Tag Archives: emr

population health

A New Dimension in Population Health

With the healthcare landscape changing from fee-for-service to fee-for-value models, healthcare provider systems (hospitals, clinics, independent physician associations, etc.) are now, more than ever, under pressure to effectively manage the health and cost outcomes of their given populations. Under such models, providers are not only providing healthcare service to the patients, but they are also sharing in the financial risk and reward of patient costs. To effectively become a value-based organization, providers today are adopting a process broadly termed “population health.”

The “population health” process usually starts with identifying key segments of a population that face certain risks of adverse health outcomes and thereby high cost — a step known as “risk stratification.” Once risk is stratified, appropriate patient intervention programs are employed to improve: access to health, targeted encounters with providers and continuous monitoring of patient risk. This leads to lower emergency room visits, better clinical outcomes (such as properly managed blood glucose levels for diabetics) and lower financial cost.

There are many proven methods of risk-stratification to assign patients to low-, medium- or high-risk groups. For example, the adjusted clinical groups method examines patient diagnoses, and the elder risk assessment method assigns risk based on patient demographics. In today’s market, we observe many proprietary methods of risk stratification developed by various provider systems. The variables used in risk stratification can be classified into the following categories:

  1. Clinical: Data from electronic medical records (EMRs), patient vitals, laboratory data, etc.
  2. Administrative: Usually patient claims that track diagnosis and procedures already conducted
  3. Socio-Economic: Patients’ social situations, family and friend support systems, language preference, community involvement, the degree of influence that out-of-pocket expenses could have on the patient’s well-being, etc.
  4. Lifestyle: Health and activity tracking devices such as Fitbit, Apple Watch, etc., which carry critical daily lifestyle data about a patient

While the above categories play a large role in risk stratification, a new dimension known as “spatial access” can significantly lend leverage to the provider systems in affecting patient outcomes. For some patients, the overall risk may increase significantly because of their spatial, geographical and transportation access to medical and wellness resources. Spatial access refers to patients’ geographic proximity and ease of mobility to resources such as hospitals, primary care physician offices, primary and specialty care clinics and nurses. The geographic arrangement of patient and provider resources can play a significant role in healthcare utilization. For example, patients living in areas with fewer healthcare resources — regions often termed “doctor deserts” — have been linked with higher rates of preventable ER visits that are notorious for raising healthcare costs without necessarily improving healthcare outcomes. Using geographical and spatial analysis to supplement existing risk stratification techniques can help providers with an untapped method of assessing risk and generating better ROI in the long run.

To incorporate spatial access analysis into risk stratification, providers must:

  1. Gather patients’ social network geographic information
    Most EMR systems already contain patient address information, but they often lack information about the patients’ social network. The following types of data should be collected and refreshed on an annual basis:

    • Distance to closest primary care clinic, both straight-line and network-distance;
    • Distance to closest primary care provider, both straight-line and network-distance;
    • Spatial density of medical resources in a given area, especially primary care services;
    • Access to vehicle transportation, either on the patient’s own or through a family member; and
    • Proximity to public transportation.
  2. Conduct “spatial access” risk stratification
    Using a geographic information system (GIS), assign relative risk to each patient based on each of the components listed above, then create a composite risk based on all of the attributes.
  3. Represent population risk stratification visually via mapping
    Examine which areas of a provider’s service areas are prone to having individuals with high risk; look for clusters of high- or low-risk patients in doctor deserts. Viewing individual or aggregate risk through mapping would offer analysts and decision makers a comprehensive view of what types of risk are occurring in their service area.
  4. Strategize how to implement interventions based on locations of high-risk patients
    If clusters of high-risk patients exist in a certain area, begin to strategize about what kinds of interventions may alleviate the problem. Interventions may include the placement of new primary or specialty care clinics. Because creating clinics can be challenging, increased use of mobile provider teams can be an alternate solution. Lastly, a combination of telemedicine and mobile medicine should be assessed for the right mix of care for doctor deserts and lack of physical clinics.

Understanding the spatial context of patient demand vs. provider supply of healthcare service is an important component for accountable care organizations to conduct accurate risk stratification. Moreover, incorporating GIS into healthcare service analyses improves decision-making capabilities for evaluating, planning and implementing strategic initiatives. By taking advantage of the analytic capabilities of GIS and spatial access risk stratification, healthcare service providers are better equipped to more comprehensively understand their patient population and to thrive in this new value-based world.

Electronic Health Records Hurt Care

Patient care as we know and expect it will diminish because of electronic health records (EHR) requirements. Society will suffer a slow degradation of artful interactive provider attention in deference to “data-field” medicine.

I am not simply referring to the very real and challenging issues in the technical application of EHR systems. Rather, I point out a more serious and insidious future threat to the actual human aura in medical practice.

There exists an unintended but real incentive for doctors and clinicians to consider task-completion as clicking through the data interface rather than interacting with and treating the patient. Legal requirements, reimbursements and potential penalties force EHR to top priority. In turn, clinicians as EHR users become more aware of and anticipate the truncated, template-driven and limited means of expressing case events via electronic reports. Therefore, their interaction with patients may be truncated.

I know this sounds callous and insulting to all good medical providers. To them, I say no insult is intended, and the fault of this perverse incentive is not theirs. They might honestly assess their experience and the actions of peers and associates within their practices given the advent of EHR. To providers, I ask: What about EHR might be sucking the creative life out of your optimal vision for the practice of your specialty?

My most stark encounter with this reality comes from a chance discussion with a longtime friend. She is a nurse practitioner who, for decades, has treated both ER and family-practice patients. As family friends, we never talk shop, and this particular conversation was not solicited by me. I politely asked, “How’s it going?” and got a surprising, soul-baring burst of frustration.

She expressed disdain. She prides herself as a master of triage, symptom investigation, on-the-spot research and communication with involved family members, and she desires to take the wide approach to patient situations as a service to them and to the doctors or specialists who may eventually carry the case, but electronic records don’t allow the narratives or collective points of data she would prefer. As such, her value is diminished, and the patient ultimately gets poor attention.

As she described her situation, I began to understand the rigid decision-tree “intelligence” in narrowing prompts for information based on how case records are initiated. She has persevered and found cumbersome work-around methods (such as editing previous fields to change next options, etc.) to combine or add issues or thoughts to a record beyond the template’s desired straight line of thought. Unfortunately, she explained, taking extra time to do anything is neither advisable nor encouraged because of the volume of patients requiring care.

Quick Tip: The Want for Data Should Not Put the Cart Before the Horse

As a foreshadowing about healthcare in general, consider what the supreme focus on automation and data collection has done to workers’ compensation. I have written extensively about the advent of electronic claim systems, over decades, reducing the adjusting job from that of an intelligent, intuitive personal-interactive specialist to the current task-level data entry clerk. We are now well into the post-paper-file generation of claim adjusters who know their job only as data-interface. Will medical clinicians meet the same fate when our current generation of providers, like my friend, move on? Will future clinicians, knowing only electronic records, assume that the decision tree of the EHR interface supersedes intuitive medicine?

Let’s hope not. Unfortunately, a simple Google search for “problems with EHR” will not sit well with anyone who embarks on some research in this area.

In claim adjusting, as in medicine, we need to intelligently feed the hunger for data but rail against a perverse desire to let automation increase case volumes or assume the template is sacrosanct. I am certainly not against all the good that electronic medical records bring to the party. However, we must first let practitioners do their jobs, not let “data screen medicine” dumb down patient care.

Perhaps provider-run coalitions should dictate standards for ever-improving EHR frameworks and interfaces so their highest-quality, real-time nimble intelligence can be best captured in all patient events. I know at least one nurse practitioner who has a lot to say on that subject.

How to Turn Workers’ Comp Into an Advantage

Workers’ compensation should be a win-win proposition for employers and employees, but many contractors describe it as an insurance and risk-management pain point. Workers’ compensation premium is a major part of contractors’ total insurance costs, and the indirect costs associated with claims are a significant multiplier.
Additionally, recent formula changes have caused some companies to receive a higher experience modification rate (EMR). The increasing use of prescription medications, improper use of medical services and diagnosis of comorbidity conditions (i.e., disorders related to a primary disease) among workers are boosting medical costs, which have surpassed lost-time indemnity benefits as the largest component of loss costs. And the construction industry’s workforce shortage is leading to the hiring of less-experienced workers, who are more vulnerable to injuries.

In short, employee injuries affect productivity, quality and profitability on projects, thereby affecting a company’s overall financial performance. As such, workers’ compensation can be either a competitive advantage or disadvantage.

Companies that do not gain control over their workers’ compensation processes will face pressures to reduce costs elsewhere or carry higher levels of unallocated overhead. The result will be felt by higher insurance costs, increased bid rates and decreased productivity yields, as well as squeezed profit margins.
Start with an audit

A workers’ compensation audit diagnoses relative strengths and weaknesses of policies, procedures and protocols, and provides a roadmap to improve performance. An insurance advisor can help evaluate the company’s capabilities in three important phases, each targeting a diferent focus and desired outcome (see chart).

It’s important to review injury and claim performance metrics. A comprehensive loss analysis of the number, type, frequency and severity of claims is useful, especially when compared with exposure (whether payroll, work hours or full-time equivalency). The median duration of lost workdays per lost workday case can be compared against industry metrics by type of contracting operation. Although these are lagging indicators, they provide clues about where to focus prevention-based activities that then can be monitored as leading indicators.
Larger contractors with more payroll exposure and more complex operations also may be interested in an alternative insurance program structure, such as intermediate or large-deductible, retrospectively rated and captive insurance programs. Many contractors seek to reinforce management accountability for workers’ compensation improvement by instituting premium-allocation and loss-cost chargebacks to operating divisions or departments. This information is useful in bonus program calculations.
A workers’ compensation audit should carefully consider the classifications of workers by job type and payroll code. Proper classification is essential to ensuring workers’ compensation premiums are being properly calculated. This helps prevent adjusted premiums or return premiums following a premium audit, and helps ensure proper classification of the company’s EMR. It may be advisable to review open major claim reserves well in advance of carriers filing unit stat reporting data for purposes of calculating EMRs.

Everything That Ails Our Healthcare System … Squeezed Into One 12-Minute Doctor Visit

A few weeks ago I taped the first episode of my new public radio show. I thought I sounded good enough, and the producer assured me that I would sound even better after I got over my cold. This would have been reassuring, except that I didn’t have a cold.

Fearful of being fired my first day on the job, I immediately called my primary care physician (PCP) to get some advice on how to sound less hoarse. The doctor’s office promptly scheduled a visit with an Ear, Nose & Throat specialist, only four days later.

The specialist scoped my nose and announced that I had polyps in my sinuses. She said she would schedule me for a CT scan of the sinuses, and offered three alternative treatments, which, she added truthfully, may or may not work.

  1. Steroid-based nasal spray
  2. Steroid-based nasal spray with a three-week course of antibiotics
  3. Day surgery followed by a saline flush for a week

“So,” she asked, about seven minutes into the appointment, “which do you want to do?”

“Um,” I replied. “Shouldn’t we try the most conservative therapy first?”

“Well, you could.”

I begged off the surgery by quite correctly observing that I wasn’t very adept at flushing my nose out, so that I would prefer one of the non-surgical alternatives. “I’m not sure I need the antibiotics because I don’t think this is bacterial,” I said.

“A lot of patients report relief with the antibiotics,” she replied, almost as if she were cast as the “before” picture in an evidence-based medicine textbook.

“Isn’t three weeks a long time to be taking antibiotics?” I asked.

“Yes. Some people say that.”

I opted for the nasal spray. I elected not to schedule the sinus CT scan. Seemed like a lot of cost and inconvenience … and didn’t I just get a diagnosis anyway? So I didn’t follow up on it.

Except that the sinus scan was thoughtfully scheduled for me, as I learned when a scheduler called me the very same day. I ignored my first voicemail from the scheduler, but after the third I realized they really did expect me to show up (that very Friday, no less), and it occurred to me I might get billed unless I affirmatively called to cancel the appointment.

And, that is what is wrong with fee-for-service medicine. Most well-insured people would have gone along with the recommended program, getting the scan, the surgery, and who knows what else.

The bottom line is, in twelve short minutes, this visit encapsulated everything that is wrong with traditional fee-for-service medicine, of the type that someday, with any luck, is going to be replaced by capitated ACOs using patient-centered medical homes, supported by electronic medical records (EMRs), to refer to salaried specialists who don’t get to bill a big chunk of money each time they do a surgery.

Except that this practice is already a designated patient-centered medical home, it already uses an EMR, it is already partially capitated by its major health plan, and its specialists are already salaried.

That is the “punchline,” and explaining a joke often ruins it, but healthcare isn’t a joke so I’ll explain.

Just changing practice incentives may not change the behavior of individual physicians, especially specialists who even in most capitated practices are/will still be paid on the basis of work performed, somehow, to some degree. (In this practice, work performed affects physician salary for the following year.)

Further, patient satisfaction also factors into compensation, and what can be more satisfying for patients than promptness and responsiveness and action? As for the checks-and-balances provided by the EMR, it turns out that the EMR is what expedited the referral in the first place. Years ago it had been noted that I had a deviated septum (like about half the world, as it turns out). That information was duly stored in my EMR, so that my primary care physician had grounds to make a referral at her fingertips, without needing me to see her first.

The coda on this story? To try to overcome this hoarseness, I took the steroidal nasal spray twice a day for a week. Then I read the FDA insert, which listed the following as a side effect: hoarseness. I stopped the spray, and told this story to my producer. My producer suggested tea with honey during each taping, surely the most conservative therapy … and I still have my job.

So domestic policy wonks in the Washington, DC market can now hear me on The Big Fix Saturdays at 4 PM on WAMU 88.5, at least through January 15, when the funding runs out. I’m still a bit hoarse, but thanks to my producer I no longer sound like that guy on Boardwalk Empire whose vocal chords were blown up during World War I.

Postscript: The first episodes have already aired, and while a few people complained, not without justification, about my hosting skills, no one wrote in to say: “This guy sounds like he needs his polyps removed.”