Vikram R. Kumar MD MBA FAAP, chief medical information officer at Arrowhead Regional Medical Center (ARMC) in Southern California and practicing pediatrician, discusses how informatics affects his daily routine, both as a leader and at a clinical level.
With all the data breaches and threats popping up all over by healthcare, expect the market for cybersecurity products and services in U.S. hospitals to grow by 13.6 percent annually between now and 2021.
That estimate comes from a new, lengthy and pricey report by research firm Frost & Sullivan on the U.S. market for hospital cybersecurity. Frost isn’t releasing dollar figures of its forecast to the media, but the Mountain View, California-based company isn’t holding back in identifying culprits in this expected market growth.
“There’s been a cultural naïveté about IT security in healthcare,” said lead author Nancy Fabozzi, Frost & Sullivan’s principal analyst for connected health.
Fabozzi said that many healthcare organizations have wrongly assumed that meeting HIPAA security requirements is enough. But the fact that, according to Frost’s research, there have been 1,437 large breaches of health data, affecting more than 154 million patient records, since 2009 illustrates that their efforts have been sorely inadequate.
More than 113 million of those records were breached in 2015 alone, so the threat appears to be growing. Of particular note, 98.1 percent of records breached last year were because of hacks or other malicious activity, according to Frost.
“Hospitals are finally now realizing that health data is so valuable,” Fabozzi said. Unfortunately, she added, until very recently, technology vendors have not had to prove that their offerings are sophisticated enough to meet the threats posed by hackers.
“In spite of a growing awareness of the problem of increased cyber threats, many healthcare organizations face considerable challenges as they gear up to do battle with cyber attackers. Hospitals’ lack of leadership, appropriately trained staff and adequate financial resources are critical concerns,” Frost explained in a PowerPoint presentation shared with MedCity News.
But they are starting to get the message. “Hospitals are transitioning from a reactive, piecemeal, fragmented approach to protecting privacy and security that is highly dependent on HIPAA compliance to an approach that is proactive, holistic and coordinated, anchored by integrated solutions designed to protect multiple endpoints (computers and connected medical devices),” the presentation said.
“The real opportunity here is for consultants — managed services and professional services,” Fabozzi explained.
In 2015, about 80 percent of healthcare security spending was on software and other products, with just 20 percent dedicated to services, Frost reported. Expect that mix to shift to about 70/30 by 2021.
With the HIPAA security rule now 13 years old — and based largely on a draft completed in 2000 — Fabozzi said that it’s likely there will be new legislation and regulation on healthcare cybersecurity in the near future, regardless of how the November presidential election plays out.
“There’s a risk in healthcare that goes far beyond anything in other industries, and that’s hacking into a medical device and harming patients,” Fabozzi noted.
Timing of this report couldn’t have been any better for Frost & Sullivan. The report — or at least the news release about it — hit the same week Phoenix-based Banner Health disclosed a major breach of payment terminals and other computer system and that Advocate Health Care Network in Illinois reached a record $5.55 million HIPAA settlement over allegedly lax security practices.
Here’s an infographic from Frost highlighting themes in the report:
Images: Frost & Sullivan, Flickr user El Hombre Negro
The surge in personalized medicine and the quantified self movement offers providers more tools than ever to engage patients. Mobile apps and online services now collect data for a deep dive into our health, from prevention to optimization.
In my years as a clinician and writer focused on preventive health, I’ve observed that simply relying on data does not always drive motivation. In fact relying on data alone may mean missing an opportunity to optimize patient engagement.
In today’s digital and mobile age, the following should be key tenets that drive engagement.
Comprehensive and Contextualized Information
While a single data point has value, there are additional pieces of data that help inform a patient even more about their health or disease risk. Consider the biomarker glucose. A high glucose level indicates elevated blood sugar levels to show early diabetes risks. If a patient’s glucose readings are out of the normal range, it could indicate a serious condition.
However, testing the biomarker HbA1c provides a more accurate understanding of blood glucose levels because HbA1c is a measure of average blood sugar over the last few months. A comprehensive look at related data points indicated a different level of risk. This contextualized view gives us a more complete picture of what is happening in the body.
Knowledge isn’t just power, it’s also empowering.
Consider a patient who learns they have elevated High-sensitivity C-reactive protein, or hs-CRP. Providing education about this biomarker to the patient tells them that hs-CRP measures inflammation, the body’s response to internal damage, and is associated with risk of certain future diseases.
Emphasis on education empowers the patient to understand they can lower their hs-CRP levels through avoiding smoking and constant high stress situations. Engaging in a moderate amount of physical activity, and eating a diet rich in anti-inflammatory foods, such as fruits, vegetables and fish, and avoiding more pro-inflammatory substances such as simple sugars, trans-fats, and alcohol can achieve the same result. These are tools that empower them make informed decisions about their health.
Therefore, technology or services that seek to educate patients with up-to-date information and research will do a more effective job in driving patient engagement can behavioral change than simply throwing numbers at them. Such education can arm patients with the knowledge to make healthy choices throughout their lifetime.
When thinking about digital patient engagement tools, it’s important to ask how a technology helps a patient use the data to make meaningful change.
Proactive Safety and Security
For a patient to feel engaged, they have to believe they can trust their health team and tools. Health companies are aware they must adhere to strict HIPAA compliance standards so that Protected Health Information (PHI) is kept safe, but it is in a health technology solution’s best interest to proactively reassure patients.
How costs in healthcare are calculated is neither straightforward nor particularly transparent. The experience is often frustrating because charges, price arrangements, and co-pays often vary.
When providing a consumer service, take pains to provide patients straight-forward, upfront billing.
According to the American Journal of Managed Care, a patient spends 20 minutes in front of their provider in an average visit. The time they’re not in front of their provider can be influenced to their advantage or detriment, depending on the type of tools and access they have to their data.
Patients can play a greater and more active role in their health if providers and technology companies enable them to have unrestricted, 24/7 access to their health plan of action.
To conclude, when digital health companies are hatching their next killer app to boost patient engagement, it’s important that they incorporate the above best practices. Only then can both providers and companies keep the patient front and center, and continue to improve health outcomes.
Photo: Getty Images, Paul Bradbury
Health IT costs for physician practices are soaring, yet there isn’t much evidence that all the spending has been worth it, a new report suggests.
In its annual report on cost and revenue for physician practices, the Medical Group Management Association found that physician-owned multispecialty practices spent $32,592 per full-time doctor on IT hardware, software, maintenance, staff and other needs in 2015. That is up 42 percent from $22,944 in 2009 and 19.5 percent from $27,285 in 2011, the Englewood, Colorado-based MGMA said.
The 2015 costs break down as $9,405 for IT staff and $23,187 for equipment, maintenance and supplies.
In recent years, providers have been hit with multiple federal mandates and programs that have necessitated health IT spending. These include the transitions to the ANSI 5010 standard for HIPAA transactions in 2012 and to ICD-10 in 2015, as well as Meaningful Use and the Physician Quality Reporting System. “It’s the sheer number of them,” said Robert Tennant, MGMA director of health IT policy.
And there has not been a solid return on investment, according to the report.
“They spend this money and they’re really not sure that they’ve gotten what they were promised,” Tennant said. The improved patient outcomes, reduced hassle and lower costs simply haven’t materialized, he explained.
“There’s really no correlation between the [Meaningful Use] program and improved patient care,” Tennant said. Usability has been a well-documented issue with electronic health records, too.
“Productivity is suffering,” Tennant added. “There’s a level of frustration with technology that I’ve never seen before.”
Healthcare has long been perceived as being far behind the rest of the business world when it comes to adopting information technology, but Tennant didn’t think that the need to play catch-up has been a major factor in the escalating costs.
“To be competitive in today’s healthcare environment, you have to offer all the bells and whistles,” he said. For medical practices, that means patient portals, 24/7 access to test results and the ability to schedule appointments and pay bills online. “In the D.C. market, that’s a huge selling point,” the Washington-based Tennant said.
Plus, he added, new physicians, who grew up in the digital age and used EHRs in medical school and residency, do not want to work at paper-based practices.
Photo: RoBeDeRo/Getty Images
Accountable care is supposed to be about paying for value. But six years after passage of the Affordable Care Act heralded the shift away from fee-for-service, Dr. Greg Carroll, corporate clinical leader of GOHealth Urgent Care, has an important question: “Where’s the value?”
That was the subject of a lively panel discussion at MedCity CONVERGE this week in Philadelphia.
“We really need to get to the level of what motivates behavior change,” said Carroll. After all, everybody is a little bit different in what motivates them, Carroll explained, and the movement to performance-based payment requires behavior change on multiple levels.
Those paying the bulk of the bills in healthcare for patients not old enough for Medicare — employers, via insurance premiums — don’t seem to get value-based healthcare yet.
Christina M. Miles, senior vice president for delivery system transformation at human resources consulting firm Aon Hewitt, presented some eye-opening data from a 2015 company survey. Just 11 percent of respondents said they “fully understand” healthcare provider performance from a cost perspective, while 9 percent said the same about provider performance from a quality standpoint.
In each case, more than 31 percent were not even aware of clinically integrated performance initiatives within their company plan’s healthcare networks, Miles said. “In most cases, the majority of employers just aren’t there.”
Those in on the front lines are not discouraged, though. “Value-based contracting is one of our key corporate pillars at Aetna,” said David Van Houtte, of the payer’s Accountable Care Solutions division.
Aetna currently puts about 40 percent of its total healthcare dollars into value-based contracts, Van Houtte said. The goal is to have that at 75 percent by 2020.
That aggressive shift parallels efforts at the federal level. The Centers for Medicare and Medicaid Services has said it wants 85 percent of all Medicare fee-for-service reimbursements tied to quality or value by the end of 2016, including shifting 30 percent of reimbursements to alternative payment models — think bundled payments or Accountable Care Organizations. The goals rise to 90 percent and 50 percent, respectively, by 2018.
Miles said to “be encouraged” that for the first time, CMS is driving much of the evolution.
It has providers rethinking what they do, for sure.
“My full-time job is basically change management,” said Dr. Katherine Schneider, president and CEO of Delaware Valley ACO, comprising Main Line Health, Jefferson University and Hospitals, Holy Redeemer Health System, Doylestown Health, and Magee Rehab in the Philadelphia area. It’s one of 77 ACOs contracting with Aetna, she said, and the organization also participates in the Medicare Shared Savings Program.
The hope for Delaware Valley ACO was to get 5,500 lives in MSSP in its first year. The organization actually enrolled 35,000 the first year, and now is above 130,000, plus 100,000 more commercially insured members in ACO programs. Participating organizations earned $6.5 million from CMS for saving Medicare $13 million last year, Schneider said.
She offered some words of advice to those contemplating their own ACOs. “The ACO is all about the C. It’s the care model that matters,” Schneider said.
“We’re very primary care-centric even though we’re part of an integrated health system,” she added.
Miles also emphasized primary care and prevention. “The hospital bed becomes a cost center rather than a profit center,” she said. The same is true about the emergency department.”
“We tend to forget the patient,” Miles said. “They’re the end user.”
Miles noted that employers today are hesitant to require their employees to choose a PCP, a throwback to the unpleasant HMO era. She surmised that it may be time to go there again.
“We have to keep our eyes on the True North here,” Miles said. That’s the Triple Aim of safer care, improved population health and lower costs.
Photo: Meghan Uno/Breaking Media
In a panel discussion at MedCity CONVERGE this week, participants shared what they’ve learned from working with big data, especially when their big data ambitions hit bumps on the road and things go pear shaped.
Dr. Edward Ewen brought an interesting perspective to the panel discussion at the MedCity CONVERGE conference in Philadelphia this week. A physician, he now works as director of clinical data and analytics at Christiana Care Health System. Back in the day, he was one of the architects behind the assembly of Delaware’s health information exchange, the first in the country. It was no mean feat. Now, Christiana Care is “beginning our ACO journey.” He said, “I think a big part of the transition is shifting activities away from physicians and to the care team….In my experience, physicians love innovation and hate change. If you can craft tools to allow me to do what I want to do, you will see rapid adoption… We are not resistant to new tools.”
Hal Andrews, president of healthcare at Digital Reasoning called attention to one example of a failed analytics effort that was intended to identify sepsis cases. Unfortunately, the data the customer provided for the model had already been coded as sepsis, which pretty much defeated the purpose of the exercise.
“It’s one thing to have advanced analytics but getting it into a workflow in a timely manner is something else,” Andrews observed. “A critical part of the journey is the worklflow — delivering it to the right person who needs it when they need it.”
Nicholas Stepro of Arcadia observed that the need to avoid interfering with workflow can have it’s downsides, too. “It’s important to listen to end users, but you cannot be a slave to them.” He used the example of electronic health records. Because health IT vendors did not want to disrupt existing workflows, they did not take risks and create something that could have been easier to use.
In the question and answer session, an audience member wondered how Ewen would handle a patient’s Fitbit data. “Where would you draw the line on patient-generated data? Where does that fit on the ethical line for you, as a physician? Ewen answered this way:
“I really feel like you need to have patient consent to do that and have transparency so they know how you are using the data. Having a default opt-in or opt-out will undermine trust or slow adoption.”
CORRECTION: An earlier version of the story had the wrong title and company association for Hal Andrews. It also misspelled Nicholas Stepro’s name.
Photo: Meghan Uno/Breaking Media
The pro: Billing for transitional care management — services rendered for certain patients during their transition from an inpatient hospital setting to their home — boosts income for physician practices. In 2013, the Centers for Medicare and Medicaid Services began paying for TCM, which could, in some cases, yield physicians more than twice the reimbursement of a hospital follow-up office visit.
The con: Operational challenges make it difficult to meet regularly requirements.
These requirements state that physicians must provide initial contact with the patient within two business days of hospital discharge. Within seven or 14 calendar days (depending on the patient’s complexity), they must provide a face-to-face visit. In addition, transitional care management is for 30 days of services, so physicians can only bill TCM once every 30 days.
Dr. Lonnie Robinson, a family physician at Regional Family Medicine in Mountain Home, Arkansas, said that without the help of technology — specifically an easy-to-use TCM app called Phyzit — he would have had a difficult time meeting TCM requirements. In a busy practice of eight family physicians and three nurse practitioners, he said it’s difficult to track hospital discharges and meet the deadlines for patient contact. That’s where the app helps. And now he bills for TCM at least once a week.
“Care coordinators don’t have to sit down and figure out who’s due for a phone call, who’s due for an office visit and what day the billing has to take place for this all to work properly,” said Robinson.
Local hospitals send patient admission and discharge information to care coordinators working at the practice who then enter this information — along with patient demographic data — into the app. Coordinators also monitor the state’s health information exchange for admission and discharge information. The app handles the rest of the work for them, notifying them as deadlines approach.
“The care coordinators tell me it’s a good value for the price, and they would like to keep it,” he said.
Since Robinson began billing for transitional care management in March 2015, he has noticed a 40 percent increase in revenue for eligible hospital follow-up visits and a decrease in readmission rates from 13.1 percent to 8.2 percent. He said the cost of the app is minimal considering the short- and long-term payoff to ensure compliant TCM billing.
“I think TCM fits into the bigger picture of value-based reimbursement,” said Robinson. “A lot of our incentive programs are tied to a shared-savings model — especially Medicare. TCM improves your chances of achieving a Medicare shared-savings bonus if you’re involved in an ACO.”
Photo: Flickr user forayinto35mm
Nomad Health, a nearly one year-old healthcare staffing startup, has developed a way to automate the process of collecting applications, including licensing and credentialing information. The New York City-based business sees an opportunity to match clinicians with healthcare facilities looking to fill short-term clinical vacancies and cut out brokers in favor of greater billing transparency and lower commissions. Alexi Nazem, Nomad Health co-founder and CEO, also views telemedicine as the next frontier for its service.
Nazem said in a phone interview that the startup would use the more than $4 million from a Series A round that it closed this week to ramp up its marketing and sales teams, with plans to add seven more staffers over the next six to nine months for a total of 12. First Round Capital and RRE Ventures led the round and .406 Ventures also participated. The company has raised about $5.3 million to date. It received seed funding from angel investor Kevin Ryan, who co-founded Business Insider, and serves as Nomad Health’s chairman. Ryan also took part in the Series A. First Round Capital also invested in Nomad prior to the latest financing round, Nazem said.
“Our core product is a marketplace that allows doctors to search for jobs and clinics to search for doctors,” Nazem said.
An algorithm matches the needs of hospitals with the most qualified clinicians based on licensing, dates available, specialty, and location, among other things. Nazem emphasized that it’s the job of each institution to verify the information.
“We are trying to return control back to the people responsible for hiring,” Nazem said. “We think adding brokers to the conversation is only adding to inefficiencies and expenses —they charge a 40 percent to 60 percent commission. We charge a 15 percent commission and we’re totally transparent.”
The company began a beta test of its service just a few months ago and its hospital clients are based in the Northeast, such as St. Luke’s Hospital. When asked about the market opportunity for its service in telemedicine, Nazem said he sees a lot of potential.
“We expect to get involved in telemedicine. We think it will be a really exciting area for us. Telemedicine is a force multiplier — doctors can see more patients in more places in more settings. None of our current clients are telemedicine providers, but they will be soon. It is right on our roadmap.”
Prior to Nomad, Nazem said he was a practicing physician in internal medicine. He also worked for the Institute for Healthcare Improvement and on the 100,000 lives campaign to reduce morbidity and mortality in healthcare.
The company’s home for the next 12 months is Grand Central Tech. The two year-old incubator provides free shared workspace and networking opportunities for startups without requiring companies to give up equity. Out of 1,000 businesses, Nomad Health was one of 19 to secure a spot. The chairman for Grand Central Tech is Michael Milstein, a member of the billionaire real estate family.
As reimbursement evolves from fee-for-service to alternative payment models, incentives will shift from treating sickness to keeping the population healthy. New investments will be made in technologies that reach into the home and enhance care team communication. 2016 saw an acceleration of telemedicine/telehealth. 2017 will see exponential growth.
Telemedicine is hard to define. It could be real-time video teleconferencing between clinicians (a consult), between a patient and clincian (a visit), or group to group (tumor board discussion). It could be the transmission of a static photograph, such as the poisonous mushroom/plant teleconsultation I do 900 times per year. It could be secure texting to coordinate patient care.
Patients might provide care teams with objective data from devices in their homes. Patients might answer surveys about their mood, activity or pain.
All of these are telemedicine.
Many companies will offer cloud-based tools and technologies to support these new workflows. Some organizations will use bridging technology to link together every kind of endpoint (Skype, Facetime, commerical telemedicine apps) with every kind of endpoint.
There are so many use cases and so many possibilities that one approach will not serve all needs, so most organizations will have a multi-faceted strategy.
There are some unanswered questions:
- How do you bill for telemedicine? There is a new CPT code, but it’s not clear how it should be used.
- How do you address multiple conflicting state laws when consulting across borders?
- How is the record of a virtual encounter stored and who is the steward of the record?
For my personal telemedicine practice, toxicology consultation, I use an iPhone and email to review cases and images. No protected healthcare information is exchanged.
I am credentialed by Beth Israel Deaconess Medical Center for telemedicine practice
I am malpractice-insured for telemedicine practice.
When consulting across state lines, I provide advice to licensed physicians in that state and never interact with patients directly (or prescribe medications).
I do not bill for these services. They are a public good.
Medical records are kept by the physician consulting me, and that physician is the steward of the record.
As hospitals expand to serve patients at the national and international level, as payment models require more home care/wellness care and as consumers demand the same kind of convenience from healthcare that they get from other industries, telemedicine will expand and mature.
Telemedicine at BIDMC (part of Media Services) reports to me and I’ve requested additional staffing and investment for 2017. Technology, business needs, and customer demand are aligning to make telemedicine an increasingly important service offering for clincians and hospitals.
But the research community has been able to pull in information from Fitbits and other connected, wearable devices for four years with the help of a research platform called Fitabase.
This week, Fitbit announced that Fitabase, made by San Diego-based startup Small Steps Labs, has now collected more than 2 billion minutes of Fitbit data for research purposes. Fitabase also has supported more than 200 research projects since its 2012 founding, the company also disclosed.
“What we’ve built is kind of the missing piece for research,” said Fitabase CEO Aaron Coleman. The platform collects and de-identifies data from Fitbit users and offers data pools to academic researchers, including many in healthcare. “This removes a lot of privacy concerns,” including those around HIPAA, Coleman said.
“This is a technology that bridges a consumer device like Fitbit with the needs of research,” Coleman said. “Researchers are loving this new paradigm of research.”
That’s important because millions have purchased and regularly use activity trackers. The data these wearables collect provide insights about movement, heart rate and sleep patterns that previously had not been available, plus people actually enjoy wearing their Fitbits.
“It was really difficult to get people to use pedometers,” Coleman noted. That made it tough for researchers and clinicians alike to collect good data and, more importantly, improve health.
“Devices help people better tailor their activities and their health,” Coleman said. “Interventions shouldn’t be the same for everyone.”
For example, Fitabit is helping researchers determine how quickly people regain their previous level of activity following surgery. “They can tailor interventions to people who need it most,” Coleman said.
So what about the “2 billion minutes” of Fitbit data? “We provide the researcher with de-identified data at the minute level,” Coleman explained. Each person’s activity levels can vary at different times in the day. Having this insight allows researchers — and, ultimately, healthcare professionals and caregivers — to schedule interventions when they are most likely to be effective, according to Coleman.
Coleman pointed to a research project at Arizona State University, where Eric Hekler, director of the school’s Designing Health Lab, is applying engineering strategies to study what Hekler calls “precision behavior change,” a complement to precision medicine. Hekler and research partner Daniel Rivera, director of the ASU Control Systems Engineering Laboratory, are testing “health interventions that are adaptive and individualized, versus static and generalized,” according to a Fitbit statement.
Coleman himself also has applied individual Fitbit data to control the level of difficulty in an app called Tappy Fit, a Flappy Birds-like mobile fitness game.
Photos: Fitabase, Fitbit