Meaningful Use

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.

MIPS impacts how doctors get paid. Are you ready?

The April 2015 signing by President Obama of the Medicare Access and CHIP Reauthorization Act (MACRA) effectively changed the healthcare game for individual clinicians working in physician practices. The MACRA legislation repeals the existing Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new Quality Payment Program (QPP) with two tracks: The Advanced Alternative Payment Models (APMs) and the default Merit-based Incentive Payment System (MIPS). A new Medsphere resource takes a closer look at MIPS, which will subsume existing EHR incentive programs.

While the popular misconception is that MIPS has replaced Meaningful Use, this is far from the case. How, then, are things different with MACRA and MIPS? The biggest change is that MIPS effectively alters performance measures for payment reimbursement related to EHR use as outlined via four categories:

  • Quality
  • Advancing Care Information (ACI)
  • Clinical Practice Improvement Activities (CPIA)
  • Resource Use

The Centers for Medicare & Medicaid Services (CMS) measures physician performance in each category and compares it to a predetermined national performance threshold. Data is then used to make adjustments to Medicare Physician Fee Schedule (MPFS) payments, creating incentives for those who score above the national threshold and penalties for those who score less.

Do you know what you need to know to ensure high scores, proper reimbursement and incentive payments? 

Click on MIPS to access Medsphere's resource and learn more about the new federal regime.

Patients are consumers, too. Your portal strategy should embrace both.

Patient engagement is easy, right? Just create a portal and tell patients it’s there.

Of course, no one who puts a little thought into this idea believes it can be so simple. Healthcare isn’t “Field of Dreams,” after all. We can build it. They still might not come.

But we still need to try and understand why, as this 2014 Health Affairs study found, the increased use of EHR technology has not created a parallel increase in electronic communication among patients and clinicians. In short, if patient portal use is an accurate indicator, how do we get patients engaged and hold their attention?

One key issue might be that we’re not in agreement on what patient engagement is and what it is not.

“Although highly supported by technology and its significant innovative leadership contributions, patient engagement is not an IT, HIT, regulatory, or vendor-driven initiative, but rather it is a patient-facing, patient driven strategy,” writes UPTONGROUP President Richard Upton on the KevinMD blog.

Patient engagement, says Tom Giulianni, MD, is not the same as a patient-centric model, which would certainly employ a patient portal to enable certain tasks, but it will also do a lot more.

“There are lots of other little things a practice can do to provide a positive experience that makes them want to come back and helps them feel more engaged in their own wellness and can even improve outcomes,” Giulianni says in The Health Care Blog. “This consumer-like experience is really what patients want not just a portal.”

Think, for a moment, about your relationship as a consumer with other businesses. You get order confirmations and delivery emails when you buy something from Amazon and other online retailers. Special offers and requests for feedback on your customer experience appear in your inbox. Online sites regularly upgrade functionality and user options to your benefit.

Chances are, the relationship you have with your physician resembles none of these.

This enhanced idea of patient engagement often includes the concept of patient as consumer for very logical reasons. In 21st century America, we are all consumers to a greater or lesser extent. We expect commercial enterprises to earn our business and make us feel valued. Technology simply strengthens this expectation.

But healthcare and medicine are not the same thing as selling books online. The patient-as-consumer idea also divides providers, as the following examples demonstrate.

Shirie Leng, MD, writing on the KevinMD blog, says patients are not customers, offering these points:

  • Patients are not relaxed, having a good time and simply comparing available options.
  • Patients often have not chosen to buy a healthcare service and are not paying for it.
  • Patients are not buying a product from which they can demand a positive outcome.
  • The patient is not always right.
  • Patient satisfaction does not always correlate with the quality of the product.

Contrast that stance with the position of David Lee Scher, MD, who argues that, especially with the advance of healthcare IT, patient engagement means consumer engagement for five reasons:

  • Patients have choices.
  • Patient satisfaction counts.
  • All stakeholders in healthcare are looking for market share.
  • Mobile health technology success hinges on social engagement.
  • Most mobile health technologies are patient-facing.

They’re both right. I mean, look at each set of bullet points and imagine a scenario in which it is true. It’s not hard. Some patients have choices and some do not. Some have mobile health technologies, as Scher mentions, and some do not.

“Sometimes we view ourselves as patients, including when we await surgery for an acute, inflamed appendix,” writes Robert Pearl, MD, in a Forbes magazine piece that effectively captures the conflicting personas we’ve all embodied at various stages in the healthcare experience. “And at other times, such as when we compare the costs and benefits of different health insurance plans, we’re clearly consumers. But most of the time we are both.”

So, is it possible to come up with a universal definition and a set of recommendations for patient engagement? No, not really. The definition will depend on the provider, the facility and the patient/client base seeking treatment/services.

Still, most providers can up their game. Hospitals and physician practices need to explain how patients benefit from a patient portal, then make it easy to enroll in and use it. Clinicians can promote portal usage to each patient on every visit. Administrators should establish policies that define message response times, test result release times and internal processes for routing messages and responses.

Because patient portals aren’t currently wowing anybody, healthcare IT has to up its game, too. For starters, polling data shows patients want the ability to schedule appointments, pay bills and view records online. Make that the functional starting point. In a broader sense, healthcare IT vendors also have to make EHRs and portals more straightforward and easy to use.

Think of the patient portal as a tool, because that’s all it is, in a broader patient engagement strategy. Yes, the tool has to be functional, but it also has to be used correctly.

As Shahid Shah explains in Healthcare IT News, in some ways EHRs have to resemble customer relationship management (CRM) tools (think Salesforce) and “… support outreach, communication, patient engagement, and similar features we're more accustomed to seeing from marketing automation systems than transactional systems."

The comparison seems apt, especially because CRMs and other marketing and sales-enabling tools don’t close deals, they just make it easier to organize and find information, much like an EHR.

In the end, the implementation of EHRs, changes in payment models, the emergence of new concepts like medical homes and accountable care organizations—all are efforts to move toward healthcare based on quality instead of services and fees. If quality is the goal, then patients are going to evaluate that quality, and in the new paradigm you want that evaluation to be positive.

Can we engage people through the patient portal in a way that appeals to them as both consumers and patients? The lack of strategy for appealing to both personas could prove the difference between the success and failure of portals and other patient-facing technologies.

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

How will the new rule on EHR pricing and transparency affect you?

One requirement of the 2014 Final Rule on Health Information Technology is for pricing transparency and disclosure. Certified electronic health record (EHR) vendors have been required to disclose any “additional types of cost that an EP (eligible provider), EH (eligible hospital) or CAH (critical access hospital) would pay to implement the Complete EHR’s or EHR Module’s capabilities in order to attempt to meet meaningful use objectives and measures.”

The rule has not required public disclosure of an actual price but instead information about the types of costs that might be incurred: Is there a one-time fee? A recurring cost? Both? For what features or services? Providers and hospitals should not encounter “unfair surprises” that materially affect their ability to meet Meaningful Use. The 2014 pricing transparency rule has only required disclosure of the various types of costs that would be encountered in the process of demonstrating Meaningful Use with a Complete EHR.

This requirement was recently expanded “to require greater and more effective disclosure by health IT developers of certain types of limitations and additional types of costs that could interfere with the ability to implement or use health IT in a manner consistent with its certification.” The revised rule, finalized in October 2015, expands the transparency statement. Costs that must be disclosed are not just those the user “would” pay to try to implement MU. Now, vendors must also address costs the user “may pay” to use the system within the scope of certification, as well as limitations the user might encounter.

The pricing transparency statement is pretty easy to understand, which is good since nobody likes costly surprises. But what are these “certain types of limitations” that the 2015 rule mentions? Shouldn’t the fact that a product is certified be the final word on meeting MU requirements? The final rule contains an example “scenario” that clarifies what sorts of limitations inspired this wording.

In this scenario, just suppose that a vendor of an EHR implements the capability to meet the Transitions of Care objective by sending secure messages with CCDAs attached. And suppose that the health information service provider (HISP) that connects this EHR to others is run by the EHR vendor. And suppose that the vendor chooses to only connect to other hospitals and providers who run that vendor’s EHR – and transmits those messages for free. In this scenario, connecting to another vendor or network is costly, if it is even possible -- and then there is a per-message fee. These types of “limitations” must be disclosed.

It is not surprising that new certification requirements, which drive new software development and associated services, have costs. In the market for certified health information technology? Be sure to look for the “transparency and disclosures” statements that should be posted on vendor web sites. And if you don’t see one, ask where it is!

To learn more about the federal requirements that EHR vendors must comply with, contact us

Learn more by visiting the ONC website

Tom Arnold, MBA, PMP, is Director of Meaningful Use for Medsphere Systems Corporation.

Category: Meaningful Use

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, 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.

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