Access to actionable lab data is essential for the success of care management for Health Plans & ACOs

Lab_data_health_plansHealth insurance and Accountable Care Organizations (ACOs) are faced with constant challenges due to a rapidly evolving health care landscape fueled by change from compliance initiatives, health reform and an unstable economic environment.  To tackle these challenges, health plans and ACOs need to develop go-to-market strategies and analytics solutions that define the organization’s future position and answer critical questions surrounding growth, profitability and sustainability. The ultimate success of these organizations will be determined by its ability to:

  • Predict shifts in their customer-base
  • Manage the cost of care
  • Collaborate more effectively with providers
  • Increase NCQA and HEDIS quality scores and Medicare Five-Star rating

Access to actionable lab data plays a significant role in the success.

Health plans utilize care management programs that typically implement a variety of interventions tailored to needs of specific groups of affected individuals.  A model that identifies those individuals who have high risk of complications has the greatest potential to impact outcomes and lower healthcare cost. Complete and real time lab results can help health plans model individuals who have high risk of complications, greatest potential to impact outcomes, and lower healthcare cost.

It is necessary for health plans to access to lab results to help them better determine the effectiveness of care management programs.   Some of the challenges and opportunities regarding lab data include:

  • Health Plans and ACOs typically experience difficulty receiving clinical data from labs.
  • Clinical data can have a significant impact on a health plan’s Medicare Five Star Rating, NCQA and HEDIS quality scores.
  • Health plans and ACOs seek laboratory data to reduce instances of drug contraindications, generate clinical alerts, and populate personal health records.
  • Lab results can demonstrate the efficacy of care management programs.
  • Ability to provide clinical data can be an important factor for a lab to achieve in-network status with a health plan or ACO.
  • Health Plans and ACOs share in a unique position to help a lab understand leakage (testing performed by out-of-network lab).

Health plans and ACOs need a true interoperability solution for lab and clinical data which can better enable their organizations to manage and lead in the coordination of individual care, support shared savings models, and deliver measurable and actionable outcomes that help health plans drive down the cost of care and ultimately improve population health.

Brian Muck is the SVP of Sales & Marketing for Halfpenny Technologies

Interested in more?

EHR Adoption for All – Now and Not Later!

The American healthcare system is fragmented, costly, hence underperforming. Despite significant islands of excellence, overall demographic measures position the U.S. far from the top of the developed countries, while health expenditure is the highest, and rising at an accelerating rate. There is a broad consensus that these trends are unsustainable and a change is mandated.  And while the type of change is still open for debate, the current law is threatened with repeal, and incentive payments may be cut or scaled down, it is generally agreed that health information technology (HIT) must play a significant role.

Despite playing a leading role in the development of health information systems and healthcare informatics research, such advances were slow to trickle down to the rank-and-file physicians in the US, and the adoption of electronic health records (EHR) lags significantly compared to other nations. Among the many reasons for this gap are lack of orchestrated effort and cost.  In the last several years we have witnessed a major change.  Government initiatives endorse and mandate the use of HIT across the continuum of care. The flurry of activities is accompanied by numerous new regulations that are difficult to comprehend and to comply with, especially by the providers that are supposed to implement them. They also result in higher development and implementation cost of new HIT systems and sustain a large and costly echo-system, thus maintaining a significant barrier to wider adoption.

Coupled with the technology initiative, there is also a move towards more comprehensive, integrated, community-based care delivery systems. ACO (Accountable Care Organization) is the new buzz word that describes a population-based, yet patient-centric, approach that promises to deliver cost-effective, comprehensive care. This has been long overdue. For many decades, healthcare delivery has been moving away from the community-based Primary Care Physician (PCP) model towards the partialist/specialist model coupled with healthcare consumerism.  Unique to the government’s ACO approach, is the combination of HIT and reporting measures to ensure quality of care and measure population health improvements. This initiative is attractive to practices and healthcare organizations since it promises to split any realized savings with the ACO.

Reviewing the draft regulations for ACOs, it appears that relatively small groups of physicians can form such an ACO. After all, this is a community-based approach, and a minimum of 5000 Medicare beneficiaries is required. However, a high bar is set by requiring appropriate administrative and clinical systems to be in place. Since only about 10% of physicians have even the most basic form of sanctioned EHRs, the cost of the required technology is likely to exclude many community physicians from participating in this community-based initiative.

The most basic building block of the HIT initiative is a compliant EHR whose data is standardized, potentially sharable, and can be queried in any meaningful way. The government EHR adoption incentive programs mostly address eligible providers. There are many physicians who are not eligible for participation. Thus, with or without incentives, the cost of EHR technology is still a significant barrier, most likely to postpone wide spread adoption, at levels such as in the Netherlands or Great Britain, for many more years. In turn, reduced levels of adoption will reduce and delay the effectiveness of many initiatives such as quality measures and ACOs.  As CMS and ONC ratchet-up the technology and compliance requirements, it is even more important to ensure faster and wider adoption of EHR technology by all physicians.

For effective delivery of coordinated healthcare in the community, there are many more participants than the physicians. Care coordinators, dietitians, social workers and many others are involved. Most are not eligible providers, but require supporting technological solutions that are not covered by current initiatives. It is quite likely that initiatives such as the adoption incentives and shared savings for ACOs will not cover the cost of the initial investment in technology required for effective population-based community healthcare. Perhaps it is the time to reassess our current approach, and focus more on wider adoption of EHRs and other first-line support systems for all providers (physicians and non-physicians) rather than follow, at this time, increasingly sophisticated schemes.

Gai Elhanan, MD is Chief Medical Information Officer at Halfpenny Technologies, Inc., a leading provider of clinical data exchange solutions.

Hospitals/Labs Outsourcing EHR Integration is an Emotional Hurdle, Not Financial

Healthcare is the largest industry in our economy, yet it is the last to migrate into the “digital or electronic” age. Healthcare has been last to the party largely because of the incredible amount of fragmentation within the industry. Additionally, the best of breed attitude regarding testing, diagnosis and treatment has resulted in the development of unique systems, equipment and protocols that were never designed to feed into a single or “connected” database.

Many factors are helping to fuel this change, but certainly the biggest factor is the federal government incentives for physicians to implement EHRs in their practices. Over 500 unique EHR vendors are participating in the biggest land grab that the industry has ever seen! While integrating one laboratory information system to one EHR may not present significant challenges, integrating 40 to 50 different laboratory and registration systems to over 500 different EHRs could tax any IT department. To add to the chaos, the hospitals and labs cannot predict or control the demand they will have from a quantity standpoint or from which EHRs.

Most businesses will evaluate their core competencies and decide which functions should be outsourced as opposed to keeping in house. For example, a law firm will probably outsource their printing, but keep their firms legal work in house. Healthcare facilities have been slow to subcontract anything due to the implications and potential effect it might have on patient care. As every piece of medical equipment now provides a digital record, how will facilities react? Should healthcare facilities farm out some of their information technology demands or should they staff up to meet the current peak demands they are experiencing?

Here are some reasons to outsource EHR connectivity:

  • Reduced cost from direct labor as well as general and administrative expenses
  • Move staff to more critical/unique tasks, providing flexibility
  • Allows for erratic demand; do not have to staff for peaks
  • Reduce start/completion time for projects

Outsourcing EHR connectivity is a lower cost alternative than keeping the function in house. Hundreds of facilities across the country have conducted an ROI analysis and determined that subcontracting is the more cost effective path to take. While the argument can be made that if current staff is under-utilized, performing this function in house would not add any incremental cost, few if any healthcare facilities find themselves in this position. Additionally, efficiencies exist when utilizing a team that has a successful track record to complete EHR connectivity projects because that is what they do “all day, every day!”

With all the demands that IT departments have to integrate equipment or systems within the four walls of the facility, by outsourcing EHR connectivity, options exist to be more responsive to those demands. Typically most facilities will put EHR connectivity at the bottom of the priority list, which can have a significant negative impact to growing/maintaining an outreach program.

As external physician groups sift through the 500 EMR vendors to find the right one, they generally do so without consulting their lab providers as to which one they chose or the timing for implementation. Most lab providers find out only when the EHR has been installed and they receive a call from the practice saying, “connect us.” Staffing for the peak is not cost effective and alternatively making the client wait until time is available usually results in a lost business opportunity.

It is very difficult, if not impossible, for an in-house staff to compete with a third-party provider regarding project completion. Constantly being pulled away for “higher priority” projects that will always be more interesting to the internal team can mean that the completion of EHR projects could drag on for several months, when in fact could be completed in a few weeks.

Why then is subcontracting such a huge hurdle for many organizations? Although there are very good reasons to subcontract, many administrations appear to want to internalize EHR connectivity for non-financial reasons that in some cases maybe emotional or “fear based” in nature. Because healthcare facilities are not traditional outsourced, they usually dismiss the notion without giving it a fair evaluation. IT departments, in particular do not want to give up the opportunity to increase their influence and or increase staff, and initially resist outsourcing.

Many in house staffs will embrace the idea of expanding their influence outside the walls of their facility and the challenges that new EHR connectivity projects can offer. What happens next is that they become embroiled in the “perfect storm” of ambulatory physician practices, the myriad of EHR vendors with their various capabilities, and their own clinical or business development staff. IT staffs quickly become disinterested in the repetitive nature of the process to electronically connect their clients, as well as meeting the objectives of all the different stakeholders. IT departments are usually not geared to be able to successfully meet all the challenges that these groups can present. Deadlines are missed, existing or potential clients are lost, and confidence in the internal staff to get things done suffers.

While outsourcing may not be the perfect answer for all, it clearly should be given greater consideration to meet the incredible demands that healthcare facilities will face over the next five years. At a minimum, it could be utilized as a backup strategy to augment internal staff and allow the facility to concentrate on its core competency of delivering the best in patient care. As their trust with the third-party provider grows, and emotion is taken out of the equation, it just might become a critical part of your “connected” strategy.

 

Where There is Change, There is Opportunity

As I was coming into Vegas, it occurred to me that never before in my 20 plus years of lab it experience have I seen so much change occurring in such a short period of time. We have ACOs coming at us, ICD9 to 10, there is the 4010 to 5010 conversion happening soon, the HITECH Act, stimulus funds, bending the healthcare curve, meaningful use for both ambulatory and acute, wild fires in Arizona and have I mentioned ACOs? We’re also seeing new and strange bedfellows coming around. Insurance companies are getting into the HIE and connectivity business, Quest has an ‘open connectivity strategy’ with Medplus and an EHR 360.

But on the other hand, I don’t think I’ve ever been so optimistic, too! All and all, the hospital and reference markets are doing very well.

If you look at the laboratory market in its entirety, 22% is the national, Lab Corp and Quest. They are organized. They seem to be everywhere telling their and your clients they can connect to an EHR in two weeks for practically free. But here is a surprising statistic; 54% of the lab market is hospitals, the rest is reference specialty labs and 5% POL. But the nationals at 22% are not nearly as big as what I would have guessed and, here is the kicker, they are not growing organically, it’s thru acquisition! Hospital labs are growing organically, so something is going right! Here is another statistic I picked up from an insurance company presentation. People in their 20s and 30s use on average two lab tests a year! People in their 50s, 60s and 70s use over eight! The sea is going to rise as all of us young baby boomers get a tad older.

But there is competition and change, and where there is change, there is opportunity. Let’s take the EHR market for a moment. It’s expected to grow from a 20-80% adoption rate in just a few years. Seventy percent of all EHR data is lab! Seventy to eighty of diagnosis are in part based on laboratory data! So what good is an EHR without the very valuable services the laboratory service market provides? Docs want the data in there, the EHRs want the data, insurance companies want the data and so does the government and, of course you know, it is in part tied to the subsidies.

So in our own analysis, we have determined that a physician on average trades with 2.8 laboratory service providers each and many have more than this. Physicians will want this data electronically, including orders and, if they don’t get it, they may decide to go elsewhere. So here is the opportunity and the threat. Without a strategy and connectivity, your clients might go elsewhere to get it, but with a strategy you can secure, clients who might otherwise leave and you may be able to expand you market share (organic growth) from those labs that are not so well prepared. As an aside, there are there are around 375 to 400 different EHRs out there and we haven’t seen a consolidation yet, we actually are meeting new ones still.

Okay, here is the crass commercial. At Halfpenny, we connect to EHRs, to approximately 128 different EHRs today. We provide this connectivity day in day out and are good at it. We are ‘the’ strategy for some organizations and others we augment or are a backup to existing IT initiatives. We also push results to hand held devices, now orders too, and provide LOINC mapping. Okay, I am done. Anyway, my encouragement is to develop a strategy if you don’t have one and or you might consider a backup position too … and if interested, we’d love to talk with you.

 

When Splitting Up is for the Best

Centralizing. One-stop-shopping. Consolidating. Sole sourcing. Streamlining. All of these actions have one common denominator; unifying a set of activities under one umbrella. Why not? It’s easier, more convenient, and should be cost effective, right? Maybe, but perhaps not when it comes to hospitals, labs, and physicians needing their lab orders to be routed to more than one testing laboratory for various legit reasons.

Ordering lab tests can be a complex process, even within a health network. Oftentimes a single lab order should be divided into two or more requisitions. The reasons can be many. The physician’s office can perform one or more of the tests in the office. The insurance company requires the separation. It’s most cost effective to send one of the tests to an outside lab. The order needs to go to a third-party subcontracted by the first lab. The provider prefers to bill insurance companies directly in order to obtain markup revenue, regardless if test is or is not conducted in their office. Hence, this is definitely an instance when splitting up is for the better.

Since test results from labs due influence nearly 70% of all healthcare decisions made today while representing only 2% of total healthcare costs, hospitals, labs, and physicians should have the choice and flexibility of splitting a requisition when needed. But let’s throw another monkey wrench, so to speak, into the mix while we’re at it. Does the hospital, lab, or physician office have an existing electronic health record (EHR) system in operation to automate and streamline the clinician’s workflow, reduce any errors and offset costs? What happens when there is an EHR system in place? What happens when there isn’t? How does an EHR system facilitate splitting an order? Better yet, how do you split a requisition without an EHR system?

Questions, questions, and more questions. Well, here are some answers.

The best action is to provide hospitals, labs and physician offices with a simple way to divide a single lab order into two or multiple, with or without an EHR system. A foolproof method to automatically split orders right from the start, during order entry and based rules on sample type, storage temperature, testing location, test type, order location, billing status, CPT code, order choice priority or type, insurance, physician preference and/or other measures.

Halfpenny Technologies (HTI), a leading provider of healthcare connectivity and integration solutions, offers hospitals, labs and physicians the means to split a single lab req into two or more requisitions with or without an existing physician EHR system. This capability is not only priceless, but essential as most physicians utilize multiple labs and route their test orders in accordance with the patient’s insurance, type of tests required, billing practices, or their own preferences.

Here’s how Halfpenny generates split requisitions. With an EHR system, Halfpenny receives the lab order from the EHR and automatically splits it according to rules controlled by authorized users and then prints specific labels, requisitions, and/or manifests as needed and routes the orders to the correct testing laboratory based on the hospital or physician’s workflow requirements. When the results are received, Halfpenny re-bundles and forwards them into the appropriate patient record within the EHR.

When there is not a physician EHR system, Halfpenny will implement one of its own proprietary solutions, ITF-Portal® or ITF-GoDoc® MobileOE, to facilitate the order entry directly and split the req utilizing the same rules described above. Either way, the split successfully occurs and the results can be combined and incorporated into an EHR system if available or viewed within one or both of the HTI solutions.

Splitting up a req to be routed to the correct testing laboratory is not only in the best interest of hospitals, labs, and physicians, but in the long run it’s also in the best interest of the patient who receives better care and better patient services. It saves valuable time, unnecessary costs and precious manpower. If you are still sole sourcing your lab orders to one facility, look a little further to the many benefits and advantages of splitting up a requisition. You might realize that breaking up is not so hard to do after all.

Back to the Past with a New Exploding Market

What is the most closed hospital information system (HIS) system available today? Who are open vendors? Sunquest, Cerner, McKesson. Do they have a proprietary integration engine? No, they partner with vendor neutral solutions. Will they coexist with competitors solutions, or allow the hospital to make best in class and best in service choices without penalty?

Historically, open systems architecture and service philosophy has been the topic of many tradeshow seminars, not to mention the promise of most vendors in the HIS market today. It wasn’t always that way. Why? Their constituency wanted the ability to choose specific solutions that best fit their departmental or enterprise needs without bias.

It is a rare hospital that buys all of its IT from a single supplier. Many will argue that a single supplier just does not exist that can competently supply all. Therefore, their clients want a fundamental ability to simply choose and an ability to interoperate without bias. Popular terminology then and now includes ‘best in class,’ ‘best in suite,’ ‘best in service’ or ‘open architecture.’ Can you imagine all the hundreds of vendors trying to work out how to integrate with each other? This is just one of the reason HL7 gained adoption.

Users wanted their systems to work together efficiently, with full functionality and without the penalty of high costs of proprietary integration. From this desire or requirement, open tools were developed to promote this concept of open systems, called integration engines. These engines currently sit in the middle between systems to transfer data allowing all systems equal access and could even conformed to specific formatting requirements. They work very well within this environment and nearly all hospitals have one. They are the clinical, administrative, and ADT information highway within a hospital, and they are open to all applications capable of connectivity.

These engine vendors, not surprisingly, were and are NOT owned by the major HIS vendors. Why? It would be a clear and loud conflict of interest. Would a major HIS vendor be incented to invest in connectivity to its competitors? Absolutely not! An engine vendor that is vendor neutral is very incented; in fact, that is how they make money. It is fundamental to their value. So, many forward-thinking HIS vendors partnered with engine vendors, like McKesson, who used ITC or DataGate for example.

So what is happening now? It is sort of ‘Back to the Past!’ There is a new exploding market, with nearly 400 different ambulatory EHR vendors and growing. Market adoption is going from 20 to 80% in the near term future, an astounding rush to connect with suppliers of clinical information. So the value and promise of an EHR is gained, not to mention stimulus money, but the vendor tactics are as old as the hills!

It seems every vendor with a bias, or ax to grind, wants to control/own the information highway. EHR vendors are developing HIEs that work well with their EHRs but not with others. Big surprise, insurance companies are buying HIE companies. Now this is scary and service providers for laboratory are also trying to own the highway to the physicians EHR. How open are they going to be if they allow another laboratory service provider to play on their highway they lose money? It is fundamental.

But who loses the most? The physician receives one choice free and clear, however, the other choices, if available at all, will come at a penalty, of time, money availability or choice. To trade with other service providers, they will be strapped with multiple point-to-point interfaces that, when evaluated individually, may be cost prohibitive or the expense of operating on multiple highways, which is actually a lot harder than it sounds.

Even though the service providers, out of the goodness of their hearts, are offering to put their proprietary infrastructure in place, it may not be worth it. It reminds me of a Trojans bearing gifts. Don’t be fooled. A service provider who is recommending an open solution is listening and taking a broader view of the market. Look for suppliers who are promoting open systems architecture and mean it.

 

What is the Right Connectivity Strategy for My Outreach Program

and how about them U of A Wildcats; I think they have a real chance this year in the NCAA!

Let’s review the environment. In many areas of the country, the penetration rate of physician of EHR/EMRs will drive from a lowly 20% to nearly 80%. This adoption rate is fundamental to the changes necessary to drive more effective and efficient healthcare. But let’s also be honest, too; it is also driven by funding from good old Uncle Sam. These physicians and physician groups will also want to comply with meaningful use criteria to qualify for stimulus funding to underwrite their costs of entering the new electronic medical record and health record era.

Meaningful use criteria, as many already know, in stage one, two and three begin and then accelerate sophisticated use of these systems. Early stages mandate the storage of discrete data like lab which comprises nearly 80 to 90% of the potential data within an EMR. Let also not be modest; laboratory diagnostic data represents probably the largest data source for diagnostic efforts of physicians. No bias here! Later stages mandate Order Entry so drug-to-dug, drug-to-disease interactions can be checked, and – drum roll, please – laboratory ordering which eliminates errors, reduces manual data entry, (there is a solid ROI behind clean orders and getting paid, but that’s another blog) and promoting quality and efficiency across the spectrum of care.

It only makes sense. Reality check number one; there are at least 375 different EMRs out there that we know about. We are learning about new ones on the pace of a couple per month. It is the Wild West, and it sort of feels like a there is a stampede coming over the hill doesn’t it?

If you are one of the 75% of hospitals laboratories in America with an outreach program or are a reference lab, you could be facing this stamped and that’s actually not the worse part. The worst part is they are all DOCTORS!!!!! (By the way, I hope our Chief Medical Information Officer does not read this blog, but I couldn’t help throwing that analogy in. You should see him when he is mad; he turns all sort of funny shades of red and purple! Anyway…) So, you are facing the stampede and wondering what’s the right strategy. Okay, let’s start with the options.

Option 1. My IT department controls an Interface Engine. Why can’t I just connect my orders and results to it, and let them connect to all the different EMR’s? Sounds simple, right?

Here are a couple questions to ask yourself.  Does your IT department have a lot of extra time on their hands? Have they already completed the ICD9 to ICD10 and 4010 to 5010 conversions? Are they prepared to handle the stampede? Can they deal with 375 different EMR systems? Are they good with doctors?

Option 2. I could use the physician access system/portal vendor I am currently doing business with! Sounds good, doesn’t it? If you are using one of them, they probably already have some connections out there. You have used them for quite some time. You like them or maybe not.

Okay, here are a couple questions to ask yourself. Are they prepared to handle the stampede? Can they scale to the demand you have and all of their other customer’s needs, too? Is EMR connectivity a sideline or are they really in this business with both feet? How is there service now? What might it be like when things get really crazy?

Option 3. Use the local HIE. This one usually comes from corporate. “We don’t want you wasting time building interfaces to EMR’s, because we have that covered with this here strategic relationship with the state’s HIE!”

Okay, you have got my pattern figured out. Here are some questions to ask yourself. Who is faster at building interfaces to my clients’ EMR, the HIE or my competitor? Can you afford to wait? Does the HIE initiative take care of the special requirements and workflow of lab order and result processing? How are the specimens going to be received? Will I be able to get paid with the information they are sending? How will MRN, Event, Episode or Account Numbers be associated with the order when transmitted to the LIS? Will the physician be presented with ask-at-order-entry-questions? Will an ABN get printed, signed and will the transaction contain an indicator of same? Is the HIE technology biased in any way that might prevent it from interfacing really well to all my customers EMRs?

(Note to reader: some HIE technology vendors are also EMR vendors and may not play nice with other EMRs or heavily influenced by your competitor. You get the picture. Their goals may not coincide with your goals to protect and grow your business.  At the worst case, you might want your own strategy in place or at least a backup!)

Option 4. Find a vendor who does this for a living: just this.

Big Finish – I hope you find the rather weak attempts at humor and analogy not too distracting. There is merit within each option and other’s I haven’t mentioned, but I pick on each pretty hard for a purpose. There is a are large demand for connectivity now and we expect it to grow.  Your strategy and options deserve careful consideration and potentially a multifaceted approach. If you already have a strategy, great, what’s your back up plan? If you don’t have a strategy, it’s probably time to start the process.  I welcome any and all comments, thoughts, concerns as long as they are positive and constructive, for the rest I’d like to introduce you to our CMIO; he’d love to hear from you!!!!!

(Note to reader: Our CMIO, Dr. Gai, is actually an incredibly smart, nice, and visionary individual. His face doesn’t turn red when he gets mad either. I’ve never actually seen him mad, and I enjoy his company. I just made all this up to see if he would read my blog!)