Saturday, July 16, 2011

HIT Megatrend: Patients will have Instant, Complete, Unfettered Access to their Medical Records

Healthcare Needs Help On Transparency

(from Information Week - Posted by Chris Murphy on Thursday Jul 14th at 6:11pm)
Dr. Neil Calman wrapped up Tuesday's InformationWeek Healthcare IT Leadership Forum in New York City with a few predictions, including one portending radical change in people’s access to their health records.
He started with the big picture. "If there's one thing that's going to revolutionize healthcare--whether it's IT, ACOs, any aspect of health reform--what you're going to see is patients taking back healthcare from their providers," said Dr. Calman, a physician who is CEO and cofounder of the Institute for Family Health, which runs 17 health centers in the Bronx, Manhattan, and the mid-Hudson Valley in New York State.

Then Dr. Calman got more specific, including one prediction destined to raise some blood pressure:

"You're going to see patients want complete and unfettered access to their medical records. Forget all this about where we're going to keep the data to ourselves for seven days before it's released to patients, or we're going to create models of abstracted data to give to people. They will have total and complete, instant access to their medical information, whenever, in multiple formats, however they want it."

Each of those modifiers -- complete, unfettered, instant -- would rip away a security blanket that healthcare providers and health IT leaders cling to when they start talking about giving patients access to their medical records.

Instant: Some providers give patients access to lab results, but they wait several days so that doctors have time to talk with their patients about the results.

Complete: Should patients be allowed to read their doctors’ notes? To access every lab result? To see images they aren't qualified to assess?

Unfettered: This will mean letting patients have their full health records -- and not just through a hospital's sanitized portal, but as a raw download they can take with them, Dr. Calman predicted. And they'll have to offer a means for the patient to make comments, or corrections in places where they think the information is wrong, he said. Dr. Calman's fellow panelist, Karen Marhefka, associate CIO for UMass Memorial Healthcare, said giving patients the ability to comment on records was a concern when UMass Memorial assessed vendors for its planned patient portal. Its lawyers advised against allowing other sources into the providers' clinical data, even if comments could be identified as coming from the patient.

Dr. Calman predicted that every major electronic health record system or portal will soon allow patient input, and that it shouldn't be controversial. "Every single thing we do in medicine depends on what the patient told us," he said. "… The subjective part of every progress note is us writing down what the patient told us. We don't have any way of independently verifying it. But all of a sudden, when the patient can write it themselves, it becomes something the lawyers are all freaked out about. Anyway, these are the transformations that are going to take place. They just change the way we think about everything in healthcare."Some 15,000 people now use the Institute of Family Health's portal to view records, Dr. Calman said. But he predicted it won't be long until patients expect to get their records in a downloadable form of their choosing--and that HIPAA and other regulations will be amended to give patients that kind of portable access to their records.

Concerns that patients will misinterpret lab results are legitimate. And letting patients add their own comments or data to their health records does raise some new legal liability questions. But health IT leaders and their clinical peers shouldn't waste their time trying to stop this transparency movement and instead must pour their energy and intellects into coming up with workable solutions. (And there was plenty of that in evidence at the forum.)

Concerned that a patient will misunderstand a test result? Health providers will need to arm that patient beforehand with information about what the test's looking for, and where to get more information about it. They'll need to push EHR vendors to build more such links into their products -- links to reliable data sources, right from an EHR portal.

Giving people access to their medical records is closely related to another phenomenon: people turning to Google or Facebook as soon as they get a diagnosis. Anyone who has done that knows you're likely to read a lot of worst-case scenarios and quackery, and can understand why Debra Wolf, a professor of nursing at Slippery Rock University, says that social media "frightens me to death."

People are "going out to find patients like themselves," said Wolfe, in an earlier discussion at the InformationWeek Healthcare Forum. "What frightens me is they don't know how to safely evaluate a website."

Noteworthy is the fact that Wolfe is looking for ways providers are helping patients get better information, not hoping to cut off access. At some hospitals, when nurses are discharging patients, they’ve been trained to ask, "Are you using a website for health information?" and offer tools to assess a site's quality and reliable sites that people might consider using. People will inevitably look to the Web and social sources for healthcare insights, so "we need to meet them out there," Wolfe said.

Same goes for people's digital health records. As patients demand access, health IT leaders will need to focus on making that experience valuable, not getting in the way.

Thursday, April 21, 2011

The Teaching Health Center: A Great Program Threatened by Republican Shortsightedness

After decades of concern for the deep and worsening crisis in our country due to a shortage of primary care physicians, the Obama administration proposed - and passed as part of the health reform bill, a program to directly fund health centers for the training of primary care physicians. Combining the longstanding committment to excellence in primary care with the social committment of the primary care providers that practice in community health centers, the idea of using this successful model to train a new generation of primary care providers was brilliant. Directly funding these programs was essential in that programs funded through hospitals often direct large portions of the training to the inpatient setting to extract more inpatient service from the residents in training. But the model, like other important parts of the health reform legislation is under attack.

H.R. 1216, authored by Congressman Brett Guthrie (R-KY), rescinds the unobligated portion of the $230 million in total mandatory funding available to support Teaching Health Centers (THCs) for FY2011-FY2015. This bill would make the program subject to the annual appropriations process rather than committing the $46 million per year for FY2012-FY2015 in the health reform legislation to fund Teaching Health Center activities.

This year HRSA announced 11 THC grantees, of which 9 are community health centers with our own Institute for Family Health's Kingston Family Practice among them. Funding this year through this program will support the expansion of our Kingston rural residency by 12 residents. The residents will train along side our dedicated primary care physicians - all practicing in medically underserved communities. 6 of these residents will be training in our remote rural center in Ellenville, New York, (pictured below) where they will learn what rural medicine is really like, and, upon graduation, will become part of a cadre of physicians trained to practice in parts of the country where there are few if any primary care services.

If enacted into law, H.R. 1216 will make it challenging for us and the other 10 programs that have already made the decision to participate in this program based on a promise of continuous funding. The new legislatiion being proposed means that the programs would have to fight for limited discretionary funding each year. The National Association of Community Health Centers has said "In this difficult budget climate and with House Republicans reluctant to support the implementation of health reform, despite clear statements by Energy and Commerce Members on both sides of the aisle that this legislation advances a worthy goal of training more primary care physicians, if H.R. 1216 were to become law it puts the new THC grantees future funding in jeopardy."

We need to do everything we can to support the continued funding of Teaching Health Centers. The primary care shortage is real and even in its first year, substantial increases in primary care training will be achieved through this program. Let's keep a good thing going!

Sunday, April 3, 2011

ACOs and Federally Qualified Health Centers: A Lost Opportunity to Transform the Health Care of America’s Most Needy?

As our Nation struggles with the troublesome duet of embarrassingly poor health outcomes and seemingly unstoppable escalations in health care costs, a model has emerged with promise to blaze our way out of this quagmire. And unlike many other advancements in medicine, the first beneficiaries of this model are America’s most needy residents. The model, the Federally Qualified Community Health Center, incorporates almost every aspect of what health care experts believe are the fundamental characteristics of an advanced model of health care organization. Strangely, unless action is taken immediately, that model will be overrun by the implementation of Accountable Care Organizations – or ACOs – when ACOs have been developed to accomplish many of the same goals. Here’s what is happening…..

The Medicare regulations for ACOs were released on March 31, 2011 in draft for public comment. In brief, ACOs are meant to establish a financing system where payment enhancements are made to the ACO, and then to the providers, based on achieving specific health care outcomes and reducing (or in some cases stopping the escalation of) health care costs. This is achieved by assigning patients to ACOs based on their historical place of care and assigning cost predictions based on their historical utilization of health services and other health-related characteristics. So everyone – or almost everyone – wants to be an ACO so they can get the financial rewards from their efforts to improve care for their patients and reduce overall health care costs. In New York City, hospitals, medical groups and FQHCs have been planning their ACO strategy since the legislation outlining the goal of ACOs was passed last year in the health reform bill. Yet to the shock of the FQHC community, they were determined, along with Rural Health Centers (RHCs) and some others, to be ineligible to sponsor an ACO.

The implications of this will have enormous, negative impact on the future of FQHCs. To understand this, one needs to envision the advanced model that FQHCs have been developing over the past decade. To start with, they are governed – not just advised – by a board of directors that is made up of a majority of the health centers users. They are built in the community, governed by the community and therefore, serve as a model of how health care providers must be responsive to the needs of those they care for. They have been early adopters of electronic medical records, have been achieving certification as Medical Homes at a blinding rate (the highest recognition a primary care provider can achieve today). They have expanded hours to expand access, provide multilingual care where appropriate, and often integrate chronic disease management, mental health and dental services in one location. They engage networks of specialists to care for their patients – even though 1/3 of the patients they serve nationally lack health insurance. In short, they are the model for what everyone in the U.S. needs. So what is the issue?

ACOs will control the flow of funds for improved care and reduced costs and to insure that the benefits of these added payments accrue to those who have invested in the formation of advanced delivery systems, they must be in a position to control the distribution of these funds. We have always said that a rational system of care is built around a strong foundation of primary care – the FQHC. With hospitals and multispecialty groups in control, the same power relationships that exist now will exist in the future and what is worse – the same model of care and the same catastrophic economic results. We cannot afford to let this happen. The main question at stake here is whether we want hospital controlled ACOs sitting at the center of these new models, struggling to make up for the falling volumes of high-cost services they provide by fighting over market share with other hospitals, whether we want multispecialty group practices at the center of the ACO model with their frequent overrepresentation of specialists and underrepresentation of primary care or whether we want primary care as the ACO’s core – providing a rationally constructed system where the training of primary care practitioners in preventive care, care coordination and chronic disease management provides the foundation for improving quality and reducing cost. We all know what we need to do!

The elimination of FQHCs from the list of eligible ACO sponsors seems to result from a technical issue but it is hard to imagine that a technical work-around could not have been developed by CMS before the release of the draft regulations. The technical problem is that FQHCs are required by CMS to bill Medicare differently than practitioners in private practices bill. FQHCs do not use HCPCS codes to indicate the type and level of procedure done and they do not indicate the specific doctor who saw the patient as the claim form has only a place to indicate the clinic provider number. Because of this historical method, CMS claims the inability to collect baseline data back 3 years as they propose to do and the inability to attribute care to an individual provider. But for those FQHCs that choose to sponsor an ACO, this data is retrievable through a review of the medical records that contain this information. For those on electronic health records, this data could be extracted electronically. For those whose records are still on paper, a sampling methodology could be developed. Claims could be reprocessed for qualifying Medicare patients – those that CMS tells the center might be a candidate for an ACO by virtue of the FQHC providing a plurality of visits to the individual patient. The reprocessing would not effect payment but merely provide the needed baseline data for these patients. I am sure there are other solutions as well – and they need to be developed now.

The country needs FQHC’s as the sponsor and integrator of ACOs – especially as more uninsured patients achieve coverage through health reform in the ensuing years. ACOs sponsored by FQHCs would be based in a system with the most sophisticated primary care delivered in a fashion that by its very nature treats patients in order to improve their health outcomes and reduce their costs of care. We need to advocate quickly and powerfully that FQHCs be included as potential leaders of ACOs, in a position to insure that the distribution of funds through the proposed shared savings models is done in a manner that preferentially supports primary care.

Saturday, April 2, 2011

ACOs and Population Health - It's the Denominator, Stupid !

ACOs or Accountable Care Organizations were created by the health reform legislation proposed by President Obama and passed by the legislature one year ago. They are the Nation's new hope in reorganizing the financing (and, it is hoped, the delivery) of health care to support improved outcomes. Patients are not required to belong to an ACO and the ACO does not restrict the patient's access to any caregiver they choose. The ACO is, however, incentivized financially to help the patient organize their health care to achieve a better outcome and thus, save the health care system money. The money saved, in one model being proposed, is then shared between the payer (the insurance company or government in the majority of cases) and the provider (the ACO).

Now that the Medicare regulations have been proposed (by CMS on 3-31-11) it is clear that the attribution method used to assign patients to an ACO does nothing to encourage a health care provider to reach out to their community to engage new patients. To be in a particular ACO, the patient has to get the plurality of their care with a provider in that ACO. To be paid a premium for that patient's care, the provider must focus on optimizing the care of that patient - definitely a good thing to do.

But if I want to improve the outcomes for people with diabetes in the community, I have to outreach to the community, focusing not just on the patients who are already getting a plurality of care from me, their doctor, but rather on the at-risk patients, patients lost to follow-up, and patients who have scattered and disorganized care - using emergency rooms as their family doctor. Only by reaching those patients who are not regularly in the care of a given provider can we achieve better outcomes at a community level.

The problem is not unique to ACOs. All quality improvement programs, rewards for doctors to improve the care of their patients and all quality recognition programs for providers focus on improving the care of patients we already see. This is surely important as doctors everywhere give suboptimal care - usually missing needed preventive health care interventions and focusing on acute care needs. But to improve population health we must reach out to those who do not have a regular source of primary health care.

To accomplish this we need to change the entire process of quality reporting and add some community based outcome measures into the expanding list of measures that are used to evaluate the work of physicians. As we move our patients into ACOs, we must be sure to simultaneously increase our focus outside of our practices and make sure that we engage people not currently in organized primary care systems.

As we develop quality reports we should run them all in two ways. First, we should run them to assess the quality of care we are giving to the patients who have committed their care to us - those who, for example, have been to see us at least twice in the past year. Second, we should run our quality reports using, as a denominator, any patient who has ever been into our health center with the condition being evaluated. This will measure how well we do with patient engagement, how well we are doing with outreach to those lost to follow-up and will encourage patients who have dropped out of care, to re-engage. Even if we do not have the resources to do frank community outreach, efforts to reach this group of patients will help to address those who are not in care and will help build our patient base as well. ACOs need to develop a mechanism to support this type of work in our practices, lest they just become another reward for caring for those who are already committed to a source of care.

Sunday, March 28, 2010

Let the Work Begin !

It is hard not to be amazed by the accomplishment of our President, Barack Obama, in getting a complex, far-reaching, health reform bill through the legislature. It took his focused vision and a determination to use the mandate of his election to make it happen – the most important health care legislation in the nearly 50 years since Medicare and Medicaid were enacted.

Lest anyone think that politicians truly represent their constituents one needs only to look at the unified position the Republicans took against the health reform bill. It was summed up best at the beginning of the debate on health reform when the Republicans declared that they needed to beat Obama on health care to bring down his administration. They tried. They lost. The American people won.

Now comes the time to make health reform work. To do that we will need to focus on a few important issues. First, we must insist on forward motion, paying no attention to the remaining opposition. Passage of the bill is only the first step. Implementation of the many opportunities we now have will require all of our attention and our creativity as health professionals. Second, we will quickly need to focus on the question of primary care supply. In the two free clinics that are run by our Institute for Family Health, more than half of the people who come for care come for preventive health services and for the management of common chronic illnesses such as hypertension and diabetes –the effective treatment of which is closely linked to improved health outcomes and reduced health care costs. But primary and preventive health care providers are in short supply and we will need to address the workforce issues now, or find ourselves with a newly insured population with nowhere to use their new insurance card. During the Clinton health reform attempt I appeared on McNeil-Lehrer on PBS and said “Even if every American were to get an insurance card today – most would have nowhere to take it – especially if they live in the inner-city or in a remote rural area.” Unfortunately, years later the story is still the same.

Even with these issues ahead of us, one thing is undeniable. Lack of health insurance disproportionately effects people of color in New York City and New York State and across other areas of this country. To the extent that lack of insurance is also closely tied to delays in care and worse outcomes for almost every condition studied, providing insurance for tens of millions more Americans will help to decrease (but not eliminate) health disparities between people of color and whites. And for that reason alone, we should celebrate!

Let the work begin!

Saturday, November 21, 2009

How to Guarantee Disparities in Health Outcomes: A Primer

Bradford Gray, PhD, a distinguished health services researcher has published a very important study which demonstrates yet another reason why our health care system is designed perfectly to get the disparities in health outcomes that result.(1) Dr. Gray and his colleagues concluded that “minority patients in the New York City area are significantly less likely than whites to be treated at high-volume hospitals for cancer surgeries, cardiovascular procedures, and other services for which high volume and positive outcomes are related”. In other words, racial and ethnic minority patients are much more likely to get essential procedures done at hospitals that do fewer of them per year – a factor well known to contribute to poor health outcomes.

For those of us who provide health services in New York City none of this is a terrible surprise. We all know that those specialty hospitals that advertise on radio and television that they provide the best care in their field – Memorial Sloan Kettering for cancer, Joint Disease and the Hospital for Special Surgery for orthopedics, NYU’s Rusk Rehabilitation Institute and Calvary Hospital for end of life care – all have among the lowest rates of admissions for the uninsured and those on Medicaid.(2)

There are many reasons for this, as we have come to learn. For one, most Medicaid patients are in managed care now and hospitals and managed care companies must negotiate rates in order for the hospital to be considered "in-network" and thus accessible by people who have chosen to enroll in that managed care company. But as we have learned from folks at Sloan-Kettering, no Medicaid managed care company want to contract with them for their Medicaid enrollees. With a reputation as the only specialized cancer center in New York City, a single managed care company that puts Sloan-Kettering in its network will find itself the plan of choice for people with cancer, thus driving up its costs and reducing its profits. The same dynamic will take place for the other specialty hospitals as well. Do patients know, when the sign up for a particular managed care plan that it will likely restrict them from recieving services at the highest volume specialty hospitals if and when they come to need them? I think not. Young people don't sign up for a managed care plan thinking that they might develop cancer - yet when they do - and find themselves unable to go to a specialty hospital for treatment - they unknowingly become a potential victim of health disparities - treatment at a lower volume hospital with a potentially poorer outcome. Sad, when we are talking about the basic human right - the right to live.

There are no villians here. The facts are that we continue to create - through policies in the State, through limitations in funding, through a competitive rather than a cooperative marketplace of health plans, hospitals and doctors - a system that perfectly produces the disparities in outcomes that we achieve.

Bronx Health REACH is a consortium of over 40 community and faith based organizations that has been working in the Bronx for over a decade to reduce – no, eliminate – disparities in health care treatment and health outcomes. We have been working to change the policies which create racial disparities in out-patient care in the voluntary hospital sector in New York City. In facilities that operate “clinics”, the clinics are the places where the poor are treated in a system that provides care that is inferior in many aspects to the “private” care given in other parts of the system. Students, interns and residents - often supervised by a rotating group of attending physicians – are the main health providers that patients see. Troublingly, these doctors rotate monthly through the clinics making continuity of care almost impossible. The clinics have very limited ability to coordinate care with referring community physicians, another cause of discontinuity. Obviously, these doctors are also the least experienced, and these factors together explain, with an unproven yet logical extension of Dr. Gray’s research, another reason why outcomes can be expected to be worse. Everything that contributes to inferior care contributes to the premature death and disability people of color in New York experience.

Like I said before, the system of care in New York is designed to get just the disparate outcomes it achieves. Let’s redesign it.

1. B. H. Gray, M. Schlesinger, S. M. Siegfried et al., Racial and Ethnic Disparities in the Use of High-Volume Hospitals, Inquiry, Fall 2009 46(3):322–38
2. New York State SPARCS Hospital Discharge Database,Table IX

Saturday, November 14, 2009

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.