Today, in the third and final entry (see Parts I and II) of Pierre Valette’s journal from Haiti, we experience the first fully electronic patient encounter at the St. Boniface Hospital and learn more about 16-year-old Mamaille; she had been crushed by a falling building at a Port-Au-Prince school, abandoned on the Haitian border, and eventually brought to St. Boniface.

When reading Pierre’s entries, I can’t help but think of how fortunate we (U.S. citizens) are to have the level of health care that we do in the U.S. Sure, there are many things we need to improve (such as data sharing and the ability to shop for care), but those pale in comparison to the day-to-day struggles some Haitian caregivers and patients have to overcome. – Michelle, Social Media Manager

My last day. Our fifth day here.

We now have running cold water. Yesterday, the plumber made the eight-hour round-trip drive to Port-Au-Prince to buy a new pump for the water cistern on the hospital roof. This means we no longer have to carry buckets from the well in the courtyard up to the bathroom to bathe or flush the toilets. We may have lacked running water over the past few days, but the rhythm of the hospital never dissipates. Each day, hundreds of patients arrive as they always do—on foot, by motorcycle or via donkey—to receive the level of care that only the St. Boniface Hospital can provide.

Over a dozen babies have been born since we arrived. Three babies are in the NICU (Neonatal Intensive Care Unit), kept thriving by ventilators powered by ever-humming power generators. In the small pediatric ward all beds are occupied by children suffering from HIV, malaria or other ailments that plague Haiti. Their parents sit by their sides. At night, they curl up with them on their beds to sleep.

Dr. Desiree arrives late for his electronic health record (EHR) go-live today after performing an emergency C-section in the hospital’s operating room, supplied with donated equipment from a Florida hospital. Without taking a breather, he comes straight from the OR to our makeshift training area, a big smile on his face, ready to begin his first electronic encounter for the Spinal Cord Injury (SCI) Program. He will be seeing Mamaille (photographed, right), the 16-year-old girl abandoned on the Dominican border about two years earlier. Though she seems healthy by all appearances, Mamaille currently suffers from persistent infections caused by her wounds. In fact, on our third day here, when Jackie Mow, head of the athenahealth video team, filmed two of the SCI kids going to the nearby school (carried in their Walkabout wheelchairs due to the school’s lack of ramps), Mamaille had to stay behind because her wounds had become irritated.

Dr. Desiree logs onto athenaNet and is now ready to see Mamaille in his office, conveniently located across an open walkway from Mamaille’s room. There’s just one hitch. No Mamaille. Realizing that she might be photographed, Mamaille is delayed in her room, unsure of what earrings to wear. She fusses with a bag full of earrings she has made over the past year—the output of the SCI’s vocational program that has taught her basic jewelry-making skills. The normally soft-spoken Dr. Desiree calls out to her from across the hallway. Je m’habille,—I’m getting dressed—she yells back. A little white lie. Appearances are important here in Haiti—especially to Mamaille.

With the perfect set of earrings dangling from her ears, she makes her way to see Dr. Desiree’s office. To start, he encounters a small problem entering her name. Seems he hasn’t perfected the “Search Patient” function on athenaClinicals, entering far more letters than necessary. Jamie Mercurio, another member of the athenahealth implementation team, shows him that he only needs to type a few letters of her last name. He enters “L-E-J.” Mamaille LeJeune’s record immediately pops up.

Dr. Desiree takes her vitals and enters the discrete data into the system. As he talks to Mamaille, he selects the patient’s chief complaint and quickly documents the history of her present illness—all in Creole. At the end of the encounter, he enters her prescription into the system. It’s a short visit. More of a test than anything else. Dr. Desiree is slowed down a little by having to visually scan the screen for fields he’s not yet familiar with, Jamie helping him search for the prescription he needs. But with very little training and only a modest amount of assistance, Dr. Desiree successfully documents the encounter into athenaClinicals.

As Mamaille leaves the exam, Jamie and Dr. Desiree exchange a high five. Dr. Desiree did it! The St. Boniface Haiti Foundation’s SCI Program has its first electronically documented patient care experience. One small step for EHRs, one giant leap for health care in the Third World countries.

I ask Dr. Desiree what he thinks. He confides that the process took a little longer than “de documenter avec un stylo.”— to document with a pen. “Is it worth it?” I ask. “Bien sur”—of course—he responds. He’s confident that he and the care team at St. Boniface Hospital will soon develop the muscle memory needed to use the EHR efficiently.

That learning curve will be worth it as athenaClinicals begins to provide the data needed to track progress and coordinate care more effectively. Betsy Sherwood, coordinator of the SCI program couldn’t be happier. For months she’s known that this experiment in implementing electronic health records at the SCI Program could only succeed if Dr. Desiree was on board. He was indeed and has taken the first step. The staff can now follow his lead.

It’s a good day. The cloud did what it was supposed to do—bring rural Haiti an efficient and effective means of documenting, tracking and managing patient care across all care providers. Dr. Desiree is satisfied. And I can now go take my first shower since we arrived.

Look for a guest post from SCI program coordinator Betsy Sherwood later this month where she’ll speak in greater length about health care in Haiti and the day-to-day struggles physicians are faced with.

Just last week, athenahealth announced the launch of the newest member of our suite of EHR, practice management and care coordination solutions, athenaClarity. This comprehensive cloud-based service helps our clients manage their network of physicians and populations of patients, and we’re thrilled to offer it.

What does it bring to the health IT landscape? Well, in case you hadn’t heard, the health care industry is changing rapidly, and part of that change involves the movement toward new payment models. Provider organizations everywhere are downing the “blue pill,” going with the option to take on responsibility for the total cost and quality of the population of patients under their care.

If you’re a provider, health care leader or network executive, you’re probably thinking: How in the world am I going to do this? Well, to do this profitably, you’ll need help (unless you’re Superman). You’ll need help wading through and mashing up the myriad data from your administrative and practice management sources, EHR and clinical systems, and payers, and then turning it into information. Even when you get that done, it’s still not enough. You’re still not there. You’ll need a way to turn this information into insight—the kind of insight you can act upon, to deliver real results to your organization. Without this critical last step, all you have is, well, data.

athenaClarity was built to be the trusted service to help you through this entire process. In short, the athenaClarity turns data into actionable insight, designed to drive quality and efficiency directly at the point of care.

Now, in case you’re wondering, it’s pretty doubtful that the fee-for-service structure is going away. The single claim will live on as the fundamental unit of utilization and, if history can teach us anything, it’s that health care reimbursement is cyclical and unpredictable. That’s why athenaClarity was built to help you succeed under any payment model, no matter your reimbursement environment. Our analytics services help you measure performance within practice, geography or specialty, and our action-focused services enable your providers to understand their individual performance and what they’ll need to do to improve. We certainly believe that, as you contemplate risk, there is no better time to get better control over your traditional revenue cycle.

So, to recap: athenaClarity turns data into insight that you can act on right at the point of care, natively in the provider workflow. We’re ready for risk. And we want you to be, too.

In my last blog post, I talked about managing care within the medical neighborhood, what I consider the health care version of “it takes a village.” Now, let’s move beyond the neighborhood and talk more specifically about the neighbors.

“Who is my neighbor?” may sound like the title of a sermon, but to paraphrase an old political slogan, “It’s the relationship, stupid.” If we retreat into our private little kingdoms like tribal warlords, we will never achieve better outcomes for our patients.

In Colorado, there is an excellent medical neighborhood in the city of Grand Junction. In last November’s Forbes magazine, Rick Ungar detailed the success that the doctors, hospital and major health insurance plan have been able to achieve. I’ll hit the high points here.

Medicare spending in Grand Junction is just $5,873 per patient, compared to the national average of $8,304. The cost of chronic disease management in this area is 1/3 the national average. Low-income patients on Medicaid are more than twice as likely to get preventive care. Low birth weight babies are a rarity.

How was all this accomplished? Did the citizens of Grand Junction form a consumer group? Did the government provide a new program?

No, the doctors, hospital executives and predominant insurance company in the region worked together. Specifically, the doctors formed an IPA (Independent Physicians Association) where good relationships amongst the doctors allowed them to take a hard look at spending. With a solid primary care base, care management was more taken care of more easily.

The insurer, Rocky Mountain Health Plan, a non-profit company, agreed to pool the money collected from private payers with the money collected from Medicaid and Medicare. This allowed the doctors to treat everyone the same, no matter who was paying the bills. Finally, the hospital was able to manage its own costs so even as the number of bed days declined, the hospital could stay financially viable.

For another example, let’s move across the country to Camden, New Jersey to look at “Hot Spotters.” Atul Gawande’s wonderful New Yorker article from January 2011 has all the details but, again, I’ll hit the highlights below.
Dr. Joseph Brenner is a family physician living in an impoverished community in New Jersey. Poring through data provided by local hospitals, he identified the sickest individuals in his neighborhood. Then, by “building relationships” with these people, managing their care and coordinating their community resources, Dr. Brenner and his colleagues have been able to reduce medical costs for these first 36 “super-users” by over $500,000 in just two years.

This is not to say we must all become like Grand Junction, Colorado or Camden, New Jersey. But, I think there may be some themes worth copying.

First, primary care physicians must have the resources necessary to manage their patient populations. This means being able to look at their data with an eye toward chronic disease management and proactive care for high risk patients.

Second, PCPs must be able to look at the care provided by their sub-specialist neighbors. This means outcome and cost data must be readily available.

Third, hospitals must take a hard look at their revenue streams and stop the medical arms race for the fanciest new suite for the care of this or that disease. Finally, insurers must provide meaningful data back to the doctors so we can see where the money is being spent and who is spending it. Risk stratification is not just a term for health insurance companies—all care givers must become comfortable looking at the data.

The stakes are high. As a country, we can’t continue to increase health care spending. The good news is that relationships with our neighbors in our medical neighborhoods can still save us.

If you follow us on Twitter, you may have seen a recent tweet or two about the free webinar we held at lunchtime yesterday focused on getting care coordination right. You’ve missed it by now, but you can always attend our webinars on-demand, whenever you have time. For this one in particular, just register here.

If you aren’t dialed into the issues of care coordination, you should be. It matters whether you are sending patients from your practice or receiving them at a hospital, a lab, an imaging center, or a specialty practice. Changes in the current and often fast-moving health care landscape are making the efficient exchange of patient information more important than ever before.

Why? Well, that’s what the webinar is for. But until you log on, think about how the right solution can cut down on denials, redundant work, errors, and worse, compromised patient care.

At athenahealth, we’ve developed a sustainable model for care coordination that benefits everyone in the circle of care. It saves time, encourages participation and effectively “closes the loop” on patient care.

Take part in our care coordination webinar today.

On October 3, the Health IT Initiative of the Bipartisan Policy Center released two complementary reports on the need to move forward with electronic health information exchange (HIE). We collaborated in the creation of the recommendations in both reports, and I represented athenahealth for a panel discussion of the findings.

The reports covered a lot of ground and here are some highlights:

• A business case for health information sharing is now emerging, but athenahealth’s position is that there are still not enough great business models to spur exchange of information
• The Department of Health & Human Services (HHS) should establish an Anti-Kickback Statute Safe Harbor and Stark Law Exception for payment associated with electronic transmission of data that accompanies a referral or order—and we could not agree more
• Federal policy makers should develop and implement a national strategy for improving accuracy of matching patient identities with their health data
• HHS should issue comprehensive and clear guidance on compliance with federal privacy and security laws for exchanging health information

On that last point, it’s critical that the solo doctor and the multi-state health system are on the same page about what HIPAA allows, without involving a cadre of lawyers.

How to Make HIE Work

You may recall that late last year, athenahealth secured a favorable opinion on HIE from the HHS Office of the Inspector General (OIG). This decision enabled our model for care coordination and it also paved the way for transaction-based payment HIE models. With the opinion came a better solution than the existing, inherently unsustainable HIE models that largely rely on government grant funding or sky-high subscription payments.

Of course we welcomed the decision but our one gripe is that it’s only binding on and only benefits us (and our clients), since we requested the opinion.

So how does this potential for competitive advantage turn into a bad thing? Well, if the exchange of health information is going to work as it should, we need WAY more people coming to this party—we really want competition. We need that OIG opinion to be turned into permanent, universally applied national policy so that brilliant innovators—like those in our More Disruption Please program—can develop business models for HIE with the assurance that their good ideas will not be deemed illegal under the Anti-Kickback Statute or Stark Laws.

The BPC reports have many great recommendations, all of which we are happy to support wholeheartedly. They focus on the need to increase public and private sector efforts to develop interoperability standards. We agree, but our view is that if national policy allows business models that put a direct financial incentive behind exchanging health information—information critical to coordinated care and high quality patient outcomes—interoperability standards will evolve quickly and naturally. People seem to agree on a way to do something, like exchange information, when there’s a financial incentive. Just ask the credit card industry!

We Need to Change the Paradigm, for Innovation

The idea that the Anti-Kickback Statute and Stark Laws would be inhibiting HIE is typically met with puzzled looks. After all, this is fairly uncharted territory. Additionally, like it or not, we still live mostly within the confines of a fee-for-service model. We think about health care as what happens in the exam room/laboratory/imaging center with a patient because this is how physicians get paid for their services. The Anti-Kickback Statute and Stark Laws are aimed at mitigating the risks that are associated with fee-for-service, where we pay for quantity and not quality.

And yet we know that successful health reform relies on shifting that paradigm and paying for quality—where care coordination is key—over quantity. The only problem is that as we make that shift, the fee-for-service policies make less sense. We need to look no further than the Accountable Care Organizations (ACOs) to prove this principle. The ACO regulations included a waiver of the Anti-Kickback Statute and the Stark Law, since those laws would make it impossible for ACOs to exist and share the risks and benefits of patient outcomes.

Shifting to a model where we pay for quality will require a similar loosening of the Anti-Kickback Statute and Stark Law so that real financial incentives can be created for care coordination and so the innovators can respond to those incentives.