The CMS Comprehensive Primary Care (CPC) initiative is a four-year multi-payer initiative designed to strengthen primary care. CMS has collaborated with commercial and State health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “Comprehensive” primary care functions.
These five functions are: (1) Risk-stratified Care Management; (2) Access and Continuity; (3) Planned Care for Chronic Conditions and Preventive Care; (4) Patient and Caregiver Engagement; (5) Coordination of Care across the Medical Neighborhood.
I was asked to participate in a video (above) about the University of South Florida Morsani College of Medicine's graduate program for Health Informatics. Because it is an online program, there were students from across the country as well as Florida. I was able to finish the program in a little over a year.
If you're interested in learning more about Health Informatics check out the curriculum on the USF website.
Health Data Management (in the above link) reported savings from use of Telehealth that resulted in reductions in readmissions and healthcare costs. The ONC's Federal Health Information Technology Strategic Plan 2011-2015 described the use of technology to improve care, improve population health and reduce per capita costs of health care. Goal II defined opportunities to Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT.
This same technology could be used in an Accountable Care Organization (ACO) to improve care and reduce costs. Systems, like telehealth, have been implemented in certain ACOs. Remote monitoring, mobile health (mHealth), and the medical home have the potential to positively affect patient lives.
The light bulb has been turned ON. Healthcare is migrating from a disease management system to a “National Prevention and Health Promotion Strategy” that prevents adverse health conditions where possible, anticipates and responds to threats and emergencies and identifies at-risk populations. To me, this strategy represents the goals for ACOs.
Reducing spend for ACO populations is key to health transformation and overall cost reductions in Medicare spending. According to the Banner Health Telehealth pilot, results were dramatic. By having a strong support system for patients, clinicians were able to "collect and analyze objective and subjective health information to identify early stages of deterioration" and to prevent worsening health conditions. Banner health reported enrolling its 500th patient into their program.
An Accountable Care Organization has a minimum of 5,000 patients with care coordinators responsible for monitoring patient status. Their beneficiaries are located throughout a geographic area and the ACO could gain significant cost reductions with positive patient care opportunities using Telehealth.
Several years ago, I was asked to be a panelist on a Bloomberg webinar on Telehealth. The question at the time was simple, "Is telehealth a viable alternative to face-to-face patient care?" I believed it then, and I believe it now, when used in appropriate situations. For more information on Telemedicine and its Telehealth subpart, read this post about the World Health Organization and Telemedicine Opportunities.
SEC. 3021 of the Affordable Care Act established the Center for Medicare and Medicaid Innovation (CMI) within CMS. The purpose of the CME is to establish demonstration projects (i.e. tests) of innovative payment and service models that improve the quality, coordination and efficiency of services and reduce expenditures.
CMS may consult with Federal agencies or external parties with its commitment to open door forums. The types of models to be tested by CMI may include:
a) Promoting broad payment and practice reform for primary care.
b) Promoting innovative delivery models through risk-based comprehensive or salary payments with groups of providers or services/suppliers.
In general, these models should apply to geriatric patients with multiple chronic conditions that would benefit from services that include care coordination between providers and suppliers. These models may also support care coordination for patients with high risk of hospitalization. The model could support a chronic disease registry and home tele-health technology.
Other characteristics of models initiated by CMI may include payment variations to physicians based on appropriateness of services, using medication services described in section 935 of the Public Health Service Act, and using community-based health teams to support small-practice medical homes.
Additional factors include consideration for monitoring and updating patient care based on the needs and preferences of patients. In summary, goals of the CMI include improved quality of care and reduced spending. Other specifics of the CMI program may be found on CMI’s website.
As I am reading the goals of CMI, I can't help but wonder about the influence successful tests may have on future healthcare regulations. In recent months, we have seen the following significant updates to Accountable Care (ACO) regulations. The following information was obtained from the CMS website at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html
Internet resources can provide benchmarks and analysis for Medicare Populations.
The CMS Chronic Conditions Data Warehouse website is located at www.ccwdata.org. As described on the site, the warehouse provides Medicare and Medicaid beneficiary claims and assessment data, linked by beneficiary across the continuum of care. This website provides dashboards that provide the ability to look at chronic conditions, by age, by location, or demographics. Other websites provide dashboards of health outcomes by state and zip code.
The amount of data collected by ACOs will grow rapidly over time and become a critical source for measuring quality of care, costs and operational efficiency. Generally, ACOs need to either build or outsource development of a central data warehouse to gather, store and analyze data. Development of a data warehouse happens to be one of the challenges of a big data implementation. Three characteristics of big data include size, complexity, and technologies. EMRs are optimized for rapid data input of transactions. Often there are a number of standard reports that can be produced for a given period of time, or as of the date they are run. A key aspect of transaction systems is also the amount of “care and feeding” they require. For example, updates, backups, disaster recovery, etc.
Accountable Care Organizations have the task of gathering patient data from wherever it may originate. Care Coordination may also occur wherever the patient is located. Successful strategies for care coordinators begin even before a patient is discharged from the hospital.
Managing large amounts of data requires a robust infrastructure of databases, networks, and the ability to exchange data among ACOs. Analyses of large databases typically use regression analysis techniques for prediction and forecasting. Regression analysis may identify clinical predictors of health that alert staff to declining health situations or when interventions are needed. One of the biggest successes noted by ACO executives was to use predictive analytics to identify high-risk patients for proactive care.
Challenges and barriers related to informatics and technology are often reflective of the knowledge needed to use tools to analyze data. Other barriers include financial investment and operating costs. In addition, hospitals and clinics must be able to exchange patient data for episodes of care in the emergency department, in-patient stays, or clinic visits. Many ACOs use HIEs or Health Information Exchanges to share data not only from hospitals and clinics, but also from specialty providers. CMS Claims data is received monthly and should be stored in a database for analysis. Registries, CMS Reporting, GPRO and performance data sites require secure Internet access. The HITECH Act provides regulations to ensure Privacy and Security of protected health information using various technologies. Of course it should be noted that none of these technologies come without their share of operating costs and can become barriers when knowledgeable staff are not available.
In September 2013, the FDA published final guidance on the two categories of applications they regulate:
1) Accessories to regulated medical devices, and
2) Transformation of a mobile platform into a medical device (e.g. smart phone).
As mentioned in the above link, the FDA reportedly cleared about 100 mobile medical applications over the last 10 years. The link also provides information regarding the FDA-cleared mobile medical applications and guidance for mobile health device makers.
Incidentally, discussion over whether or not to include Electronic Health Records (EHR) as a regulated medical device has been discussed as recently as November 2013 as reported on Health IT Exchange. In an opinion letter to HHS Secretary Kathleen Sebelius, the HIMSS Electronic Health Record (EHR) Association expressed concern that regulation of EHRs “beyond what is currently in place is not appropriate until further analysis of data and the establishment of a risk-based framework have been completed. The association’s letter also stated that such a 'formal, regulatory approach' to health IT is not warranted.”
The current controversy regarding EHRs as medical devices likely originates from unintended consequences, research and testimony to federal committees raising the issue that EHRs may cause errors, as well as increased incidence of adverse events and near misses associated with their use. Given the potential for patient harm, one must consider that EHRs are tools. People use these tools, and the tool does not substitute for professional knowledge and judgment in its use. That said, certification criteria should also ensure proper functioning of applications to prevent problems as the result of improper functioning.
So what's the point? Healthcare tools (EHRs, medical devices, and mobile applications, etc.) used in the delivery of care to patients, absolutely requires knowledge of how to use the tool and the necessary education that could prevent unintended miss-use as well as prevention of errors in the application and device.
Considering the future opportunities for national use of Telemedicine, proper functioning, knowledge and education related to use of the applications and technology are critical.
The largest investment in Healthcare technology goes beyond installation and to the training and use of these systems. Training is often a hidden cost which impacts perspective on Total Cost of Ownership that may, in fact, be one of the largest costs.
Keep in mind that from a clinical perspective, one of the most important benefits of HIT is to reduce inefficiencies and improve the quality of care. So, there are some costs savings to be realized when the technology is used accurately.
Improving the quality of patient care is a major goal for healthcare, across all disciplines, driven by the National Quality Strategy (among others) for adoption of quality and compliance measures to monitor quality of care. Compliance with these aims can be monitored in the aggregate or at a patient level in most CDS systems.
The National Quality Strategy is driving change in healthcare to improve quality. The 3 aims of the National Quality Strategy are:
Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
But a new twist on the value of Clinical Data available for "mining" and "drilling" are "databases of clinical information" that can be used for medical research.
Given this opportunity, some costs associated with traditional Clinical Trials may be mitigated by using information obtained from an EMR and Clinical Decision Support system (CDS).
Using this technology, data can be massaged and analyzed in a manner that provides retrospective views of medical data for research. These technologies become enablers for Medical Research and Clinical Decision Support Analysis.
Optimistic predictions by RAND Corporation in 2005 encouraged adoption of electronic medical records (EMRs) and encouraged the federal government to "give billions of dollars in financial incentives to hospitals and doctors that put the systems in place." Does HITECH Meaningful Use come to mind?
Interestingly, RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, who profited from widespread report dissimenation describing the value of technology. It is no surprise that "Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005."
"The 2005 report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. However, the study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems (EMR)."
No doubt the savings was overstated and the report (sponsored and paid for by those who could benefit) causes healthy scepticism in its results. Other reasons cited for increased costs in the report include:
"Sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and
The failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT."
Although I agree there has been sluggish adoption, I disagree that we MUST reengineer care processes to reap the benefits.
EMR systems should be flexible enough to adapt to the workflow of users - even if minimal changes to the workflow are necessary. The ability to analyze the system and compare features to the clinical workflow (for example) will result in less risky patient care. Re-engineering the entire clinical workflow to adapt to the system is permeated with risk and could be a potential source for unintended patient harm. This is the "Geek Nurse" in me talking now..