Portal not "Port-All"

doorBy: David Hirshfeld

Whether as a means of satisfying the Stage 2 “meaningful use” requirements of the HITECH Act, or in an effort simply to enhance the efficiency of their practices, many of our clients have been implementing electronic medical records software that includes patient portals.  A “patient portal” is an electronic doorway between patient and practice.  Portals often allow patients to check and download their own treatment records, and to use digital messages as a means of communicating with clinicians.  Portals can be awesome tools with which to enhance your practice, but they need to be implemented thoughtfully.

A portal is often an excellent way in which to add operational efficiencies that reduce costs, increase patient satisfaction, and increase positive outcomes; BUT, if not carefully monitored, they can become inadvertent points of entry for information, the meaning of which can only be appreciated when delivered in a face-to-face office visit, where other aspects of the patient’s condition would be evident (e.g. pallor, swelling, confusion).

Portals should be limited to more benign encounters, such as: patient registration, financial clearance, medical history, appointment scheduling / confirmation, specialty referrals, notification of test results, online bill payment, non-narcotic prescription renewals, follow-up of specific conditions for which there has been a course of in-person treatment that included an agreement as to the use of the portal for follow-up.

I recommend that practitioners train their patients how and to what extent they should use the portal by presenting patients with a “Terms of Use” agreement (that they must sign); and by reminding patients of the Terms of Use if and when they use the portal for an encounter that should have been handled by an in-office visit.

A good “Terms of Use” agreement ought to convey the following information to patients before they use the portal:

  • Identify the proper subject matter to be communicated through the portal and, just as important, the types of communications that should NOT be made through the portal.
  • In addition to communication, what other functions the portal will make available to the patient (e.g. what records can patients view, can they download, can they transmit to other providers, refill prescriptions, help practice to monitor an ongoing condition, etc.).
  • The portal is highly secure, more secure than conventional email, and should be the only way that patients should convey information to the practice other than in-person or, perhaps, on the telephone.
  • Everything conveyed to the practice through the portal will become part of the patient’s medical record.
  • Not only the physician, but other clinicians and practice staff may read communications made through the portal.
  • How quickly, and in what format, will the practice respond to patient communications made through the portal.
  • Whether and on what terms the practice will allow access to records of its minor patients.
  • How modifications to the “Terms of Use” and portal functionality will be conveyed to patients.
  • A primer, as simple as possible, on how to effectively use your practice’s portal.

Portals can be awesome tools with which to enhance your practice; but they need to be implemented thoughtfully, and in conjunction with patient training.

 

CMS Seeks to Delay E-Reporting Requirement

The CMS has proposed an array of rule changes affecting physicians and their use of health information technology under various Medicare and Medicaid payment regimes, including delaying for at least a year a requirement for the direct, electronic reporting of physician quality data as part of the meaningful use requirements of the electronic health-record incentive payment program under the American Recovery and Reinvestment Act of 2009.

“One key change in the rule is a proposal to continue to allow physicians and other eligible professionals (collectively referred to as EPs under the program) to qualify as having met a portion of their meaningful-use requirements for clinical quality measures by submitting attestations to the CMS.”

The 621-page proposed rule, released by the CMS this month, but not scheduled for official publication in the Federal Register until Wednesday, is open for public comment through August 30.

Via Modern Healthcare  7-13-2011

Odd Little Facts about ACOs


  • The Medicare patients will be invisible to the providers for one year so as to discourage lowering costs improperly. How will this affect the providers’ ability to design cost-lowering programs?
  • ACOs are not closed networks;
  • When ACO beneficiaries go outside the ACO, and healthcare cost savings or excess is passed onto the ACO, even though the ACO had no control over such things. Imagine how seasonal residence plays into this;
  • Demonstration projects show a lot of patient “churn,” further challenging the ability of an ACO to control costs;
  • It looks like the two sided model will put 25% of reimbursement at risk;
  • Even Mayo, Geisinger and Cleveland are saying they won’t participate in ACOs.


ACOs are S.T.U.P.I.D

We have probably never seen so much enthusiasm and spending on anything in our history as we are on healthcare reform. The point is to slow spending and improve quality by incentivizing cost-saving, quality-enhancing behavior. And the Accountable Care Organization is the new healthcare delivery model designed to save us from our greedy, over-utilizing selves. Here’s how it works:

First, you take a lot of primary care physicians and tell them they will get more money by (1) taking an expanded role in taking care of patients, and (2) reducing the expenses associated with that care. Then you tell them two really special things: first, you tell them “Uh, since we’re afraid that you will improperly reduce the amount of care the patients need, we won’t tell you which patients are in an ACO and which are not.” Second, you tell them “We really mean it when we tell you that we intend for you to make more money, but we won’t tell you exactly how we’re gonna do that. Trust us, ok?”

Second, you empower physicians to lead the charge. After all, they’re the only participants in ACOs that smart people think can control costs and quality. And you do this by telling them to (1) shell out about $26 Million to form an ACO, (2) go to Wharton and get an MBA, (3) educate themselves about all the intricacies of information technology and work out the kinks involved in implementing electronic medical records, and (4) keep taking care of those patients while you do all this. Finally, you keep the identity of patients secret from the physicians so there is no way to prepare care plans that take into account the diseases faced by the patients. No problem.

Third, you let patients run amok. They can go into an ACO…or not. They can go in and out of ACOs. They’re like kids that way, but they’re responsible for reading the 397 pages of ACO regs and then deciding whether they like the idea of not. Oh, and they have absolutely no incentive to sign up for ACO care. And why would they? “Hey, how about you go with this ACO, which will get more money if they spend less on you. How’s that sound?” How could this possibly be sold to Medicare patients? “This ACO will get paid for getting you well! Your primary care doctor that you’ve trusted for 20 years and who helps you get and stay healthy…that person doesn’t have the same incentive to get you well.” NOT.

Simplicity. There is none. Never before in our history have we seen something so simple (patient rationing) become so complicated (rationing = less expensive care). And so many acronyms and governmental departments and positions too! There are one sided models, two sided models and now a Pioneer model, for those who are especially adventurous. And did I mention that the basis for healthcare reform, the one that only the state of Washington has the courage to articulate, is really just rationing?

Troubling to pretty much everyone. Yes. Except for policy makers, there has yet to be any significant support for anything other than the IDEA that healthcare should cost less and be more outcome oriented. Even the Mayo, Geisinger and Cleveland systems have all politely declined at this point.

Unlimited flexibility. Yes, this is true, especially as it relates to patients. See, patients can be in a cost saving ACO or not. They can go in and out of them and the ACO will bear the cost. That’s right: patients can go in and out of them—ACO, non-ACO, and yet only the ACO will be penalized for cost increases. Let’s see, the ACO model is the cost saving model. And the plan is to allow patients to choose for society to save money or not. And the patients have zero incentives for participating in an ACO. And who is responsible for the behavior of these patients? Uh, well, we all are.

Patient accountability. This is completely lacking in the ACO model. There is absolutely nothing to incentivize patients for making healthy decisions and to punish them for making unhealthy ones. Also primary care driven. Not really. There aren’t enough to go around, but some guy who knows a doctor is free to see you now. Oh, also pro competitive, meaning everyone will wanna be an ACO, so that will create competition in the market and a tremendous drive to drive costs down and quality up. Ok, not really, but wouldn’t it be nice if that COULD happen. In fact, healthcare reform is functioning to do one sure thing—reduce competition, since only the biggest, strongest organizations can afford to compete or to be one.

Inexpensive. Nah. While the initial cost projections suggested about a $2 Million price tag for forming one, they are now up in the $12 to 26 Million range.

Direct and demonstrative. NOT. The entire healthcare reform delivery plan is like pushing a mouse through a maze by its tail.

Healthcare reform is like Alice in Wonderland at its best. It only makes sense on mind-altering drugs. Moreover, the shizo message from our policymakers on the whole issue is dumbfounding. “We are committed to lowering healthcare costs. ACOs will do this. Patients can be in them…or not.” Some legislators think they’ve created a panacea with ACOs, but then don’t want to compel them. It’s just political nonsense.

Look, slowing healthcare cost creep and quality enhancement are good things. We all (patients included) ought to be outcome driven and focused so that the end result is actually healthcare. ACOs just don’t and won’t do that, which may have something to do with the recent announcement by Mayo, Cleveland and Geisinger that they’re really not that interested in playing with them.


Federally Funded Electronic Health Recordkeeping: Friend or Foe?

The Federal HITECH Act will provide over $20 billion to promote health care provider use of electronic health records.  Starting this year, “meaningful” EHR users can earn $44,000 under Medicare and $64,000 under Medicaid over 5 years.  Those who enroll early will benefit the most, because nearly 70% of the payments come in the program’s first 2 years.  Physicians who have engaged in PQRI and electronic prescribing in the past few years have put another $6,000 to $8,000 in their pockets.

The Federal push for electronic health records isn’t going away.  Over $7 billion has been released to fund state capacity for exchanging health information across the health care system both within and across states.  The Florida Agency for Health Care Administration received nearly $21 million to develop this state’s health information infrastructure.  The intent is to assure a fully connected national health care IT system to provide all health care providers and their patients seamless access to a patient’s medical information.

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