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Monitoring and Predicting: The Promise of Digital Health
August 3, 2015 10:47 AM by Silas Gossman

[Editor’s Note: this article was originally written by Eric Venn-Watson MD, MBA, senior vice president - Clinical Transformation, AirStrip]

This is the third in a three-part series looking at how digital health is transforming healthcare.

The Goldman Sachs report1 I mentioned in the first part of this series mentions that remote patient monitoring (RPM)2 enables healthcare providers to better manage high risk patients, potentially decreasing healthcare spending through better chronic disease management. Further, the report notes that most chronic disease spending can be attributed to heart disease, asthma and diabetes-disease states that represent the most fertile ground for digital health.

This is one of the most promising – and limitless – opportunities in healthcare today. Current RPM devices3 allow us to monitor CHF patients from home, providing a real-time assessment of their heart health and decreasing their risk of readmission. In the case of an asthmatic patient, RPM devices can monitor a patient’s respiratory health and provide notifications when factors such as the local air quality puts them at risk for an exacerbation. For diabetic patients, RPM can provide continuous blood glucose levels and help provide a level of glucose control that was previously unachievable. The future of RPM involves combining these tools and the patient’s entire health history with streaming analytics and clinical decision support tools that can detect when a patient’s physiologic parameters are trending outside of the normal range, and send a notification to the patient and potentially the care team when appropriate. As a result, we are able to predict and track diseases before they become acute – and potentially even prevent them from ever happening. In essence, we will be able to shift the management paradigm from reactive care to proactive care, which is mission critical in an environment where caregivers are scarce.

Ultimately, clinicians want to provide the best care possible and make a positive impact on our patients’ quality of life. The digital healthcare revolution is helping us achieve that goal, improving the way we practice and provide medical care, streamlining our clinical workflow, and helping us to make the vast number of patient data sources relevant and actionable. The old ways of doing business are no longer acceptable. The new financial and regulatory models won’t allow for it – and ultimately, the patients won’t stand for it.

The digital healthcare revolution has arrived.

1. http://www.businessinsider.com/goldman-digital-healthcare-is-coming-2015-6
2. http://www.wsj.com/articles/remote-patient-monitoring-comes-to-health-care-1424145642
3. http://www.airstrip.com/airstrip-one
Digital Health and Behavioral Modification
July 29, 2015 8:03 AM by Silas Gossman

[Editor’s Note: this article was originally written by Eric Venn-Watson MD, MBA, senior vice president - Clinical Transformation, AirStrip]

This is the second in a three-part series looking at how digital health is transforming healthcare.

Last time, I talked about how the digital healthcare revolution has arrivedand its potential applications, including telehealth. Another way this digital transformation is changing healthcare is how it affects behavioral modification and adaptation.

Over the past few years, I have noticed a significant culture change in my patients. They are more knowledgeable about their health in general, more informed about management options and more likely to want to work toward an improved level of health. They also tend to be more open about sharing their health profiles and results with family members and friends and more inclined to gradually change their behavior if they can get real-time feedback illustrating the impact of their efforts. Digital health technology provides this feedback and can be as simple as providing daily step counts or charting caloric intake vs. calories burned, or more complex by combining live physiologic monitoring with complete past medical histories to create a real-time health dashboard.

True success, however, can be achieved when patient behaviors are modified using customized health programs based on individual profiles. Digital health applicationsare rapidly evolving as a method for affecting behavior through customized, real-time interventions that can be adapted for each individual based on prior outcomes, previous responses to intervention, current physiologic and psychologic parameters, environmental and social context, as well as a range of other variables that influence the state of an individual’s health. These tools allow us to change our focus from differences between individuals to differences within a single person over time.

As more and more data sources become available and integrated into the feedback loop in a manner that provides value, we will see a continued increase in people intimately engaged and driving their own healthcare.

We’ll be wrapping up this blog series with a look at remote patient monitoring, so be sure to check back.

1. http://mobilehealthmatters.com/2015/07/15/the-digital-health-revolution-has-arrived/#more-690
2. http://www.airstrip.com/airstrip-one 

The Digital Health Revolution Has Arrived
July 20, 2015 2:08 PM by Silas Gossman

This is the first in a three-part series looking at how digital health is transforming healthcare.

[Editor’s Note: this article was originally written by Eric Venn-Watson MD, MBA, senior vice president - Clinical Transformation, AirStrip]

Digital healthcare holds the promise of saving a staggering $305 billion, according to a recently published report from Goldman Sachs1. The report predicts the technology revolution will come from increasing access to diagnostic, treatment and preventative care, coupled with dramatic cost reductions. In particular, they see significant opportunities for digitally-enabled telehealth, behavioral modification and remote patient monitoring, while much of the savings will be generated by the elimination of redundant and wasteful spending in the area of chronic disease management. 

They are right, and here’s why. Digital technology has already transformed a multitude of industries including banking, travel and retail by aligning provider and consumer. Almost every aspect of our lives is being touched by digital technology; we are more ‘connected’ than ever before. Concurrently, a number of factors are driving a similar transformation in healthcare: increased consumer demand for better, more convenient and more cost effective care, changes in reimbursement and the shift to value-based care, and of course, the availability of tools such as smartphones, tablets, wearable sensors and portable diagnostic equipment. Thanks to a digital health ecosystem that brings it all together, the relevant data becomes available through streaming analytics, clinical decision support tools and immediate communication back to patient and provider via mobile devices, when appropriate.

The Goldman Sachs report points to the following three specific opportunities: telehealth, behavioral modification and remote patient monitoring. Today we dive further into this first topic: telehealth. 

Telehealth applications are being driven both by consumers and providers, and are rapidly changing the way healthcare is practiced. I am seeing this with my own patients, who have busy schedules and a desire for convenience. They are asking for easy and efficient alternative methods such as secure texting and videoconferencing to connect with me outside of the traditional office visit and receive medical guidance. This model of care has gained significant traction, as evidenced by Teladoc’s 11 million consumers and its recent, very successful IPO.

There is another important and exciting aspect of telehealth: clinician-to-clinician communication. Telehealth tools enable me to reach out to fellow physicians and specialists rapidly to share and view secured, real-time patient information. This collaboration expedites my workflow and enables me to make quicker, data-driven management decisions. I have no doubt that these models of care will continue to expand and become, as the Goldman Sachs report states, a ‘viable component in daily healthcare practice2.’

1. http://www.businessinsider.com/goldman-digital-healthcare-is-coming-2015-6
2. http://www.businessinsider.com/goldman-digital-healthcare-is-coming-2015-6

Will The Joint Commission’s New Standards Keep You Safe from Unnecessary Medical Imaging?
July 15, 2015 10:39 AM by Silas Gossman

[Editor’s Note: the following blog was written by Karen Holzberger]

The Joint Commission has issued new standards around protocols, documentation and education that are designed to reduce unnecessary medical imaging and improve quality and safety. But is it enough?

The Joint Commission standards1 for diagnostic imaging, which recently went into effect, are designed to help prevent duplicate and unnecessary medical imaging of patients, and reduce potentially harmful exposure to radiation when patients need CT scans, MRI or a combination of these and other diagnostic tests. Beginning July 1, 2015, these standards require protocols, documentation and data collection, staff education and other criteria that raise the bar for quality and safety at ambulatory imaging sites, critical access hospitals and accredited hospitals. What do these standards really mean to the patient?

The new imaging standards focus primarily on the radiation dose index2. There are a number of uncertainties tied to the long-term impact of imaging on patients, but researchers agree it impacts patients differently depending upon sensitivities to radiation, age, body parts being tested, absorption rates and other factors and these are still being studied. In the meantime, to prevent undue risk, The Joint Commission has put a stake in the ground with these specific standards to help improve patient safety. The Joint Commission joins other accredited healthcare organizations, such as the American College of Radiology (ACR) and other clinical associations that are releasing new quality-focused recommendations, enhanced education tools and technologies3 to make it easier for healthcare teams to keep you safe from unintended risks while you receive diagnostic imaging that could shed light on serious health conditions.

As a patient and someone who has worked in healthcare technology for more than 20 years, I believe the combination of diagnostic imaging, evidence-based medicine and expert medical oversight that exists today will help organizations big and small better manage radiation exposure and protect patients today and in the future. These efforts provide great improvements in reducing unnecessary testing and putting safeguards in place to generate important results, while mitigating the long-term risks to patients when they need different exams.

The Joint Commission’s imaging standards were initially intended for release last year, but they were postponed due to lack of detail and clarity. In conjunction with imaging guidelines provided by the American College of Radiology’s4 “Body Imaging Commission” and other clinical associations, they help providers focus on the right testing to do at the right time to improve quality of care when radiologists face a flurry of different kinds of patient cases every day.

The Joint Commission’s report explains that knowledge of a patient’s previous imaging exams helps prevent duplicate imaging examinations and further radiation exposure, and they recommend considering a patient’s age and recent imaging studies when deciding the most appropriate exam. The same precedent exists for surgery today so it makes sense that something similar would apply to diagnostic imaging. The fundamental part of medicine is based on “do no harm.”

Obstacles to accurate and reliable imaging
While The Joint Commission’s standards will ultimately benefit hospitals, there are a few challenges they face in complying with these new regulations based on healthcare delivery today. Compliance becomes difficult when a patient is seen by multiple healthcare providers – especially in different geographic regions – and when the patient’s journey spans different facilities, specialists and time zones as they strive to get well.

Today, many hospitals keep a record of a patient’s medical images in their facility, and they typically provide a CD of relevant images to the patient to take with them when being treated somewhere else. However, too often the CD will end up damaged or unreadable to the next physician, and even if it works, the CD will not contain a complete story of the patient’s health including their medical imaging history. Incomplete or missing information creates doubt and risks that are not welcome in healthcare. The patient is looking for certainty in their diagnosis, the radiologist is looking for certainty in recommending next steps and the referring physician wants to ensure that he or she is providing the right treatment for the best outcome. Without accurate and reliable imaging information, everyone may not have the answers and assurances they need. The result? Repeat medical imaging.

Repeat exams are particularly problematic for patients who are most at risk because of the cumulative effectives of overexposure to radiation, such as the elderly and children. Concerns over unnecessary use of medical imaging and unnecessary costs of these tests have been around for years, but despite concerns, recent statistics show it is still a common practice. A study published in the Journal of Emergency Medicine in March 2015 shows 97% of ED physicians order unnecessary imaging because of worries that they will miss something and be sued5. Half of these physicians identify that improved education on advanced diagnostic testing would help cut down on this practice of over-ordering tests.

This all goes back to certainty. With regulations changing, clinical guidelines evolving, patient volumes growing and information access ranging from hard to get to hit or miss, the implications are clear. When physicians are unfamiliar with the appropriate diagnostic tests or the clinical best practice for a specific symptom, or they can’t see the complete patient story such as prior radiation dosing for the patient, they try to do what’s best and that often leads to repeat medical imaging.

1. http://www.jointcommission.org/assets/1/6/Approved_Revisions_Diagnostic_Imaging.pdf
2. http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_hiw_09
3. http://www.nuance.com/ucmprod/groups/healthcare/@web-enus/documents/collateral/nc_037321.pdf
4. http://www.nuance.com/company/news-room/press-releases/NC_035230
5. http://onlinelibrary.wiley.com/doi/10.1111/acem.12625/abstract

Karen Holzberger is the vice president and general manager for Diagnostics at Nuance Communications. This post originally appeared on Nuance’s blog, What’s Next.

Let Doctors be Doctors
June 30, 2015 7:25 AM by Silas Gossman
Physicians don't always realize the correlation between their clinical documentation and the level of credit they get for providing quality patient care.
[Editor’s Note: the following blog was written by Jennifer Woodworth]
No one chooses to work in the healthcare industry because it’s easy.  We do it because we want to help others. The mounting frustrations doctors face as the result of an increasingly burdensome healthcare system are not only understandable, they are justifiable. These men and women did not go to medical school to sit through hours of meetings about code sets.  Their primary responsibility is to treat patients.  And for those of us who work with them, it is our role to be the trusted partner of our doctors and clinical care teams — to ensure they share the right information where and when it’s needed. I’ve spent close to a decade working with physicians on clinical documentation to make sure it reflects their intent and they get credit for the level of care they are providing.
Over the years, the doctors have taught me some valuable lessons. When it comes to implementing a successful clinical documentation improvement (CDI) program, start with these three fundamentals:
Skip the catering: meet your doctors where they are
Everyone is busy, especially doctors, and initially, we tried to engage with them by holding early morning meetings where we provided breakfast and information about our CDI program.  We quickly discovered that we were left with not much more than a tray of cold eggs and pancakes.  So we made adjustments and began meeting doctors where they were — in their departments, on grand rounds and within the agenda of a medical staff meeting. This significantly improved physician engagement and helped us better collaborate on capturing the patient’s care in a way that was accurate and complete not just to other doctors. CDI programs are not one-size-fits all, and keeping this in mind as you reach out to your physician teams is very important.
Become a translator for health IT language
Because specialty groups each have their own medical vocabularies, different registries and workflows, they will also face unique challenges and concerns. Swedish Health Services is a multi-hospital health system that includes a heart and neural hospital. When we implemented our CDI program, we realized that we needed to tailor our approach by physician specialty — what was an important quality driver in one clinical area is not necessarily the same in another. Swedish is a “5-star institution,” and we need to uphold that reputation. So, in order to do this, we first had to figure out what each specialty group’s quality scoring was based upon, and then sit down and work with our physicians to show them the impact their documentation was actually having on their scores.
Seeing clinical data is believing
Doctors have analytical minds, after all, that’s how they decide how and when to modify treatment plans — by looking at results and analyzing the data. This holds true for clinical documentation, too.  They don’t always realize that how they document is just as important as how they are providing care; in fact, it’s the proof they are doing the right thing for patients. When we reviewed our clinical data, we found that our ICU patients were typically on ventilators longer than the average, which was negatively impacting our quality scores. Sitting down with our ICU physician team, we conducted a retrospective review and discovered that the majority of these patients had pre-existing respiratory conditions that necessitated an extended time on a mechanical ventilator. It wasn’t that they weren’t receiving good treatment, it was, in fact, our doctors doing the right thing for these patients — keeping them on the ventilator longer because they needed it — that was negatively skewing our numbers.  It was a simple error of omission: our doctors didn’t realize that by not fully documenting their patients’ pre-existing conditions in the clinical record, they were hurting their reputation as great doctors, and ours as an excellent hospital.
While not always easy, changing a culture to support a value-based care model makes sense: hospitals and healthcare organizations get paid, or not, based on how they care for their patients. Our physicians trust us to help them accurately represent the good care they are providing, and, in turn, we use CDI data to identify areas where together we can optimize quality to do what’s best for the patient.
The accurate clinical data that results from an effective CDI program not only helps our doctors earn credit for the good work they do, but also improves patient care and reimbursement for our organization. Accurate clinical data also enables us to get a clear picture of who our patient population is so we can adequately prepare for their future health needs. And, at the end of the day, that is what healthcare and the continuum of care is all about.
Jennifer Woodworth is the Director, Clinical Documentation Integrity Program (CDIP) at Swedish Health Services in Seattle, Washington. This blog originally appeared on Nuance Communications’ blog, What’s Next.

The Eligibility Impact: How and Why Eligibility Data Issues Affect Payment Integrity
June 23, 2015 8:06 AM by Silas Gossman
[Editor’s Note: the following blog was written by Paul Vosters, Discovery Health Partners president and COO]
Organizational and technology structures can keep health plans from recognizing, understanding and resolving their payment integrity challenges. However, another factor may be at the root cause of some of those challenges: eligibility. 
Eligibility issues impact a multitude of payment integrity areas including Coordination of Benefits and Medicare Secondary Payer validation and, to a lesser extent, Workers’ Compensation, Other-Party Liability and Subrogation. In fact, our research indicates that approximately 30% of payment integrity costs are driven by eligibility errors. In addition to the financial cost of payment integrity errors, eligibility issues can also have a direct effect on member satisfaction. Claims that are declined due to inaccurate or out-of-date eligibility data can lead to member abrasion and lost market share as well.
At their core, these issues all stem from the fact that health plans lack a single, definitive resource for making eligibility status determinations prior to paying a claim. This creates tremendous downstream issues as health plans make business decisions and pay claims based on flawed data.
The complex structure of health plans means that member eligibility is updated at multiple points in the claims payment process and is managed by multiple departments across the organization. As a result, it’s often inconsistent, outdated or inaccurate, and leads to improper claims payments. Until plans are able to establish a single source of the truth for eligibility, these inaccuracies can cost plans millions of dollars. Let’s examine a few of these challenges more closely: 
Multiple data sources
The sheer number of data sources feeding the master eligibility file has a significant impact on accuracy. Information comes from the members, providers, CMS, data-match vendors and other data sources. These feeds are all subject to their own timelines, standards and information challenges. In addition, these external feeds to eligibility status have a high rate of change, creating a complex hierarchy of overlapping status updates. Plans are challenged to manage these work processes and make a clear determination of primacy and eligibility that can support all of the transactions that rely on this data. 
Organizational challenges
The eligibility challenge isn’t just technical, it is also frequently organizational. Eligibility is commonly managed by line of business, meaning that status updates made by one group are not necessarily shared across the organization. For example, changes in a member’s eligibility status might not be effectively communicated between the commercial and government lines of business as the member moves from commercial to Medicare Advantage coverage. With no clear owner of the member eligibility status, managing the data across departments adds an additional level of complexity.  
Existing solutions
In addition to being spread out across different departments, responsibility for managing eligibility status is shared by several administrative systems. Plans often make the mistake of addressing eligibility in a single point solution, rather than taking an enterprise view of member eligibility management. Claims and enrollment systems often fail to address eligibility on a consistent transactional basis, and frequently capture crucial updates in notes or text format. Eligibility data is rarely shared between systems, and because there is no single data master, the priority of status changes is unclear. 
Looking to the future…
Health plans have the opportunity to dramatically improve their payment integrity performance and member retention by managing member eligibility as a business asset. The ideal solution will provide a complete and integrated picture of eligibility status across membership types and lines of business, while providing validated data for downstream applications. Doing so will require a shift in culture, as well as new technologies. Nonetheless, there are strategies that let you achieve progress in a staged progression, which we will explore in future posts. Managing eligibility data as a strategic asset is worth the effort, as it will result in millions of dollars in recoveries and cost avoidance.

Why Knowing How to “Speak Doctor” is Important for Population Health
June 16, 2015 8:47 AM by Silas Gossman
[Editor’s Note: The following blog was written by Dr. Anthony Oliva] 
Being able to "speak doctor" ensures that physicians are accurately capturing the level they provide to patients, and enables healthcare organizations to correctly identify their patient populations and predict their future healthcare needs.
I’ve worked as a CMO at hospital systems for much of my career, and one thing that I’ve learned is the importance of knowing how to speak doctor. This means listening for clues one physician shares with another about a patient that are critical to their immediate assessment and delivery of patient care. Physicians can communicate a lot of information very quickly, in very few words, and because other clinicians are trained to understand and to act quickly, the system worked… most of the time. Until recently. Now short written notes or verbal handoffs are a thing of the past and what is being conveyed about patients’ conditions may not be clear or may be buried in charts with note bloat, which is a real problem for money, patients, and predicting risks. Here are the three big problems you need to fix to get ready for population health:
Problem #1: Say what you mean
The way doctors speak is different than the coding language needed for billing and hospital payments. The impact is real, unrealized revenue for a hospital or health system when care is provided, but not documented by a physician in the EMR. The last place I worked realized $9 million of traditional revenue by fixing physician documentation up front, and Swedish Medical Center secured more than $18 million in appropriate reimbursement. Better translation of what doctors say up front through a Clinical Documentation Improvement (CDI) program brings predictable financial improvements.
Problem #2: It’s in the patient story details
When a doctor’s clinical documentation leaves clues everywhere in the chart pointing to a risky condition, but sparse clinical documentation leaves out specific details, good care may not look like it. That carries big risks for physicians and healthcare organizations that need to look good on scorecards and quality outcomes. When clinical speak indicates a potential condition, complication or cause for treatment, but it isn’t translated into co-morbidities or diagnosis codes in a record, a patient receiving healthcare may look much healthier than he or she really is. I can’t tell you how many times I’ve seen a chart when a patient spent three days in the ICU being treated for sepsis, which is a very serious and expensive situation, but the chart classified the patient through codes as having something close to a bladder infection because the diagnosis was not properly identified. In today’s competitive healthcare environment, a doctor cannot afford to look bad to payers or patients.
Problem #3: Know your patient population
Your crystal ball better predict the future correctly. When it comes to population health and accountable care, the rules are changing. If your charts don’t accurately reflect how sick your patients are or the conditions you treat in your community, there will be no path to population health management because you won’t really know your populations.
Healthcare is changing and everyone is assuming more risk ‒ physicians, provider organizations and even patients ‒ and in order to stack your team with the right types of providers, who are resourced to deliver the right services that your patients want and need, you have to know what those needs are and what they will be in the future. Accurate clinical documentation that starts with physicians today is a prerequisite for predictive modeling. No one wants to prepare for one patient population and then look back later wondering why mortality is so high or the level of care and resource drain is so much greater than anticipated. That is a problem we are solving for today.
And it starts with physicians. Hearing and understanding them, and then helping them translate what they do into the appropriate documentation is key. What a physician sees when he looks at a chart may seem completely obvious, but we live in a world where unless the words are documented in that chart, the care being provided won’t count. It’s time to retrain doctors to explain what they do in a language everyone will better understand, and reap the clinical and financial benefits.  We can do this with the basic building block of a clinically-focused CDI program to help with the translation.
Dr. Anthony Oliva, DO, MMM, FACPE, is the National Medical Director at Nuance Communications. This blog first appeared on What’s Next.

Getting the Right *Beeping* Results: Innovations in Radiology
June 1, 2015 9:41 AM by Silas Gossman
There is a culture of certainty in healthcare that is driving unnecessary testing and increasing costs. But some organizations are using the latest technology innovations in radiology to help improve patient care and protect their bottom line.
[Editor’s Note: the following blog was written by Karen Holzberger]

A few years ago, there was a witty car commercial advertising an alert feature that took the guesswork out of filling your tires by gently beeping to signal the appropriate pressure had been reached.  It featured a series of vignettes where the car horn would beep, cautioning the owner to reconsider just as he was about to overdo something (for instance, betting all of his money on one roll of the dice).  The concept of getting a reminder at the point of a decision is a compelling one, particularly if it can save you time or aggravation and guide you to do the right thing. In healthcare, any technology that can provide that level of support will have a profound impact on patient care.
Albeit humorous, that car commercial wasn’t far off the mark with healthcare challenges. Unnecessary medical imaging exposes patients to additional radiation doses and results in approximately $12 billion wasted each year, but it has also had another unintended downstream effect.  It has fueled a culture of medical certainty, where tests are ordered in hopes of shedding light on some of the grey areas of diagnostic imaging, including incidental findings.  The reality is that incidental findings are almost always a given, but not always a problem.  So how do you know what to test further and what to monitor?  And while one radiologist may choose the former option with a patient who has an incidental node finding, another might decide to go with the latter option, so who is right?
Beep! It’s important
This is a jarring situation when so starkly presented, which is why the American College of Radiology (ACR) has released clinical guidelines on incidental findings.  By offering clinical decision support on findings covering eleven organs, the ACR is helping radiologists protect their patients through established best practices for diagnostic testing.
While this is a great step forward for the industry, some hospitals are taking it one step further.  Massachusetts General Hospital (MGH) is using its radiology reporting platform to provide real-time quality guidance at the point-of-care to drive better patient care. Now, when a radiologist is reading a report and notes an incidental finding, the system will automatically ping her with evidence-based recommendations for that finding.  For instance, if the node is a certain size, it should be tested further.  These clinical guidance best practices are updated constantly, which means that radiologists have access to the most up-to-date information when treating their patients and can make the most informed decisions based on industry best practices.
Patients deserve and need to have the best and most thorough care; however, this shouldn’t put them at risk for unneeded radiation exposure.  It is neither safe, nor financially sustainable.  Health IT innovations like these – that can ping clinicians in real-time with the latest in quality guidance – will be the tipping point in the shift to value-based care.  They will forever change the standard of patient care and the landscape of the healthcare industry, and that is exactly what we need.
Karen Holzberger is the Vice President and General Manager for Diagnostics at Nuance Communications. This blog originally appeared on What’s Next.

Our High Technology May Actually Be Impairing Communication within Healthcare Facilities
May 26, 2015 9:16 AM by Silas Gossman
[Editor's Note: the following blog was written by Brian Garavaglia]
As we become more technologically advanced, we have come to increasingly enjoy many of the immediate pleasures of using such things as smart phones, emails, webinars, and  teleconferences just to name a few to communicate with others with a level of immediacy that has never before been witnessed.  Yet, has it really enhanced our communication?  Many have come to think so.  However, given the high level of technology and the great availability of communication technology that avails itself to so many individuals, one has to wonder why so many communication problems continue to happen.  
Healthcare facilities, including hospitals and nursing care centers, have frequently been plagued with communication issues.  Many of the problems often lead to serious errors in treatment.  As we have come to be more involved in constant communication with others, using our cell phones, our emails, and our Twitter accounts, we have also become more involved in using poor syntactical methods for conveying information.  I am amazed at the poor structure that I often receive in these various modes of communication.  I often witness broken sentences that are disconnected and fragmented, often without any proper syntactical structure.  This often leads one to infer what is being conveyed through these pieces of disjointed communication.  As should be quite evident, when individuals start to infer about the meaning of ambiguous and muddy communication, incorrect assumptions can be made, which can often lead to critical errors, and in the case of healthcare issues, errors that can have fatal consequences.
Unfortunately, we have continued to experience severe issues in communication within healthcare.  Part of it is due to the culture of healthcare.  We have often become quite accustom to using brief, arcane symbols for larger meanings.  For years the use of these forms of medical communication, such as b.i.d for two times daily, or NPO for nothing by mouth have come to be standard ways of communication.  Yet, they have been far from unambiguous and have frequently led to errors due to a less than clear form of communication.  Now, we have come to use cell phones and emails that we feel can be used with total disregard for any proper grammatical standard.  Interaction among physicians, nurses and other medical practitioners using these forms of communication have often led to a form of brevity in which subjects and objects are deleted from the sentence structure, fragments now become substitutes for sentences, as well as creating forms of communications that often fail to make sense because of the brief, unstructured, and agrammatical forms of communication we have come to take as standard forms for communication through these modalities.  Many of these forms of communication become a scattering of neologisms, which if they were to happen within a normal form of verbal communication, would frequently be manifestations of schizophrenia.  Yet, we have come to tolerate this type of poor grammar, syntax, and hence poor communication techniques, especially for important levels of communication in our healthcare environments. 
What is becoming apparent is that as we come to rely more on higher levels of technology to communicate, we continue to face further degradation of our communication ability.  We previously relied considerably on interpersonal, written, and vocal levels of communication.  However, with modern technology we have continued to use mediums such as email, Twitters and text messaging that has further made use of cryptic methods of communication, symbols and emoticons as well as used partial phraseology instead of sentences with proper and clear syntax.  This type of ambiguous communication that has become so readily accepted and used creates the potential for disastrous implications in healthcare.  In an area, such as nursing care facilities, in which you often need to communicate with greater precision for the health and welfare of the residents that you serve, having to be a cryptologist to decode the poor communication that has become all too common through our texting and emails is creating situations that is rife for continued uncertainty among the communicants.  
I continue to be amazed at how intelligent individuals have come 1) to rely on heightened forms of communications that they 2) use so poorly.  I must make it clear that it is not technology that has led to the poor communication that has come to exist in many areas of our society, including healthcare.  In fact, one would think that with the ubiquitous modes of high levels of technology that we can now use, it would make communication much clearer.  Technology has the potential to make us communicate with greater precision.  However, we have come to take technological innovations for granted because they are so readily available to us.  We have come to use these forms of modern technology in a sloppy manner, which has obfuscated our ability to communicate with a level of clarity.  
Furthermore, our continuously increasing levels of reliance on these technological modalities for communication have further led to a degradation of our interpersonal ability to communicate with each other in a situational context.  Think about the problems that this portends, especially in healthcare.  This is an organizational climate that depends on interpersonal interaction.  Our healthcare environment has already become quite alienating with the higher levels of technology that often distance the patient from the caregiver.  Now, with individuals walking around healthcare facilities, with cell phones and other forms of computerized devices that they cryptically use to communicate with and that we have become so reliant on, we often have lost many of the very important skills that make care so ‘human,’ our ability to communicate in a clear and precise manner. 
Mistakes in healthcare are not new.  Furthermore, communication problems have frequently been endemic in healthcare, and in particular, as it applies to this article, long-term care.  Mistakes found within long-term care are frequently the result of poor communication and with the use of our more advanced communication technology, coupled with acceptance, if not an outright toleration for, using vague, ambiguous and often highly cryptic phraseology, the likelihood for further issues related to the technology and associated ways of communication that we have come to employ with this form of technology foreshadows continued problems in the years ahead.  
It must be remembered that again this is not an indictment against technology.  As stated if used appropriately it can have the potential for enhancing our communication as well as the provision of care to those in long-term care environments.  However, we must be aware that using technology to communicate in the manner that we are currently using it only alienates the caregiver from the person that is receiving care.  Furthermore, and even more important, unless we correct the way we communicate, using more appropriate syntax and communicating our thoughts in a clear and concise manner, we will create a toxic environment, filled with ambiguity and the need to infer meaning that will only have a deleterious impact on those that we care for in our long-term care facilities.

Denial Management: How to Harvest Your “Lowest Hanging Fruit”
May 20, 2015 9:33 AM by Silas Gossman

[Editor’s Note: the following blog was written by A J Johnson, general manager of analytics solutions, TriZetto Provider Solutions]

In today’s healthcare environment, it is challenging for providers to succeed financially. Operational costs for providers continue to rise while reimbursement rates decline. And, it’s harder to get paid as more employers shift medical costs over to employees. In fact, more than half (55%) of patient payment responsibility after insurance ends up as bad debt.

To help offset these financial challenges, you need to get paid correctly from payers. A big part of that is identifying, appealing and tracking claims that were denied incorrectly. However, provider offices are already so busy, and arguing with payers about claims denials is probably one of the last things you want to add to your “to do” list.

When appealing all of your claims denials seems out of reach, focus on harvesting your “lowest hanging fruit” to see a better return on your time investment. Here are two ways to identify which denials will yield the highest return when appealed.

1.     Focus on denials with the highest probability of getting paid. These are denials that you can most easily address, such as denials where information was missing from a field or where coding or data was incorrect due to human error. You can quickly fix this information and resubmit the claim for reimbursement. 

2.     Other denials may be out of your control, such as denials due to a service that was never documented or benefit eligibility issues. You won’t be able to convince the payer to pay for undocumented services or change their fee schedule contract, so these denials are not worth your time to appeal. However, to help stop this type of denial from occurring in the future, you should go back and review your eligibility verification process to ensure it is working correctly.

Of all the efforts you put toward ensuring your organization is financially successful, managing denials may be the most critical step – especially when you consider that providers transmit millions of claims every day and even the best-performing medical practices experience a denial rate of 5%.2 In addition, the transition to ICD-10 is expected to compound this problem with denial rates projected to rise anywhere from 100 - 200%.3

The potential revenue loss from claim denials isn’t easy to see when it’s hidden. But, letting denials pile up can hurt your bottom line, and leaves behind revenue that is ripe for the picking. Focusing on “low-hanging fruit” denials will help you receive the best return on your staff time investment 

For information on other types denials that represent the “lowest hanging fruit,” read this free e-book: Denials Management Best Practices: Identifying the Lowest Hanging Fruit.

1“Overhauling the U.S. Health Care Payment System,” by McKinsey & Co., June 2007; “Cultivating the Self-Pay Discipline,” The Advisory Board Company, Financial Leadership Council, 2007.
2Medical Group Management Association, Performance and Practices of Successful Medical Groups, 2013.
3Workgroup for Electronic Data Interchange, “ICD-10 Critical Metrics.” October 2012.

Nebraska Medicine Decreases Costs by Trialing Google Glass and Video Conferencing with Telehealth Carts
May 13, 2015 9:36 AM by Silas Gossman

[Editor’s Note: the following blog post was written by Greg Girard, director of product, HealthCare with Calgary Scientific]

At Nebraska Medicine, technology innovations bring with them opportunities to enhance patient care. The ability to integrate patient images with synchronized and simultaneous audio and video has Nebraska Medicine’s telehealth coordinator Kyle Hall looking at new ways to implement telehealth and mobile devices, such as iPads and Google Glass, at clinics and hospitals.

Video Conferencing and Medical Imaging

“Marrying video conferencing to imaging has been really difficult,” explains Hall. “Now with ResolutionMD’s support for audio visual data, we have a one stop shop that allows us to access patient images from multiple modalities while viewing audio video feeds.”

In hospital and clinic settings, telehealth sessions are frequently conducted with the use of telehealth carts which integrated wireless Internet access, video monitors, cameras and CPUs on a mobile cart that can be wheeled between patient rooms or from bed to bed in an ER. While patient images from specific PACS or image modalities have been integrated with telehealth video conferencing systems that run on these telehealth carts, Hall is experimenting with adding enterprise-wide image access to the carts by using ResolutionMD for both viewing images and displaying real-time audio visual feeds. With this combination of health IT, no matter what the source of a patient image is, the telehealth cart will display it during a video conference.

“Now with grand rounds and patient care conferences, specialists can be part of the process without being there in person,” says Hall. “Multiple video connections that include the patient and provider and the specialists can be running while they all view the same image.”

The combination of ResolutionMD with telehealth carts is not only efficient, it’s also cost effective.

“We anticipate that we can significantly reduce the amount spent on audio visual equipment,” he explains. “With an Internet connection, the cart can go anywhere and offer an all-inclusive solution”

Most exciting, the video feed to the telehealth cart can be coming from any source including Google Glass. In a teletrauma situation, for example, the provider can be the source of the patient feed while patient images are displayed on the monitor. Using Google Glass, the provider can move around while providing the real-time patient conferencing feed instead of relying on the telehealth cart’s fixed camera.

“With this set up, the telehealth cart becomes the center point of communication, displaying patient images coming in from a PACS, the connection with a remotely located specialist and the provider’s view of the patient through the Google Glass,” says Hall.

While challenges remain in implementing this combination of technologies, using such a system for local connections between providers on a hospital campus is not far off. Keeping the communications local, or within a hospital campus network, eliminates security issues as well as transmission issues that come with using the cloud for Google Glass feeds.

“Localization takes the jitter out of wearable telepresence,” explains Hall. “It also improves speed, lowers costs on the network side and makes the security team happy.”

With new rules that allow the use of telehealth by Accountable Care Organizations and the increased emphasis on coordinated care, health IT departments are turning to telehealth as an efficient way to connect providers that work at the same hospital or within the same integrated health system. In the near future, Nebraska Medicine’s providers may be using Google Glasses to facilitate these connections.

Big Data and Value-Based Care
May 4, 2015 11:05 AM by Michael Jones

[Editor’s Note: the following blog post was written by Steve Whitehurst, CEO of Health Fidelity]

As we continue our transition from a fee-for-service world to a new set of programs promoting value-based care, it is apparent that data is going to be a key factor in separating the successful programs from the failures. Value-based care takes into account patient outcomes over a period of time and aims to deliver these outcomes at a reasonable cost to both the individual and to the overall system. The delivery side of value-based care typically relies on evidence-based medicine and best practices in providing care.

A number of value-based care models and related programs are being tested through various public and private initiatives. Among them are:

1. Medicare Shared Savings Program - also known as Medicare Accountable Care Organizations (Medicare ACO)

2. Physician incentive programs such as Physician Quality Reporting System

3. Medicare value-based purchasing

4. Bundled Payments for Care Improvement (BPCI) for episodes of care

5. Capitated payment programs that quantify long-term risk such as Medicare Advantage

6. Value-based payment modifier

A common theme among these is the necessity of data to evaluate success or failure of the programs. Since many (if not all) of these programs are in the experimentation stage, a deep understanding of data can transform the way populations are evaluated and cared for. Additionally, data can change the payment equation by accurately predicting the cost of care for patients by understanding risk factors and health trends.

Big data in healthcare refers to the identification, capture and rationalization of data from traditional and non-traditional data sources. Traditional data sources include clinical, financial and operational data. Clinical data is typically obtained from electronic health records, which are now pervasive in the country as a result of the Meaningful Use program. Financial data is obtained from claims, revenue cycles and other billing systems. Lastly, operational data is obtained from supply chain management, resource management and purchasing systems. Non-traditional data sources include patient-reported data via tools such as personal health records and patient forums/affinity groups, data collected through devices that ranges from monitoring vital signs to measuring blood glucose and other important indicators as well as public health data sources such as infectious disease registries, immunization registries etc. Last but not the least are health and wellness trends that add to available data.

As is apparent, this is a treasure-trove of data and, if used correctly, it can further the goals of value-based care. For example, using available demographic data, clinical data, risk factors and long-term prognosis can be determined, and thus the suitability for membership in an ACO from a population of eligible patients. Similarly, risk due to chronic conditions can be correctly identified, analyzed and managed for better long-term clinical and financial outcomes in certain Medicare programs. Quality measures that impact incentive programs for physicians can be more accurately measured by having access to a variety of data sources.

To summarize, data is already helping make value-based care more successful. We are still in the nascent stages of being able to collect, analyze and use all available data sources. In fact, it is not immediately clear how the non-traditional data sources will impact care delivery and cost reduction; however, the trend is unmistakable that having access to large volumes and a wide variety of data will allow us to ask questions that influence the way care is delivered, outcomes are improved and cost is reduced.

Building a Culture of Sustainability
October 15, 2014 12:00 PM by Lynn

[Editor's note: This blog is posted on behalf of Paul Spiegelman, chief culture officer, Stericycle, Inc., award-winning speaker and best-selling author of "Patients Come Second."]

Gallup, a global research and consulting firm, annually conducts a survey called "The State of the American Workplace." This year the results should alarm American business leaders, particularly our healthcare colleagues.

Of the approximately 100 million people in America who hold full-time jobs, 50% of American workers are not engaged. Another 20% of those surveyed - 20 million people - are actively disengaged from work. Chances are these employees - statistically 70% of our workforce-will not improve our patient experience or fulfill our institutions' mission unless the culture changes. 

Their discontent affects your bottom line, too. Disengaged workers cost the U.S. between $450 billion to $550 billion each year in lost productivity. They can also cause increased physical injury. Gallup compared the top 25% of engaged teams with the bottom 25% and found that the poorly managed teams experienced 50% more accidents than their counterparts. Employee injuries mean risk-particularly related to costs, compliance and reputation.  With millions of dollars now at risk based on patient satisfaction and the increase in pay for performance initiatives, how do we prioritize our efforts for the best return on investment?

The answer is we need to start inside. We need to show our commitment to our own employees first, because engaged employees will provide better patient care, which in turn will drive patient loyalty, and positively impact the bottom line. We need to focus on our core purpose as healthcare organizations to heal and promote health. And we need to rally around initiatives that make our employees feel good about the impact they are making. One such initiative that touches all of these issues, makes the world a better place, and impacts the bottom line is sustainability. Greening operations is an opportune platform to align employees to your institution's values, provide them with more training for a safer work environment and bolster pride in their employer-all of which results in better engagement. 

Here's how:

Define and Align Your Values

The healthcare landscape is in a state of constant change:  90% of newly hired physicians are employed by brick and mortar hospitals and our networks are getting more spread out with multiple sites with the growing development IDNs and ACOs.  This is why we need to align our teams with a common strategy and purpose.

Getting Started

The first steps in making sustainability an element of your cultural framework is  to make sure that it is stated as part of your organizational vision .  For example:

  • Define sustainability as a core value
  • Quantify what it means to have a sustainable "impact" for your organization - measure and monitor over time
  • Recruit executive buy-in; the message has to be delivered repeatedly and consistently from the top

Help the Initiative Trickle Down

Establishing "green teams" empowers employees to help manage sustainability initiatives with pride.

  • Find internal champions and develop an oversight committee
  • Recruit department representatives to be the conduit to their teams. Engage in friendly competitions and publish results and best practices
  • Become a thought leader in your own community by publicizing your impact on patient safety and the environment via your organization's public channels and trade media

Learn From Others

When it comes to building great cultures around sustainability, there are some influential examples in our industry.  Consider the following:

  • John Hopkins Hospital found employee education a critical component to green operations. Through recycling, its overall trash production decreased by 17 percent.

Beaumont Hospital, Royal Oak, a 1,070-bed hospital in metro Detroit, has 500 "green officers" - employees who are ambassadors of green practices to their departments. 

Measure the Initiative: Going Green, Seeing Green

Can greening operations also drive financial results? With a culture of properly engaged employees, of course it can!  Arkansas Children's Hospital saw a significant cost savings with a "Know Where to Throw" campaign that educated employees about red-bag disposal, resulting in a 32% waste reduction and a six-figure savings. 

Sustainable Change

By making purposeful culture changes, supported by consistent and ongoing training and communication, your management team leverages the power of engaged employees. As this base grows, your patients, community and environment can feel the power of a well-managed and motivated staff.  And if we have a motivated staff, we'll see better patient care, better safety scores and better financial results.

The Paradox of Innovation: Overcoming Resistance to Change
December 5, 2013 11:37 AM by Robby Chakler

Editor's note: the following blog post was written by Tom Hills, executive vice president of sales, PerfectServe

I regularly cross paths with hospital executives looking to integrate the latest and greatest health IT tool or processes. By far their primary challenge in adopting new technology is dealing with resistance to change. Last month, I attended a bi-annual Health Management Academy meeting that addressed this common obstacle. The forum - which brought together CEOs, CMOs, COOs and CFOs from the largest health systems in the US - sparked me to think about a few things causing this barrier to adoption, and how we can overcome them:

  • The value of time - In healthcare, time is money. But when the next big thing is at our fingertips, how do we capture the attention of administrative leaders when there are so many initiatives competing for their time? I think the solution lies in physician leadership. I can attest to the fact that hospitals and health systems with early adopter physician visionaries are more successful in rallying their organization to consider innovative, easy-to-use technologies that support more efficient and higher quality care. It's important to involve these doctors in the decision-making process from the get-go, as this often spurs adoption of the technology once it's been implemented.
  • Real-time revenue vs. long-term investment - Current change in health care is requiring CFOs to attack every budget line item. Thus, providers are wary of implementing something new and innovative if it can't demonstrate clear and immediate ROI. But oftentimes, the real value of a solution comes from using it over a long period of time. Key to the successful implementation of technology is considering the long-term value - in helping to drive more efficient communication processes, a more mobile clinical workforce, faster time-to-treatment, etc. - versus focusing only on the short-term return on the investment.
  • The "risk" of implementation - Health systems all across the country are consolidating resources through M&A, reorganization and downsizing, often causing leaders to be more averse to taking risk.  New technology isn't often apt to make it into the mix, as it adds another unknown variable that clinicians need to get used to. But it can be a valuable tool in standardizing care across multiple facilities and departments. Provider leadership must show a commitment to innovation by devoting time and budget to it, perhaps by even creating a separate "innovation fund" to fuel these critical projects.

What's clear to me is that while the industry as a whole recognizes that innovation is critical to improving care delivery, it can be challenging during tough times to inspire the adoption of new technologies across provider organizations. Providers need to be sure to continue to commit to funding innovation despite uncertain return. Fostering collaboration between physicians and executives to choose the best new technologies can help ensure the innovations that do make the cut are ones with the highest odds of success.

Optimizing Labor Management in Accountable Care Organizations Part 3: Key Technologies
November 13, 2013 1:53 PM by Robby Chakler

Editor's note: this is the final installment of the 3-part series on ‘Integrating Labor Across ACOs.' It was written by Chris Fox, CEO of Avantas

In the first two posts of this three-part blog post series, I outlined the current state of ACOs, the need to focus on labor across the organization, including medical groups, and offered a few key labor management strategies to take advantage of the opportunities of belonging to an ACO (and not let the potential inefficiencies of a larger organization take hold).

In this final post I'll discuss technology, specifically what you should look for in labor management software to effectively manage your workforce at the enterprise level - the key to capturing economies of scale in an ACO. Before I get into that however, I want to stress the importance of what we see as one of the most integral, but too often neglected steps in a technology implementation: policy and process alignment.

Labor management is complex. You can't just plug in a solution and expect all the pain points to disappear. It takes some due diligence to make sure the foundation is set; then comes technology. Part of that due diligence is policy and process alignment. Every organization has specific business rules it operates under. These rules can be things like last float/last cancel policies and protocols for how staff sign up for open shifts. Within the outpatient/clinic world, this can include things like consistent shift start times, the ability to share like skills across locations, and standardized labor targets within like cost centers. It is crucial that any policies your organization is utilizing are standardized across the enterprise and that they are carried out in practice, every time.

The alignment between policies and practices is crucial because your workforce management software should serve to automate them. By embedding your rules into your labor management tool you all but ensure consistency - and consistency leads to predictable and sustainable results. Within an ACO, as multiple hospitals and clinics may be involved, standardization can yield substantial savings and process improvements. This brings us to the list of what to look for in labor management software:

  1. Customizable. As I just mentioned, your software should have your business rules embedded. Ideally, the vendor you partner with for your software solution will have expertise in best practice labor management strategies. If they do, they will understand how crucial this step of the process is. If your solution is going to help you achieve your specific business goals and work within your unique culture, it must be tailored to help you do just that.
  2. Accurate Forecasting. This is virtually becoming a standard feature in labor management software. Many vendors tout the accuracy of their predictions, but the key question to ask here is how far out are the predictions accurate. Many are claiming a high degree of accuracy, but it's only a day or two before the shift. This does little to help an organization build better initial schedules. Once schedules are built around an accurate prediction, that forecast must be continually refined in the weeks leading up to the shift, with anticipated holes in the schedule being automatically posted as open shifts for qualified staff to pick up. This increased accuracy of initial schedules along with a continually refined prediction of needs will help your organization be proactive in its approach to delivering patient care.
  3. Analytics Powered. Famed management consultant Peter Drucker said "What gets measured gets managed." This has never been more true, but one of the problems today is that there is so much to measure. A health system can generate hundreds of metrics. The key is deciphering what metrics are the most meaningful - which ones, if tracked and improved on, will help the organization realize the greatest benefits. For analytics to be powerful they must be transparent. Meaning, everyone who should have access does have access. Next, the data must be easy to understand and prescriptive, so those who view it know what to do to improve. Finally, it must be timely. If it is not timely it is not actionable. Lessons can be learned from older data, but true power comes from the ability to leverage data to make course corrections so targets are hit now, not the following pay period or next quarter.
  4. Cloud-based. With virtually all organizations we partner with, we are replacing a competitor's software. Typically, the tools we replace are not cloud-based. This usually means we are supplanting a software that is several versions outdated. This happens for several reasons, one of which is "version fatigue." It often seems like no sooner has a tool been installed, the vendor is back pushing the organization to purchase an upgrade. This can be an especially hard sell if the software does not have widespread user adoption and is, consequently, not producing the results the vendor promised. With a web-based tool there is no versioning. You always have the latest enhancements and functionality. And most vendors provide, or should provide, these updates at no additional cost. Within an ACO, web-based software solutions, where applicable, can provide substantial cost savings and provide greater flexibility to staff, who can access the tool any time anywhere.

It's important to mention here that cultural change must be a key component of any new technology implementation. Technology serves to automate best practices. It will not fix anything unless the people using it are focused on doing so. An organization's leaders and employees must be committed to learning what they must do to reach their objectives and then make the necessary changes to actually do it. Within an ACO, whose members may be dozens of hospitals and/or clinics, the need to address cultural change elements is absolutely crucial.



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