Interoperability

Hurricanes highlight healthcare IT improvement, expose gaps

Yes, Katrina was already losing appeal as a girl’s name by 2005, when it had fallen to 247th most popular in the United States. But the so-named hurricane that swamped New Orleans in August of that year pushed it off a ledge. By May of 2007 Katrina had fallen more than 100 spots to number 382, its lowest level since the 1950s.

Less trivial is the impact of Katrina on hospitals and healthcare, which has regularly measured itself against the ghost of a seemingly manageable Category 3 storm that morphed into a disaster of historic proportions and nearly destroyed one of America’s more storied cities.

Since Katrina there’s been Rita and Wilma, also in 2005, and Superstorm Sandy on the eastern seaboard in 2012, but nothing else. The recent arrivals of Harvey in Texas and Irma in Florida are healthcare IT’s first real opportunities to test existing infrastructure against mother nature.

So, what are the early reports on the shift to electronic records, remote / cloud hosting and disaster recovery sites after the hurricanes? Things are better, but it’s still a work in progress. After all, many hospitals in New Orleans had EHRs, but it didn’t matter when the water kept rising.

“When Hurricane Katrina smashed into New Orleans in 2005 … tens of thousands of patients lost their entire medical histories—boxes of paper files disintegrated or washed out to sea by the rising waters,” writes Megan Molteni in Wired magazine. “Widespread data loss won’t be as much of a problem for Houston. Today, about 75 percent of providers keep records electronically. But patients still may have trouble accessing their records when it matters most: in the middle of crisis and recovery.”

That’s right. Interoperability remains the hill healthcare IT still has not taken, despite the proliferation of EHRs.

The fear of a Katrina redux inspired many hospitals to improve their physical infrastructure by installing “submarine doors, flood gates, and above-ground backup generators,” which kept 90 of 110 Houston-area hospitals from having to evacuate patients. Darrell Pile, CEO of an organization that coordinated patient evacuation and relocation related to Harvey, said he knew of no hospitals in Houston that lost access to patient records.

And yet, everything was still not totally copacetic in Texas.

“For lots of these patients, these are not their normal clinics,” explained Dan Jensen, manager of 11 clinics in the VillageMD Houston network. “We can try to pull data on some of them, but it’s very limited what we can get. A lot of times we have to start from scratch.”

But Jensen also illustrated the ways in which healthcare IT enables flexibility and rapid response during emergencies. Able to reach only 10,000 of 160,000 patients before the storm, VillageMD Houston’s IT provider was able to engineer a patient portal fix overnight that extended portal communication to all patients, even those who had not signed up.

While Houston was drying out, Irma’s visit to Florida ended up being less destructive but more directly impactful because it shut down most of the state. In total, 36 Florida hospitals closed either in anticipation of the storm or because of its impact. Statewide, 54 hospitals were forced to use backup generators and some reported modest flooding but remained open.

And the Florida Hospital Association received no reports of EHR failure.

Arriving so close together, Harvey and Irma almost entered the national consciousness as one storm. Taken together, early returns suggest healthcare IT has progressed significantly since Katrina.

“Policymakers and health care providers can celebrate one quiet success in the wake of the Houston storm: the computers are still running,” writes Darius Tahir in Politico. “The preservation of patient health records represents a partial vindication for the HITECH Act … that was conceived, in part, as a way to ameliorate natural disasters like Hurricane Katrina by replacing waterlogged paper with modern technology.”

But it wasn’t just Katrina that spurred lawmakers to pass the HITECH Act. It was also the VA’s response to the hurricane.

“The VA — with its pioneering VistA EHR — was able to retain records and access them much more rapidly than its private-sector peers during Katrina,” says Tahir, “… the organization restored access to records from 40,000 New Orleans-area veterans within days; it would take years for the private sector to reassemble its records.”

Indeed, where former Surgeon General Regina Benjamin thought she couldn’t afford an EHR before Katrina, she knew she couldn’t run a hospital without one after.

And yet, despite the generally positive results and clear benefits of healthcare IT proliferation, obvious gaps remain. Patients often scatter to the four winds in a disaster and reattaching them to their records is both challenging and not yet reality.

Plans are, however, in the works to fill this gap. The PULSE project, initiated by the Department of Health and Human Services in 2014, is working to create a data-sharing network that’s switched on in emergencies and makes patient records available to first responders and clinicians when they enter patient name, birthdate and gender.

Initial PULSE tests in disaster-familiar California have gone so well that the California Emergency Medical Services Authority plans to keep the system in place and may switch it on during one of the Golden State’s regular events.

All the testing in the world can only provide so much real-world preparation. With climatologists suggesting that the relatively hurricane-free period between Katrina and Harvey is probably over, it’s encouraging to see the progress represented by both PULSE and the performance of Texas and Florida hospitals. Any optimism at this point, however, should be buffered by an urgency to get it even more right the next time the winds start to swirl in the Atlantic, regardless of what name we give them. 

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

Michigan study: Information blocking as a sales strategy

Looking to boost the entertainment value of this blog, a couple of years ago we compared information blocking to the mythical jackalope—a creature no one has seen in nature but many have encountered hanging over bars in various western towns.

Continuing with that metaphor, it now appears someone has actually seen an antelope-horned jackrabbit bounding through sage brush and pinion. I’m talking about a recent University of Michigan survey that asked health information exchange (HIE) professionals about their experience with information blocking. Respondents clearly indicated that information blocking is real and is practiced by both health systems and EHR vendors.

“Half of respondents reported that EHR vendors routinely engage in information blocking, and 25 percent of respondents reported that hospitals and health systems routinely do so,” write professors Adler-Milstein and Pfeifer in their report. “Among EHR vendors, the most common form of information blocking was deploying products with limited interoperability. Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology.”

The survey results are especially incriminating for EHR vendors, who either “routinely” or “occasionally” engage in information blocking, according to 88 percent of respondents. Hospitals and health systems fared better, but 59 percent of survey participants still used “routinely” and “occasionally” to describe information blocking behavior.

The survey gets more interesting as it delves into specific tactics. Respondents said information blocking among EHR vendors usually takes these eight forms and occurs with a corresponding frequency shown in parentheses.

  • Products have limited interoperability (49 percent)
  • High HIE fees unrelated to cost (47 percent)
  • Third-party access to data is difficult (42 percent)
  • Refuse to support particular HIEs (31 percent)
  • Data export is difficult (28 percent)
  • HIE contract terms change after implementation (19 percent)
  • Unfavorable HIE contract terms (17 percent)
  • Gag clauses on speaking about info blocking (12 percent)

Hospitals and health systems, the survey showed, try to block information by pressuring providers to adopt specific technology (28 percent), controlling patient flow through selective data sharing (22 percent), and using HIPAA as an excuse to not share patient data (15 percent).

The ‘Why?’ in all this is what one might expect from companies working to ensure profitability. Survey respondents mostly said they think EHR vendor goals are to maximize short-term profit and increase the likelihood their products will be selected.

Of course, as has been pointed out many time and in various forums, healthcare is not just like any other marketplace. In truth, EHR vendors are caretakers of information that nurtures a public good. The measures of success in this arena are both patient health and sales totals.

The Michigan study survey results are supported by the anecdotal experience of individual physicians like Peter Masucci.

“I went digital 11 years ago and embraced an electronic health record,” writes Masucci in a recent article on STAT. “While things aren’t perfect, they’re very good. Yet now I’m being told by the managers of my affiliated group that I and all of the other physicians in the affiliated group must adopt and use the same new electronic health record platform.

“That doesn’t make sense to me. I have an iPhone and my neighbor has an Android, but we can still communicate. My bank account is with TD Bank and I regularly get my money from Citizens Bank ATMs; communication seems to be working there. Why in 2017 must all doctors be on the same system to communicate and share information?”

Why? Because that’s the business model that most benefits EHR companies and many of their large hospital and health system surrogates. Even while the technology to readily enable interoperability is not there yet, interfaces can still be built, all HIEs can be supported, and there simply is no legitimate healthcare-oriented reason for gag clauses.

“What has been substantially underappreciated, however, is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not [participating in HIEs],” writes Julia Adler-Milstein in Health Affairs. “And as a result, these actors may behave in ways that interfere with the free-flow of patient information that is needed to improve health and health care.”

The solution, according to the Michigan study, is a change of incentives. While the federal incentives for EHR adoption are obviously reimbursement, the incentives enabling free flow of patient information between systems and doctors remains elusive.

How might those incentives change? One obvious approach is government regulation, which is mentioned in last year’s Twenty-First Century Cures Act, but more oversight is not what most in healthcare want to see. Since five EHR vendors control roughly 70 percent of the EHR market, a better approach might be to willingly embrace HIE and the policies/technologies necessary to make it happen.

Is that asking too much of for-profit businesses? It might be. But as with most issues in healthcare, what is not effectively managed to benefit patients eventually becomes something potentially regulated by Congress.  The question now might be who will blink first—the information blockers or Congress.

Richard Sullivan is chief government and revenue officer for Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Interoperability

It’s 2017. Do you know where your interoperability is?

With January barely behind us and new occupants in the White House, perhaps it’s a good time to set aside what might change for a moment and focus on what must. Interoperability is a more urgent concern in 2017 due to goals established last year by the Office of the National Coordinator (ONCHIT) and the passage of the 21st Century Cures Act, which legally requires healthcare IT interoperability by the end of the current calendar year.

The Interoperability Standards Advisory for 2017, released by ONCHIT in December, is an effort to facilitate interoperability by releasing “essential standards and implementation specifications” determined in dialogue with public and private sector partners. These partners include healthcare IT vendors with products installed in 90 percent of U.S. hospitals that have also made a public commitment to the ONCHIT-created Interoperability Pledge and its essential elements:

  1. Use standardized APIs.

  2. Make it easier for patients to access data.

  3. Don’t block information.

Even if the pledge itself promises little in the way of holding signees to their promises, the Cures Act will likely prove thornier. As detailed in the legislation, technology certification will require vendors to demonstrate that they are not blocking information or in any way inhibiting data transfer. They must also utilize application programming interfaces (APIs) or a similar data transfer enabling technology.

But while 21st Century Cures may be the match that lights the interoperability pilot, it won’t be the source of heat and energy. If interoperability is achieved this year, it will be because significant technological and policy goals have been identified and realized.

So where do we stand on interoperability in early 2017?

  • Almost all hospitals now have a certified EHR. No, this does not represent a conclusive accomplishment. Rather, virtually universal adoption of EHRs gives us a moment of pause as we look to what still needs to be done. We have the necessary platform, and now we need to keep improving to exchange data amongst entities in a way that makes clinicians more satisfied.
  • Work on an interoperability standard is progressing and showing promise. The Fast Healthcare Interoperability Resources (FHIR) standard that Health Level 7 (HL7) has been working on is maturing; the organization expects a normative version to be released this year. That’s good, given the Cures Act mandate.
  • The shift to value-based care is happening and will continue. According to a recent KPMG survey, half of health systems are now reimbursed in part for value-based care hinging on cost and quality factors. A full quarter of survey respondents said they would be engaging in value-based reimbursement plans in the next three years. Only 7 percent said they would not. The train is in motion and it requires comprehensive healthcare IT that is fully enabled to exchange information as effectively as possible.

Of course, no one is arguing that now is the time for clinking champagne flutes and excessive back-slapping. Industry surveys and anecdotal data tell us a story of unsatisfied clinicians who still lack full patient data and are hindered clinically as a result.

What must still be accomplished in 2017 to move closer to fulfilling visions of a comprehensive healthcare IT system nationwide?

  • Continue pursuit of a standard. Right now FHIR is the front-runner for default healthcare IT standard. The smart money might bet on FHIR because it has a development timeline advantage, but there are no guarantees. Normative status for FHIR means vendors could potentially include it in products in time to meet Cures Act requirements.
  • Create application programming interface (API) initiatives. Earlier this year, Chilmark Research released a report on APIs in healthcare with recommendations for each industry participant.
    • Health care organizations should initiate API programs, urge EHR vendors to develop APIs, start API governance discussions and focus on user interface issues.
    • HIT vendors must start programs with FHIR and APIs, and re-evaluate interfaces from a product rather than services perspective
    • Payers need API programs, too, starting with paid claims data. They should also cultivate relationships with independent developers.
    • Data integrators should understand how to support FHIR and utilize a value-based monetization model as opposed to an access-based model.
    • Device manufacturers will look to partnering with EHR vendors and integrators, and should also embrace a value-based monetization mode.
  • Revamp healthcare further. It’s not just value-based payment models that are changing the provision of healthcare. As John Glaser writes in Hospitals and Health Networks, collective industry actions point toward establishing healthcare IT solutions that include but do not culminate with APIs and FHIR. The number of accountable care organizations, currently approaching 800, continues to grow as technology enables both care coordination and multi-payer risk.

The larger message and broader vision in Glaser’s interoperability article is one healthcare would do well to embrace. Healthcare is not simply engaged in technical interoperability; the industry is also breaking out of an approach to care that walls off bits of patient data in the separate files of different providers, that primarily pays for procedures and solutions after the patient has fallen ill, and that too often proscribes incomplete solutions for complex, comorbid health concerns.

Healthcare is moving toward an industry-wide interoperability that can’t fully emerge until the technology to enable it has matured. There’s a better-than-average chance 2017 is the year we start to see real benefit.

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

Category: Interoperability

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

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

When illnesses collude: How comorbidity threatens American healthcare

Comorbidity is not a word heard every day—not even in healthcare, where it applies. But researchers and physicians, assisted by IT-derived diagnostic data, have come to understand that comorbidity is essential to understanding and managing population health, especially among vulnerable populations challenged by mental illness and addiction.

A patient with comorbidity has at least two chronic diseases at the same time that interact in such a way as to worsen the impact of each illness on the individual. Imagine irritable bowel syndrome or Crone’s and diabetes working in tandem, for example, and it’s not hard to see how comorbidity becomes a tag-team bludgeon.

Among the total population of the United States, 25 percent have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC). Of course, those chronic conditions are not limited to the physical. Once we include mental illness and substance abuse in the definition of comorbidity, rates rise dramatically and are often more debilitating.

There is simply no denying that even the most common mental illness creates the risk of comorbidity with drug and alcohol abuse. According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes.

In this environment, doctors and the healthcare system are not tasked with just treating a physical illness or three. They also have to treat a physical challenge that may have been neglected due to mental illness made worse by substance abuse. Or maybe they’re trying to wean a patient off heroin used to deal with chronic pain after the OxyContin subscriptions ran out.

It’s this complex self-medication dance that regularly doubles back on itself and dramatically ratchets up costs in terms of both healthcare dollars and lives. Opiate-related deaths just recently surpassed those from gun violence, and healthcare costs rose 3.4 percent last August, the highest one-month rise since 1984.

“On average individuals with chronic medical conditions incur health care costs two to three times higher when they have a comorbid substance use disorder compared with individuals without this comorbidity,” wrote Surgeon General Vivek Murthy in his recent report on addiction in America.

No, mental illness does not always lead to substance abuse and an often irreversible downward spiral. But addiction always makes both physical and mental illnesses far worse, even if we cannot determine causality or directionality.

A survey by the National Institute on Alcohol Abuse and Alcoholism, for example, identified comorbidity in a majority of respondents. A separate study by the NIAAA found that 56 percent of subjects with bipolar disorder also practiced some form of alcohol abuse and were more likely to have medical comorbidities like lung and breathing issues because smoking is so common.

How can we deal with mental illness to try and avoid substance abuse and medical comorbidity?

  • Catch it early. “… research indicates that 90 percent of people who develop a substance use disorder started their use before age eighteen,” writes Alexa Eggleston of the Conrad Hilton Foundation in a recent Health Affairs blog post. Eggleston speaks of substance abuse in general, but the risks are greater in the teenage years, when most mental disturbances manifest, making increased awareness even more necessary.
  • Initiate treatment. Addressing a mental issue is more straightforward before comorbidity becomes a factor. If mental illness and substance abuse comorbidity happens, treatment should focus on both issues at once, according to the National Institute on Drug Abuse.
  • Break down silos. The unfortunate tendency in healthcare going back decades has been to silo information and care. Treatment has tended to focus on independent specialists treating separate aspects of the patient condition without fully addressing how they impact one another. That must end. The placebo effect, for example, shows us that the brain and the body are not separate and that treating them as unrelated makes as much sense as changing the oil on a car with four flat tires.

To be sure, changes to the way we provide care—paying for value, Patient Centered Medical Homes, ACOs, HIEs, etc.—have gained great momentum that should continue. As mandated by the recently passed 21st Century Cures Act, interoperability among healthcare IT systems must become a reality so ER docs can see when a patient is bipolar and family practitioners know immediately that their new patient is on anti-psychotics.

Annually, the United States spends $35 billion from both public and private payors to treat substance misuse, but that’s a small fraction of the amount addiction extracts from American society in terms of services for the homeless, work absenteeism, broken families and other types of fallout. In total, substance abuse is estimated to cost the United States more than $400 billion each year, an amount that is 2/3 that of the Pentagon budget.

We are currently in the midst of one of the worst drug-addiction epidemics the nation has experienced. No, integration of patient record systems and patient care protocols will not prevent the destructive chain of events that leads to substance abuse, but becoming more alert to the frequency and severity of comorbidities may enable us to see warning signs sooner, share information and work more interactively with other caregivers, and more effectively improve patients’ overall health and quality of life. And this multi-pronged approach to quality of care will very likely minimize the costs to society in the process.

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

Cures Act: A bag of holiday gifts for healthcare

On Tuesday, President Obama signed the 21st Century Cures Act, codifying a broad and far-reaching effort to achieve medical breakthroughs in Alzheimer’s and other debilitating afflictions through improved, streamlined, well-funded research.

The Cures Act gives particular attention to cancer and Vice President Joe Biden’s Cancer Moonshot initiative, which hopes to transform research and make certain varieties of the illness either manageable or history.

“God willing, this bill will literally, not figuratively, literally save lives,” Biden said at the signing ceremony. “But most of all what it does … is gives millions of Americans hope. There’s probably not a one of you in this audience or anyone listening to this who hasn’t had a family member or friend or someone touched by cancer.”

The Cancer Moonshot illustrates well how most of the Cures Act focuses on research and additional funding for the National Institutes of Health and similar agencies. But it also focuses on bettering the current provision of healthcare by improving behavioral health care and healthcare IT.

Viewed from a high level, Congress is focused on stemming the tide of mental illness and opioid addiction in America, as well as making sure healthcare information flows freely and safely among providers to improve patient care. Read on for highlights.

Mental Illness and Addiction

Via the specific proposals below, the Cures Act endeavors to better fund mental health care and opiate addiction, improve leadership and planning, ramp up research, enforce parity and improve preparedness among police and in the legal system.

  • Over the next two years, the Cures Act provides $1 billion in state grants for opioid abuse prevention and treatment. Specific parts of the proposal include prescription drug monitoring, healthcare provider training and better access to treatment programs. Indeed, block grants to state agencies are clearly aimed at helping individuals break out of the addiction cycle that so often includes homelessness and limited family support.
  • Grants will also go to higher education and professional training programs to put more mental health professionals in the field.
  • The Act also creates new positions—an assistant secretary for mental health and substance use, and a chief medical officer—in the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Apparently not a sanctioned SAMHSA component previously, the Center for Behavioral Health Statistics and Quality is now codified in the Cures Act, as is the requirement that SAMHSA create a strategic plan every four years to identify priorities and strengthen the mental health workforce.
  • Mostly through reauthorizations, the Cures Act provides funds for mental health programs that pay specific attention to some vulnerable populations: college students, women and children.
  • Mental health parity, already a law but sometimes inadequately enforced, will become more of a focus for HHS, which is being asked to draw up a federal and state compliance action plan.

Healthcare IT

While there are efforts in the Cures Act to improve the functionality of EHRs and access to records for patients, the real focus is on improving the flow of information.

  • Apparently fed up with allegations of information blocking, Congress included in the Cures Act $15 million in funding for improved interoperability and less information blocking. Some of the money will support a voluntary framework for information exchange and some will go to HHS to investigate claims of information blocking and punish the blockers to the tune of $1 million per violation. The Government Accounting Office is also required to evaluate patient access to personal health information and why it might sometimes be difficult to get.
  • Congress is also requiring HHS to change the terms of Meaningful Use to include interoperability. Moving forward, healthcare IT vendors must develop application programming interfaces (APIs) and apply real-world tests of interoperability to EHR systems.
  • If the Cures Act has a measurable impact, EHRs will become more patient-centric. Incorporated language speaks to making patient records more simple and easier to use, and continuing to grow Health Information Exchanges (HIEs) to expand patient access to care.
  • A new HIT Advisory Committee will make recommendations to the national coordinator on a host of healthcare IT concerns. Of particular interest will be the segmentation of data so that only select parts of a patient record can be shared and sensitive data related to mental illness and drug addiction can be closely controlled.
  • The Advisory Committee will also have the authority to make recommendations on population health, healthcare for children, telemedicine and other potential improvements to healthcare available through IT.

At nearly 1000 pages, the Cures Act obviously includes much more than the greatest hits included here. The curious might visit this highlights document and find specific objectives that perhaps are more relevant and important.

As with all federal legislation, efficacy is measured by impact over time, not number of pages or total appropriations. With the Cures Act, we can hope that the grant money will make a significant difference at the local level and that patient health information will flow more freely between coordinated providers. A cancer breakthrough wouldn’t hurt, either.

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

Cures Act is a strong mental health vaccination. Booster shots required.

Remember that the two things you don’t want to watch being made are sausage and law. Then recall that while the process for both may be unappealing and seem incongruous, the product is not always so.  

Take the 21st Century Cures Act, for example, which is a lengthy (996 pages) piece of legislation (summary here) that focuses primarily on health-related scientific research and medical devices. It also broadly outlines the terms for an upcoming drawdown of America’s strategic petroleum reserve, which may look like a rider but is actually a way to pay for the bill.

The sale of crude will also help fund mental health and addiction treatment, about which the Cures Act has something to say thanks to language appropriated from the Helping Families in Mental Health Crisis Reform Act. That bill passed the House earlier this year but has languished in the Senate since.

It’s encouraging to see Congress address mental illness and addiction, and the Cures Act works to address many of the issues that plague American mental health care and bleed into acute care as well.

Read on for more on what the Cures Act does and doesn’t do to improve mental health care.

What does the Cures Act do for mental health care?

  1. Provide More Money: Over two years, the Cures Act provides $1 billion in block grants to the states for opioid abuse prevention and treatment through prescription drug monitoring, prevention programs and healthcare worker training. It also provides or reauthorizes a host of other targeted grants focused on specific goals and populations, including treatment of students on college campuses.

  2. Create New Leadership and Planning: The bill establishes a new assistant secretary for mental health and substance use to head the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as a chief medical officer within SAMHSA to help with program creation and development. 

  3. Promote Cutting Edge Research: Moving forward, a new National Mental Health and Substance Use Policy Laboratory (NMHSUPL … whew!) would be responsible for focusing evidence-based, scientifically oriented treatment on mental illness and addiction. The laboratory would also identify and respond to regionally specific mental health and addiction challenges.

  4. Push Parity: The Cures Act puts the onus for verification of compliance with parity legislation—the requirement that insurance policies cover mental and physical health equally—on Health and Human Services (HHS), Labor and Treasury. Down the road, the Government Accounting Office and CMS will evaluate whether or not parity compliance is happening. 

  5. Support Mental Health Training in the Legal System: Approved use of existing funds would empower law enforcement to create mental health crisis intervention teams and pay for targeted training. Additionally, the Cures Act requires the attorney general and courts to create a drug and mental health court pilot program.

What does the Cures Act NOT do for mental health care?

  1. Enable Integration with Acute Care: Despite there being funds for many programs, none were appropriated for expanding use of EHRs in mental health facilities. It seems like an omission, especially given the success of EHR adoption in acute care hospitals and the interoperability requirements included in other sections of the act. Interoperability is great and overdue, but it should be spread across the continuum of care to maximize impact.

  2. Add Beds: This isn’t a completely fair criticism, given that there is grant funding to states in the Cures Act that perhaps could be used for new facilities with more beds. But there isn’t a mandate with supporting funds to make up for the 4,500 public psychiatric beds that were lost between 2009 and 2012 and pretty much remain so. Indeed, when the need seems to be increasing, the number of psychiatric beds in the U.S. remains at record lows, contributing greatly to homelessness in urban areas and misuse of emergency department resources.

  3. Expand the Pool of Therapists: Outside of urban areas, professional therapists are hard to find and referring physicians have few options. Federal programs already exist that give teachers and doctors financial incentives (loan forgiveness) to work in areas where their skills are most needed. It seems like doing the same for therapists of various stripes—assuming such programs don’t already exist—is warranted. States could conceivably use grant funds to accomplish this goal, but federal law could offer more support. 

  4. Appropriate Enough Money: Looking at the number alone, $1 billion looks like a lot of money. As a sliver of the federal budget, and given the mental health and addiction challenges plaguing states, it may prove inadequate without viewing it as a down payment on a larger commitment. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, from 2009 to 2012 the states cut roughly $5 billion in mental health services, so 20 percent of that total at best may be restored.

Given what we know in the 21st century about mental illness—how common it is and how much human potential and productivity it drains from society—it’s not hard to envision behavioral health and addiction issues as some of the nation’s most daunting challenges.

But the 21st Century Cures Act, while focused on improving healthcare through better, more rapid research, perhaps tries too hard to be all things to all people. It won’t be. As with most legislation, the Cures Act will hopefully establish a foundation on which additional legislation can build. Subsequent legislative efforts should focus on expanding the pool of beds and therapists, and on integrating with acute care.

Let’s make sure those changes happen before there is a 22nd Century Cures Act.

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

Is information blocking finally on its last leg?

Healthcare industry market analysts, technology gurus and IT reporters sometimes like to envision a powerfully capable future in which software architectures are open, small application developers are thriving, and healthcare IT solutions from numerous sources create a confluence of patient data that will advance healthcare quality.

A survey organized by the California Health Care Foundation and Health 2.0 suggests we may be far from that ideal.

In a nutshell, the survey of more than 100 small healthcare IT companies tells us this:

  • Information blocking is a real thing, though it’s not always the fault of big EHR vendors and there is broad variation in the degree of blocking by individual companies.
  • Only two EHR companies have an actual program for integrating with smaller applications, all impose interfacing costs of some kind, and most small companies feel the customer has to apply pressure before they are permitted EHR access.
  • For the most part, EHR vendors are not enthusiastic or helpful when it comes to integrating with small patient data applications. Small development companies were split 50-50 when asked if the larger entities helped or hindered integration.
  • The small vendors say most APIs designed by the large EHR companies are poor.

Then there’s the fact that small application developers are not the only ones accusing bigger players of being uncooperative. The American Board of Family Medicine, the American Academy of Ophthalmology and the American College of Cardiology all accuse EHR companies of blocking access to clinical data registries.

As reported by Politico, “’The vendors often delay requests to connect, quote prohibitive prices for integration, or flatly refuse to transmit the data and instead offer to sell physicians their own software,’ says Marta Van Beek, co-chair of the American Academy of Dermatology’s registry committee.”

The importance of data in improving individual and population health, a benefit to the public as a whole, is what leads to relatively normal business practices being labeled as information blocking. In other industries this might be considered simply protecting your market position.

But healthcare is not a typical industry because health is not breakfast cereal. More information available to providers at the point of care makes for more positive clinical outcomes, which has to be a goal for all in the industry.

Of course, the Centers for Medicare and Medicaid Services (CMS) is all for full interoperability. But at the onset of the Meaningful Use era, CMS seemed to naively expect that providers attesting with certified EHRs would achieve this goal through trickle down pressure on the EHR vendors. It didn’t happen. As various leaders from the Office of the National Coordinator for Health IT (ONC) have lamented, EHR vendors as a group were not incentivized enough by sales potential to make genuine interoperability part of their deliverables.

Now, CMS is engaged in catch-up strategies to offset this Meaningful Use miscalculation.

For example, CMS undertook a major PR effort at HIMSS 2016 to get vendors to sign the toothless Interoperability Pledge.  Most recently, the 2000-plus pages of the final MACRA rule include requirements that providers attest to not blocking information. Commenters on earlier draft versions complained that, “EHR vendors are unwilling to share data in certain circumstances or charge fees that make such sharing cost prohibitive for most physicians.”

In recent remarks to the American Osteopathic Association, CMS’s Acting Administrator Andy Slavitt put the onus for EHR interoperability squarely on the shoulders of EHR vendors, not end-users.

“The burden needs to be on the technology, not the user,” he said. “EHR vendors and hospitals that use them will now be required to open their APIs — so data can move in and out of an application safely and securely — and technology can become plug and play … Today’s data silos are more a function of business practices than technology capability and we cannot tolerate it any longer.”

Real interoperability and the free flow of patient data depend on providers and EHR vendors implementing and embracing core prerequisites:

  • A single standard: Perhaps the data exchange standard will be FHIR or maybe it will be something else, but one standard for the industry is necessary.
  • Granular data: The FHIR standard enables the exchange of pieces of patient data instead of whole documents, giving power to application developers, who traffic in data pieces and chunks.
  • Application programming interfaces: A public API is a unified approach to data exchange. Ideally, it enables a plug-and-play scenario similar to the relationship between your phone and the thousands of apps in the App Store and Google Play.
  • Fines for blocking: To convince EHR companies that cooperation is in their best interest, penalties of some sort, e.g., fines, and a monitoring agency will have to be identified. Absent that, corporations will respond to their own DNA and continue working toward domination.

There are those in healthcare who consider information blocking by EHR vendors unethical, but ethics are beside the point in this conversation. There is more at stake than protecting competitive advantages because this is not a scenario to be viewed through the lens of traditional business.

Again, we are not talking about producing breakfast cereal. Viewed broadly, permitting information blocking to harm healthcare consumers might be akin to allowing corporate mergers to harm technology or entertainment consumers, except that good health is far more important than low costs for hundreds of TV channels.

The job of CMS and Congress is to consider the American people collectively.  When discussing interoperability, the financial goals and revenue projections of healthcare IT companies are no more relevant to CMS and Congress than is the profitability of pizza companies to the FDA. The goal must be to establish a network of incentives and penalties that yields a system in which patient care improves and costs decline. Anything that detracts from those goals should be set aside.

The good news – or perhaps the bad, if you represent a recalcitrant EHR vendor – is that in a final rule released last month, the ONC will have more oversight of EHRs and other technologies that store, share and analyze patient data. The rule also gives ONC the authority to ask developers to pull noncompliant products from the market.

With this final rule, the ONC has the power to decertify health IT products that don't comply with regulations or are found to pose “serious risks to public health or safety.” If ONC decertifies a product, the developer must notify affected customers and providers, and the ONC can also issue a cease-and-desist notice to prevent the future sale or marketing of the product.

It feels like this essential focus on technological cooperation is long overdue.  So, can we finally say, “Interoperability, here we come?”

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

Category: Interoperability

Is telemedicine the key to making addiction treatment work?

In a world where only the wealthy suffered from addiction, we wouldn’t have to worry so much about the effectiveness of treatment or who was going to pay for it.

But most people don’t live in Malibu or have access to Betty Ford, so efficacy matters.

Especially to insurance organizations, including the federal government, which have become increasingly more hesitant in recent years to pay for inpatient addiction treatment when it seems no one can demonstrate what actually works.

“Substance abuse providers generally have insufficient data to demonstrate the effectiveness of their treatments,” writes Health Data Management reporter Joe Goedert. “As a result, insurers are becoming highly distrustful of addiction treatment; and reimbursement amounts are falling as payers start to move to value-based contracting.”

The use of telehealth and telemedicine to track the effectiveness of treatment among those plagued by addiction is only the most recent trend in remote patient care. According to the American Telemedicine Association, about half of all states have passed laws mandating coverage by insurers of telemedical services. The legislation could prove useful to insurance companies and CMS if telemedicine provides better data on what works in treating addiction.

Map Health Management, a data analytics firm focused on behavioral health and addiction treatment, is working with insurers to determine effective treatment modalities and identify care providers that effectively maintain a relationship with patients after they leave the hospital. Telehealth / telemedicine offers a tool that both enables these efforts and makes them cost effective.

According to Map Health Management CEO Jacob Levenson, the effective use of telehealth technologies may be so important to effective addition treatment in the future that they become the dividing line between failure and success for providers.

“Some 30 percent to 40 percent of providers may not be in business within five years because they can’t adapt,” Levenson told Health Data Management.

Telehealth is one component in an innovative opioid treatment research project being conducted in Washington, DC. In a departure from the norm, the program is oriented around the practice of Edwin Chapman, MD, in partnership with Howard University’s Urban Health Initiative.

In this impoverished corner of the nation’s capital, Dr. Chapman’s patients in the study average 52 years of age and 10 years of incarceration. About 60 percent live with hepatitis C, 10 percent are HIV positive and all are long-term users of opioids, primarily heroin.

Chapman’s experience showed him that the opioid replacement buprenorphine effectively stabilized his patients’ addiction issues enough that they could face other life challenges so long as they had access to comprehensive care, including psychiatric services. While access to the opioid replacement was available, care and counseling were not.

So Chapman and Howard Professor Chiledum Ahaghotu, M.D., worked together to create the Buprenorphine Integrated Care Delivery Project model.

“I was looking to improve care for vulnerable populations, and to avoid an overutilization of [high-cost] resources,” such as emergency care, says Ahaghotu.

Thus, the project incorporates three essential components:

  • Comprehensive care coordinators work closely with both primary care and behavioral health providers to help develop patient-centered care plans.
  • A shared electronic health record platform across all providers delivers services to the patient. Patients consent to share their health data with various providers.
  • A telehealth program allows Chapman's patients to see him as well as a behavioral health specialist during the same office visit.

The entire project is funded by a four-year grant from Washington, DC’s, department of health and aims to reduce the cost of addiction treatment, which generally costs Medicaid roughly five times that of a typical Medicaid patient.

If the DC project and others like it prove effective in reducing incidences of drug relapse and lowering costs of treatment, you can be sure that the federal government and private insurers will notice and implement policies aligned with what works. Evidence suggests telehealth and telemedicine solutions will be a part of that overall solution. 

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

How do we balance civil liberties with treatment of the mentally ill?

In January of this year, political analyst Norman Ornstein lost his 34-year-old son, Matthew, to accidental carbon monoxide poisoning. While Matthew’s death was a tragic blow to family and friends, it was not the kind of out-of-the-blue shock that comes with absolutely no forewarning. Matthew, as Ornstein says in a New York Times op-ed published last month, had struggled with mental illness for 10 years, which contributed to poor decision making and his untimely death.

A resident scholar with the American Enterprise Institute and writer for The Atlantic and Washington Post, Ornstein says that perhaps the most difficult aspect of Matthew’s death was the inability of family and friends to help treat Matthew’s mental health challenges after he had his initial psychotic break.

“Whatever his illness … Matthew was particularly afflicted by one component of his illness: anosognosia, the inability of a person to recognize that he or she is ill,” Ornstein writes. “Since Matthew was over 18, neither family members nor professionals had any legal authority to get him treatment for the symptoms that kept him from living a stable life.”

Having a mentally ill child, as Ornstein describes, means living in constant fear the child will be injured or killed by police who are unaware of or misunderstand his condition. It also spawns semi-desperate visions of what Ornstein calls a “happy ending”—peaceful arrest followed by a compassionate judge mandating assisted outpatient treatment.

Matthew did not see himself as sick and was not perceived as a threat to himself or others, so there could be no happy ending.

There are, as a resident of or visitor to any American metropolis knows, millions of Matthews out there. According to the Treatment Advocacy Center, the U.S. has 3.9 million U.S. adults with untreated severe mental illness in any given year (1.2 percent of the population).

“The true insanity is that our laws leave those who suffer to fend for themselves,” Ornstein says.

Representatives Tim Murphy (R-PA), the House’s only clinical psychologist, and Eddie Bernice Johnson (D-TX), a psychiatric nurse, are sponsoring legislation with the goal of patching some holes in America’s mental health system, notably by expanding assisted outpatient treatment (AOT).

“The specifics of A.O.T. vary by state, but judges can order patients to undergo treatment while they live in the community instead of in prison or a hospital,” Ornstein writes in support of both the Murphy-Johnson bill and AOT. “It has been proven to reduce crime by or against those with illnesses, as well as suicide … In many states, families can petition the court directly based on the likelihood that their loved one has a grave disability or condition.”

As with all things mental health, the devil is in the detailed application of legislation and policy. No, AOT is not universally embraced. One need look no further than the responses to Ornstein’s op-ed to find those who respectfully disagree with his promotion of the strategy.

“The Murphy Bill is driven by fear and a poor read of the best evidence on what is helpful for people who experience psychiatric struggles,” writes Kendall (no last name given), a social worker from New York. “It dismantles [the Substance Abuse and Mental Health Services Administration] in its current form. It violates the civil liberties of those diagnosed with a psychiatric disorder without cause (it really should be IOT not AOT - it is involuntary not assisted).”

In many ways, the civil liberties concern Kendall mentions is the crux of this issue, so I want to be clear: I am not advocating the violation of anyone’s civil liberties. Legislation must be drawn up and put into practice with great care and deliberation.

But I think we must also question how and what civil liberties are appropriate for the mentally ill. How high a priority is self-determination for people effectively locked up in their mental illnesses?

As reported in a New York Times story on a controversial New York State law, Michael and Barbara Biasotti watched their mentally ill daughter in her 20s cycle in and out of hospitals and treatment programs while engaging in all kinds of other risky and dangerous behavior. The Bisasottis got a court order compelling treatment under what’s called Kendra’s Law, so named for a woman who was pushed onto New York City subway tracks in 1999 by a schizophrenic man.

“I really don’t think she would be alive” without it, Barbara Biasotti told the Times. “And we don’t know if she would have taken a couple of people with her.”

Living in San Francisco, I see dozens of people each week like the Biasottis’ daughter. Some are lucid and conversational; many are clearly unable to provide for their own needs. Should my concern be for the civil liberties of these individuals, my fellow citizens? Or should my empathy be for other human beings plagued by a sickness for which they are incapable of seeking help? Can I find a balance between the two?

It is important to recognize that those who argue on behalf of civil liberties make a noble and worthwhile point.  But we are faced with a scenario in which the mental health system is broken to such an extent that inaction is not an acceptable response.

Action in the form of early intervention probably saved the life of Tiffany Martinez when she started to experience symptoms as a college student of the same schizophrenia her father suffered. Early intervention programs surround the patient with enough support and counseling to turn a debilitating disease into a manageable condition.

"If you can get at [mental illness] early enough, before it becomes too severe, there is a very good chance that the person will recover, which is just very, very exciting," Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, told USA Today.

But how do we get to the not dangerously ill early without some kind of compelling event, especially when they are adults and courts can’t or won’t act on the experiences of family?

“Here is the Kafkaesque irony: Far from respecting civil liberties, legal obstacles to treatment limit or destroy the liberty of the person,” wrote author and consultant Herschel Hardin in 1993. In addition to serving on the board for Canada’s Civil Liberties Association and working with Amnesty International, Hardin had a schizophrenic child. “Medication can free victims from their illness—free them from the Bastille of their psychosis—and restore their dignity, their free will and the meaningful exercise of their liberties.”

Of course, AOT is only one component of the Murphy-Johnson legislation, even as it is probably the most controversial. Earlier versions of the bill included provisions for expanding federal subsidy of electronic health record purchase by mental health facilities. Those sections were stripped out in committee, leaving hospitals and clinics to fend for themselves in acquiring the kind of technology that enables ER docs to know immediately when someone with a mental illness walks through their doors.

Perhaps expanded AOT and early intervention could have saved Matthew Ornstein, or perhaps it can save the next troubled son or daughter. Some kind of compelled treatment may have been the unmet holiday wish of the Ornsteins last season. So this Christmas, it is my wish that Congress act in some way to stem the tide of untreated mental illness in America.

While not perfect, the Murphy-Johnson bill is the most significant mental health legislation considered by Congress in decades. It has the potential to make Christmas 2016 much brighter for some family that this year is desperate for help. 

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

Can your hospital benefit from e-prescribing?

On the face of it, the use of computers to order prescriptions seems like a no-brainer. Who, after all, is capable of reading a physician’s handwriting?

But if we set aside clichés, there is still this question: Does e-prescribing provide distinct benefits over handwritten patient prescriptions? With acknowledgement of some drawbacks, it would seem the scales tip decidedly toward e-prescribing as a net positive.

E-prescribing Benefits

Electronic prescriptions help keep patients focused, according to a Health Management Technology (HMT) report on a 2012 Surescripts study that found a 10 percent uptick in “medication adherence” to prescriptions filed electronically.

“The Surescripts analysis is an important contribution to a growing body of literature on e-prescribing and on medication adherence,” Harvard Medical School’s William H. Shrank told HMT. “In a huge study, they have shown a clear link between e-prescribing and first-fill medication adherence.”

According to the World Health Organization, roughly 50 percent of patients globally don’t follow their prescription regimen, resulting in 125,000 preventable deaths and billions of dollars in unnecessary healthcare costs. Surescripts estimates that more rigorous commitment by patients to taking medications could create between $140 billion and $240 billion in savings and better outcomes.

Perhaps the most obvious benefit of e-prescribing is the one initially referenced—improved legibility. According to research conducted in two Sydney, Australia, hospitals and reported on by PLOS Medicine in 2012, this is one component in a broader patient safety benefit.

Using hospital wards with no e-prescribing as controls and separate e-prescribing wards as test subjects, the researchers identified “statistically significant” error rate reductions of 66.1 percent and 60.5 percent as a product of “a large reduction in unclear, illegal, and incomplete orders.” More importantly, the bulk of the improvement came from reductions in “serious errors” as opposed to what the study calls “clinical errors” of less significance and potential impact.

Additional analysis by Surescripts shows cost savings as a result of fewer adverse drug events and patient readmissions, as well as reductions in unnecessary staff hours, can range from roughly $100,000 annually for a small hospital to over $1 million for a very large inpatient facility.

A 2013 study published in U.S. Pharmacist concluded that e-prescribing’s benefits (lower overall costs, better access to prescription records, improved workflow, time saved on verifying handwritten orders, access to patient insurance information) outnumber costs: difficulty of fixing incorrect orders, problems with software design, prohibitive software purchase and start-up costs.

“It is anticipated that, with continued advances in technology, these problems will be resolved and e-prescribing will yield more benefits than risks for patients, providers, and pharmacists,” write the U.S. Pharmacist authors. “Utilization of technologically advanced e-prescribing software is projected to improve pharmacy workflow and efficiency while reducing prescribing errors, and to ultimately enhance patient safety.”

E-prescribing also gives hospitals and physicians a tool in America’s current surge of opiate addictions and deaths. So alarming has been this trend that the state of New York has mandated the use of e-prescribing by 2016. Already, New York reports a decrease of 75 percent in “doctor shopping,” the practice, usually by addicts, of going from doctor to doctor to obtain prescriptions for controlled substances.

Currently, only New York and Minnesota require electronic prescribing, even while the potential benefits to individual patients with addiction issues has been apparent to many physicians for some time.

"I had an example last fall of someone getting Ritalin from 16 doctors. I spent a half hour on the phone with him, that day, and I then called a psychiatrist from whom he'd brought the letter saying he had ADHD symptoms,” Texas physician Matt Weyenberg told Dana Blankenhorn of ZDNet Healthcare. "The doctor asked how I figured it out. I said with my Electronic Medical Record (EMR), and he said what's an EMR."

E-Prescribing Considerations

So, what should a healthcare organization consider in implementing an e-prescribing solution? For most hospitals, e-prescribing decisions will be made in the context of acquiring an electronic health record (EHR), which is a serious and extensive process. Part of that process includes engaging with a health information network provider that connects hospitals and pharmacies.

Hospital administrators and leading physicians should ask themselves questions about an e-prescribing solution AND a prospective network provider when looking at EHRs.

  • Will clinicians use the e-prescribing solution? Meaningful Use Stage 2 requires that 50 percent of all prescriptions be sent electronically. Unwieldy systems give clinicians reasons to not use them.
  • Is the information network secure? Ask questions about system and network security. The use of VPN and SSL network technologies to meet HIPAA requirements should be part of the discussion.
  • What do the pharmacies we work with use? Check with the external pharmacies you currently engage with to determine which information network they currently use.
  • Are there transaction fees on the network? As with any transaction, ask questions to find out where additional fees might be hiding.
  • How do we introduce e-prescribing to patients? Especially with older patients, e-prescribing may be a source of some insecurity because they don’t get an actual paper prescription. Take the time to explain how it works and perhaps, at least initially, give them something to take to the pharmacy with them.

Even while there is considerable consternation and debate about the efficacy of EHRs, the value of e-prescribing functionality has become more readily apparent to physicians, hospitals and health systems.

According to Persistence Market Research, the e-prescribing global market, valued at $250.3 million in 2013, is expected to grow 23.5 percent annually to 2019 and achieve an estimated value of $887.8 million.

“Thanks in large part to two federal initiatives – first the Medicare Improvements for Patients and Providers Act of 2008, or MIPPA, and later meaningful use – e-prescribing has made huge gains through the first quarter of 2014,” Mike Miliard of Healthcare IT News writes about an Office of the National Coordinator (ONC) report. “Using data from Surescripts, the nation's largest e-prescription network, the study shows a steep and steady climb for eRx – from 7 percent in 2008, when MIPPA was passed, to 24 percent in 2011, when meaningful kicked off, to 70 percent today.”

In all likelihood, your healthcare facility’s e-prescribing decision will be one component in a more extensive health information technology strategy. Talk with colleagues outside your immediate sphere to see what they’re using and how they feel about it, or spend some time with a consultant to learn more about all your options.

D'Arcy Gue is Vice President of Industry Relations for Phoenix Health Systems - a division of Medsphere Systems Corporation. 

Can technology transform mental health care?

Any conversation focused on what’s great about America usually includes a mention of optimism, hopefulness or some variation on the theme.

Americans generally still believe in a brighter future, and especially the ways in which technology can enable that future. But that sense of optimism contains a kernel of potential disappointment when we ask technology to do too much.

Consider the case of mental health care, a profession that faces significant budget shortfalls.

According to Robert Glover, executive director of the National Association of State Mental Health Program, from 2009 to 2012 states cut roughly $5 billion in mental health services and eliminated about 4,500 public psychiatric beds. As with all of healthcare, mental health is using technology to try and fill economic gaps.

Of the roughly 40,000 health apps available for smartphone, there are about 800 apps oriented around mental health. So, if the key to effective therapy, as most professionals argue, is human interaction, can apps provide any benefit at all? According to David Mohr, professor of preventive and behavioral medicine at Northwestern University, the answer is yes.

“A large body of clinical research shows that web-based and phone applications can treat depression and anxiety,” writes Mohr in the New York Times’ Room for Debate opinion page. “To be effective, behavioral intervention technologies (B.I.T.s) require repeated use over a number of weeks — an obstacle because many people with depression or anxiety have trouble staying engaged long enough to make substantial improvements.” 

That last part seems relevant and important. If technology shortens attention spans and perhaps makes us less patient, then mental illness would seem to exacerbate that scenario.

“Immersing myself in a book or a lengthy article used to be easy,” writes Guy Billout in his landmark 2008 Atlantic essay “Is Google Making Us Stupid?” “That’s rarely the case anymore. Now my concentration often starts to drift after two or three pages. I get fidgety, lose the thread, begin looking for something else to do. I feel as if I’m always dragging my wayward brain back to the text. The deep reading that used to come naturally has become a struggle.”

Studies focused on the use of health apps, the overwhelming majority of which deal with diet and exercise, suggest guarded optimism and unmet potential. In the popular technology vernacular, there is no ‘killer app.’

“These findings suggest that while many individuals use health apps, a substantial proportion of the population does not,” write the authors of a recent study on health app use in their abstract conclusion, “and that even among those who use health apps, many stop using them.”

The idea of staying engaged—of coming back again and again to ideas and ways of thinking that alter perspectives and patterns—seems essential to improved mental health. (Mohr says as much when he references “repeated use over a number of weeks.”) But technology seems to create the exact opposite—detachment instead of engagement.

“One of the most significant problems with apps is the high attrition rate: People begin using them but often tire of the required dedication quickly,” writes Matthew Hertenstein, an associate professor of psychology at Depauw University, in the same New York Times Room for Debate op-ed. “More important, using an app doesn’t allow individuals to deeply connect to other humans – be they therapist or friend.”

That deep connection is crucial because, as Galit Atlas, faculty in NYU’s postdoctoral psychotherapy and psychoanalysis program, says, “Psychological pain, including depression and anxiety, emerges largely in response to problematic human relations and traumatic history, and it is healed through a human relationship.”

While smartphone apps may not provide that human bond, they may still prove useful to mental health professionals because they track our every movement. Writing for thedoctorweighsin.com, John Torous and John Sharp, both physicians associated with Harvard University, suggest that smartphones may be a great source of “passive data” on patients struggling with depression.

“The symptoms of depression can vary greatly between people and are made even more complex by other co-morbid psychiatric conditions … Sometimes worsening depression can also cause cognitive changes so that those suffering do not fully realize the extent of the illness or their symptoms.”

Contrast the perspectives on mental health apps with those related to telemental health, the use of telecommunications technology to make mental health services available where few professionals reside. The National Institute of Mental Health reports that half of U.S. counties have no mental health professionals even while the Affordable Care Act’s insurance mandates make mental health care more readily available.

According to an article in Behavioral Healthcare, “… patients surveyed have consistently stated that they believe telemental health to be a credible and effective practice of medicine, and studies have found little or no difference in patient satisfaction as compared with face-to-face mental health consultations.”

With telemental health, the technology does not seem to be an obstacle. In some ways this seems intuitive. We probably all have the experience of establishing or prolonging strong relationship bonds through technology. Decades ago, a weekly phone call with distant relatives re-established emotional connections. Now, a video chat on Skype bonds service men and women to families back home. Can’t a similar relationship be built through regular interaction with a therapist? According to a five-year study of telemental health at the VA, the answer is yes.

And then there are electronic health records (EHRs), by comparison a venerable technology available for mental health care that proliferates in acute care thanks to federal Meaningful Use stimulus. No, EHRs don’t give patients an electronic tool with which to heal themselves, if such a thing is possible. They don’t readily connect patients who live where there are no psychiatrists and psychologists to professionals where there are many.

But interoperable EHRs do tell an emergency room doctor that the guy who just walked in with a broken arm also suffers from bipolar disorder and might be off his meds. They connect members of a treatment team and save them the hassle of having to assemble paper notes. They make it easier to know what coverage a patient has and what his insurance company will pay for.

Most importantly, given the frequency of co-morbidity in mental health patients, EHRs are the technological enabler of coordination across the continuum of care with the patient and patient’s family at the center. It will be difficult to transform the care model and access relevant and timely information without EHRs.

Our relationship with technology is not unidirectional. We use it, and it changes us. But it cannot alter fundamental realities regardless of how hopeful Americans are or how much faith we have in it. More and better technology is not a substitute for adequate funding and coordinated planning, especially when we’re talking about the very significant funding issues around behavioral health.

Sure, we can get excited about the newest app and the latest EHR functionality, but we must also maintain a focus on meeting the needs of the mental health professionals committed to keeping our fellow citizens from falling through the cracks.

Even while there is no magic in technology, there is also no reason to believe we can’t fix a broken mental health system through hard work, empathy and thoughtful planning. Time and again, our faith in those principles has been rewarded.

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

Four Reasons for Optimism about the Ongoing Health Care Overhaul

None of us would have the jobs we currently occupy without some ability to focus on details. Running a company, developing IT systems, managing a hospital, seeing patients and evaluating their concerns—all require the ability to dig deep and identify root causes and effective solutions.

But maybe that focus on the trees blinds us to changes in the forest, to use a well-worn aphorism.

With that broader perspective in mind, I’d like to suggest four reasons for optimism as we continue to move through this wholesale experiment in tinkering with the health care system of a large and diverse nation.

Accountable Care is the way of the future.

The last week of August, CMS released numbers for the 333 Medicare shared savings program (MSSP) ACOs that both Healthcare IT News and Health Data Management characterized as disappointing.

Looking at the numbers, I understand why. In 2014, a modest 92 of 333 reduced spending enough to qualify for financial incentives; in total, those 92 reduced spending by $806 million and earned $341 million in reimbursement. (An additional 89 were able to cut costs, but not enough to qualify for payout.) The modest numbers give rise to concern because Track 2 of the program would create a scenario where ACOs might have to reimburse CMS if they cannot cut costs further.

So, why am I optimistic about ACOs when most have been unable to significantly reduce costs? Because the program is trending significantly in the right direction. Examples:

  • No MSSP ACO in Track 2 of the program had to pay CMS in 2014.
  • The savings numbers for last year (recall that 92 ACOs reduced spending by $806 million) are notably better than in 2013, when 538 ACOs created $315 million in shared savings.
  • Of the ACOs that have been in the program since 2012, 37 percent generated shared savings compared with 27 percent for those that entered in 2013 and 19 percent in 2014.
  • The ACOs that reported in both 2013 and 2014 improved in 27 of 33 measures of quality care.

The ACOs that have been doing it for longer are getting better at improving care and cutting costs. The odds of a replicable care model coming from the collective experience of these organizations seems pretty good. And if the fact many have not met CMS standards seems discouraging, keep in mind that CMS has the flexibility to adjust timeframes and measurements moving forward to recognize where the model is working and how it offers promise.

HIE participation is increasing.

According to the ONC, 96.9 percent of hospitals reported using a certified EHR system in 2014. We are almost at EHR saturation among hospitals, meaning the infrastructure is in place for wholesale data exchange. Evidence of this is the fact 76 percent—a number that has been rising since 2010—reported record exchange with external ambulatory care providers and other hospitals.

What remains are the technical, operational and financial issues that keep full interoperability from occurring. These technical issues can be eliminated with time and energy. The operational issues will probably have to be overcome with ingenuity, cajoling, negotiation and hopefully only a small amount of manipulation and public shaming.

Much has been made of the obstacles to interoperability, but I’m no longer of the opinion these are insurmountable so long as we operate with close to complete information, the key to an open and balanced marketplace. Information proliferation and the attending response caused one large EHR vendor to dramatically reduce file transfer fees. It has caused one former hospital CEO to allege antitrust violations by the same EHR vendor and a major client.

Sunshine is the best disinfectant. Vigilance is still necessary, but I think faith is warranted.

Open-ended premium pricing for EHRs is coming to an end.

According to recent analysis by IDC Health Insights, the Department of Defense’s selection of Leidos and Cerner will have “significant” impact on the EHR marketplace.

“IDC Health Insights expects that the impact of this award will be significant because it will end a period of open-ended and premium pricing for EHR that to date has been largely driven by government incentives but which in the future will be driven by calculations of business value and return on investment (ROI).”

While pricing analyses vary, IDC Health Insights believes the overall Leidos / Cerner bid was considerably less (this says nothing about what it ultimately will be) than that of IBM / Epic, making untenable the argument that taxpayers could recoup the investment in a higher priced EHR platform. Additionally, the IDC report says “Cerner will gain competitive traction at Epic's expense,” and the DoD selection demonstrates a focus on interoperability and open architecture.

Of course, IDC is only one firm. What might bring more pressure to bear on EHR pricing is providers and hospitals taking on more direct financial risk for patient outcomes. When readmissions become more costly, one-off Epic and Cerner implementation projects really are unsustainable.

Behavioral health is finally a priority. Really.

We can’t really modify and improve the health care system in America if we continue to pretend like mental illness is not an essential component in that overhaul. Legislation making its way through both houses of Congress seeks to raise the visibility of mental health in the overall care system.

Representative Tim Murphy (R-PA) is back in the House with his Helping Families in Mental Health Crisis Act, reintroduced this past June. Joining him in the Senate is Chris Murphy (D-CT), who recently introduced the Mental Health Reform Act of 2015.

While neither bill has been approved, both legislators are already coordinating on what a final bill sent to the entire Congress for approval might look like.

If a final bill is endorsed by Congress, at least some credit will go to a heightened focus on mental health in the media. In recent months, the Washington Post reported that in 44 of 50 states and the District of Columbia, the largest corrections facility (prison or jail) holds more mentally ill persons than the state’s largest psychiatric facility. Early this summer, The Atlantic published a lengthy expose of Cook County Jail as America’s largest mental health facility.

Morally, America is failing the mentally ill. Importantly, from a utilitarian perspective, we’re paying a high financial price for doing so. Anecdotal factors seem to indicate a greater awareness of those concerns. Keep your fingers crossed.

To be sure, there are valid statistics and perspectives with regard to each of these four areas that suggest a less rosy outcome. You’ll have no problem finding physicians and hospital administrators who think Meaningful Use and other health system fixes are an unmitigated disaster.

And I will certainly admit that there is tremendous room for improvement, but I believe that improvement will happen. I believe we have the intelligence, fortitude and ethical grounding necessary to make necessary adjustments.

Change is happening. It will not soon, if ever, be halted. So, I ask you, is there not some aspect of health care overhaul you can get behind and constructively support?

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

FHIR will not save us. We need national patient identifiers.

Graham Grieve is a data architect who thinks like a mountain climber.

“You build a mountain, you stand on top of it and see a bigger mountain that you can go and stand on top of,” Grieve said in an interview with HIStalk. “The urgent need to build bigger mountains never goes away. We’ll just keep climbing up the stack towards a useful system.”

Setting aside the idea of “building” mountains, Grieve is describing something very familiar to seasoned hikers and climbers—a false summit. When you are so close to the mountain, and we are all so very close to health IT and the constant interoperability updates, it’s impossible to see the higher peaks in the distance.

Which begs the question: When will we summit this range?

“Each mountain is about a 10 to 15 year building process,” Grieve says. “That’s how it has gone historically.”

In other words, we probably can’t even see the next peak from where we’re standing, the initial false summit still looming above us.

In his conversation with Mr. HIStalk, Grieve makes a compelling argument for modifying expectations, working diligently and putting all the pieces in place to ensure future success.

For example, Grieve is working on HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification enabling EHRs to exchange information. If you’re one of the many that hope FHIR becomes healthcare’s silver bullet, Grieve would like you to rethink that expectation.

“There’s people out there who think that with FHIR we’ve solved all the problems,” he says. “We haven’t, because we’re not authorized to solve lots of the problems.”

Primary among these other problems is the lack of a single patient identifier via a Master Patient Index (MPI) for use across the American healthcare system. Quite simply, FHIR alone is not a fix.

“Yup. MPI is unavoidable,” Grieve told Forbes blogger and author Dan Munro, whose analysis of interoperability and MPI is highly valuable and relevant (see, for example, automobile industry reference and link below). 

And why don’t we have MPI in place already? Because in 1998, long before interoperability approached Kardashian-like frequency on the Internet, Congress passed and President Clinton signed a law forbidding federal funding of any effort to create national patient identifiers. This was two years after Congress mandated the creation of a patient identifier when they passed HIPAA.

(Staying with the mountain metaphor, one might believe the two years between legislative acts were the peak of health IT lobbying and campaign contributions.)

As we all know, incentives for EHR adoption have expanded the use of health IT platforms to somewhere in the neighborhood of 75 percent. But with few standards for exchanging patient data, we’ve created silos of patient information and a system that still benefits just about everyone in it more than the patient. Health IT vendors have enriched themselves with tax dollars. Hospitals are using EHRs to keep patients from going elsewhere and gobbling up small physician practices. Status quo incentives remain for influential segments of the overall health IT marketplace.

As former hospital CEO and THCB blogger Paul Levy wrote, “We’ve been swindled.”

And it’s not like this kind of situation is completely new. People are not cars, to be sure, but a similar scenario endured until 1981 in the automobile industry. Chaos convinced the National Transportation Safety Administration (NTSA) to implement the national Vehicle Identification Number (VIN) system to more effectively track thefts, accidents, damages and recalls. The use of VIN numbers also makes businesses like CARFAX possible.

It’s clear that VIN numbers enabled the NTSA to more actively and accurately track the sale and registration of autos. It’s also clear that automakers had no financial incentive to resist the national standard other than to avoid accurate tracking of defects that could put driver safety at risk, making VIN implementation as much a moral issue as anything else.

National schemes? A moral component? Congressional discretion? That scenario should sound familiar to you.

Indeed, as quoted in Bob Wachter’s book The Digital Doctor, UCSF Medical Center CIO Michael Blum called Congress’s failure to establish a universal patient ID “the biggest single failure in the history of health IT legislation.”

“Our national interest does not coincide with those corporate strategic interests,” says Levy.

In other words, what patients lack is an organized lobby, which is unfortunate since it seems that all roads on the health IT progress roadmap eventually lead back to Congress.

“There’s a number of industries where they have data sharing arrangements of one kind or another,” says Grieve. “Those things are possible and they work to some degree. They need some kind of governmental interference or mandate to make them happen. Very often, most of those industries wouldn’t go back to the chaos they had before.”

This is disconcerting. On the one hand, the current Congress is passing legislation like the 21st Century Cures Act that mandates interoperability without mandating a certain standard. On the other, a previous Congress avoided the responsibility of creating the prerequisite for interoperability in a national patient identifier.

“Standards arise in a broken market,” Grieve told HIStalk. “We’re trying to move the market to a better, stable place.”

We have one prerequisite—a broken market. We need Congress to implement the other—a national identifier. Yes, an adoptable data exchange standard like FHIR is necessary, but without a national patient identifier it is not sufficient. Until then, every goal we achieve in the foreseeable future will be a false summit. 

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

How can we commit to better mental health care right now?

Restoring lost beds, expanding health IT incentives and rapidly embracing ACOs are steps forward in addressing America’s mental health crisis

Chances are good someone close to you is suffering from a mental health disorder right now.

You may not know it. While paranoid schizophrenia is pretty obvious, major depression can be hidden during periodic interaction.

The Centers for Disease Control estimates that 25 percent of Americans have a mental illness, and almost 50 percent will face at least one mental health challenge at some point in their lives. The U.S. Department of Health and Human Services says 8 percent of Americans could benefit from drug or alcohol treatment.

These are eye-opening figures that most outside the mental health community probably don’t know about. Here are some more.

  • Annually, about 38,000 Americans take their own lives, and 90 percent of those suicides are related to a mental health issue, according to National Institute of Mental Health (NIMH) Director Thomas Insel.
  • According to Health Affairs, two-thirds of primary care physicians are unable to find a mental health professional to care for their patients after diagnosis.
  • Robert Glover, executive director of the National Association of State Mental Health Program Directors, says that from 2009 to 2012 the states cut roughly $5 billion in mental health services and eliminated about 4,500 public psychiatric beds.
  • Estimates by the Department of Housing and Urban Development show a total homeless population nationwide of 650,000. Homeless advocacy organizations suggest the total may be as high as 3.5 million.
  • 2012 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that almost 40 percent of adults with severe mental illnesses (schizophrenia, bipolar disorder) received no treatment in the previous year; among those with any kind of mental illness, 60 percent went untreated.
  • The largest mental health facility in America is Chicago’s Cook County Jail, where, according to a recent Atlantic article, officials estimate as many as 33 percent of inmates have some kind of mental illness.
  • Estimates suggest as many as 590,000 people annually end up in America’s de facto mental health system: jails and prisons, streets and homeless shelters, the morgue.
  • According to Insel and NIMH research, mental illness costs America about $444 billion a year, with a third of that going to medical care and the majority to disability payments and lost productivity.

We all tend to walk around the homeless in big cities because we don’t know what to do, but these anecdotal experiences also tell a tale. The chronically homeless, those who don’t show up at shelters and soup kitchens to be counted, have completely fallen through the societal cracks. They are apparitions on corners and in doorways, like Dickensian ghosts sending a message we don’t much care for.

I could add more bullet points to this list above, but you get the idea. And, no, I am not suggesting the solution to each of these problems is the same. I am suggesting that the solution is to treat mental health as one component in overall health and start to develop a legitimate mental health system. It can happen on the state level, but those states need to share data or we end up with silos and ineffectiveness.

And the federal government must get involved or there simply is not enough money to make this happen. The feds are certainly aware of America’s converging mental health challenges, but in many ways they seem more interested in measuring than addressing them. Greater scrutiny of records and treatment plans is becoming the norm with regard to Medicare and Medicaid, putting strain on fractured and mostly paper-based inpatient mental health facilities.

So, what can we do right now to start to grapple with America’s looming mental health crisis?

  1. Restore the psychiatric beds lost during the economic downturn: Most states cut budgets during the recent recession, which hit mental health facilities particularly hard. Tax revenues are starting to tick up, but the federal government will probably have to get involved through block grants or other incentives to bring the beds back online. This effort must be coordinated with local law enforcement so we lessen the number of disturbed people in jails and instead send them to a place where they can get treatment.
  2. Push the Accountable Care Organization model: Currently, ACOs are happening through the Affordable Care Act. In the event the ACA goes away, the idea behind ACOs should be pursued by other means. Because ACOs are responsible for the entire patient, not just that deep cut or broken finger, there is a pathway for treatment of mental health and addiction challenges. This is the future model for American healthcare, and we’re not getting there fast enough.  
  3. Expand health IT incentives to mental health care: Reporting requirements for mental health facilities are getting more stringent, and yet most are still managing with paper records. Without Medicare and Medicaid reimbursement, many mental health and addiction facilities will go under, leaving even fewer beds available. If we believe that computers are a benefit with physical and surgical care, then they are also a benefit with mental health care.  
  4. Make parity work: Yes, federal legislation requires that insurance companies cover mental health on par with physical health IF the policy includes it. But parity legislation has not achieved its goals because there is no agreed upon definitions of adequate mental health care between insurance companies and caregivers. There is also the question of whether or not insurance should include mental health care. If almost half the country will need the care in a lifetime, why are we excluding it? 
  5. Build public transitional housing: Cities are finding that building apartments and staffing them with nurses is cheaper than rolling out emergency services every time a homeless person requires care. The chronically homeless—those with debilitating illnesses like bipolar disorder and schizophrenia—can be treated and monitored in an apartment complex.
  6. Outreach, outreach, outreach: The military and VA are working to locate, educate and treat veterans, but it’s not nearly enough. Only 72 percent of Iraq and Afghanistan veterans were employed in 2013, according to government statistics, exacerbating the tendency to drink. Public service campaigns encouraging corporations to give to mental health organizations would also be helpful. Billions go into cancer research every year, and a fraction of that is donated to mental health, despite the crippling impact on productivity mental illness has.

What none of these efforts alone can do is remove the stigma of mental illness—the myth that instability is manifest weakness. Government and corporations cannot engineer a more compassionate, understanding society. That part starts with each of us as individuals making choices.

However, if we, as a society, can succeed in treating the mentally ill, the stigma can disappear all by itself because we will have overcome the mental health challenge. Our fellow citizens are depending on us.

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

 

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