll undermine their own market share by making it easier to share patient data. Hospitals fear losing patients who can easily switch providers without having to provide a complete medical history.

The federal government, however, is the only semi—objective advocate for healthcare IT systems that focus on patients. It’s also the only entity with the funds and heft to get some things on the wish list done. Far from arguing for big government, I am instead promoting dialogue that takes advantage of a healthy tension that empowers each entity to pursue the best possible outcome. If this gets done in a timely fashion, both carrots and sticks are necessary. What other entity has both?

“If interoperability were a ‘stay-in-business’ issue for either vendors or their customers, we would already have it, but overall, the opposite is true,” wrote Julia Adler-Milstein in a NEJM Catalyst article on interoperability. “… the weak regulatory incentives pushing interoperability … even in combination with additional federal and state policy efforts supporting HIE progress, could not offset market incentives slowing it.”

I agree with Halamka and Tripathi that mandating technological solutions is a bad approach in that it shackles ingenuity and picks winners and losers. But there is still a role for government in terms of providing strong incentives, setting realistic deadlines that advance the overall mission more rapidly and perhaps funding certain projects where no business solution is truly viable.

A year since Adler-Milstein’s article was published, we seem to be in the same place, despite the effort TEFCA represents. While foot-dragging may be an effective business tactic, it often forestalls broader public goods. To improve America’s fragmented healthcare system, it’s past time to make that the highest priority.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Category: Interoperability

Interoperability standards are essential, and someone has to create them.

It’s not exactly a sweater or tie that gets worn once and then relegated to the top of the closet, but it turns out that patient data may have something in common with unloved holiday gifts. Both, it appears, are shared and then seldom used.

At least that’s one takeaway from a recent Health Affairs study on interoperability and how far forward we’ve actually moved the ball. The authors used the most recent available data (2015) and the four interoperability standards established by the Office of the National Coordinator (ONC)—finding, sending, receiving, integrating—to conclude that progress on this measure is lagging, at best.

“… progress toward interoperability has been slow, with fewer than 30 percent of hospitals engaging in all four domains of interoperability in 2015 and with an increase of only 5 percentage points from 2014,” the authors write.

The low percentage of hospitals using all four standards is particularly significant in that simply sending or receiving data does not guarantee its use. Of those hospitals that said they sometimes, rarely or never use outside patient data in care (55.8 percent), or didn’t know (11.2 percent) how often they used it, the most oft cited explanation was that “clinicians could not view the information in the EHR as part of their workflow.”

“Issues with integrating information into existing EHR systems and clinical workflows were the most commonly cited barriers for hospitals that were not routinely using external information for patient care, which further underscores the need to shift the policy focus from transmitting information to information usability.”

Ah, yes, usability … yet another technological imperative that ends in ‘ability.’ Health Affairs suggests that data usability has a lot to do with EHR sophistication.

But is it having an advanced EHR that improves data usability? Or is it perhaps having the same EHR as the facility you share data with? As Health Affairs points out, those hospitals that most frequently share patient data via HIE are those working with an EHR and HIE from the same source.

“Without strong incentives that would have created market demand for robust interoperability from the start, we now must retrofit interoperability, rather than having it be a core attribute of our health IT ecosystem,” writes Julia Adler-Milstein, also an author of the Health Affairs study, in a recent NEJM Catalyst article. “And, if there had been stronger incentives from the start, we would not now need to address information blocking: the knowing and intentional interference with interoperability by vendors or providers.”

Adler-Milstein argues that policymakers dropped the ball more than any stakeholder group. The EHR vendors and providers, she says, are just working within the boundaries to retain or improve their respective positions.

“Of the stakeholders, only policymakers have a clear, strong interest in promoting interoperability,” she says. “Therefore, it is up to them to ensure that robust, cross-vendor interoperability is a stay-in-business issue for EHR vendors and providers.”

To suggest, however, that the onus is on policymakers to alter the incentives for adopting shared standards is to concede that healthcare is merely a business. In America, this is pretty much true. And where else might the incentives to adopt common standards come from, anyway?

“This is the basis for a system,” said Larry Weed, MD, in 1971, as he held aloft a think folder of patient data. “The record has to be. You can write a check in Atlanta on a New York bank, why? Because there’s a system, and it’s known throughout. But you get a coronary in Atlanta and your records are in Chicago, just try to find things out in the first 24 hours.”

“The historic lack of structured data and standardization in the healthcare industry today causes problems when sharing EHR content between providers,” wrote Tom Murray and Laura Berberian in a Computerworld op-ed. That was 2011.

To paraphrase one commenter on Adler-Milstein’s Catalyst article, Weed—or Murray or Berberian—could give the keynote at HIMSS 2018.

“Once the business case for interoperability unambiguously outweighs the business case against it, both vendors and providers can pursue it without undermining their best interests,” says Adler-Milstein to wrap up her Catalyst article.

A business case created by which group of stakeholders? Vendors have made and continue to make their case on interoperability by effectively controlling how rapidly it happens, or whether it happens at all. But what of providers? Is there a coordinated message from that group of stakeholders that might shift the interoperability landscape?

If so, it’s time to hear it. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Interoperability

Hurricanes highlight healthcare IT improvement, expose gaps

Yes, Katrina was already losing appeal as a girl’s name by 2005, when it had fallen to 247th most popular in the United States. But the so-named hurricane that swamped New Orleans in August of that year pushed it off a ledge. By May of 2007 Katrina had fallen more than 100 spots to number 382, its lowest level since the 1950s.

Less trivial is the impact of Katrina on hospitals and healthcare, which has regularly measured itself against the ghost of a seemingly manageable Category 3 storm that morphed into a disaster of historic proportions and nearly destroyed one of America’s more storied cities.

Since Katrina there’s been Rita and Wilma, also in 2005, and Superstorm Sandy on the eastern seaboard in 2012, but nothing else. The recent arrivals of Harvey in Texas and Irma in Florida are healthcare IT’s first real opportunities to test existing infrastructure against mother nature.

So, what are the early reports on the shift to electronic records, remote / cloud hosting and disaster recovery sites after the hurricanes? Things are better, but it’s still a work in progress. After all, many hospitals in New Orleans had EHRs, but it didn’t matter when the water kept rising.

“When Hurricane Katrina smashed into New Orleans in 2005 … tens of thousands of patients lost their entire medical histories—boxes of paper files disintegrated or washed out to sea by the rising waters,” writes Megan Molteni in Wired magazine. “Widespread data loss won’t be as much of a problem for Houston. Today, about 75 percent of providers keep records electronically. But patients still may have trouble accessing their records when it matters most: in the middle of crisis and recovery.”

That’s right. Interoperability remains the hill healthcare IT still has not taken, despite the proliferation of EHRs.

The fear of a Katrina redux inspired many hospitals to improve their physical infrastructure by installing “submarine doors, flood gates, and above-ground backup generators,” which kept 90 of 110 Houston-area hospitals from having to evacuate patients. Darrell Pile, CEO of an organization that coordinated patient evacuation and relocation related to Harvey, said he knew of no hospitals in Houston that lost access to patient records.

And yet, everything was still not totally copacetic in Texas.

“For lots of these patients, these are not their normal clinics,” explained Dan Jensen, manager of 11 clinics in the VillageMD Houston network. “We can try to pull data on some of them, but it’s very limited what we can get. A lot of times we have to start from scratch.”

But Jensen also illustrated the ways in which healthcare IT enables flexibility and rapid response during emergencies. Able to reach only 10,000 of 160,000 patients before the storm, VillageMD Houston’s IT provider was able to engineer a patient portal fix overnight that extended portal communication to all patients, even those who had not signed up.

While Houston was drying out, Irma’s visit to Florida ended up being less destructive but more directly impactful because it shut down most of the state. In total, 36 Florida hospitals closed either in anticipation of the storm or because of its impact. Statewide, 54 hospitals were forced to use backup generators and some reported modest flooding but remained open.

And the Florida Hospital Association received no reports of EHR failure.

Arriving so close together, Harvey and Irma almost entered the national consciousness as one storm. Taken together, early returns suggest healthcare IT has progressed significantly since Katrina.

“Policymakers and health care providers can celebrate one quiet success in the wake of the Houston storm: the computers are still running,” writes Darius Tahir in Politico. “The preservation of patient health records represents a partial vindication for the HITECH Act … that was conceived, in part, as a way to ameliorate natural disasters like Hurricane Katrina by replacing waterlogged paper with modern technology.”

But it wasn’t just Katrina that spurred lawmakers to pass the HITECH Act. It was also the VA’s response to the hurricane.

“The VA — with its pioneering VistA EHR — was able to retain records and access them much more rapidly than its private-sector peers during Katrina,” says Tahir, “… the organization restored access to records from 40,000 New Orleans-area veterans within days; it would take years for the private sector to reassemble its records.”

Indeed, where former Surgeon General Regina Benjamin thought she couldn’t afford an EHR before Katrina, she knew she couldn’t run a hospital without one after.

And yet, despite the generally positive results and clear benefits of healthcare IT proliferation, obvious gaps remain. Patients often scatter to the four winds in a disaster and reattaching them to their records is both challenging and not yet reality.

Plans are, however, in the works to fill this gap. The PULSE project, initiated by the Department of Health and Human Services in 2014, is working to create a data-sharing network that’s switched on in emergencies and makes patient records available to first responders and clinicians when they enter patient name, birthdate and gender.

Initial PULSE tests in disaster-familiar California have gone so well that the California Emergency Medical Services Authority plans to keep the system in place and may switch it on during one of the Golden State’s regular events.

All the testing in the world can only provide so much real-world preparation. With climatologists suggesting that the relatively hurricane-free period between Katrina and Harvey is probably over, it’s encouraging to see the progress represented by both PULSE and the performance of Texas and Florida hospitals. Any optimism at this point, however, should be buffered by an urgency to get it even more right the next time the winds start to swirl in the Atlantic, regardless of what name we give them. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Michigan study: Information blocking as a sales strategy

Looking to boost the entertainment value of this blog, a couple of years ago we compared information blocking to the mythical jackalope—a creature no one has seen in nature but many have encountered hanging over bars in various western towns.

Continuing with that metaphor, it now appears someone has actually seen an antelope-horned jackrabbit bounding through sage brush and pinion. I’m talking about a recent University of Michigan survey that asked health information exchange (HIE) professionals about their experience with information blocking. Respondents clearly indicated that information blocking is real and is practiced by both health systems and EHR vendors.

“Half of respondents reported that EHR vendors routinely engage in information blocking, and 25 percent of respondents reported that hospitals and health systems routinely do so,” write professors Adler-Milstein and Pfeifer in their report. “Among EHR vendors, the most common form of information blocking was deploying products with limited interoperability. Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology.”

The survey results are especially incriminating for EHR vendors, who either “routinely” or “occasionally” engage in information blocking, according to 88 percent of respondents. Hospitals and health systems fared better, but 59 percent of survey participants still used “routinely” and “occasionally” to describe information blocking behavior.

The survey gets more interesting as it delves into specific tactics. Respondents said information blocking among EHR vendors usually takes these eight forms and occurs with a corresponding frequency shown in parentheses.

  • Products have limited interoperability (49 percent)
  • High HIE fees unrelated to cost (47 percent)
  • Third-party access to data is difficult (42 percent)
  • Refuse to support particular HIEs (31 percent)
  • Data export is difficult (28 percent)
  • HIE contract terms change after implementation (19 percent)
  • Unfavorable HIE contract terms (17 percent)
  • Gag clauses on speaking about info blocking (12 percent)

Hospitals and health systems, the survey showed, try to block information by pressuring providers to adopt specific technology (28 percent), controlling patient flow through selective data sharing (22 percent), and using HIPAA as an excuse to not share patient data (15 percent).

The ‘Why?’ in all this is what one might expect from companies working to ensure profitability. Survey respondents mostly said they think EHR vendor goals are to maximize short-term profit and increase the likelihood their products will be selected.

Of course, as has been pointed out many time and in various forums, healthcare is not just like any other marketplace. In truth, EHR vendors are caretakers of information that nurtures a public good. The measures of success in this arena are both patient health and sales totals.

The Michigan study survey results are supported by the anecdotal experience of individual physicians like Peter Masucci.

“I went digital 11 years ago and embraced an electronic health record,” writes Masucci in a recent article on STAT. “While things aren’t perfect, they’re very good. Yet now I’m being told by the managers of my affiliated group that I and all of the other physicians in the affiliated group must adopt and use the same new electronic health record platform.

“That doesn’t make sense to me. I have an iPhone and my neighbor has an Android, but we can still communicate. My bank account is with TD Bank and I regularly get my money from Citizens Bank ATMs; communication seems to be working there. Why in 2017 must all doctors be on the same system to communicate and share information?”

Why? Because that’s the business model that most benefits EHR companies and many of their large hospital and health system surrogates. Even while the technology to readily enable interoperability is not there yet, interfaces can still be built, all HIEs can be supported, and there simply is no legitimate healthcare-oriented reason for gag clauses.

“What has been substantially underappreciated, however, is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not [participating in HIEs],” writes Julia Adler-Milstein in Health Affairs. “And as a result, these actors may behave in ways that interfere with the free-flow of patient information that is needed to improve health and health care.”

The solution, according to the Michigan study, is a change of incentives. While the federal incentives for EHR adoption are obviously reimbursement, the incentives enabling free flow of patient information between systems and doctors remains elusive.

How might those incentives change? One obvious approach is government regulation, which is mentioned in last year’s Twenty-First Century Cures Act, but more oversight is not what most in healthcare want to see. Since five EHR vendors control roughly 70 percent of the EHR market, a better approach might be to willingly embrace HIE and the policies/technologies necessary to make it happen.

Is that asking too much of for-profit businesses? It might be. But as with most issues in healthcare, what is not effectively managed to benefit patients eventually becomes something potentially regulated by Congress.  The question now might be who will blink first—the information blockers or Congress.

Richard Sullivan is chief government and revenue officer for Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Interoperability

It’s 2017. Do you know where your interoperability is?

With January barely behind us and new occupants in the White House, perhaps it’s a good time to set aside what might change for a moment and focus on what must. Interoperability is a more urgent concern in 2017 due to goals established last year by the Office of the National Coordinator (ONCHIT) and the passage of the 21st Century Cures Act, which legally requires healthcare IT interoperability by the end of the current calendar year.

The Interoperability Standards Advisory for 2017, released by ONCHIT in December, is an effort to facilitate interoperability by releasing “essential standards and implementation specifications” determined in dialogue with public and private sector partners. These partners include healthcare IT vendors with products installed in 90 percent of U.S. hospitals that have also made a public commitment to the ONCHIT-created Interoperability Pledge and its essential elements:

  1. Use standardized APIs.

  2. Make it easier for patients to access data.

  3. Don’t block information.

Even if the pledge itself promises little in the way of holding signees to their promises, the Cures Act will likely prove thornier. As detailed in the legislation, technology certification will require vendors to demonstrate that they are not blocking information or in any way inhibiting data transfer. They must also utilize application programming interfaces (APIs) or a similar data transfer enabling technology.

But while 21st Century Cures may be the match that lights the interoperability pilot, it won’t be the source of heat and energy. If interoperability is achieved this year, it will be because significant technological and policy goals have been identified and realized.

So where do we stand on interoperability in early 2017?

  • Almost all hospitals now have a certified EHR. No, this does not represent a conclusive accomplishment. Rather, virtually universal adoption of EHRs gives us a moment of pause as we look to what still needs to be done. We have the necessary platform, and now we need to keep improving to exchange data amongst entities in a way that makes clinicians more satisfied.
  • Work on an interoperability standard is progressing and showing promise. The Fast Healthcare Interoperability Resources (FHIR) standard that Health Level 7 (HL7) has been working on is maturing; the organization expects a normative version to be released this year. That’s good, given the Cures Act mandate.
  • The shift to value-based care is happening and will continue. According to a recent KPMG survey, half of health systems are now reimbursed in part for value-based care hinging on cost and quality factors. A full quarter of survey respondents said they would be engaging in value-based reimbursement plans in the next three years. Only 7 percent said they would not. The train is in motion and it requires comprehensive healthcare IT that is fully enabled to exchange information as effectively as possible.

Of course, no one is arguing that now is the time for clinking champagne flutes and excessive back-slapping. Industry surveys and anecdotal data tell us a story of unsatisfied clinicians who still lack full patient data and are hindered clinically as a result.

What must still be accomplished in 2017 to move closer to fulfilling visions of a comprehensive healthcare IT system nationwide?

  • Continue pursuit of a standard. Right now FHIR is the front-runner for default healthcare IT standard. The smart money might bet on FHIR because it has a development timeline advantage, but there are no guarantees. Normative status for FHIR means vendors could potentially include it in products in time to meet Cures Act requirements.
  • Create application programming interface (API) initiatives. Earlier this year, Chilmark Research released a report on APIs in healthcare with recommendations for each industry participant.
    • Health care organizations should initiate API programs, urge EHR vendors to develop APIs, start API governance discussions and focus on user interface issues.
    • HIT vendors must start programs with FHIR and APIs, and re-evaluate interfaces from a product rather than services perspective
    • Payers need API programs, too, starting with paid claims data. They should also cultivate relationships with independent developers.
    • Data integrators should understand how to support FHIR and utilize a value-based monetization model as opposed to an access-based model.
    • Device manufacturers will look to partnering with EHR vendors and integrators, and should also embrace a value-based monetization mode.
  • Revamp healthcare further. It’s not just value-based payment models that are changing the provision of healthcare. As John Glaser writes in Hospitals and Health Networks, collective industry actions point toward establishing healthcare IT solutions that include but do not culminate with APIs and FHIR. The number of accountable care organizations, currently approaching 800, continues to grow as technology enables both care coordination and multi-payer risk.

The larger message and broader vision in Glaser’s interoperability article is one healthcare would do well to embrace. Healthcare is not simply engaged in technical interoperability; the industry is also breaking out of an approach to care that walls off bits of patient data in the separate files of different providers, that primarily pays for procedures and solutions after the patient has fallen ill, and that too often proscribes incomplete solutions for complex, comorbid health concerns.

Healthcare is moving toward an industry-wide interoperability that can’t fully emerge until the technology to enable it has matured. There’s a better-than-average chance 2017 is the year we start to see real benefit.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Category: Interoperability

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

When illnesses collude: How comorbidity threatens American healthcare

Comorbidity is not a word heard every day—not even in healthcare, where it applies. But researchers and physicians, assisted by IT-derived diagnostic data, have come to understand that comorbidity is essential to understanding and managing population health, especially among vulnerable populations challenged by mental illness and addiction.

A patient with comorbidity has at least two chronic diseases at the same time that interact in such a way as to worsen the impact of each illness on the individual. Imagine irritable bowel syndrome or Crone’s and diabetes working in tandem, for example, and it’s not hard to see how comorbidity becomes a tag-team bludgeon.

Among the total population of the United States, 25 percent have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC). Of course, those chronic conditions are not limited to the physical. Once we include mental illness and substance abuse in the definition of comorbidity, rates rise dramatically and are often more debilitating.

There is simply no denying that even the most common mental illness creates the risk of comorbidity with drug and alcohol abuse. According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes.

In this environment, doctors and the healthcare system are not tasked with just treating a physical illness or three. They also have to treat a physical challenge that may have been neglected due to mental illness made worse by substance abuse. Or maybe they’re trying to wean a patient off heroin used to deal with chronic pain after the OxyContin subscriptions ran out.

It’s this complex self-medication dance that regularly doubles back on itself and dramatically ratchets up costs in terms of both healthcare dollars and lives. Opiate-related deaths just recently surpassed those from gun violence, and healthcare costs rose 3.4 percent last August, the highest one-month rise since 1984.

“On average individuals with chronic medical conditions incur health care costs two to three times higher when they have a comorbid substance use disorder compared with individuals without this comorbidity,” wrote Surgeon General Vivek Murthy in his recent report on addiction in America.

No, mental illness does not always lead to substance abuse and an often irreversible downward spiral. But addiction always makes both physical and mental illnesses far worse, even if we cannot determine causality or directionality.

A survey by the National Institute on Alcohol Abuse and Alcoholism, for example, identified comorbidity in a majority of respondents. A separate study by the NIAAA found that 56 percent of subjects with bipolar disorder also practiced some form of alcohol abuse and were more likely to have medical comorbidities like lung and breathing issues because smoking is so common.

How can we deal with mental illness to try and avoid substance abuse and medical comorbidity?

  • Catch it early. “… research indicates that 90 percent of people who develop a substance use disorder started their use before age eighteen,” writes Alexa Eggleston of the Conrad Hilton Foundation in a recent Health Affairs blog post. Eggleston speaks of substance abuse in general, but the risks are greater in the teenage years, when most mental disturbances manifest, making increased awareness even more necessary.
  • Initiate treatment. Addressing a mental issue is more straightforward before comorbidity becomes a factor. If mental illness and substance abuse comorbidity happens, treatment should focus on both issues at once, according to the National Institute on Drug Abuse.
  • Break down silos. The unfortunate tendency in healthcare going back decades has been to silo information and care. Treatment has tended to focus on independent specialists treating separate aspects of the patient condition without fully addressing how they impact one another. That must end. The placebo effect, for example, shows us that the brain and the body are not separate and that treating them as unrelated makes as much sense as changing the oil on a car with four flat tires.

To be sure, changes to the way we provide care—paying for value, Patient Centered Medical Homes, ACOs, HIEs, etc.—have gained great momentum that should continue. As mandated by the recently passed 21st Century Cures Act, interoperability among healthcare IT systems must become a reality so ER docs can see when a patient is bipolar and family practitioners know immediately that their new patient is on anti-psychotics.

Annually, the United States spends $35 billion from both public and private payors to treat substance misuse, but that’s a small fraction of the amount addiction extracts from American society in terms of services for the homeless, work absenteeism, broken families and other types of fallout. In total, substance abuse is estimated to cost the United States more than $400 billion each year, an amount that is 2/3 that of the Pentagon budget.

We are currently in the midst of one of the worst drug-addiction epidemics the nation has experienced. No, integration of patient record systems and patient care protocols will not prevent the destructive chain of events that leads to substance abuse, but becoming more alert to the frequency and severity of comorbidities may enable us to see warning signs sooner, share information and work more interactively with other caregivers, and more effectively improve patients’ overall health and quality of life. And this multi-pronged approach to quality of care will very likely minimize the costs to society in the process.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Cures Act: A bag of holiday gifts for healthcare

On Tuesday, President Obama signed the 21st Century Cures Act, codifying a broad and far-reaching effort to achieve medical breakthroughs in Alzheimer’s and other debilitating afflictions through improved, streamlined, well-funded research.

The Cures Act gives particular attention to cancer and Vice President Joe Biden’s Cancer Moonshot initiative, which hopes to transform research and make certain varieties of the illness either manageable or history.

“God willing, this bill will literally, not figuratively, literally save lives,” Biden said at the signing ceremony. “But most of all what it does … is gives millions of Americans hope. There’s probably not a one of you in this audience or anyone listening to this who hasn’t had a family member or friend or someone touched by cancer.”

The Cancer Moonshot illustrates well how most of the Cures Act focuses on research and additional funding for the National Institutes of Health and similar agencies. But it also focuses on bettering the current provision of healthcare by improving behavioral health care and healthcare IT.

Viewed from a high level, Congress is focused on stemming the tide of mental illness and opioid addiction in America, as well as making sure healthcare information flows freely and safely among providers to improve patient care. Read on for highlights.

Mental Illness and Addiction

Via the specific proposals below, the Cures Act endeavors to better fund mental health care and opiate addiction, improve leadership and planning, ramp up research, enforce parity and improve preparedness among police and in the legal system.

  • Over the next two years, the Cures Act provides $1 billion in state grants for opioid abuse prevention and treatment. Specific parts of the proposal include prescription drug monitoring, healthcare provider training and better access to treatment programs. Indeed, block grants to state agencies are clearly aimed at helping individuals break out of the addiction cycle that so often includes homelessness and limited family support.
  • Grants will also go to higher education and professional training programs to put more mental health professionals in the field.
  • The Act also creates new positions—an assistant secretary for mental health and substance use, and a chief medical officer—in the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Apparently not a sanctioned SAMHSA component previously, the Center for Behavioral Health Statistics and Quality is now codified in the Cures Act, as is the requirement that SAMHSA create a strategic plan every four years to identify priorities and strengthen the mental health workforce.
  • Mostly through reauthorizations, the Cures Act provides funds for mental health programs that pay specific attention to some vulnerable populations: college students, women and children.
  • Mental health parity, already a law but sometimes inadequately enforced, will become more of a focus for HHS, which is being asked to draw up a federal and state compliance action plan.

Healthcare IT

While there are efforts in the Cures Act to improve the functionality of EHRs and access to records for patients, the real focus is on improving the flow of information.

  • Apparently fed up with allegations of information blocking, Congress included in the Cures Act $15 million in funding for improved interoperability and less information blocking. Some of the money will support a voluntary framework for information exchange and some will go to HHS to investigate claims of information blocking and punish the blockers to the tune of $1 million per violation. The Government Accounting Office is also required to evaluate patient access to personal health information and why it might sometimes be difficult to get.
  • Congress is also requiring HHS to change the terms of Meaningful Use to include interoperability. Moving forward, healthcare IT vendors must develop application programming interfaces (APIs) and apply real-world tests of interoperability to EHR systems.
  • If the Cures Act has a measurable impact, EHRs will become more patient-centric. Incorporated language speaks to making patient records more simple and easier to use, and continuing to grow Health Information Exchanges (HIEs) to expand patient access to care.
  • A new HIT Advisory Committee will make recommendations to the national coordinator on a host of healthcare IT concerns. Of particular interest will be the segmentation of data so that only select parts of a patient record can be shared and sensitive data related to mental illness and drug addiction can be closely controlled.
  • The Advisory Committee will also have the authority to make recommendations on population health, healthcare for children, telemedicine and other potential improvements to healthcare available through IT.

At nearly 1000 pages, the Cures Act obviously includes much more than the greatest hits included here. The curious might visit this highlights document and find specific objectives that perhaps are more relevant and important.

As with all federal legislation, efficacy is measured by impact over time, not number of pages or total appropriations. With the Cures Act, we can hope that the grant money will make a significant difference at the local level and that patient health information will flow more freely between coordinated providers. A cancer breakthrough wouldn’t hurt, either.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Cures Act is a strong mental health vaccination. Booster shots required.

Remember that the two things you don’t want to watch being made are sausage and law. Then recall that while the process for both may be unappealing and seem incongruous, the product is not always so.  

Take the 21st Century Cures Act, for example, which is a lengthy (996 pages) piece of legislation (summary here) that focuses primarily on health-related scientific research and medical devices. It also broadly outlines the terms for an upcoming drawdown of America’s strategic petroleum reserve, which may look like a rider but is actually a way to pay for the bill.

The sale of crude will also help fund mental health and addiction treatment, about which the Cures Act has something to say thanks to language appropriated from the Helping Families in Mental Health Crisis Reform Act. That bill passed the House earlier this year but has languished in the Senate since.

It’s encouraging to see Congress address mental illness and addiction, and the Cures Act works to address many of the issues that plague American mental health care and bleed into acute care as well.

Read on for more on what the Cures Act does and doesn’t do to improve mental health care.

What does the Cures Act do for mental health care?

  1. Provide More Money: Over two years, the Cures Act provides $1 billion in block grants to the states for opioid abuse prevention and treatment through prescription drug monitoring, prevention programs and healthcare worker training. It also provides or reauthorizes a host of other targeted grants focused on specific goals and populations, including treatment of students on college campuses.

  2. Create New Leadership and Planning: The bill establishes a new assistant secretary for mental health and substance use to head the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as a chief medical officer within SAMHSA to help with program creation and development. 

  3. Promote Cutting Edge Research: Moving forward, a new National Mental Health and Substance Use Policy Laboratory (NMHSUPL … whew!) would be responsible for focusing evidence-based, scientifically oriented treatment on mental illness and addiction. The laboratory would also identify and respond to regionally specific mental health and addiction challenges.

  4. Push Parity: The Cures Act puts the onus for verification of compliance with parity legislation—the requirement that insurance policies cover mental and physical health equally—on Health and Human Services (HHS), Labor and Treasury. Down the road, the Government Accounting Office and CMS will evaluate whether or not parity compliance is happening. 

  5. Support Mental Health Training in the Legal System: Approved use of existing funds would empower law enforcement to create mental health crisis intervention teams and pay for targeted training. Additionally, the Cures Act requires the attorney general and courts to create a drug and mental health court pilot program.

What does the Cures Act NOT do for mental health care?

  1. Enable Integration with Acute Care: Despite there being funds for many programs, none were appropriated for expanding use of EHRs in mental health facilities. It seems like an omission, especially given the success of EHR adoption in acute care hospitals and the interoperability requirements included in other sections of the act. Interoperability is great and overdue, but it should be spread across the continuum of care to maximize impact.

  2. Add Beds: This isn’t a completely fair criticism, given that there is grant funding to states in the Cures Act that perhaps could be used for new facilities with more beds. But there isn’t a mandate with supporting funds to make up for the 4,500 public psychiatric beds that were lost between 2009 and 2012 and pretty much remain so. Indeed, when the need seems to be increasing, the number of psychiatric beds in the U.S. remains at record lows, contributing greatly to homelessness in urban areas and misuse of emergency department resources.

  3. Expand the Pool of Therapists: Outside of urban areas, professional therapists are hard to find and referring physicians have few options. Federal programs already exist that give teachers and doctors financial incentives (loan forgiveness) to work in areas where their skills are most needed. It seems like doing the same for therapists of various stripes—assuming such programs don’t already exist—is warranted. States could conceivably use grant funds to accomplish this goal, but federal law could offer more support. 

  4. Appropriate Enough Money: Looking at the number alone, $1 billion looks like a lot of money. As a sliver of the federal budget, and given the mental health and addiction challenges plaguing states, it may prove inadequate without viewing it as a down payment on a larger commitment. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, from 2009 to 2012 the states cut roughly $5 billion in mental health services, so 20 percent of that total at best may be restored.

Given what we know in the 21st century about mental illness—how common it is and how much human potential and productivity it drains from society—it’s not hard to envision behavioral health and addiction issues as some of the nation’s most daunting challenges.

But the 21st Century Cures Act, while focused on improving healthcare through better, more rapid research, perhaps tries too hard to be all things to all people. It won’t be. As with most legislation, the Cures Act will hopefully establish a foundation on which additional legislation can build. Subsequent legislative efforts should focus on expanding the pool of beds and therapists, and on integrating with acute care.

Let’s make sure those changes happen before there is a 22nd Century Cures Act.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

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