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Re-imagining the EMR:  Three essential and transformative innovations for caregivers in value-based world.

Posted by Dan Mazanec, MD on Oct 26, 2016 3:16:29 PM


The transformation of the U.S. health care system to a value-based orientation based on evidence-informed practice and patient-centered outcome metrics is accelerating. The EMR is central to this process but current technology simply hasn't kept pace. Physician burnout is epidemic in today's health care system. Depending on specialty, 40-55% of doctors reported symptoms of burnout in a recent survey describing loss of enthusiasm for work, increased cynicism and a decreased sense of personal worth. Frustration with dated, antiquated electronic medical record technology is a major contributor to burnout as increased computer data entry consumes precious time better devoted to genuine patient care. A just-released survey of more than 15,000 practicing physicians on EMR use found 57% reported decreased face to face time with patients. In comparison with 2014 data, more physicians (27%) reported serious dissatisfaction with the electronic record. 64% of doctors in their most productive years (aged 46-55) noted the EMR slowed their workflow.

More time spent at the keyboard steals from time with family or restorative recreational activities. In addition to spawning an entirely new health care specialist - the scribe - as a workaround for poor technology, EMR-related burnout is leading to early retirements, career changes, and ultimately decreased access to care.  

Here are three essential features - "must haves" - which should serve as the guideposts for design of innovative health care technology that really works best for clinicians and patients in the new world of health care:

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Betting on Bundles: CMS launches new mandatory orthopedic and cardiovascular programs

Posted by Dan Mazanec, MD on Sep 14, 2016 10:24:10 AM


CMS is doubling down on the bundled payment reimbursement model as the key driver of the transformation from a fee-based to a value- based health care system. On July 25, the agency announced plans to expand the model to include cardiovascular disease (myocardial infarction and coronary bypass grafting) to hospitals in 98 metropolitan areas. Participation is mandatory and begins July 2017. The expanded program builds on the Bundled Payments for Care Improvement Initiative (BPCI) launched in 2013 and the  Comprehensive Care for Joint Replacement (CJR) program- already mandatory in 67 regions including 789 hospitals for total hip and knee replacement surgery since April 2016. CJR will be expanded to include surgical treatment of hip fracture. Significantly, the proposal also notes that both the extended CJR program and the cardiovascular bundles can qualify as Advanced Alternative Payment Models (AAPMs) under the Medicare Access and Chip Reauthorization Act (MACRA).  

In contrast to physicians enrolled in the more complex Merit-Based Incentive Payment System (MIPS) of MACRA, AAPM participants will receive an annual lump sum bonus of 5% without exposure to risk of MIPS penalties.  It's likely we'll see the bundled reimbursement model extended to other surgical as well as medical conditions as CMS drives toward it's goal of 50% of all medicare payment through alternative models by 2018.

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Three reasons that scribes are not the right answer to EMR physician burnout

Posted by Dan Mazanec, MD on Aug 11, 2016 10:45:41 AM


Next time you visit your doctor, there's a growing likelihood a third person will be in the exam room - the medical scribe. This new category of health care "specialist" has emerged to deal with the widespread and growing physician disatisfaction with the current versions of the electronic medical record (EMR). The recently created American College of Medical Scribe Specialists (ACMSS) estimates that there are already more than 17,000 scribes working in more than 1700 health care organizations with predictions of more than 100,000 by 2020. The growing army of medical scribes is largely a "workaround" for poorly designed EMR technology. I've already described the negative impact of current, dated EMR technology on both caregivers and patients. At least 50% of physicians currently report symptoms of burnout, frequently attributed to daily confrontation with the  click-happy EMR. The few small studies of the impact of scribes on medical practice all have flaws but suggest improved caregiver satisfaction and at least no negative effect on patient satisfaction. Modest increased revenue related to improved documentation and coding as well as increased patient numbers has been noted by some. However, the most recent report of physician, scribe and patient perspectives on their experience raised serious and important questions about the quality of documentation, patient privacy, and even "scribe burnout." Do we really want to deal with bad health care technology by bringing tens of thousands of additional personnel into exam rooms across the country? I'd suggest medical scribes represent, at best, a temporary band aid for bad health care technology. Here's my top three reasons why.

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Effectiveness of Clinical Decision Support in the EMR: The glass is half full

Posted by Dan Mazanec, MD on Jul 25, 2016 12:08:29 PM


A recent Wall Street Journal article highlights the work of Dr. Thomas McGinn in embedding clinical decision support tools in the electronic medical record (EMR). Integrating clinical decision rules (CDRs) for various conditions into the EMR assists physicians in determining the probability of a particular diagnosis (e.g. pneumonia vs. acute bronchitis). CDRs are presented in the EMR based on the patient's symptoms (e.g., cough) and typically consist of a set of evidenced based questions which categorize the likelihood of a diagnosis (e.g. pneumonia) from low probability to high.  Based on the predicitive results, tests and treatment may be deemed appropriate or inappropriate.

Clearly, implementation of such clinical practice guidelines based on the best medical evidence available in clinical workflows is central to the value-based model of care. By reducing inappropriate variation in care, the expectation is for improved patient outcomes (quality) at reduced cost, i.e., increased value. Integration of clinical decision support (CDS) based on best medical evidence into the EMR at the point of care is fundamental to this strategy. As the WSJ article points out, however, many physicians are resistant to adoption of CDS. Important concerns include loss of autonomy, EMR-related "click-fatigue," and dehumanization of medical care. Moving forward, these issues must be addressed. I've recently written about a hybrid approach - "customized evidence-based medicine" which merges the best of standardized medicine and craft-based  personalized care. Of equal urgency is the need to evaluate the effectiveness of EMR-enabled clinical decision support in controlling costs and improving patient-centered clinical outcomes. CMS and health care organizations are betting heavily on this model as the lynchpin of the transformation to value-based care. The evidence for efficacy at this point is promising but surprisingly thin and spotty. While I think the "glass is half full", much work needs to be done.

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Tablets in the exam room deliver improved efficiency & patient communication - who would have thought?

Posted by Dan Mazanec, MD on Jul 12, 2016 9:47:36 AM



The use of mobile technology use in health care has exploded in the past 5 years with 87% of physicians reporting using a mobile phone or tablet in their clinical work. Until recently, studies have shown physicians used mobile devices primarily for search and continuing medical education. Clinicians now have access to a wide array of medical apps providing point of care access to medical calculators, clinical decision support tools, and literature search portals. I've previously described the use of an antibiotic stewardship "app" to improve drug usage and reduce the risk of bacterial resistance. A logical next step is movement of the tablet into the patient encounter itself for real time documentation with decision support, patient education, and ordering. Two new studies provide strong evidence that using a tablet computer linked to the EMR in either an outpatient or hospital setting improves provider efficiency and increases time with patient, actually improving patient satisfaction.

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MACRA Update: 5 Clear Messages to CMS - Now What?

Posted by Dan Mazanec, MD on Jul 5, 2016 10:37:03 AM



On April 27, 2016 the Centers for Medicare and Medicaid Services (CMS) published proposed rules for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). In addition to defining a new value-based reimbursement model, the proposal also refocuses health IT on clinician friendly technology and increased patient engagement and interoperability. MACRA drives a continuing restructuring of the American health care system and a new generation of technology to support it. In a prior post, I described the potential risks MACRA poses to both doctors and patients. The MACRA comment period ended on June 27, 2016. CMS received more than 3,700 comments, some running to more than 100 pages. After review, CMS is scheduled to publish the final rules on October 1, 2016 with implementation beginning in January, 2017. While feedback was wide-ranging and not unexpectedly stakeholder-specific, there are at least 5 clear, consensus messages to CMS:

  1. Delay implementation - at least until July 1, 2017
  2. Quality measures need to be fair to both specialists and primary care doctors, practicing in or out of the hospital.
  3. The Advancing Care Information (ACI) portion of the Merit-based Incentive Payment System (MIPS) needs to significantly revamped.
  4. Small groups or solo practitioners need special consideration for an even playing field with larger organizations.
  5. The Advanced Alternative Payment Models (APMs) need to be broadened to include other programs.
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(Buyer) Beware The Status Quo

Posted by David Fairbrothers on Jun 30, 2016 9:55:03 AM

This post was originally published on the athenahealth CloudView blog.

Imagine the following scenario. You are a physician specializing in spine care. You've added an urgent consult to your medical office schedule. The patient, who lives 110 miles away, arrives after a two hour drive in early morning rush hour traffic in severe (10/10) pain. She describes a two week history of nearly disabling, excruciating left leg pain ("sciatica"). She's already seen two other physicians (a surgeon and an interventionist) who offered two very different opinions on treatment and she is looking to you for a ‘tie-breaker’. She was unable to obtain her medical records or copies of her recent spine MRI from the other physicians. Unfortunately, both outside physicians use different electronic medical records (EMRs), neither of which communicates with your EMR (yet a third brand). While the patient waits 35 minutes in the exam room, your office staff hurries to call both outside offices to request records be faxed. The surgeon's office is closed for the day (the phone message is "if this is an emergency, call 911). The other office's nurse assures you the records will be sent immediately. After another 25 minutes, the fax machine delivers the records. Of course, as you explain to the now very frustrated patient, the actual MRI images can't be faxed and all you have is a report. To deliver the most definitive and conclusive opinion, you need to see the films. What now?

a.)    Ask the patient's family to make a 220 mile round trip to pick up and deliver the records and MRI.

b.)   Order a clinically not-indicated, repeat MRI adding $2,500 to the cost of the visit.

c.)    Provide a best-guess opinion based on inadequate information.

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EMR ROI - Prognosis for doctors and hospitals: guarded

Posted by Dan Mazanec, MD on Jun 28, 2016 10:33:54 AM


Installing and operationalizing a new EMR is a major investment for physician practices and health care organizations. Earlier this year, Partners Healthcare, the largest network of hospitals and doctors in Massachusetts, announced it expected to take a $200 million hit to its bottom line over the next three years as it as it implements a new EMR at its sites which include Masschusetts General and Brigham and Woman's hospitals. Beyond the cost of the software and hardware, 600 new employees in addition to multiple consultants are being hired for the training and support needed for the launch. The system also expects to lose revenue as schedules are cut during the roll out of the new EMR. Investing in EMR technology is expected to produce returns in multiple dimensions of patient care. In an era of declining reimbursement and increasing focus on health care costs, it's essential to scrutinize the financial return on these sizable IT costs. 

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The MACRA Threat: Risks to both doctors and patients

Posted by Dan Mazanec, MD on Jun 10, 2016 10:40:50 AM

On today's Wall Street Journal opinion page, several letters describe potential consequences for both doctors and their patients as CMS writes the rules for the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA)- "The Creature from the Black Lagoon."  This complex piece of legistlation (962 pages) affects more than 800,000 physicians and their millions of medicare and medicaid patients.   As I suggested in a recent blog, MACRA is about much more than reimbursement.  The program drives a continuing restructuring of the American health care system and a new generation of technology to support it.  CMS emphasizes the potential positives:

  • Reimbursement based on value, not volume
  • IT/EMR focused on performance, not process
  • Comprehensive health care integrating multiple providers

However, "the devil is in the details."   As the rules for implementation are being written, many physicians and health care organizations are voicing serious concerns.   Just this week, the AMA and 36 medical societies wrote to the Office of the National Coordinatior for Health Information Technology and the acting administrator of CMS expressing concern that the metrics used to define interoperability of EMRs in the new law must focus on clinical value to patients rather than just the quantity of information exchanged.   Current rules for "meaningful use" of the EMR are widely viewed as requiring documentation of clinically irrelevant information rather than true patient outcomes.  

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MACRA and Interoperability: Finally REAL 'Meaningful Use'?

Posted by Dan Mazanec, MD on Jun 9, 2016 8:56:27 AM

Visualize this scenario. You've added an urgent consult to your medical office schedule - actually you're double-booked at 8AM. The patient, who lives 110 miles away, arrives after a somewhat harrowing  2 hour drive is early morning rush hour traffic in severe (10/10) pain. She's stressed but very grateful for the appointment which was just scheduled the evening before.  She describes a two week history of nearly disabling, excruciating left leg pain ("sciatica"). She's already seen two other physicians who offered two very different opinions. One neurosurgeon suggested immediate surgery which is tentatively scheduled next week. The other physician offered an injection and a trial of physical therapy for several weeks. The patient's seeking a "tie-breaker" recommendation from you. Since the appointment was made just 12 hours ago, she was unable to obtain her medical records or copies of her recent spine MRI from the other physicians. Unfortunately, both outside physicians use different electronic medical records (EMRs), neither of which communicates with your's (yet a third brand of EMR). While the patient waits 35 minutes in the exam room, your office staff hurries to call both outside offices to request records be faxed. The surgeon's office is closed for the day (the phone message is "if this is an emergency, call 911). The other office's nurse assures you the records and reports will be sent immediately. After another 25 minutes, the fax machine delivers. Of course, as you explain to the now very frustrated patient, the actual MR images can't be faxed and all you have is a report. To deliver the most definitive and conclusive opinion, you need to see the films.  What now?  

         a) Ask the patient's family to make a 220 mile round trip to pick up 

            and deliver the records and MRI

        b) Order a clinically not indicated repeat MRI adding $2500 to the cost

            of the visit  

        c) Provide a second rate opinion based on inadequate information

Of course, the correct answer is none of the above.

Unfortunately, this vignette isn't a fairy tale. As a spine medicine consultant at Cleveland Clinic, I experienced variations of this story countless times in my practice over the past several years. Currently, virtually all EMRs operate in silos with minimal capacity for sharing of information. Lack of data interoperability of current EMRs contributes to unnecessary duplication of medical testing, miscommunication of critical clinical information, delay in medical decision making, and poor coordination of care when multiple clinicians are involved. The recently published proposal for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) highlights improved interoperability of EMRs as a high priority.

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Antibiotic stewardship: dealing with bad bugs and fewer drugs

Posted by Dan Mazanec, MD on May 25, 2016 9:25:46 AM

At the dawn of the 20th century, the top three causes of death in the U.S.  were infectious diseases -  pneumonia, influenza, and tuberculosis.  By mid-century the balance in the longstanding battle between bacteria and the human race shifted in our favor.  Public health policy which encouraged widespread immunization helped tip the balance.  The real game changer though was the rapid development of multiple antibacterial drugs, beginning with the introduction of penicillin in 1947.  During the so-called "golden age of antibiotics"  between 1940 and 1962, more than 20 new novel classes of antibiotics were discovered.  Bacterial resistance to an antibiotic was met with a new and stronger drug.  As we began the 21st century, the death rate due to infections had declined 97%!   Heart disease and cancer now topped the mortality rankings.   Seemingly the "bugs" were on the ropes.  Antibiotics were the widely acclaimed "wonder drugs."  Unfortunately, multiple bacteria resistant to one or more classes of antibiotics have emerged over the last decade, while the development of new antibiotics has slowed significantly.  Only 2 new classes of systemic antibiotics have been introduced since 2000. Deaths in the U.S. related to multiple drug resistant (MDR) bacterial infections now exceed 23,000 per year.  A just released report commissioned by the U.K. estimates that these so-called "superbugs" could account for 10 million deaths internationally by 2050 - one death every three seconds!  To confront the escalating national and international threat, in 2015 the White House published an executive order outlining a national action plan for combating antibiotic resistant bacteria.  Antibiotic stewardship programs are a key element of the multi-pronged strategy.

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Transforming Heathcare: CMS releases outline of MIPS physician payment model

Posted by Dan Mazanec, MD on May 23, 2016 9:54:37 AM
With its recent release of a proposal for reorganizing how physicians are paid for providing care to medicare patients under provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Department of Health and Human Services pushed government-driven health care reform to the next level.   Much more than simply a new reimbursement model, the draft rules, if implemented, will accelerate the transformation of medical care in the U.S. by emphasizing:
  • Reimbursement based on value, not volume
  • IT/EMR focused on real clinical performance not process
  • Integrated group practice models not solo providers

 The proposal seeks to "streamline" a patchwork of programs into two paths for value based reimbursement, aligning medicare payments with cost and quality of patient care.  The law is complex - 962 pages! - and will affect more than 800,000 eligible physicians.  The newly proposed rules are intended to address physician concerns about excessively burdensome reporting of quality measures as well as EHR "meaningful use" process metrics of doubtful relevance to patient outcome.    While subject to modification and open for comments until June 26, 2016, implementation in 2017 will drive change throughout the health care system beyond simply how caregivers are paid.  From accelerating the demise of solo or small group practices to refocusing health IT/EMR on clinician-friendly technology that supports increased patient engagement and caregiver communication the proposal reshapes how health care is delivered in the next decade and beyond. Though many details need to be filled in  here's what we know at this point.

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Are medical errors really the third leading cause of death in the U.S.?

Posted by Dan Mazanec, MD on May 12, 2016 2:32:17 PM


A recent analysis by Malarky and Daniel published in the British Medical Journal (BMJ) suggested that more than 250,000 deaths in hospitalized patients in the United States are a result of medical errors.  If correct, this would place medical errors third behind only heart disease (611,000) and cancer (585,000) as causes of death in the United States.  The analysis suggests that deaths from medical errors are 7-8 times more common than gun-related deaths.  Rather than relying on death certificate information, the authors call for improved tracking of medical related deaths.  They suggest adding an additional field to death certificates to record "whether a preventable complication stemming from the patient's medical care contributed to the death."  Arguing for a more scientific approach to medical error, they suggest ICD coding should be improved to capture medical error including the physiologic cause of death as well as the related issue with the delivery of care.

Patient safety has been a major priority in healthcare for the past several years.  Hospitals are scrutinized by the Joint Commission on a regular basis with a strong emphasis on promoting a culture of safety.  Most institutions perform detailed root cause analyses for so-called sentinel events.  A sentinel event is an unexpected event resulting in death or serious physical or psychological injury to a patient.  Before the 250,000 number is widely disseminated as fact, a critical review of the BMJ report is warranted.

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Bundling Healthcare Payment: CMS strategy to drive value-based care

Posted by Dan Mazanec, MD on May 11, 2016 9:27:00 AM



  • Expanding the "episode of care"
  • Shifting financial risk
  • Driving increased coordination of care
  • Central role for Health IT

On April 1, 2016, the Center for Medicare and Medicaid Services (CMS) Innovation Center announced a potentially transformational program - the Comprehensive Care for Joint Replacement (CCJR) model for payment for total knee and hip replacement surgery.  Building on bundling pilots since 2013, the new initiative is a game-changer.  Surgeons are very familiar with an earlier "bundle" concept - the "global surgical package".  This package simply represents a single payment for all care associated with a surgical procedure.  Depending on the extent of the procedure, it can encompass payment for all services provided by the surgeon over 1 to 92 days from preoperative to postoperative care.   Of note, this model doesn't include payment to the hospital for the bed, use of the operating room, anesthesia services, or any post acute care.  Beginning with the Bundled Payments for Care Improvement Initiative introduced in 2013, CMS has explored expanding the bundle concept to multiple providers and health care organizations involved in a single "episode" of care with an emphasis on shared financial risk and responsibility for patient outcomes.   By changing the reimbursement/risk landscape and redefining the episode of care, CMS incentivizes more nimble healthcare organizations to create a more integrated structure to deliver value-based evidence informed services across the full continuum from outpatient through hospitalization and the post acute care space.  State of the art, smart and user friendly health IT platforms will enable linkage of diverse providers in different settings across this broader spectrum of care.

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Telemedicine 2016: New studies show promise, expose pitfalls

Posted by Dan Mazanec, MD on May 2, 2016 9:48:45 AM


Health care providers and payors are both converging on telemedicine as a potential solution to several challenges in providing value-based health care.   Can telemedicine improve patient access for care, including specialists?   Will expanded use of telemedicine assist in better management of serious chronic diseases, improving adherence to complex drug therapies and reducing ER visits or hospitalizations?   Will telemedicine really improve both patient-clinician and clinician-clinician communication?  Three recent studies suggest that the answer to all these questions is a solid "yes."  As with any rapidly evolving technology, however, longstanding structural and regulatory systemic issues remain as potential barriers to full realization of the powerful potential of this strategy.

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The Changing Ecology of Healthcare: Implications for Health IT

Posted by Dan Mazanec, MD on Apr 29, 2016 9:49:00 AM

In their current review of the future ecology of health care, West and Mehrotra identify three key drivers transforming the delivery of medical care as we know it:

  •  Patient self-care and diagnosis
  •  Virtual patient encounters
  •  Alternative health care settings

Ecology in health care refers to how individuals seek and receive medical care.  Enabled by technology, prospective patients now frequently consult the internet for both diagnosis and treatment options, often before visiting a more traditional caregiver.  As health care is increasingly "customer" driven, the usual face to face interaction with a clinician is increasingly supplemented or even supplanted by virtual communication via email, videoconference, or telephone messages.  Finally, delivery of face to face care now stretches from retail clinics in the local CVS, Walgreens or Walmart to a greatly expanded homecare setting providing services once reserved for in hospital care only.  This rapid transformation of healthcare delivery is occuring simultaneously with the paradigm shift from traditional fee-for-service reimbursement to the value model, linking reimbursement for care to documented quality outcome metrics.   In this "brave new world" of health care, it's no surprise that many patients may be confused and caregivers report record levels of stress.  In the midst of this shifting healthcare landscape, the urgency to transform health IT to meet the needs of both caregivers and patients is clear.

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The Dark Side of Too Many Clicks

Posted by Dan Mazanec, MD on Apr 18, 2016 12:32:35 PM
  • Burnt-out Caregivers
  • Unhappy Patients
  • Inefficiency and Rise of the Scribes
  • Nonsense Notes

Do you spend more time clicking away on a keyboard than actually making eye contact and engaging with the patient?  Are you spending more time after clinic completing chart notes in the EMR? Do your notes really reflect your clinical thinking and plans?  A recent report found that adoption of an EMR by physicians now exceeds 90%, more than doubling since CMS launched "meaningful use" in 2011. While the EMR has improved documentation of medications and allergies and probably reduced handwriting errors, there's a dark side to all those clicks for both caregivers and patients.  Clicks really do add up.

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Literature to the Exam Room: Sorting out guidelines, pathways, and workflows

Posted by Dan Mazanec, MD on Apr 14, 2016 9:03:42 AM



The practice of evidence-based medicine (EBM) is at the center of the tectonic shift to a value based delivery model currently sweeping through the healthcare industry. EBM, as defined by researchers at McMaster University in the early 1990's, represents a "systemic approach to analyze published research as the basis of clinical decision making."  Driven by an intensified focus on improving value, healthcare organizations and medical specialty societies have adopted EBM as the principal strategy to enhance patient outcomes.  Ultimately, it's about bringing established best practices to every clinical decision.  These efforts have spawned development of a multitude of "clinical practice guidelines" (CPGs).  

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EMR in Home Health Care II: CMS launches bundled payment initiative

Posted by Dan Mazanec, MD on Apr 6, 2016 8:25:15 AM

After several years of anticipation as well as trepidation, the paradigm shift in health care from fee for service to value based has begun in earnest.  On April 1 CMS kicked off the so-called "bundled payment initiative" for total knee or hip arthroplasty.  The pilot program affects hundreds of hospitals which account for about a third of these procedures. The program sets a target payment based on the hospital's historic costs.  Providers, including surgeons and post acute care providers, are payed on a fee for service basis.  However, at the end of the year, if aggregate billings exceed the target, the hospital must REIMBURSE Medicare for the difference.  

As I discussed in another recent post, this pilot madates hospitals and health care systems focus on integrating workflows across the full continuum of care, including the post acute space.  

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The EMR in Home Health Care: aiming to improve patient outcomes

Posted by Dan Mazanec, MD on Apr 1, 2016 9:38:14 AM

Almost 40% of Medicare patients discharged from the hospital require "post-acute care" services.  Almost 80% of these services are provided either in a skilled nursing facility (SNF) or in the home by home health caregivers (HHC).  Newer, innovative models of health care delivery such as the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACO) emphasize managing illness across the full continuum of care and focus particularly on integrated "post acute care" to reduce costly hospital readmissions.  The role of the EMR in this space is largely unexplored territory.   As recently as 2007, only 28% of more than 10,000 HHC were using an EMR.  As adoption increases, we need to look beyond simply improved documentation and billing to how best to leverage the technology to improve patient outcomes in a value based world.

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