Saving Primary Care: Team-Based Delegation Software may be our Best Chance!

This new article by Bodenheimer, et al. points out that our current system (making docs do everything) is absolutely not sustainable.  So what can we do?  It turns out the critical solution to make our system sustainable is to start delegating certain activities to the physician's team using protocols!  

But now I'll ask the more tactical question - does anyone expect us to use paper based protocols???  We all know those are hard to maintain and no one actually looks at them.  So what if there was a new type of healthcare IT software which could hold all these protocols in "the cloud", and then apply them against the data stored in EMRs, and then send back specific messages into the EMR - pushing the right information to the right person on the team.  In other words, automating the process so everyone works "to the height of their license".

Is there an app for that?   YEP!! I've been working with the great team at healthfinch the past two years to develop this type of "Team-based Delegation Software" which uses a cloud-based protocol system (all protocols are held and edited in the cloud) integrated with a variety of EMRs to produce a "team-based decision support and workflow tool" that saves physicians time, while also ensuring high quality care is delivered in a consistent and documented way by their team.  

We have RefillWizard for medication renewal requests (this alone saves docs 30 minutes a day)… and we plan to keep making more on the electronic delegation platform that has been developed. We seem to be in the RIGHT space at the RIGHT time! :)

For more info, here is a summary of the Bodenheimer article from a Medical Economics story:

Study: PCPs must delegate some preventive, chronic care

Publish date: Oct 25, 2012

There is one primary care physician per 1,500 Americans, yet most PCPs have panel sizes in excess of 2,000 patients. With no surge in PCP numbers expected anytime soon, a new report suggests a shift from physician-based care to team-based care, with PCPs delegating up to 77% of preventive services to non-clinicians.

“Our nation will need to implement models that reengineer the delivery of primary care and deploy our physician supply in a more efficient manner,” say researchers from the University of California at San Francisco in a new paper titled, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation.” The paper was published in the Annals of Family Medicine in the September/October 2012 issue.

The average PCPs panel size is too large to deliver consistently high quality care, according to the report. Researchers estimated that it would take a PCP nearly 22 hours a day to provide all the recommended care for the average 2,300-patient panel. But decreasing PCPs means panel sizes will continue to rise, especially considering about half of all Americans have at least one chronic condition.

The study highlights two alternative practice models that might hold the key to solving this dilemma. The first model is to reduce panel sizes so physicians can provide comprehensive patient care. Concierge medicine, for example, utilizes panel sizes of 200 to 600 patients. However, without enough PCPs to go around using this type of model, the study determines this model would leave many patients without primary care.

The alternative model, the Organized Team Model, advocates building primary care teams that delegate patient care responsibilities among a healthcare team, allowing the physician to practice high-quality care without a large, but manageable panel size. Screening and performing certain tests should be left to the physician, according to the report, but tasks such as administering immunizations could be delegated to non-clinicians—with the clinicians explaining the services to their patients. All routine preventive counseling could be delegated, the report authors note, freeing up too three-quarters of a PCP’s time.

For chronic disease management, the report recommends that PCPs could delegate 75% of the time spent on chronic cases in good control and 33% of the time spent on patients in poor control. Non-clinicians could provide most of the routine chronic services such as patient education, behavior-change counseling, medication adherence counseling and protocol-based services delivered under standing physician orders.

Overall, this model would allow 77% of preventive care and 47% of chronic care to be delegated to non-clinical staff. All acute care would be provided by physicians, the authors note.  The study does not address the additional staff training that would be needed to prepare non-clinicians to handle additional tasks, or the payment reform that would be needed.   

“Such an unprecedented change in both the culture and structure of primary care practice can be accomplished only through a change in clinical mindset, the training on non-clinician team members, the mapping of workflows and tasks, the creation of standing orders that empower non-clinicians to share the care, the education of patients about team-based care, and the reform of primary care payment,” the study authors conclude. 

Why the next wave of health IT innovation will build on EMRs, cater to “physician happiness”

I am always impressed when a reporter can ask a few questions, listen to me talk for 30 minutes, and then assemble it into a great article which really explains my thoughts well... and I am even more amazed when they can do it in 24 hours!  Thanks to reporter Deanna Pogorelc from MedCityNews for doing such a great job - and I love the title too: Why the next wave of health IT innovation will build on EMRs, cater to “physician happiness”... Here it is (with a few bolds and comments in brackets from me):

There’s no shortage of primary physicians, but rather a shortage of primary physicians who are able to use their time efficiently in today’s healthcare environment.  That’s why the industry is moving away from the first version of the EMR, according to Dr. Lyle Berkowitz, the associate chief medical officer of innovation at Northwestern Memorial Hospital and Medical Director of IT & Innovation at for Northwest Memorial Physicians Group in Chicago. 

The inaugural EMRs are basically computerized versions of paper records that weren't necessarily designed with usability in mind, he noted. So rather than saving time and making administrative processes easier, they’re in some cases adding to doctors’ workloads.
[Or as many say - they focused on just documentation and billing, not clinical workflow] 

Enter the next wave of health IT innovators, who are taking EMR data and using it elsewhere to improve workflow. “(EMR vendors) are kind of stuck to Meaningful Use and creating a standardized format to make sure everybody is at the first-base level,” Berkowitz said. “That’s a good start, but we have to start building tools that can fit on top of these. A whole ecosystem is going to build up on top of EMR systems to make them easier and faster to use.”
[Check out the ONC Standards Hub to see how Meaningful Use Part 2 will require all EMR vendors to adhere to certain standards which will make it even easier for 3rd party vendors to work with them]

And, it seems that EMR companies are getting on board with that as well. “They buy into this idea that innovation comes from the outside by saying, we’re going to open up our system and let others build on it,” he said. “AllScripts I think is leadingthe charge. Athenahealth is moving that way, and some others. EMR vendors are going to be end up being able to provide more and more solutions to their users this way.”

EMR extender companies have been around for a while; business intelligence and data analytics are well-established industries. But we’re seeing the dawn of a new category of innovation focused on workflow tools to make doctors more productive and efficient – what Berkowitz calls “physician happiness.”

There’s evidence of that, in the form of companies like Modernizing Medicine, which makes a touch-based “electronicmedical assistant” for specialists, and SchedFull, which is working on a way to help physiciansfill canceled appointments that it hopes to integrate with web-based EMRs.

There’s also healthfinch, the company Berkowitz co-founded with designer Jonathan Baran and programmer Ash Gupta in 2010. It’s focused on making the practice of medicine more enjoyable for physicians by letting them focus on the higher-order thinking they’re good at, rather than spending their time on paperwork. (He compared this to the process of making a new car, and the absurdity of the idea that the people who design technology for the cars would spend part of their time working on the assembly line.)
[What I was trying to say is that a car company knows that their smart car engineers should spend time on solving problems and designing cars, not on screwing in car seats… let them focus on the higher order stuff, and delegate the assembly line work to the people on the floor… another analogy would be that you don't walk into a bank and ask the VP to withdraw $200 - you go to the teller, or the ATM!]

The place where doctors can best apply their skills is the 10 to 20 percent of very sick, complex patients they see, Berkowitz said. That’s precisely why healthfinch focuses on the other 80 percent of patients who might be fairly stable. By creating protocols and automated processes for meeting the needs of these stable patients, other staff members can work together to take care of them, and the doctor has more time to spend with sicker patients.

Its first product focuses on using data to design a protocol for handling medication refills. Doctors receive many refill requests every day, many of which require them to review charts to ensure patients have completed follow-ups or lab tests. Some of this work could be delegated to the nursing staff or medical assistants. To make that happen, RefillWizard leverages EMRs to help practices manage prescriptions more efficiently.
[By using their rules based workflow software to allow for safe and easy delegation of tasks away from docs and towards their team]

Healthfinch plans on using the same technology and philosophy to continue developing products that will save doctors more time by using every person on the staff to the highest level of his or her licensure.  “I’m always on the lookout for things I do repetitively, to see if they can be automated,”Berkowitz added, in illustrating what inspires his innovation. “I’m always trying to figure out how to take something I do in 20 steps and cut it down to five steps or, even better, zero steps.”  [That's one of our new slogans - "The Power of Zero"!]

Abuse of EMRs? Really - Let's Take a Closer Look!

The New York Times recently published an article called "Abuse of Electronic Medical Records", in which they started off by saying "The Obama administration has issued a strong and much-needed warning to hospitals and doctors about the fraudulent use of electronic medical records to illegally inflate their billings to Medicare."

REALLY?!?!   Let's take a closer look:  First, the evidence is that billings and coding has gone up over the past 5 - 10 years, and EMR vendors tout better billing as one of their benefits.   Hmmm... that's not exactly a smoking gun.

But fair enough, so let's review why we might get increasing billings and coding:

1. The EMR makes it easier to code appropriately.  I hate when they say "upcode", which implies fraud.  Rather, I think that many doctors (especially primary care and other non-proceduralists) have undercoded for years... and the EMR actually allows them to document all the "thought work" they have been doing for a long time.  The E/M system was designed to help value "thinking doctors" - and it's starting to work!  Let's applaud that, not try and make it sound like fraud.

2. The EMR allows docs to do more at a single visit.  I think this is an often overlooked reason to explain what has happened.  I know in my practice that having an EMR allows me to get to more things in a single visit than in a paper-based system.  So without an EMR, if a patient came in for a sprained ankle - I might just take care of that and told them to come back for their other issues.  With an EMR, it makes it easier to see everything at once and manage multiple issues.  This is an incredibly GOOD thing for the patient, and for the system - since one "bigger visit" (e.g. "Level 4") is cheaper and more efficient than two "smaller visits" (e.g. Level 3).   So maybe the government should not just look at billings, but also at the total number of visits a patient had - and see if that decreased over the past 5 - 10 years... maybe because docs were doing more work in less visits!

Oh wait, they did do this!?  One of my favorite blogs (HISTalk) actually ran this snippet of info today: The Census Bureau says adults under age 65 made an average of 3.9 visits to physicians in 2010, down from 4.8 visits in 2001. Possible explanations: more uninsured, fewer physicians, higher patient costs, innovation that allows providers to accomplish more in a single visit, and more meds available without a prescription.  So maybe the attorney general and HHS could talk to their own colleagues a bit more before throwing around accusations slandering docs who use EMRs?

3. Docs are using EMRs to defraud the government.  Obviously, there will always be some small amount of doctors who commit fraud - whether that is on paper or EMRs... but I certainly don't think that using an EMR all of a sudden makes doctors more fraudulent.  And by the way, since this fraud is happening in both paper and IT systems... I'd appreciate if our government didn't just pick on EMRs, and said something like this instead:   "We know most doctors are outstanding citizens who give of their time to help others, but there are a few who commit fraud... and whether they do so on paper or EMRs - we will find them and prosecute them!  And while healthcare IT may make it easier for some to perform some fraud, it also makes it easier for us to catch them - so watch out bad guys!" 

Addendum

• Coding: Up, Down or Around? I'm quoted in this HDM article - basically saying EMRs make us more efficient docs and better coders (in contrast to the HHS report trying to make EMRs sound like fraud machines)!

Reducing ReAdmissions... Another Obvious Thing We Need To Do!

Reducing readmissions is a very hot topic now since the government and other payors are starting to create an incentive system which punishes hospitals who have high readmission rates (at least for some of the top categories like CHF and Pneumonia), they do this by basically saying they will not pay if the patient is readmitted within 30 - days of discharge. So I do like the idea of creating well aligned incentives... as long as there is also upside to doing things well.

So how can a hospital succeed here? CSC recently published a report about reducing readmissions. Key Points include:

• Hospital efforts to reduce readmissions have become more visible and important because of the financial stakes — disincentives being incorporated into payment reform — are now high enough to be noticeable in the bottom line.

• Variability in rates across hospitals and regions of the country suggests that significant reductions are possible if practices in better performing hospitals are adopted more uniformly.

• Current measures employed in Medicare incentives target acute care hospitals and high-risk patients defined as those with heart failure, pneumonia, or an acute myocardial infarction. Any re-hospitalization to any hospital within 30 days, for any condition, is counted.

• Preventing readmissions is very challenging because so many community and patient factors contribute to the problem, many of them outside of the direct control of the hospital.

• However, research, combined with practices in hospitals with a track record of reducing readmissions, shows that comprehensive discharge planning and post-discharge care and support during the transition period reduces readmissions in high-risk patients.

• The next scope of work will be to achieve a formal connection with organized care management for every patient covered by this type of program.

• As more high-risk patients are covered by these programs, this will decrease the role of the hospital in providing post-discharge care and support, but formally link patients back to organizations accountable for ongoing care.

• Key elements of the resulting model will be organizing and operating transitional care as a process in its own right, laying out each patient’s transition and hand-off in a time-limited transition clinical pathway, and new uses of health IT in patient tracking and transition care planning.


So the report states that one major key to reducing readmission rates is patient-centered discharge planning. That absolutely makes sense... but hey - it is certainly not a surprise! The real surprise is simply that it is not done more often (Why? Because payors don't pay for it - they pay for procedures over process or thinking). Like much of what we do, if you ask someone outside of healthcare if they thought we did this routinely - they would assume that of course we did it - it just makes sense to create a highly personalized and integrated discharge plan for a complex medical patient when they are discharged from the hospital.

Of course, times and incentives are changing, so clearly we will hear about more emphasis on this type of patient centered planning; on the other hand, we will see hospitals having to cut corners by firing discharge planners and asking RNs to do more of it themselves.

But assuming we are doing more of this, the next issue is "The Details"... will there be a secret sauce or consistent algorithm to make this easy, safe and cheap? Or is it simply about having a smart person use higher order thought processes to create a very personalized approach to each patient. I think it will be a bit of both; the more in the former category - the more likely we can spread this work and make it cost-effective and successful!

ER Visit Cost Reduction Theory; Patient "Web Searchers"

I get a lot of eNewsletters sent to me about healthcare IT and innovation - and there are often articles which catch my eye (AWCME).  They might talk about an interesting study or person, and when I read them I have some immediate thoughts because it resonates with my experiences or thinking in some way.  I'll sometimes do a quick post to FB or twitter so I can track the stories, but I've never been great about blogging on them since it takes extra time... but I'm going to try and get a little better at it.  So this will be the first edition of Articles Which Catch My Eye (AWCME)!  I will provide summaries of the article and then my "biased thoughts" (being a PCP, IT-savvy, Innovation promoting doc)!

A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department

(Link to the article in the Annals of Emergency Medicine)

A Modern Healthcare story on this article summarizes: "To maximize cost savings, hospitals and health systems should focus on reducing avoidable patient admissions to the hospital from the emergency department rather than on preventing non urgent emergency department visits… Researchers with Boston's Beth Israel Deaconess Medical Center and Harvard Medical School argue that more money can be saved by reducing the number of patients admitted to the hospital from the ED because there are no other good care options for them at the time or because a patient's complex chronic conditions were not treated properly. The researchers estimated that minor injuries and illnesses accounted for 12% to 40% of ED visits but only 0.4% to 1.6% of overall healthcare expenses, so even reducing these visits by 50% would result in savings of less than 1% of costs. On the other hand, patients with intermediate or complex conditions account for 31% to 57% of all ED visits.

MY THOUGHTS:  One on hand, I love that they did this relatively logical analysis on the stats (and it's amazing how rarely this is done in healthcare - other industries live and die by these types of stats, of course they also have an incentive system which is more consistent than our hodgepodge).  And their findings make sense: that even if the "low acuity visits" are high volume, they don't cost that much - so don't worry about them - just focus more on the high acuity visits.  However, this is where I think they missed the big picture.  IF we actually spent a bit more time figuring out how to deal with the low acuity visits (e.g. a free Primary care clinic next to the ER; or even machines which dispense antibiotics based on a few questions) - then we'd actually have much more time to spend on the high acuity patients, making it more likely they won't get admitted.  In other words, instead of thinking about absolute value, we need to look at this equation with the understanding that a given physician or ER has a limited amount of time and "cognitive load" they can use... so let's create a system where the top people (doctors) are focusing on the sickest people, and we create a system which automates or appropriately delegates lower acuity visits to other members of their health team. 

The Prepared Patient: Information Seeking of Online Support Group Members Before Their Medical Appointments

(Link to the article in the Journal of Health Communication)

Abstract: The authors examined online support group members’ reliance on their Internet community and other online and offline health resources as they prepare for a scheduled medical appointment. Adult members of an online support group (N = 505) with an upcoming medical appointment completed an online questionnaire that included measures of illness perceptions, control preference, trust in the physician, and eHealth literacy; a checklist of actions one could take to acquire health information; and demographic questions. A factor analysis identified 4 types of information seeking: reliance on the online support group, use of other online health resources, use of offline health resources, and personal network contacts. Pre-visit information seeking on the Internet was extensive and typically augmented with offline information. Use of online health resources was highest among those who believed they had control over their illness, who attributed many symptoms and negative emotions to it, and who were more eHealth literate. Reliance on the online support group was highest among those who believed they had personal control over their illness, expected their condition to persist, and attributed negative emotions to it. Trust in the physician and preferences for involvement in decision making were unrelated to online information seeking. Most respondents intended to ask their physician questions and request clinical resources based on online information.

An iHealthBeat story on this article summarizes as follows:

Researchers found that patients were more likely to look for health information online if they (1) Believed their medical conditions were long-term; (2) Felt they had some degree of personal control over their illness; or (3) Were distressed about their medical condition.  Researchers also found that: 70% of study participants said they planned to ask their doctor questions about information found online; More than 50% planned to make a request of their doctor based on information found online; and 40% printed information from the Internet to bring to their doctor's appointment. 

MY THOUGHTS: Most of this is consistent with what I've seen - that many patients will find info online and share it with me and ask questions (although not close to 40% would print it out ahead of time).   I generally find that the online patients fall into three categories: 

1. The Worried Well: They will look online anytime they have any symptoms, and find something scary, and then make an appointment to be reassured.  This is usually the largest group, and their web activities usually drive up the volume of business.  Which may be an ironic twist as there once was an assumption that having information online would avoid visits - but that is the exception - there is often just too much information for a consumer to fully understand.  These are usually quick and easy discussions - most of these patients know they over-reacted, and just need the reassurance from their physicians. 

2. The Savvy Searcher: Someone who knows what they have and does the research to help either diagnose or manage their care better.  An example might be if I tell a patient they have high cholesterol, and they use the web to find better diets for them; or patients with a "strange problem" who identifies a possible diagnosis or new medicine to try.  These folks are very much partners in the process - and I love working with them. 

3. The Truly Tragic: People who have a very bad diagnosis (e.g. Cancer, Lou Gehrig's disease...) and then obsess about it - and look at every website they can... to the point where they often drive themselves crazy because of the immense information overload.  And the worst case scenario is that if you look hard enough, they can almost always find what they want to find - such as the side effect to a drug, or that some obscure tree root is the cure which is being hidden by the establishment.  It is important that we let these patients know they should keep us in the loop because they sometimes can go on dangerous tangents if they think everything they find online is true.  

Dr. Larry Weed is The Oracle: Medical Records Should Guide and Teach!

Dr. Larry Weed was an amazing visionary physician.  Let me start by summarizing what he started saying in the 1960s:  "We need to better organize our records, better utilize paramedical personnel and appropriately use computers" - over 40 years later, and we still haven't followed his advice very well!  But we know it's true more than ever now, and we better start moving in that direction quickly!

Thanks to the internet, much of his original work exists, and it should be mandatory reading (and viewing) by anyone developing healthcare IT software or trying to change the system in any way.  Here are some of his papers:

• Medical Records that Guide and Teach: His original 1968 paper in the NEJM explained the Problem-Oriented Medical Record (POMR) - which has since become the standard of documentation across the globe.   NOTE: Unfortunately, this system has often been incorrectly thought to mean the whole note should be in SOAP format (Subjective, Objective, Assessment, Plan) vs. having a SOAP component for each individual problem.  The result is that many notes are harder to create and read since they don't group relevant information together.  
• Managing Medicine: His 1983 book which: "Contains the best of previously-published materials on Problem-Oriented Medical Records, and explains the Knowledge Couplers which have occupied Dr. Weed up to the year 2000. Much of this material is transcribed from lectures and conversations, so it preserves the candid tone, energy, and eloquence of Dr. Weed that can usually only be experienced in person or on videotape. Illustrated, with highlights captioned throughout." (per Amazon description).
• Interview with Dr. Weed: A 2009 article written by a former student who says, "We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing."
• Medicine in Denial (2011) According to Dr. George Lundberg's commentary, "In 267 pages, they sharply dissect virtually every sphere of medical education and medical practice. The tenet is familiar; the need to couple patient data with medical knowledge. This is not just a critical rant; it is a detailed "how to" fix the broken system.  Specifics such as "Changing medical education from a knowledge-based to a skills-based approach" and "Information processing, clinical judgment, and the two stages of decision-making" are good examples of the original 1970s premise still awaiting mass application in this century."  You can get a PDF overview here.
• Other: "Medical Records, Patient Care and Medical Education" (1964), his first paper on the topic, and in a later paper he explains, "The Problem-Oriented System, Problem-Knowledge Coupling, and Clinical Decision Making" (1989).

Finally, I especially enjoyed this video of his 1971 Grand Rounds at Emory University (see below).  Some key takeaways from his presentation include:

• Physicians need to be guidance systems, not oracles.  
• The medical record provides the data needed to be a successful guidance system, and is critical for the best Education, Care and Research. 
• Every patient and their problems are unique - just like there are 88 keys on the piano, but millions of symphonies can be played.  
• Treating a sick patient is like a Chess game... you make your move, Nature plays her move, and then back to you.

The EMR Race is Over, Long Live EMR Extender Tools!

I've been increasingly talking about the concept that the EMR race is over, and that EMRs now serve as the infrastructure and platform upon which innovative companies will develop "EMR Extender Tools", in areas such as: Physician Productivity (e.g. healthfinch), Decision Support (e.g. Zynx), Business Intelligence (e.g. DrEvidence), and Patient Outreach (e.g. Healthloop).  This seems to resonate well with mature EMR users since they often feel like the EMRs they have are rather stagnant - and the vendors will be focusing for years on just getting basic things right and fulfilling Meaningful Use, and thus has no ability to add innovative features.

This is particularly relevant as a recent article came out asking, "What is the future of healthcare innovation now that Epic has become the dominant EMR player?"  The author offered a variety of scenarios, but I think Mr. HISTalk had the best analysis when he said:  "Companies should stop fixating about mounting a full frontal attack on Epic that’s sure to fail and instead innovate on building products and services for Epic’s large client base just like the companies that coexist successfully with Meditech."

Oh yeah!  Now we are talking about an ecosystem that will really let innovation flourish (I think it will be Epic and a few others).  Big Kudos to Allscripts and Greenway for walking the walk and being the first to launch official "platforms" for allowing third parties to build tools upon them.  And nod of the hat to other EMR vendors who are at least talking the talk - even if their "Platforms" are not quite launched yet... such as GE, NextGen, AthenaHealth.  And here is hoping that Epic and ECW will eventually come around and create official platforms to encourage innovation... I think they will eventually move to this, and/or their customers will do it for them.  Finally, I'll be closely following a few other companies trying to build "Uber-Platforms" in this space, including Optum, Aetna's Medicity and the GE/MS spinoff Caradigm.

Of course, how cool would it be if we had one platform upon which any third party vendor could integrate their tool... and it would magically work with any EMR?  Oh wait, we actually do have the government sponsored SMARTPlatform... now we just have to get the vendors to agree to work with it!  The geniuses behind this platform (Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D.) just wrote another NEJM article (Escaping the EHR Trap — The Future of Health IT), if you are interested in hearing what they think the future should look like.  Here are a few good quotes from their article:

• “[T]here’s a clear path toward better, safer, cheaper and nimbler tools for managing healthcare's complex tasks.”
• “Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation,” the authors concluded. “New companies will offer bundled, best-of-breed, interoperable, substitutable technologies … that can be optimized for use in healthcare improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of ‘meaningful use,’ signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.”

Getting back to reality (meaning we don't have seamless platforms to do all this yet)... I do think we are seeing an explosion of small companies creating great niche products and figuring out how to work with EMRs.  So whether there is an official platform or not, the EMR Extender Tools are here to stay and they are only going to grow bigger and better!

Past Blogs on this topic
* Rise of the EMR Extenders (March, 2011)
* EMR Apps Taking Off (April, 2012)

Six Steps to Saving the Country with Preventive Care

Joe Flower is one of the best healthcare futurists an authors out there… which is why I quote him so often!  In his recent article, "Save the Country with Preventive Care", he explains how we can save the healthcare system by focusing on the treasure in plain sight: "It is those thousands and millions of patients with poorly treated and untracked chronic disease that flood our EDs every day. We can mine those cases to reduce health care costs drastically, put our hospitals and health systems on a sound economic footing, make people healthier and, by the way, save the country."

He then goes on to describe the SIX WAYS to do this, which I will help summarize:

1.      Coverage. Everyone needs to be covered, even illegals and those who won't pay for it - because otherwise they just cost everyone more later on.  He notes, "If they are covered, it is much easier to fashion preventive and outreach programs to keep them from your door."

2.      Shift in risk. He explains this well, "Shift from the standard model (fee-for-service, with all financial risk in the payer) to various models in which the provider takes on some risks (as with bundles, warranties, capitation, minicaps, alternative quality contracts and other models) and the patients take on some risk for making a good decision (going to a clinic or an urgent care provider instead of the ED with a minor matter).

3.      Incentivized wellness. These types of programs "give people financial rewards (such as lower premiums) when they participate and meet simple goals. Correctly done, these programs reduce the actual costs for covering the whole population (including those who do not participate) by 10 percent or more."

4.      Targeting. "Find and go after that 5 percent, that 1 percent who are costing the most money. Some of the cost will be recoverable, some will not; but go after them anyway, because the costs spiral out of control once they cross your threshold."  This includes putting in more clinics in high risk sections of town, as well as "HotSpotting" individuals, as popularized by Dr. Atul Gawande.  There is a lot of energy and momentum to do this - which is a good thing.  I'd just point out at the same time we pour resources into these folks, we need to efficiently take care of the other 95% to make sure they stay stable and healthy (which is a focus of a lot of my recent work).

5.      Public health. Consider how you can better work with your federal, state and local public health officials to address the health needs in your community.

6.      Healthy Communities. "Finally, at the furthest remove from your ED threshold is the Healthy Communities movement. There are local groups in most places across the country, supporting programs dealing with everything from effluents to traffic to education to AIDS awareness. The return on investment is always large because the investment is so small compared with the ED visits, surgeries, premature births, and NICU and ICU use that they eventually prevent."

He finishes with:  "We will save much more money, shore up our finances and help solve the deficit problem when we stop waiting passively for people to cross our threshold and begin aggressively exporting health to those who need it the most."

EMR Apps Taking Off, Starting with Refill Requests

About ten days ago, the new Technology Editor for Healthleaders magazine (Scott Mace) interviewed me about a range of healthcare information technology topics, and within a week he put out an article - these writers are getting quick!   He was especially intrigued about healthfinch, the company I helped co-found last year to build HIT tools which, "make life easier for physicians, and better for patients".  We talked a lot about our first product, RefillWizard, which is an "EMR Extender Tool" that uses the new concept of "team-based decision support" to help improve efficiency (by task-shifting work away from physicians and towards their team) AND quality (by increasing compliance with protocols).

I've talked about these ideas in previous posts (Rise of the EMR Extenders, Need for New Clinical Workflows and EMR Usability Update), and have hinted that I was working on putting these ideas into reality... I guess now the cat is out of the bag!   So if you have an EMR in place and want to implement tools which actually decrease the amount of work your physicians have to perform (while improving quality and documentation), then check out what we are doing!

Of note, Scott did a great job of explaining our philosophy and I liked how he stressed the importance of getting clinically active physicians more involved in these types of companies.  He even says at the end that if someone like DrLyle can do this - then anyone can!!!  That's OK - I know what he meant :)

Here is the article, with a few addendum from me in brackets:

EMR Apps Taking Off, Starting with Refill Requests

Scott Mace, for HealthLeaders Media , April 24, 2012

Lyle Berkowitz, MD, has graced the pages of HealthLeaders Media before, but with the new twist his story is taking, healthcare technology leaders everywhere should take notice.

Berkowitz was one of the HealthLeaders 20 in 2008—"20 people who make healthcare better."  [At that time], Berkowitz had recently founded the Szollosi Healthcare Innovation Program while continuing his primary care practice at Northwestern Memorial Physicians Group, the largest primary care group in the city of Chicago.

Now, in addition to these ongoing duties, add entrepreneur to his CV. In the process, he's using more technology to disrupt current healthcare best practices.

"I'd argue that primary care physicians should never have to be directly responsible for preventive care measures," Berkowitz says. "When I say that, people gasp. But when you look at the most efficient clinics and some of the highest-quality clinics, they actually have shifted a lot of that work to nurses who are very focused on that particular issue."

Back in 2010, Berkowitz was speaking on this very topic at the Mayo Clinic's invitation on how EMRs could make doctors' lives easier. In the audience were two young aspiring consultants who got so excited about a mock-up Berkowitz was showing, they proposed a new company to put actions behind Berkowitz's philosophy and inspiration. Thus was born Healthfinch. Berkowitz is chairman and chief medical officer and leaves the day-to-day operation to his partners.

Today, Healthfinch ties into most popular EMRs and runs prescription refill requests through a Web service, making it simple for physicians to delegate those refill requests to nurses and other medical office support staff.

At Elmhurst Clinic, based in nearby Elmhurst, Ill., one physician using the Healthfinch service is seeing real productivity gains. He sees less than half the refill request messages he used to see, according to Elmhurst Clinic CEO Donald Lurye, MD, MMM, CPE.  [To clarify, it was one physician interviewed, but their group actually has over 50 doctors using the system and they are each saving around 15-30 minutes a day!]

"The management of refills is a major activity, particularly in primary care where you're dealing with a lot of people with multiple chronic illnesses, that can have complicated prescription regimens and necessarily so," Lurye tells HealthLeaders Media.

"Dealing with refill requests sounds simple but it isn't. Many times, there's a need for a physician taking a look at a chart to decide whether a refill is appropriate. It can involve checking to see whether various types of follow-up have occurred, or whether certain lab tests have been done in a timely manner, that either just need to be done for monitoring or should be there to guide the therapy."

Healthfinch's rules-based engine, configurable by the Healthfinch staff in collaboration with customers such as Elmurst, automates the decision-making and offloads it from doctors.

When I first heard of this concept, I figured there might always be some super-cautious, belt-and-suspenders type physicians who would still insist on checking every detail.

"First of all, the protocols that Lyle presented to us initially were very conservative, and correctly so," Lurye says. "In fact, in his own personal use, he was still looking at every refill request. He just wanted to see, 'Okay, these are the things I think can be done automated. Now let's see if I actually agree with myself.' And we did the same thing here. And we've kept it fairly conservative. So that's one answer.

"And again, if we ever needed to they're fairly easy to adjust."

As for the rest of the care team, "it really makes them feel much more like participants," Lurye says. Refill requests can be "opportunities for patient education and encouraging people to come back in for necessary care."  [It turns out that the Nurses and staff like it more than we initially would have thought - they love being able to answer patients more quickly rather than playing EMR message-tag with their doctors.]

Deployed initially in primary care, the Healthfinch service will find its way into Elmhurst's specialty practices, Lurye says.

Healthfinch is extracting info from the NextGen EMR in use at Elmhurst. I was surprised that existing EMRs don't yet have the refill-request-delegation features built into them.

"The evolution of EMRs didn't really come from the clinical side so much," Lurye says. "The real return on investment on EMRs initially was that they helped to do charge capture better and meet coding criteria for various types of visits. They've become over time much, much more clinically oriented, and that's great."

Berkowitz sees EMRs as a platform on which a multitude of apps can be built, much as apps now get built on mobile platforms such as Apple's iOS or Google's Android.

"EMR vendors are pretty much focused on Meaningful Use right now," he says. "Nothing in Meaningful Use really says, 'Make a tool that makes the doctor more efficient.' Our tool doesn't help Meaningful Use. It simply helps the doctor be more efficient and provide higher-quality care."  [I love this line!]

EMR vendors are beginning to open up their platforms to allow third-party vendors to build these apps. "Allscripts and Greenway are leading the charge," Berkowitz says. Others will follow. For now, that means apps such as Healthfinch have to find more cumbersome ways to extract and use data.  [We have built our systems in a way which actually makes it now so hard to get the data we need from EMRs.]

But clearly this notion of EMR apps is going to be much, much bigger than just delegating refill requests. The healthcare ecosystem, ranging from payers to caregivers and encompassing financial analysts, quality mavens, and researchers, is starting to tap vast quantities of patient data that will accelerate the pace of innovation in healthcare technology by leaps and bounds.

To me it's very encouraging that there are physician-leaders such as Berkowitz who, while keeping their day jobs, have found ways in their spare time to advance this ball. The message is clear to healthcare technology vendors: If the Lyle Berkowitzes of the world can get this done, you should, too—and more.  [Well... I've been waiting long enough - glad my hat is in the ring now!]

View Online at: http://www.healthleadersmedia.com/print/TEC-279324/EMR-Apps-Taking-Off-Starting-with-Refill-Requests

And here was a summary from another HIT blogger who picked it up the next day: http://www.hospitalemrandehr.com/2012/04/27/will-next-generation-emrs-be-platform-stack-of-apps/

The Future of Physicians

My friend, CIO Extraordinaire and fellow blogger Dale Sanders, thought I might want to respond to the following... he was right!   This past week, Ezekiel J. Emanuel, MD posted an editorial in JAMA entitled, "Shortening Medical Training by 30%", in which he argues that we should spend less time and money on training doctors: "there is substantial waste in the education and training of US physicians. Years of training have been added without evidence that they enhance clinical skills or the quality of care. This waste adds to the financial burden of young physicians and increases health care costs. The average length of medical training could be reduced by about 30% without compromising physician competence or quality of care."

The well known KevinMD blog posted a response from Karen Sibert, MD, a professor at Cedars Sinai, Reducing training will diminish the status of physicians, in which she argues the dangers of this option and that the real motive is to be able to pay physicians less long-term by lessening what they do.  She says, "The Emanuel prescription for cutting [training] by 30 percent would downgrade the profession of medicine.  Instead, the prescription should be to support medical education at every level, and uphold the practice of medicine so that the brightest young students will always aspire to be physicians."  

I would even argue a more extreme reversal to Dr. Emanuel's theory and suggest that we actually spend more time and money to make sure physicians are trained VERY WELL... to take care of patients directly, but also to lead a team in the world that will be tomorrow's healthcare system.  But the catch is that we ALSO have to train a lower level of physician extenders to staff that team. In other words, the key is not to simply cut training costs nor to even increase the number of physicians by 10-20%, but to make the physicians we have 100-200% more productive by giving them well designed HIT systems which allow them, empowered by their teams, to take care of a greater number of patients in a much more consistent manner.  

The future of healthcare should see physicians doing less of the structured/mundane/checklist type work (which includes both indirect and direct patient care), and more of the higher ordered care - mainly direct contact with a smaller number of complex patients who really need that level of attention.  Studies have found that this high level of attention on the most complex patients improves care and saves money, while other research has shown that nurses and other paramedical personnel actually do better at handling preventive care and treating stable patients with chronic illness.  So let's free up our doctors to do the hard stuff where they can add the most value (and make sure we train them well to do so)!  

Meaningful Use - Part 2 Intro

The Notice of Proposed Rule Making (NPRM) for Stage 2 requirements for meaningful use of electronic health records (EHRs) was released by the Centers for Medicare & Medicaid Services (CMS) on February 23, 2012. There will be a 60-day comment period starting on March 7, and then a final rule will be published. The final rule is expected in the summer of 2012. Here are some key links and summaries:

• CMS EHR Incentive Program Overview
• CMS EHR Meaningful Use Overview
• CMS EHR Meaningful Use FAQs

Hints if you want to submit anything to CMS (from a HIMSS meeting with the CMS folks):
1. The best comments are well thought out explanations based on evidence whenever possible.
2. It is fine to comment as an individual, but of course it's more powerful if you comment as the consensus of a larger group.
3. Make sure to comment on both the pros and the cons.  If you just comment on the cons - then CMS needs to just focus on fixing those.  In other words, if you like something - let them know that too... otherwise someone who does not like the same thing will have more sway if they comment negatively about it and no one comments positively. 


Things I like include focus on CPOE and messaging.
Things which worry me include:
- The increase in eRx from 40% to 65%: As there are still many patients who want a printed Rx since they are not sure of their pharmacy address or want to shop around first; and not all pharmacies or PBMs accept eRx.  It's actually easier for docs to do eRx than print... but CMS has to understand that not all patients or pharmacies are ready for eRx yet.  Maybe going to 50% is a good compromise.
- Imaging requirement: As a PCP, do I really need to view the images of an xray... I am quite happy just seeing the report.  I don't think I am going to see anything the radiologist did not!  I am not sure if they are saying this requirement is for both inpatient and outpatient.
- Med Reconciliation: If a requirement for ambulatory care - I am curious on how they monitor it. On one hand, I do this every time I see a patient.  On the other hand, I don't use a special function to do this... so I am not sure how we measure it.
- Structured Family History: I am curious as to whether this will mean vendors create a new functionality for this since we've been using an older functionality for 10 years... and they might find it is easier to meet the letter of the law by using a new function rather than support an old one.

High level Summary (per HIStalk Blog)

The broad themes to be addressed in the Notice of Proposed Rule Making for Stage 2 are:

• Increased emphasis on health information exchange.
• Increased emphasis on patient engagement.
• New requirements for hospital patient safety, specifically with regard to electronic medication administration records.
• Requirements involving tying clinical decision support to quality measures.
• A philosophical goal of flexibility and reducing provider and vendor burdens.

Specific issues are:

• The Direct protocol will be required.
• SNOMED will become the standard for encoding problem lists.
• Infobutton (i.e. the blue button initiative) will be expanded, with requirements that patients be able to view, download, and exchange their own information. The proposed legislation calls for 10% of patients to actually do this.
• While Stage 1 required theoretical information exchange capability in test mode, Stage 2 will require providers to exchange information “across organizational and vendor boundaries,” which also includes submission to public health agencies.
• Encryption and usability requirements will increase.
• Viewing of images will be supported as an optional item.
• Physicians in group practice will be allowed to submit their quality measures electronically as a group.
• Stage 1 will be extended for another year, though 2013 for those who first attest in 2011. Providers can then stay on Stage 2 for another two years.
• The last date to attest without penalties will be October 1, 2014.
• An increased emphasis will be placed on making referrals electronic.
• Electronic submission to cancer registries will be added as a menu item.

  

SUMMARY OF KEY PROVISIONS IN PROPOSED RULE 

FOR STAGE 2 OF MEANINGFUL USE

(per a memo from the Global Institute for Emerging Healthcare Practices at CSC)

This memo provides a summary of the most significant changes and clarifications in the rule. A more detailed white paper will be published later. The Stage 2 proposed rules for meaningful use have many changes — some are subtle.

In addition to the new requirements to be a meaningful user of EHRs, there is one important clarification to the requirements for avoiding penalties. To avoid penalties starting in 2015 for not being a meaningful user, hospitals and eligible providers (EPs) need to either attest to meaningful use in 2013, or have achieved and attested to the first year of meaningful use by July 1, 2014 (October 1, 2014 for EPs).

As reported earlier, the requirement as to when different Stages of meaningful use need to be met was officially relaxed. Those that attest to meaningful use first in 2011 must meet Stage 2 criteria in 2014 and Stage 3 in 2016. All others will be required to demonstrate 2 years at Stage 1, 2 years at Stage 2 and then 2 years at Stage 3 (assuming the cut-off date for the program’s payments have not passed).

Quality measures are still not final, but in 2014 they will be submitted electronically. Quality measures are now a distinct category of meaningful use and the schedule is not tied to a particular Stage. In 2014, all those attesting to any Stage of meaningful use will need to electronically report the 2014 quality measures. The proposal is that EPs will submit 12 measures (some may be required, others selected from a long list of potential measures). Hospitals will select 24 measures (50 possible measures are proposed). In both settings, at least one measure will need to be reported from each quality domain: patient safety, care coordination, population and public health, efficient use of resources and clinical effectiveness. The final list of quality measures will be published with the final rule. This delay affects both users and vendors, vendors are likely to require significant development effort to be able to capture and report on the expanded list of quality measures.

There are many changes in requirements. The proposed rule generally makes Stage 1 optional (menu) items required (core) in Stage 2. Stage 2 does retain the concept of core and menu requirements for new requirements; for example use, of e-MAR is now a core requirement for hospitals and the ability to view images is a new menu requirement. Many of the thresholds from Stage 1 have been raised — some to a higher level than those recommended by the HIT Policy Committee. For example, the requirement for CPOE for medications is 30% in Stage 1, the Policy Committee recommended it be raised to 50% and the proposed rule raises it to 60%. Other new requirements include CPOE for laboratory and radiology orders, the ability of patients to view, download and transmit their health information, and public health reporting to cancer registries and other specialized registries. The CPOE measurement was changed from being based on one order per patient to a percentage of all orders — which will raise the bar considerably.

The only major recommendation from the policy committee that was not included in the NPRM was for an electronic physician note for 30% of office visits and 30% of hospital days. While no longer required for meaningful use, physician notes are a major source of data that will be required for electronic reporting of quality requirements.

To ensure that systems certified for Stage 2 can also meet Stage 1 requirements, a few Stage 1 requirements will be modified somewhat for 2014 onward. All the changes in requirements (even small ones) will have a major impact on vendors, since the entire installed base will need systems that meet these requirements. It is likely that vendors will only have the more recent versions of their products certified for Stage 2 — increasing the number of customers that will need a major upgrade.

The table below provides a summary of all the changes in requirements proposed for Stage 2. Hospitals will have 16 core (required) measures and must select two of four menu (optional) objectives. EPs will have 17 core objectives and be required to select three of five menu objectives.

Summary of Requirements for Stage 1 and Proposed Changes for Stage 2

Requirement	Stage 1 Final Minimum Requirement	Stage 2 NPRM Minimum Requirement
Maintain medication, problem/diagnosis, allergy lists	80% of patients have an entry or indication of none	No longer separate requirement, must be included in the electronic record for patient access and transmitted at transitions in care.
Demographics recorded	50% of patients	80% of patients
Vital signs recorded	50% of patients over 2	80% of patients over 3
Smoking status recorded	50% of patients over 13	80% of patients over 13
Family history	Not required	Menu item: 20% of patients have family history recorded as structured data
Computerized Physician Order Entry (CPOE)	30% of patients have a CPOE medication order if they have any med orders	60% of medication, laboratory and radiology orders entered using CPOE
Info on Advanced Directive	Menu option for hospitals — indicate if patent has advanced directive for 50% of hospitalized patients 65+	Remains menu item for hospitals.
Drug-drug and drug-allergy checking	Enabled	Enabled — now combined as one requirement for decision support
Drug-formulary checking	Menu option	Incorporated as a requirement for e-Rx
Medication reconciliation	Menu option, performed for 50%	Required
e-Prescribing	40% of prescriptions for eligible providers	Required — 65% of prescriptions for eligible providers Menu 10% of new or changed medications for discharged hospital patients, must include a drug formulary check
Summary of care record transmitted between providers at transitions in care	Menu option, performed for 50% of transitions (can be on paper)	Required for 65% of care transitions; must be electronic for 10%
Ability to view images	No requirement	Menu option: 40% of all scans and images available for viewing on the EHR
Secure messaging	No requirement	10 % of patients have sent at least one message to eligible providers
Electronic medication administration (eMAR)	No requirement	Required for 10% of all medication orders for hospital patients

Other Useful Links

• Summary from American Medical News (3/5/12)
• Summary from Unchart.com
  

Care Innovation Summit (Jan 26, 2011 in DC)

I was one of 1200 "healthcare innovators" attending the annual Care Innovation Summit last week, sponsored by CMS, the West Wireless Health Institute, and Health Affairs magazine.  The day started with a fantastic keynote by Atul Gawande, MD, and then there were assorted panels talking about healthcare innovations across the US. 
My thoughts and reflections on the day:

First, it was a good use of time.  It is hugely important to be able to hear innovation stories, and it is important the providers, industry, and government are all sharing with each other and trying to figure out this mess we call a healthcare system.  Additionally, the networking is always fantastic at a place like this.  I was able to see some old friends like Ted Eytan (Physician Innovator and awesome blogger), Margaret Laws (CHCF), and Carleen Hawn (Healthspottr), as well as meet some new friends who do great blogging, like Andre Blackman (Pulse and Signal) and Dr. Joseph Kim (Medicine and Technology).

Second, Gawande's keynote was really great - how can a surgeon be such a good writer and excellent speaker?!?!?  He focused a lot on the importance of creating easier systems which cost less and deliver all the appropriate care to as many people as possible. A few comments he made which stood out:

• Healthcare Costs are Killing the American Dream.  The "typical" US family has seen almost all of their increase in take home pay in the past decade go to paying for their healthcare costs. 
• We need Automation and Teamwork.  The complexity of healthcare is increasing exponentially but we have not really altered how we deliver care - one physician at a time.  In the past "2 generations" (about 100 years), we have expanded to over 13,000 known conditions, 6,000 meds, and 4,000 types of procedures - physicians have to know all these and then deliver them to every single American - not exactly efficient (and rarely consistent).   In other words, "We need Pit Crews, not Cowboys".  Every other industry has learned how to automate and task shift… it's time for healthcare to do the same!   [Side note... I think this is so important for the future of healthcare - that it is the basis of a new company I helped create in the past year... more to come later]
• We need better Data!  I love the analogy he gave… He said, "the way we currently provide data is like driving your car, but when you look at your speedometer, all you see is the speed of other cars from 4 yrs ago." We need to have real time data, specific to our needs!
• The Best Places Act like Systems.  He noted these three key skills are needed:
• The ability to recognize Success vs. Failure (i.e. need up-to-date data which is focused on a specific issue).
• The ability to identify failures and then devise solutions for them… he of course pointed out that you should consider Checklists to help organize the "best care".  I agree!
•  Make solutions easy to implement.  Keep them simple and cost-effective, and recognize the importance of consistency and teamwork.

Third, the government folks said that they know we have to become more innovative.  Dr. Richard Gilfillan (acting director of the CMS' Center for Medicare and Medicaid Innovation) said, "We need to decide now whether to make the commitment to adopt innovation that will fundamentally change the way we operate, change the way we deliver care, change the way we think about these organizations that we run. This is not an abstract notion; this is a very concrete question that each of us will have to answer."

Marilyn Tavenner (acting administrator for the Centers for Medicare & Medicaid Services) highlighted a variety of innovations, and expressed urgency in pressing forward with the “triple aim” goals of better individual healthcare, better population health and lower costs called for in the health reform law.

As a reminder, the summary of the Healthcare Reform law essentially comes down to four things: 

• Value: improve quality and cut costs  (and the part that is TOP on the mind of everyone)
• Access
• Insurance reform
• Medicare improvements

And the Triple Aim (as defined by Dr. Berwick) is:

• Better care (at an individual level) - including the STEEP criteria (Safety, Timeliness, Effectiveness, Efficiency, Equitable, Patient-Centered)
• Better health (at a population level)
• Lower costs

CMS also recognizes that the only way to do all this is for government and payors to better align incentives (hence the experimenting with ACOs and other reimbursement changes).  And as Todd Park (CTO for CMS) said, do anything they can to help America's "innovation mojo" heat up to start solving problems (such as by promoting the challenges below). 

Fourth, they released a series of private-backed Challenges throughout the day.  ONC posts these challenges at www.Challenge.gov/ONC.  Here are the ones announced at the Summit:

• Sanofi Diabetes challenge: www.datadesigndiabetes.com 
• JNJ-Janssen care coordination (hospital handoffs):  http://www.janssenhealthcareinnovation.com/connected-care-challenge
• KP HIV challenge: www.kp.org/hivchallenge  - actually more of a self-help tool for any HIV clinic in the nation to learn from what KP has done
• Allscripts CDS Challenge for CAD: www.Allscripts.com/cdschallenge 
• Janssen, Pfizer and Geoffrey Beene Foundation Alzheimer's Challenge: http://www.alzheimerschallenge2012.com/

Fifth, they had a variety of payors, disease management companies and providers talk about "innovative programs".  Health 2.0 blogged on some of these innovators, and here are two that stood out to me:

• The WellPoint "Care More" model focuses on the 15% of patients which account for 75% of costs.  "Extensivists" work with PCPs to provide early and quick intervention (e.g. patients see the Extensivist clinic a few times a year, in addition to the PCP).  This model also uses a host of other providers as well (e.g. home care, social workers, dietitians...) to create a fabulously deep and rich team for these patients.
• ChenMed is a provider group which focuses only on complex elderly patients.  Their mantra is "Coordination, Collaboration, Convenience, Compliance".  They succeed because they limit MDs to just 350-400 patients and build a whole system around these patients.  

So while these are both great programs, they also represent the weaknesses in the conference:

• The majority of presenters focused on Medicare patients - understandable since that is of utmost interest to CMS… but there is much to learn with younger patients too.  Additionally, CMS must realize that poorly controlled younger patients will wind up in their lap eventually!  We have to somehow integrate CMS with the private insurers in some way to keep them both aligned.
• The majority of presenters said they achieved some quality benefits by focusing a high amount of care on the "most complex 15%" of patients.  On one hand, this is great stuff - and important to learn how they did it so it can be replicated.  On the other hand, it should not come as a shock that expensive heavy lifting on those folks improved outcomes… were these innovations or simply sound logic?  Are they reproducible?  And did they cut costs (e.g. what was the ROI)?  

Additionally, I think a key quote of the day came from Aetna's CMO when describing a program they implemented to help patients after a heart attack. He said, "we gave them free meds after an MI, and compliance was still only 49%!"  So whatever we do we better make sure it is "easier" for patients than their current lives... because behavior change is really hard!!!

And one other great quote came from a nurse who was talking as a patient, knowing she was dying from cancer.  She did her research and chose to not try end-stage treatment that would hurt her quality of life and only possibly give her a small amount of extra time.  She reminded us not to "force" care onto everyone, for as long as someone has been educated, "There are no wrong choices, only informed choices."

Finally, how about some more IT Innovations?
We heard how IT could help collect, analyze and display data… which could be used to find problem areas or identify high risk patients (e.g. predictive modeling).  We even heard how the Archimedes Model can help predict the outcomes of various interventions.  However, we did not hear how IT innovations could allow for better economies of scale (via automation) and easier spread of improved processes.  My theory is that we use IT to help automate the care for the 85% of patients which are "healthy and stable", so that the high touch care for the complex 15% can continue.  I plan to do my best to support companies that fall into either of these buckets!