Can healthcare IT save rural hospitals?

In business, disruption is often seen as a good thing, e.g., digital photography disrupting Eastman Kodak’s business so significantly that the company has scrambled in recent years just to stay afloat, the thing they once did better than anyone now largely irrelevant.

So, disruption is a negative for employees of old technology companies, but it’s a boon for workers in cutting-edge businesses and generally for consumers as well. Those who benefit greatly outnumber those who don’t.

And disruption isn’t limited to photography, of course, but in other industries it’s more difficult to blithely nod to the gods of commerce and light another candle on the shrine of economic casualties.

The best example of this scenario we have right now is American hospitals, where Morgan Stanley says nearly 20 percent are either teetering on the edge of insolvency or are “weak.” Of the roughly 6,000 hospitals in the United States, more than 1,000 exist on shifting financial sands. In recent years, an average of 30 hospitals have closed each year, according to the American Hospital Association, and that seems likely to continue.

Among those threatened hospitals, the threat hangs disproportionately over rural areas.

“Since 2010, 86 rural hospitals have closed and 673 others — a third of all rural hospitals in the U.S. — are vulnerable and could shutter their doors,” says Healthcare Dive. “And currently, 44 percent of rural hospitals are operating at a loss, up from 40 percent last year.”

What factors are making it so hard to function outside America’s urban zones?

  • Shrinking reimbursements
  • Higher costs
  • Fewer inpatient admissions
  • Many Medicare/Medicaid patients and few with private insurance
  • Competition from alternative care sites

And let’s be clear about the impact of these hospital closures. When a hospital is shuttered in an urban environment, it creates an inconvenience and a slightly longer car/ambulance ride. When hospitals close in rural areas, towns lose jobs, a source of civic pride and community engagement, and often lives as well.

But the current hospital closure rate need not continue. As healthcare moves through dramatic changes, re-imagined processes and sparkling new tools can empower key preservation strategies:

Establish Telehealth Partnerships: When Plains, Georgia, the home of former President Jimmy Carter, lost its only clinic in March, the Mercer University School of Medicine stepped in and opened Mercer Medicine Plains. Offering both onsite and telehealth services, Mercer Medicine Plains is just the most recent project managed by Jean Sumner, dean of the School of Medicine, who has managed similar efforts in other rural parts of Georgia.

“It’s a way to bring some healthcare to people who don’t often see it, but who do need it,” Sumner said. “In these areas, you need to figure out what you have, and then work with it.”

Telehealth also offers the potential to simplify revenue cycle through enhanced billing and collections. As direct payments by patients have become a larger segment of hospital revenue, organizations must now collect as many outstanding dollars as they can. With telehealth, patients are often willing to pay upfront for convenience and ease.

If we want other communities to benefit as Plains, Georgia, has, we must make sure sufficient infrastructure is in place. In recent testimony, the American Hospital Association encouraged Congress to make sure broadband networks proliferate more widely to the areas where telehealth can have a dramatic impact.

Use the Cloud: In northern Kansas, rural Republic County Hospital used to have an expensive relationship with a radiology organization that read images for the hospital. With the current cloud-based, vendor neutral PACS system in place today, Republic cut their imaging costs in half and can now give clinicians access to patient images through any internet connection. The update to an internal fiber optic network opened a new world of possibilities that the hospital is now starting to maximize.

Beyond PACS, how else might Republic use the cloud to further cut costs and improve revenue?

A cloud-based storage and healthcare IT platform would empower Republic to save money on servers and other local infrastructure, provide better access to patient data beyond just imaging, access solid backup and disaster recovery options, scale for expanded storage without having to buy hardware, and run analytics on patient and organization data to identify opportunities for greater efficiency.

Increase Reimbursements: Hospitals are reimbursed by the federal government, in part, based on a formula that uses a national average and local factors like cost of living and level of competition. This wage indexing of reimbursement, not to mention other regulations, makes profitability more of a challenge for rural hospitals than it arguably is for their city cousins.

“Rural is experiencing death by a thousand cuts,” said one rural hospital CEO.

The issue here is that while cost of living in rural areas may be less, the cost of providing care is not. Members of Congress have asked why CMS has not yet fixed this problem, and the agency may have to come up with a different reimbursement scheme or decide in the interim that rural healthcare is a public good the government must preserve while financial viability is worked out.

Reduce Regulation: Yes, telehealth shows strong early promise, but many of those providing care in rural areas believe it could have more of an immediate impact with fewer shackles. Currently, Medicare’s telehealth limitations include geography, setting and type of service provided.  

Rural healthcare is also subject to policies and regulations that may work perfectly well in city hospitals but are much more difficult to comply with where resources are scarce. Rural hospital administrators argue that what they need is the flexibility to solve problems in a manner that makes sense locally. In essence, these same administrators are making the argument for the freedom to remain viable, which seems like a clear-cut public good on the face of it.

Amid the ongoing turmoil, many clinicians and administrators lament the way technology is turning the traditional hospital environment upside down. It’s a completely understandable response to upheaval. But technological change would not be possible in an environment that was not already ripe for disruption. And the good news is that technological change does not just plow through an industry like a tornado through a Kansas trailer park. It leaves a different, usually more flexible order in its path.

So, to revisit the original question, can technology save the rural component of American healthcare from destitution? Not alone, but many of the policy changes necessary to save rural care are enabled by advances in technology. We’re better served by an integrated, collaborative approach regardless of which healthcare sector we work in.

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

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

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

5 ways technology makes behavioral health care better

Are you old enough to remember the pre-concert security searches for recording devices that were once part of every live music experience? Yes, musicians once had some semblance of control over bootleg audio and video.

But the proliferation of tiny hand-held computers that happen to also make phone calls ended all that. Now, tossing music-lovers who pull out a phone to record would empty entire arenas save a few luddites with flip phones and mullets.

Sometimes silently, other times with great fanfare, technology has wormed its way into almost every aspect of life. Much has been written about the use of electronic health records in healthcare, for example, but EHRs are just one example.

In behavioral health, EHR adoption lacks financial incentives so the rate of adoption has lagged that of acute care. And still technology creeps into the way we provide behavioral health care, in many ways transforming and often improving treatment, compliance and reporting.

One could argue that the potential for positive disruption is greater in behavioral health than in any other subset of medicine and healthcare. So how, exactly, is technology upsetting the behavioral health apple cart in beneficial ways?

  1. Improving correlation of health information: There is a strong likelihood that a patient with bipolar disorder or a similar affliction is also self-medicating with drugs and alcohol. Sure, a caregiver somewhere along the way might notice the physical signs of abuse, but they also might not. A comprehensive EHR that includes patient data from coordinated providers would provide that information, just as it would when the bipolar patient shows up at the ER with a broken arm.

    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. Therapists might sometimes have the luxury of just treating a mental illness, but around half the time they will also be working with an addiction problem and must aware of both.

  2. Making care available outside urban areas: The numbers suggest mental health counselors are jockeying for clients in urban areas and scrambling to meet overwhelming demand in rural sections of the country. Rates of alcoholism, opiate abuse and generally risky behavior are higher outside of major cities, creating a burgeoning healthcare crisis in the parts of the economy oriented around agriculture and energy.

    With few promising alternatives, much of the push to resolve America’s rural health conundrum is now focused on telehealth, and with good reason. Telehealth has proven effective thus far in treating depression and PTSD. According to a 2012 Institute of Medicine report, telehealth also increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. 

  3. Boosting the bottom line: A comprehensive EHR combined with robust revenue cycle tools and services ensures that behavioral health care providers are compensated more reliably for the care they provide.

    “An EMR is an investment because it provides long-term benefits and may be an important tool for reducing the cost of expenses,” writes Carol Turso in Behavioral Healthcare.

    Turso uses the example of a social services organization that over three years after implementing an EHR reduced bad debt by 93 percent, lowered outstanding accounts receivable of more than 151 days from 24 to 9 percent, and trimmed the time staff spent per week entering remittances and payments from 40 hours to 10 minutes. In every instance, these EHR benefits improve the organization’s bottom line. Even if they don’t technically create new revenue, they are still financially relevant.

  4. Enabling self-directed care: At its core, self-directed care is empowerment focused on dealing with pain and frustration, getting regular exercise, eating well and communicating with counselors and family. Self-directed care engages the patient more fully in the care process, even in some instances allowing patients input on how and where to spend the money applied to their treatment.

    In recent years, the self-directed care model has gained more currency in the provision of behavioral health care. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, technology, especially mobile phones, offers support and assistance. 

  5. Giving kids something to do: Do mobile devices keep kids off drugs? The jury is still out, but it’s one explanation for a steady downward trend over the last decade of teenagers experimenting with drugs and alcohol. Correlation, of course, is not causation, which is why the National Institute on Drug Abuse plans to make this the subject of a study over the next several months.

    While many teenagers seem as addicted to mobile phones as they might be to marijuana, parents will probably rest easier knowing the former might be preventing the latter.

The proliferation of technology, especially in healthcare, is something that must be monitored over time and re-evaluated regularly. As some healthcare economists have pointed out, technology drives up healthcare costs more than any other factor.

But behavioral health, specifically, will never have to invest in massively expensive tools like MRI machines, creating an opportunity for the grassroots use of relatively affordable handheld and desktop technology that over time can affect measurable change in the lives of patients.  

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

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.

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. 

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