Consortium News

  • 03 Jun 2015 3:58 PM | Deleted user

    Agency also moves from annual to quarterly update of data, Acting Administrator Andy Slavitt announces at Health Datapalooza

    from   |   June 3, 2015   |   By Katie Dvorak

    The Centers for Medicare & Medicaid Services is opening up its data stores to innovators to help them create tools for the commercial marketplace, Andy Slavitt, acting administrator for the agency, said Tuesday morning at Health Datapalooza. CMS is starting to use information to improve the care delivery system, but "needs your help," Slavitt said to the audience at the annual event in the District of Columbia.

    "While this is a big departure, we do this with a clear expectation that you will create a new stream of tools that will improve care and personalize decision-making," he said. "We're allowing companies to combine CMS data with other data, so even what were small silos of data can have enough credibility" to be of use.

    The Medicare claims data will be stripped of patient, but not provider, identifiers. In addition to opening the data, which was previously only available to researchers, Slavitt said the agency will move from an annual to a quarterly update of its data for researchers and innovators. CMS also will require certain data submitted to the agency for use by consumers to arrive in machine-readable format, he said.

    As long as innovators and entrepreneurs are willing to go through the process of having their work designated as HIPAA-approved research, they will have virtual access to granular CMS claims data in the CMS Virtual Research Data Center, Niall Brennan, chief data officer for CMS, added during a panel later in the day.

    "That is really cool; you're not limited in how you use the results or integrate them into your tool," he said.

    Slavitt said as innovators create new business models and determine priorities, areas they should considering focusing on include:

    Making healthcare the most private and secure data in any industry 

    Creating products and services that help take care of the country's sickest and most difficult to treat patients

    Giving doctors and nurses what they want and need the most, including more time with patients

    In keeping with its shift to greater transparency of data, the agency also just released information on Medicare reimbursements. The data shows that Medicare reimbursements to doctors are far from evenly distributed, while hospital charges for top procedures and conditions have increased moderately

  • 03 Jun 2015 3:53 PM | Deleted user

    from  |  June 2, 2015 by Gabriel Perna

    McKesson, the large San Francisco-based healthcare technology vendor, announced this week it is getting out of the care management software business.

    The company sold its McKesson Care Management business to Comvest Partners, a West Palm Beach, Fla.-based private investment firm, for an undisclosed amount. Comvest is planning on renaming the business, AxisPoint Health. The company, which has a care management software platform, will have its headquarters in Westminster, Colo., where it was previously located under McKesson. 

    For McKesson, selling off its care management is a chance to focus on its "core strengths," according to prepared comments from Jeff Felton, president, McKesson Connected Care & Analytics. The company recently announced its quarterly earnings, where most of its divisions did well. The one exception was health IT, where revenues fell 10 percent for the quarter and 8 percent year-over-year. Approximately 900 employees at McKesson were affected and are now employed by AxisPoint Health, of which approximately 700 are nurses and other clinical professionals.

    Comvest said it plans to invest in AxisPoint Health. Mosaic Health Solutions, a healthcare technology investor based in Durham, N.C., is on the deal with Comvest.

    “In the new era of value-based health care, the entire industry is reorienting around achieving the best outcomes by identifying the most appropriate levels of care,” Roger Marrero, Partner at Comvest Partners, said in a statement. “We believe that AxisPoint Health starts out with deep experience and capabilities in the market for connecting members to the right care in the most cost-effective way.” 

  • 03 Jun 2015 3:48 PM | Deleted user

    Of the 23,138 claims filed, 20,306 were accepted, though most of the rejections were caused by issues not related to ICD-10. 

    retrieved from
    Henry Powderly, Managing Editor

    More than 88 percent of ICD-10 claims filed during the latest round of Centers for Medicare and Medicaid Services end-to-end testing passed, the federal agency said, with only 2 percent of rejections coming as a result of ICD-10 coding errors in the claims.

    CMS said 875 Medicare Administrative Contractors participated in the testing from April 27 through May 1, showing a higher success rate than the previous testing session in January.

    The ICD-10 diagnostic coding vocabulary is expected to go live on Oct. 1. It contains nearly 70,000 codes, a major jump from the 14,000 codes in the current ICD-9 set.

    Advocates say ICD-10 offers providers a way to be more detailed and targeted with their diagnosis records, which improves the overall health records that follow patients across their various healthcare providers.

    While most of the world’s healthcare systems are already using ICD-10, the United States is unique in that its diagnostic codes are also used in reimbursement claims. That's what has ICD-10 opponents worried. In the worst case, coding errors can cause claims to be held or not paid, which strains on providers’ finances.

    CMS said its latest round of testing suggests most providers are ready, though.

    Of the 23,138 claims filed to its Common Electronic Data Interchange, 20,306 were accepted. Also, most of the rejections were caused by issues not related to ICD-10.

    This round’s 88 percent acceptance was higher than its last round of testing in January, when 81 percent of claims went through.

    CMS will hold another round of testing in July.

  • 03 Jun 2015 3:18 PM | Deleted user

    retrieved Jun 3, 2015   |   Boston Business Journal   |   Jessica Bartlett 

    Blue Cross Blue Shield of Massachusetts has found a new way of innovating in health care: partner with fledgling startups.

    The state’s largest insurer has been investing in startups for the last two years through its investment arm Zaffre Investments, partnering with companies that can provide new services to its members.

    But lately the insurer is going one step further, discussing with fledgling companies what needs to be created to better the health care system, and acting as an accelerator program to more closely foster innovation.

    “As we were thinking about our new location here (at 101 Huntington Ave.) and what could we do differently to be that convener, it struck us as an opportunity,” said Jason Robart, president and CEO of Zaffre.

    The innovation hub concept has so far materialized into a competition through startup connector Elevar, bringing 150 companies to the insurer to help develop solutions. The insurer wanted companies to solve one of three problems: engaging with millennials, engaging with baby boomers, and engaging with communities around health.

    “In almost all cases, they were companies that had a product or idea already,” Robart said. “It was a great example of a two-way street of innovation. These were some smart folks with great ideas. We were able to give them the payer’s perspective and with a few tweaks, it might address a different problem.”

    The companies were since narrowed down to three. Zaffre is in the final stages of putting in place a pilot program with one of the companies focused on engaging baby boomers and seniors.

    The process is helping Blue Cross have a hand in the innovations being developed from the ground up, as well as continuing to diversify Blue Cross Blue Shield of Massachusetts’ business – the insurer typically takes an equity stake in exchange for funding.

    Already Zaffre has invested over $10 million in a variety of companies, including Ovuline, a fertility and pregnancy app that helps the insurer better connect to its members using the app, and InformDNA, which acts as a counselor to patients and to insurers to make genetic testing more streamlined and efficient.

    “We realized that as we think about how the market is evolving, the opportunity for us to get closer to where innovation is happening in the market was going to be critically important, particularly as we thought about things like consumer engagement, and … how do we start to think differently about individual consumers that need support,” Robart said.

  • 02 Jun 2015 3:23 PM | Deleted user

    From  |  Eric Chabrow, June 1, 2015

    In assessing risk, computer security has three characteristics: confidentiality, integrity and availability. But not all of those traits help systems designers assess privacy risks. So the National Institute of Standards and Technology is developing a privacy risk management framework.

    NIST has issued a draft of the privacy framework, Interagency Report 8062: Privacy Risk Management for Federal Information Systems, which identifies the objectives of privacy risk as predictability, manageability and "disassociability." It's designed to be used by designers and engineers in building information systems that implement an organization's privacy goals and support the management of privacy risk.

    "We wanted to be able to build a distinct but complementary framework that would provide some of those tools to help understand where the overlap and distinctions are between security and privacy risk," says NIST Senior Adviser Naomi Lefkovitz, who worked on the report.

    Defining Disassociability, Other Traits

    According to the report:

    • Predictability enables reliable assumptions by individuals, owners and operators about personal information and its processing by an information system.
    • Manageability provides capability for granular administration of personal information, including alteration, deletion and selective disclosure.
    • Disassociability allows the processing of personal information or events without association to individuals or devices beyond the operational requirements of the system.

    How Security, Privacy Risks Differ

    Designers think of security risks as threats and vulnerabilities, and design systems to address them. But Lefkovitz points out that privacy risks are often caused by the way designers architect systems, even secure ones. Operations that process personally identifiable information could pose privacy threats. "When security people think about threats, they think of bad actors or events out of their control, such as natural disasters," Lefkovitz says. "But [in regards to privacy], it's the operation of the system that's giving rise to the risk."

    As an example, Lefkovitz points to smart metering of electricity. The systems can be built securely to protect the private information collected, but the data itself can reveal people's behavior inside their homes. In addition, the report says, security tools designed to safeguard PII from malicious actors, such as persistent activity monitoring, could reveal information about individuals that is unrelated to cybersecurity.

    The privacy framework NIST is developing also is creating a common vocabulary for privacy risk. "Privacy principles are these general, high-level terms, and it's hard for engineers and designers to translate them into specific requirements for the system," Lefkovitz says.

    As the draft report states, risk is often expressed as a function of the likelihood that an adverse outcome occurs multiplied by the magnitude of the adverse outcome should it occur. The draft examines this concept of risk and how it can be expressed in terms that facilitate improved identification and management of privacy risk.

    To aid agencies in using the privacy risk management framework and to apply the privacy risk model, NIST has developed an initial set of worksheets, collectively referred to as the Privacy Risk Assessment Methodology, or PRAM. This document describes the inputs to the PRAM, and provides examples for organizations to follow when applying the privacy risk management framework to their own systems.

    Privacy Risk Assessment Methodology

    Though NIST is developing the privacy framework for U.S. federal agencies, Lefkovitz says it could easily be adopted by other governmental and nongovernmental organizations, including entities in the private sector. Several organizations that are piloting authentication and identity systems for NIST's National Strategy for Trusted Identifies in Cyberspace have used worksheets in the privacy framework to help develop their projects.

    NIST is seeking feedback on the privacy framework that could be incorporated when the final version of the report is issued. NIST does not provide a firm date fir when it issues final versions of its publications, but publication often occurs within three to six months after releasing a draft. Comments should be sent to by 5 p.m. EDT, July 13 by using this comment form.


  • 01 Jun 2015 3:51 PM | Deleted user

    Tinker Ready, for HealthLeaders Media , June 1, 2015

    John Halamka, MD, the Beth Israel Deaconess Medical Center CIO who is co-chair of the federal HIT Standards Committee, shares his views on interoperability, information blocking, and the lifespan of Meaningful Use.

    John Halamka, MD, chief information officer of Beth Israel Deaconess Medical Center, has issues with the way both Congress and the federal government  see the state of health information technology. Last week he wrote in his blog about "how Congress… [has] entered the Trough of Disillusionment for EHRs and interoperability."

    Halamka spoke with HealthLeaders Media on May 29 about interoperability, Meaningful Use, and information blocking. The transcript has been edited for brevity and clarity.

    HLM: Interoperability has emerged as a major issue in the push for health information technology. Why isn't the system where Congress and the Department of Health and Human Services say it should be?

    Halamka: Think about Meaningful Use. The idea is—Stage 1—Let's get folks to adopt electronic health records. The country had about a 20% adoption rate. Stage 2 is to get them to start exchanging data. The concept was that, by Stage 3, we would be sharing data for care coordination, population health, genomics, clinical research, and all the rest.

    This has always been the plan. So people say, 'Wait a minute. Here we are in the middle of Stage 2. Where's all the interoperability?'

    It was a five-year project and we're just at the beginning of where we're supposed to be. We're on course. It's all OK. EHRs are recording data electronically. Systems are sharing data for many purposes—public health, lab results, syndromic surveillance, and transitions of care. And now we get to the next step and there are a few necessary requirements.

    HLM: What are those requirements?

    Halamka: Suppose you are seeing Dr. Bob over in Cambridge and he needs a copy of your records from Beth Israel Deaconess Medical Center. How do I know how to reach Dr. Bob? What is Dr. Bob's electronic address?

    It turns out that Massachusetts has a provider directory that provides that information. Most other states don't. So there is some enabling infrastructure that could be provided at a regional level and national level to help us route information from one place to another.

    It's not information blocking. It's not HIT vendors being reluctant or hospitals holding their data hostage.

    Similarly, suppose that you have a negative HIV test. In Massachusetts there is a law that says if you have an HIV result in your record, we need very special permission to exchange your record. It requires you to consent to disclose.

    It also requires that for every episode of care, for every doctor, you have to have another consent for that data to be viewed. You've already said you are completely fine sharing your HIV results, but you are going to be consented every time you go to the doctor.

    We have this heterogeneous fabric of privacy laws across our states.

    HLM: A national patient identifier would accelerate interoperability. You suggest a program for a voluntary identifier. Is there any effort to change privacy laws preventing the creation of a mandatory identifier?

    Halamka: There are always going to be some people who say, 'I don't like anything, whatever it is.' What if I had safe, coordinated efficient care, with mandatory national identifiers? 'That's too much government. I worry about my privacy, and I don't want a national identifier. I'm a human, not a number.'

    There are others who say, 'If my care would be more efficient and safer and higher quality, I would very happily have an identifier for healthcare because I don't' want the wrong kidney removed.' So, with that spectrum… the only thing we can do is voluntary.

    HLM: ONC and some lawmakers think that one of the barriers to interoperability is information blocking. They define it is as companies limiting data sharing, or overcharging to set it up as a way to gain a competitive advantage. Can you describe how you see this issue?  

    Halamka: You have policy makers saying, 'There's no interoperability.' It must be the vendors or it must be the hospitals, or it must be the standards. But, it's more complex than that.

    Unfortunately, Congress, which often wields the blunt instrument of legislation, says we'll just make information blocking illegal and that will fix all the problems. No. It doesn't really help.

    HLM: You describe reaction to information blocking as reaction to the Loch Ness monster—everybody is talking about it, but nobody has seen it. Do you think information blocking is a myth?

    Halamka: I have never seen it. If the definition of information blocking is that the vendors have all hired Chief Information Blocking Officers who spend their nights thinking about ways to restrict information flow, I've never seen it. Find me one example.

    HLM: ONC says it's gotten 60 reports of information blocking. Might it be happening in a less obvious way?

    Halamka: I am guy who has no agenda. I am not dogmatic. I will evaluate any evidence that it put front of me. Maybe there's a niche vendor that's doing it, but I've never found a mainstream vendor who is going to go against the wishes of its customers to exchange data.

    HLM: One complaint is not that vendors refuse to share data, but that they are charging a lot to do it.

    Halamka: The question is, what's a lot of money and what is the work involved? If people complain that 'my lab interface was $5,000, well, if it's a novel lab interface that's never been done before, it is a substantial amount of work to map all the lab tests.

    It actually takes me about 16 weeks to produce a lab interface. So I don't think $5,000 is unreasonable. Others may. Again, look at the data. Let's see what people want done and what's being charged for it.

    HLM: You have said that companies could also use a law against information blocking to their competitive advantage. Would they do that by filing complaints to hinder competition?

    Halamka: They could say, "We lost this deal to ABC vendor. They are information blockers. Let's send OIG [the Office of Inspector General] and the FTC [Federal Trade Commission] to torture them for years. "

    HLM: Can you describe your objections to Meaningful Use Stage 3?

    Halamka: Meaningful Use Stage 1 was a wonderful foundation. It really brought us up to a level where everyone is using electronic health records that are good enough.

    Stage 2 got a little bit aggressive. It moved too fast and was too much. We didn't' have enough time between when the regulations were finalized and the reporting period began for the vendors to actually create easy to use products. They had to really rush these things through development. It was a disservice to the industry to move that fast.

    Now Stage 3: With accountable care organizations and various kinds of patient-centered medical homes, we are starting to develop quality registries and interoperability. The private sector has incentives to do all this stuff. So, at this moment, we don't really need more regulation. We just need more time.

    If you want to put out a few merit-based incentive programs, fine. But it's probably time to retire the Meaningful Use construct and just let the private sector, with incentives from the ACA, go forward for the next few years.

    HLM: So you think Meaningful Use Stage 3 should be abandoned?

    Halamka: If you want to call Meaningful Use Stage3 a small number of merit- based incentives, that's OK. But to create 731 pages of regulations that are going to co-opt the agenda of vendors and providers seems like a mistake.

    HLM: Wasn't the original idea behind Meaningful Use accountability? We're going to give you money for an HIT system, but we need to make sure you are using in a way that benefits your practice, patients, and payers.

    Halamka: So, do that with ACA. You are going to be paid for outcomes—keeping people healthy. You can't do that unless you've implemented IT effectively. I love the idea of payment based on outcomes. But don't prescribe—with 731- pages—the minutiae I have to do for every process to get there.

    HLM: What is your advice to hospitals that are trying to make sense of all this?

    Halamka: Don't listen to the rhetoric. These issues are complicated. They involve people and politics and technology. There is no magic bullet here. There is just hard work. If we all agree that we want to make patient care better in this country and that we are going to look at a roadmap and step-by-step make it better.

    That's where we need to focus. Let's not eliminate this committee and form another. Let's not go blame the vendor. Those are simplistic, naïve solutions. We just need to keep our eye on the prize and make progress.

  • 01 Jun 2015 10:25 AM | Deleted user

    retrieved from  |   May 29, 2015

    Federal regulators appear to be getting closer to conducting the next round of HIPAA compliance audits, so now is the time for covered entities and business associates to prepare for potential enforcement scrutiny, says healthcare attorney Brad Rostolsky.

    The Department of Health and Human Services' Office for Civil Rights recently began sending screening surveys to covered entities and business associates to identify potential candidates for the upcoming phase two of OCR's random HIPAA compliance audits.

    A copy of the OCR survey that's available on the Office of Management and Budget website says: "This screening questionnaire is intended to gather data about the size, complexity, and operations of potential auditees for the HIPAA Privacy, Security and Breach Notification Audit Program."

    The survey notes: "Data will be used with other information to help us select entities that reflect a variety of types, size and locations for the Audit Program. Please note that if your organization is selected for audit, communications from OCR will be sent to the email addresses of the contact persons identified below."

    A description of the survey on the OMB website says OCR is approved to send out surveys to 500 covered entities and 200 business associates.

    An OCR spokeswoman declined to offer more details on the timeline for the audits. "OCR can confirm that we have started verifying contact information for covered entities," she says. "Additional information about the audit program is forthcoming. Check our website for updates."

    Just because a covered entity or business associate receives a pre-audit survey from OCR, it doesn't necessarily mean they'll definitely be audited, Rostolsky says in an interview with Information Security Media Group. "However, it narrows the pool."

    Time to Prepare

    All healthcare organizations and business associates need to take steps now to prepare for a potential audit, a breach investigation or other inquiry from federal regulators, Rostolsky says.

    "Now, before anyone receives a screening or any other OCR inquiry ... take a moment while there is no chaos going on and do a good status check on your overall compliance efforts," he urges.

    "Make sure your policies and procedures are in place; you've conducted your security risk assessment ... and it's been updated. Make sure you've been conducting [security] training and have evidence of that training."

    Also, in anticipation of an audit or other potential regulatory enforcement actions, Rostolsky urges organizations that have had health data breaches or HIPAA violations to carefully reassess their actions in the aftermath of the incidents. "Take a look at your files in terms of how you've handled incidents of potential privacy rule violations. Did they amount to breaches, and when you determined the breaches, did you follow the rules correctly? Understand what you have in your files so that you're prepared for what OCR is going to see."

    In the interview, Rostolsky also discusses:

    • The differences between potential audits of covered entities versus business associates;
    • What OCR will likely examine during HIPAA compliance audits;
    • How to prepare for on-site versus remote desk audits. OCR officials have previously said both types of audits might be conducted, depending upon available resources (see HIPAA Audits: A Revised Game Plan).

    OCR did not immediately respond to an ISMG request for comment on the status of the HIPAA audit program plans.

    Rostolsky is a partner in the life sciences health industry group at the law firm Reed Smith. With a focus on healthcare regulatory and transactional law, he leads that group's HIPAA and health privacy and security practice. He's also a member of the firm's global Ebola task force. Rostolsky has extensive experience advising clients on all aspects of health information privacy and security compliance.

  • 29 May 2015 1:57 PM | Deleted user

    from Dr. Halamka's Life as a Healthcare CIO blog, May 27, 2015

    Every technology has an adoption journey.     The classic Gartner hype curve travels from a Technology Trigger  to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.

    Have you noticed that Congress and the popular press have entered the Trough of Disillusionment for EHRs and interoperability over the past month?

    Congressional staffers writing the 21st Century Cures bill (which is not yet law) seem to have concluded

    1) we don¹t have interoperability (although no one is sure what exactly we have and do not have)

    2) therefore we need more standards and that will solve all the business, political, and policy barriers to health information exchange

    3) The Health IT Standards Committee must not be doing a good job because there are not enough standards

    4) Therefore we should disband it and create a new politically appointed body

    5) That new body will invent all the standards we need and then force vendors to stop their information blocking behavior (whatever that is), enabling precision medicine

    USA Today, in one of the most one sided articles I’ve read, confuses ACA and HITECH, ignores the data about EHR adoption/health information exchange and concludes that EHRs “don’t talk to each other”, whatever that means.

    It’s time to take a step back, define our requirements, examine our current state, and then focus on closing any gaps we find.

    I oversee 5,000 patient data exchanges at BIDMC every day.   50,000 patients view/download/transmit their data every month.   We’re in beta testing with apps using Apple HealthKit, connecting home devices, iPhones and our EHR.     We have numerous affiliates with bidirectional data exchange.    There are few technology limitations.  The real challenges are political and policy barriers.

    The Direct protocol, although more complex than the RESTful methods used by Facebook, Amazon and Google that we should embrace, has provided a foundation for health information exchange across the country.    Below is a snapshot of the current Massachusetts State HIE (the Mass HiWay) connections to Health Information Services Providers (HISPs), creating thousands of connections among hospitals and eligible professionals nationwide.   Every week, some new practice or hospital comes knocking at the BIDMC door and within hours we can create a connection.

    Interoperability is real.  Interoperability has a very positive trajectory.   Saying otherwise is oversimplifying the reality of ongoing good work in progress.

    When confronted by naysayers, we have only three choices

    1.  Give up and declare defeat

    2.  Get angry, frustrated, and flustered by the negativity

    3.  Move forward with gusto, identifying gap after gap, then solving them.   We eat the elephant of interoperability one bite at a time.

    Over the past week, I’ve found myself setting aside my emotions.   I’ve redoubled my commitment to doing the right thing, hiring great people and broadly communicating the change processes needed to ensure more data is exchanged with more people for more reasons, while still respecting patient privacy preferences.

    I’ve thought long and hard about the day to day criticism we hear from government, special interests, and various press resources.  We have to avoid being distracted by the politics of any given moment.  In  a year and half the federal government will change completely .  Every major political leader in healthcare IT has changed since 2013.

    If we stay above the fray, work on interoperability one practice and one institution at a time, and toil diligently to enable new infrastructure such as record locator services/provider directories/quality registries, we will create a learning healthcare system that is better with each passing year.

    So next time you encounter the Trough of Disillusionment about interoperability, do your best to educate stakeholders about the trajectory we’re on and the challenges we can overcome by focusing and working together.

    Maybe we can all stand on a hilltop and sing "I'd Like to Teach the World to Interoperate (In Perfect Harmony)" celebrating our progress to date and highlighting the work yet to be done?


  • 29 May 2015 10:15 AM | Deleted user

    May 28, 2015  |  Joan Stephenson PhD  |  MedPage Today 

    Proponents of less-is-more medicine stress that its focus is avoiding harm rather than mere cost-cutting, which consumers fear might reduce access to necessary care. But it's also clear that targeting tests and procedures that offer little or no value will reduce wasteful spending. From MedPage Today.

    When billionaire-entrepreneur-Dallas Mavericks owner Mark Cuban lobbed a Tweet in early April advising his followers to have their blood tested "for everything available" every 3 months, he probably didn't expect to unleash a Twitterspheric debate on medical overuse.

    Scores of health journalists and clinicians jumped on this ill-advised tweet, explaining that such overtesting can result in false positives, further testing, unneeded treatment, patient stress, and considerable costs.

    Although it's unlikely that the furor swayed opinions on either side, it reflects a larger, thoughtful conversation within the healthcare community. That discussion is the "less is more" movement to reduce overuse of "low-value" services such as screening, diagnostic tests, or treatments that are unlikely to help patients and pose risk of harm.

    Proponents of less-is-more medicine stress that its focus is avoiding harm rather than mere cost-cutting, which consumers fear might reduce access to necessary care. But it's also clear that targeting tests and procedures that offer little or no value, involve unnecessary risks to patients, and result in avoidable downstream care will indeed reduce wasteful healthcare spending.

    Researchers have suggested the cost of wasted healthcare dollars, including from overuse of low-value services, makes up a third of the nation's $2.8 trillion healthcare bill. Despite this hefty price tag, U.S. healthcare ranks last overall compared with 10 high-income countries, as well for three other health indicators: infant mortality, mortality from conditions amenable to treatment, and healthy life expectancy at age 60.

    Choosing Wisely

    The less-is-more movement has percolated against this backdrop over the past decade, gaining traction with the 2012 launch of the Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation. The campaign enlisted clinician groups to help galvanize change by naming an evidence-based top 5 list of tests and procedures that physicians and patients should question because they offer little or no benefit and may cause harm.

    To date, more than 70 specialty societies have joined the campaign, each offering a top 5 list (some later updated to a top 10 or 15 list). Consumer Reports and other consumer groups have also signed on to help educate patients about how more medicine can be harmful.

    In addition, major medical journals are highlighting research findings that provide data illuminating low-value care, including the JAMA Internal Medicine Less is More series and the BMJ's Too Much Medicine campaign. Annual conferences, such as Preventing Overdiagnosis and the Lown Institute-sponsored RightCare Conference, are raising the medical community's consciousness about medical overuse.

    Bold vs. Timid Choices

    Some specialty groups embraced the challenge, and despite potential effects on their members' financial bottom lines, presented top 5 lists that included services often performed within their own specialty that could be considered low value.

    For example, the Society of General Internal Medicine advised against the routine annual physical, and the American College of Radiology listed five imaging tests to avoid under certain circumstances, such as admission or preoperative chest x-rays for ambulatory patients without specific findings from the physical exam and history.

    But in an analysis reported last year, researchers at Dartmouth and Harvard pointed out that 83% of the tests and procedures selected by medical groups, especially "proceduralist societies," for their top 5 lists are either rarely done or are typically performed by clinicians in other fields.

    "One of the interpretations of this was that specialty societies weren't choosing things that affected their own revenue streams, they were choosing things that affected others' revenue streams," said Carrie H. Colla, PhD, one of the Dartmouth researchers who co-authored the analysis.

    For example, the American Academy of Orthopedic Surgeons' top 5 list included three items related to patients with knee osteoarthritis: use of chondroitin and glucosamine supplements, a rarely performed procedure called needle lavage, and use of lateral wedge insoles.

    Noticeably absent from the list were some commonly performed orthopedic procedures that evidence shows are unlikely to help many of the patients who undergo them, explained orthopedic surgeon James Rickert, MD, president of the Society for Patient Centered Orthopedics.

    To take one example, each year 700,000 U.S. patients with knee osteoarthritis and degenerative meniscal tears undergo arthroscopic surgery, despite evidence from a 2002 randomized, controlled trial that found the procedure was no better than sham surgery in relieving pain or improving function in such patients.

    The orthopedic surgeons also didn't discuss spinal fusion, which has increased six-fold in the U.S. over the last 2 decades and is done much more frequently than in Canada, Europe, Australia, and New Zealand. Spinal fusion was also absent from the North American Spine Society's top 5 list. The spine surgeons did advise against performing elective spinal injections, such as steroid injections, without imaging guidance.

    What's problematic about the latter recommendation is that it doesn't specify that studies have found epidural steroid injections offer little benefit for the many patients who have back pain without sciatica who undergo this procedure, said Richard Deyo, MD, MPH, an expert in low back pain management at Oregon Health and Science University.

    "These injections have increased several hundred percent over the last 15 to 20 years, and it's hard to justify," said Deyo. Although epidural steroid injections are considered relatively safe, a 2012 outbreak of spinal meningitis caused by contaminated steroid injections underscored that rare, potentially serious complications do occur.

    Similarly, the American College of Cardiology, passed over a major -- and profitable -- overused intervention: stents in patients who have stable angina.

    "It's estimated from the cardiovascular data registry that 30% or possibly more of people who are getting stents are asymptomatic, and there has not been any benefit shown for cardiac stents over medical therapies in people who don't have symptoms and questionable benefit in people who do," said Rita Redberg, MD, MSc, of the University of California San Francisco (UCSF), and editor of JAMA Internal Medicine.

    A Bird in the Hand ...

    Even though critics have appropriately pointed out that some of the societies "went easy on themselves," it's more important at this point that the profession has started to engage with the issue, said John Santa, MD, medical director, Consumer Reports Health.

    Santa makes the case that small steps could lead to more significant changes down the line. "It was quite the accomplishment that [the ABIM Foundation] got all those doctor associations to admit they're overusing products and services," he said.

    "This is a new kind of activity for us all, and I think we're going to get better," said Daniel Wolfson, MHSA, executive vice president and chief operating officer at the ABIM Foundation. "People will be developing new lists, with better evidence, and I think there will be bolder recommendations coming down the pike."

    With the campaign's clout growing, "now is the time for professional societies to be bolder in identifying common interventions that add little value to our medical care," Redberg wrote in an April editorial in JAMA Internal Medicine.

    Impact of Efforts

    Even with a lack of boldness in some of the specialty societies' Choosing Wisely top 5 choices, emerging evidence suggests that the less-is-more movement is indeed gaining traction.

    As a sign the overtreatment tide is turning, H. Gilbert Welch, MD, of Dartmouth Medical School and a long-time critic of medical overuse, points to the 2014 recommendation by health experts to raise the threshold for beginning drug treatment for hypertension from 140/90 to 150/90 for people 60 or older. "It was the first time in my career that the guideline has called for a higher threshold, so I think we are seeing the beginning of a rebalancing," Welch said.

    "It's become legitimate to talk about overuse and not get accused of being a lackey for the insurance industry, an out-of-touch doctor, or -- dare I say it? -- a member of a 'death panel,'" said Santa.

    A national survey of primary-care and specialist physicians commissioned for the ABIM Foundation found that nearly three in four physicians said that unnecessary tests and procedures are a serious problem and 72% said the average physician prescribes an unnecessary test or procedure at least once a week. When asked about their own practice, nearly half said patients ask for an unnecessary test or procedure at least once weekly, and 30% said they get such requests at least several times a week.

    The surveyed physicians conceded that they sometimes order an unnecessary test or procedure for a host of reasons, including malpractice concerns, a desire "just to be safe" and obtain information to reassure themselves, patient insistence on a test, and not having enough time to spend with patients. Compared with physicians who didn't recall exposure to the Choosing Wisely campaign, those who did said they were less likely to suggest a "low-value" test or procedure (62% versus 45%).

    Institutional Buy-In

    Some academic medical centers have spearheaded initiatives that tackle specific examples of medical overuse and are seeing positive results. For example, after a team of physicians at Mount Sinai Hospital in New York launched a "Lose the Tube" campaign to address the inappropriate use of urinary catheters in five hospitalist medicine units, catheter use and associated urinary tract infection rates dropped sharply.

    Although professional societies can provide leadership, as U.S. medicine moves toward paying for the quality and effectiveness of care rather than the sheer volume of services, some interventions to reduce low-value care need to be taken on at the physician group level, said Colla. "Risk-sharing and moving away from fee-for-service allow physician groups to make decisions that would work best for their group to control utilization of low-value services, through things such as clinical decision support [such as reminders embedded in an electronic health records (EHR) system], physician education, and feedback."

    Some institutions are also embracing the effort and embedding the campaign's lists into clinical settings. When Christiana Care Health System in Delaware focused on reducing inappropriate use of continuous telemetry monitoring outside of intensive care units, an item on the Society of Hospital Medicine's Choosing Wisely campaign, it resulted in a 70% reduction in telemetry use overall without any negative effects on patient safety.

    In a more comprehensive effort, Cedars-Sinai Health System in Los Angeles has incorporated Choosing Wisely recommendations into its electronic health records system to provide alerts to help physicians avoid ordering potentially problematic tests or treatments.

    After an alert was set up to warn against use of benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium, such use decreased 30%, said Scott Weingarten, MD, MPH, senior vice president and chief clinical transformation officer at Cedars-Sinai. (Weingarten is chairman of the board of Stanson Health, which markets the clinical decision support software being used at Cedars-Sinai.)

    "Long-acting benzodiazepines can cause patients to fall, develop hip fracture, and get into motor vehicle accidents. They're actually associated with increased death," said Weingarten.

    When an alert is triggered, the system displays links to citations provided by the specialty society that made the recommendation. Physicians can still override alerts if they wish, but the process makes it more likely they will consider the information provided before reflexively issuing an order.

    Reviews of medical records indicate that orders have dropped about 20% on average for items linked to soft stops (which don't require an explanation to place an order) and by about 40% for medium stops (which do require physicians to say why they are making the order), said Weingarten. So far, this reduction translates into an annualized savings of about $4 million, he said.

    Each alert also links to the Consumer Reports patient information that explains why the test or procedure may not be appropriate, which the physician can share with a patient who is pressing for it. "Our hope is that physicians use this opportunity as an opportunity to talk to patients," Weingarten said.

    Educating Patients

    But physicians have limited time to talk with patients to help them understand that more medicine isn't necessarily better medicine, an important message in light of direct-to-consumer advertising of medical products and services that stokes consumer demand. Santa points to the hundreds of millions of advertising dollars fueling an increase in prescriptions of testosterone replacement therapy, from 1.3 million patients in 2009 to 2.3 million patients in 2013, despite warnings about the possible risk of heart attack and stroke.

    Even when advertising isn't an issue, it's important to educate patients about practices that should be avoided altogether, said Harlan Krumholz, MD, SM, director of the Center for Outcome Research at Yale University School of Medicine. But, if possible, patients also need to be engaged in shared decision-making with physicians, to ensure that risks, benefits, and the patient's preference are weighed.

    "For the vast majority of tests and procedures, there's a fair amount of uncertainty, and physicians often don't disclose these uncertainties," said Krumholz.

    There is evidence, however, that decision aids can clarify for patients the benefits, limitations, and potential harms of tests and procedures, so they can have better-informed discussions with their physicians.

    "Decision aids are a practical solution to the problem that doctors don't have enough time to get into nuances," Deyo said. "They also have an important role in the gray areas of medicine, where reasonable people might make different choices." A 2014 review of studies of decision aids found that many patients who use them are more likely to choose less-aggressive or no treatment after learning about potential benefits and risks.

    Doctor in the trenches have their own ideas about what will help foster a less-is-more culture. In the ABIM Foundation's survey, 91% said malpractice reform; 85% said specific, evidence-based recommendations that a physician can use with patients; 78% said having more time with patients to discuss alternatives; and 61% said changing the system of financial rewards some physicians receive for ordering tests or procedures.

    What's needed, given these various pressures, is likely to be "a multifactorial approach" to reducing low-value care, said Colla, who described a range of "supply-side" interventions (targeting healthcare providers) and "demand-side" interventions (aimed at patients) in a recent article.

    Payment reform can play a substantial role in reducing low-value care, Colla added.

    "Through accountable care organizations, for example, the physician group would be responsible for the total cost of care," she said. That responsibility provides an incentive to doctors to think through with patients the value of services they are providing.

    Moving away from payment systems that reward volume to those that reward value -- which is what Medicare is rolling out in the post-SGR era -- may also help accelerate investment in clinical decision support linked to EHRs to reduce low-value care.

    "Right now, there is no financial reason for a physician group to invest in that kind of technology," said Colla. "Risk-sharing arrangements such as accountable care organizations may create an impetus for physician organizations to put things in place like what Cedars-Sinai is doing, providing financial reasons to invest, on top of the motivation to improve quality of care."

    Whatever changes are needed to move the less-is-more movement forward, the idea has staked its claim in the culture of medicine. "What's been accomplished," said Santa, "is a cultural sea change, a cultural wave around safety issues and a cultural wave about overuse."

  • 28 May 2015 3:17 PM | Deleted user

    May 28, 2015   |   Jessica Bartlett   |   Boston Business Journal

    The state’s largest independent physicians’ group has a new CEO, the company announced Thursday.

    Dr. Steven Strongwater, the chief transformation officer and chief medical executive for Acquisition Integration at Pennsylvania-based Geisinger Health, will become Atrius Health’s new president and CEO, leading the 42-practice, 750-physician organization into its next chapter.

    He will start in the position in late July or early August.

    “We are truly fortunate to have found a leader with such a solid record of driving positive change,“ said Dr. Guy Spinelli, chair of the Atrius Health Board, in a release. “We welcome Dr. Strongwater and look forward to working together to continue on the path to achieving our goals of outstanding quality, exceptional patient experience, lower cost of care, and market-leading physician and staff experience.”

    Atrius Health - which is comprised of Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates, and VNA Care Network & Hospice – serves 675,000 patients across the state.

    Though the position is new role for Strongwater, he is not unaccustomed to executive level positions. Prior to working at Geisinger Health, Strongwater served at the University of Massachusetts Medical Center as its medical director and assistant chancellor. He has also worked as CEO of Stony Brook University Hospital.

    He has also served as the advisor to the Association of American Medical Colleges, and held numerous positions at the University of Connecticut Health Center.

    Strongwater was chosen for the Atrius Health role after a six-month nationwide search led by Russell Reynolds Associates.

    “I have tremendous admiration for what Atrius Health has accomplished and look forward to working with all the talented and dedicated healthcare professionals at Atrius Health to ensure we remain connected to our patients and the communities we serve, and at the cutting edge of healthcare,” Strongwater said in a release. “Atrius Health has demonstrated it is possible to provide the highest level of care and convenience at the lowest possible cost.”

    Strongwater will take over for Dr. Gene Lindsey, who stepped down from the health group in September 2013 but remained CEO emeritus until the end of the year. The Atrius website lists Dr. Daniel Burnes, who has worked with Harvard Vanguard's Board of Directors, as the transition CEO.

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