One of the best read ideas of 2012 that's going to ignored...Time to close speciality training

A friend of mine, Dave Fiorella, published one of the most widely read paper in the radiology literature this year.  

Should neurointerventional fellowship training be suspended indefinitely? -- Fiorella et al. 4 (5): 315 -- Journal of NeuroInterventional Surgery

He argues that the world has enough of his own subspecialty, neuro interventional surgery (NIS), and that training programs should voluntarily close.  You may not have heard of NIS.  These physicians care for a small group of patients that typically need blood vessels in their brain opened or closed.  Examples include stroke patients (blocked vessels need to be opened) and aneurysms (diseased vessels need to be closed). People like Dave do their work by running a small tube, a catheter, from the groin up to the head and then inject things through these tubes to open or close the vessels-pretty cool stuff!  and a huge advance from 25 years ago.  Before NIS, neurosurgeons would open your skull, do their work, and close you up.  And now, Dave says we have enough.  Why?

After training (which included NIS) my first job was at a good, but smaller community hospital outside Seattle.  In part, I was hired to build a stroke program and grow neurosurgical services.  However, these skills require constant practice, and 6 months at this hospital I had only done a handful of cases.  As far as the professional requirements were concerned, I was competent to do these procedures.  However, deep down I wasn't so sure. Within 18 months I gave up doing these procedures, preferring to send patients to the university up the street.  

A coiled aneurysm.  The big ball is the aneurysm.  
Imagine pushing a wire into a basketball, replacing air  with wire.

My experience is similar to many physicians.  There simple aren't enough patients needing high end procedures to go around.  As a result, skills and quality suffer.  Unfortunately, hospitals want to compete.  Every center wants to be a stroke center or a chest pain center, a (you fill in) center of excellence.  In part this is done for branding, in part this is done for contracting.  Insurers want to simplify the process and get all the services they need from a few hospital partners.  The big loser here is the patient.  Many studies have documented a relationship between volume and outcomes (https://leapfroghospitalsurvey.org/web/wp-content/uploads/2012/03/Fact_Sheet_EBHR.pdf).

You or a loved one may need these services.  A physician will come to talk to you about the risks (you could die), benefits (the procedure may help you), and options (they hopefully mention other treatment alternatives, but they may not mention that you can go down the street to another facility).  Your outcome will be tied to the experience and volume the physician has done.

If there were fewer NIS physicians, there would be more cases/practitioner and better outcomes.  But the likelihood of programs are going to voluntarily shut down- that's not going to happen as long as hospitals are hiring.  There is a way out of this dilemma.

At the consumer level, you should ask the hard questions.  Doctor, how many of these have you done of these, when was the last time you did one of these?  Is there anyone else who has done more of these procedures in a 20 mile radius?  At the payer level, there should be a a requirement for a certain experience before paying a provider, and then there should be recertification, a certain number of on going cases to keep getting paid.  Ultimately, the payer should ask for outcomes from the provider, information about how their patients are doing 3, 6 and 12 months after the procedure.  

In short, Dave is right.  Practice makes perfect.  There just needs to be a business model supporting the desired (patient) outcome.

Why I use LinkedIn, and hope you do too....in the New Year, build your "hubness"

I am a Jew married to a Catholic.  Neither of us practice.  Next year we'll be married 25 years.  We have 3 children, all whom I am proud to call a friend.  But, I have this nagging feeling.  At the end, I'll get to the gate and be brought before (Jesus, Budda, Mohammed) who will ask why am I deserving.  Or at a minimum, with my last breath, I want to reflect on a life well lived.  That's why today I use LinkedIn.  Most people look at Linkedin and see a job board on the web or a professional Facebook.  I see something else: an accelerator of human potential.

Several years ago I read Malcolm Gladwell's Tipping Point.  He talks about the spread of ideas and how if you are lucky enough to meet a hub, the chance of your idea spreading to the next person, the right person, goes up exponentially.  At that moment, I realized that I wasn't getting any faster, or better looking and that senility was fast approaching. Though in spite of this inevitability, I knew that I could actively pursue my "hubness"… that I could become a connector.  When I met new connections I could learn about these people, what they were interested in, what they aspired to do, and file that information away until the day when I met their puzzle piece, the person who completed them.  Together, the two people could go on to accelerate human potential.

Fast forward to 2003: along comes Linkedin.  I had found the perfect tool.  Ii told me what people were doing, what they cared about, and when they changed paths.  It is the perfect tool for finding the missing puzzle pieces.

If you look at your world there are probably 20 people you see on a daily basis.  There is another 100 whom you like, respect and perhaps see every other year.  The is a larger circle beyond that, with some affiliation, but perhaps they have particular skills or knowledge.  With LinkedIn these secondary and tertiary circles become your world.

Today, I may spend as much time collaborating with people in my network as I do with people in my building.  I actively go through my network once a month, introducing people in my network simply because they should know each other.  Their pieces may fit, they may not, but I hope the world is a better place because of it. Of course in all honesty, I am the big winner.  I hear about interesting things people do, and sometimes join in the projects I helped catalyze.

Just imagine if each of us made it a New Year's resolution to build our “hubness”; to look for ways to bring strangers together so that they might call each other a colleague.  LinkedIn, or at least the process it enables, is one of the most powerful tools we have...we just need to use it correctly.

Shoe boxes should be for shoes, not medical records

If you ask a person coping with a chronic illness for their medical records, they may take out a shoebox with a neatly organized papers and CDs.  They hope the next doctor or nurse will open the box, look inside and help them.  This almost never happens.

What's in your box?

There is simply no time for providers to put this information into a meaningful story.  The provider tends to reorder labs, and begin from scratch.  

Patients and providers agree this is absurd.  Records should be immediately at the time of care.  This would enable better, more cost effective care.  Industry has spent decades trying to solve this problem, but it is a work in progress.

Centralized versus decentralized records.

In part, this failure reflects American healthcare's focus on the doctor and the hospital rather than the patient.  There is an expectation that others will care for us, rather than engage us.  Medical record solutions tend to pass centrally from patient, to doctor, to EMR, to a central clearing house (sometimes called an health information exchange, HIE).  

HIE, centralized healthcare records

HIEs sound like a great idea.  If the patient goes to 2 facilities or 2 different doctors, records would magically be collected and viewable by all participating facilities.  Unfortunately, HIEs are more concept than reality.  HIEs require high level collaboration from competing healthcare systems.  Further, there is first adopter risk.   Imagine buying the first fax- who would you send to? 

An alternative solution would centered around the patient.  In this case, the patient acts to collect data about themselves.  But rather than the shoe box, the information is organized so that others use it effectively. 

Google and Microsoft in fact took this approach and spent billions to create PHRs- this has largely been a failed effort  

Google Health shut down after several years

The medical apps industry is another approach.  Apps allow the people to collect all sorts of data about themselves (weight, blood pressure, physical activity) People can look at the information themselves or  present it to their practitioner.  As yet, industry has not achieve significant adoption or investor value.  

Both apps and PHR currently reach the wrong market. Apps and PHR tend to be used by the "super fit," the people trying to obtain that last little bit of potential immortality.  Although the super fit are a market, they are not the market insurers and providers are trying to reach.  The people who need PHR and apps, the sick, tend not to use them.  These people are typically older and less tech savvy, they tend to be less focused on their "wellness."  

Portal or PHR?

Hospitals are currently implementing portals, web based tools for patients and providers to see medical records. Healthcare systems view portal as an evolving service expectation, a chance to build customer loyalty.  However, this strategy is limited.  Portal is an extension of the hospital EMR.  Current portals do not aggregate records across the continuum or enable the patient to collect information about themselves.  

Would it be better if hospitals provided PHR?  This could be a card given to patients leading all providers, those from the hospital and their competitors, a web site where they could view and enter enter information for the patient.  Rather than centralize the information via an exchange, this would decentralize efforts around the patient.  At a minimum, this would allow providers to note that the patient received care and there are records to share.  Better would be an upload of records to the PHR; this is already possible via an accepted standard (CCD).  This would not replace EMR (which provide necessary documentation, scheduling and billing) but instead supplement care documentation.

Decentralized, Collaborative PHR records could supplement EMRs.
Providers across the continuum  could add to the record for the patient.
Most PHR ask the patient to do all the work currently

Compassionate Capitalism- towards a sustainable business model for collaborative healthcare records 

As mentioned earlier, centralized health exchanges, with a centralized business models, have largely failed.  The return on investment ratio for the early adopters has not enabled wide spread adoption.  However, decentralizing the offering may have unique benefits for a healthcare system.  Registration in a system showing patients their hospital records, occurrences or records from other providers  as well as chance to record their own observations is value, something patients can't get or can't maintain (eg...the Microsoft and Google offerings) on their own.  Building brand through patient value equates to loyalty. Further, collaboration across the continuum, provides the necessary infrastructure for value based  cost effective care delivery.  This is not rocket science, but rather a repurposing of existing market tools.

Best Wishes for the New Year

The National Rural Health Resource Center wishes you a happy and healthy season and all the very best in 2013!

We look forward to working with you in the new year!

To survive, radiology should become a horizontal

The future of radiology is bright, but its not so clear for radiologists....Lawrence Muroff, RSNA 2012

I attended the recent RSNA in Chicago this year.  Each year 60,000 people come to talk and sell all things imaging.  However, after years of short sighted, self destructive life style based decisions, radiologists have now successfully commoditized their specialty.  Although imaging will remain central to care, reimbursement for these services will likely change to align with the ACO/CIO agenda.  It remains to be seen if the specialty can reinvent themselves moving forward. 

Image isn't everything.

Radiologists are obsessed with the image.  This is understandable.  No other the speciality takes ownership of the quality and safety related to image production.    However, this focus on constant image improvement has to some degree been at the expense of image value for the patient. In the new world of value based care, every provider, every speciality will be measured against the patient's ultimate outcome.  Traditionally, radiology's relationship with the patient ends with the dictation.  There is no follow up.  Did the study decrease morbidity or cost of care?  Were care decisions influenced by imaging findings.  Were there differences between general and specialist interpretations influencing outcome or utilization?  This type of information, eminently obtainable via patient registries or directed personal health records, would add relevance to discussions with the payers moving forward.

Radiology as a “horizontal”

Radiologists and the imaging vendors can continue to ignore the the changes going on around them, or perhaps it is time to think about “creative destruction” of imaging.  These is a phrase coined by Eric Topol reflecting the rest of healthcare. 

Today, radiologists are paid for the transaction, the dictation.  Tomorrow we are paid for patient value.  How can we cross the chasm to this new world?

There is some good news.  There are some unique aspects of imaging services.  Unlike almost any other field in healthcare, radiology is a horizontal.  As opposed to neurology, obstetrics, surgery, relatively siloed verticals of care, imaging is required for all areas of medicine.  Radiologists have a broad understand of care across the continuum and could help navigate the patients course, suggesting appropriate next steps to arrive at cost effective diagnosis.  

(Radiology circa 1965...the reading room was the center of the hospital)

I am not suggesting the imaging subspecialists generalize themselves, but rather imaging services as a department begin to think of themselves as part of the care team, requiring and synthesizing clinical information to offer appropriate next steps.  Vagaries such as “stroke” or pain should not be accepted as clinical history.  Comparison studies should be found.  After an imaging study, there should be ownership of the outcome so that radiologists can effectively participate in utilization management.

These changes will not happen over night.  Currently, the IT tools supporting this type of practice are not offered- but markets respond.  If there is an ask, there will be product.  This is also anathema to the current practice patterns- aka, the referent is always right.  

Currently, it is almost like there is a sense of the “end of days,” make as much as you can now because the end is coming.  The end isn’t coming.  Imaging is here to stay.  Change is coming.  We can chose to plan for it and align with value, or deal with an abrupt, painful transition

Terry Hill, Executive Director

One method of acquiring and transferring knowledge used by The National Rural Health Resource Center (The Center) over the past decade has been holding national summit meetings on specific rural hospital topics. This method does not replace formal research, but instead is designed to supplement more scientific research and is usually translated into short white papers for national distribution and discussion.

This past June, The Center, with support from HRSA’s Office of Rural Health Policy, brought a small group of critical access hospital (CAH) financial experts and thought leaders together to address issues related to CAH financial performance. The meeting was prompted by the declining financial circumstances of many CAHs, as well as the new challenges presented by the Affordable Care Act.

Participants included accountants from the major accounting firms serving CAHs, rural CFOs and CEOs, researchers, state Flex program staff and federal officials. The participants did extensive pre-work and then engaged in a structured dialog designed to address the Summit goals. A white paper including the major Summit outcomes was developed and will soon be distributed nationally.

Summit participants agreed that most CAHs are not maximizing their reimbursement, due partially to the complexity of the rules and regulations and due partly to limited use of needed expertise.  CAHs often turn to consulting experts for help, but when negative bottom lines become common, many hospitals seem reluctant to pay for all that is needed. There are also questions as to which CAH financial measures are most important, and which financial consultations are most productive.

The Summit participants identified the following 10 measures as most important to maintaining the financial health of CAHs:

1.    Days in net accounts receivable

2.    Days in gross accounts receivable

3.    Days cash on hand

4.    Total margin

5.    Operating margin

6.    Debt service coverage ratio

7.    Salaries to net patient revenue

8.    Payer mix percentage

9.    Average age of plant

10. Long term debt to capitalization

The participants then identified the financial interventions that would have the most positive impact on the average CAH’s bottom line. These included:

·         Cost report review and strategy;

·         Strategic financial and operational assessments;

·         Revenue cycle management; and,

·         Physician practice management assessments.

The participants recommended ongoing financial education for hospital boards, mid-level managers and senior leaders. On site education was deemed to be optimal, however, there was considerable value seen in good webinar presentations that could be recorded, stored and used on-site with various shifts. Lean training was also recommended as a method of improving business processes as well as a good way of saving money.

The Summit participants concluded the meeting by noting that the American health care system is transitioning from a “Pay for Volume” system to a “Pay for Value” system. In the years ahead, CAHs will be challenged to maximize and document their value, as well as calculate where they fit into the new value-based reform models. In that regard, they will be somewhat like an intrepid explorer, going down treacherous river rapids, with one foot in one canoe (the old system), and the other foot in an accompanying canoe (the new system). At some point, they must cross over to put both feet into the new canoe, but the timing will be critical. Too early or too late a transition and they risk going under.

Honoring Veterans at End of Life

Kami Norland, Community Specialist

How can we best serve the unique end-of-life care needs of our veterans? Through my involvement with the Palliative Care Rural Initiative project in Veterans Integrated Service Network (VISN) 23 over the past year, I learned that one out of every four dying Americans is a veteran, yet 96 percent of veterans are cared for outside of the Veterans Affairs (VA) health care network, according to the National Hospice and Palliative Care Organization. This means that the majority of veterans are cared for by hospice and health care professionals in their hometown.

As health care providers, we work diligently to assess each patient as an individual and deliver high-quality, customized care. No time is more crucial to provide this level of customized service than hospice, where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses.

It has been pointed out time and again that when people reach the last chapter of their life journey, there is a natural tendency to reminisce, resolve issues, and reference previous experiences of emotional intensity—which, for veterans, includes their history in the military.

Both research and evidence-based practice have demonstrated that a person’s military history can exacerbate physical, psychological, social, and spiritual symptoms toward the end of life. The Department of Veterans Affairs notes, for example, that Vietnam veterans may still suffer from “trench foot,” a fungal infection of the feet from walking in wet conditions; that symptoms of posttraumatic stress disorder may surface; that social isolation and distrust of authority may develop (or redevelop) in veterans who have felt a lack of support in the adjustment from military to civilian life; and that spiritual questions may arise as individuals encounter death outside of the battlefield.

The VA also cites the following contributing factors that may influence a veteran’s behavior and responses to end-of-life issues:

·         Entry status: enlisted or drafted-  drafted veterans may experience higher levels of distrust of authority than veterans who enlisted.

·         Branch of service and rank- Each branch of service has its own distinct culture. Veterans do not always share their rank with friends and loved ones yet sometimes reactions to life events are better understood when this status is revealed. Regardless of rank, each veteran carries a responsibility for fellow soldiers although they cannot ensure their well-being and safe return.

·         Combat or noncombat experience- veterans who were directly exposed to the effects of combat may experience elevated levels of anxiety and posttraumatic stress disorder but noncombat veterans can experience these symptoms as well.

·         Type of war or time served- each war or conflict carried its own significant burdens which may be re-experienced by veterans at the end of their lives.

·         Prisoner of war experience- we cannot begin to imagine what our POW veterans have experienced physically, mentally, and emotionally.  At the end of life, these experiences may be the ones that color their memories.

For health care providers, being aware of an individual’s military history and the elements to which the veteran was exposed can assist in proper diagnosis and intervention. Establishing a process to inquire about an individual’s military history has proven successful for numerous health care providers. The VA, in collaboration with the National Hospice and Palliative Care Organization, has developed a simple Military History Checklist that reviews the above factors for each patient to enable providers to best serve Veterans’ unique health care needs. The Military History Checklist is available online at www.wehonorveterans.org and through numerous electronic health record platforms.

In addition, it is important to invite veterans approaching the end of life to tell their stories, to celebrate their accomplishments, and to express appreciation for their service to our county. Thank you veterans, for your service to our country. 

Contact Kami Norland for more information about how the National Rural Health Resource Center is involved in honoring veterans end-of-life care needs.

Health Care Provider Retention

Angie LaFlamme, Program Coordinator II

In September I attended the 17^th Annual National Rural Recruitment and Retention Network (3RNet) Conference in beautiful Tacoma, WA. This conference is always great for reconnecting with colleagues and friends to catch up, share stories and best practices as well as discuss and learn about all things recruitment and retention. The conference agenda was packed full of extremely knowledgeable speakers on a variety of topics including recruitment and retention, National Health Service Corps news, immigration updates and rural education to name a few.

One of the agenda items that really intrigued me was a presentation called Retrofitting Retention Resources by Sharon Vail, Executive Director of the Rimrock Health Alliance. She shared an effective tool for the retention of physicians in rural communities where each factor within the matrix was assigned a color, as well as a numeric value and was broken into 5 divisions: Geographic, Scope of Practice, Medical Support, Hospital/Clinic/Community Support and Future Opportunities. The assessments are not tied to performance reviews, but used to help physicians be as successful as possible. The Rimrock Health Alliance believes that knowing your strengths and challenges as a health care facility is extremely important and that the importance of a good retention plan will leave nothing to chance.

At The Center we recognize the importance of a good retention plan and believe it is vital in retaining providers and protecting that investment both from a business and community perspective. The estimated costs of replacing one primary care physician can result in a minimum of $20,000 to $30,000 in recruitment costs and a loss of $300,000 to $400,000 in annual gross billings plus additional expenses related to ancillary employment within the community.

Health care provider turnover is disruptive to health care delivery, continuity of care and patient loyalty within the community. Other negative effects such as low morale and decreased efficiency only add to the reasons to why it is so critical to have an effective provider retention plan aimed at decreasing turnover and preserving a stable health care provider workforce. Keep in mind that retention plans will only be successful if an organization and surrounding community are committed to it.

The Midwest Retention Toolkit is an excellent tool to help guide you in creating your own retention plan. It was created by The Center and the National Rural Recruitment and 3RNet under contracts with the Indiana State Department of Health; Minnesota Department of Health, Office of Rural Health and Primary Care; and Wisconsin Department of Health Services, Primary Care Office; and the Wisconsin Primary Health Care Association through funding from the National Health Service Corps.

This toolkit includes worksheets, sample surveys, agendas, and plans that may be utilized with all of these types of providers although many of the samples are based on physician retention. The tools ensure they are properly orientated to the practice, integrated into the community along with their family and recognized for their service and impact on local health care. The toolkit also features a national resource section with websites and contact information.

To access the Midwest Retention Toolkit and begin building your retention plan, log onto https://www.3rnet.org/resources.

 “Physician retention is more than keeping physicians from leaving the organization. It is about retaining the hearts and minds, commitment and loyalty of our physicians.” Kaiser-Permanente

EHRs and the Long Road to Quality Excellence

Terry Hill, Executive Director

(This content was originally published for the Texas Organization of Rural & Community Hospitals)

My mom often told me, “The road to hell is paved with good intentions.” Her words come to mind now, as I consider rural hospitals’ long, bumpy road to meaningful use of electronic health records (EHRs).  In the past several years, our National Rural Health Resource Center has worked with dozens of rural hospitals across the United States. Almost all have struggled to meet the challenging deadlines, with insufficient resources and inadequate understanding of how it’s all going to work. Rural hospitals started out in EHR adoption significantly behind their urban counterparts, and they continue to trail in the race to meaningful use and the associated financial incentives.

Many of the obstacles and breakdowns are beyond the control of individual hospitals. National legislation locked in some of the deadlines, incentives and processes, and federal agencies such as the Office of the National Coordinator (ONC) have good intentions, but limited understanding of rural hospital circumstances. We should all be used to this by now. Health policy makers have historically overlooked rural in most of their major plans and policies.

Instead of lamenting the unfairness of the circumstances, let’s look instead at what rural hospitals can control with EHR implementation. At the top of the list is the crafting an inspiring vision as to why all of this disruption is necessary. And, this must be developed and communicated by top leadership, and cannot be delegated to others. Ultimately, EHR implementation has to be about quality and patient safety, not technology. At its best, an EHR system can hardwire quality. Paper medical records have proven to be dangerous and inefficient, and are archaic holdovers from the twentieth century.  Almost all other industries have moved on to electronic records because they are more accurate and provide vastly superior information for decision making. Health care is not an exception; numerous studies have shown the benefits of EHRs, and their role in improving quality and safety is no longer in question.

After leadership develops the compelling EHR vision, it is necessary to plan the road from where the hospital is now, to where it wants to be. This strategic plan for EHR implementation must include improving clinical quality processes, providing education, and communicating to staff why this difficult change is eventually going to be worth the time and effort.  In short, IT HAS TO BE ABOUT QUALITY!  In most hospitals we’ve worked with, this key message is not adequately communicated. The road to meaningful use, to financial incentives or to some techie’s vision of nirvana, does not inspire the staff, nor does it enlist the physicians.

Determining the inspiring destination, charting the course and getting the right people on the bus does not mean that the road will be easy, but it will mean that arrival at the final destination will be worth the long trip, and you may enjoy yourself more along the way.  In this approach to EHR adoption, technology will be appropriately used as a tool and not as a destination. Improved patient care will be the big payoff, and staff and leadership will look back proudly at having survived the turmoil and making their local health care system safer and more efficient. With this approach my mom’s road to hell will turn out to be the road not taken.

Back to the Future- The New Black Bag, an iPad

In the early 60's, my father started in medicine making house calls.

He would carry his black bag from home to home.  It had all he needed to make a diagnosis and get the patient on the road to recovery.  Now, 50 years later, no one can lift this black bag.  It is too heavy with options. Improvements in care have meant more options, so much to know that no single person can have all the right answers.

Overall, Americans have benefited from medical advances.  We are living longer than in the 1960's.  But, it has also had the perverse effect of fragmentation.  Take the example of my mom, a quadriplegic.  

At times her care sounds more like a text on physiology.  There is someone for the lungs, the kidneys and the neurologic system.  Yet, no one is responsible for her.  In part, this is too much for one person, there is not speciality called "quadraplegia" and all that goes with it.  In part, this is how healthcare is reimburse- money is paid for problems, rather than wellness.

However, I see hope on the horizon.  Like Hermione's magical bag in the Harry Potter series, we can give our providers all that they need as they travel from house to house, or at least room to room.  Collaborative technologies can deliver the community, rather than strictly the provider, to the bedside.  In this world, the black bag is replaced by an iPad or other PDA.  The specialist is available for advice, supporting and reassuring the patient and local provider alike.  This is our future.  We need to learn to scale our healthcare ecosystem, to not rely on the best available locally but rather the the best available from anywhere in sustainable ways.  New economic incentives are accelerating these solutions.  Time to upgrade that old black bag, time to go back to the future.

Alan Pitt Health 2.0 - YouTube

A Gaping Hole in Achieving MU Beyond 2014

Joe Wivoda, Chief Information Officer

The new Stage 2 requirements for meaningful use have a significant focus on patient engagement and information exchange. There are also more requirements for physicians and others to use their electronic health records (EHRs) more completely (e.g. increased use of computerized provider order entry), but the requirements for information exchange and patient engagement represent a significant challenge, and exciting opportunity, for hospitals and clinics, both rural and urban. The requirement to have 5% of unique clinic patients (5% of hospital discharges) actively view their health information will take concerted communication and marketing efforts, but the electronic exchange of summaries of care at transitions will be the most difficult.

The reason this requirement will be the most difficult is because many of the players, such as long term care and home care, have no financial incentive to implement EHR technology that can accommodate electronic exchange. The rule states that 10% of transitions to a new care setting must have a care summary transmitted electronically. Consider a rural hospital as an example: Rural populations are often older than urban, and many care transitions are to home care or long term care (LTC). The numbers are difficult to find, but according to Examining Post Acute Care Relationships in an Integrated Hospital System (Feb. 2009, available from http://aspe.hhs.gov/health/reports/09/pacihs/report.shtml), 35.2% of Medicare patients were discharged to either long term care or home care. Considering that the majority of discharges are to the patient's home, long term care and home care represent the majority of discharges to other facilities.

Many long term care facilities have EHRs that are used for documenting care, but like hospitals and clinics, they vary in their capabilities and level of adoption. Most LTC EHRs are designed around payment requirements; documenting primarily what is required to get reimbursed by Medicare and Medicaid. Since meaningful use does not apply to LTC or home care, their EHRs are not focused on information exchange. Thus, we are faced with the requirement of exchanging information with facilities that have no financial incentive to implement expensive upgrades to their EHRs to accommodate the hospital's requirements so the hospital can get more money. That is a tough sell.

We know that this is the right thing to do for patient safety and efficiency. Hospitals should be looking at their referral patterns and talking with long term care facilities about the benefits of exchanging information electronically. Networks are perfectly positioned to facilitate these conversations. Know that it will take time to implement the technology required, both at the hospital and the LTC facility, so start planning now. Without partnering with LTC it will be nearly impossible to meet the information exchange requirement in Stage 2.

There Are Points for Speed

I am radiologist, an MD specializing in CT and MR interpretation. When I was training, I had a Professor who would say "there are no points for speed."    What he meant was, if you missed something, the lawyers didn't care how fast you read the case, just whether you got it right.  Unfortunately, he is wrong.  Speed matters in medicine, a lot.

Doctors are paid for speed.  The current reimbursement system pays us on how much we do, not necessarily how well we do it.  There are metrics related to outcomes and complications, but they tend to be relatively infrequent outliers and disconnected from the care and reimbursement process.  

In the case of radiology, there is an expectation of a certain number of cases/day by each physician.  A radiologist’s productivity posted and often related to bonus pay.  

ED physicians are paid on the number of patients seen per shift.  Doctors have learned to order tests first, and then see the patient second- it is faster.  THis is one of the reasons there has been a 5 fold increase in CT for emergency room patients over the last decade.  Imaging has largely replaced the physical exam  (‎www.emedmag.com/PDF/043070006.pdf).  This results in over utilization of expensive imaging studies and lab work for the patient and for the payer.  

With bundled payments, hospitals are on the hook for this over ordering .  Hospitals are paid a set fee for diagnostic code (stroke, pneumonia, etc..)  irrespective of the number of studies ordered by the doctors caring for the patient.  Ultimately, it may be cheaper for hospitals to incentivize their physicians to slow down and make the right decisions rather than simply order another test.

The medical legal system, thought to protect the patient from mistakes (due to speed) perversely accelerates this process.  Doctors are rarely, if ever, sued for ordering tests.

Doctors are human.  They respond to individual incentives like everyone else.  If the system pays for volume, we will continue to get more volume.  If we want quality, intelligent decision making, incentives need to be aligned for quality.  Unfortunately, as long as there are points for speed, we'll all lose.

Hospice Redirects Newton’s First Law of Motion

Kami Norland, Community Specialist

It is easy to get wrapped up in the day-to-day doldrums of life even if you are leading a “mission-driven” life of working for a non-profit health care organization. One can easily become consumed with tasks and deadlines and forget about how each of these daily, “up-stream” tasks contributes towards making a positive impact on the world; after all, it’s only natural to follow Newton’s first law of motion which states: Every object in a state of uniform motion tends to remain in that state of motion unless an external force is applied to it.

Recently I was preoccupied with Newton’s first law until an external force jarred my uniform motion into a new awareness. This external force was a lesson I learned through The Center’s contract with the Department of Veterans Administration (VA) where we partnered with five community hospice organizations to focus on improving care coordination for rural Veterans requiring end-of-life care. I observed how these hospice providers work diligently to assess each patient as an individual and deliver high quality, customized care where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses. In my opinion, the concept of hospice care is valuable because it leads the American health care system in providing holistic care where individuals are treated as complex, multi-dimensional creatures that require support and dependence in all aspects of living, not just physical, but mental, social and spiritual as well.

As I listened to these hospice providers share their stories of facing mortality daily, I felt their compassion and their wisdom for what it means to truly embrace life and the value of relationship building. They spoke of their patients with genuine care as they described how they stop their Newton’s law of motion to simply listen and accommodate to their patients’ needs. They acknowledged that there is so much they can do for people at the end-of-life: pain relief, support for emotional, social and spiritual care and that hope does not have to be lost when looking at options such as hospice and end-of-life care. Each of the community hospices also described how they embrace the philosophy to live life to the fullest—even until death.

Despite this philosophy sounding so cliché; I find solace in this perspective because it enables me to establish a well thought out plan of how I want to perish, where, with whom and under what circumstances I am presented with reaching this stage of life. I know myself best and know how I want to be cared for. Noting how there are discrepancies in how my family members perceive mortality, I want to be able to eliminate potential disagreements, distress and financial strain on my loved ones when it is my time to go; so even though I am relatively young, safe, and healthy, I want to document an advanced care plan so I can be assured that my desires for living life to the fullest even until death will be met by my care team.

“Advanced care planning, if done at the right time, and done well, helps prevent unnecessary suffering at end-of-life” explained one hospice provider. As a society, I think we need to recognize that at the two poles of life—when we’re born and when we die—we have to be fully dependent on others. We don’t consider the absolute dependence and vulnerability, even incontinence, of infants and toddlers as anything abnormal or undignified because we’re physically dependent on others, so why do we as a culture view this differently towards our exit in life? At both poles of life, caring for another is what we do; it’s part of our very humanity and hospice providers can offer this type of humanity more effectively if this service is offered locally and a plan has been discussed.

Receiving hospice services is rare for several reasons. Foremost, it’s because we live in a culture of advanced medicine where physicians are trained to provide every intervention possible to treat or cure - and most often, up until death. There appears to be a common perception that if the physician, the patient, and the family can’t do “everything possible to treat”, then they have failed—the illness or injury won. The result of this action is that the patient will sometimes endure ongoing, painful and expensive treatments because it is admittedly extremely difficult to “let go”. Then in the end, the patient and the family has little or no time to process or prepare for this important transition in life and the family is left with exorbitant medical bills and a sense of loss and defeat. Hospice services may also not be formally offered in hospitals because it is not historically considered a profitable service. However, on the contrary, hospice services can provide financial benefit to a hospital as it eliminates the number of emergency room visits and costly medical treatments. Research indicates that the last six months of an individual’s life are the most expensive if traditional medical treatments focused on curing, rather than providing comfort are administered.

I can imagine that most of you are now thinking “what a morbid thought” and may feel uncomfortable approaching this taboo subject of death. I get it, I come from a stoic Norwegian family and even broaching a blog about this topic is reminiscent of the awkward conversations driven by parents about teenage sex, and akin to that conversation, I, like my parents felt then, feel now that this is a life lesson that if we prepare ourselves for this stage in our lives, we could prevent unneeded suffering, reduce the burden on our families, all the while having our needs met. So, I encourage you to create that external force in your uniform motion and consider an advance care planning conversation for yourself, for your loved ones; for this is not a conversation about death, rather a conversation about living and how you choose to live your life up until death.

To aid in this discussion and for more information, reference the video and discussion guide at http://www.considertheconversation.org.

Final Meaningful Use Stage 2 Rule Commentary--"Now Is the Time"

Joe Wivoda, Chief Information Officer

The final rule for Stage 2 of Meaningful Use came out August 23rd--earlier than expected and with few actual surprises. CMS took the public comments seriously and modified the proposed rule in many areas based on those comments. The final rule is released with commentary and is a full 672 pages long, and this overview is based on a quick review. More information will be available as we dig into the rule further.

Don't forget, this rule does not go into effect until 2014 at the earliest. If you attest to Meaningful Use Stage 1 you get two years to reach Stage 2, unless you attested in 2011, in which you get three years.

There is no reason to panic, you have time to understand the new rule, but there are some themes that are important to be aware of now.

Utilize Your EHR

The menu requirements for Stage 1 have, for the most part, been incorporated into core requirements in Stage 2. Many of the core requirements have higher thresholds under Stage 2. This means that you will need to utilize your EHR more. For example, in Stage 1 the CPOE requirement was that 30% of patients have at least one medication order. One could argue that if you met that requirement exactly, and no more, you would be operating in a less safe manner, since you now have multiple processes for the same tasks. The new rule for CPOE is that 60% of medication, 30% of lab, and 30% of radiology ORDERS need to be in CPOE.

Now is the time to understand the new core requirements and begin planning and redesigning workflows to meet them.

Information Exchange

Electronically transmitting information for transitions of care for 10% of care transitions is a new requirement for Stage 2. The work that is being done on HIEs today will create the infrastructure for these transmissions, but more work will need to be done. Since so many hospital discharges are to long term care (LTC) facilities, hospitals will need to work with them to participate in the HIE. LTC does not receive any incentives for Meaningful Use, and many LTC EHRs are not prepared to exchange information today (though some are).

Now is the time to consider your referral patterns and engage those providers to begin planning for information exchange.

Patient Engagement

Under Stage 1 providers only needed to provide electronic information to patients when they asked for it, and then providers were only required to provide it 50% of the time. Stage 2 will require hospitals and eligible professionals to not only provide the information, but it also requires that 5% of patients access their information through a portal. There is also a requirement that 5% of patients are communicated with using secure messaging. There are exclusions for areas that have limited Internet connectivity, but almost all providers will need to meet these requirements.

Now is the time to talk with your vendor about their portal offerings, or if they can interface with a Personal Health Record (PHR), and begin planning how you will engage patients to actively view their information online.

Clinical Quality Measures

The requirements for Clinical Quality Measure reporting in Stage 1 were fairly easy, although the measures did not necessarily apply well to rural facilities. The new rule provides many more options for reporting and electronic submission will be required. More information will be available about the quality measures that you can choose from.

Now is the time to speak with your vendor to make sure that the reports you think are most appropriate are incorporated into the Stage 2-certified version of your EHR.

Some Changes to Stage 1

There are some changes to Stage 1 requirements that go into effect in 2013 and 2014. Many are additional exclusions. For example, if you can demonstrate that collecting some vitals are not part of the scope of your practice (e.g. Chiropractor), then you do not need to meet the objective of collecting vitals. The requirement of exchanging clinical information will be removed in 2013, but since the Stage 2 exchange requirements are so important, you cannot put off work on the exchange requirements.

Now is the time, if you have questions about those exclusions, to understand the changes to Stage 1.

Conclusion

The new Stage 2 rules for Meaningful Use have only been out for a few hours, and for the most part do not go into effect until 2014 at the earliest. This provides time to fully understand the rules and begin discussions with your vendors, referral partners, patients, HIE, and other stakeholders to properly prepare to meet the rules. The purpose of these new rules is to encourage health care providers to utilize electronic systems to be more safe and efficient, and to improve quality. Information exchange between providers of care and providing relevant clinical information directly to patients electronically are important ways to achieve these goals.

More Information

CMS final rule * CMS final rule (42 CFR Parts 412, 413, and 495) * Fact sheet on CMS's final rule

ONC standards and certification criteria final rule * ONC final rule (45 CFR Part 170) * Fact sheet on ONC's standards and certification criteria final rule - forthcoming

More information on the Stage 2 rule * HHS news release * CMS EHR Incentive Programs website