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The Politics of Health Care

Understanding and Addressing Physicians' Barriers to Achieving Better ACO Quality Metrics
March 24, 2015 8:35 AM by Robby Chakler

[Editor's note: the following post was written by Dan Malloy PhD, executive vice president, Quantia, Inc.]

ACOs have long understood that patient engagement is a critical element to keeping individuals healthy and the chronically ill stable. Now ACOs are beginning to appreciate the importance of  physician engagement and alignment around the cost and quality measures that have emerged as the performance threshold for their organizational health. After all, the criteria driving these metrics often lie in the hands of the physicians associated with the organizations.  

However, many ACOs struggle to know for sure that their physicians are aligned in ways that will achieve such metrics. When they're not, it's crucial to understand why. By offering physicians access to web-based, expert-led content on topics that drive these metrics, ACOs and other health systems are helping avoid potential financial penalties associated with these measures, not to mention improve patients' quality of life.

Depression screening

ACOs that fail to reach the quality metric in the area of depression screening may face reduced reimbursement. Yet a recent poll of over 3,500 physicians who participated in an expert-led QuantiaMD content segment on depression screening performance measures found that the majority (61%) only screen patients who present with symptoms. Just 25% say they screen every patient, and 7% say they don't screen any patients at all.

That healthy percentage of physicians who are only screening patients with symptoms may be putting their patients - and their quality metrics - at risk.  As one physician remarked, "Since I've started screening every new patient, I've been astounded at the number of ‘good actors' there are in this world with very high numbers on their PHQ but who I would never have dreamed are depressed by their affect. It's been a very gratifying activity."

As part of this segment, these physicians offered their own reasons for the inconsistency, and opportunities for systems to address these barriers.

Reasons cited for inconsistent depression screening include:

  • Lack of time (63%)
  • Lack of access to mental health services (14%)
  • Uncertainty on how to screen (10%)

Opportunities physicians cited to help increase depression screening include:

  • More time with patients (57%)
  • Better access to mental health services and better screening tools (40%)
  • Staff-assisted onsite care support (27%)
  • More education on depression (20%)

While physicians may always feel strapped for time, their call for increased education and exposure to available screening tools is something that can be addressed through web-based content, including expert advice on how to best manage these screenings. Concise, interactive presentations that are convenient for physicians-along with the ability to ask questions directly of these experts-enable  providers to address the reported  obstacles and help them  to better leverage the resources that are available to help achieve these metrics.

Colorectal cancer screening

Another key ACO quality metric for which physicians have significant potential impact is colorectal cancer screening rates. Thousands of physicians engaged in an expert-led interactive presentation on the topic on QuantiaMD to brush up on best practices for increasing compliance rates. 

Based on a follow-up survey of nearly 300 physicians who interacted with this segment, they appear to have gained a deeper understanding of their influence on increasing screening rates in their practices, and feel greater confidence in their ability to improve screening rates after interacting with the expert led content. For example:

  • 75% of physician respondents say the content influenced how they manage colorectal cancer screening in their practice
  • 68% feel they can increase colorectal cancer screening compliance rates in their practice after interacting with this presentation
  • The number of physicians who say they've initiated a patient activation system since interacting with this content increased by 65%, and the number of those who have since designed a delivery system within their practice to enhance screenings increased by 36%

While many physicians acknowledge that a lack of patient activation is one of the toughest obstacles to overcome, some physicians suggest that we all have a role in helping reverse the major image problem that the preparation for this test has.  

As one physician remarked, "The procedure is not always the hesitancy...word is out there that the prep is vile. That said, there are MUCH better preps now (bisacodyl + miralax as one example), which makes it way more tolerable. One awful prep, folks tell 10 people, and then 10 do not go. Easy prep, IV sedation, easy procedure...we need to get the word out there."

The good news is that based on this survey population, at least, the majority of physicians are leading by example-less than 10% of those doctors who are eligible for colorectal cancer screenings themselves admit non-compliance. The reasons they cite for avoiding the test are the same ones their patients have - fear, laziness, other medical problems taking a higher priority, and even the self-described "lousy excuse" of not wanting to give up two days in the office to get the procedure. Recognizing these universal barriers to optimal preventive health can help physicians approach their patient conversations with greater empathy.

Key takeaway

The consequences of inconsistent screenings-in terms of undiagnosed medical conditions and reduced reimbursement-are obvious. Gaining a window into physician's attitudes and behaviors around these metrics helps identify and address these issues. 

Do you have the insights and physician buy-in needed to address these and other quality and patient care outcomes? The nation is watching.

A New Perspective on Privacy and Security as Foundational Components of Information Governance (IG)
March 16, 2015 2:01 PM by Robby Chakler

[The following blog post was written by Rita Bowen, MA, RHIA, CHPS, SSGB, Sr. VP of HIM and Privacy Officer, HealthPort] 

Healthcare must move beyond compliance to a greater model of IG.

For the past three years, the Privacy Point column has focused primarily on privacy and security- issues, challenges, priorities along with strategies to promote compliance and mitigate risk. During that time, the HIPAA Omnibus Rule was piloted and refined in 2013 and 2014, with September 23, 2014 as the final date for all business associate agreements to comply with the current regulations. With procedures in place for that phase of compliance, the focus is now shifting to the value of information governance (IG) in healthcare.

Going Beyond Compliance

Despite decades of privacy and security regulations, many organizations lack proper governance and management practices to address ever-increasing risks and threats. According to the Identity Theft Resource Center, approximately 42 percent of major data breaches reported during 2014 were attributed to healthcare organizations. That's a stunning statistic. And security risks may be on the rise for 2015, especially if the HHS Office for Civil Rights (OCR) follows through with its random audit program to assess compliance with HIPAA privacy, security and breach notification rules.

Traditional privacy and security solutions are not sufficient to address rapidly emerging risks and threats. Data and security breaches and compliance penalties point to inadequate control of information. Establishing proper controls requires effective IG that ensures protection of trusted information. Compliance alone is not enough.

AHIMA's IG principles recommend a proactive, collaborative, interdisciplinary approach. Privacy and security must be viewed from a new perspective-as foundational components of an enterprise-wide information governance model.

Former AHIMA CEO, Linda Kloss, MA, RHIA, FAHIMA and author of Implementing Health Information Governance: Lessons from the Field, states: "Leading organizations understand that governance and management of privacy and security must be in full compliance, but must also build trust and transparency through ethical stewardship practices that may go beyond compliance. . . They also understand that a compliance mindset does not fully serve the interests of the patients they serve. . . Their sound governance of privacy and security considers ethical compliance and fiduciary responsibilities."

As the demand for trusted information increases, leading healthcare organizations are moving from a compliance approach to a broader IG perspective aimed at improved quality of care and organizational performance. Fortunately, AHIMA has taken the lead toward a smarter, strategic maturity model. And HIM professionals are best qualified to educate all stakeholders on the value and responsibility of stewardship-privacy and security, risk management, and overall data integrity-critical components of trust in information.

Advancing IG through Collaborative Leadership

While some organizations have taken steps to initiate an IG program, most are still in the infancy stage of implementing consistent and collaborative IG practices. Whether your organization is just beginning or in the process of refining its program, here are four strategies for advancing IG:

  • Assess existing policies, procedures and systems for capturing, processing, delivering and storing data. Set priorities to build a program aligned with your organization's goals.
  • Engage an executive sponsor by showing the business value of IG-quality of care, cost reduction, compliance, improved patient outcomes, risk mitigation, accurate reimbursement.
  • Create an interdisciplinary team including HIM, IT, compliance, C-suite, revenue cycle, legal and risk management.
  • Develop a plan for implementing the AHIMA principles.

HIM professionals already know the value of IG. Their knowledge, skills and experience will advance enterprise-wide information governance through strong collaborative leadership.

Focusing on the Essentials

Once an IG framework is established, organizations should focus more closely on the essential elements of an effective program-privacy and security, quality and integrity, data capture, records management, availability and use of information. While privacy and security concerns continue to occupy center stage, each component is an integral part of a greater IG model. 

In the coming months, IG Matters will delve deeper into the various aspects of each component, including the following:

  • Clean master patient index (MPI)-Ensuring a high level of MPI integrity must be a top priority for enterprise-wide IG programs. Preventing errors and inconsistencies is critical to patient safety.
  • Data dictionary and data map-Both tools are key to understanding the source and meaning of data across systems.
  • Best practices to promote data integrity-Quality and integrity management are the foundation for trust in information.
  • Interdisciplinary education-Ongoing education regarding privacy and security, risk management, and quality of information builds a culture of IG.

In today's evolving regulatory environment, healthcare providers cannot afford the risks of ineffective management and governance of information. That is why 2015 must be the year of IG in healthcare. And HIM is ready to lead the way.

Welcome to the IG Journey

With many thanks to all the dedicated followers of Privacy Point, I now invite you to join the IG journey. Throughout 2015, IG Matters will focus on strategies for building and sustaining a successful program, the essential elements of IG, lessons learned from case study organizations, and more. Your ideas for future topics are most welcome.

Rita Bowen is senior vice president of HIM and privacy officer at HealthPort. She can be reached at rita.bowen@healthport.com.

Data Security Dilemma
March 3, 2015 12:09 PM by Robby Chakler
[Editor's note: the following blog post was written by Jeff Margolis, chair and CEO, Welltok]

Data, data, everywhere...the practical dilemma is that even as the increasing threat of data security challenges is hitting the front page, healthcare industry leaders and pundits are in nearly universal agreement that far more - not less - consumer interaction and engagement with meaningful healthcare data is necessary to drive significant improvements in healthcare value. It's perhaps analogous to the notion of a person needing water to drink, but the water around them is either saltwater or it potentially contains harmful bacteria or parasites. Frustrating to say the least! 

While all of the facts around the Anthem breach aren't known yet, other health plans and providers are - as any rational person might expect - expressing heightened concern and examining their own vigilance. It's difficult to feel "safe" when you contemplate the awe-inspiring scope and alleged consumer-harming intent of the breach. Although healthcare industry organizations endeavor to follow best practices, even the most prepared organizations can be subject to the challenge of a data breach. And beyond the challenges of Anthem and its members, digital innovations across the industry that can generally benefit consumers will almost certainly face potential delays. 

Allow me to put the healthcare industry data security dilemma into practical terms. First, understand that the HIPAA and HITECH Acts establish minimum requirements for compliance with the Security and Privacy Rules, with the intent of these regulations being to define a common baseline across the healthcare industry. Second, understand that these regulations do not set forth best operational practices for assuring the protection of consumer data, nor do they impart a step-by-step security and privacy framework that establishes best practices for the dizzying array of computers and devices that consumers use today to interact with their health plans, doctors, hospitals and pharmacies.

To be sure, there are excellent and capable people, consultants and security-centric companies to drive and share best practices. However, I feel legacy technologies and existing platforms in healthcare will struggle to apply new security advancements at a sufficient rate to mitigate efforts by the "bad people" who plague multiple industries today.

Today's healthcare consumer-interactive platforms need to be built on the fundamental principle of anonymity with security and privacy engineered into the core design, unlike those based solely on HIPAA. This includes applying the HITRUST CSF security framework and data segregation of PHI/PII from consumer facing capabilities. We began the development of our CaféWell Health Optimization PlatformTM from the perspective that there needs to be a better way to deliver both an engaging, personalized user experience and a safe, secure environment that also mitigates risk.

As my intent is not to be overly technical, I'll conclude with this thought. Figuring out how to help consumers benefit from more data about themselves without increasing the risk of exposing their identity is not easy...but it is possible!

Will 2015 Be The Year Your Watch Teaches You About Your Health?
February 5, 2015 8:57 AM by Robby Chakler
[Editor's note: the following blog post was written by  Dr. van Terheyden, CMIO at Nuance Communications.]

Regardless of which side of the exam table you sit, we're all healthcare consumers. Technology holds the potential to create clinical synergy between patients and caregivers, providing better intelligence about personal health data and outlining proactive measures to take to become better partners in health care.

There is no known medical condition that enables an individual to predict the future.  While such an ability would be extremely useful for myriad reasons, we have, instead, learned to hone and leverage our analytic skills to deduce what might occur, relying on the data we cull and parse to help forecast the future.  So, when it comes to predicting the year ahead, we should consider the one we just had.

Regardless of which side of the exam table you sit, we're all healthcare consumers

Consumer technology is often a good indicator of what type of capabilities and functionalities might be in store for health IT.  This past year, we saw major players in the tech space announce their forays into healthcare.  While this will not be without its challenges, it does not diminish the underlying fact that there is a need and want for better technology in healthcare- regardless of whether you are a patient looking to effectively manage your weight or a physician struggling to juggle patient care and administrative duties.

In the last year, we saw a wave of next-generation wearable devices flood the market, and as a result, we, as patient consumers, now have streamlined access to information such as our daily step count and average heart-rate on our watches.  We know that ease-of-use, understandability, and some level of gameification ("Congratulations! You've reached your target heart rate today!") are vital to maintaining engagement.

I believe this is the beginning of something much larger, a groundswell movement that will result in patients wanting more information about their health data, and, more importantly, craving a better understanding of what all these numbers actually mean and how to positively impact them. Achieving this level of engagement demands a simpler intelligent interface that doesn't require a learning curve, but is one that consumers can just use. Clever user interface designs can only go so far, particularly given the small visual real estate available on wearable devices, and the addition of capabilities such as intelligent voice assistants will be an integral part of this explosion of personal health management.

Having a heart-to-heart about your heart

Technology holds the potential to create clinical synergy, bringing patient consumers (who have become professional health IT consumers, or health prosumers) better intelligence about their personal health data and outlining the proactive measures they can take to become better partners in their own health.  The average patient consumer may not have a reaction to the phrase "Your Protime this week is 3.3," but for someone with a heart condition, this number is very important and indicates how fast her blood is clotting.  The data, while extremely useful to a clinician, is only helpful to the patient if she understands what it means and how she can take the right actions as a result.

The future is about patients managing their own care and working alongside clinicians to drive better outcomes.  To the woman who has a Protime of 3.3, access to these results supplemented with clinical guidelines would mean that she wouldn't need to wait for her physician to call with diet recommendations, she would know her blood is clotting too slowly and that she might have an inadequate protein consumption or might need to increase her vitamin K intake.  If the number required that her Coumadin dosage be adjusted, this would be the point where her physician would reach out to her to discuss.

Although a basic example, it is one that has endless permutations when it comes to building a more engaged patient population.  There is no one more invested in your health than you, and the person who cares the next most about keeping you well, is your physician.  I believe that clinical synergy will be driven by both patients, who want to actively manage their chronic conditions and take meaningful preventative care measures, and physicians who want to empower their patients to better understand how the choices they make have significant health implications.  Technology is the connective fiber that can enable the transmission of this important data, and help translate it into wisdom.  And that truly is the crux-the data flowing between patient and physician must be relevant and meaningful.  That ability for technology to determine the relevancy of health data information is just around the corner and soon our wearables will be able to notify our health information data that deviates from our personal "normal" results.

Approximately 75 percent of U.S. healthcare expenditure is related to chronic care management, imagine the impact this level of clinical synergy will have on driving a healthier population while reducing cost.  I'm ready, are you?

ICD-10: Ready, Set, Code
October 2, 2014 10:10 AM by Robby Chakler

[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation for Nuance.] 

Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.

In its latest news, CMS announced that Oct. 1, 2015 is the ‘new' final ICD-10 compliance date. "ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics," argues CMS in its July 31 announcement. I could not agree more!

My advice is stay positive, nimble and be wise by reading between the lines. Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Our current administration in Washington, DC has been riddled with constant criticism and commentary scandals and may view the transition to ICD-10 as risky. All healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.

What steps do you do now to ramp up readiness efforts?

  1. Stay the course!  You have an ICD-10 transition plan at hand; move forward with it.   Update your ICD-10 project plans with dates and deliverables, built for an October 1, 2015 compliance date.
  2. Be nimble.  Don't ever find yourself thinking ‘black and white.'  We must expect the unexpected. If the government changes the deadline again, you adjust and do a course correction, but you don't stop and never blow up your plan.
  3. Focus on improving clinical documentation integrity throughout the patient stay. Be the champion for clinical documentation improvement (CDI) and focus on getting the right information into the right medical record at the right time because this will have a positive impact on quality, reimbursement, and coding regardless of shifting dates.
  4. Leverage technology to enhance your clinical documentation and coding workflow. Many providers use many manual processes, for instance,, Spreadsheets and sticky notes, for clarifications and queries in medical records and emails to physicians. Take this opportunity to assess your workflow and plan for technology-enabled solutions for assisting your medical staff and clinical documentation specialists with your CDI program and coding/compliance.
  5. Now you have 14 months to develop a customized dual coding program plan for your organization.
  6. Know your own data!  Identify your high impact surgical procedures in various clinical specialties and train your coders the nuances of coding in ICD-10-PCS.

Stay positive, plan for success and always be willing to course correct should there be a shift in the ICD-10 compliance date.

Bonnie Cassidy is the senior director of health information management (HIM) innovation for Nuance, where she oversees the development and implementation of HIM strategies. She currently serves on the Commission on Accreditation for Health Informatics and Information Management (CAHIIM) Board of Directors, is a Fellow of AHIMA, an AHIMA Academy ICD-10-CM/PCS Certificate Holder and ICD-10 Ambassador, and a Fellow of HIMSS. Prior to joining Nuance, Bonnie served as the vice president of HIM product management & innovation at QuadraMed, and served as an executive with the Certification Commission for Healthcare Information Technology (CCHIT), Ernst & Young and the Cleveland Clinic Foundation. She was the 2011 President/Chair of AHIMA.

Global Healthcare Megatrends: Clinical Challenges
September 3, 2014 1:36 PM by Robby Chakler
[Editor's note: the following blog post was written by Toby Samo, M.D., chief medical officer, Allscripts. This is the first installment in our 5-part series focusing on Global Healthcare Megatrends] 

There are more than 7 billion people on the planet today. Our growing global population has triggered some of the biggest healthcare challenges we'll ever face. Listening to clients in Australia, Canada, Singapore, United Kingdom and United States, I believe many of these issues are universal. This post is one of a five-part series that explores the clinical, population health, financial, regulatory and technical challenges we share as a global healthcare community.

Caring for more patients than ever before
Worldwide healthcare providers are seeing more patients than ever before. In part, because we're living longer. In developed nations, there has been a huge increase in life expectancy over the last 50 years, and experts believe the trend will continue.

For example, U.S. citizens had a life expectancy of 68.2 years in 1950, which jumped to 76.6 years in 2000, and is expected to reach 83.9 years by 2050. Not only does that mean caregivers have more patients overall, but these patients are aging and require more health care.

Other cultural and economic factors contribute to an increasing number of patients. As middle classes expand in some nations, they seek more health care, more often. Countries that adopt universal health care models will also increase the patient population.

This growing number of patients heightens another global challenge: a shortage of primary care providers.

Providing the right caregiver at the right time
With more patients, the healthcare industry needs more caregivers. Several countries are employing "physician extender" positions to handle and coordinate routine care.  These staff additions free the physician to provide expert care. Physicians can then practice at the top of their licensure, which is a better use of resources. 

It also helps with clinician satisfaction as they are focusing their time on the patients that need their help the most.   However, in some cultures this approach is more of a challenge, as patients may insist on seeing only the physician.

There is also an increasing types of sites of care.  No longer will a patient only be seen in the physician's office.  They may also receive care in pharmacies, schools, offices and grocery stores. 

We must remember that quality clinical care is not just that patients can see any caregiver.  It's that people receive the right level of care, no matter where they are.

Driving towards a single patient record
Most countries we work in are all large enough that choosing a single electronic medical record (EMR)* to facilitate data sharing is simply not an option. So everyone in the world is looking for ways to connect a virtual single patient record.

Even as EMRs gain traction in developed countries, we still struggle to communicate between organizations. Patient data does not easily flow among caregivers.  New technologies are now appearing in the realm of Healthcare Information Technology to standardize and connect various systems.  This technology will be at the hub of future healthcare delivery facilitating the movement of information between the many stakeholders of healthcare at the point of care.

Many cultural factors affect healthcare communications worldwide, including language. There are more than 6,900 languages spoken on this planet. Roughly 5% of the world's population speaks English as a first language, which takes third place to Mandarin and Spanish. This variety affects the single patient record on a most basic level: How do we manage patient data in different languages?

Measuring to ensure best practices
Many countries have identified important clinical measures. For example, it might be simple rates of immunization among children and influenza vaccine among adults. Or it could be more complicated measures of chronic diseases, such as regular Hba1c evaluations for diabetic patients.

Some countries are ahead in this process. Most developed countries have reporting requirements aims at improving quality of care.  These is a movement towards setting up parameters that result in rewards, similar to Meaningful Use in the United States. Because it's not just about "checking the box" by ordering a certain test - it's about improving outcomes.

As we look at all of these clinical requirements, it's clear that proper use of EMRs can make a difference. There is still a lot of work to be done, and specific challenges to address in each region. But I'm encouraged by the progress I see globally.

Do these clinical challenges resonate in your part of the world? What other aspects would you add?

* Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).

Please check back on Executive Insight for the rest of our Global Healthcare Megatrends series. We will highlight Population Health, Regulatory requirements, Technical landscape, and Financial models.

Are You Adding Value?
June 30, 2014 2:22 PM by Robby Chakler

[Editor's note: the following blog post was written by Neil Pithadia, founder and CEO, I Will Change Healthcare

Moe, the Two-Star Motel Repairman

I arrive at my motel on a road aptly named Motel Circle. As I approach my accommodation in my rental car, a man in a blue shirt that looks of Middle-eastern descent greets me. As he approaches me, I see his name, "Moe" sewn into his shirt I figure likely shortened for Mohamed. His sleeves are rolled up, he is carrying a paint bucket in his left hand and his pants are well worn with paint stains. I quickly deduce that Moe is the motel's repairman. He asks my name and we make small talk. We depart as I park my car and walk to the front office to check in.

"Good afternoon, Mr. Pithadia. I hope your journey from Texas was well." Perplexed, I ask the front desk person how he knew my name and furthermore how did he know I was coming from Texas. "Well, Mr. Pithadia I would like to say I have special powers, but you see Moe let me know that you had arrived and as per Texas, when booking with our agent, she made a note in our system that you were coming from Texas.  So would you like to see my next trick?"  Astonished, I nodded like a child. "Very good, you see this contraption to my right, I will now press this button and it will produce a document. This document is very important, so please focus." He pulled the document from the laser printer and flipped it so that I could read it, "you see that line [I nodded again], I need you to sign it should you incur any incremental charges." I chuckled as I signed and left the front office. 

I booked the motel online two months ago getting a 15% discount. I thoroughly read the reviews online which were positive so I already knew I was getting good value in pricing. I was looking for an adequate no-frills budget motel to sleep for the night. However, the experience with Moe and the front desk was the type of welcoming you expect at a four or five-star hotel, but not the $58-a-night two-star Vagabond motel. Yup, that's right, Vagabond motel. The check-in experience was not expected and I wanted to know why Moe did what he did.  I caught up with Moe working on some fencing and asked him if he did this for all customers. He chuckled with a genuine smile. He mentioned that even though this was a budget motel chain, the manager of the motel was a really good guy.  "My family went through a rough patch with illness and the manager and owner helped me financially and allowed me to keep my job after being away for an extended time. It is the least I can do for them." In the scheme of things, any capable and competent handy person could do Moe's job. He, however, approached his job from a different angle. Moe was generating value for this motel all because Moe had a sense of purpose. His loyalty to the motel and manager was genuine. In his book, Drive, Daniel Pink points out that employees like Moe outperform once they are given two things: financial security and a sense of purpose.

All afternoon, I thought about Moe's situation. I was not asked nor given a survey to fill out, but instead I had a genuine desire to find a way to rave about what had just happened. I ended up spending two hours writing reviews on various websites.  Whether the motel realized it or not, they had just generated "thick value." In his book, The New Capitalist Manifesto, author Umair Haque defines "thick value" as value, which is authentic, not created at someone else's expense, and is meaningful on human terms. According to Haque, organizations in the 21st century need to generate "thick value" to remain viable and that the era of "thin value" where organizations are shifting societal benefits to shareholder benefits is not viable.

Treat the Employee Right in Order to Treat the Patient Right.

If we treat our employees with the same level of care, we get those outcomes we so badly desire. A great example of a large organization that has embedded this mantra is the Ritz-Carlton. This motel group is synonymous with the best customer experience and they are upfront about it; their motto (Fig. 1): "We are ladies and gentleman serving ladies and gentlemen." Every employee carries around a pocket-sized card that describes the motel group's motto.

Be warned, having a flashy motto and forming a policy that all employees carry a card displaying it on their ID badge does not automatically translate into each and every employee indoctrinating the motto. This is where many of us in healthcare fail. We want to be sexy in healthcare: "Patient-first," "Top-tier," "World class," yet this falls short when it comes to translation. Why is that?

Ritz-Carlton knows that in order to translate its motto to a meaningful purpose, they must first empower their employees to do so. Each employee has the ability to spend upwards of a mind-staggering, $2000 a day per guest (1). This level of trust allows this organization to translate and deliver on their motto.  What is Ritz-Carlton in essence?  It is an experience, where luxury and desire intersect. They have developed a structure capable of providing this and have equipped their employees to deliver this experience. Accountability of delivering this experience lies solely on the employee.

What is healthcare in essence? You may mutter something along the lines of "delivery of quality patient care". Yet, these days we see zoom-creep in Doctors' offices, where we focus too much on an add-on service rather than the essence, itself. Things such as elaborate buildings, "diamond" or "medallion" services and free valet parking do not replace the fundamentals of quality patient care. 

Lack of empowerment. How many frontline employees in Providers' offices do you know that are as empowered to take ownership of the patient experience?  Most have become robotic "I apologize" machines. "I apologize Mr. Pithadia, the doctor is running late/behind" or one of my favorites, "I apologize Mr. Pithadia for waiting for an hour, but the doctor had to go to the hospital, he's going to have to reschedule your appointment." I have been short-changed many times when it comes to my time vs. their time to which I hear, "I apologize...."  Never once has a front-desk employee said, "Mr. Pithadia, the doctor is running 20 minutes late, I'm going to tell him that you are waiting and he will be here in 5 minutes." These individuals are not empowered to make decisions that are best for the patient experience. The sexy motto of "Patient-first," can never translate into fruition because we have neutered our front-line employees.

The Powerless Healthcare Customer.

I knew exactly what type of service I would receive during my stay at the Vagabond motel. I was going to get a two-star motel for $58 a night. I had power as a consumer. By deciding to buy or not buy, consumers have created and decimated businesses-from motels, banking, travel to cellphones, pressure from consumers drive innovation and ultimately shift competition, prices, quality, and value. Yet, here is where healthcare remains unique. Healthcare has little price sensitivity and things such as market forces and consumer pressure do not affect price elasticity, quality or value.

Therefore, healthcare in America represents "thin" value. There are numerous articles getting lots of publicity regarding this. Steven Brill's Time's article, "The Bitter Pill: Why Medical Bills are Killing Us" (2) comes to mind which has stirred much attention. Brill mentions that large healthcare systems are thriving in this market, especially non-profits, terming them "non-profit profitmakers." Yet, it is these profits that are divorced from people being better off.  So I ask you, healthcare leaders, what type of value are you creating for your patients? 

We can open the discussion of how we got in this mess and how the larger issue is that millions of Americans are insulated from the true cost of healthcare. The point remains, that we are at a critical juncture where the purchasing power of the healthcare customer is becoming more relevant with advances in technology, pressure from government, and increasing transparency into our operations. Just in late April 2014, CMS called for the new P4P (Pay for Performance) measures in its Inpatient Prospective Payment System including requiring hospitals to disclose a standard list price for all medical services they provide.  Whether or not this comes to fruition is yet to be determined, nevertheless, the customers are asking, "Where is the value?"

If we stick to the fundamentals of delivering quality patient care while instilling a sense of purpose and empowering our employees to make the best decisions for the patient experience and bring transparency to the consumer, we start to increase perceived benefits of the customer and this generates "thick value."  We need a paradigm shift where we change the public's perspective of us. Not as "profit makers," but instead contributors to society, after all this is our distinct advantage.


1. Reiss, Robert. "How Ritz-Carlton stays at the top." http://www.forbes.com/2009/10/30/simon-cooper-ritz-leadership-ceonetwork-hotels.html

2. Brill, Steven. "The Bitter Pill: Why Healthcare Bills are Killing Us." http://www.time.com/time/magazine/article/0,9171,2136864,00.html

Neil Pithadia manages a multidisciplinary surgery group in Dallas, Texas.  He is also Founder and CEO of I Will Change Healthcare (www.iwillchangehealthcare.com)

Preserve the HIM Workforce During the ICD-10 Delay
June 23, 2014 12:04 PM by Robby Chakler

[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation, Nuance]

With the ICD-10 transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind

The American Health Information Management Association (AHIMA) represents 74,000 members who have been preparing for ICD-10 for years.  With the transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind. Across the U.S, ICD-10 transformation teams have been assessing, training and implementing technical changes that were to be in place on October 1, 2014.

 "This frustrates me. For the last 4 years of my career I have prepared for this transition, passed the AAPC ICD-10 Proficiency Assessment, and our government once again decides THEY aren't ready. How am I supposed to convince my surgeons that they have to work on this when it keeps getting delayed?" certified coder/auditor

Hospitals and provider offices in the U.S. hired skilled HIM coding professionals to prepare for the transition to ICD-10.  Some were consultants, coders, and project managers while others supported revenue cycle and HIT initiatives. What are these organizations going to do now with these highly-skilled members of the workforce? There are concerns that smaller hospitals and health systems may be forced to have layoffs, while others may redirect these resources to Meaningful Use initiatives or stay the course while being champions for ‘No ICD-10 Delay'!

As a past president of AHIMA, I have been meeting daily with HIM colleagues across the country as they rethink their strategies for ICD-10 implementation. The ripple effect of this latest delay has been devastating for some, particularly new graduates. There are still so many refinements that must be addressed for ICD-9 and ICD-10 coding workflow redesign, that HIM resources are critical for the much needed fine tuning of clinical documentation to ensure the highest level of accuracy for both financial and clinical success - not to mention optimizing the use of new technologies tied to the current and future state of the healthcare coding system.

"We are going to find ways to use these employees we hired to do I-10 coding. There seems like there is so much need for documentation, classification and informatics in healthcare we will make sure to find use for these folks in the interim," reports Todd Strumwasser, CEO of Swedish Seattle.

The Impact of the Delay on Resources

  • New grads and new hires - They expected their coding skills would be in high demand and now find that some of the anticipated vacant positions have vanished. This delay casts a cloud on the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs. We must ‘stay the course' and hire these precious resources.
  • Physicians and practices - Some fell behind on their ICD-10 implementation and rejoiced at the delay news, but professional practices should use the time to prepare their clinical documentation for improved ICD-9 coding while they implement CDI programs.
  • Coding educators - Coding education programs and educators had switched to teaching only ICD-10 codes to students, but now are reevaluating their educational plans and transition timelines, and are putting ICD-9 back into the curriculum and certification exams because new graduates need both ICD-9 and ICD-10 to work.  This is a costly effort, as it requires re-training as well as redesigning coursework to appropriately prepare students.
  • Tax payers - CMS estimated that another one-year delay of ICD-10 would cost the industry an additional $1 - $6.6 billion on top of the costs already incurred. This does not include the lost opportunity costs of failing to move to a more modern and specific code set, which better supports population health and data analytics to identify optimum clinical treatments on different types of patients. Don't kid yourself. We are all paying for the delay in some way.

The ICD-10 delay has been devastating to some and costly to all. My advice to healthcare executives and clinicians is do not stop your ICD-10 transition planning. Stay the course and use the time for testing and auditing so you will be prepared for success.

When is the Right Time to Add Provider Coverage? Medical Scribes vs. PAs/NPs
March 21, 2014 12:39 PM by Robby Chakler

[Editor's note: this blog post was written by Michael Murphy, MD, founder of ScribeAmerica] 

Medical scribes and medical scribe vendors are riding a new wave of change in the American healthcare system where doctors and hospitals are being consistently called upon to do more with less. But if there's one thing to remember in medicine it's that there's not always a one size fits all solution for every problem.

Medical scribes work hard to master the complexities of various EHR systems to help doctor's focus on medical decision making rather than being highly paid data entry specialists. As scribes continue to become the standard practice in emergency departments from coast to coast some groups are critically evaluating their provider to patient staffing ratios and whom they use to work those provider hours.

But when is it the right time to add medical scribes? No doubt the simplistic mind looks at scribes as a line item, but are they really an added cost or if implemented correctly a net revenue item? Would it be a better investment to hire a nurse practitioner (NP), or physician assistant (PA) who potentially can do more within the organization than just document on EHRs?

That answer historically depends on the needs and size of your organization, but I would argue it depends more on the provider to patient staffing ratios, which really should drive decisions about additional coverage. Most large emergency departments with more than 20,000 annual visits likely have the resources and needs to bring on both scribes and PAs/NPs. What if your hospital is smaller than that? Does it make more sense for you to bring on a PA/NP rather than a medical scribe or vice versa?

Looking at the numbers
For many hospitals PAs and NPs have proven to be an effective means of dealing with the demand for more doctors without having to pay the full salary of a doctor. Nationally, the average salary for a Emergency Medicine doctor is about $250,000  per year, versus $87,000 for nurse practitioners, and $79,634 for physician assistants.

However, for an average of $20-$23 per hour you are able to hire a medical scribe with the ability to customize their hours to fit the needs of your organization. So taking an 18k volume ED where you see on average 2 patients per hour but experiences boluses of up to 5 patients per hour. The department may want a PA/NP for about 6 hours per day to cover those busy hours, however cannot hire someone for 6 hours and are forced to pay for a 10 or 12 hour shift and thus significantly affecting the revenue flow. Replacing the PA/NP with a medical scribe will put a spring back in your provider coil and allow you to see those large volumes of patients that you once could not, without one. At the end of the day, you have a net revenue positive of $200,000 annually while not compromising patient care.  In today's Healthcare environment, this is a significant impact on the bottom line.

Medical scribes enable a physician to see and treat more patients. Whereas a PA or NP can help divert patients with smaller problems away from a doctor to allow them to focus on the most serious cases. A study by medical system reviewer Software Advice found that NPs and PAs on average can perform about 80 percent of the same tasks that a doctor can.

When is a right time to add PA/NP? Well let's look at a 60k volume ED with an average provider to patient ratio of 2.08. This site has 56 physician hours and 24 PA/NP coverage daily. Due to decreased reimbursement and a new lower payer mix, the emergency department now requires a subsidy from the hospital to keep its doors open. Instead of taking this subsidy why not consider changes to the staffing model to increase your PA/NP utilization and reduce your physician hours? If you were to go to 36 physician hours and increase your PA/NP coverage to 48 hours you could even add 60 hours of medical scribe coverage and be budget positive roughly $320,000.

The above approach reduces the provider to patient ratios to 1.98 and emphasizes the physician as the quarterback, assisting the PA/NP with most cases.

Consult the budget
With those numbers in mind the next step in your decision-making is to consult the budget. Can you really afford to hire, a PA/NP or a medical scribe, considering that reimbursements cuts are a common theme in government discussions.

If the answer is no, you might consider looking at it in another way. Will your organization in its current form be able to effectively weather the big changes taking place in the American healthcare system over the next year? Between the ICD-10 implementation, the Two-Midnight Rule, and the major provisions of the Affordable Care Act taking effect it's likely you need to be preparing either through hiring additional staff, training existing staff, but more likely, both.

Assess EHR comfort levels
The next step is to assess your physicians' comfort level with EHR's. Many physicians find them challenging and get in the way of patient care.  National data on EMR implementation has shown, that physician productivity decreases and persists 6 months after implementation. A medical scribe solution could be the best answer and most cost effective.

Consult your Press Ganey and HCAPS scores
Next you can consult your Press Ganey and HCAPS scores to see where there is room for improvement, regardless of whether your scores are high or low overall. For example if patients are complaining about long wait times to see a doctor, more than their quality of interaction with the doctor then either a scribe or mid-level provider solution will reduce the door to provider times.

Making your decision
The prevalence of both medical scribes and PAs/NPs are the result of the changing landscape of healthcare in America. Your critical analysis should consider the cost benefit of a scribe or PA/NP, take into account how your physicians are incentivized, and the overall provider and patient satisfaction. It's important to be prepared for the big changes ahead, but it's also important to consider other options when increased coverage is demanded.

5 Simple Steps to Get Your ICD-10 Plan Started
January 2, 2014 10:24 AM by Robby Chakler

[Editor's note: this blog post was written by Jackie Griffin, associate vice president of client services at TriZetto Provider Solutions]

It's less than 10 months until the ICD-10 deadline, but many providers are finding it difficult to get started with their ICD-10 planning. Others have started their efforts, but a transition of this magnitude can be overwhelming, and many don't know what the next step should be.

Whether you're stuck in the middle of planning or still trying to get started, here are five steps to help make your ICD-10 plan more manageable:

  1. Identify all the places where your practice uses ICD-9 in current workflow. Some examples of areas where ICD-10 will impact are clinical documentation, EHRs, superbills, paper claims, electronic claims and reporting for government agencies. Wherever ICD-9 is used, there will be an ICD-10 impact, so identifying these areas now will help you plan how to transition them.

  2. Conduct a gap analysis to understand where you need to be by October 1, 2014. The results of the analysis will help identify any gaps within your workflows, documents and technology systems that will make it difficult to transition to ICD-10. You'll need to focus your preparations here to avoid any negative impacts to your practice, such as delays in reimbursement or inefficient use of staff time.

  3. Identify solutions that can help your practice transition in these areas, such as new coding books, new superbills and new paper claim forms. For nearly every practice, these solutions should include updating your existing software to accommodate ICD-10 codes. Your practice management software vendor and your clearinghouse may have already notified you about how they are updating their systems for ICD-10. If you haven't done so, contact your vendors to learn whether you need to install new upgrades for ICD-10.

    In addition, you need to think about how you will train your clinical and front office staff for ICD-10. Some industry associations, such as AAPC, offer training boot camps to get your staff up to speed. Other organizations, including CMS, offer ICD-10 resources on their websites for you to use to help prepare staff.

  4. Outline your ICD-10 plan. Start by listing the solutions you plan to pursue, steps needed to implement them, expected cost for each step and timeline for completion. This will help you budget your time and resources appropriately.

    Industry research estimates that transitioning to ICD-10 will cost the average 10 physician practice more than $200,000. In addition to the costs associated with preparation, many practices will experience delayed reimbursements and decreased productivity once ICD-10 takes place. It's recommended that you secure a line of credit at least six months prior to the ICD-10 deadline so you can keep your practice afloat.

  5. Implement your ICD-10 plan. This will include training your staff, learning how to use new versions of your EHRs, installing software upgrades, adjusting internal processes, testing your claims with your clearinghouse or payers, and establishing a line of credit.

In addition to these steps, this ICD-10 Planning Worksheet is a helpful tool to guide your practice through each part of your ICD-10 transition.

Planning for ICD-10 is overwhelming, but attempting the transition without a well-organized plan could be catastrophic for your practice. I encourage you to take the time now to organize your efforts, one step at a time, to ensure you are ready for the deadline.

Fixing Healthcare Costs
May 17, 2013 10:43 AM by Kelly Wolfgang
Editor's note: This blog post is written by Alex Tolbert, founder of Bernard Health.

Our healthcare system is broken partly because consumers don't know what anything costs. As patients become more proactive in making informed healthcare decisions, we all agree this should be fixed. But why is it so hard?

Achieving price transparency in healthcare is difficult because healthcare business models rely heavily on a lack of transparency.

Insurers, hospitals and providers want a better healthcare system as much as anyone, but can't afford to inflict damage on their businesses by making prices transparent overnight.

To better understand how transparency affects healthcare, let's take a look at the business models for insurers and hospitals.

Insurer Business Model

If prices were completely transparent, then insurance companies who had negotiated the lowest prices would begin to lose their primary advantage. This is because that pricing information would give medical providers and other insurance companies more power when negotiating and competing with them.

An insurer's business model can be boiled down to this:

  1. Negotiate discounted prices with providers.
  2. Insure people, collect premiums.
  3. Pay claims to providers at discounted prices.
  4. Keep the difference.

Since that is the business, here is how you win financially:

  1. Negotiate the lowest prices with providers.
  2. Offer the lowest premiums so you can attract the most insured people.
  3. Enjoy the virtuous cycle that ensues.

What virtuous cycle?

The more people you insure, the lower the prices you can get from providers. If you can get the lowest prices, you can offer the lowest premiums. Offering the lowest premiums will win you the most insured people, and so you can continue to negotiate the lowest prices from providers. And so on.

Hospital System Business Model

If prices were completely transparent, then it would be difficult for the hospitals to justify the high prices they charge for things available elsewhere for a fraction of the price. In other words, if everyone knew that "Procedure ABC" costs $3,800 at the hospital and $600 for the same quality at a standalone facility next door, the hospital would lose a lot of business.

The typical hospital system business model can be boiled down to this:

  1. Negotiate prices with insurers to be "in-network."
  2. Get paid at those prices on patient claims submitted to insurers.
  3. Pay your doctors, "midlevel" providers, nurses and facility/equipment costs.
  4.  Keep the difference.

Since this is the business, here is how you win financially:

  1. Negotiate the highest prices with insurers.
  2. See as many patients as possible.
  3. Submit as many claims as possible for each patient.

It's a lot easier to do more tests/procedures per patient than to attract more patients. As such, your contracted prices for tests and procedures are really important.

Fortunately, as a hospital system, your size gives you leverage when negotiating with insurers. The insurers need you in their network more than they need a given imaging center. As a result, you're able to negotiate prices that are a lot higher and still be in-network.

Fueling the Movement Toward Transparency

Creating a better healthcare system starts with price transparency. The growth of health savings accounts and transparency start-ups, like Healthcare Blue Book and Change:Healthcare have fueled the movement toward price transparency.

In addition, insurers and hospitals are working hard to provide transparency. To offset the damage transparency will inflict on their business models, they're working to develop other competitive advantages.

As consumers continue to share the burden of ever-increasing healthcare costs, it's only fair that they be armed with the information needed to make informed decisions about their healthcare. This transparency will lead to a better-functioning and lower-cost system with happier providers and patients.

Patient Confidentiality and Social Media
April 26, 2013 11:22 AM by Kelly Wolfgang

Editor's note: This article was posted with permission from its author, Christine Gondos, Igloo Software. She can be reached at cgondos@igloosoftware.com.

The fastpaced healthcare industry is continuously evolving -- whether it be newly released studies, new best practices or new techniques, the healthcare community thrives off of innovation.

While annual conferences provide the opportunity for healthcare professionals to connect, the majority of professionals rely on email to exchange new findings. Healthcare professionals have recently placed an importance on social media networks (such as Twitter) as an additional outlet to exchange ideas. While social media provides an opportunity for medical professionals to connect and discuss best practices, this ultimately becomes problematic due to the confidential nature of the discussions.

So how can healthcare professionals network, engage in conversations about practice and share knowledge while maintaining confidentiality and ethical standards?

Igloo Software's Senior Vice President of Marketing & Operations, Andrew Dixon recently presented at the CIO Healthcare Summit where he discussed "How Healthcare Organizations are Moving from Social Media Marketing to Social Business Strategy." Instead of connecting on public social networks, more and more healthcare organizations are creating a social business strategy so they can collaborate on their own private network.

Secure enterprise social platform organizations like Igloo unite healthcare professionals, practitioners and patients so they can collaborate on ideas and keep information in one area. After a patient leaves the office, you no longer need to feel that sense of ambiguity questioning if you remembered everything he or she said. No longer does a conversation need to live in the room you had it; nor your email inbox, nor your notebook.

Enterprise social software erases ambiguity and allows information to be accessible yet secure. Here are four use cases of how enterprise social software enables healthcare professionals to stay connected outside the office.

  • Kimberly-Clark Clinical Solutions is a health division of a large consumer goods company that has a very large health product portfolio including medical devices & infection prevention. To facilitate research, they launched a social extranet solution to act as a product evaluation center for open innovation & customer engagement.
  • Ontario Health Quality Council, an independent provincial body for patient care, coordinates a myriad of stakeholders in a member portal to report on the health system's effectiveness and opportunities for process improvement.

Patient Communities

Are your patients curious about learning more information about what you said in a recent appointment? While you may question the validity of checking Wikipedia or the intimidating results Google reports back, patients often feel alone when they leave their provider's appointment. Healthcare organizations realize this and have bridged the gap by offering patients a portal where they can connect.

  • Children's National Medical Center provides patients with a secure, private virtual place where they can ask questions, find answers and share experiences around a specific health condition. Their Emergency Medical Services for Children Program (EMSC) National Resource Center also provides a secure portal for grantees to interact and share information with each other in support of EMSC's national child advocacy programs.

Practitioner Communities

Want to bring together key stakeholders within a healthcare association to work together and  improve healthcare delivery? A conference may be a great way to get everyone together, but how will you collaborate after?  

Enterprise social software platforms provide practitioners a specific work area where they can collaborate on documents and share best practices.

  • Drug Information Association uses a social extranet to connect their 18,000 members in the biopharmaceutical industry for online learning, collaboration and managing their communities of practice. Since adopting this new form of technology, their collaboration tools are now streamlined and this area facilitates knowledge exchange and relationship building in a private member portal for their 32 special interest groups.
  • American Academy of Family Physicians (AAFP), representing more than 100,000 family physicians and medical students nationwide, improved their collaboration since launching an online community for peer networking, information sharing and practice transformation. Members have access to online seminars, practice tools and the "Ask An Expert" area. Known as Delta Exchange, the award-winning online network connects physicians, clinical staff, office staff and primary care-focused residency programs committed to the Patient Centered Medical Home.
  • TransforMED, a wholly-owned subsidiary of the American Academy of Family Physicians (AAFP) also capitalized on the benefits of social collaboration. In an effort to improve patient care and assist primary care physicians with medical practice redesign, over 500 practices and more than 5,000 medical professionals across the country connect and collaborate using Igloo Software.

Internal Communities

External facing communities (extranets) have gained tremendous momentum for healthcare organizations. Effective collaboration, improved knowledge sharing, and accessibility anywhere - it is no wonder that more and more healthcare organizations like The College of Family Physicians of Canada, Aetna, and Femnene are adopting social intranets to collaborate inside their organization.  Bye bye filing cabinets and shared folders.

The organizations mentioned above stay organized with hierarchical storage of documents with unlimited folders, inline preview and full version control. Organizations and associations in the healthcare industry now have the power to stay connected to other healthcare professionals, practitioners and patients in a secure environment where confidential information is safe.

For more information, visit http://www.igloosoftware.com/blogs/inside-igloo/continuingtheconversationoutsidethedoctorsoffice4waystostayconnected

Cloud Computing Meets HIPAA Omnibus: A Provider Checklist
March 26, 2013 12:08 PM by Adrianne OBrien
(Editor's Note: This guest blog was written by Frankie Rios, CISSP, VP information security and compliance, GNAX.)

Cloud computing and storage is an undeniable migration path and IT strategy.

Overall spending on cloud technology is expected to reach an estimated $150 billion annually by 2014, according to a recent Gartner Group study. And within healthcare, 35 percent of health IT professionals surveyed said their organization was implementing or maintaining cloud computing in 2012, up from 30 percent in 2011, according to a new survey by Vernon Hills, IL, technology vendor CDW.

However, not every software application in healthcare is a candidate for moving to the cloud. And many old myths about cloud computing and cloud storage continue to confuse both covered entities (CEs) and business associates (BAs).

The HIPAA omnibus rule, released in January 2013, basically incorporates the HITECH Act security provisions into HIPAA, confirming the security and privacy requirements in the utilization of technology in healthcare. Below are five key changes under the HIPAA Omnibus Rule:

  1. BAs of CEs are now directly liable for compliance of certain privacy and security rules.
  2. The rule strengthens the limitations on the use and disclosure of PHI for marketing and fundraising, and it prohibits the sale of PHI without individual authorization.
  3. It adopts the increased and tiered civil monetary penalty structured by the HITECH Act.
  4. It mandates breach notification for unsecured PHI under the HITECH Act.
  5. It modifies the HIPAA privacy rule as required by the GINA (Genetic Information Nondiscrimination Act), prohibiting health plans from using or disclosing genetic information.

With the increased focus on cloud computing, healthcare organizations should develop a set of criteria that helps evaluate potential cloud vendors and their compliance with these requirements. Here is a list to help healthcare providers get started.

Risk Assessment

In order to protect themselves, CEs should perform a risk analysis on all potential cloud vendors. The risk assessment should include policies, privacy and security awareness training, account management, physical security, business continuity, incident response, and media disposal.  Maintain assessment documents and vendor responses for six years and have them readily accessible should Office of Civil Rights auditors come knocking.


Review your existing Business Associate Agreements (BAAs) with cloud computing partners and ensure they are updated to comply with HIPAA omnibus. For example, contract language should be specific as to the service, usage, and location of the data to be stored in the cloud.

For cloud-based partners using multi-tenant hardware, specific technical and procedural controls for sequestering information by CE or BA should be stated and included in contracts. An indemnity clause must be included stating that the cloud vendor carries enough insurance to cover a breach.


Know if the existing or potential cloud vendor has been audited. Do they have a current SSAE report? If there were findings, is there a documented remediation plan? Are regular, internal audits conducted, and is the cloud vendor willing to share the results?


Does the vendor provide encryption for the communication of information and the data at rest? Encryption is the best way to protect data and prevent breaches. HITECH requires that communication pathways and data storage devices are encrypted.  Ask cloud vendors to define their encryption methodologies for both.

Business Continuity

Business continuity has always been a must have with cloud-based solutions. Some of the new omnibus requirements make it even more important for CEs and BAs. Questions to answer include:

  • How redundant is the vendor's power?
  • How many power feeds does the vendor utilize?
  • How many Internet feeds?
  • How often do they perform tests of their systems?
  • Do they keep their equipment sufficiently maintained?

Cloud solutions will keep your PHI private, secure, safe, and in compliance with HIPAA's omnibus rule. Your effective due diligence ensures that they do.

Implications of the Affordable Care Act
March 13, 2013 12:40 PM by Kelly Wolfgang
Editor's note: This blog is written by Anthony J. Hall, RN, BSN, behavioral health charge nurse at Atlanta Medical Center.

The Affordable Care Act (ACA) means major changes in the way Americans view health issues and treatment options. While there is increased optimism building around the plan's effect on patient care, healthcare providers will bear the burden of the plan's negative impacts, such as a shortage of primary care providers. Though the full impact on the medical profession has been hard to gauge, providers can be primed for some positive adjustments as a result of ACA.

It's easy to see the immediate benefits of the ACA for healthcare recipients - many more families will be able to schedule regular visits to a general practitioner or family clinic, meaning more check-ups and preventative treatments.

For healthcare professionals, this increased patient load means more providers will be needed; some will gain traction in positions of greater authority as those with less experience are hired. The shortage of primary care physicians will mean increased access to nurse practitioners (NPs) and physician assistants (PAs), allowing localized healthcare to more patients, making it unnecessary to travel to distant hospitals.

The increased presence of non-physician providers such as laboratory professionals, respiratory technicians, NPs and PAs in decision-making positions will bring a heightened awareness and a sense of respect that has been long overdue. In my work with patients and the general public, I've encountered many people who are uncertain of the role these professionals play; by virtue of increased demand, more patients will become aware of our importance in healthcare.

While many hospital systems are consolidating, combining forces and units to avoid producing duplicate services, job cuts in the hospital sector will provide an upswing in business for small practices, family clinics and general practitioners. This change is likely to mean an increase in employment for providers in all areas of specialization.

If you are interested in submitting to the Politics of Healthcare blog, please contact Kelly Wolfgang at kwolfgang@advanceweb.com.

Medicaid Expansion
February 15, 2013 1:26 PM by Kelly Wolfgang

Editor's note: This blog is written by Miguel A. Bustillos, department chair and professor at California University of Management & Sciences in Virginia.

Most of us have heard about the Medicaid expansion and how states like Florida, Texas and Virginia are against it. Some do not understand why the Medicaid expansion has become such a big issue or what exactly the Medicaid expansion is.

The Medicaid expansion, expected to be fully implemented by 2014, is a plan under the Patient Protection and Affordable Care Act (PPACA) to expand medical coverage for a number of people who do not qualify under the current plan. The Medicaid expansion mandates that a state must meet PPACA standards to receive full federal funding, which is needed to increase the current plan. The largest problem involving the mandate is how states will cover the "new eligibles," those patients who are receiving Medicaid assistance for the first time. It is estimated that 15.9 million new enrollees will participate in the plan by 2019.

The federal government currently pays, on average, about 57% of the total cost of Medicaid enrollees in each state. Of those that qualify for Medicaid, only 62% have signed up for Medicaid benefits, leaving the remaining 38% without benefits. Generally, those that are not taking the benefit either don't know that they qualify or refused the benefit.

If states were to accept the Medicaid expansion, they would continue to pay for the benefits of the 62% that are currently covered; in addition, they will have to cover the 38% that qualified under the previous requirement, but did not take the benefit. According to the new mandate, states must also provide for the new eligibles.

Under the Medicaid expansion mandate, the federal government will continue to pay the cost for about 57% of the 62% that are currently taking the benefit. With the new law, the 38% that did not receive benefits will now either take the benefit or pay a tax penalty. Some states believe that those who are qualified will take the benefit rather than pay the penalty. Despite the "new enrollee" status of those patients, the government will not support funding for any persons who previously qualified but did not receive benefits.

With regards to the true new eligible, the states believe that the cost of providing Medicaid is just too large for any state to handle.  To lessen the burden, the federal government has penned an agreement to cover 93% of the cost of the true "new enrollees" till the year 2020.

Many states will decline to take on the Medicaid expansion because it's a voluntary program. The new law can be very taxing to any state's budget and in most cases, there are not enough incentives for states to adapt the program.

The federal government is, however, not worried. When Medicaid was first signed into law in 1965, only six states agreed to participate. But by 1982, every state had joined. As 2014 comes along, and the law comes into full effect, it will be interesting to see what develops and what does not. With the cost of providing healthcare to so many people being so high, and the fact that Medicare benefits will be cut to fund the Medicaid expansion, I foresee much resistance on its implementation.



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