It has become part of my holiday season tradition to take a look back over the articles I have written in the past year and pull out a handful of quotes that I found insightful or thought-provoking on some of the key issues facing the healthcare sector today. What follows is my selection for 2019, broken down by topic and with a little context to help set up the quotes.
Changing Role of Health Information Exchanges
In November the Michigan Health Information Network Shared Services (MiHIN) and Great Lakes Health Connect announced plans to merge by the end of 2019.
Earlier in the year, Tim Pletcher, MIHIN's executive director talked about how his organization develops use cases and metrics with stakeholders, including payers. Once a new use case is in place, MiHIN runs the report cards on how health systems are doing. Are they sending data and how clean is the data and how consistent? “We are like teachers who want everyone to get an A. We send report cards home to Mom and Dad – the payers or the state government,” Pletcher said. “They decide whether they are going to give everyone their allowance. We don’t measure HIE participation, because just being part of a club does not mean you are creating value.”
Imaging Informatics
Starting Jan. 1, 2020, Medicare is going to require proof that clinicians who order advanced imaging for their outpatients have consulted an approved appropriate use knowledge base as a prerequisite for the imaging provider to get reimbursed. Next year is a testing year, and potential penalties kick in the following January.
Keith Hentel, M.D., executive vice chairman of the Department of Radiology at the New York-Presbyterian Hospital/Weill Cornell Medical Center, described the new requirement as like a new flavor of pre-authorization. “We are used to making sure that we have a specific code associated with an imaging exam before we do it or otherwise we are not going to get paid. Commercial insurers have been doing this for years. In many ways, the appropriate use criteria program is better, because there is a lot more transparency and more rigor around how the rules are created that suggest and deny imaging. But when you distill it down, it really is pre-authorization all over again.”
Primary Care and Genomics
Mylynda Massart, M.D., Ph.D., an assistant professor of family medicine at UPMC in Pittsburgh, described her work trying to integrate genomics and primary care. “Ten years ago, when I gave talks to primary care doctors on genomics, the response was a complete shutdown. They didn’t want to see it or hear about it. Now I see that changing. When I teach residents, I tell them to be open. Whether a direct-to-consumer test was clinically important or not, it is a great way to jump-start a conversation with the patient to try to understand what motivated them to do the test — whether it was general knowledge-seeking or something particular they are worried about. Use that as a stepping stone to apply the tools we have to answer that question.”
Open Notes
Jared Klein, M.D., M.P.H., a physician at the Adult Medicine Clinic and medical director of the After Care Clinic at Harborview and a University of Washington assistant professor of General Internal Medicine, gave some advice about implementing Open Notes. “We recommend directly and respectfully addressing concerns. Discuss what you write and write what you discuss. I try to angle the computer so we can both see. You can ask them to look at the note to make sure you are both on the same page and help you get feedback, and then you can ask them if they read the notes and whether they had questions or concerns.”
Trusted Exchange Framework and Common Agreement (TEFCA)
Early in 2019, Claudia Williams, CEO of California-based health information organization Manifest Medex, expressed some skepticism about the timing of TEFCA. “We are in complete alignment with ONC and CMS in their rulemaking regarding the urgent need for reducing information blocking,” she said, “but we have two proposed regulations that have a lot of new policy, and we have national networks that are showing extraordinary operational success around connecting EHRs. Our belief is that this is a bad time to introduce additional complicated policies. It would be smarter to hold back on TEFCA and let information blocking and other parts of the policies take effect and then assess in two to three years if additional policymaking or guidance is necessary.”
Value-Based Care
Rob Fields, M.D., senior vice president and chief medical officer for population health at Mount Sinai, said that although Mount Sinai faces the problem often described as one foot in the value-based care boat and one foot on the fee-for-service dock, the health system is interested in making “no-regret investments” that make sense in both environments. “We are experimenting with things you would do in both camps, including improving data infrastructure and embedding more resources into practices,” he said. “It’s never wrong to have a culture of continuous improvement and team-based care.”
Patient Engagement
Sandra Van Trease, group president for BJC HealthCare’s ACO, spoke about patient engagement in an ACO setting at the NAACOS Fall meeting. “I don’t think engagement is sending people a letter telling them they are in an ACO. We work to understand who would benefit from direct engagement to help them lead a healthier life. That may be talking to a pharmacist, a dietician or a social worker. It takes the data to identify people and then the work of care managers and clinicians to stay connected. That is why it is expensive. But stories suggest that is the way to change behavior and improve outcomes.”
Medicaid Transformation
In a presentation about statewide transformation in North Carolina, Mandy Cohen, M.D., M.P.H., Secretary of the North Carolina Department of Health and Human Services, admitted that the state government has a long way to go in terms of data infrastructure. “The capacity and sophistication of data at the state level is pretty weak,” she said. “It is surprising how hard it is to use data created for one purpose for another,” she noted. For instance, using data systems originally designed for fee-for-service to manage a population is messy and sometimes wrong. “We have to deal with that. We are at the crawl stage of being able to use our data well.”
Social Determinants of Health
I will close with two quotes on how health systems are addressing social needs and working on data issues surrounding social determinants.
Andrew Renda, M.D., M.P.H., associate vice president of population health at Humana, said Humana is committed to addressing social determinants, but the proof is in the pudding. “We need to generate clinical outcomes and a business case that shows that by addressing them, we are keeping people out of the hospital and lowering the total cost of care. The challenge for us is that the further upstream you go, the longer it takes to see return on investment. I don’t think these patients are going to cost more in the long run, but we have to open the aperture a bit. We can’t think we need one-year return on investment. It may take three years, five years or longer. The payoff may come further down the road.”
Laura Gottlieb, M.D., M.P.H., director of the Social Interventions Research and Evaluation Network (SIREN) at UCSF, is working on data standards around sharing social determinant data. She spoke about getting beyond the hype around social determinants. “I am from the Bay Area. I like to say that we are at the beginning of what is called in tech startup language the innovation hype cycle. The first phase of that cycle typically involves the peak of inflated expectations, where early publicity produces lots of success stories. But unfortunately that peak is often followed by what they call a trough of disillusionment, where early innovations don’t systemically deliver. As researchers, we are responsible for helping to move through that trough and up the slope of enlightenment.”
