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Government IT needs 'urgent' help

Government IT needs 'urgent' help | Healthcare and Technology news |

Even as a couple of Congressional panels are bent on achieving health IT interoperability, where the industry has not yet been able to, it appears the government itself could use a helping hand on this complex matter – and many other aspects of IT work.

new report from the Government Accountability Office, calls for "urgent action" on all government IT projects.

David A. Powner, director of IT management issues for the GAO, testified June 10 before the House Subcommittees on Government Operations and Information Technology, Committee on Oversight and Government Reform.

He told the panels that from October 2009 through December 2014, GAO made 737 recommendations to the Office of Management and Budget and other agencies to improve the management and oversight of IT. However, as of January 2015, only about 23 percent had been fully implemented.

The government spends more than $80 billion a year on information technology, according to the GAO report.

"These investments frequently fail, incur cost overruns and schedule slippages, or contribute little to mission-related outcomes," Powner reported. "This underperformance of federal IT projects can be traced to a lack of disciplined and effective management and inadequate executive-level oversight."

The report comes just as the Department of Defense is scheduled to announce this month its pick for its massive planned EHR project.  

The DoD's $11 billion Healthcare Management Systems Modernization Electronic Health Record program would replace and modernize the existing EHR system, which supports more than 9.7 million beneficiaries, including active duty, retirees and their dependents. It serves patients and clinicians in 2,300 locations around the world.

The vendor teams in the running for the government contract are:

  • IBM and Epic
  • Computer Sciences Corp., partnered with HP and Allscripts
  • Cerner, Leidos, Accenture Federal and Intermountain Healthcare

In listing a half dozen particularly troubled IT projects, Powner named the DOD's and VA's efforts to modernize their EHRs.    

"DOD's and VA's initiatives to modernize their electronic health records systems are intended to address sharing data among the departments' health information systems, but achieving this has been a challenge for these agencies over the last 15 years. In February 2013, the two departments' Secretaries announced that instead of developing a new common, integrated electronic health record system, the departments would focus on achieving interoperability between separate DOD and VA systems," Powner noted in his report.

"The departments' change and history of challenges in improving their health information systems heighten concern about whether they will be successful," he added. 

Powner also put the spotlight on troubles at the VA, noting the agency had invested "significant resources" in developing an outpatient appointment scheduling system, yet the initiative has been riddled with setbacks.

After failing to implement a new platform, in October 2009, VA began a new initiative it refers to as HealtheVet Scheduling.

"In May 2010, we recommended that, as the department proceeded with future development, it take actions to improve key processes, including acquisition management, system testing, and progress reporting, which are essential to the department’s second outpatient scheduling system effort," Powner said.

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Modernizing Medicare: An important first step

Modernizing Medicare: An important first step | Healthcare and Technology news |

The Medicare program is at a crucial juncture: it is responsible for 25 percent of all federal outstanding debt this century, and the total continues to grow. Every day, 10,000 newly eligible seniors enter a Medicare health insurance program whose budget needs are already escalating out of control. This path is simply unsustainable. 

Just as troubling is the fact that all those Medicare dollars are not delivering the top-quality health care that senior citizens deserve.  A quick look at how Medicare pays for care makes plain why this is so.  Under its antiquated “fee-for-service” approach, Medicare pays for services delivered, rather than for outcomes achieved.  We know that prevention and care coordination are essential, for instance, but the current payment system does little to encourage or reward this.  Since Medicare is the largest payer of medical bills in the United States, the poor incentives embedded in its fee-for-service approach set a subpar standard for care throughout the American health care system.

It’s past time for Medicare to be modernized. A sensible first step toward this objective is with post-acute care bundling – payment based on the treatment of an entire illness or injury, not each individual service provided. 

Over the next 10 years, Medicare is projected to spend nearly $1 trillion on medical treatment for seniors who have been discharged from a hospital. But what are we currently getting for all that money?  A study by the Alliance for Home Health Quality and Innovation showed that primary chronic conditions do not explain variation in Medicare payments across setting or clinical conditions. Many seniors are returning to the hospital while millions of others are receiving treatment that is not coordinated, is not of sufficient quality, and is not being delivered in the most clinically-appropriate and cost-effective settings. The fee-for-service approach costs Medicare money and seniors’ their health.

Research suggests that one way to approach reform would be to replace fee-for-service with condition-specific bundled payments modeled on the DRG system that hospitals have been using with great success for three decades. This would allow patients and their families to choose their own providers and networks to coordinate patient care for a period of time, such as 60 or 90 days following discharge from the hospital at a rate determined based on the patient’s clinical condition. If a patient returns to the hospital during that period, or if the cost of her care exceeded the amount of the bundle, the coordinator would bear the loss. If the patient’s needs were met effectively such that she didn’t need to be re-hospitalized and her costs were less than the bundle amount, the resulting savings would be split among the coordinators, physicians, discharging hospital, and the participating post-acute care providers.

This type of approach was effective in the past was the Department of Veterans Affairs’ Home Based Primary Care demonstration program, which used teams of health care providers to provide coordinated care for participating veterans with chronic and disabling conditions who needed more continuous care. This program was able to reduce days spent in hospitals by 62 percent, and overall care costs for this uniquely expensive population dropped by 24 percent.

Applying this type of program to Medicare would modernize it by rewarding participants for the delivery of high-quality, coordinated care in the most clinically appropriate, cost-effective manner possible. Different approaches to this reform have previously been proposed by Reps. David McKinley (R-W.Va.) and Tom Price (R-Ga.) and by Rep. Diane Black (R-Tenn.). Post-acute care bundling would simultaneously keep costs low while preventing risky hospital readmissions for seniors.

Taxpayers and the Medicare Trust Fund would likewise benefit.  This type of proposal could limit overall spending on post-acute care to a percentage of what those same services would cost in a fee-for-service setting without the need to make cuts to provider reimbursement. 

Modernizing Medicare is no longer an option – it’s an imperative.  Bundling post-acute care services is an important first step.

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The Coming Global Boom in Private Healthcare

The Coming Global Boom in Private Healthcare | Healthcare and Technology news |

To many Americans, whose multi-trillion dollar government has just executed a hostile takeover of the healthcare industry, the future of care looks like lawyer-laden socialized medicine in General Motors-style hospital factories.

But Americans are only 4% of the world’s population, and the rest of the world is moving in a very different direction.  They have much to teach us.

My job is to scan the world looking for commercial and social innovations that entrepreneurs can bring to scale.  I do this mainly on the ground, monitoring large networks like transportation, water, food, energy, education, health care, media….looking for small sparks that can transform these networks rapidly.

I have done this commercially for 30 years in more than 40 nations.

Right now some of these sparks are:

  • Genetic “bio-remediation” transforming human water and waste systems.
  • Geothermal and solar energy in millions of New World houses (beyond US and Europe)
  • Global electronic education that will make obsolete many schools in the Old World (US and Europe).
  • Mobile human body sensors that will challenge the 20th century “clinical trial” by giving scientists real-time biological information on literally millions of people….

….and innovation in neighborhood private healthcare throughout the once poorest regions of the World.

Big facts

2 billion people have emerged from poverty to middle class in the last 20+ years.  2 billion more are moving to middle class right now, much more rapidly.  7 billion humans own or have access to an online mobile device, and they are transforming the world.  See Alibaba, and the seminal opening of Chinese equity markets as recent visible outgrowths of a wired world.  Mobile computing has built the second largest capitalist economy inside a communist nation.

There are more than 3 billion newly-moneyed, newly-wired humans seeking the same kind of health care Americans and Europeans have enjoyed for decades

Many (most?) of them are seeking this health care by building private health care networks that may soon span the globe. They are increasingly bypassing the local public healthcare systems that many US and Europeans think are the salvation of the developing world.

There has always been a globally-traded private health care industry

World class hospitals have targeted newly wealthy patients in distant lands for decades.  In the middle 1970’s hospitals like the Cleveland Clinic, Mass General and others learned how to welcome patients with new oil-money bank accounts.  The wealthy in poor countries always traveled far for good care.

By the 1990’s some European hospitals created explicit “corporate” strategies to win global customers from specific US hospitals, just like Honda targeted GM and Ford.

About 10 years ago the American press began to notice ordinary uninsured Americans traveling to Bumrungrad Hospital in Thailand, clinics in Mexico and Chile, and other world-class global traders in patient care.  Most Americans thought that “foreign” medical care could not possibly be good.  Some unions went to court to prevent employers from contracting with foreign hospitals for employee surgery.

Most Americans did not notice that a plane flight to India, Latin America, or Europe was significantly shorter than waiting for a doctor’s appointment in the US…and that equivalent care with US-trained doctors in foreign hospitals could cost 60% to 90% less than in the US….within credit card range.

Just as Americans ignored global competition in cars, computers, mobile phones, and streaming internet music from Sweden (Spotify) – they missed 15 years of rapidly globalizing health care.

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Fixing health care doesn't necessarily need political reform

Fixing health care doesn't necessarily need political reform | Healthcare and Technology news |

It’s very hard to find a product or service that is both lousy and unaffordable. Such expensive duds are usually quickly replaced by cheaper and better competitors. Prior to the Affordable Care Act, health care was becoming more expensive every year while simultaneously becoming less convenient, less personal, and less satisfying. In 2009, I wrote a series of four posts explaining how the health care marketplace reached such a sorry state and offering a suggestion for reform.

Since then, the Affordable Care Act has passed. For many, insurance has become much more affordable, but whether this translates to better or more affordable care remains to be seen. If it results in many patients receiving affordable insurance that very few physicians accept, then the situation will be a repetition of the Massachusetts experience with universal coverage: Everyone has insurance; no one has a doctor.

At the same time, the intrusive and complex bureaucracy that physicians must navigate to collect insurance payments has vastly expanded. Physicians are now coerced into serving as the workforce for Federal plans to collect health care data, cut costs, and make their care increasingly legible to payers but increasingly opaque to patients.

Bear with me for just a few examples. In an ill-advised plan called “meaningful use,” physicians receive incentives for submitting complex reports documenting their use of electronic health records (EHRs). The time and effort required to comply with this program has earned it much scorn from physicians. And the incentives will likely distort the true value of EHRs and inflate their costs.

The International Classification of Diseases (ICD) is the coding system used by physicians and billers to report to insurance companies patients’ diagnoses. In October, the government will update ICD to its tenth version. ICD-10 will contain radically more complexity than its predecessors. It is widely ridiculed for the detail with which diseases must be reported. (Code V91.07XA is for a “burn due to water-skis on fire.”) The transition to ICD-10 was already postponed once, and I predict it will cause much disruption and grief.

My last example is the recently passed sustainable growth rate (SGR) fix which gets rid of the annual congressional scramble to increase Medicare reimbursement to physicians by increasing reimbursement in the short term, but tying reimbursement to outcomes measures in the long term. This is sure to become a data collection and reporting hassle that makes doctors long for the simpler days of meaningful use.

I honestly believe that there has been more bureaucratic complexity added to the typical physician’s life in the last few years than in the twenty years before that. None of it cares for a single patient.

Two weeks ago, my family and I spent ten days visiting New York City. We had a wonderful time. The services that completely transformed our experience were the ride sharing services of Uber and Lyft. We never used public transportation. We never hailed a taxi. For longer trips (and a family of five) this was likely cheaper than train tickets. For shorter trips, it meant not handling cash, never finding bus or subway stops, and never referring to transit schedules.

For years, passengers complained about high taxi prices and poor taxi service, and potential competitors complained about the legalized monopolies given to taxi companies by city governments. But rather than bang their heads against these barriers, companies like Uber and Lyft just started giving people rides.

This was an epiphany to me. I had always assumed that fixing the health care marketplace would mean political reform — undoing the myriad laws that substituted insurance for health care and caused prices to skyrocket, and dismantling the byzantine bureaucracy that physicians must navigate. Now, I understand that political reform is both unrealistic and unnecessary.

Doctors and patients aren’t waiting for political reform. More and more doctors are “going off the grid” to provide excellent care unencumbered by insurance regulations. Concierge primary care is just one example. The Surgery Center of Oklahoma lists on its website the prices for every surgery it offers. The prices are all-inclusive. You won’t get a separate bill from the anesthesiologist, the surgeon, and the facility. And they don’t care what insurance you have because they won’t deal with any insurance company. Other innovative companies are using video conferencing technology to connect patients to doctors thousands of miles away. LUX Healthcare Network (with which I’m proud to be associated) is building a multi-specialty concierge physician network.

I argued six years ago that using insurance for routine care is wasteful. I now realize that attempts at universal coverage and the bureaucracy that comes with it — ICD-10, meaningful use — will never be repealed. This bureaucracy will become the taxi monopolies of health care — increasingly ignored by both doctors and patients and increasingly irrelevant. The successful enterprises in health care will connect doctors and patients and then get out of the way. Like Uber and Lyft they will help patients find the service they want at a price they’re happy to pay, and they will facilitate not regulate the delivery of excellent care.

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Personalized Medicine Informatics: The Sky’s the Limit

Personalized Medicine Informatics: The Sky’s the Limit | Healthcare and Technology news |

President Obama’s 2016 budget includes a $215 million investment in research on personalized medicine to provide clinicians with new tools, knowledge, and therapies to select which treatments will work best for which patients. That figure includes $5 million for the Office of the National Coordinator to support the development of interoperability standards and requirements that address privacy and enable secure exchange of data across systems.

Last week I had the opportunity to interview A John Iafrate, M.D., Ph.D., founder and director of the Center for Integrated Diagnostics (CID) at Massachusetts General Hospital, about some of the informatics challenges his organization faces as personalized medicine takes off.

The CID was one of the first centers to look at large panels of genes in cancer to support clinical decision-making, Iafrate said. It looks for mutations and other genetic alterations in patient tumors with the idea of getting those patients on new targeted agents. Its SNaPshot assay screens for well over 100 cancer-associated mutations that have important clinical implications. Iafrate’s organization has begun using the HealthShare health informatics platform from InterSystems to target issues involving large data set management and cross-organizational collaboration in support of genomic research and clinical innovations.

At Mass General, once a tumor is genotyped, the patient’s oncologist receives that information in a plain-text report in the EHR. The oncologist can act on that information if they have a clinical trial open or a drug available, Iafrate said.

 I asked him how the oncologists keep track of all the available trials.

“In fact, one of our first projects with InterSystems is a clinical trials locator,” he said. “That is app No. 1.” An oncologist who sees 100 patients, all with different genetics, cannot keep track of it. “If I am in an academic practice group, maybe there are 50 trials. Someone could make an Excel spreadsheet of genome types and trials available,” Iafrate explained. “But how would I know next Wednesday, when I see Mrs. Smith, whether or not she has other clinical parameters that make her ineligible? But a piece of software can have all the entry criteria, know the lab values for all the patients, and in real time know the genotype and entry criteria for trials and whether there is a spot available in those trials.”

Iafrate says that there seems to be some consensus that this “apps” model is the approach of the future. “To get novel analytics, you need a stable database structure and then let people build reliable apps you can put on top,” he said. “That is what we are excited about. I think most people would view that as the most efficient way forward.”

He said InterSystems has helped solve a lot of the problems around data security and data formats. “One of the reasons we liked InterSystems is their focus on building HIEs,” he said. “This is not a research project. We are dealing with identified data that needs the highest level of security. The capabilty to share between sites is critical.”

There are still many informatics issues to address, he said. “How do we get data out of the current data repository and how do we share data between institutions in a safe way that limits the risk?”

There are big macro-issues with genetics, he added. “In this day and age, when we can sequence a genome, is any data de-identifiable? You can de-identify some clinical data, but if you have DNA sequence linked, that is no longer de-identified,” he said. “There is no consensus on how to deal with this issue,” he said, and no national consensus within the healthcare informatics world on how risky someone’s DNA sequence is.

Iafrate said another challenge is all the unstructured data in healthcare settings. “That is the major issue we are dealing with,” he said.  “As good as any natural language processing software is, there will always be data quality problems.”

He said the CID hopes to create a physician portal — not just a viewer, but a way for clinicians to generate their notes in a way that is as fully structured as possible. “To do cutting edge research and cutting edge clinical analytics, you really need the highest quality data possible,” he explained, because every data point will have noise associated with it. You can have a physician’s note that says ‘Mrs. Johnson has been receiving chemotherapy and is doing fantastic. She feels great.’ If you want to do research on quality of life, natural language processing will hone in on it, but there is noise associated with it. “What you really want is a scale of 1-10,” he said. “We want to build into a physician portal a way they could enter data that is as high quality quantitative data as possible.”

I asked Iafrate if it was likely that EHR vendors would soon start to build in tools that support genetic data sharing. “Definitely, everyone is moving in that direction,” he said. “Epic has a working group around that. Everyone understands that personalized medicine is important.”

Iafrate is working with the Global Alliance for Genomics and Health, which was formed in 2013 to create a common framework of harmonized approaches to enable the responsible, voluntary, and secure sharing of genomic and clinical data. He said most of the work in genomics has been done by a few large research facilities. “They have an interest in sharing data among large genome centers but not in sharing it widely with community hospitals and primary care physician practices,” he said. “They can agree on one or two large databases they share with each other, but that does not solve the problem of how we democratize it,” he said. “Without standards, you are limited in transporting data and comparing studies. We won’t get companies like Epic to invest a whole lot unless there is a standard format.”

Iafrate said that once data is structured sufficiently and a single database can store large amounts of genetic data and can bring it together with clinical data, then “the sky is the limit.” 

“We could create real-time clinical analytics apps that you could put into Epic or another EHR, he said. One future app could be called “Patients Like Mine.”

Here is how Iafrate explained it to me: Twenty years ago oncologists would rely on their medical knowledge and experience to make decisions because they didn’t have so much data. Now when the genetics results come back, they are complicated. “Can we help those clinicians by showing them real-time survival rates?” he asked. “How can you generate a Kaplan-Meier curve, a survival curve, for the patient sitting right in front of you? This is not a research tool, but a clinical real-time tool.” What if you had structured data on every time the patient came in, what drugs and dosage they had, and a CT scan measurement of the size of the tumor at each point in time. You could do a quantitative measure of drug response in that patient — and that is the equivalent of a clinical trial, he said. “Today that is not done in routine clinical care, where you quantitate the response rate or tumor shrinkage, because there is not a need for doing that in the clinic.” But now there would be a reason. If you measure the tumor size of every patient that comes through, the oncologist sitting with that patient could pull up a Kaplan-Meier curve of all the patients in their practice and say ‘query the data by defining 50-year-old females with this mutation and this tumor type. Tell me how my patients have done.’

And providers could toggle between looking at only their own patients or patients in the HealthShare HIE network. “Once you structure that data, if you can de-identify it to some degree,” Iafrate said, “then it could be shared and turned into something really special.”

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