Posts Tagged ‘quality’

There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week.

Yesterday evening the New England Journal of Medicine published the research paper: Electronic Health Records and Quality of Diabetes Care, which provides clear evidence, albeit a little fuzzy around the edges, that physician use of an EHR significantly improves quality metrics over physicians who rely on paper-based medical record keeping processes.

The research effort took place in Cleveland as part of Better Health Greater Cleveland from July 2009 till June 2010 and included 46 practices representing some 569 providers and over 27K adults with diabetes who visited their physician at least twice during the study period. Several common quality and outcome measures were used to assess and compare EHR-based care to paper-based. On composite standards of quality, EHR-based practices performed a whooping 35% better than their paper-based counterparts. On outcome measures, which are arguably more difficult for physicians as patients’ actions or lack thereof are more integral to final outcomes, EHR-based practices still outperformed their paper-based peers by some 15%. The Table below gives a more detailed breakout.

While the authors claim that insurance coverage has little bearing on the final analysis (i.e., Medicare, commercial and Medicaid patient metrics are similar) there is a surprisingly high percentage of patients in paper-based practices who do not have any insurance which makes one wonder: Will future Health Insurance Exchanges (HIX) and the individual mandate, should it survive the Supreme Court, have some bearing on what physician a patient may chose in the future? Will patients migrate to those doctors that use more advanced technologies (EHRs)? Also, there was an abnormally high percentage of patients in paper-based practices that were “Nonwhite” which raises another question: Could those practices that still rely on paper-based processes be in more disadvantaged neighborhoods? If that is indeed the case, will HITECH and its incentives trickle down to this strata of the healthcare sector? All in all though, these are relatively minor points in relation to the broader implications of this paper.

This research paper could become a seminal piece in support of the current administration’s efforts to reform the healthcare sector as it not only supports efforts to digitize the healthcare sector via EHR adoption, but may also provide an added incentive that goes beyond HITECH Act incentive payments.

Throughout the healthcare sector reimbursement models are changing from fee for service to value-based contracts. Such value-based contracts, be they ACOs, PCMHs, P4P, or whatever other acronym you want to throw at it, are accelerating coming not only from the government but also commercial payers. A key component of these value-based contracts is achieving certain quality metrics and moving from episodic care to continuous care models. This research paper is one of the first and most comprehensive that has come across our desks here at Chilmark Research that clearly shows the use of an EHR has a significant impact on key quality measures, in this case diabetes care. While virtually all hospitals are on the HITECH bandwagon, it is less clear just how many private physician practices are jumping in and adopting EHRs for their practices. For many such practices, the HITECH incentive payments may not be enough of a reward for the numerous Meaningful Use hurdles that a physician needs to jump through. But if you hit these physicians directly in their wallet with value-based contracts and they see that EHRs provided demonstrably better quality care metrics, then we may see broader EHR adoption in the ambulatory sector. Bit of a crystal ball forecast, but the logic is there.

Ultimately, what we are seeing happen in the healthcare sector is not dissimilar to what we saw occur in the manufacturing sector. In manufacturing the lag between adoption of enterprise software systems and subsequent increases in productivity has a special term: the “Productivity Paradox,” wherein it was some ten years after wide spread adoption and deployment of these enterprise systems that improvements in productivity metrics could be measured.

Might the healthcare sector have its own paradox? We think so and from this point forward will refer to it as the Quality Paradox.

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If you have read previous posts this week, you know that I was attending MIT’s EmTech conference. Event is a focused on technology and innovation of all stripes bringing together some pretty big names to discuss where we are today and where we are headed. For the first day, I had one continuous and long post, which in retrospect, I am not fond of – just too much to wade through to get to what may be important to you, dear reader.

The second day, I put up two separate posts, one on Craig Mundie’s keynote and the other on the Personal Genomics session. This approach came across clearer, and more focused.

So with that in mind, I am reposting the EMR session notes from day one. This will not be a verbatim repost as reflection on what I learned as well as comments by HealthVault’s Chief Architect, Sean Nolan, to the first post necessitated some revisions.

Recap of EMR Session:

Panel includes John Halamka (Beth Israel’s CIO), Karen Bell (HHS), Craig Feied, (Chief Strategy Officer, Microsoft Health Solutions, he developed Azzyxi at MedStar) and Girish Kumar Navani, (Founder & President, eClinicalWorks). Decent size audience, easily a third of the total attendees at EmTech (there are currently 3 concurrent sessions).

Karen started off basically setting the stage giving a broad overview of the challenges in healthcare and subsequently HIT, for the audience with the HIT Hierarchy of Needs slide (pyramid, privacy at the base up to public good at the pinnacle). For us in the HIT space, nothing new here, but for those in the audience, most of whom who do not work in healthcare, Karen’s presentation provided a good backdrop for follow-on discussions.

Halamka followed with the common statement regarding lack of EMR adoption. Halamka claims that EMR systems today are still too expensive. With an average cost of $40-60K per practice and the common drop in productivity of 25% for first 6 months after deployment, few physicians will shoulder this cost.

Despite this apparently prohibitive cost, Beth Israel is requiring all affiliated physicians to adopt and use an EMR. Beth Israel will subsidize adoption of EMR by offering a hosted eClinicalWorks solution for these affiliated practices at a big discount to encourage adoption. The plan is that through adoption of EMR, BI and affiliated practices will be able to better track and report quality and performance metrics that will result in higher payments, via P4P payouts, from CMS and other payers. This will augment the cost of hosting the EMR.

Halamka also talked of consumer’s abilty to move PHR data from BI’s PatientSite to either Google Health or HealthVault. Today, the only thing you can move into either repository from BI’s PatientSite is data pertaining to medications and allergies. Not much value there for the consumer, though this is the low hanging fruit of what physicians would want to see in a PHR, particularly in an emergency situation.

Kumar was next. eClinicalWorks is now in over 20k physician offices. Kumar talked in broad terms, not terribly specific. Does believe that “patient-centered healthcare” is the next major change in healthcare that will be a forcing function for EMR adoption. Not to surprising to hear from an EMR vendor.

The highlight of Kumar’s remarks was him stating that he does not like the term of EMR. For him, EMR is a static term that does not fully capture th purpose of an EMR, helping physicians deliver better, more informed care to their customers. Hmm, like this statement – he is absolutely right, EMR is a dead term, we need something new.

They just did a quick survey of audience, Managing Personal Health Information: 14% would trust lab or pharmacy, 32% would trust a company such as Google or Microsoft and 54% would trust only themselves or a doctor. Pretty liberal crowd here in that nearly 50% would trust a third party, beyond their doctor with the personal health information.

Craig talked about the development of Azzyxi and how what all he wanted to do was try to provide the most information possible at the point of care, in this case the ER. Believe that errors/failures in medicine are not about Execution, but in Planning. Unfortunately, he claims all the effort now is on Execution (meds, wrong patient, wrong procedure, etc.), rather than upfront Planning. Talked of the “Spectrum of Wellness” as core to MS’s health sector strategy – a rethinking of what healthcare is and how it is delivered, not only when you are sick, but when you are well. Good speaker, a bit heavy on the sales pitch though he does seem genuinely sincere.

Q&A Session: What’s the value to a primary care physician in adopting EMR. Halamka claims that P4P and quality reporting is becoming an ever bigger issue for physicians and that these systems can actually help doctors ultimately earn more and earn it easier (HIT can greatly facilitate all sorts of transactional processes). Kumar followed up stating that it will help physicians better understand what they are doing as well as help doctors prepare more effectively for patient visits. Supported Halamka’s view that quality and P4P will also push adoption going forward. These programs start to really put some cost justification behind EMR adoption. Craig thought that it is up to software vendors to create sufficient value in their solutions that will lead to adoption.

Status oF PHRs: Halamka – we have 40K users of PatientSite and believe in patient control, thus opening up to Google Health and HealthVault. Karen, still informative stages but right now pretty wide open as the apps are simple today and maybe not what consumer will use tomorrow.

Addendum to EMR Session – picked-up through conversations after formal session:

  • According to recent HHS calculations, there is over $700M in incentives, via payers, through various P4P and quality improvement programs that can be used to subsidize EMR adoption by practicing physicians. Clearly, there is money to be had, though I am not sure that most physicians know how to capitalize on it. Unfortunately, few, if any EMR vendors today are helping physicians understand that there is an opportunity to augment the cost of EMR adoption. Truly, a missed opportunity.
  • Today, Beth Israel is allowing their customer to export their PatientSite PHR data to either Google Health or HealthVault. Problem is, a BI customer can only export medications (includes immunizations) and allergies. I asked Halamka why they are not exporting the full record and he told me that neither Google nor Microsoft’s offerings can handle anymore than that and used the example of imaging data, stating that the data models for both Google and HealthVault just aren’t there yet. There may have been some misunderstanding as Sean Nolan quickly commented on the previous post that HealthVault was capable of accepting numerous data types, (e.g., labs, clinical notes, etc.) with the exception of images. Sean went on to check with Halamka who states that he was just referring to images when I initially spoke to him. But that just brings me back to my original question to Halamka: Why are you not allowing customers to export as much of their record as a service like HealthVault can accept? Will need to follow-up on this one.
  • eClinicalWorks is seeing no issue with reluctance in market to adopt EMR solutions. Kumar told me they have plenty of business and are still on a very rapid growth path. Early problems precipitated by a couple of huge orders (e.g., NYC) are behind them now and they are meeting target implementation and delivery dates. Also, despite all the rumors of eClinicalWorks relying heavily on offshore developers, over 80% of all employees are based right here in the US. Kumar does use resources in India, but on a flex model to address pressing, unexpected customer needs, which are not an every day occurrence.

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Last year, I attended one of my first healthcare conferences, that sponsored by the federal agency, Agency for Healthcare Research and Quality (AHRQ). While I had mixed feelings about that inaugural event (at least inaugural for me), I returned this year to see what progress has been made on the quality front and whether or not the growing trend of consumerism in healthcare is having any impact.

I may have been expecting too much as it seemed more like a step back in time, a deja vu event.

First off, this is by and large an academic research crowd, not a group prone to uttering such phrases as “the business case of quality” or “consumerism”. No, this is a crowd that talks of patients, patient safety, research methodologies, and the like. Nothing wrong with that, from a strict research sense, but I see big problems with this if AHRQ wants to transition funded research to something beyond an academic exercise, something AHRQ has stated some intention to do with their new Innovations initiative.

But maybe it is not entirely AHRQ’s fault. The lack of innovation in healthcare, as it relates to quality, may be systemic. AHRQ Director Clancey, basically inferred such in her keynote stating that there is a lack of linkage among healthcare institutes between quality and profitability that needs to change, that today, focus is on short-term results and not long-term impacts.

In all the presentations I heard thereafter, however, never was profitability/business case for quality mentioned again. No talk of quality and cost savings, no mention of quality metrics and customer retention – Nothing. Maybe AHRQ needs to begin rethinking its grant proposal process and prompt researchers to consider such factors, develop metrics to measure such, and deliver such results as part of a researcher’s final report.

As for quality, Clancey stated that AHRQ analysis of quality metrics has found no significant change in the last several years. In fact, in some cases quality is actually decreasing, particularly disparities in care for at risk populations. The proverbial ball is not moving forward – it is in stasis or worse, like Sisyphus, rolling backwards.

Makes me begin to wonder: If quality is not improving then why exactly is AHRQ in business and why are they funding all these various research projects at institutions, that honestly, should be paying for this research themselves – that is of course if these institutions see the business value of quality?

Some quick impressions and highlights:

  • Attendees are a tight knit group of researchers (~85% from academia), AHRQ employees and a smattering of government contractors. Incestuous
  • Lots and lots of “Quality” templates being created to overlay on top of EMR systems to report on quality metrics. Seems as though everyone is building their own set of templates unique to their organization – a lot of reinventing the wheel here. Is this a business opportunity???
  • Universal number one factor hindering adoption of quality initiatives is time. Does the reporting of quality metrics/actions put a time burden on clinicians, if yes, forget about it, it will not be adopted. Strategies to overcome include: deploying speech recognition. streamlining process as much as possible through pre-populating data fields (pull from existing EMR/PM data stores), and/or look more broadly at clinician workflow to find opportunities to “save time”.
  • Clinicians prefer unstructured text entry versus pick lists as pick lists often do not adequately capture an encounter. This has led to design of multiple micro templates with branching logic for quality reporting to minimize unstructured text inputs, but provide needed flexibility.
  • Majority of quality research efforts have no tie-in at the institution level to P4P programs. Again, getting back to the business case – where is it? Did ask one presenter if there was any tie-in to P4P. She stated that they are thinking about P4P, see it coming and what they are doing today should set them up to capitalize on this opportunity once it is presented to them by payers.
  • According to one researcher/presentation, there are no metrics to measure quality improvements resulting from HIE/RHIO programs. Wow, that was a shocker! If true, quite embarrassing seeing as how much money federal, state and other organizations have invested in such programs to date.
  • In a telehealth demonstration project, the lead investigator spoke of the numerous issues they had while working with the HIT/telehealth service vendor. This researcher stated that the market is full of telehealth service providers with such a wide range of capabilities, service level agreements, privacy policies etc., that it really needs some form of oversight, be it certification or regulation. This industry needs to get its act together and start self-policing, or else they’ll have regulators on their back in the very near future which could become a very big problem for this extremely young and rapidly evolving sector.

That’s all for now as I need to run into the next session. Will provide a brief recap, some notes on AHRQ’s Innovation Initiative, etc. in a follow-on post.

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Last year I attended the Healthcare Quality and P4P (Pay for Performance) conference put on by the World Health Congress. This was my first healthcare conference and it provided me a great opportunity to gain a better understanding of the healthcare market and critical issues therein.

Well, its been a year now and once again I had the opportunity to attend this event. Unlike last year, I knew a lot more about the industry and market trends, thus did not get as much out of the event. But having been to more conferences than I could ever count one thing I have learned is that conferences are much like panning for gold – you have to sort through a lot of fool’s gold before you come across a nugget of the good stuff.

Following are gold nuggets I walk away with from this event.

P4P is out, gainsharing is in

Presenters, particularly payers discussed how they were using gainsharing (share the savings across all stakeholders contributing to quality improvements). A presentation by Howard Beckman of the Univ of Rochester was particularly insightful as he outlined three key terms of quality (underuse, overuse, and misuse) that were used when conversing, in a non-judgmental fashion, with physicians. By using these terms, backed with metrics from internal studies, they were able to gain much quicker buy-in among physicians into their quality improvement initiatives.

Another “hot” term was Value-based measurements – this may become the new P4P mantra for the coming year.

Future will see multiple forms of tiering

All payers are looking much more closely at stratifying populations for risks and becoming much more like disease and care management companies than just straight ahead insurers. This has been occurring for some time but the change here will be bringing in quality metrics to the equation and stratifying providers and payment schemes as well. During the medical home session, John Tooker of the American College of Physicians talked about a future where payment will be divided into three distinct categories (tiers): payment for procedure/service, another for care coordination and the third for meeting quality metrics/objectives.

There will be losers

Spoke to Dana Gleb Safran of BCBS-MA about the P4P initiative at BIDMC and asked what about radiology at BIDMC that saw a drop in business as a result of that program – will there be any gainsharing with them. She replied simply: No, we will not pay for unnecessary services, period.

Clearly there will be winners and losers as quality initiatives permeate the healthcare sector, but with numerous powerful and entrenched interests therein, even payers will struggle to get complete buy-in. One of the big problems they will face is defining what quality metrics to use, how to balance these measurements against such mitigating factors as population served and more broadly, coordination across multiple entities (local, state and federal government, internal operating procedures, employer-driven initiatives, specialists’ guidelines, etc.).  It’s still a rat’s nest and it may take a while to untangle.

CMS moves at a snail’s pace

CMS presented their plans for a trial quality initiative to manage chronic care cases in a number of communities across the country. Plan is to provide an additional monthly payment to physicians providing care management with ongoing evaluation across a number of categories (e.g., value add, quality improvement, patient satisfaction, physician satisfaction, savings, etc. All good but it won’t be until sometime in 2010 that they actually begin the demonstration. That seems like an awfully longtime for just a demo. Are we in academia?

Another odd thing about that CMS demo is the requirement that the physician use IT to manage the care but there was no definition as to what that technology may be.  Completely open-ended which makes me wonder how valid their results will be at the end of this demonstration as I have no idea how they will account for that variable.

Other Tidbits:

  • Group Health doc told me that PHR adoption at Group Health is now about 50%!  That’s the highest percentage I have ever heard quoted. Hat’s off to them! He told me he loves it, his patients love it and that he has been doing email communications with his patients while sitting in on the various sessions.  Hmmm, I hope those were just simple consultations and appointment reshedulings.
  • United Health executive told me that they have signed an agreement with Google Health and another will be signed with HealthVault any day now that will allow members to export their records into these personal health systems (PHS).  As UHG is the second largest insurer in the country, this is some pretty big news and could give a substantial boost to these nascent platform plays.
  • Despite the success that BIDMC and BCBS-MA have seen with the deployment of SafeMed and subsequent savings, John Fallon, SVP at BCBS-MA told me they have no plans to replicate this success anywhere else.  They are now focusing all their attention on the MA eHealth Collaborative program.  Talk about odd!  Not that I am against such programs as the MAeHC, but with literally millions of dollars saved per year at BIDMC coupled with the well-known issue of run-away imaging costs one would think that they would want to see that program replicated.  Oh, how those political winds do blow…
  • Everyone talks about the patient, almost no one spoke about the consumer, nor did they take a consumer’s perspective on what all this means to them.  In many respects presentations came across as distant and disconnected from the reality of the consumer.  Many at this event are in for a very rude awakening.

Another good event by the World Congress Group.  I am always impressed with the level and quality of speakers and attendees they attract.  I may not always agree with what is being said, but I always find a few sizable nuggets of gold.  This event was no exception, which is more than I can say for quite a number of other events I have attended

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Aetna, under pressure from the New York Attorney General’s office, has agreed to change its physician quality ranking system.  This follows a similar move by Cigna about two weeks ago.  Both UnitedHealth and WellPoint BS/BC are the remaining hold-outs, but I expect them to follow suit in the near future.

What is interesting about the Aetna announcement was that they not only agree to comply with New York state, but stated that it would reassess its program nationwide.  After the Aetna announcement, Cigna also stated that it to would also reassess its ranking system nationwide.  In their previous announcement, Cigna agreed to only look at how it assessed physicians in New York.

From this vantage point it looks like we may actually move towards some consistency in quality rankings, though it remains to be seen how consistent those rankings would be from one payer to the next.  Hopefully, a federal agency such as AHRQ will step in to assist payers in establishing clear, agreed to metrics across the industry by which all providers will be measured and reported.

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Was just over on my Gmail account and there was this discrete little advert at the top of my screen about the five top things to never say at work.  No problem with that, as I see such little advice teasers all the time in these quick sound-bite, better yet, word-bite messages in Gmail.  What really struck me was that this advert was not from some job search firm like one would expect such as Monster, dice or TheLadders, no this came from Revolution Health.

Looks like Revolution Health, who has struggled to establish a presence in the personal healthcare space is really stretching its boundaries to be relevant to some aspect of an individual’s life.  Then again, maybe this posting is relevant to its primary source of income today, employers who are rebranding Revolution Health for their internal health and wellness services for employees.

Rather than putting out such rather simplistic drivel, Revolution Health and its constituency would be better served if they focused on more relevant topics like having a truly useful hospital search tool that tapped into existing databases to provide information not only on which hospitals can perform a given procedure, but what the relative costs and quality metrics are as well.  Such information is beginning to pop-up in a number of state-led initiatives such as this example from Massachusetts on congestive heart failure.

Now that’s relevance!

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