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Accountable Care and HealthIT Strategies Summit 2015: Still early days

Patients and providers both need to be empowered to deliver on the promises of the Affordable Care Act. That was the major theme and takeaway of the recent “Accountable Care and Health IT Strategies Summit” that I attended a few weeks ago in Chicago. I would add to this sentiment that IT needs help to implement technologies that empower these end-users. While not underestimating the importance of making sure technology is secure, and scalable, with too much focus on the back-end, IT can miss an opportunity to help deliver real value and change by putting tools in the hands of end-users.

Since value-based payments require health systems to be able to impact patient behavior outside their four walls, technology (and therefore IT departments) have the ability to play a greater role in helping to monitor and manage patients, and scale healthcare providers. Access to real-time data can also help identify issues and impact patient behavior before small problems turn into big ones.

While some of the stories and sessions at the conference were promising, I came away with the impression that we are still in really early days, and the leaders in this care transformation are willing to take leaps without having all the data. Considering that even with data, it still takes 17 years from innovation to transfer from research to clinical best practice, it seems that some amount of faith is required for this healthcare transformation.

In no particular order, here are a few of my notes from the 2-day conference.

Theme: Population Health 2.0: Accountable Care, Big Data and Healthcare Analytics

Population Health seems the furthest along in this transformation both in the way care is delivered and how technology supports care. Participants on this panel from Partners, Geisinger, and Hackensack University Medical Center, along with population health vendor Wellcentive debated the differences between Population Health 1.0 and 2.0. They even tried to see the future with Population Health 3.0.

Population Health 1.0 was seen as identifying risk and gaps in care, and attempting to plug those gaps. Although many organizations are still in this stage, some haven’t even gotten there yet. The panel saw themselves moving to a more evolved state of Population Health where data is used to drive better care, while responsibility for population health moves to the individual primary care physician rather than being managed in aggregate by remote care teams. However, this type of shift requires engagement by both the patients and the physicians which is still a work-in –progress.

The representative from Geisinger stressed for an effective implementation of population health, a multi-disciplinary team needs to be assembled that includes both clinical and IT. Wellcentive agreed and added that analytics need to be in the hands of end-users so they can make informed decisions.

The panel was also asked to speculate on Population Health 3.0: historical data, data driven decisions, and patient empowerment through data from sensors and surveys were all seen as key.

Honestly, my biggest takeaway from this session is that while some organizations may be claiming it’s time for Population Health 2.0, many haven’t gotten to 1.0, and no one seems to be in agreement on the definitions of each stage. Given today we already have the ability to collect survey and sensor data in the context of care, it seems like we are already have the tools for Population Health 3.0. But, we haven’t implemented the technology to address Pop Health 1.0 & 2.0 to achieve value…..so how can we even look to addressing the road to 3.0?

Theme: EMRs and Enabling Technology for ACOs

Another major theme that arose across many sessions at the conference is the limitations of current technology to support the infrastructure of new models of care. While organizations are looking for the EMR to be the Holy Grail, it’s a challenge as most EMRs are built to support older models of care, specifically around billing and reimbursement. Renown Health’s Accountable Care Organization, in Northern Nevada, will look to EPIC to solve some of their technology care needs, but realizes the need for M-health and other care coordination technologies to move up the stack, and exist separately from the EMR will be required.

Many of the participants are either trying to collect and track ACO data in the EMR or build their own systems to engage patients that fed data back into the EMR. Others acknowledged that new systems to directly engage patients need to be built on new technology stacks, although surprisingly one panelist on the Connected Care – How Trends in mHealth, Wearables and Connected Medical Home are Shaping Healthcare keynote boasted about 20-30% engagement rates with paper surveys. Yes, paper.

Theme: Engaging Patients and Providers

For ACOs and the ACA in general to be effective, the consensus at the conference was the need to enable both patients and providers. Adding individual providers into the mix seems to be a bit of a shift in thinking, and one that we’re supportive of at Wellpepper. We know that a key driver of patient adherence is the relationship between patients and providers. With our system, a good provider can influence patients to be over 85% adherent to their treatment plans. Some key ideas at the conference were providers may still need to be convinced of the need to influence patients directly, and that showing them data is the way to do that. However, the method of communication to that patient needs to connect in a way that is of their everyday life routine.

Overall, the conference presented some early wins in the shift to ACOs and value-based payments, but showed that we still have a long way to go and a lot of opportunity to improve care based on data. That said, this was the first conference I’ve been to where IT was front-and-center at the table and able to drive change if they wanted to. We have an opportunity to leapfrog old ways of doing things and implement new systems that have focus on the patient and provider, and are based on data to drive better outcomes. I for one am excited about this new opportunity and how it will change the way we deliver care in the future.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Outcomes

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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UW Medicine’s Journey To Become An Accountable Care Organization

As part of the newly forming Health IT community in Seattle, the Unveristity of Washington and the Washington Biotechnology and Biomedical Association have partnered on the “Health Innovator’s Collaborative” which launched with a series of seminars on how the coming changes in US healthcare affect organizations and innovation.

Accountable Care OrganizationsThis past Tuesday, I attended a talk by Paul Ramsey, MD, and CEO of University of Washington Medicine entitled “The Transformation of Healthcare: Forces, Directions and Implications.” Despite this lofty title, Dr. Ramsey focused on the nuts and bolts of the new Affordable Care Act (ACA) with specific examples of how UW Medicine is becoming an Accountable Care Organization (ACO).

First off, Dr. Ramsey started with some definitions of the goals of the Affordable Care Act and Accountable Care Organizations. When asked if the ACA is having a profound effect, he stated that regardless of any other measures, the number of individuals who are now insured is significant. Harborview Medical Center, a member of the UW Medicine System that covers a diverse and often low-income population, has already seen a 2% decrease in patients without coverage.

What was striking about the session was Dr. Ramsey’s clear conviction that while the ACA is morally just (we need to stop pricing people out of healthcare) organizations becoming ACOs were currently doing it because it makes human sense, while not currently financial sense. The reason it doesn’t currently make financial sense is that the first ACO contracts between payers and providers are still in negotiation and in the switch between reimbursements for procedures to reimbursement for outcomes providers initially see lower revenues as they decrease the number of unnecessary procedures. In the long run, this is mitigated by getting the right care to patients and by managing population health in addition to individual health

The triple aim of the ACA is to improve experiences for individuals, improve overall population health, and reduce the cost of care: lofty but extremely important goals. While managed care and HMOs were supposed to do this in the 90s, their main failure was having the primary care physician as the gatekeeper to all other services. This did not guarantee that the patient received the best and most cost effective care. Dr. Ramsey contrasted this to the goals of an ACO, where a patient might call a nurse hotline and be referred to emergency, their primary care physician, or receives an e-care visit, depending on which was best for the patient and most cost effective in the long run.

When asked if this model was a capitated model, Dr. Ramsey said yes, but at a population level, and that is why the current negotiations between payers and providers are so important. Providers are choosing which measures they will be held accountable for in their first year as an ACO. UW Medicine is choosing seven disease management measures, three health status and screening measures, and number of caesarian sections, which is apparently a hot button measure for CMS. Because all measures will not be implemented immediately UW Medicine will spend some time transitioning between models, however, this does not mean they won’t continue to improve care in all areas. He cited his own recent experience as a cataract patient at UW Medicine as of an example where high quality outcomes, patient care, and cost-effectiveness were combined.

As a guide for these types of measures, and as an example of the medical profession taking on best practices regardless of financial incentives, Dr. Ramsey cited http://www.choosingwisely.org where each medical specialty association provides their own guidelines for reducing unnecessary procedures and promoting best practices. This is a great resource for patients as well to review whether costly procedures are actually recommended and effective.

Accountable Care OrganizationsThere was some discussion that the US medical system as a whole could decrease costs by 25% without reducing the quality of care. UW Medicine has been able to reduce costs by $90M annually which is only a 2-3% of their operating budget and remain a top hospital. UW Medicine will continue to improve on both costs and their overall ratings.

Interestingly, the most important factor in patient satisfaction, a key health system rating, is the communication with their healthcare provider, rather than the outcomes. Improving patient/provider communication is an extremely cost effective way to ensure great care.

This was a great talk, realistic yet optimistic about the challenges and opportunities inherent in this transition to the new models of care we so desperately need.

The two remaining talks are:

May 13, 2014: “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research”

Larry Kessler, ScD, Chair of UW Department of Health Services and former Director, Center for Devices and Radiological Health, FDA, will consider the coming necessity for innovations to demonstrably provide value and how the experience with comparative effectiveness can help innovators gather the needed evidence.

June 3, 2014: “IT can make a big difference in health: Why hasn’t it?”

Peter Neupert, Operating Partner of Health Evolution Partners and former VP of the Health Solutions Group at Microsoft will draw on his extensive experience with both institutional and consumer aspects of health IT to consider the enormous potential and serious pitfalls that make this area of innovation so challenging.

Editor’s Note: The primary care physician as gatekeeper is a failure in the single payer system as well. It denies patients access to the care they need and also adds waste into the system. In Canada for example, a referral to a specialist must be done by a primary care physician and expires every 6 months. So, if a patient has a chronic disease that they need to see a specialist for, the patient cannot keep seeing that specialist without getting another referral, even if all parties agree the patient should keep seeing that specialist.

Posted in: Health Regulations, Healthcare Disruption, Lean Healthcare

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