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Tag: Vince Kuraitis

Will ACO IT Models Be Walled Gardens or Open Platforms?

Will ACO (accountable care organization) IT models be walled gardens or open platforms?  i.e., will ACO IT platforms focus on exchanging information within the provider network of the ACO, or will they also be able to exchange information with providers outside the ACO network? (If the question still isn’t clear, click here for a further explanation.).

One POV: ACO’s Will Need Open IT Platforms

Mike Cummens, M.D., associate chief medical information officer at 750-physician Marshfield Clinic in Wisconsin, is quoted in a recent article in Healthcare Informatics. Dr. Cummens argues for an open ACO IT approach:

There will be an emphasis on transfer-of-care summaries and how to facilitate information sharing across the full continuum of care, he said. “For instance, you will have to work into care management plans the notification of home health agencies,” Cummens added. “In an ACO model, you will have to have methods in place to communicate all this information to providers who are not part of your own organization. People will have an option to see providers outside an ACO, so you will need to be able to transfer care summaries and discharge summaries outside the ACO.”

Also, because patient involvement is a key part of ACOs, the IT infrastructure will have to support patients signing off on their care plans and document their progress toward reaching goals, he noted. That will involve some type of self-management tools and personal health record access to their own data.

Cummens noted that the patient-centered medical home is geared toward an individual practice, and meaningful use metrics are geared toward providers, but ACOs will require managing data across enterprises. “When we visualize this and realize we are dealing with multiple electronic health records, the infrastructure for ACOs really has to ride on top of that,” he said. He sees the need for a new type of system, probably outside the EHR, that can bridge organizations, allow for risk assessment and analytics and reach down into tools for day-to-day management. That’s a tall order.

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The Penguin Problem

Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves.

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before.  His essay is entitled “Meaningful Use — Doctors Have No Choice”.

Physicians Have No Choice Other Than to Adopt EHRs?

Dr. O’Connor argues that physicians are effectively being forced into adopting EHRs.  He cites facts and reaches a powerful conclusion:

1. CMS penalties begin in 2015.
2. What if you won’t or don’t accept Medicare/Medicaid patients (13 percent of practices in 2009, up from 6 percent in 2004? In August, four major insurers (Aetna, Highmark, United Health Group, and Wellpoint) announced that, at a minimum, they will link their pay-for-performance programs to federal meaningful use criteria. Other insurers are likely to follow.
3. Do you run one of the increasing number of “boutique” or VIP practices that work on a cash-only basis? The American Board of Medical Specialties (ABMS) released a statement in August saying that they intend to link meaningful use of health information technology into the ABMS Maintenance of Certification© program.
4. You don’t care about being board certified? (Sound of crickets chirping.) The Final Rule gives states the authority to impose additional requirements that promote compliance with meaningful use. As reported in Physicians Practice, the state of Massachusetts may take away your license to practice medicine in 2015 unless you demonstrate meaningful use of an EHR system. In Maryland, private insurers will be required to build incentives for acquisition of EHRs and penalties for not adopting them into their payment structure.

OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No.

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Does This ACO Thing Really Mean We Need to be ‘Accountable’?

Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]

Translation:

Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

Vince Kuraitis, JD, MBA is a health care consultant and primary author of the e-CareManagement blog where this post first appeared.

Care Coordination Metrics: One Can of Worms that NEEDS to be Opened

“Track who is on a care team — and share info with the patient.”

That’s just one of the summary recommendations coming from expert testimony given in a recent public hearing on how to improve care coordination through the use of health information technology. The Meaningful Use workgroup and Quality Measures workgroups are now wrestling with how to translate this recommendation into meaningful use criteria for HITECH Stages 2 and 3.

Seems like a good idea — simple, straightforward — perhaps even obvious. The EHR (electronic health record) could be a great tool for keeping care team members in the loop and on the same page about a patient’s care.

But then I thought about this for a few minutes, and the complexities started dawning. This seemingly simple recommendation — “Track who is on a care team and share info with the patient” — is the proverbial can of worms.

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If HIT Plan A Doesn’t Work, What’s Plan B?

By VINCE KURAITIS, JD, & DAVID KIBBE, MD

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue.  He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

  • Defending Plan A to your dying breath?
  • Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.Continue reading…

Gimme My Damn Data!

So far in this series has looked at HITECH participation by hospitals (grumbling but in the game) and physicians (wary, on the sidelines), kudos for ONC’s three major policy points, and how HITECH is already moving the needle on the vendor side. Today we’re going to look at the reason the whole system exists: patients.

It’s possible to look at the patients issue from a moral or ethical perspective, or from a business planner’s ecosystem perspective. In this post we’ll simply look at it pragmatically: is our approach going to work? It’s our thesis that although you won’t see it written anywhere, the stage is being set for a kind of disruption that’s in no healthcare book: patient-driven disruptive innovation.

We’ll assert that in all our good thinking, we’ve shined the flashlight at the wrong place. Sure, we all read the book (or parts), and we talk about disruption – within a dysfunctional system.

If you believe a complex system’s actual built-in goals are revealed by its actual behavior, then it’s clear the consumer’s not at the core of healthcare’s feedback loops. What if they were?

We assert that to disrupt within a non-working system is to bark up a pointless tree: even if you win, you haven’t altered what matters. Business planners and policy people who do this will miss the mark. Here’s what we see when we step back and look anew from the consumer’s view:

  1. We’ve been disrupting on the wrong channel.
  2. It’s about the consumer’s appetite.
  3. Patient as platform:
    • Doc Searls was right
    • Lean says data should travel with the “job.”
    • “Nothing about me without me.”
  4. Raw Data Now: Give us the information and the game changes.
  5. HITECH begins to enable patient-driven disruptive innovation.
  6. Let’s see patient-driven disruption. Our data will be the fuel.

1.     We’ve been disrupting on the wrong channel.

The disruptive innovation we’ve been talking about doesn’t begin to go far enough. It’s a rearrangement of today’s business practices, but that’s not consumer-driven. Many pundits, e.g. the ever-popular Jay Parkinson, note that today’s economic buyer isn’t the consumer, which is screamingly obvious because consumer value isn’t improving as time goes by.

When we as patients get our hands on our information, and when innovators get their hands on medical data, things will change. Remember that “we as patients” includes you yes you, when your time comes and the fan hits your family. This is about you being locked in, or you getting what you want.

I (Dave) witnessed this in my first career (typesetting machines) when desktop publishing came along. We machine vendors were experts at our craft, but desktop publishing let consumers go around us, creating their own data with PageMaker, Macs and PostScript. Once that new ecosystem existed, other innovators jumped in, and the world as we knew it ended.

(Here’s a tip from those years: this outcome is inevitable. Ride with it, participate in it, be an active participant, and you can “thrive and survive.” Resist and within a generation you’ll be washed away.)

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Chilmark Needs to Chill Out on CCR/CCD Findings

Picture 112 John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.

However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” on THCB. He writes:  “In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future.  The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.”Continue reading…

“Meaningful Use” Criteria as a Unifying Force

Vince-20kuraitis09-small

Over the past several years, many diverse initiatives have arisen offering partial solutions to systemic problems in the U.S. health care non-system.

We see Meaningful Use Criteria recommended by the HIT Policy Committee as a unifying force for these previously disparate initiatives. These initiatives have included:

  • Patient Centered Medical Homes (PCMHs)
  • Regional Health Information Organizations (RHIOs)/Health Information Exchanges (HIEs)
  • Payer Disease/Care Management Programs
  • Personal Health Record Platforms — Google Health, Microsoft HealthVault, Dossia, health banks, more to come
  • State/Regional Chronic Care Programs (e.g., Colorado, Pennsylvania, Improving Performance in Practice)
  • Accountable Care Organizations — the newest model being proposed as part of national reform efforts

Today

While there are some commonalities and overlap, to-date these initiatives have mostly arisen in isolation and are highly fragmented — they’re all over the map. Here’s a graphic representation of the fragmentation that exists today:

MU1

Tomorrow

The HIT Policy Committee recently recommended highly detailed Meaningful Use criteria for certified EHRs.  Doctors and hospitals who hope to receive HITECH Act stimulus funds will have to demonstrate that they are meeting these criteria; the criteria are not yet finalized.

The Committee website describes the central role of the Meaningful Use criteria:

The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care.

The HIT Policy Committee also is recognizing that there are multiple routes to achieving Meaningful Use beyond the traditional EMR 1.0, e.g., modular Clinical Groupware software.

While some might view the Meaningful Use criteria as limited to the world of health IT — something happening “over there” — we see much more going on. We believe the Meaningful Use criteria are becoming a powerful unifying force across the health system, with potential to converge previously disparate initiatives.  Here’s our conceptual representation:

MU2

Let’s consider a couple examples to demonstrate how convergence is occurring.

RHIOs were formed primarily with a mission of developing health IT infrastructure for local data exchange; they had little need to think about how care providers, health plans and others would actually use the data.

Patient Centered Medical Homes have been built around seven principles (e.g., physician directed medical practice, care coordination) — none of which directly relate to a need to develop health IT infrastructure; the fact that IT infrastructure is necessary to implement these principles has been assumed but not defined.

RHIOs focused on health IT with little thought about objectives, while PCMHs had grand objectives with little thought about needs for health IT.

All this is changing.

RHIOs are recognizing that achieving meaningful use of data is essential; PCMH initiatives are recognizing the need for a robust IT infrastructure and the need to match their efforts to Meaningful Use criteria.

Here are some broader implications about Meaningful Use criteria becoming a unifying force:

  • These diverse initiatives will have more commonalities and will look more and more alike
  • Expect previously disconnected regional initiatives to start talking to one another about collaboration.
  • A common phrase we are hearing is “We need to do a crosswalk of Meaningful Use criteria with our initiative/organization/application functionality.”
  • Vendors must ask: “What are we doing to contribute to Meaningful Use of EHRs”
  • Care providers (doctors and hospitals) must ask: “How are vendor offerings helping us to achieve Meaningful Use of EHRs?”

These are positive developments.  Meaningful Use criteria are becoming a powerful unifying force toward integrating our fragmented health system.

Vince Kuraitis JD, MBA is a health care consultant and primary author of the e-CareManagement blog where this post first appeared. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.  Steve Adams is Founder and CEO of RMD Networks, a Denver, Colorado based company.