Joel Diamond 8/8/12

Accountable Care Organizations

I have this deep dark fantasy I want to tell you about.  I’ll admit that it’s unlikely that I will ever obtain it, and even if by chance I could, it’s doubtful that I would really know what to do with it. (Get your mind out of the gutter… it’s not twins.)

I was referring to an Accountable Care Organization.

The truth is that before we become a nation of well-intentioned “Accountable Care Organizations,” we must inevitably concede our current state as Unaccountable, Don’t care, Disorganized  (Everyone’s Readmitted).

Hey, wait a minute… I just realized that makes an acronym: UDDER. A rather apt visual of insatiate calves, hungrily sucking on the proverbial government teat.

But I digress.

Speaking of acronyms, if you Google ‘ACO,’ you’ll find a long list of other official definitions. Use your imagination and a few of these seem to actually work as metaphors of our national experiment in payment reform:

• Algorithms, Combinatorics, and Optimization
• Automatic Cut Off
• Ant Colony Optimization
• Animal Control Operation

Apropos of nothing, I include another actual ACO listed here, for no other reason other than I personally found it extremely funny:

• American Cornhole Organization

Sorry.

I guess that’s the point, though. The term ‘Accountable Care Organization’ is ambiguous and offers no insight into what it actually is. Its abbreviation, in fact, might better connote what might Actually Come Operational only in some American Congressman’s Op-Ed piece. (Notice the clever way I incorporated the letters A-C-O twice in that last sentence…  I continue to amuse myself.)

Here are some probably more realistic ACO acronyms:

• Actually Can’t Operate
• Aspirin Costs Onehundreddollars
• Accept Colonic Opening
• Ain’t Covering Oldpeople

Seriously, there is no doubt that all of us need to have skin in the game if we are ever to reduce the economic burden that healthcare places on this country. Ongoing efforts to align financial incentives through shared risk clearly makes sense. The need for integrated data, improved analytics, and intelligent point-of-care quality improvement interventions are the great responsibility of the HIT community.

Since I can’t really think of a better term than ACO, then at least let’s make sure that the emphasis is on “care” (i.e. compassion) in organizations that are accountable to their patients first.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. 

News 8/7/12

Montefiore Medical Group (NY) deploys Phytel’s population health management tool to identify and manage patients for preventative and chronic care.

The AAFP issues a statement expressing support for electronic prescription drug monitoring programs and the interstate exchange of prescription drug registry information to reduce the abuse of opioid analgesics for pain control.

Market analysts say the economic recovery has helped drive a 5% increase in physician visit volume in the second quarter of 2012 compared to a year ago. Another contributing factor: the growth of high-deductible insurance plans include no out-of-pocket costs for preventative and other primary care services.

The Tucson paper profiles Jeffrey Selwyn, MD an self-professed EMR skeptic who seven years ago was the last physician in his eight-provider group to adopt NextGen’s EHR. Despite having to initially cut back on his patient load, he soon was “amazed at what it did to enhance care” by boosting the continuity of care and allowing for electronic chart sharing. Selwyn is now chairman of the board of the ACO Arizona Connected Care and has elected to defer his retirement to help other physicians convert to EHRs.

E-mail Inga.

From the Consultant’s Corner 8/4/12

Business Intelligence: Shifting from Generating Reports to Creating a Body of Knowledge

Five years ago, the industry was buzzing about the concept of "business intelligence." Large, sophisticated healthcare organizations were gathering lots of data and running many reports in an attempt to answer key business questions. While this scattershot approach provided insight into certain aspects of the organizations, it did not help paint a comprehensive picture of enterprise-wide performance.

The reality is business intelligence isn’t about the amount of data or types of reports your organization generates. It involves creating a body of knowledge about your organization’s patients, care, and costs that you can use to drive process improvement, reflect compliance, and support decision making.

What I’ve noticed in talking with healthcare organizations around the country is that the art of leveraging business intelligence is not just for the large, sophisticated hospital or medical group any more. It is now a necessity for any organization that wants to survive and grow.

In fact, in the current age of data-driven healthcare policy—including Meaningful Use, patient-centered medical home, and healthcare effectiveness data and information set (HEDIS) requirements—organizations of all shapes and sizes need to use business intelligence to not only demonstrate compliance but, more importantly, to get paid.

A first step in the process of leveraging business intelligence is to take some time and clearly define what your organization’s approach to it will be. As part of this effort, I recommend creating a team of business intelligence consumers who can work together to determine what information is really needed and how your organization will use this key information.

The team’s membership should be diverse and include multiple perspectives, such as finance and accounting, clinical, and quality. The chief medical informatics officer (CMIO) should play a critical role on the team because he or she will bring both the business and the clinical perspectives to the table.

Note that the role of this group is not to figure out the technical aspects of gathering business intelligence. Leave that to the IT folks. This group needs to figure out the strategic goals for business intelligence and decide how the organization will use all the information it gathers. The ultimate purpose of business intelligence is to supply usable data that help develop better care for a better cost, so in my view, the team should be focused on things like how to develop a picture of overall performance, clinical quality, and patient satisfaction. BI should also reliably identify gaps in care and ways to improve revenue cycle efficiency.

I would caution you when taking this strategic look to consider not just what your organization needs now, but also what it will need five years down the road. As I mentioned earlier, many healthcare organizations used to take a more limited view of business intelligence and focused their attention on generating volumes of reports. Now these organizations are replacing many of the systems they purchased five years ago because they don’t have the bandwidth and capability to do what is necessary to meet current information needs. Your organization can avoid making this same mistake by focusing on the future, so that five years from now, you are optimizing solutions for business intelligence not replacing them.

Kyle Swarts is regional vice president for Culbert Healthcare Solutions.

News 8/2/12

The HIT Policy Committee’s Meaningful Use Workgroup presented its preliminary draft recommendations for MU Stage 3 on Wednesday, planning to present the final draft in November. Some notable recommendations impacting EPs include:

• More than 50% of all prescriptions written by an EP are compared to at least one drug formulary and transmitted electronically.
• Implement 15 clinical decision support interventions related to five or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period.
• Enable functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.
• Store more than 80% of all clinical lab results ordered by the EP into the EHR as structured data.
• Present real-time dashboards of patients with specific conditions for quality improvement, reduction of disparities, research, or outreach.
• Record electronic notes in patient records for more than 30% of office visits within four calendar days.
• For non-English speaking population, provide additional patient education materials.
• Engage at least 15% of patients in secure messaging communication with EPs.
• Support the electronic receipt of immunization histories from an immunization registry or information system for at least 30% of immunized patients.
• Offer at least 10% of patients the option to submit histories or clinical data online.

Pine Medical Group (MI) says that its use of SRS’s Continuity of Care Exchange (CCX) platform to share discrete clinical data with the Wellcentive registry has resulted in increased practice revenue and helped the practice meet PCMH care management requirements.

Kareo CEO Dan Rodrigues advises physicians on the use of technology to thrive in business. Specific recommendations include eliminating paper, sharing office space with other practices, and using social media to get referrals.

GE Healthcare IT reports that its customers have received more than $100 million in MU incentive payments since the program’s inception, including 4,250 EPs earning $80 million using Centricity Practice Solution or Centricity EMR.

Thanks to the reader who forwarded this link to CMS’s a 15-minute video slideshow, which overviews the PQRS and e-prescribing incentive programs. It’s a nice tutorial for someone who wants to learn the basics of the programs.

Hello Health announces the addition of 20 practices to the Hello Health Electronic Medical Revenue Platform.

Latest MU numbers from CMS as of the end of June:

• Medicare and Medicaid have issued over $6  billion in payments.
• Medicare has paid more than $1 billion to 62,177 EPs (including 55,275 physicians).
• Medicaid has awarded 46,136 EPs (34,067 physicians and more than 9,000 PAs/NPs/MWs) a total of $963 million.
• Family practice and internal medicine specialists represent 43% of all doctors or medicine or osteopathy receiving MU funds.

Speaking of CMS, Medicare.gov issued a Tweet today reminding EPs that October 3 is the last day to start their 90-day MU reporting period for calendar year 2012. That’s just over 60 days from now, meaning if you don’t yet have a certified EHR in place but want to attest for MU funds, it could possibly be too late to make a purchase or implement an upgrade.

Minnesota achieves the highest rate of e-prescribing use in 2011, with 61% of prescribers routing prescriptions electronically. Massachusetts and New Hampshire had the highest physician adoption rate at 86%.

One-third of US physicians say they will leave medicine within the next decade, including more than half of all hematologists and oncologists. Their primary drivers are economic (medical malpractice and overhead costs) and regulatory (health reform changes.)

E-mail Inga.

DOCtalk by Dr. Gregg 7/28/12

Days of Whine and Proses

In the midst of just another day of too many patients with far too many unexpected problems squeezed into far too few time slots within which were too few moments to reflect and consider, I had an epiphany: I, we, all of us in healthcare delivery are living in the midst of the Days of Whine and Proses.

The Whine? We are still, as I said several years back, in the very midst of the birth pangs of the delivery of this huge "enfant terrible" known as digital healthcare. We are whining about the fact that this infant was ever conceived, we’re whining about the cramps, and we’re whining about the lack of an epidural equivalent.

We whine because it costs us money. We whine because it costs us time. We whine because it invades our processes. We whine because it intrudes upon our interactions.

We whine when it doesn’t work at all, when it doesn’t work correctly, or when it just doesn’t work exactly the way we want it to. We whine when it is less than perfect even when we don’t really have a true reference for just what such perfection is.

We whine because it is different from what we know.

On this particular day, I found myself in the midst of an unspoken internal whine about a merely tangential HIT issue. I had just realized that all of the prose I was "prosing" as I attempted to document by point or by click, by dropdown or by pop-up, by two-fingered typing or by fat-fingered falter was fairly futile.

My whine wasn’t just bemoaning the fact that the process of digitization of my thought processes was far from an enjoyable experience. And, it wasn’t a whine about the less than optimal ergonomics still involved in mental to machine interpolation.

No, within the soundproof walls of my internal mental monologue was a whine about all of the prose I was digitizing for near eternal salvation to be forever lost within the silent world of HIT Neverland.

Think about it. We spend hours each week away from our families and friends, away from the actual act of caring for the health of our patients (or ourselves), away from sleep or supper just to document items and issues with details, many of which, if not most of which, will never be read by anyone, ever.

Every single provider, every one of us, whether digitally or pen-and-paperly, spends countless portions of our working lives documenting things large and small which will never be noted by another human being as having ever been so documented.

Nobody is ever going to read virtually any of the hundreds of thousands of times I’ve written (or clicked) that a tympanic membrane was clear. Few will ever note any of the tens of thousands of exudative pharyngeal tonsils I’ve documented. Only rarely will anyone ever notice any of the thousands of soft systolic heart murmurs heard over all of those left sternal borders that I so meticulously marked down.

I realize that all of those pertinent negatives and their typically more glamorous counterparts, the pertinent positives, are important to note and to note down. But, just thinking about how many numbers and letters and words and phrases I have documented over the years which no one will ever, ever read and then multiplying that by the millions of healthcare providers across the globe who are doing similarly, I found a whine I had never before considered – that is, we are generating billions, maybe trillions, of these precious pieces of pertinent prose for the purpose of… what?

If a tree falls in the woods and no one is around to hear, does it make a sound?

If a documented finding is never read again, was the documentation of that finding worth the time it took to document? Is the disk space it consumes worth the electromagnetic energy it takes to maintain it?

I’m not even thinking about the appropriate answers to those rather rhetorical queries. I’m just whining… whining about all the prose, all the prose that nowhere goes, here in the Days of Whine and Proses.

From the trenches…

“This is the way I look when I’m sober. It’s enough to make a person drink, wouldn’t you say?” – Kirsten Arnesen Clay in Days of Wine and Roses, 1962

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).