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Readers Write: Will Blockchain Survive Healthcare?

June 22, 2017 Guest articles No Comments

Will Blockchain Survive Healthcare?
By Daniel Kivatinos


Blockchain technology is here and thriving, with bitcoin as its primary use case. I expect it will be applied to many industries in the coming years; but the question is, will it work for healthcare? Generally, healthcare has lagged in adopting newer technologies. We have seen the medical industry struggle to move fully off paper, slowly digitizing medical records over the last several decades. The digitalization of healthcare is still happening. Ten years from now, everyone will have easy access to their medical information from around the world via their smartphone. But will blockchain survive the healthcare hype and end up the game-changer some are predicting it will become?

Blockchain Basics

Blockchain’s initial HIT use case began in cryptocurrency along with bitcoin. At the simplest level, blockchain is a distributed ledger. The power of a distributed ledger is that there are many copies, and it creates a new system of checks and balances. As we’ve seen from the headlines, the concept of an encrypted distributed ledger via blockchain is now spreading to other areas like healthcare.

Today, organizations typically have one central administrator that holds the key(s) to the kingdom, one canonical source of truth, one ledger, and one log of transactions. The ledger isn’t spread across a network of different parties. The concept of having multiple digital ledgers from different parties offers a number of security benefits:

  • It would be very hard to simultaneously hack all digital ledgers.
  • Errors in one ledger can be checked against other ledgers from other parties.

Healthcare Use Cases

Here are several use cases that illustrate how blockchain could work in the healthcare industry:

Use Case 1: If a physician specialist needs access to a patient’s health history, blockchain would duplicate the medical record and log transactions. One transaction would happen at a physician encounter where a checkup might happen, maybe a radiology image is taken and a prescription refill occurs. After the encounter, a trusted party would validate the transaction with an access key. The blockchain app would timestamp the verified block and add it to the chain of older blocks in sequential order, hence adding a block to the chain. Then the transaction would be distributed to other ledgers, giving other parties copies of the medical record. This would be a great way to keep up to date on a patient’s health if, for example, two providers from different organizations needed to keep track of a patient.

Use Case 2: Blockchain technology could also be used for medical billing, logging with blocks on a chain and showing all payments from claims from multiple payers. With the United States GDP Health expenditure growing from 13.1 percent in 1995 to 17.1 percent in 2014, according to worldbank.org, having a bit more logging around medical transactions might help identify billing discrepancies and potentially reduce costs.

Use Case 3: Organizations are also thinking about how they can apply blockchain internally to boost their infrastructure while having multiple parties that, under lock and key, have copies of the ledger. This has the potential to stop hospital ransomware attackers in their tracks.

In summary, healthcare organizations of all sizes are contemplating the ways in which blockchain may benefit their business models. But as we’ve seen with healthcare, its adoption will occur only after its obstacles have been overcome and its value-adds fully realized. Time – and lots of it – will be the barometer of blockchain’s survival in healthcare.

Daniel Kivatinos is co-founder and COO of Drchrono in Mountain View, CA.


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Readers Write: America’s Doctors Need a Neutral Internet

America’s Doctors Need a Neutral Internet
By Matthew Douglass


In 1984, Stewart Brand, a close friend of the founders of the Internet, famously said, “Information wants to be free. Information also wants to be expensive.” Three years ago, I detailed why classifying the Internet under Title II of the Communications Act was so important to preventing Internet services and accompanying information from becoming expensive for Internet consumers and businesses. An active public debate occurred that year, with a record 3,700,000 public comments submitted to the FCC, including the views of hundreds of top investors, leading technology companies, churches, and civil society groups.

After much public debate and consideration, the FCC in 2015 voted to regulate broadband Internet service as a public utility in an effort to “protect innovators and consumers” and reassert the Internet’s “core of free expression and democratic principles.” Cable and telecommunications companies are now explicitly restricted from discriminating among website providers and content, or treating them in a different manner. Today, the Internet thrives as it has since its invention: There are no fast lanes or slow lanes, and no company’s Web traffic can receive preferential treatment or prioritization.

Just two years after that rulemaking by the FCC, Ajit Pai, the new head of the FCC, has now proposed repealing that critical decision. Changing these existing rules could allow Internet service providers to charge different prices to consumers and businesses based on the influence of the company transmitting data or the type of information being transmitted.

As was successfully argued a few years ago, differently priced lanes on the Internet would primarily benefit incumbent Internet applications and be particularly burdensome for Internet consumers and small businesses fighting to compete with larger, entrenched companies.

The Health IT Connection

Medical practices in the US are becoming increasingly reliant on EHRs to run their businesses and treat patients. The future of EHRs is in the cloud, especially for independent physicians who are particularly sensitive to technology costs for their lean, small businesses. The last thing that independent physicians need is to have to bear additional costs to their business on top of what they already spend on critical medical technology.

Imagine if there were more expensive lanes on the Internet that promised faster speeds. By definition, the less expensive lanes would be slower. Since healthcare applications are now mission-critical for doctors to be able to treat their patients, customers of ISPs that introduce tiered pricing would be forced to choose the faster, more expensive plans. Physicians operating their practices on a shoestring budget would be directly affected and would potentially face significant harm. At a time when the entire healthcare industry is shifting to value-based care, we should be looking at ways to ensure the financial viability of independent practices, rather than endangering their existence by imposing additional, unnecessary costs.

Another ramification of allowing ISPs to determine which traffic belongs in a fast lane is that they could preferentially speed up or slow down the services of specific companies. For instance, a digital health company owned by an ISP could be given preferential speed over the services of competitors. This situation would directly impede competition, discourage startup companies from entering the space, and reduce freedom of choice for physicians and patients. America’s doctors and patients should determine which Internet-enabled healthcare services will thrive based on better functionality, not because of delivery speeds decided by ISPs with potential conflicts of interest.

If it Ain’t Broke, Don’t Increase the Cost

The Internet Association and its member companies, including mine, has reasserted its support of the existing FCC regulation of the Internet: “The [I]nternet industry is uniform in its belief that net neutrality preserves the consumer experience, competition, and innovation online. In other words, existing net neutrality rules should be enforced and kept intact.”

Doctors need new, innovative technologies and freedom from the burden of new, unnecessary costs to be able to do their jobs well in our rapidly evolving, 21st century information economy. The last thing they need is the heavier burden of additional costs required to run technology that is essential for patient care. A neutral Internet without fast or slow lanes is crucial for the US to maintain the innovative and entrepreneurial engine that has driven our powerful information-driven economy for decades.

When medical students begin studying for careers as physicians, they pledge to “first, do no harm.” The FCC would be wise to take a similar approach to net neutrality as it stands today: “If it ain’t broke, don’t fix it.”

Matthew Douglass is co-founder and SVP of customer experience at Practice Fusion in San Francisco.


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Readers Write: Patient Relationship Management Key to Attracting (and Keeping) Millennial Patients

Patient Relationship Management Key to Attracting (and Keeping) Millennial Patients
By Jim Higgins


Ask any physician what they think of millennial patients, and you’ll often get a skewed perspective of people born between 1980 and the late 1990s. Compare a typical millennial patient with their physician and you’ll probably find that they use different technologies, have contrasting communication preferences, and have distinctly different expectations when it comes time for an appointment.

For all the good-natured (and sometimes snarky) ribbing they take, millenials are a presence not to be ignored – especially when it comes to their roles as patients. By 2025, they are expected make up 75 percent of the US workforce. As such, their healthcare needs will grow, along with their earning power. And while millennials love technology (more than nine out of 10 own smartphones), they also love personal attention in the healthcare setting.

As millennials influence the marketplace, a physician practice’s success will be increasingly tied to its ability to attract more of this age group. By leveraging new technology platforms to reach millennial patients in compelling ways, healthcare organizations will be in a better position to engage existing patients, improve satisfaction, boost retention — and even save their physicians from burnout.

A Closer Look at Their Technology Habits

As physicians consider the benefits of updating their outreach efforts and business practices to better appeal to millennials, it’s important to first understand this demographic via their love of technology. When it comes to finding a doctor, nearly 88 percent of consumers trust online reviews (e.g. Yelp, Healthgrades) as much as personal recommendations. This research shows that millennial patients find significant value in the testimonials of other patients. In terms of scheduling an appointment with their physician of choice, a majority of adults aged 18 to 24 (63.6 percent) said they would prefer using an online calendar over talking on the phone to schedule appointments. Often times, information comes through social media channels: 87 percent of adults online in the US ages 18 to 29 use Facebook; 53 percent use Instagram; 37 percent use Twitter; and 34 percent use Pinterest.

With a wide range of preferences, it’s no wonder that millennials require a different engagement strategy. Don’t let the stats intimidate you, though; these patients can be loyal consumers once a business has won them over and proven its value.

Reaching Millennials via Patient Relationship Management

Understanding how millennials think is a great start, but only by truly leveraging the right patient relationship management technology will physicians truly be able to target them in a – dare I say it? – meaningful way. PRM technology enables physicians to engage with these patients in a smarter, more personalized way – one that is aligned with their preferences. In doing so, PRM helps a healthcare organization not only attract 20- and 30-somethings, but also engage with patients in a way that will ultimately improve outcomes and retention.

The challenge of engagement is the most pressing issue among providers, who are under more pressure than ever before to seek out new ways to connect with patients between office visits. PRM solutions feature multiple applications, such as appointment reminders and secure messaging. For millennials, text and email is always a better way to connect and ensure scheduled visits aren’t missed.

PRM tools can also help a practice boost its marketing efforts and better monitor its online reputation. For example, a practice could use a PRM tool to dispatch a post-visit satisfaction survey immediately after a patient’s scheduled appointment to gauge how they thought things went went. A practice would then be able to tailor their outreach to those specific patients moving forward. For example, if a patient was not happy with their visit, the practice could offer immediate resolutions before an issue affects a practice’s rating and turns off potential new patients.

The most compelling way a PRM tool sets itself apart from other technology solutions is through its email and social media marketing platforms, which help providers deepen their connection with patients on a regular basis.

Since millennials tend to stay loyal to businesses that they can engage with, leveraging digital technology with the goal of growing great patient relationships helps organizations stay fresh and relevant — while keeping their patients happy.

Jim Higgins is CEO of Solutionreach in Lehi, UT.


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Readers Write: A Proposed Rule Peace Offering: More Regulatory Slack

Proposed Rule’s Peace Offering to Physicians: More Regulatory Slack
By Kerri Wing, RN


Items outlined in the proposed rule for the 2018 Inpatient Prospective Payment System (IPPS) recently released by CMS signal a growing awareness of the need for relaxed regulatory burden in healthcare. The proposed rule seeks to counter regulatory sprawl by realigning various reporting programs around common quality measures, and by actively seeking stakeholder feedback on additional opportunities for reporting program simplification.

While the bulk of the rule relates to hospital reporting programs, proposed changes for eligible professionals are also highlighted. Items in the proposal impacting physicians and EPs include:

  • Bringing the EHR Incentive Program (Meaningful Use) reporting period and clinical quality measures into alignment with the Merit-based Incentive Program (MIPS).
  • Eliminating MU penalties for EPs using de-certified EHR technology.
  • Exempting EPs who furnish “substantially all” of their services in ambulatory surgery settings from MU payment adjustments.

The Meaningful Use / MIPS Crossover

Proposed updates echo the “pick-your-pace” flexibilities extended to physicians under MACRA, which reduced clinical quality measure (CQM) and reporting period requirements for physicians on the quality payment program’s MIPS track. Under the IPPS rule, CMS is proposing to modify the MU reporting period for EPs to a continuous 90-day period during the 2017 calendar year. The rule also proposes that CQMs available to EPs under MU mirror those available under MIPS.

Streamlining that CQM cross-walk should simplify reporting for physicians and specialists participating in hospital programs. It’s nice to see CMS recognize that hospitals are part of the larger hub where data resides, and the value of migrating the industry in unison.

EHR Limitations

From a clinician perspective, the biggest challenge is having the right technology to meet CMS requirements. Providers often struggle to keep pace with reporting periods because regulations often don’t leave EHR vendors enough time to develop the regulatory requirements. The proposed rule would give providers hinged to EHR technology that has been de-certified by the ONC an opportunity to apply for penalty exemption.

Keeping up with ONC certification is a challenge that only so many EHRs can sustain, and market consolidation leaves providers with fewer options. Many providers who have invested heavily in these platforms are at the mercy of their EHR for quality reporting, but the technology is unable to maintain updates needed to keep pace with shifting requirements. The proposed penalty avoidance keeps providers from suffering twice for EHR limitations and offers providers breathing room to evaluate alternative technology solutions. (Though it’s worth noting that although MU penalties may be avoided, certified EHRs are still required for MACRA.)

ASC Exemptions

Many specialty EPs furnish the majority of their services in ambulatory surgery center settings. The proposal to exempt these EPs from 2017 and 2018 MU payment adjustments would eliminate reporting burdens for EPs with limited office time. CMS is requesting feedback on whether to set the “substantially all” ASC threshold at 75 percent or 90 percent of patient cases.

An Industry-wide Rally for Less Regulatory Burden

While the IPPS proposed rule’s impact on EPs is limited, the message it conveys is promising for physicians. CMS recognizes regulatory burdens to be a widespread problem. Offering more of a grace period and relaxed reporting requirements reduces the burden on everyone.

Equally notable is the open invitation to submit feedback on a gamut of issues related to regulatory overhaul. This includes an RFI on topics including but not limited to data sharing, payment system re-design, reporting elimination or streamlining, and how CMS issues regulations and policies. The RFI points to increased opportunities for provider influence and collaboration in assuaging regulation.

Providers interested in weighing in on the RFI have until June 13 to comment. Those commenting should encourage CMS to continue aligning quality reporting programs and further streamline the submission process. Essentially: Do more of what you’re doing right now.

As the industry inches towards a universal reporting program, it behooves both hospitals and physician practices to stay attuned to regulatory changes in inpatient and outpatient settings alike. Additional reporting program crossover is highly probable.

Kerri Wing, RN is director of clinical analytics at IHealth Innovations in Louisville, KY.


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Readers Write: Carrot or Stick? Physician Compensation in Value-Based Cancer Care Delivery

April 27, 2017 Guest articles No Comments

Carrot or Stick? Physician Compensation in Value-based Cancer Care Delivery
By Lucy Langer, MD and Lalan Wilfong, MD

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A previous post on re-designing cancer care in the context of the Centers for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model focused on physician engagement in cancer care delivery redesign and how to create a framework to engage physicians in quality improvement and the delivery of better patient care. In this article, we will discuss considerations around physician compensation when trying to strike a balance between productivity and value in this new care model.

The OCM pilot, which began in July 2016, is an alternative payment model designed to test whether specific changes in the payment for cancer care delivery can result in better care, smarter spending, and healthier people. Under the OCM, physician practices are subject to both financial and performance accountability during episodes of care defined by active chemotherapy administration to cancer patients. Reimbursement in the OCM is fee-for-service, but also includes a per-beneficiary Monthly Enhanced Oncology Services payment. According to CMS, this $160 MEOS payment is intended to assist participating practices in effectively managing and coordinating care for oncology patients during episodes of care. The potential for a performance-based payment is designed to incentivize practices to lower the total cost of care and improve the quality of care for beneficiaries during treatment episodes.

Evolving Models

Physician engagement is an essential component for success in payment models like the OCM. Practices can change physician behavior through the compensation model. Most oncologists are compensated based on relative value unit-generation, and some contain a small, additional bonus or incentive for activities such as supporting leadership roles in the practice. But how will compensation models evolve in the era of value-based care delivery?

New compensation models ought to include:

  • Productivity measures.
  • Incentives to provide high-quality care and thresholds that are relevant to the practice.
  • Visibility and reporting once key quality metrics are included.
  • Physician buy-in and full engagement to support the quality initiative.

In the new era of value-based care, practices must determine how to recognize physicians for their contributions to the larger practice’s ability to meet quality and cost-containment targets. This means creating a financial incentive for balancing both personal productivity and practice accountability to improve the quality of care provided.

Real-World Experiences

The US Oncology Network brings together more than 1,400 independent physicians from more than 45 physician-owned practices and over 400 sites of care across the United States, including primarily medical oncologists, radiation oncologists, surgeons, and urologists. We are both part of a committee within the network that has come together to think through and provide guidance as we transition to value-based care. Collectively, this committee has put resources in place to help 14 affiliated practices successfully enroll more than 19,000 Medicare patients (to date) in the OCM. In addition to the OCM, many practices affiliated with our network are participating in similar APMs.

As a result of this level of participation and the potential impact of these programs on each practice’s financials, key questions regarding physician compensation have emerged. For instance, with more than 420 physicians, Texas Oncology is focusing efforts to use a small proportion of compensation to incentivize clinical guideline- or pathways-based treatment protocols. With the implementation of a clinical decision support tool and tying 2 percent of salary to pathways performance, we have seen pathway adherence increase from 78 percent to 90 percent over a one year time frame*. On the other hand, Compass Oncology, with over 40 practitioners, is pursuing a different model and moving towards implementation of a novel total compensation model that shifts away from RVUs to a “Balanced Scorecard.” The Balanced Scorecard emphasizes three key elements – practice growth, fiscal responsibility, and quality metrics – that identify where physician behaviors can align with practice goals, patient needs, and payer contracts.

Productivity remains an important contributor to the health of a practice, and eliminating productivity from physician compensation entirely would be unwise. By pairing productivity with value and quality goals set at the practice level, we believe that physicians will be more likely to alter behaviors towards a more team-based approach.

The transition to true patient-centric care is the essence of new payment models aimed at reducing waste, enhancing patient services, and optimizing patient outcomes. An engaged physician brings value to the practice by providing leadership as a member of a larger team focused on meeting the patient needs. While the doctor-patient relationship remains central to this care, additional services are recommended to meet the needs of the patient. These include social work and financial counseling to decrease the barriers to receiving care, survivorship and palliative care to address patient symptoms and advance care planning, and triage nursing and advanced practice providers to provide clinical services between physician visits. Physicians should be incentivized and compensated for facilitating effective teams and providing mentorship, education, and leadership to drive practice transformation and success in value-based payment policies.

Metrics, Metrics, Metrics

Practices that participate in the OCM and similar models will be held to reportable metrics that emphasize value. Payments will be made based on performance compared to historical data for our own practices as well as the performance of other practices in the model. Baseline value metric data is available to us through CMMI, and tracking performance to these value metrics is an important element when considering physician incentives.

We believe that by incentivizing performance via novel payment models to address quality metrics and improvements in patient care, we must also ensure this approach fully aligns with our practice culture, values, and goals. Metrics that are widely held to be important in oncology as indicators of ‘best practice’ and high-level care, such as days on hospice, performance to established pathways and guidelines, and patient satisfaction, are under consideration for inclusion in the model.

Carrot or Stick?

Ultimately, in considering how to incentivize and motivate physicians through enhanced compensation models, each practice will have to wrestle with some fundamental questions: Is it better to use a carrot or a stick? How can the practice ensure ‘buy in’ to any major changes in compensation? What are the underlying values and strategic goals that you are trying to achieve? How do we balance productivity and value-based care? While we do not purport to have THE answer to physician compensation in the era of value-based care, it is clear that for our practices, legacy RVU models may not truly reflect physician activities that contribute to success with non-fee-for-service contracts. Each practice will have to customize any compensation formula to fit the practice culture, demographics, and payer contract mix.

Lucy Langer, MD is president of Compass Oncology in Portland. Lalan Wilfong, MD is medical director of quality programs at Texas Oncology in Dallas. Both practices are in The US Oncology Network.


1J Clin Oncol 34, 2016 (suppl 7S; abstr 187)


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