Medicare, Telehealth and congress

Medicare annual spending on Telehealth is around $5M. Compare that number with $505B annual spend for covering about 60 million Americans and you get the idea that Telehealth is not a prevalent service. CMS stipulates allowable originating sites of care  to be where the patient physically is. Like the home which is where most patients end up recovering. It is arguably their preferred place to be. Care can and should be provided where the patient is and it should be cost effective and clinically approved.

At the moment Telehealth is only available to Health Professional Shortage Areas and not in larger metropolitan areas where population is more dense. By eliminating this restriction there will most probably be an overflow of service requests where medical services and consultation could be conducted from the comfort of one’s home.

Currently Telehealth is restricted to voice and video. Congress can aid by expanding and adding other modalities to active monitoring with the use of wearables and sensors. This will require an expansion of CPT and HCPCS codes to actually cover these real time and on going services.

Lastly congress can consolidate states and federal offices in normalizing the licensing process to allow physicians to care for patients beyond their state’s borders. This will elevate demand from physicians in larger and more dense populations and also provide patients with choices.

There are 6 acts under way which are relevant to Telehealth:

Interstate Telehealth licensing

The Federation of State Medical Board (FSMB ) will enable physicians to practice across state lines. This compact was adopted by legislators in Alabama which is the 7th state required to enact it. 11 other states have the act pending approval.

Medicare Telehealth parity act 2015 – H.R.2948

This act discusses the expansion of Telehealth in 3 phases:

Phase 1

Expands what sites qualify as “originating site” to include federal health centers, rural health clinics, and counties in Metropolitan areas with populations less than 50,000.

Include services provided by diabetes educators, respiratory therapists, audiologists, occupational therapists, speech language therapists, and physical therapists.

Phase 1 also provides Medicare coverage of asynchronous (store & forward) Telehealth services across the country (beyond Alaska and Hawaii).

Phase 2

Expands qualifying originating sites to include a “Home Telehealth Site”, to include counties in Metropolitan Areas with populations of 50,000-100,000.

Phase 3

Originating locations definition expanded to include counties in Metropolitan areas with populations above 100,000. CMS is also authorized to develop and implement new payment methods for these services.

ACO improvement act – H.R.5558

An act to improve the ACO model by providing additional incentives based on quality of care and increasing collaboration between patients and physicians. Among the financial incentives for performance, this act includes patient’s option to choose their primary care provider, a nurse practitioner or physician assistant in rural and underserved areas.

Telehealth enhancement act – H.R.3306

This bill and it’s revised 2014 version, will add Medicare home health payments to remote monitoring services and is aim to expand coverage to all critical access and sole community hospitals. It would also cover home-based video services for hospice care, home dialysis and homebound beneficiaries and allows states to set up high-risk pregnancy networks.

what google brillo means for healthcare IT

today google announced brillo, their IoT operating system based on android and it’s matching communicating protocol. brillo will be  live later this year and so will weave, the communication protocol. google is now making moves to join apple and microsoft, a timely move.

brillo and weave will work well on light weight devices, like cameras, door locks, etc. essentially home devices. in the growing market of health related devices and monitors, this announcement means another stride in that direction, in the shape of affordable scales, wearables, remote monitoring, telehealth and other means to collect specific and relevant information from patients where they are.

with small computers scaling up, a low memory foot print we should expect a wave of innovation when it comes to healthcare related products.

patient engagement

doctor-and-patientpatient engagement as defined by

“Patient engagement refers to ongoing and constructive dialogue between patient and practitioner. Within the scope of healthcare IT, patient engagement is driven by technology ranging from patient portals, which enable patients to view test results and records online and communicate with doctors, to electronic data capturing platforms that result in more accurate and streamlined diagnostic information. A high emphasis has been placed on patient engagement in Stage 2 meaningful use.”.

the healthcare system in the US is wonderful in focusing on one thing that has gone wrong and fixing it. it is not so effective in dealing with comorbidities and not so much when it comes to taking daily actions to maintain a state of harmony. mobile devices seem like the right channel to revolutionize the current state. can healthcare be as engaging as our digital social lives? can the same social circle serve as a catalyst to push us in the right direction when it comes to making healthier choices?

why does it seem like we are not getting patient portals and PHR right? to start off, the sicker the patient the less likely they are to use the portal. to put this in perspective, 78% of physicians use EHR while 17% of patients use portals (this data dates back to 2013 by Research Ancker). it is clear that patients do not see the value of the portals yet nor gaining access to their PHR. what is the right model to bond the patient and provider together?

considering that PHR is mostly provider facing, i.e. they are laid out and detailed in a clinical way which makes more sense for the physician than the patient. take clinical notes for example which include terms which do not make much sense to the patient.

but hold on for a second. aren’t the patient already so very much engaged? they suffer the pain, go through the medical procedure, pay the bill… patient are indeed engaged as they fill out the same form multiple times as they visit different departments within the same hospital. as they are expected to accurately name the medications they are taking and the dosage. isn’t it the system that, inadvertently, discourages engagement?
today providers are almost exclusively responsible for deciding a patient’s treatment, next site of care, medications, etc. seeking patient engagement, those key decisions should include the patients and their families, where they can voice their opinion, participate and share responsibility.

consider nutrition and financial wellness as important gaps. patient should know who is responsible for delivering their care. critical data elements can be tied to services rendered to improve outcome in a clear and concise way. regardless of a patient’s spoken language, in order to engage them they should be able to specify clearly and effectively specify what is going on, why they need help and know that someone got their message and is “working on it”. all that within as little clicks as possible.

patient engagement may be the holy grail when it comes to improving outcome and reducing costs. having the patient and their family and friends participate in the process in a meaningful way and be proactive in a timely manner can assist advancing the healthcare system in our country forward.



2014 new year tech resolutions

it’s that time of the year again to contemplate, appreciate how much we have come and look forward with excitement and anticipation to what is ahead. our team is growing and so the challenge. i am learning to appreciate the intricacies of managing a diverse tech team and providing a solution that is both granular and all encompassing simultaneously. it may sound like an oxymoron though i’m sure this statement holds ground for most HIT startups involved in care coordination and the BPCI program. the truth is that when dealing with standards, data feeds should be synthesized and clean. yes, being compliant with MU1 should mean just that, but the fact of the matter is that it does not. it’s easy to point a finger at the hospitals but that is just not fair. the same is true for browsers who implement web standards. if you are involved in web development you will have to optimize and tweak your code per offering. it’s just how it is. this is where i hope that one day the state HIEs will step up to provide a more robust infrastructure that is both available and clean. the winner will be the one who will have critical mass and will do somewhat of a good job. a good job may mean a decent and somewhat relevant snapshot of the patient. and then some. HIEs can and should be smarted than their users soon. that alone will justify their existence rather than aggregators. it will be  interesting to see how  shiny pans out.

so new year tech resolutions:

1. make the switch from SVN to GIT and implement gitflow. this will allow us to get releasing more quickly.
2. BDD is not just a cool term. it’s how we will ensure quality and scale.
3. quicker more rapid and agile releases. move as close as possible to continuous integration.
4. tailor a winning hybrid schema between document storage and relational. find the balance between the two.

why we have switches to git from svn

the debate within the team has been going on for a while… should we stay with svn or should we move to turvald’s git? should we stay centralized or is it time to decentralize our version control system?

on the personal level git will allow move a bit faster with a full local history for every developer and the benefit of quickly switching between branches. as a team we saw the flexible workflows was can work with under git and really take advantage of branches as frequently as we checkout an issue on jira. though the top of the pile was the lack of merge hassle. almost every developer on the team has some fear associated with merging their code and the longer they have been working on their branch – the bigger the elephant in the room grew.

1. create a read only copy of our repository
2. pull all the changes from subversion
3. migrate our toolset away from svn to git (CI, code reviews etc)
4. make the switch

re-educating the development team is one of those harder tasks. ideally there are a few git champions within the team that can infect the rest with their passion for the switch. take under account that no matter what you do, some will resist and it will take a few months before everyone is aligned and appreciative of the change.