- Monday, April 26: ONC announced that they will release the NPRM for Privacy and Security in the next few weeks. As with “Meaningful Use,” this proposed rule will be available for comment for several weeks, informing the final rule.

- Monday, April 26: For those of you who missed HHS CTO (and athenahealth co-founder) Todd Park, here’s a fun video of him talking about the newly announced ‘HHSinnovates’ program with federal CTO Aneesh Chopra. It’s basically an internal effort to improve recognition of innovative ideas within HHS. This country needs some good ideas, so good luck Todd!

Spotlight on: MEGAHIT

The coolest-named project in the federal government, ‘Medical Evidence Gathering through Health IT’ is designed to facilitate the information gathering for Social Security Administration’s (SSA) disability benefits program. When a person becomes disabled, they have to submit an application to SSA for benefits. Traditionally, in order to justify the disability benefits, SSA staff spends dozens of hours trying to track down an enrollee’s medical history. This costs SSA money in processing costs, but more importantly it delays benefits that allow patients to get and pay for care. That’s where MEGAHIT comes in. Run through the National Health Information Network (NHIN), MEGAHIT is a processing engine for routing electronic requests for information to electronic health information sources. These messages are automatically processed by the HIE, saving the providers a lot of work and phone calls. It promises to reduce the processing time of claim from up to eight weeks down to mere minutes.

Yesterday, The New York Times quietly exposed a raw nerve in the physician community that we at athenahealth have been concerned about from the day we first opened our doors.

In an article entitled “Fueling the Anger of Doctors” Pauline Chen, MD cited some of the most devastating findings from our recent Physician Sentiment Index℠ conducted with Sermo. Namely, as she sums it up, that “Nearly two-thirds of doctors felt that the current health care environment was detrimental to the delivery of care, and more than half believed that the care quality would only decline over the next five years. Less than a fifth of doctors felt they could make clinical decisions based on what was best for the patient rather than on what payers were willing to cover. And an overwhelming majority believed that getting reimbursed was becoming increasingly complex and burdensome.” 

Doctors — like the colleague Dr. Chen calls out in her piece who left the profession because she consistently worked overtime on “mindless paperwork, just so the insurance companies can deny payment” — feel the actual quality of care they want to provide is being compromised by a broken system. Throughout the health care reform debate, publications developed charts and analyses galore about “what reform means for patients,” “what reform means for employers,” “what reform means for insurers/government.” Rarely was it asked in the mainstream media what reform means for doctors and the care they’ll be able to give. We recently made an effort to do that here in an attempt to fill that unfortunate gap. As Dr. Chen makes clear, a system that makes doctors unhappy and hinders their ability to do what they do best is not good for anyone – least of all patients.

Please no.

Not another CEO who thinks he’s gonna be a girl-of-the-people by blogging in an over-controlled way. I’ve been blogging internally here at athenahealth for a couple years now and even THAT gets reviewed by our legal team before our own employees see it. Oy.

That said, I just can’t stand to not make noise.

Ya know that movie on the Clancy book where the CIA guys are watching the poor soldiers get massacred on satellite and they can’t do anything about it?

Well with 40 million patients and 25,000 providers on one network, I see in real time dozens of such massacres (and some victories too) all the time that don’t seem to find their way into our national debate.

So here goes another blog…but more of a rant really. You can feel free to post comments—and I’ll even respond—though we all know this is mostly about me talking…as well as a few of my similarly Napoleonic and backed-up-with-things-to-say colleagues (and some guest bloggers doing cool things).

OK, here are just a few of the topics I’d like to cover in more detail in the coming months on the athenahealth blog, along with other stuff I’ll cook up:

1. Uniform theory of medical practice – Yes, I do believe that there is one way to move patients through the office. I believe that every practice who says they are different is making a mistake. They either aren’t as different as they think OR they are different but SHOULDN’T be. There, I said it. No, this isn’t about dehumanizing the process. It’s about maximizing the human-to-human (as opposed to human-to-paper) time doctors have with their patients.
2. Payers – Whine all you want about these national payers and the profits they make. I watch them move in ways that are certainly not taught in Sunday school and I’m here to tell you: they are a lot more predictable and reliable than state Medicaid plans. The irony of states going after these big nationals while they stink up the place with their own plans drives me berserk—and when you see this year’s PayerView℠ data, it’ll do that to you too.
3. Culture – Culture is the most powerful asset of any business. Anyone who tells you that their people are the most valuable thing is a namby-pamby. If they say it’s the customer, they are shallow. If they say it’s profit…well at least they’re honest. Culture is the one thing that you can actually make as a business that:
   • Can’t be off-shored
   • Can’t be taken away by an employee who leaves you for a better offer
   • Keeps management in line as much as it does employees
4. Product design – We are done with products, for the most part, as a society. We are too impatient for them. A product is usually a thing that you buy and then use to get some outcome. But this is America people! Just buy the outcome! It is an exhausting thing to build a service that depends on results for revenue, but it is killer once it gets going.
5. Innovation – Never think big in this area. Think tiny and then run like mad. Before you know it, big happens. This is seriously at odds with everyone and everything I have seen in the realm of healthcare reform (and not just the Obama thing but every bloody PowerPoint keynote I have ever seen at every bloody conference, class, etc.).

The list goes on…For the two of you reading this, I will also answer any questions for which I can think of a sassy answer that I also happen to believe in.

Thanks for peeking. I hope this works for you over time.

I also hope it makes more doctors learn that athenahealth exists!! We EXIST!!!!!!

At athenahealth we recently ran a patient flow study in the office setting. We wanted to find out how clients using athenaClinicals, our electronic health record service, could maintain or even boost their productivity. With the collaboration of my colleague Aixa Almonte and others here, we set out to learn just how.

Lean methodologies were originally invented by automakers to boost efficiency and quality on the production line but have been adopted and utilized by the healthcare industry in recent years. The basic idea behind lean methodologies is to understand the steps in a process and remove or re-engineer waste while preserving and optimizing the steps that add real value.

We used lean methodologies to study how patients are processed in the office setting. We developed a Value Stream map and then collected data over six months from 25 of our athenaClinicals providers at 12 different practices from California and Texas to Massachusetts. We observed over 300 patient visits, logging over 100 hours of study in pediatric, internal medicine/primary care, orthopedic, and obstetrics/gynecology practices.

We all know a patient visit is not a one-on-one encounter between the doctor and patient. From arrival to check-out, a patient interacts not only with the provider but also with administrators, medical assistants, nurses, and technologists. It’s a delicate process of coordinated hand-offs that can go poorly without the right tools and strategies to make it run smoothly.

Armed with stopwatches and clipboards, we measured:

• patient process times and wait times
• triggers of patient flow
• who worked each phase, especially if the right resources were available to complete tasks
• first time quality – did the right thing happen the first time or was rework required?

We had stopwatches but we also had a secret weapon. Our athenahealth web-based platform allows us to measure and monitor performance across our entire network. With that unique insight, we could enrich the data collected in the field with weblog data pulled directly from athenaNet.

So what did we find? After sifting through significant amounts of data, we discovered distinct patterns of provider behavior that clearly separate highly efficient providers from less efficient ones. Our highest performing providers are highly focused on the today’s tasks, adapt well to obstacles that arise throughout the day and employ strategies to ensure their patients move through their offices smoothly and efficiently. These providers minimize wait times while maintaining normal face time with patients. They start on time, do the majority of their work in real-time and, importantly, are supported by flexible, cross-trained staff.

We found that a provider’s strength at executing patient flow processes resulted in their ability to finish all the work of the day’s patient visits on the same day. The efficient ones wrap up work the same day by completing the encounter documentation in real-time instead of waiting until later, on nights or weekends.

The insights gained from this study informed our decision to incorporate the 5-stage encounter functionality into athenaNet to help streamline patient flow and enable us to measure these processes using our EHR platform. Our next step is to deliver this insight, using reporting tools and benchmarking, directly to our providers so they become more aware of their own processes and adopt our best practices that enable smooth patient flow.

I spend a lot of my free time reading healthcare information technology plans for state and federal government. I know, it’s not much of a pastime, but it’s probably a better use of my time than watching re-runs of Caddyshack. In the past, these HIT plans were heavy on vision and light on funding. But in the last year, they started swimming in dollars at every level. Generally speaking this is great: government can provide a ‘public good’ by creating standards, funding research, setting security and privacy standards, and initiating information exchange. Unfortunately, some of these ideas would require that physicians do more without addressing how to pay for more.

Let’s start with the good, and there’s a lot of it. If you like quality of care and transparency, check out ONC’s Draft Strategic Framework. If you’re more interested in regional data exchange, flip through the state reports. Minnesota eHealth Initiative’s report to the Minnesota Legislature provides leadership on Health Information Exchanges and the potential for increasing efficiency. Iowa’s strategic plan addresses creating security and trust in health information exchange – great responsibility for government to assume. And if you’re interested in access to care, many of the state plans address safety net clinics. Nebraska’s plan even tackles the lack of specialists in rural communities by promoting telehealth capabilities, the very definition of government leadership in action. All these plans have innovative, occasionally inspired visions for how state and federal government should be developing a healthcare information infrastructure.

But if this mix of government leadership, money and HIT results in a metaphorical pumpkin pie of public good, this pie is undercooked: These strategic plans call for physicians to do more – more reporting, more coordination, more exchange, more expenditures on technology – without explaining how physicians are going to be reimbursed for playing along.

Which takes us to the federal government’s HITECH Act, the county fair-winning pumpkin pie. Smarter people than I suggest that it is an incentive program that appropriately funds for reporting, healthcare IT adoption, connections to HIE and the rest. And I completely agree – but only in 2011-12. When you reach 2014-15, where physicians have to do the most reporting and maintain complex HIE connections, you’re looking at just $2,000 per provider – less incentive for more work! Go out another year and you’re looking at a one to two percent decrease to the fee schedule. In that case the financial incentives just don’t match, or incent, the work required. And while we can all dream, you can’t realistically ask the world’s largest industry to make significant investments in technology, processes or people without a serious indicator that the payment model is changing.

So is anyone doing it right? The patient-centered medical home (PCMH) model, which is being embraced by some states and payers, has a strong emphasis on payment reform to create a “reimbursement structure that supports and encourages this model of care”. And HITECH is doing some very good things in terms of transparency and information exchange in the beginning years. We at athenahealth are also running into more payers and governmental leaders who understand that payment alignment can turbocharge quality, efficiency and access improvements. A good example is BCBS-MA’s Alternative Quality Contract, through which organizations like Caritas Christi are leading the way to transparency and high quality care.

As we look for solutions in the coming years we need to keep in mind the importance of aligning reimbursements with requirements with the goal of a greater public good in mind.