P4P, Change & Vested Interests

Matthew Holt provides some interesting, and spot-on commentary regarding last weekend’s article in the New York Times on the misuse of technology. The technology in this case is the use of 64 slice CT scans for cardiology, a technology that is widely used, but rarely needed.

Very serendipitous timing of the article as just last week I had the pleasure to meet with Dr. Richard Parker, the medical director for Beth Israel Deaconess Physician Organization (BIDPO). It is BIDPO who works directly with the 1,500 or so physicians that are affiliated with BIDMC throughout eastern Massachusetts. The purpose of the visit was to follow-up on a conversation I had in late May with SafeMed’s CEO, Richard Noffsinger, regarding their partnership with Google Health.

While Noffsinger related to me many of the unique attributes and features of SafeMed during our call, I wanted to hear first-hand from one of their customers as to their experiences with the SafeMed platform. A few weeks later I was sitting in Dr. Parker’s offices.

Background on SafeMed:

• Physician founded (Ahmed Ghouri) in 2000 as a clinical decision support (CDS) platform. But like many a technologist founded company, big on technology and addressing needs, but short on go to market strategy.
• July 2007 saw Hicks Equity Partners make a significant investment. Time to ramp up that go to market strategy and Richard Noffsinger was recruited.
• Core to their CDS platform is the Rules Engine. Platform also provides a comprehensive thesaurus and is optimized for extremely fast processing speeds. I’m quite sure that Google Health was intrigued by all three of these features, which are a very nice fit for their PHR platform.

Leveraging SafeMed at Beth Israel:

BIDPO was approached several years ago by BCBS of Massachusetts to consider using SafeMed as part of a Pay for Performance (P4P) program targeting imaging. BCBS/MA offered to sponsor initial deployment and outlined for BIDPO that there could potentially be several million dollars in P4P payments if deployment went according to plan and P4P targets were met.

The problem BCBS/MA was having was that as imaging technologies were proliferating, physicians were often prescribing tests that had not shown efficacy. This resulted in significant cost overruns, similar to what the NYT article alluded to. BIDPO physicians, for example, had over 2,000 different radiological studies at their disposal which they could potentially order. Unfortunately, this plethora of choices led physicians to not always choose the most appropriate tests for a given condition and patient profile.

The physicians had a few headaches of their own as well. In an effort to crack-down on run-away imaging costs, insurers were requiring pre-authorizations. This was, and continues to be with some insurers, a time consuming and subsequently frustrating process.

To address these problems, BCBS/MA introduced BIDPO to SafeMed sponsored deployment of the solution, which is now fully integrated with BIDMC’s homegrown EMR. Today, BIDPO is in its third year of using the solution with all imaging orders for BCBS/MA members processed through the SafeMed CDS. Dr. Parker was kind enough to give me a live demo of the SafeMed solution at BIDPO and it was impressive.

First was the ease of use. In looking to perform a radiological test on a patient, the physician enters the type of condition being tested for (one can even use layman terms), say severe headache and the SafeMed thesaurus automatically guides the physician to which tests may be most appropriate based on the patient’s profile (takes into consideration medications, allergies, weight, age, and numerous other parameters).

A selection of radiological options sorted in ranking order by evidence of efficacy. Cost information is also provided as well as alerts (in red) of any technologies that show risk based on patient profile. When a physician clicks on a given test, a brief informative summary of the test is provided including where it is most appropriately used and why. Upon selecting a test for the patient based on this information, approval is virtually instantaneous. (Remember, this is for BCBS/MA members only, for other plans, BIDPO physicians must still go through a lengthy pre-authorization process that takes on average 15 minutes/transaction.)

Throughout the demo, the SafeMed CDS was blazingly fast in delivering results. Note, nothing in this demo was scripted – Dr. Parker did demos on anything I asked him to, in real-time.

As with any technology deployment, there was initial resistance by some physicians and there were bugs in the system that took about six months to work out. Now, Dr. Parker claims, they have 100% adoption and use by physicians of the system who are all benefiting from those P4P bonuses from BCBS/MA.

Benefits Seen to Date:

When asked what kind of benefits has BIDPO seen from the use of SafeMed, he broke it down into the following:

• Physicians are getting instant approvals to their radiological requests, making life easier (Note, in addition to being integrated to the BIDMC EMR, SafeMed platform is also a part of their CPOE.)
• Physicians are also getting a nice little P4P payment at the end of the year. Since deployment, the system has met P4P targets each year.
• Patients are safer as physicians are making better decisions regarding which tests to use for a given condition and patient profile. Within BIDPO, 50% of all radiological orders are placed by internists and general practioners who typically do not have as much experience as specialists in various applications and best practices radiological tests.
• Approximately 1,000 radiological transactions/month are run through the SafeMed CDS. Typical time to get a pre-authorization the industry standard way is 15 minutes. With SafeMed, pre-authorization is immediate. This quickly adds up to 1.6 FTE (full time employee), who can be better deployed doing something more valuable like attending to a patient.

The Big Loser:

As with anything, where someone gains, another loses and with P4P initiatives such as this, it is no different, which gets back to that NYT article:

In the case of BIDPO’s use of SafeMed, the radiological department at BIDMC has seen a measurable drop-off in revenue creating some internal friction. Dr. Parker readily acknowledged this and in thoughtful reflection stated that many changes are occurring in healthcare, this just being one example with many more on the horizon. One can not sit back and await these changes to come to them. Rather, one must take initiative, as to wait puts the entire organization at a competitive disadvantage and subsequently at risk.

Now, how does this all relate to consumer-facing healthcare IT?

SafeMed is now “running under the hood” at Google Health, driving the medication checking algorithms for potential adverse effects of multiple medications. SafeMed joins quite a few other applications and services that provide similar capabilities such as A.D.A.M., Drugs.com (using Cerner), Drug Digest, and DoubleCheckMD. What is attractive about the Google Health-SafeMed partnership is that Google has signed agreements with a large number of pharmacy companies and pharmacy benefits management firms (PBMs) allowing the consumer to automatically load their medications into their Google Health account where they can readily check their meds for any adverse interactions.

Matthew Holt, co-organizer of the Health 2.0 conference did test drive of Google Health, including the SafeMed platform in Google Health and found the current solution lacking, particularly the UI and how information was presented. More than likely, the problem lies in SafeMed not fully completing the drug interaction platform prior to launch. This is a common issue with Beta or early releases and will in all likelihood be resolved over the next few months. What will be more interesting longer-term is to observe how SafeMed may expand beyond medication checking into other critical areas that may be useful for consumers. Not sure exactly what those might be, but SafeMed does have a powerful rules engine that is very fast making it attractive for Web-based apps. Being agnostic, SafeMed could become a key ingredient in other personal health applications (PHAs), becoming not just a CDS, in the clinical sense, but also a CDS in the consumer sense.

But this gets back to one of the features in the BIDPO deployment that I found so intriguing and also raises challenges for SaferMed. The BIDPO team that led that deployment spent many hours building out the meta-data and decision support capabilities for their SafeMed radiology solution. SafeMed will be challenged to find partners with a similar willingness to do such heavy lifting in other markets such as the consumer market. Not sure Google is up to the task. Hopefully, SafeMed has a few other partners who are.