Population Health

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

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

The viability of rural healthcare relies on evolution

Choice can be a double-edged sword—we all want more of it, but with too many choices paralysis can set in. Choosing a physician or hospital, for example, in an urban or suburban area without some kind of recommendation can truly be a daunting task.

But it beats having few or no choices. Increasingly, that’s the situation rural Americans find themselves in as the number of hospitals decreases and specialists stay in the cities.

While this may have been the trend in rural healthcare over the past 10 or 15 years, the current advance of technology in healthcare and the introduction of new care models offers rural hospitals much-needed opportunity. Heartland hospitals have the ability now to revamp and re-envision care in the essential areas where America produces energy and food.

What strategies and adaptions available now can ensure affordable and efficient rural care for the foreseeable future?

Strategy 1 - Forge relationships. As with all hospitals, Winona Health (99 beds, Minnesota) had more than a few patients using the ER for chronic but manageable health conditions. To get ahead of and maybe prevent ER visits, Winona Health established relationships with organizations that included a nearby senior center, the state health department and Winona State University to provide support for the chronically ill. This led to the formation of the Community Care Network in 2012, through which Winona Health trained Winona State University students as health coaches.

By providing basic emotional support and performing a few tasks like grocery shopping, the Community Care Network reduced ER visits by 91 percent and hospital readmissions by 94 percent in the first 90 days of the program.

Are there organizations in your community that can contribute to managing the health of those who need support and preventing health emergencies in the ER?

Strategy 2 – Innovate around care. Even where there are sufficient providers in a rural area, there are seldom enough specialists, which means patients sometimes have to travel long distances for specialized care. The University of New Mexico’s Project ECHO works to address this need through educational innovation by connecting specialists with physicians in rural areas, giving them the understanding they require to meet particular patient needs.

For more than 20 years, Stanford University has organized the Chronic Disease Self-Management Program (CDSMP). The program trains patients with chronic illnesses to manage their own emotions and behaviors—eating well, taking medications appropriately, communicating with friends and family, getting enough rest. Results demonstrate that the CDSMP improves the lives and satisfaction of chronically ill patients, and it saves money on reduced hospitalizations and readmissions.

Are there cost-saving care innovations your organization is not yet utilizing? How can you implement proven programs to keep costs down and bring patients deeper into the provision of care?

Strategy 3 – Focus on what you do well. Most doctors willing to live in rural areas are not specialists.

“Specialty has a powerful effect on physician location choice …” according to a study on physicians and rural America published in the Western Journal of Medicine.  “Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.”

Specialized care is not and probably never will be the strong suit of rural physicians. But this perceived weakness gives rural hospitals the opportunity to focus on natural strengths.

“A rural environment lends itself to population health and wellness,” says Jennifer Lundblad, CEO of Stratis Health, a Bloomington, Minnesota, nonprofit that promotes innovation and collaboration. “Providers probably know the patient and their family, they may go to church with them, they see them at the grocery store. If rural communities can figure out how to harness those assets, they will be well-positioned for the future.”

Of course, rural health providers remain the most important interface with patients, making them primarily responsible for creating access to specialists by forging relationships and innovating around care (above), and by maximizing the use of technology (below).

Are the wellness and population health efforts in your organization robust enough to create lead time when your patients have to utilize your relationships with specialists?

Strategy 4 - Use technology. Much has been written about the potential of telehealth to alter the rural healthcare landscape.

In South Carolina, the state Department of Mental Health worked with the University of South Carolina School of Medicine and 18 hospitals, mostly rural, to provide telepsychiatry services. Most of the hospitals had no psychiatrist in the ER when mentally ill patients arrived, and the program provided that resource 16 hours a day, 7 days a week.

The telepsychiatry services have reduced both wait times in the ER and inpatient admissions, and it has lowered costs. Patients are going to their scheduled outpatient appointments more often, and levels of satisfaction are up for both patients and physicians.

Telehealth services, while not the only approach to technological innovation, are now seen as the most promising technical cure for what ails rural hospitals.

“There are two kinds of healthcare innovation: more-for-more and more-for-less,” write Nathan Washburn and Karen Brown in the Harvard Business Review. “The American healthcare system exemplifies the first kind, offering more and more value at higher and higher costs … Virtual consultations … are at the heart of a reconceptualization of rural hospitals (and eventually urban clinics and hospitals as well) because they provide access to higher-quality care at much lower costs.”

Of course, rural hospitals cannot provide effective population health and wellness services without effective, affordable, interoperable healthcare IT systems; the technology is a prerequisite. While rural health organizations currently lag behind their urban and suburban cousins in terms of adoption, government initiatives are helping to close the gap.  

Is your organization maximizing affordable technologies, including telehealth and electronic health records, that improve the bottom line without busting the budget?

Strategy 5 - Merge. Wafer-thin profit margins (if they exist at all) and threats of insolvency would cause any rural hospital executive to consider merging or being acquired. Predictably, activity in the hospital M and A sector has been brisk over the last several years as rural facilities sign on with larger, more financially stable urban and suburban health networks. 

So, is independence even realistic, let alone desirable, for rural facilities? The answer is yes, though with caveats.

“The trick to staying local and ‘going it alone’ is often through configuring creative but limited partnerships with larger systems,” writes Beth Nelson in Hospitals and Health Networks. Complete independence may be completely historical, but that doesn’t mean rural hospitals can’t maintain a semblance of self-determination.

Have you explored the alliances available to you that may enable your hospital to survive and provide for the needs of the surrounding community?

A piece of good news: At least one study shows that rural hospital closures have not had a measurable impact on local mortality. The not-so-good news: rural residents are generally less healthy than urbanites, so having no local hospital and healthcare organization eliminates the opportunity to improve care through various wellness and population health programs.

Just as they always have, rural hospital executives and clinical leaders are doing all they can with the resources available. The difference in our current technological age is that so many more cost-saving tools exist than just ten years ago. By employing strategy and technology, rural healthcare organizations finally have the tools to move beyond survival and become catalysts for healthier communities. 

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

On engaging patients and having the patience to make it work

When people in healthcare use the phrase ‘patient engagement,’ they mean involving patients more in their own care, perhaps urging them to be more responsible for their own health.

From a costs perspective, this makes sense. No one argues that the healthcare system is not rife with waste and duplication, and much of the treatment would be unnecessary if patients paid attention to their health well before dramatic efforts are the only remaining option. Also unarguable is the impact healthcare has on the American economy as it steadily gobbles up higher shares of national revenue. 

But simply identifying patient engagement as one solution to systemic healthcare challenges achieves little. Sure, Americans would have fewer health problems if they ate better, lost weight, took their medications regularly and got more sleep, but most everyone already agrees on that. Human behavioral change is difficult and gradual, and it happens through incremental approaches, not general pronouncements.

So what tactics can hospitals and providers use to shift some responsibility onto patients themselves?

  1. Teach patients to do what they can. In a fascinating example, a hospital in Sweden transitioned more than half of dialysis patients to a self-management program after a single patient asked for control of his own care. 

    “Shortly afterward, the patient was managing his own dialysis and experiencing fewer side effects of the treatment, such as nausea, edema and hypotension,” according to an American Hospital Association case study. “The patient and the nursing staff took this success to the next level and began training other dialysis patients interested in self-dialysis.”

    Similarly, Dallas’s Parkland Memorial Hospital began a program in 2009 that trained patients on long-term antibiotic therapy to administer the drugs to themselves at home. The benefits of the program today include shorter hospitals stays, lower readmissions and millions of dollars saved while still achieving comparable outcomes. 

  2. Change the dialogue with patients. For decades, medicine has used the language of subject or actor and object—the doctor applies his wisdom and knowledge; the patient accepts the treatment. Arguably, this manner of speaking about the doctor/patient relationship has contributed to a level of patient passivity. 

    “Under that outdated model, patients were expected to comply with treatment plans, not contribute to the development of them,” writes Ginny Adams, a clinician and consultant. “Certainly, we as clinicians meant well, but our style of caring was sometimes distant and too directive.”

    The language of medicine often widens the gap between physician and patient. If doctors and nurses want patients to be more involved in their own care, they must take the time to explain in layman’s terms. If patients want to truly understand their situation, they must ask clinicians for more explanation and understandable language. 

  3. Engage technologically. Especially for younger generations, communication is now the product of more applications and devices than even the savviest consumer can keep track of. If healthcare organizations want to embed in the lives of patients, there needs to be some adapting to the predominant media of the day. 

    What does that mean, specifically? Should hospitals be on Instagram? Probably not, but that’s a decision for each provider and organization. It does mean patients should have access to a robust patient portal (see more on the benefits of long-term portal use here) that enables viewing of records, scheduling, communication with providers and paying bills. It might also be helpful if patients could see an explanation of their records; for most, blood on the brain is more understandable than subdural hematoma.

  4. Partner with the community. As healthcare shifts to a more consumer-oriented and patient-focused model, it’s hard to not see most healthcare organizations as population health entities. Sure, we’re talking about how patients can take on more of the responsibility for their own health, but that has to include making sure they have the information and knowledge necessary to do so.

    Wisconsin’s Bellin Health, for example, engaged with the local community through The Live Algoma Coalition, a partnership that includes local businesses and government, the school district and community agencies. With grant funding from the Institute for Healthcare Improvement, the Algoma Coalition will “help communities further their capability to improve the health of targeted populations and develop ways to share and spread community-driven approaches across the country.”

Beyond engaging in strategies to improve patient engagement, it might also help if we could alter our perspective of medicine and caregivers.

“We have a certain heroic expectation of how medicine works,” Atul Gawande, MD, writes in a recent New Yorker article. “We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.

“But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.”

In other words, because we too often view doctors as fire fighters, by the time many of us ask for help, the house has already burned to the ground.

Realizing the kind of patient engagement we’re talking about is no easy task, to be sure. While pursuing it, we also have to deal with ancillary concerns: making EHRs work effectively, expanding health insurance so citizens have access to care, integrating physical and behavioral health to reduce comorbidities. And that doesn’t even address the fact that changing attitudes and behaviors across a large, diverse society is more challenging than doing an about face in an ocean liner.

But the evidence for moving forward is clear. Engaged patients are healthier and more active. Health systems and practices that engage patients reduce costs. Communities with embedded healthcare organizations are more cohesive. In a society that measures success in hours and days, not months and years, it will be crucial to highlight the victories along the way and enable both patients and caregivers to celebrate improvements. Hopefully, a society that celebrates the individual might see the value in a self-empowered approach from the very start. 

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

Category: Population Health

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.

WSJ: Medsphere chairman talks new health IT and barriers to acceptance

Few if any physicians, administrators or policy experts have more experience in the American healthcare arena than Kenneth W. Kizer, MD. The Medsphere chairman and director of the Institute for Population Health Improvement at UC Davis has served as the top health official for California and undersecretary of health for the VA. Kizer was also the founding president and chief executive for the National Quality Forum, which focuses on healthcare performance measures and quality standards.

Kizer recently had a conversation with Laura Landro of the Wall Street Journal on population health, healthcare IT and barriers to adoption of various technologies. Included below are some of the interview highlights. Click the link at the bottom to access the full WSJ article.

What is population health?

“The term population health was introduced about a decade ago to recognize the important role that factors other than health care have in determining health outcomes … Many people are surprised to learn that these social determinants of health have more to do with reducing preventable deaths and improving population health than health care itself.”

How does technology improve population health?

“Many of the new information and communication technologies have begun to be used in health care in recent years …These new technologies necessitate that we fundamentally redefine what access to health care means, since access is no longer only about face-to-face visits. Information can now be exchanged between caregivers and patients in multiple ways, which means we can design innovative ways to tailor health care to someone’s individual needs and lifestyle. The stage is set for a virtual-care revolution … These technologies also can help overcome transportation, language and other access barriers to health care for rural and inner-city populations.”

What keeps that technology from being effective?

“Perhaps at the top of the list is health care’s conservative culture, which is notoriously slow to embrace new ways of doing things, followed by lack of health-insurance payment for most virtual-care methods. Lack of payment can undermine an effective method of virtual care by making it economically nonviable … Additional barriers to virtual care include lack of infrastructure—both technological and in terms of personnel—concerns about data accuracy and reliability, especially for wearable devices, and interoperability problems among technologies, which tend to complicate collecting and analyzing the data … Overcoming these barriers will require concerted collaboration between government, health-care providers and technology vendors.”

How does technology integrate care?

“New virtual-care technologies such as health-information exchanges allow providers in different health systems to quickly and securely share information—for example, about medications, allergies or lab tests.”

How can technology and digital patient data improve outcomes in patient populations?

“Social media can be used to track infectious-disease outbreaks such as influenza and food-borne illnesses. Online immunization registries and portals can help parents and schools ensure children are appropriately vaccinated. Electronic health records can be especially useful for identifying patients who need close monitoring or extra effort to avoid emergency visits and hospitalizations. Linking electronic health records with other virtual-care technologies is being used to support new models of care like community paramedicine, in which paramedics provide home health checks or other basic services.”

Click on Wall Street Journal to read the entire excerpt from the conversation between Dr. Kizer and the Journal’s Laura Landro. 

Do we have to define population health to make it useful?

Maybe the initial challenge of population health is deciding exactly what that phrase means.

Well before it became a catchphrase in health IT, population health was the province of academics who devised predictably academic definitions like “… the aggregate health outcome of health-adjusted life expectancy (quantity and quality) of a group of individuals, in an economic framework that balances the relative marginal returns from the multiple determinants of health.”

Originally created and recently revisited in a Health Affairs blog post by Population Health Sciences Professor David Kindig, this definition may help with understanding, but it makes specific application outside of academics kind of problematic. Today, there are many more minds working on population health matters, which has created what Kindig admits is “a conflicting understanding of the term today.”

Which version of the “conflicting understanding” a person subscribes to seems largely determined by prevailing questions. Are we trying to track the health of people in a geographic area? Is the primary concern the health of a particular ethnic group? Is economics the challenge in growing a client base enough to scale the costs of population health? Are we trying to track spreading disease?

Because the end goal determines where boundaries are drawn around subjects, the answer is ‘Yes’ to these and almost all population health objective questions.

The Affordable Care Act (ACA) and Accountable Care Organizations (ACOs) are making it more expensive to readmit patients soon after treatment, so the bottom line comes into play regardless of which question is being asked. But the spread of technology like electronic health records (EHRs) and other applications also makes it possible to use data in a variety of ways, perhaps many of which we have yet to discover and define.

“A critical component of population health policy has to be how the most health return can be produced from the next dollar invested, such as expanding insurance coverage or reducing smoking rates or increasing early childhood education,” Kindig writes.

More bang for the buck—everyone wants it.

“To do population health, insurers must have a critical mass of members in each of several high-cost diseases: diabetes, heart disease, cancer, behavioral health,” says Indianapolis Business Journal reporter JK Wall in an article posted on The Health Care Blog earlier this year. “Otherwise, it will be too expensive to hire the clinical staff to develop the necessary clinical protocols, to staff the high-touch patient intervention programs and to develop the data analytics and customer engagement technology seen as vital for doing effective population health on a large scale.”

Wall adds that much of the insurers’ population health strategy is driven by two facts: The ACA squeezes per-patient profit margins, and maintenance of many diseases is expensive.

If you are a physician or hospital administrator, you will be concerned with chronic disease in a defined population from a causes-and-treatments, as well as a financial perspective. To that end, hospitals are frequently using remote patient monitoring and analytics as embedded components in the care process, writes reporter Jessica Davis in Healthcare IT News.

But even while much data is being gathered, there is a gap between the data we can compile and knowing what to do with it.

"Analytics provides a huge opportunity, but we lack the data science and medical algorithms," Gregg Malkary, managing director of Spyglass Consulting Group, tells Healthcare IT News. "We don't really know how to translate certain data because medical science is immature."

A high-profile example of what Malkary describes is the recent failure of Google Flu Trends (GFT), the company’s effort at tracking search data and alerting public health officials of flu outbreaks before the Centers for Disease Control could know about them.

“When Google quietly euthanized the program … it turned the poster child of big data into the poster child of the foibles of big data,” write political science professors David Lazer and Ryan Kennedy in the October issue of Wired.  “But GFT’s failure doesn’t erase the value of big data … The value of the data held by entities like Google is almost limitless, if used correctly.”

Google’s adventure becomes a lesson for those that come after, adding to acquired knowledge and contributing to later success. In many ways, that same ethic is at the heart of the optimism surrounding all these piles of data we are starting to acquire. Right now, the rhetoric is ahead of the reality, but the gap between the two is closing rapidly enough that there is reason to believe the use of big data in population health will become common.

But do we still need an accepted definition to work from?

Actually, according to Kindig, we need two.

While population health is often viewed as a mostly clinical measure, Kindig feels the terms population health management or population medicine better describe this physiological aspect of group wellness.

“The traditional population health definition can then be reserved for geographic populations, which are the concern of public health officials, community organizations, and business leaders,” he says, and which factor in contributors like education, employment and other non-clinical issues.

Geography on one side and whatever the determinant is—ethnicity, education, diet—on the other. It may not get us down the path to universal understanding, but it does provide the kind of flexibility that will probably come in handy as we look for new ways to analyze mounds of data in search of healthier populations.  

David Macfarlane is a writer, editor and marketing communications manager for Medsphere Systems Corporation. 

Category: Population Health

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 clich├ęs, 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. 

RWJF Report: Time to adjust expectations and settle in for the long term?

Context and perspective matter.

And it’s often both context and perspective that are lacking from the daily snapshots we get of health information technology, meaningful use, interoperability and the progress we are either making or not making, depending on your perspective.

So I welcome a report like the one the Robert Wood Johnson Foundation (RWJF) released last month on the state of health information technology circa 2015 in these United States. Subtitled “Transition to a Post-HITECH World,” the detailed report, created in collaboration with the University of Michigan School of Communication, the Harvard School of Public Health and Mathematica Policy Research, takes a 10,000-feet view of the ongoing digitalization of healthcare and what the priorities are as we approach the terminus of HITECH.

But before I delve into what I believe are the more interesting aspects of the RWJF report, I think it necessary to mention some other bits of information that filtered my way this past week.

  • The official transition to ICD-10 happened. Many analysts compared it to Y2K in that nothing dramatically awful has ensued thus far, despite the dire warnings of the American Medical Association (AMA), which still could come true via upcoming reimbursements.

  • Becker’s published quotes from an AMA town hall event to illustrate just how frustrated physicians are with electronic health records (EHRs). Many are not happy.

  • The Surescripts’ Connected Care and the Patient Experience report was released, showing that most patients think their medical history is inaccurate or incomplete when they visit the doctor.

It’s necessary to mention these health IT-related events and reports because I think they support what I most strongly infer from the RWJF report—namely, that we can’t see the finish line from where we stand. In other words, HITECH and similar legislation created an idea of a finish line that is now clearly false.

As RWJF reports, there is reason for optimism. In 2014, 76 percent of hospitals “reported exchanging data with outside health professionals … up from 62 percent in 2013 and 41 percent in 2008.” Most hospitals have at least a basic EHR now, which means much of the track has been laid for a full-fledge health IT train system.

But enthusiasm is waning. Fatigue is setting in.

“In 2014, 1,826 hospitals successfully attested to meeting Stage 2 criteria (approximately 38% of all hospitals registered for the meaningful use incentive program)—far fewer than the 4,379 ever attesting to Stage 1,” RWJF reports. “Moreover, overall participation in the program declined between 2013 and 2014 for eligible health professionals in both the Medicare and Medicaid EHR Incentive Programs.”

As the authors of the RWJF report clearly understand, for reasons that have much to do with American society, what started out as a sprint to better healthcare enabled by IT now looks more like a marathon of gradual improvements enabled by IT as one component among several.

“Other nations—many with a long-standing history of supporting HIT adoption—are still aspiring to realize the goals which HITECH anticipated could be accomplished in three years. To compound these challenges, America faces tremendous impediments which many other countries do not have to overcome, such as competing, proprietary health care systems, the lack of a universal patient identifier, and tremendous regional variation in terms of policies, infrastructure, and culture.”

While there is much to be gleaned from the RWJF report, I find chapter 5 to be the most compelling section. Here, the authors make a case for payment reform as the primary driver of health system change. With fee-for-service (FFS) and total-cost-of-care (TCOC) models, there is little incentive for separate health systems (an “archipelago” of healthcare, the report calls them) to liberally and willingly share patient data. 

“The larger vertically ‘integrated’ health systems are rushing to warehouse clinical and financial data, but ultimately for the wrong reason. They simply want to enhance their private holdings. Very little information emanates from these private islands unless there is a mandate compelling it … in the total wallet share game, controlling information matters, which is why the mode of payment matters.”

Instead of a fee for services rendered, or reimbursement of total costs plus a profit margin (virtually impossible when most hospitals don’t know enough about actual costs), RWJF re-asserts what many have already said—that we should be paying for distributed episodes of care, including outpatient visits and in-home care. Cost effective at-risk care drives coordination among nimble providers—a group that will not include most large hospitals and health systems.

“This will significantly increase the likelihood of data sharing if the health professionals co-managing the patient come from different health professional organizations … while total cost of care payments (and variations thereof) almost always call for vertical integration of health professionals; payments centered on episodes don’t.”

If payment is restructured, there will be an incentive to exchange data, which is the second half of RWJF’s proposed solution for making HITECH work. What we must achieve is semantic, not syntactic, interoperability. In other words, the data exchanged must have unambiguous shared meaning across the spectrum of providers and facilities.

“Syntactic interoperability enables a base level of communications and information exchange … Syntactic interoperability (or information exchange) is the necessary but not sufficient condition for semantic interoperability.”

While versions of HL7 have been the standard for data exchange thus far, these are largely syntactic and insufficient moving forward. Fortunately, the RWJF authors believe alternative technologies in development will enable us to achieve, technologically at least, true data interoperability BETWEEN health systems.The report highlights these three solutions:

  • Resource Description Framework: “RDF makes it possible to build models called ‘ontologies’ that are more rigorous because they support automated reasoning … Ontologies are better at dealing with changing and ambiguous medical knowledge.”
  • Fast Health Interoperability Resources: “The new HL7 FHIR … initiative explicitly recognizes … difficulties for developers by creating very simple and readable information structures that are not derived from an abstract information model.”
  • SMART: “FHIR and SMART adopt the ‘RESTful’ architecture of the Web. REST stands for representational state transfer and ‘is a software architecture style consisting of guidelines and best practices for creating scalable Web services.’”

Lengthy at more than 100 pages and rather technical in sections, the RWJF report is still worth a read for both the reality and the reward. No, we cannot see the health IT finish line from where we stand. Yes, HITECH and perhaps the whole reform program are in a precarious place where failure might be as likely as success. Yes, initial estimates and expectations were wildly off the mark. No, it is not true that little has been accomplished.

As former National Coordinator Farzad Mostashari said:“’Oh, the marvels of technology that would have emerged had the government not stepped in. Oh, you should have just waited.’ So, first of all, waited until when? We waited 20 years, right? Waited for what? Second of all, where’s the counterfactual? You know what the counterfactual is? Behavioral health. You know what the counterfactual is? Long-term care. Show me the beautifully innovative technology that’s now easily adopted by long-term care health professionals. It doesn’t exist.”

(If you read the RWJF report, by all means include the quotes near the end from interviews with all the national coordinators from Brailer through to De Salvo. Well worth the time.)

I get that EHRs have made life harder for physicians, and I can understand why many are displeased with the HITECH program. But we are moving away from a scenario that almost all agree was not working in terms of both cost and correct focus on the patient. Collectively, why would we go back there? Click on RWJF report to access the report in it's entirety.

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

Category: Population Health

Is accountability the missing element in better healthcare?

Who is accountable for the actions of Adam Lanza, the troubled young man who in December 2012 killed 26 people in Newtown, Connecticut?

He is, of course. Some might also hold the mother he lived with accountable to some extent, but both are gone now and neither was able to keep the tragedy from occurring.

So who else in Adam Lanza’s life might have noticed disturbing patterns in his behavior and stepped in to offer help and guidance?

That’s the question Senator Chris Murphy, a Connecticut Democrat, would like to answer.

"This was a young man whose primary care doctor had no notes in his file on his behavioral health issues for a period of years because somebody else was dealing with that,” Murphy said during a recent roundtable discussion with Connecticut mental health professionals. “Nobody was really sure whether the school system was in charge, whether his primary care physician was in charge, whether the community mental health system was in charge, and we’ve got to create a system whereby we uncompartmentalize behavioral healthcare and we recognize some clear lines of accountability.”

To that end, Murphy is working with Senator Bill Cassidy, a Louisiana Republican and medical doctor, to craft a bill that will overhaul the nation’s mental health system. Among the stated goals of the bill would be to close gaps by uniting physical and mental health care under one roof.

“In order to keep somebody healthy, you might have to treat their brain and the rest of their body together,” Murphy told the CT Post. “That means that when you walk into a community health center, and you present with a behavioral health issue, you shouldn’t be sent offsite.”

The senator is only the most recent Murphy in Congress to make improved mental health care a primary objective. Representative Tim Murphy, a Pennsylvania Republican and clinical psychologist, last year introduced the Helping Families in Mental Health Crisis Act. Representative Murphy recently re-introduced Helping Families in the House, and Senator Murphy plans to write many aspects of the Helping Families bill into his legislation, expected later this summer or early fall.

Certainly, accountability is the goal of Accountable Care Organizations (ACOs). It’s right there in the name, after all. Would a group of care givers with different areas of expertise who all had access to comprehensive information on Adam Lanza been able to successfully intervene? Would someone have been accountable for changing the trajectory?

Maybe. Maybe not. No guarantees.

This much is certain, however—it is impossible to act on information you don’t have.

And that’s the rub, really. The information has to be there. It has to be accurate. And someone has to take action. This definition of accountability, which healthcare currently grapples with and must find a way to realize, is not possible without technology.

And that accountability exists among all players. We put most of the accountability on physicians, as they do on themselves, often irrationally expecting miracles. But how can a doctor fix a lifetime of bad health decisions when we’re unwilling or unable to be accountable for ourselves?

And what would motivate patients to get more involved in their own health? The patient portal, a Meaningful Use requirement and the essential component in “patient centric” electronic health records (EHRs), is the fix we’re putting faith in, but none are all that good yet and patients seem largely ambivalent as a result.

Still, it’s clear that data sharing is key to accountability, and we’re not yet doing enough of it.

In 2012, according to a Health Affairs study, only 2 percent of behavioral health hospitals had a comprehensive EHR. In a 2012 Behavioral Health Roundtable organized by the Office of the National Coordinator (ONC), participants noted the lack of federal financial incentives available to mental health hospitals for IT adoption, among other concerns.

“Aside from the relative absence of EHR financial incentives for behavioral health providers, participants voiced concerns that smaller behavioral health providers may be overburdened by adopting these systems or priced out of the EHR market; these smaller providers often lack the resources to implement and maintain an EHR system.”

Interoperable health IT systems need to be everywhere in healthcare, including mental health hospitals and clinics. It’s not that technology is a panacea for all that ails the American healthcare system—far from it, actually, as policy and finances probably have greater impact. Still, it is impossible to make sound decisions, to intervene positively at all, without relevant data. Health IT systems are not sufficient, but they are essential.

So, is there a need for more accountability in American healthcare? Of course. All the way up the chain. Will it stop the next Adam Lanza? We can only hope.

Senator Murphy and Representative Murphy believe the federal government can help with accountability by extending health IT incentives to all care providers and making other systemic changes to focus more on treating the whole patient

Patients can be accountable for their own health and lives by knowing more about themselves and working to change the unhealthy bits.

I could write a great deal about how health IT vendors are not accountable for their actions within healthcare when charging multi-millions for systems with no proven return on investment (think sunk costs), but that’s a subject for another day. What we can do is work to develop systems that are user friendly, patient centric and interoperable. Indeed, that’s probably the least we can do.

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

Category: Population Health

Feds update Medicaid rules, encourage behavioral health EHR adoption

A little more creativity, and maybe this time we’ll find a way to pay for health IT in behavioral health.

As reported in Modern Healthcare last week, the Center for Medicare and Medicaid Services (CMS) has proposed new rules to govern Medicaid managed care plans. One of these rules would enable managed care companies contracting with state Medicaid programs to include activities related to health IT and Meaningful Use (MU) in the definition of core services that contribute to the overall medical loss ratio.

“A medical loss ratio, or MLR, requires health plans to spend a minimum portion of the rates they receive on medical services as opposed to administrative costs and profits. The proposed Medicaid rule recommends that states impose an MLR of 85 percent in their managed-care plans.”

If the proposed rule is approved, it will enable managed care companies not covered by MU to pass the costs of electronic health records (EHRs) and other health IT on to the federal government as reimbursable core services.

The federal MU program directly reimburses hospitals and providers for the costs associated with purchasing and implementing an EHR, provided they demonstrate use in a way that meets federal requirements.

In recent years legislation has been proposed a few different times that would expand direct federal financial support for EHRs in behavioral health. To date, none of those introduced bills have made it out of Congressional committee.

Click to read the original Modern Healthcare story.

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