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Banner Health’s Breakthrough in Redesigning Care Delivery for Complex Chronic Populations

April 11, 2017
by Heather Landi
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First full-year patients results indicate that the Intensive Ambulatory Care program reduced the 30-day readmission rate by 75 percent
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At Banner Health, the Phoenix, Ariz.-based integrated health system, healthcare leaders built an in-home telehealth program targeting a subset of patients with complex chronic conditions following a successful tele-ICU program. The in-home telehealth pilot program, called the Intensive Ambulatory Care (IAC) pilot program, done in partnership with the Netherlands-based Royal Philips, focuses on the most complex and highest-cost patients —the top five percent of patients who account for 50 percent of healthcare spending. The program first launched in 2013 and aims to improve patient outcomes, care team efficiency, and prevent IAC patients from entering the acute care environment where costs are significantly higher.

Back in January, Banner Health, with operates 28 hospitals, reported ongoing successful results from the IAC in-home program. In this updated study, Philips and Banner examined 128 patients who had at least one year pre-IAC and one year post-IAC follow-up to examine the prolonged impact of the IAC program on patient outcomes. The analysis of patient results over the first full year of the program revealed that the IAC program helped to reduce hospital admissions by nearly 50 percent. Prior to enrollment in the IAC program, there were 10.9 hospitalizations per 100 patients per month; after enrollment, the acute and long-term hospitalization rate dropped to 5.5 hospitalizations per 100 patients per month.

Further, an analysis of the program found that it helped to reduce overall costs of care by 34.5 percent. This cost saving was driven primarily by a reduction in hospitalization rates and days in the hospital, as well as a reduction in professional service and outpatient costs, Banner Health officials reported. Additionally, the program reduced the number of days in hospital by 50 percent. Prior to enrollment, the average number of days in the hospital was 60 days per 100 patients per month, compared to 30 days after enrollment. 

Banner Health further reported that the IAC program reduced the 30-day readmission rate by 75 percent; the 30-day readmission rate went from 20 percent prior to enrollment to 5 percent after enrollment.

To delve further into Banner Health’s telehealth initiatives, Healthcare Informatics Associate Editor Heather Landi spoke with Deborah Dahl, vice president, patient care innovation, Banner Health, during the HIMSS Conference in Orlando back in February. Dahl outlined the steps that Banner Health took to build a successful telehealth and remote patient monitoring program to improve health outcomes for complex chronic patients. Also participating in the interview was Manu Varma, business leader, hospital to home and Wellcentive, at Banner Health’s technology partner Philips. Below are excerpts of those interviews.

What are some of the initiatives at Banner Health using telehealth and RPM technology?

We started with tele-ICU, and what caught my attention with Philips, as opposed to the many other vendors that we’ve worked with, is they come with a turnkey solution. A lot of companies come and say, ‘Here is your really cool widget, here’s the instruction manual and you’re on your own, have a nice day.’ Philips’ approach with the tele-ICU is ‘Here is your technology, here are the marketing materials, because you’re disrupting how care is delivered at the bedside, and here are the key points you want nurses and doctors to know if you want to do it well.’ And, they say, ‘Here is the team you want to build and some interview criteria to help you’ as you want to make sure you have the right folks behind the camera [with the virtual care.] And, we had amazing results with [the tele-ICU program]. For full-year data, we had about 2,000 people in our over 600 ICU beds who lived who were predicted to die. There were about 4,000 fewer ICU days than were predicted, 65,000 fewer bed surge days, and that’s about $135 million cost avoidance. It’s never just the tele-ICU—it’s the bedside, the organizational structure, the clinical consensus groups, you need the whole thing to be working together. But, we think of ourselves as one of the glue pieces. So that helped us them move into the bed surge, then move into the ED and now into the complex chronic patient population home as we are now responsible financially, as well as clinically, for these folks when they are not in the hospital.

What has been the key to the success of the IAC in-home program for complex chronic patients?

With the tele-ICU program, it gives you those adverse trends so you can intervene before the adverse trends become adverse health. It provides us with tools that are daily reminders our foundational best practices. Our ICU teams, like most ICU teams, I call them adrenaline junkies, they are very busy and it’s not unusual to get an admission and a code and a discharge all at the same time. This tool says out of our 600 ICU patients, these three are missing that test so nurses go in and see what it is and turn to the tele-ICU doc who will write that order and make that happen. Just that core functions that happen every day.

With the IAC at-home program, it’s that same thing, the tools are collecting the data from the patient every day, and saying, ‘Here is a person whose weight is creeping up’ and it’s not something you would go to your primary care physician for, but the patient has congestive heart failure, so let’s take a look and have a conversation. The nurse will check it out and talk to the patient and have the conversation with the tele-physician or with the pharmacist, the PharmD is there as well, and they will discuss the patient and they might have a video chat with the patient, and make those changes immediately.

What you have found with regard to patient engagement with using the technology and participating in the program?

The average age of the patient in this program is 82, the youngest is 38 and the oldest is 101. It’s an interesting spectrum. When we started, we were quite concerned about the technology being a barrier but during one of the focus groups we were talking about virtual health and the patients had that blank look at their face. Then we said, ‘You know Skyping,’ and they said, ‘Oh yes, I Skype with my grandkids all the time.’ That language was so important to get people accepting and then after that it was a piece of cake. We have a health coach that is the only out-in-the-field person who is trained in motivational interviewing. Philips designed a great program for us around patient activation. The health coaches don’t come in to tell the patient how to do X, Y and Z, it’s about, ‘What matters to you? What’s important to you? And how can we help you meet your personal goals?’ The patient might say, ‘I want to get back to my bridge game’ or ‘I want to go out to lunch with friends’ so whatever your goal is, we’re looking to see how we can make that happen.

But in the early days, the health coach is also the technical hand holder, so of the first video visits we do with a new member is our medication reconciliation. The pharmacist is in the telehealth center and the health coach goes out to the home, and the pharmacist, through the video chat, will say, ‘Bring the shoebox of meds out to the table.” And they [the pharmacist and health coach] will go through that, literally opening the pillbox to make sure what’s in the container is actually the right med for that container. We’ve been through more than 1,000 patients and so far not one of them has their EHRs [electronic health records] matched what they have for medications. So you think, this patient has a cardiologist, a nephrologist and a neurologist and their PCPs, and the electronic medical record (EMR) systems, 27 or so different ones, don’t speak to each other. We found some amazingly scary things. They can be as simple the cardiologist prescribed a beta blocker and its generic, and the hospitalist, at discharge, prescribed another beta blocker, but it’s a different generic name, so the patient is taking both. So you have to get those things corrected. It’s a combination of technology tools.

The tools really do trigger us to take those next steps for those folks. The members of the program are given a tablet and they are asked a few questions once a week, and we’re looking for early signs of depression, changes in activity level, and changes in pain scale. So a message might pop up in the depression screening that is significantly different from the last score and our social worker and cognitive behavioral therapist will pick up the phone and call the patient to see what’s going on and what’s changed. We have had suicide ideation, elder abuse, and the expected depression, stress and anxiety, the things you expect when you are 82 years old and you have five chronic conditions.

Effective care management and care coordination are foundational to population health work, so are these tools critical for population health management?

I do think so. When you start your population health journey, you can say I’m going to do wellness and that’s a pretty long payback period. Or I’m going to focus on the more expensive group of folks and I’m going to use those savings to bring into the next layer and the next layer and the next layer. So we looked at this complex chronic patient population, and one of the other criteria is that they have to a $20,000 prior 12-month spend in order to get in to the program, that’s the threshold. If we can reduce their total cost of care by 34 percent, then you can improve their quality of life, reduce the number of hospitalizations, reduce the cost to them and to the plan, and so we’ve done that quality of life and cost reduction at the same time. Now, that allows us to move into some other space, like diabetic patients who are not yet into the complex chronic category.

What would be your recommendations for other health systems that would like to replicate this program?

Look for a partner that understands the complexity of the environment. So, for us, we didn’t know what we didn’t know. We knew what an ICU was like and how to do things in the ambulatory setting; it is probably 10 times more complex than a hospital ICU patient and I didn’t appreciate how complicated that was going to be. You’ve got your own employed physicians and they are on a single medical record, so you write an interface to that. You’ve got other physicians, even if they are in your narrow network in the ACO, and with our group, there are 27 different EMRs. You’ve got a lot of political changes, because you’re in other people’s space and, in the Banner group, there are about 600 primary care physicians that we are trying to work with. If you’re only interfaced with 200 out of the 600, that means a lot of faxing and phone calls to do that. You’ve got the technology, which I think is the easy part, but if it’s just feeding you data and it’s not looking to tell you that out of your 600 patients, here are the three people you should be intervening within the next hour because if you don’t in the next 24 hours, you may have a problem, then you really haven’t solved your opportunity. You can’t just look at raw data for 600 patients, your brain can’t see the trend in that fashion. It needs to be actionable data.

Varma: It needs to be synthesized data. I would add that I wouldn’t recommend that you try to reinvent the wheel. We do see a lot of that in the market with people trying to do it from scratch on their own. I would say think about the full population in your ACO strategy or your value-based care strategy. If you can see the full population, then you can know what your incentives are for each population cohort and pick and choose. And then use the technology, but also make sure to work on things from a process standpoint, such as having the right team. To this point, when we first tried to recruit patients, we said, ‘You really need help’ and the patients said ‘I don’t need help. I’m fine.’ We realized we had to talk to people completely different from what everybody was accustomed to. So there’s a whole level of design element to this and we’ve learned a lot of lessons from that. We were stunned by how embracing people were of technology, especially the tablet, which makes so much difference as the user experience is very intuitive for people. Equally surprising for us has been that we thought it was going to be a set of medical issues, but it’s not medical issues—medical issues are almost the lagging indicator, because the issue is the patients are taking those medications twice, or they don’t have the expertise available for them, there is nobody helping them through this, which leads to all kinds of care gaps, which ultimately then leads to serious medical admissions. I think those socio-economic and day-to-day issues are a real challenge.









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Senate Passes Opioid Response Bill with Substantial Health IT Elements

September 18, 2018
by Rajiv Leventhal, Managing Editor
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The U.S. Senate yesterday passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions, by a vote of 99-1.

The bill was originally sponsored by Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), and includes proposals from five Senate committees and over 70 senators. The House passed its version of the legislation in June and now it’s expected that a committee will be convened to reconcile the differences between the two.

The legislation’s core purpose is to improve the ability of various health departments and agencies—such as the Department of Health and Human Services (HHS), including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Departments of Education and Labor—to address the opioid crisis, including the ripple effects of the crisis on children, families, and communities, help states implement updates to their plans of safe care, and improve data sharing between states.

There are several key health IT provisions in the legislation, including: enabling the Centers for Medicare & Medicaid Services (CMS) to test various models that provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record (EHR) technology to improve the quality and coordination of care through the electronic documentation and exchange of health information; requiring the use of electronic prescribing for controlled substances within Medicare Part D; facilitating the use of electronic prior authorization within Medicare Part D; and expanding access to telehealth services for substance use disorders.

Regarding telehealth specifically, the Senate version of the bill will allow for payment for substance use disorder treatment services, via telehealth, to Medicare beneficiaries at originating sites, including a beneficiary’s home, regardless of geographic location. It also requires guidance to cover state options for federal reimbursement for substance use disorder services and treatment using telehealth including, services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

Health IT Now's Opioid Safety Alliance—a working group of prescribers, health systems, technology companies, pharmacies and pharmacists, professional societies, and patients advocating for the use of technology to fight illegitimate opioid use—supported the Senate’s passing of the bill. Said Joel White, HITN Opioid Safety Alliance executive director, “We are especially encouraged by the inclusion of commonsense Opioid Safety Alliance-endorsed language in this bill that will remove bureaucratic barriers to vital telehealth services for those suffering from addiction, modernize prescribing practices for controlled substances, and streamline prior authorization claims to improve efficiency while bolstering patient safety. These solutions can make a world of difference both in dollars saved and, more importantly, lives spared."

White did add, however, as Congress convenes a committee to reconcile the differences in the House and Senate-passed bills, lawmakers ought to include the House-passed OPPS Act (H.R. 6082) as part of any final conference agreement, “thereby ensuring that addiction treatment records are no longer needlessly isolated from the rest of a patient's medical history—a practice that has hindered informed decision making and threatened patient safety for too long.”

Indeed, the Senate version of the bill requires HHS “to develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient.”

White also noted, “Additionally, OSA remains concerned about the lack of real-time, actionable data provided to clinicians by states' prescription drug monitoring programs (PDMPs). With lawmakers poised to devote additional resources toward these programs, we should know if taxpayers are getting a return on their investment. We support the inclusion of language that would require an objective study and report on states' use of PDMP technology." 

As stated in the bill, states and localities would be provided with support to improve their PDMPs and "implement other evidence-based prevention strategies.” The bill also “encourages data sharing between states, and supports other prevention and research activities related to controlled substances."

What’s more, another section of the bill reauthorizes an HHS grant program “to allow states to develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology.”

Sen. Alexander, meanwhile, said yesterday he is “already working to combine the Senate and House-passed bills into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly.”

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Survey: Healthcare Organizations Report Gaps in Disaster Preparedness Plans

September 12, 2018
by Heather Landi, Associate Editor
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As Hurricane Florence churns toward the East Coast this week, disaster preparedness is a timely topic, yet a new survey finds that only 72 percent of healthcare providers believe their organization’s disaster plan is comprehensive enough to cover a variety of disaster scenarios both inside the organization and across the community.

The findings are even more troubling among specialty care providers, such as cardiologists and endocrinologists, who provide critical treatment to individuals with chronic diseases, with just 29 percent reporting that they have a comprehensive disaster plan in place. More than two-thirds (68 percent) of survey respondents were affected by two or more disasters in last five years, according to the survey, yet most respondents doubt their organization’s disaster plans are up to the task.

DrFirst, a provider of e-prescribing and medication management solutions, surveyed 109 healthcare professionals across acute, ambulatory, hospice and home care about disaster preparedness. According to the DrFirst, the results are critical for addressing potential safety issues that affect the health and lives of millions of Americans who are increasingly subject to hurricanes, wildfires, and floods as well as other man-made disasters like digital and criminal attacks.

“The fact that almost 70 percent of the surveyed healthcare providers have been affected by more than two disasters in the last 5 years should be a major wake-up call for the healthcare industry,” G. Cameron Deemer, president of DrFirst, said in a statement. “As we learned in the aftermath of major disasters such as hurricanes Maria and Harvey, natural disasters lead to surging demands for acute and emergency care, especially from the most vulnerable patients who may have been displaced from their homes without medications or critical medical supplies, like oxygen or diabetic testing equipment. We must take measures now to address the critical gaps impacting patient care and safety, such as communication challenges and ready-access to medical records and specialty care providers.”

The survey revealed another key vulnerability—the widespread dependence on disaster communications methods that fail to meet legal requirements for secure communications between medical teams, pharmacies, and patients, according to the survey. Under the federal law known as the Health Insurance Portability and Accountability Act (HIPAA), a patient’s private health information can only be shared with the patient or other providers via secure methods such as password-protected portals and secure messaging.

One-third or more of clinicians surveyed across acute, ambulatory and hospice/home health state that calling by phone is their top method for communicating with pharmacies, EMS units, patients and families, local authorities, and community health providers in times of disaster. Secure messaging and email complete the top three modes of communication.

A striking number of clinicians use regular unsecured text messaging to reach hospitals: more than one-quarter of respondents use this mode to communicate with hospitals during and immediately after a disaster strikes, and 22 percent report using unsecured texting to communicate with patients or their family members. According to the Centers for Medicare and Medicaid Services (CMS), the use of phones for texting of patient health information is only permissible through a secure messaging platform that provides message encryption. Encryption is also required when emailing patient health information.

Healthcare professionals working in hospitals were more aware of the need for secure messaging tools than individuals working in other settings, including specialty care providers. Forty-four percent of hospital-based respondents said that secure, HIPAA-compliant medical messaging is a key requirement of a disaster preparedness plan.

In fact, hospital-based respondents indicated that the only requirements more important than secure messaging were the installation of backup generators in case of power outages (56 percent) and the ordering and maintaining of extra inventory of supplies and medications (52 percent). Yet, specialty providers place the need for including secure messaging at the very bottom of their disaster planning requirements.

Survey respondents also see telehealth is a viable disaster solution, as 45 percent cited telehealth as an effective option to provide care to patients across the community during or immediately after disasters or emergencies. However, more than half expressed concerns that connectivity and other technical issues could impact the reliability of telehealth, and only 27 percent believe their organization has deployed adequate telehealth capabilities.

Another key finding from the survey is that many organizations preparing for an impending disaster still rely heavily on paper, with most advising patients to keep copies of their medical records. Just 40 percent of respondents believe their electronic health record (EHR) has sufficient information available to take care of all patients during a disaster.


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CPT Codes Updated to Reflect HIT Advancements

September 6, 2018
by Rajiv Leventhal, Managing Editor
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The American Medical Association (AMA) announced the release of the 2019 Current Procedural Terminology (CPT) code set, with changes reflecting new technological shifts in the industry.

According to the AMA, there are 335 code changes in the new CPT edition reflecting the CPT Editorial Panel and the healthcare community’s “combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.”

Among this year’s changes to CPT include three new remote patient monitoring codes that reflect how healthcare professionals can more effectively and efficiently use technology to connect with their patients at home and gather data for care management and coordination. Also, two new interprofessional internet consultation codes have been added to reflect the increasing importance of using non-verbal communication technology to coordinate patient care between a consulting physician and a treating physician, according to AMA.

“The CPT code set is the foundation upon which every element of the medical community—doctors, hospitals, allied health professionals, laboratories and payers—can efficiently share accurate information about medical services,” AMA President Barbara L. McAneny, M.D., said in a statement. “The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice, and ensure the code set can fulfill its trusted role as the health system’s common language for reporting contemporary medical procedures. That’s why we believe CPT serves both as the language of medicine today and the code to its future.”

McAneny added that the AMA has urged the Centers for Medicare and Medicaid Services (CMS) to adopt the new codes for remote patient monitoring and internet consulting and designate the related services for payment under federal health programs in 2019. “Medicare’s acceptance of the new codes would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care,” she said.

In July, as part of CMS’ proposed Physician Fee Schedule and Quality Payment Program rule, the agency recommended various provisions that would aim to support access to care using telecommunications technology, such as: paying clinicians for virtual check-ins, paying clinicians for evaluation of patient-submitted photos; and expanding Medicare-covered telehealth services to include prolonged preventive services.

New CPT category I codes are effective for reporting as of Jan. 1, 2019. Additional CPT changes for 2019 include new and revised codes for skin biopsy, fine needle aspiration biopsy, adaptive behavior analysis, and central nervous system assessments including psychological and neuropsychological testing.

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