Forecast 2011 Part II

By George Schwend, CEO, Health Language

The spotlight will be on compliance with Stage 1 meaningful-use (MU) criteria. One of the key components of compliance is the up-to-date problem list (UTDPL) based on SNOMED CT, or the more commonly implemented ICD-9-CM.

However, many providers, already frustrated with inputting diagnoses and therapies using ICD-9-CM codes intended for billing purposes and not patient care, are resisting the inevitability of UTDPLs. Yet without standardized, accurate data capture, the goal of meaningful use — coordinated care — will continue to elude the industry.

Hospitals seeking to increase physician engagement will turn to provider-friendly terminology (PFT) and embedded tools to simplify the process of creating and updating problem lists. PFT consists of a set of problems and procedures mapped to standards such as SNOMED CT, ICD-9-CM and the upcoming ICD-10-CM that can be embedded in EHRs. This mapping ensures correct reimbursement and supports MU's quality-performance requirements.

PFT also facilitates the codification and mapping of clinical free text to the appropriate codes, which allows providers to continue documenting care in their preferred manner and maintain their workflow and productivity. Therefore, hospitals will increasingly incorporate PFT to create physician buy-in on UTDPLs.

Comprehensive image exchange

By Jeff Surges, CEO, Merge Healthcare

Image exchange is challenging. Diagnostic images are large — a cardiac cath file is the same size as the video file for the movie “Titanic.” Organizations use products from multiple vendors, each to address a specific business or clinical need, and some vendors do not adhere to standard image formats. Many systems do not allow simultaneous review of images and reports, or enable access to current and prior images. Across institutions, geography and systems, it can be difficult to reconcile unique patient identifiers and to align numerous reports and images associated with a patient.

The time is now for healthcare to leverage successful federated data models (banking's ATMs, for example) and network design (the Internet) and create exchanges that allow EMRs, HIEs and PHRs to access diagnostic content and results from any location without moving data. We should empower patients, providers and payers to manage the total healthcare experience from computers, mobile devices and new types of access points (kiosks).

Organizations should leverage current investments by using existing systems and applications and build incrementally toward a fully interoperable exchange. Organizations should adopt the newest in Web-based technologies and leverage interoperability standards (HL7, DICOM, Web services and XDS). Entities such as Integrating the Healthcare Enterprise (IHE) bring value (check out the IHE Interoperability Showcase at HIMSS). Essentially, IHE investigates business problems in healthcare and then provides international standards as a “guidebook.”

Health insurers face most significant technology overhaul in 20 years

By Ray Desrochers, COO, HealthEdge

The last time the healthcare industry underwent a large-scale technology change-out, George H.W. Bush was president, the Gulf War had just begun and HMOs were booming. In fact, it was the shift toward managed care in the early 1990s that prompted payers to transition from mainframe computing to more flexible client-server solutions.

Flash forward 20 years to 2011, and once again fundamental industry change is driving the need for next-generation technology.

According to McKinsey & Company, healthcare reform, conversion to ICD-10 and the stimulus act's healthcare IT mandates will require the transformation of more than 90 percent of a typical payer's existing IT structure.

Other major trends fueling a technology overhaul include:

• Highly customized, consumer-focused benefit plans: Payers will need to continuously develop new types of innovative products in order to truly compete in the 21st-century healthcare marketplace. Existing legacy systems require significant time and effort to implement even the most minor changes. These solutions were simply not built to address today's rapidly evolving healthcare needs.

• Operational efficiency and productivity gains: Over the years, most payers have resorted to costly and inefficient manual processing, surround systems and other workarounds to compensate for their IT infrastructure's shortcomings. Federal legislation will soon limit payers' non-medical spending — a death knell for previously tolerated administrative inefficiencies.

• Ongoing government mandates: As further details of new legislation and regulations continue to unfold, payers will need to comply quickly with new and often onerous requirements.

• Increased expectations for customer service: As customized benefit plans and value-based programs become the norm, payers will need to move beyond the limitations of their current systems and offer real-time access to information that will allow their members to make better decisions about their care.

Simply put, the current payer IT infrastructure is not going to support the needs of the new healthcare economy. Health plans that view change as an opportunity, and move quickly in 2011 to adopt new technologies, will be well positioned to lead the market. As science fiction writer Isaac Asimov once said, “No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be.”

Learning from PCI compliance

By Elizabeth Ireland,
VP of strategy, nCircle

Healthcare can gain by looking at payment card industry standards (PCI) developed by major credit card issuers to ensure credit card privacy and security. It's not a big stretch to imagine healthcare security standards are likely to evolve along a trajectory similar to PCI, especially since records exchanged over the Internet are subject to the same security concerns as any other Internet data transactions.

While both PCI and healthcare security standards already share some common features, there are a number of PCI requirements that are destined to be included in future security requirements:

• File integrity monitoring: File-level auditing tools safeguard against tampering with files. Any changes to file size and location are logged including file attributes, when the file was changed and the log-in name of the entity that changed it.

• Configuration compliance: Making sure all devices on the network adhere to security policy is critical to controlling risk and maintaining compliance. While sounding simple, gaining visibility and control of every networked device can be challenging, especially in large networks. Automating tools that make it possible to adhere to a set of best practices is an important step toward protecting the critical information healthcare networks contain.

• Web application vulnerabilities: Web applications are the primary mechanisms for over 55 percent of the conditions leading to failure of confidentiality and integrity. Web application security includes a wide variety of conditions critical to sharing EHR with other labs, clinics, hospitals and payer networks.

An early start on these areas can improve security and help with rigorous compliance requirements ahead.

Tipping point for e-prescribing

By John Klimek, R.Ph., SVP of
industry information technology, National Council for Prescription Drug Programs (NCPDP)

Momentum in electronic prescribing is stronger than ever thanks to last year's boost from meaningful use. Physician incentives, payer-led initiatives and the drive toward interoperability are sure to make the technology pervasive in the outpatient setting over the next 36 months.

NCPDP's SCRIPT standard, used in e-prescribing, has been around since 1997. Use of the standard by prescribers has been steadily on the rise, growing from 74,000 active prescribers in 2008 to 156,000 in 2009, and now up to more than 200,000 prescribers according to Surescripts, which operates a national e-prescribing network. Embedded in the meaningful-use (MU) requirements, e-prescribing adoption should jump sharply as physicians scramble to qualify for Stage 1 incentives for MU in 2011-2012.

The Centers for Medicare and Medicaid Services (CMS) and the Drug Enforcement Administration (DEA) have played a role in spurring physicians to adopt e-prescribing. CMS incentivized prescribers with a three-year, voluntary bonus program that began in January 2009 for successful e-prescribers; after 2012 CMS will begin instituting a penalty for failure to e-prescribe. And in May 2010, the DEA removed a chief barrier to adoption of e-prescribing with its rule permitting e-prescribing of controlled substances. From what we are hearing, the move to include the DEA requirements in e-prescribing tools by vendors is slow.

Payer-driven initiatives will also fuel the surge in adoption by promoting care management, wellness and prevention programs and demanding data to support their quality and safety improvement initiatives. Some payers have even developed their own e-prescribing solutions to encourage adoption and lower costs.

The drive toward interoperability requires EHR vendors to incorporate e-prescribing standards that will enable users to meet MU criteria, exchange health information and facilitate communication between prescribers and pharmacies. With no shortage of drivers, e-prescribing will hit the tipping point by 2014, enhancing quality, safety and cost effectiveness of care.

Alternative care-delivery models take root and grow

By Steve Schelhammer,
president and CEO, Phytel

A crucial component of healthcare reform is to transform our care-delivery system to improve quality and control costs. To do that, the government is working with the private sector to test and promote new structures, such as the patient-centered medical home (PCMH) and the accountable care organization (ACO). Both of these innovations, which will gain momentum in 2011, require providers to make sure that everyone in their patient population is receiving appropriate preventive and chronic-disease care.

Today, many physician practices and hospitals still operate in the traditional fee-for-service model. To build a successful medical home or ACO, providers will have to coordinate care and work with patients to improve their health. They will also have to track and monitor their patients' health status and reach out to those patients who are noncompliant or have fallen out of touch with their physicians. In essence, they will be required to adopt a population health-management approach and strategy. And more importantly, they will need automated capabilities in order to support these initiatives.

Even with financial support from payers, physician practices cannot do this type of population health management without the aid of health information technology. Beyond electronic health records, they will need registries, multi-channel patient-messaging technologies, and Web-based tools for health-risk assessments and patient self-management education. Using registry-generated data to identify care gaps, physicians will be better able to deliver necessary services to patients when they visit, matching care-team skill sets to patient-specific needs. Similarly, care managers will use advanced population-based reporting and stratification to identify patients who need personalized interventions and deliver automated methods to empower patients to become active participants in their own health.

In the next year, we'll see the spread of these automation and care-coordination tools as alternative care-delivery models take root and grow. While experts say it will take some time before population health management becomes the norm, many healthcare leaders are already jumping on the bandwagon to take advantage of the incentives that Medicare and private insurers are offering.

Connecting the dots of coordinated, accountable patient care

By Dr. Joe Bormel, M.D., MPH, chief medical officer and vice president,
clinical product management, QuadraMed

As the echo of New Year's celebrations fades, the healthcare industry returns to the challenges of meeting Stage 1 of ARRA's meaningful-use requirements, preparing for the ICD-10 transition, innovations in care coordination, mobile-device advancements and the advent of computer-assisted coding technology, as well as healthcare reform legislation and technology integration. Close behind are Stages 2 and 3 of meaningful use, as well as federal and state funding uncertainties. This unprecedented confluence of healthcare mandates and opportunities has driven organizations to launch significant investments in planning, education, training and testing … or has it?

In 2011, we will finally see mainstream healthcare organizations move beyond their economic and risk-driven inertia. As a first step, providers will need to recognize that achieving meaningful use means transcending discrete claims data by embracing a problem-aware platform. Specifically, organizations that leverage an electronic health record's integration of inpatient and ambulatory data can evaluate patients' needs within the context of a problem or set of problems. Not just any and all problems, but initially problems associated with quality measures. This natural evolution to coordinated care aligns with meaningful-use criteria, which require an up-to-date problem list, quality measures and interoperability with coded patient summaries. Additionally, the problem-aware platform facilitates the ICD-10 transition and related clinical documentation improvement goals, which will change the way health systems manage coding processes by the documented transition date of Oct. 1, 2013.

How is this different than previous years? The greater specificity of SNOMED, ICD-10 and other codes enables identification of detailed diagnoses and discrete therapies when updating problem lists. As a result, organizations will reduce manual, redundant processes; optimize operational performance; and improve care through a comprehensive patient view delivered by the contextual problem-aware platform.

The industry's heightened standards and implementation of data specificity, integration and interoperability — within and beyond up-to-date problem lists — will empower healthcare organizations to connect the dots of coordinated and, ultimately, accountable care. Now that's a New Year's resolution to keep!

CRM to gain traction

By Jim Schleck,
executive director, REACH3

In the coming year, expect hospitals and health systems to increasingly look to customer relationship-management (CRM) technology to communicate, market and strengthen ties with consumers and physicians.

Currently, only a small percentage of the country's approximately 5,000 hospitals use CRM to reach their key revenue-generating constituencies. Until now, most organizations have relied on conventional print, television and radio marketing campaigns to drive existing and potential prospects to utilize medical services. Although the approach casts a wide net, it delivers minimal bang for the buck because the promoted services are irrelevant to the majority of the targeted audience.

Physician outreach is infused with the same marketing ineffectiveness. To achieve physician alignment, hospitals create strategies using paper-based data that usually are inaccurate and outdated. When information is electronically available, it is housed in disparate systems, making it difficult and time consuming for marketers and physician liaisons to aggregate and analyze it. Usually, marketing employees must ask and wait several weeks for the IT department to produce a report. The results: lost opportunities galore.

With revenue growth rate and payer reimbursement declining while the population grows older and millions of uninsured Americans are being extended health coverage, providers will soon recognize the need to find a better way to forge closer relationships with consumers and physicians.

By consolidating their patient and physician information with data from external sources in a centralized CRM database, hospitals will be able to identify trends, patterns and problems easily and early. They will know whether Mr. Smith requires a medical service or Dr. Jones has dropped in referrals, enabling them to generate timely communications tailored to the specific needs and wants of every person in the database. The compelling agility, value and efficacy CRM offers is why the technology will emerge and become a must-have-tool for hospitals in 2011 and beyond.

The year of irreversible convergence

By Jeff Margolis, founder
and chairman, The TriZetto Group

No one can dispute that the healthcare landscape is complex and uncertain. The Great Recession has created high unemployment coupled with a slow economic recovery environment in proximity to the passage of costly healthcare reform legislation that creates myriad changes to government-sponsored and private-sector health insurance programs. No problem! Each year, I go out on a limb to identify important healthcare strategy and information technology-related predictions for organizations to consider over a several-year planning horizon. I believe that health plans, working collaboratively with providers, are up to the challenge of improving the coordination of benefits and care in this country to yield more value for every healthcare dollar spent.

In 2011, I predict that social media will begin a noticeable and irreversible convergence with organized systems of healthcare. As the popularity of specialized social networks rises, payers, providers and employers alike will need to develop new strategies and utilize analytical tools to engage consumers in these venues while maintaining quality communications and following privacy rules.

Second, I predict that efforts to increase the use of electronic health records will continue to garner broad support both legislatively and within the industry. However, their general inability to support evidence-based care and service multiple constituents (i.e., physicians, consumers, non-physician caregivers), as well as their inability to support population health management, will reignite the category of care-management solution applications.

Third (and most promising), alignment of consumer and provider incentives, likely to take the form of value-based benefit design and value-based reimbursement methodologies, will become the constructive middle ground to reach compromise on healthcare reform that is more acceptable to a majority of legislators and industry leaders.

Smaller hospitals get on board the HIS train

By Robert F. Tilley Sr., vice president and chief technology officer, T-System

In the coming year, hospitals all across America will begin implementing electronic medical records in an effort to meet meaningful-use (MU) requirements and prepare for healthcare reform.

This change will be a herculean task for the nation's small and mid-size hospitals, many of which lack a hospital-wide health information system (HIS) or use different IT systems across different clinical areas in the facility. In addition, few have the cash or credit rating needed to pay for such a significant initial IT investment.

Still reeling from the economic downturn, smaller hospitals can afford neither the millions of dollars required to implement a feature-rich enterprise HIS nor the hefty fines levied against institutions failing to meet MU criteria. Hospitals may save up-front costs by selecting systems that use a subscription model instead of a capital-intense license approach.

For many, the best option is a smaller HIS system that's less expensive and easier to install, yet provides an overall framework across the facility. Unfortunately, these systems lack the sophisticated clinical modules hospitals need, so hospitals should consider best-of-breed clinical modules. To overcome these interoperability challenges, administrators may also want to hire a consultant to develop the interfaces to integrate these modules with the HIS. These modules can cost as much as $25,000 each, but they allow hospitals to increase productivity and streamline their enterprise over time.

Smaller hospitals may be tempted to implement an HIS and stop there. The danger is that smaller HIS systems often don't offer the sophisticated coding capabilities to facilitate charge capture and may not meet the MU criteria in areas like the ED. According to the CDC, only 12.5 percent of emergency department patients are admitted to the hospital. If a hospital ED sees 10,000 patients per year, more than 8,700 of them will never be admitted. For the facility to capture MU reimbursement, they may need to include these ER-admitted patients. Without an effective emergency department information system, all the effort to install an HIS may not be enough.

Despite the challenges, smaller hospitals need to migrate to HIS systems and electronic medical records — and soon. The risks of fines, lost revenue and diminished care quality are just too grave to ignore.

Future of information exchanges depends on healthcare systems

By Ken Tarkoff, SVP and general
manager, clinical solutions, RelayHealth

The delivery system reforms initiated by the Patient Protection and Affordable Care Act will require healthcare providers to coordinate care better to improve population health and reduce the number of avoidable ER visits, hospitalizations and readmissions. Patient-centered health information exchanges (HIEs) that provide actionable, real-time information to clinicians and that engage patients in their own care are necessary to achieve these goals. Unfortunately, most of the federally funded, state-managed HIE programs are at risk of missing the boat by emphasizing large-scale statewide or regional connectivity rather than focusing on meeting local needs.

In many states, the state-designated HIE's focus is on ensuring that ER physicians can obtain care summaries for patients from other communities who come to their ERs. That can be useful in some circumstances, but what health system physicians need most for care coordination is data about the patients in their own areas and the ability to exchange data about those patients throughout their health system and with the patient directly.

To fill this gap, systems across the country are building their own private HIEs to connect their health systems together and to link with their staff physicians and patients. Some of these HIEs are adding EHR capabilities as well to enable their physicians, who don't already have an EHR, to qualify for meaningful use.

Healthcare system-based HIEs also provide the foundation for the development of patient-centered medical homes and ACOs. They will aid providers in demonstrating meaningful use, particularly in Stages 2 and 3 of the government incentive program for EHR users. Similarly, when standards are in place for connecting community and private HIEs together, connectivity will be more prevalent across the country. However, none of these efforts will produce the desired outcomes unless the patient is actively involved at every stage.

The Webcam moves from connecting people to connecting care

By Alan Roga, M.D.,
chairman and CEO, Stat Health Services

In 2011, the Webcam will be used to fuel the high-tech, high-growth telemedicine industry. Telemedicine stands to fill a multitude of gaps in healthcare delivery and simultaneously improve care and health outcomes in convenient and cost-effective ways.

Until now, telemedicine had primarily served rural populations. With the prevalence of smartphones, the availability of more sophisticated technologies (such as video conferencing) and the push toward digitizing medical records and promoting interoperability, telemedicine moves into mainstream healthcare and will prove to be indispensible in contributing to our national health-reform goals of improving the cost, quality and accessibility of healthcare. And consumer demand for the same online, anytime, anywhere conveniences enjoyed in nearly every other aspect of life, from banking to shopping and connecting with friends, will support adoption and broad utilization of telemedicine services.

With a shortage of primary care physicians and the unlikely prospect of getting a same-day appointment when the need arises, patients all too often resort to the emergency room and urgent care centers as a primary means of accessing medical care. While new care delivery models are being piloted, no one model will fix the system, be adopted universally and meet the needs of all healthcare stakeholders. Telemedicine offers a viable alternative for physicians and patients to coordinate care, despite an inefficient healthcare delivery system.

eHealth innovations (such as online doctor visits or e-visits) using a smartphone's Webcam will transform the healthcare experience. eHealth can help support the needs of rural populations, provide care to patients who couldn't afford the time away from work or family, promote wellness, get people the care they need before they become costly users and effectively fill unaddressed gaps in healthcare delivery with quality, convenient and cost-effective care. And the value of Webcams will come full circle, enabling physicians and consumers to coordinate care when it's needed and in real time, preserving health, wellness and valuable time with their families.

Health IT trends for healthcare providers

By Mark Brownlee, associate VP and head,
healthcare provider practice, Infosys Technologies Ltd.

Healthcare IT investments of providers in 2011 will be under three broad categories: healthcare reform initiatives, ICD-10 compliance projects and cost-reduction initiatives.

As part of healthcare reform initiatives, depending on their status in EMR adoption, providers will invest in implementing a new EMR system, upgrading an existing EMR system or will enhance the home-grown EMR and go for site certification. Providers will leverage learning technologies, such as computer-based trainings, online helpdesk, Web 2.0 (user communities, blogs, chat rooms) and other adoption enablers to ensure meaningful use (MU) of EMR. Exploration is on for proactive MU monitoring, compliance management and reporting solutions and these will see some traction next year.

ICD-9 to ICD-10 migration will continue to be the most important regulatory compliance initiative in 2011. There will be a lot of focus on clinical documentation-improvement programs (CDIP) to facilitate accurate ICD-10 and DRG coding. CDIP will be supported by niche IT solutions that support clinical documentation assessment, reimbursement impact assessment, physician enablement, documentation change workflow and accurate coding.

Cost-reduction initiatives will target improving back-end operations, such as supply chain integration and optimization. Providers planning to participate in accountable care organizations, patient-centered medical homes and providers impacted by episode bundling for reimbursements will invest in integrated clinical and financial analytics for better visibility into healthcare costs of their patients. 2011 may also find providers investing in disease management IT solutions to improve clinical outcomes and reduce healthcare costs of their patient population.

In addition to all these, to compete in a post-healthcare-reforms world, providers need healthcare enterprise performance-management (HEPM) systems with advanced analytical capabilities to manage clinical, operational and financial performance in an integrated fashion. With so many IT initiatives competing for budget dollars, HEPM systems may still not make it to the 2011 to-do list.

Multi-channel communications as a requirement

By Doug Cox, director of North
America enterprise business,
GMC Software Technology

The healthcare outlook for 2011 doesn't look like it will be any less competitive. Hence, reducing the complexity and costs of member interaction as well as generating that all-important positive member experience will continue to remain top of mind. The fastest way to accomplish both objectives will be providing actionable information to members that enables them to better manage their health.

This will require having the ability to determine the communication preferences of each member and the solutions in place to deliver through that channel. Whether your member likes paper (mail), electronic (e-mail, Internet) or using mobile applications, being able to meet delivery preferences when it comes to all communications is fast moving from an option to an expectation. Engaging members in one-to-one conversations that promote preventative care and other health-related changes is becoming one of the most effective avenues for cutting healthcare costs.

Easy-to-understand statements and invoices tailored to specific preferences — and sent through the channel of choice — will reduce member calls and build trust. Having the technology in place to access the data you already have from membership claims or benefits systems can put your members front and center with every communication you send them. I can't think of a better way to retain your members — or acquire new ones.

For this reason, continuing to grow in the ability to create multi-channel communications where content is converted on demand and delivered via the preferred method as part of your everyday communication capabilities should be on the 2011 goal list for every healthcare company this
new year.