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Sunday, January 8, 2012

Shovel Ready

Very funny.

So, this past week I got collared into writing a piece of our CMS "Innovations Challenge" proposal. Get out my rhetorical shovel and pile on the persuasive verbiage.

"The Health Care Innovation Challenge will award up $1 billion in grants to applicants who will implement the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and CHIP, particularly those with the highest health care needs.

I have the "workforce" piece. Specifically to address these questions: -->
  • How will the model will address the need for a transformed workforce and demonstrate a plan to update skills of existing health professionals, identify and train new types of workers to enhance care delivery, and/or expand the use of team-based care?
  • How will the proposed workforce model support the three-part aim?
  • How will staff be recruited, hired, trained, and deployed as well as the specific skills for which additional training may be required?
  • Does the proposal address the initial education or training of health professionals?
  • What workforce-related metrics which will be used to assess the impact of the model on the health workforce and to evaluate the workforce needs associated with system delivery changes, including the ratio of staff to participants?
We propose to focus on three pressing clinical areas: Cardiometabolic Syndrome, Asthma, and COPD. Basically a PCMH approach (Patient-Centered Medical Home) using "patient coaches" comprised of an increased staff of RNs. I could not agree more in principle; to wit:
“A recent Medicare demonstration program, given substantial additional resources under the new health-care-reform law, offers medical institutions an extra monthly payment to finance the coordination of care for their most chronically expensive beneficiaries. If total costs fall more than five per cent compared with those of a matched set of control patients, the program allows institutions to keep part of the savings. If costs fail to decline, the institutions have to return the monthly payments.”
“Several hospitals took the deal when the program was offered, in 2006. One was the Massachusetts General Hospital, in Boston. It asked a general internist named Tim Ferris to design the effort. The hospital had twenty-six hundred chronically high-cost patients, who together accounted for sixty million dollars in annual Medicare spending. They were in nineteen primary-care practices, and Ferris and his team made sure that each had a nurse whose sole job was to improve the coördination of care for these patients. The doctors saw the patients as usual. In between, the nurses saw them for longer visits, made surveillance phone calls, and, in consultation with the doctors, tried to recognize and address problems before they resulted in a hospital visit. Three years later, hospital stays and trips to the emergency room have dropped more than fifteen per cent. The hospital hit its five-per-cent cost-reduction target. [Atul Gawande, MD “Hot Spotters,” The New Yorker, Jan 24th, 2011, pg 46]
“Non-physician practitioners may prove to be better candidates than physicians to function in a system designed for external information tools, informed decisions, reliable execution and genuine accountability…”
“…In health care, patients and very inexpensive paramedical people who are already a permanent part of a community must be taught to use the problem solving guidance in their own records and eventually in computers. After all, rescue squads with remarkable skill in heart and lung disease have been developed all over the country, and people with only a high school education or less have been taught to do sophisticated medical work. Surely we all can learn to deal with many of the less life-threatening disorders such as sore throats and body aches if we have our records and the right guidance tools. Expensively trained medical professionals should be reserved for specialized tasks that we cannot master and cannot do for ourselves. They also should be used to build the guidance in the tools and to monitor occasionally our records and behaviors to make sure that we are behaving in a disciplined and reliable manner.” [Lawrence L. Weed MD and Lincoln Weed, JD, “Medicine in Denial,” 2011, pp 212 and 262]
“Our work groups began meeting on a regular basis to identify activities being performed by physicians that could be performed by other members of the care team. We used evidenced based measures, developed clinical practice guidelines and physician approved order sets. We built quick electronic reference tools for support staff, established written workflow protocols, trained personnel and monitored their activities. This enabled non-licensed clinical staff to perform services without asking the physician every time, i.e. EKG, strep screens, pneumovax, etc.”
“We configured population management reports on our EHR, assigned responsibilities for running them on a regular basis, along with the task of calling patients and scheduling them for services based on clinical practice guidelines (I.e. calling diabetic patients to schedule an HgA1c.) We designed electronic chart alerts so that a secretary taking a telephone request from a patient with a URI calling for a same day appointment could be prompted to also schedule that patient for a mammogram or colonoscopy.” [Mike Cracovaner, CEO New Pueblo Medicine, “Building ‘Top of License’ Care into Your Medical Home” Medical Home News, November 2011, pg 3]
“The Institute of Medicine defines self-management support as ‘the systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems and problem-solving support.’ Similarly, the Chronic Care Model defines self-management support as assisting and encouraging patients to become informed and activated in the management of their own chronic conditions. It considers self-management support a fundamental task of the clinical practice team. [Tom Bodenheimer, MD, and Sharone Abramowitz, MD, “Helping Patients Help Themselves: How to Implement Self-Management Support,” California HealthCare Foundation (CHCF), December 2010, pg 2]
“Providers will need to be trained to work in interdisciplinary teams, and financing and delivery systems need to support this interdisciplinary approach. Care needs to be seamless across various care delivery sites, and all clinicians need to have access to patients’ health information, as well as population data, when needed. Health information technology, such as interoperable electronic health records and remote monitoring, needs to be used to support the health care workforce by improving communication among providers and their patients, building a record of population data, promoting interdisciplinary patient care and care coordination, facilitating patient transitions, and improving quality and safety overall. Giving providers immediate access to patient information, especially for patients who are cognitively impaired and unable to provide their own clinical history, may reduce the likelihood of errors, lower costs, and increase efficiency in care delivery.”
“Efficiency can be further improved by ensuring that health care personnel are used in a way that makes the most of their capabilities. Expanding the scope of practice or responsibility for providers has the potential to increase the overall productivity of the workforce and at the same time promote retention by providing greater opportunities for specialization (e.g., through career lattices) and professional advancement. Specifically, this would involve a cascading of responsibilities, giving additional duties to personnel with more limited training in order to increase the amount of time that more highly trained personnel have to carry out the work that they alone are able to perform. While the necessary regulatory changes would likely be controversial in some cases, the projected shortfall in workforce supply requires an urgent response. This response will most likely have to involve expansions in the scope of practice at all levels, while at the same time ensuring that these changes are consistent with high-quality care. The third principle is that older persons need to be active partners in their own care, except when they are too frail, mentally or physically, to do so. Such partnerships need to include the adoption of healthy lifestyles, self-management of chronic conditions, and increased participation by the patient in decision making. By becoming participants in their own care, patients can improve their health, reduce unnecessary treatments, and reduce the need for reliance on formal or informal caregivers.” [Retooling for an Aging America: Building the Health Care Workforce, Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine, 2008,, pp 77-78]
Yeah, HHS is frantically shoveling yet another billion out the door. We are obligated to pursue our potential piece of such funding, risk of PPACA at SCOTUS this spring notwithstanding (CMMI, like the ACO thing, is part of "ObamaCare").

Whatever keeps the doors open.

CMS requires that innovation grant applicants adequately address its central "three part aim" -- improved patient health, improved population health, and reduced cost.

The CHCF report, however, contains some cautionary findings with respect to the 3rd aim:

To learn more about how self-management support is being implemented in primary care organizations, 42 early adopters of self-management support were identified and surveyed. Thirty-eight subsequently provided extensive information.

The survey revealed a number of broad findings, including the following: The most common conditions for which self-management support is being implemented are diabetes, hypertension, and obesity. The primary care team members most commonly offering self-management support are RNs, physicians, nutritionists, health educators, and nurse practitioners/physician assistants. In only eight of the organizations do MAs provide self-management support. Twelve organizations have at least one team member providing self-management support full-time; most dedicate considerably less staff time. For 28 of the organizations, self-management support is an expense and not a revenue source, and 24 organizations reported that self-management support is not financially sustainable [pg 5].
Well, OK.

More to come...

ATTESTATION UPDATE, FROM HEALTHDATA.GOVNice Excel spreadsheet available for download and some data grinding. You're quite welcome to download and use my copy (.xlsx file, 2.8 mb).

Basically, 10 EHR vendors account for 2/3 of the EP attestations nationally through November. And, Epic lapped its second place competitor eClinicalWorks by better than a factor of three.

Drilling down into these data at our state levels (NV, UT) at the moment.



Just saw a press release concerning a new Meaningful Use player.

Surf their site. Pretty interesting. The aesthetics certainly put me in a good early morning mood. I was particularly interested in their "Advanced Analytics" section. Far too many "certified" EHRs have reporting functionality that is simply primitive.

Gotta love all the Mac imagery, too, Mac snob that I am.

But, much more to learn about CareCloud's "usability" and their pricing model.


This is interesting. Click the banner below.

Nurses know that healthcare is in a crisis with soaring costs and rising epidemics of preventable diseases. Many nurses are calling for change to mobilize nurses in a nationwide effort. They propose that leadership provided by a National Nurse for Public Health would strengthen efforts by nurses in every community to assist in initiating a nationwide shift to prevention to yield improved health outcomes.

I put this organization in my links on the right. All of the nurses I have known (and those I continue to work with) have been uniformly totally astute and dedicated. Linchpins of health care, they are.

Apropos if this, our CMMI Innovation Challenge proposal I'm now helping with calls for expanded employment of RN "patient coaches."


Yet another "Medicine in Denial" cite:

The course of a chronic disease depends on numerous variables, none of which the practitioner personally experiences, most of which the practitioner does not control and some of which the practitioner is not aware. In diabetes, for example, blood glucose levels depend on not only insulin levels but also diet, exercise, emotion, medications, infections and co-existing medical problems, among other variables. The patient has more knowledge and control of some of these variables than the provider ever will. Managing chronic conditions demands keeping track of these variables over time and examining them for medically significant patterns and relationships…

…The patient feels the effects of the disease and its treatments, and quickly sees correlations between those subjective symptoms and detailed data on physiological parameters. Without any formal education, the patient is in the best position to observe these correlations. To that extent, information asymmetry exists in favor of the patient, not the expert provider. What the patient needs is not the broad, sophisticated scientific understanding of a physician but rather a basic understanding of principles and data that bear specifically on choosing among individually relevant options. And it is not unusual to see patients who develop more than this basic understanding. For example, diabetics of long-standing whose disease is well-controlled are frequently more knowledgeable about the disease and their personal version of it than their physicians. Most of all, the patient is the one who must summon the resolve to make the behavior changes that so often are involved in coping with chronic disease. If the patient does not feel responsible for deciding what has to be done and is not heavily involved in developing the informational basis of that decision, then very often the result is “noncompliance” with doctors’ decisions. Noncompliance may or may not be appropriate, depending on the situation. The point is that if patients are equipped to become decision makers, the problem of noncompliance with their doctors’ decisions is transformed into a problem of personal commitment to their own decisions. Patients will be more committed to their own, informed decisions than to decisions made for them by experts…[pp 224-225]
OK, in that context, consider the following (again, click the graphic below).

Providing a Bridge Between Patient Experience and Provider Expertise

Project HealthDesign is a groundbreaking national program of the Robert Wood Johnson Foundation, designed to spark innovation in personal health technology. The program advances a vision of personal health records (PHRs) as springboards for action and improved health decision-making.

Our first nine teams embarked on a user-centered design process to create health IT tools that ranged from a mobile medication management system that alerts children with cystic fibrosis when to take various medicines to a PDA that tracks patient-sourced pain and activity data. Our five current teams are examining how personal health applications and devices can integrate observations of daily living (ODLs) into personal health decision-making and clinical care.

Examining Observations of Daily Living (ODLs)

Because patient-sourced data about ODLs and symptoms provides clinicians a richer picture of an individual's health from day to day, technologies that enable individuals to track these types of data outside the clinical setting may be the most important feature of PHRs and mobile health technologies.

ODLs are sensations, feelings, thoughts, attitudes and behaviors that provide cues to a person about their health state. Our current teams are working with patients and clinicians to identify which ODLs patients value and how they can be tracked and interpreted by patients and clinicians to result in better care...
All very interesting and encouraging. Not to understate the myriad current and prospective barriers.


OK, this is cute. Courtesy of

MIT economist Jonathan Gruber calls health care reform the “biggest social policy legislation since Medicare.” So what better way to explain such a serious, complex and far-reaching topic than through comics?


This is swell.

Dr. Mike Gorman, a family physician in Logandale, Nev., recently took out an SBA loan to keep his practice running and pay his five employees.

"It is embarrassing," he said. "Doctors don't want to talk about being in debt." But he's planning a new strategy to deal with his rising business expenses and falling reimbursements.

"I will see more patients, but I won't check all of their complaints at one time," he explained. "If I do, insurance will bundle my reimbursement into one payment." Patients will have to make repeat visits -- an arrangement that he acknowledges is "inconvenient."

"This system pits doctor against patient," he said. "But it's the only way to beat the system and get paid."
Dr. Gorman is one of my REC clients. Very nice man. He finally got his Amazing Charts v6 MU Certified upgrade at the end of July. We visited with him mid-August, and his dashboard numbers were already looking good. He did his 90-day without major incident and attested by December.

Which will all be rather pointless if his practice goes under.___

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