Claims Data is NOT a Trojan Horse

dataTrustProbably the most notable development apparent at HIMSS14 was how much HIE and interoperability vendors are now talking about including claims data in their solution sets. Last year at this time, most of these vendors questioned the clinical value and utility of claims data at the point of care. In contrast, this year HIE vendors are now talking as if claims data were as liquid as orders and results between provider organizations. This is a positive, if somewhat overstated, development on the part of the vendors.

In mid-2013 we did see quite an uptick in interest on the part of payers to become more directly involved in HIE initiatives. This interest continued to accelerate through the remainder of 2013 as payers felt that they did have valuable information to contribute, such as eligibility checks when patient is being admitted to ER or information on patient follow-up post discharge and prescription refills (medication compliance). Some of this information, e.g. eligibility check can be provided in near real-time to a patient’s primary care physician.

While vendor support for claims data exchange points to the general increasing level of support for the evolution to value-based reimbursement (VBR), the problem with claims from the provider perspective is history.

Payers until now have been the gatekeepers-to-money translating in the minds of doctors, nurses and patients as gatekeepers-to-care. Payers have wanted better access to clinical data for decades but provider organizations do not want payers poking around in their clinical data. This is not the opinion of most providers, it is still the opinion of every provider we’ve spoken to. This stems from simple distrust of payer motives and the fear of ultimately having their data used against them, which regrettably has happened in the past.

Another challenge has been payers unwillingness to share data outside of a specific VBR contract. In numerous calls we have had with clinical executives, a common refrain has been that payers hold-out on sharing data unless there is something in it for them. Not exactly altruistic or in the best interests of providing quality care across a community.

Most provider organizations are only too happy to get specific about the limitations of claims data and further entanglements with payers through claims or other kinds of data:

Claims data is not that current
Most of the provider organizations we talk to maintain that the payers can only provide accurate data for things that happened six months ago. Anything of a shorter time horizon than that is subject to revision and therefore of very limited value. The exception to this is the aforementioned eligibility checks wherein a provider organization can receive near real-time visibility into network leakage.

Claims data is hard to work with
Providers correctly point out that most payer data sits in 1960s- and 1970s-era mainframe databases and file systems and is processed nightly by COBOL batch applications. While payers use this data to send lots of paper reports to providers, few providers have figured out how to use this data to improve patient care. Instead, this kind of payer data mostly just adds to the fog of data surrounding patient care and is by and large ignored.

Payers motives are suspect
Payers like to create the impression that they make healthcare happen for patients even though they do not provide the full suite of healthcare services nor do they appear to serve patients/members in a manner to truly help them with their healthcare issues. On this point, members share provider views and have strong distrust of payer motives.

Challenges Using Payer Data
Provider organizations will have challenges using claims data in the here and now. Looked at from what happens at the point of care, providing physicians with tools that somehow integrate financial relevance into the practice of delivering quality care is not something that most organizations are really prepared to do. From a more narrow technical perspective, the EHR’s ability to accept this data and make it relevant and actionable for front-line clinicians in their workflows is also something that providers (and by extension their HIE and EHR vendors) will need to address.

Benefits to Providers
But VBR is coming and payers are in a position to help solve some of the soon-to-be or already vexing problems for many provider organizations: revenue leakage, patient risk scoring, care gap identification, medications adherence, clinician performance management, care management or population health.

Solutions to these problems will provide a range of different benefits to provider organizations but genuinely hard to incorporate gracefully into clinician workflows. In addition, solving these problems will require more than just the payer claims data. A range of payer-derived data types will be needed to help provider organizations.

Changing Dynamics of the Payer-Provider Relationship
The use of payer-derived data is inevitable and providers need to look at potential silver lining. Some providers are actively talking about using payer data to evaluate and compare health plan benefit design. The thinking is that by comparing similarly situated patients from different payers from an outcomes standpoint, they may be able to link specific features of a benefit plan (e.g. free annual physical exam by PCP) to better outcomes. If the outcome variance from payer to payer is not minimal then maybe there is a member-benefit design problem that they need to raise with the payer. More importantly, it might put the provider in a better position to recommend to their patients the most effective health plan based on the patients’ overall health history. Using the same logic, providers could compare the performance of partner provider organizations as an aide to negotiation with those partners.

The point is that provider organizations need not view the use of payer-provided claims and other data as all downside. Claims data is as good a place as any to start building trust between traditional adversaries.

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HIMSS14: Patiently Waiting for Progress

patinceA grade-school English teacher of mine would write a little guide on the chalkboard at the beginning of our expository writing lessons:

Say what you’re going to say; Say It; Say what you said

Coming off another HIMSS, that lesson reminds me of the patient engagement market today, where it seems we have heard some things being said, and then being said again and again. We have been sold on the transformative promise of more proactive patient populations, fueled with education, armed with their own data, and empowered to become interactive with a connected fleet of software and hardware. Tools for medication adherence or doctor communication continue to be sold as silver bullets to bring down costs of care while improving outcomes; Scalability via SaaS and enterprise IT means that patient engagement can serve as a lynchpin in population health management. Around the corner, a safety net of Bluetooth and wireless devices promises to catch us when we fall.

Yet as John observed in his recap, there is very little out there today that suggests these solutions are mature enough to work as advertised in the real world, not just on the HIMSS tradeshow floor. With all fronts – payers, providers, device makers, and more – claiming to engage patients, the market has become a jumbled jungle with diminishing clarity around strategy – how solutions work together, what settings or populations are best suited for what products, and where one begins the patient engagement process.

However, the squawky chaos of HIMSS is nothing new, and neither is the immaturity of the patient engagement market. So beyond all of the countless patient engagement rah rahs on the expo floor, we did see a few faint signs of progress amidst the following trends, based on our conversations with a dozen or so health IT vendors, clinician leaders, and tech entrepreneurs.

EHRs Look Inward
EHR vendors are at last developing moderate to advanced functionality with their portals (refills, secure communication, education, scheduling), with improved UX/UI that is starting to conform to consumer tech standards. However, the bulk of their efforts in advancing patient engagement over the coming year will be moving “in” to the delivery system rather than “out” towards the patient.

This makes sense, as EHRs have the deep reach into HCOs to advance provider-centric functionality and optimize the patient engagement workflow. In particular, we saw abundant attention on care planning/management tools that generate task lists, discharge plans, medication lists, and so on (possibly a result of efforts to streamline workflow, as Cora described yesterday). Cerner and Epic are leading the pack in optimizing patient engagement workflow for clinical end-users (e.g. tying in medication refill tools or simple note entry based on patient interactions).

These are welcome improvements that will do much to enable better patient engagement down the road, yet:

A) they appear to remain limited to a select test-bed of all-Epic or all-Cerner deployments, or for that matter, any other EHR-system and
B) they still focus heavily on point of care workflow, signaling that EHRs may be the bottleneck when it comes to reaching out to patients between or after visits.

There are exceptions to every norm however, and PracticeFusion’s announcement of two health monitoring partnerships with AliveCor and DiaSend was an encouraging acknowledgement that the EHR can and should become more than a point of care documentation system.

HIEs Look Backward
HIE vendors are looking to build out patient portals and care coordination applications as they transition from building pipelines to demonstrating value. While this represents progress for that market, after seeing a leading vendor’s demo and speaking with leadership from two others, we are not quite ready to celebrate.

Instead of looking ahead, HIE vendors are looking at MU2 and assembling a new crop of anemic patient portals that allow VDT and little else. If HIEs really want to get involved with patient engagement in a truly meaningful transformative way and generate value, they ought to tackle a problem that nobody was talking about at HIMSS: consolidating payer and provider patient portal data to create a unified, longitudinal patient record. (Editor’s note: In our ongoing research of the HIE market (we’ve been tracking this market since 2008), Naveen’s finding is not at all surprising. The primary culprit to the lack of rich patient engagement tools among HIE vendors is simple, there has been very little customer demand.)

Maybe HealtheWay’s new CareQuality initiative will be able to bridge that gap (with Medfusion’s presence serving as a reassuring sign that patient portals might one day benefit from this work). However, given how long it’s taken Commonwell’s work to translate into real world improvement, coupled with patient data taking a backseat to provider data, we won’t hold our breath to see (and feel) results anytime soon.

Mobile Players Look Forward
Sadly, most enterprise vendors are limiting their present mobile strategies to optimized web, leaving tools like GPS, Bluetooth, accelerometers, wearables, and more on the table. Realizing that EHRs aren’t going to come knocking on their doors anytime soon, mobile plays of all types have taken these integrations on themselves. On the device side, companies are also going to market using an array of channel partnerships that range from traditional disease management call centers to Qualcomm’s ecosystem to bundling with personal emergency response system (PERS) targeted at the senior market to TelCo resale plays. We learned of one major partnership between a biometric device maker and a large MCO, and see continued growth on that front despite little buzz on the topic at HIMSS.

On the app front, IMSHealth’s recently launched Appscripts platform is positioning itself to deliver on Happtique’s failed promise, not just by curating clinical apps, but setting up a platform for docs to prescribe them to patients. Aetna, a recent darling on the consumer engagement front under their Healthagen and CarePass banners, seemed more of an also-ran this year, with great soundbytes from Mark Bertolini’s keynote belying a suspiciously quiet year save for emergence of the occasional odd story.

Other than that, mobile apps (and startups in general) are still subsisting on a traditional bait-and-tackle, door-to-door growth strategy for delivery system partners and pilots. These apps are at different stages of maturity, but some are proving that the daunting challenges faced by startups, such as clinical workflow or EHR integration, are not insurmountable. One promising trend is that more of these new “startups” seem to be run by seasoned veterans, doctors, and technologists than in previous years.

Conclusions: Signs of Progress
There is no one-size fits all approach to patient engagement, which is the ultimate shortcoming of the portal approach espoused by the Meaningful Use program. Past the immaturity of any particular solution, the abundance of fragmented approaches, and general lack of cohesion on the strategy front, there were small signs of progress at HIMSS this year. We heard how vendors and customers are working together to co-generate care plans and discharge protocols, or forging piecemeal, meet-you-where-you’re-at approaches to disease management that pair a stratification engine with a good old-fashioned call center.

As Rob pointed out, there are changes afoot in the world of post-acute care (where an estimated ~50 percent of providers still lack EHRs) and for whom a mobile app or a web dashboard is an immediate upgrade for patient management. With much of this world situated closer to patients’ homes (rehab hospitals, SNF, VNA, LTC facilities), there is a big opportunity for reminders, virtual assistance, device support, etc., that folks have started to pick up on. As one startup told us, “we’re competing with clipboards out there.” (Boy, haven’t we heard that one before!) We saw creative new uses of old data, from ADT feeds in hospitals to set up ‘project management plans for post-discharge’ to early neuralnet algorithms for a biometric device that disintermediate the doctor to provide patients with analysis of their readings, mere seconds later. More engaging than a portal, if you ask me.

Bringing it all home for me, on my last day in Orlando I happened to run into my former primary care physician, who has since become a HIMSS Rockstar. We caught up briefly outside the press room before he went on his way, off to give a speech and accept a second Stage7 award. I was left reminiscing back to when I saw him last as a patient, over a decade ago. So much has changed in patient engagement since then – EHRs, patient portals, smartphones, wearables. So while progress may appear to be lost amidst a sea of repetitive soundbytes and multi-million dollar displays, we are indeed moving forward. Let’s all remember to be patient.

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HIMSS-pressions

EpicRideWhat an epic (or is it Epic, or for that matter EPIC) ride where one seemingly goes in and out of noise tunnels on the exhibit floor all in the hopes of finding some meaningful signal as to what is really happening in the market. This is, for better or worse, what HIMSS is all about and like HIMSS conferences of yore, finding that signal could be excruciatingly difficult. But over the course of those few days wherein I was being bounced from one meeting to the next, patterns did emerge.

Thankfully, at this year’s HIMSS I was not alone and in fact, had the entire Chilmark team there, each focusing on gathering information/data points for their respective research domains. While I will highlight some of the bigger industry-wide patterns in this post, each lead analyst for our four research domains (analytics, EHR, HIE and patient engagement) will publish their own impressions over the course of this week.

Accelerating move to VBR: No doubt about it, the ACA train has left the station and we are halfway to Hicksville on the VBR train (VBR = value based reimbursement). In conversations with several senior HCO executives, there is no longer any question that the industry is moving to VBR and the train appears to be a high-speed one. Three payers I spoke with stated that roughly 50% of reimbursements in 2017 will be VBR-based. We may see a train-wreck among less savvy and astute HCOs as recent research we have conducted uncovered a market where the majority of HCOs remain ill-prepared for this transition – they are still in a reactive, tactical operating mode.

No one wants to be an HIE vendor: With the exception of one vendor, RelayHealth, every HIE vendor I met with no longer considers themselves an HIE vendor. This is partly due to the rapid commoditization of base interop technology and services and the need for these vendors to “move up the stack” and provide a higher value proposition. A few seem to be trending in the right direction but the majority of these vendors are currently pushing PowerPoint and buzzwords rather than truly reference-able clients and use cases. (Brian will take a closer look at HIE in follow-on post.)

Despite buzz, population health management (PHM) remains an amoeba. Last year the big buzz was around PHM. Well, the enthusiasm has not waned for PHM, at least from the vendors but try to get one to clearly articulate what it means and how it maps to their solution suite – good luck.

In every briefing I had with a purported PHM solution provider I asked a simple question: What is your process map to enable a client to effectively move to a PHM model of care across the community they serve with your solution suite? Only one vendor, Cerner, was able to articulate such a process map, everyone else just sort of waved their hands about and spoke of “high-level this, high-level that.” Ugh, I simply can’t stand high-level BS.

Patient engagement saw plenty of visibility but little reality. HIMSS made a big point this year to promote patient engagement, but from what I observed, that market is a mess – confusing messages, confusing positioning, questionable offerings. About the only thing that seems relevant today to most providers that I spoke to was meeting MU2 patient engagement requirements so they are simply using the lame PHR that their EHR vendor offers. For larger HCOs, there is additional interest in promoting customer loyalty. Beyond that, pilot-itis reigns supreme. (Naveen will go into far greater depth later this week.) 

Industry finally gets workflow religion. At my first HIMSS, I vividly recall the Davis Award recipient stating that he wished they had paid more attention to workflow in their EHR install. I about fell out of my chair as a CIO would have been fired in the manufacturing sector for making such a statement. Workflow considerations in that industry were part and parcel of any strategic deployment of IT – not an afterthought.

At this year’s HIMSS I heard plenty of talk about workflow integration but data-rich workflow tools that extend across a heterogenous EHR environment are still in PowerPoint. Likely the leading reason why many HCOs are rationalizing the EHRs they will support to a very select few or in the case of Epic shops, one.

Related sad story though: Met an old colleague who now leads a small ACO of 8,700 patients. She is now in the process of developing a strategic IT plan for the ACO, an IT plan that needs to take into consideration 22 different EHRs across the various practices. I don’t hold much hope for this ACO as I see no easy path to care coordination across such a disparate network.

A Few Parthian Shots
HIT spending will be flat in 2014 as HCOs focus on meeting ICD-10 and MU2 requirements. Speaking of which, there are lies, damn lies and then there are statistics. Sat in on HIMSS Analytics Leadership survey presentation, where I kid you not, according to their survey, 92% of the nearly 300 HCOs surveyed said they are ready for ICD-10 switch-over. That’s a very optimistic group they are surveying.

Not sure we’ll see any big announcements for EHR switches either in 2014 as HCOs look to stabilize their infrastructure in advance of ICD-10 conversion. Just too big a financial risk.

Spoke to a few senior executives from large HCOs that have moved to Epic. Each one stated that their strategy will be to move all physicians, owned and affiliated, acute and ambulatory, to Epic. If you want to be a participant in their contracts with payers, that will be the entry fee. They all admitted that they will allow specialists to keep their EHR but all stated this is an exceedingly small percentage (~5-8%) of physicians in-network.

Looks like CVS is dumping their longtime EHR partner for their MinuteClinics, a highly customized version of athenaclinicals (as I recall, CVS was athena’s first athenaclinicals customer) A thousand apologies athena, and thanks for informing us that CVS MinuteClinics use athenacollector, not athenaclinicals. Indeed it was a highly customized version of Allscripts that got the boot in favor of Epic’s ambulatory EHR. In a twist of irony though, CVS is now a member of Epic’s detested foe on the interop front, CommonWell.

Epic counters CommonWell by working with HealtheWay to stand-up the Carequality alliance. Details still extremely thin on this alliance with some vendors, like Greenway, a member of both CommonWell and Carequality (Is Greenway hedging bets?).

Caradigm has once again remade itself and its strategy, now calling itself a population health company. Much of their offering is the productization of Geisinger best practices. If you like what Geisinger has done to date on care coordination, Caradigm may be of interest.

Cerner’s Smart Registries, which was co-developed with Advocate and now live appears to be gaining traction with over half-dozen contracts signed so far. I like what they have done here and is much in alignment with our views on Clinician Network Management.

Orion Health continues to roll, in fact rolling much faster than I imagined having grown enterprise clients by 200% in 2013. Orion struggled in the past to move beyond the public HIE market but that issue is now in the rearview mirror. Their challenge though is to move even faster to build out functionality on top of their base infrastructure.

In closing, HIMSS is exhausting and I need fuel to move. My preferred fuel of choice is a double shot cappuccino. I sampled many on the show floor, thank you one and all for providing. But there is only one vendor that truly stands out in providing the absolutely best expresso – Agfa. So big thanks Agfa and your professional baristas for providing me the fuel for HIMSS. See you next year.

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HIMSS or Bust

CA or bustNext week is that proverbial event we all, in the HIT industry, look forward to with some trepidation - HIMSS’14. For an analyst firm such as ours HIMSS provides us a great opportunity to talk with end users, vendors of all stripes and just reconnect with like-minded folks. HIMSS is probably the only annual event that is a must attend to get a good perspective on where we are, as an industry, in advancing the adoption, deployment and use of HIT in the provider setting. That’s the upside.

There is a downside to HIMSS as well. Like most conferences of its type, HIMSS is a huge cheerleading event for all things HIT. In many ways, HIMSS is like the town of Lake Wobegon, where all of the children are above average. You will almost never hear anything called into question – no negativity here folks. Everything looks rosy and as one cruises the exhibit hall vendors pitch what they believe is the next big thing in healthcare.

HIMSS is the epitome of buzz-card bingo. Be forewarned ye vendors for which meetings between us have been scheduled for every time I hear “Big Data” I will yell out, BINGO! 

As Naveen pointed out in his recent post, HIMSS and the vendors therein must be approached with a healthy bit of skepticism. But as analysts, we must do our best to not let that skepticism slip into cynicism, for a cynic often paints a broad negative brush, losing their objectivity in the process and not see the good things that are happening as well.

HIMSS is also a fairly large event and I know that no matter how comfortable my shoes, no matter how much rest I get beforehand, by the time I take that flight back to Boston, I will be absolutely spent.

Despite these downsides, I am actually really excited about HIMSS this year and can’t wait to get there.

First and most importantly, this year’s event will be the first time that we have our entire team attending. Not only has this lessened my own meeting burden (last I counted, this year I only have 24 meetings in 3 days vs last year’s 35), it also gives us a great opportunity to interact with a far broader range of stakeholders in the HIT market with analysts focused on analytics, patient engagement, HIE, EHR and the biggest buzzword from last year, population health management (PHM).

I have always returned from HIMSS with new, invaluable contacts and an updated perspective on where the industry is truly at – not the picture the vendors paint, but the composite, the collage that is created from countless conversations over those three to four days of attendance. In having the Chilmark team there, I hope they will also walk away from HIMSS with a similarly refreshed rolodex and some nuanced thoughts on how their respective research domains will evolved in the years to come.

Secondly, we are seeing some interesting trends in the market as of late that need further validation. For example, today PHM is whatever a vendor decides it to be based on their own core competencies. Our conversations with healthcare organizations (HCOs) has not been all that insightful either as their PHM definitions are as disparate as the vendors. Where there is convergence though is on the need for strong analytics to drive PHM initiatives. So if analytics is the engine, what is the steering wheel, what are the tires, is HIE the gas tank, or the fueling station?

Looking to HIE, as we mentioned in late 2013, we see a need to redefine this sector. Where is the next opportunity for value realization for a provider once their HIE is live? Yes, we are looking beyond referrals! We have our own ideas, but we want to bounce those ideas off of others – HIMSS is a fabulously opportunity to do just that.

These are just a couple of my own thoughts. Our analysts; Cora for analytics, Naveen for patient engagement, Rob for EHR and Brian on HIE, all have their own questions they seek answers to. Hopefully, HIMSS will prove fruitful for us all in finding some of the answers we seek on the future trajectory of HIT, where the value is to be found and how together, we can all work towards a healthcare system that delivers ever higher quality care to all.

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The Glass is Half-Full…of S.H.I.T.*

glass-half-full1(*Super Health Information Technology)

I’ve had the good fortune of working with John and the Chilmark Research team in some capacity since 2011. As expected, I’ve learned a lot about the field, the technology, the policy, and so on and so forth. I’ve also picked up a great deal about what it takes to be a good analyst in a technology market that is rapidly growing, constantly shifting, and in many ways uncharted.

As an individual, I am a relatively optimistic guy – I get excited by new ideas, the potential for real improvement in healthcare, and well-crafted solutions. A solo shot of a Mostashari keynote or a Todd Park Youtube clip is all I need to get me all fired up.

Yet as an analyst, I am constantly reminded by my colleagues that it’s important to maintain a healthy disconnect from such an optimistic purview when looking at the world around us. At no time does this become more evident than at the annual HIMSS conference and expo, where we are cajoled by every company spokesperson and marketing team claiming to have the most Super Health Information Technology that has ever existed.

One of the most discerning tools in a health IT analyst’s utility belt is a good old-fashioned BS meter. In working in the health IT field as an analyst, one deals almost exclusively with sales and marketing folks from organizations that run the gamut of solo entrepreneurs to mega multinational corporations to taxpayer funded cheerleading squads. This is not a problem, per se; it is just the nature of the business. I get it, I know – it’s HIMSS, after all. Don’t hate the player, hate the game.

Reading between the lines in this rosy world is an acquired skill. In tracking a particular market – in my case, patient and consumer engagement, you quickly learn which individuals from which companies can really chop it up and share their insight, and which ones simply have an eye on your upcoming report as a sales tool. In paying attention to what’s not said, you can learn volumes about what’s not real. The interoperability showcase is much more valuable than the expo floor (unless you’re looking for free hacky sacks). We are naturally wary of the buzzword compliant vendors (I’m already bracing myself for “Patient Relationship Management”), as well as those who are caught up on meaningful use as the primary drivers of health IT adoption. Because even though MU2 is leading many CMIO’s patient engagement agendas, our standard for best in class vendors is those who build to meaningful use as a tactic, not a strategy.

So heading into Orlando in a few days, I’ll be doing my analyst-best to balance a natural, Disney-like enthusiasm for some truly amazing technology, with the grounded, cautious skepticism of the HIMSS mainstay health IT vendors that seem to have become too big to fail (more on them in a second.)

 The Good (Optimism)

Based on the 2014’s research so far, I am developing a more positive outlook on the startups and small-to medium sized outfits who are building modular patient engagement solutions, from specific care management task-lists (Filament Labs), to communication platforms (Conversa), to data integration (Validic), to video visit technologies (American Well). To be sure, they have their work cut out for them, and by analyst standards most of these companies are difficult to truly peg, with only one to two clients under their belt. So, call it a cautious optimism.

 As the healthcare system’s demand for innovation increases, legacy vendors’ ability to supply it seems to be plateauing. Chilmark suspects it will come from these smaller, nimbler “NewCos.” As EHR vendors seek to build bridges out to patients, we fully expect to see them partner with or gobble-up the best of these startups in the next 18 to 36 months.

The Bad (Skepticism)

Patient-Generated Health Data outfits: From what I saw at the mHealth Summit in December and online since then, there have been innumerable patient data plays, from device makers to app platforms to sensors and wearables that have not put an ounce of thought into how to pool, stage, present data at the appropriate level to a care manager or other medical practitioner.  In a word, workflow. What is okay for the fitness tracker is not okay for the mood tracker or the Bluetooth blood pressure cuff. Data collection is old news, and is now a component of the engagement loop that is necessary but not sufficient. It’s making that data actionable that creates the value we need in healthcare.

The Ugly (Pessimism)

This dubious honor goes to the corporate hippos who frequently succumb to the same groupthink and reactive positioning that has gotten the healthcare industry so far behind the 8-Ball in the first place. In my domain, this is the legacy EHR vendor who is putting lipstick on a pig by dressing up a patient portal that still has less functionality than a free app like iTriage. It is the insurance conglomerate with the “Blue Button Pledge” proudly displayed on their corporate website, whose company portals tirelessly fail to let patients select a doctor, pay their bills with credit cards, or set-up appointments online. It is the mega corporations who have bigger marketing budgets in their healthcare vertical than many reasonably sized office practices have in their IT budget – and still struggle to produce anything of merit (looking at you, TelCos.) It’s time to stop checking off federal mandates and telling everyone it’s “innovation.”

So while we’re well aware that HIMSS is a giant party for most, let’s not lose sight of the valuable in-person learning opportunity it can be for everyone. For vendors, instead of showing off your S.H.I.T., provide open access to your delivery system clients who are willing to show us real results, talk openly about some of their frustrations and challenges, and provide a more grounded perspective from where the rubber hits the road. For attendees reading this blog, keep a keen eye on promising developments but don’t be afraid to ask the tough questions. If you see anything you’d like to share, make sure to tweet us @ChilmarkHIT!

 

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Barefoot at HIMSS? Just Trying to Follow Dr. Google’s Orders

DrGoogle

If you see me in flip flop sandals, Vibram Five Fingers (VFF), or a barefoot-style shoe at HIMSS14 — please withhold fashion judgment. Since Jan 1, 2014, I have been performing a little “care management” on myself — as ordered by Dr. Google — and have been treating my sports injury by going about barefoot or minimally-shod.

Trusting Dr. Google over my Kaiser podiatrist (recommendation: prescription orthotics), and my Kaiser Sports Medicine Doctor (recommendation: wear a medical boot), was not easy. I was driven by: 1) pure desperation to get back to running, 2) A feeling that the KP system had nothing left to offer me, and 3) a high deductible health plan.

When my healthcare was paid for, and the doctor was all-knowing

I began running as a teenager and within a few years had developed posterior tibial tendinitis (pain and swelling along the inside of the ankle/foot). The podiatrist told me I had flat feet/over-pronated, and that I needed custom orthotics. I blindly trusted him, accepted his diagnosis as fact and was soon running again — pain-free and happy. Pre-Internet, I had no easy way (and no inclination) to really understand the biomechanics of running gait and why the orthotics fixed my symptoms.

A few decades later, I found myself again in a podiatrist’s office. I was suffering from some intermittent pain in my left ankle/foot, and assumed I needed the latest and greatest orthotics.

However, this time around I was no longer that oblivious teenager. I had read the book Born to Run and had also witnessed my husband suffer through various running injuries over the years — injuries that immediately disappeared after he started running in a VFF toe shoe.

I distinctly remember asking the podiatrist if there were any exercises I could do to strengthen my foot, negating the need for orthotics. He told me no, my problem was genetic, and that I would need new $300 prescription orthotics.

Turning to Dr. Google Instead of Dr. Kaiser

After running for several months in the new orthotics the pain came back ten fold. In order to simply walk, I began wearing an ankle brace in addition to the crippling orthotic. After 6 months of not running, I was in as much pain as ever, and was desperate.

During this time period (late last year), a perfect storm of events pushed me towards Dr. Google and healthcare consumerism.

I read The Story of the Human Body, by the “barefoot professor”, Daniel Lieberman of Harvard. Lieberman discusses how the habitual wearing of shoes since childhood deforms and atrophies the human foot — causing a host of problems including flat feet/overpronation. Lieberman also rails against the orthotics industry, describing how orthotics cause the foot to progressively weaken over time until wearers lose the ability to walk barefoot.

Feet

At the same time as I was learning about the deleterious effects of shoes on the human foot, I was transitioning into a high deductible Kaiser plan via Covered California. This meant that I would pay dearly for each office visit, and, at that point in time I didn’t feel like spending a dime on KP with regards to this injury. I very much felt (and still do) that I had been duped by both the orthotics maker, and the orthotics-salesman podiatrist.

In short, I had nowhere else to go except to Dr. Google, who was available for free, 24/7, instantly. Over a week I obsessively googled various keyword combinations. I found communities of barefoot runners, flat-foot sufferers, and numerous YouTube videos. Most helpful were the videos and blogs that described in detail, exercises to strengthen arches in flat feet. I also learned the important role of the big-toe in supporting the arch (in nearly all womens’ shoes, the big toe is pushed and squeezed to the side, causing the arch to oftentimes fall).

I formed a hypothesis that this barefoot stuff might cure my foot injury, and so on Jan 1, 2014 started slowly going barefoot as much as I could around the house and doing various foot and lower leg strengthening exercises. I wore VFFs and flip flops outside, and got rid of the ankle brace.

Testing My Barefoot Hypothesis, On a Sample Size of One

Wearing orthotics for so long, I hadn’t realized how weak my feet actually were. In going barefoot, I felt could feel just how feeble each tendon, ligament, and muscle was. At the same time (and despite the ongoing soreness), the post tib pain was subsiding. After 2 days barefoot I could walk without much pain.  7 days barefoot and the pain was gone completely. This was after 6 months of suffering.

Some other outcomes: My foot became noticeably wider, more muscular, and lo and behold I developed an arch in my foot. I have tried to prove these outcomes to myself by trying on a narrow shoe that used to fit but now does not, and by observing my footprint coming out of the pool — before it was a blob, now it looks like a normal footprint.

Disclaimer: yes, I am a sample size of one, this was a non-controlled study. I acknowledge that I too suffer from Optimism bias and Confirmation bias.  Also, I don’t yet have enough runs under my belt to know whether or not this barefoot transition will really enable me to run injury-free for a long time. (To date I have been able to run 4 miles at a stretch in the VFFs.)  I may get injured tomorrow but for now I am declaring victory.

Analysis: Why Didn’t Kaiser Care if I healed or Not?

Of all healthcare providers, KP as a capitated system should have cared about healing my foot and preventing the need for surgery. However, in this case KP acted completely episodically.

What about population health management outreach? I didn’t receive a single outreach from KP, checking in as to whether the orthotics worked or not. Not even a simple email. (Actually, I am naïve to expect this. KP is a smart actuarial organization and has made the calculation that this type of outreach is more likely to increase utilization for a generally healthy member. Not so for the sickest, most complex patients.)

What about care coordination? I visited a primary care doctor after the fact for a routine checkup. Why didn’t she ask me how my foot was doing? Maybe going through my (very short) medical record was too much to ask? Why then install Epic at $6B?  If this kind of basic care coordination isn’t being achieved within a closed, integrated system who has been on Epic for years and touted by many as the “gold standard” then how do we expect loosely integrated clinical networks to share data?

Note: In Kaiser’s defense, before I visited Dr. Google I did make one last attempt and had a phone conversation with a sports medicine doctor (no deductible charge) who wasn’t interested in talking about orthotics and told me the next step was a medical boot. I asked him about barefoot running and he didn’t disregard it as possibly helpful.

In Summary: Healthcare Consumerism Driven by Complex Factors

With this post, what I want to do is shed some light on the complex conditions driving healthcare consumerism today. In this case, my ACA high-deductible plan offered me some tough love and forced me to take control of my own health — though there are many use cases where these plans might backfire.

There is also the role of tech/IT therein. Aside from the obvious benefits and pitfalls of going to Dr. Google, this use case made me think deeply about just how far providers are from truly harnessing user-generated data. For example, KP in the far future might want to exploit my smartphone’s GPS data to predict if I am trending towards a sports injury in the first place.

I have also written this post as a small way of adding my voice to Dr. Google — I hope it can be useful to anyone who has suffered from similar injuries. You don’t always need to mindlessly believe a podiatrist who tells you that your feet are genetically defective and need to be propped up by an expensive orthotic.

I am now preparing to walk ~8 miles daily through those long hallways at HIMSS, and looking forward to it, though be forewarned, I may be not be wearing the most stylish shoe.

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