Author Archives: Zach Urbina

HIMSS Board Chair Scott MacLean opened the early conversation at HIMSS14 on Monday with the clear goal of “connecting and engaging all stakeholders.”  MacLean’s remarks set the tone for the keynote address by Aetna CEO Mark Bertolini who began his talk by asking: What is health?
“Health is a more productive individual who is economically viable and is more satisfied or happy. That is our outcome.”
Bertolini continued to outline the goals of healthcare that provide for a basis in “information not ideology.” His remarks highlighted the maze-like architecture of healthcare in which there remains great difficulty ascertaining the cost and navigability of a vast, interconnected system.
The Aetna CEO continued by setting forth the goals of healthcare reform into the context of individual, population, national, and ultimately worldwide impact.  He highlighted the $800 billion in waste currently ham-straining both the healthcare industry and the US gross domestic product, as well as data showing the growth of healthcare premiums at 4 times the rate of inflation.
By defining the components of a different vision of the future of healthcare, Bertolini offered up 3 ideas for a fresh foundation including aligned incentives, chronic illness care, and wellness initiatives.  Next in Bertolini’s crosshairs were the requisite digital tools that connect consumers to their providers in technologically sophisticated ways.  His anecdote of using a smartphone to find the cheapest price for his daughter’s sweater was particularly well received by those in attendance.
“The new definition of quality is convenience.”
Bertolini presented some sobering figures around fee-for-service healthcare spending.  In 2009, the top ten percent of the most costly patients drive 57% of all costs.  After looking at the troubling recent past, Bertolini next heralded the more promising near future; “In the next 6-7 years, 75 million Americans will be retail buyers of healthcare.”
Also on the theoretical horizon is an era in which the cost of care as a percentage of GDP begins to drop.  Bertolini envisions a 25 to 30 year journey toward wellness, as a meaningful metric.
Aetna’s plan for the changing healthcare industry include population health management, better assessing cultural and environmental trends, all of which leading to consumers who are healthy, more productive, and enconomically viable.  The strategy includes aligned incentives, transparency for the consumer, and technology that’s already in the hands of most individuals.
If Aetna, one of the largest and oldest healthcare organizations in the US can look ahead to technology-centered, consumer-oriented access to health services, certainly other providers can see room for improvement, and a meaningful, lasting impact as well.
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Guest Blogger: Andrew Porterfield

When the Florida Department of Children and Families (DCF) was faced with budget and staffing cuts of nearly 50%, it looked toward an electronic solution to maintain benefits. The department, charged with approving and distributing benefits for 3.5 million people on Medicaid, 4.6 million on Supplemental Nutrition Assistance, and 189,000 recipients of Temporary Assistance for Needy Families while slashing its staff from 7,200 to 4,100 employees, decided to make all applications and distributions online.

Unfortunately, this decision gave the state another distinction—Florida became number one in the nation for identity theft complaints, most of which arose from government document or benefit fraud. Two DCF officials and an executive from LexisNexis, which provided the department with a fraud-fighting solution, shared their story at the HIMSS14 convention in Orlando.

“We’re Florida State graduates, and we’re proud of being a national champion, but number one isn’t always a good thing,” said Andrew McClenahan, director of public benefits integrity for DCF.

While Florida moved from offering services only in person, in brick-and-mortar offices, it was shifting away from a model known for long waits, crowded offices, forcing low-income clients to take time off and travel to a DCF office. The new model, called ACCESS, was all virtual—24/7 access over the internet, convenient community settings or applications from home, and a paperless, payment-card based benefit system. About 96-97% of DCF’s benefit services were online. “We were number one in the US, which also made us the number one target for identity fraud,” McClenahan.

Identity theft has risen about 50% in 10 years, said Clint Fuhrman, national director of government healthcare for LexisNexis. “It’s an easy crime to commit, it’s everywhere, and a huge and growing problem,” he said. “But you need to balance fraud protection and prevention, with access to benefits. It’s about getting to the right patient or beneficiary, at the right time, and getting benefits to people who really need them.”

Faced with growing fraud numbers, the Florida DCF turned to LexisNexis for a solution. LexisNexis took technology that had been used by banks and financial services firms for years, and adopted it to healthcare and government social benefits distribution. The firm integrated a customer authentication tool into the web-based ACCESS program, which asked a series of security questions derived from information the applicants had filled out online. The answers were then compared with other records (death, addresses, prison records, etc.,) to look for mismatches. If such a mismatch occurred, a DCF employee would call the applicant with a few more security questions. And if no matches were resolved by that call, the applicant had to come in to visit a DCF office. For most fraud cases, this program prevented fraud from occurring before an application was even completed.

“The LexisNexis tool is running behind the scenes, as an XML program, capturing information as it’s entered, said Sharron Washington, interim director of DCF’s office of economic self-sufficiency.

The program has worked well so far. During its five-month pilot implementation, the authentication program resulted in $11 million in savings, from avoiding benefit payments to unqualified people, reduced online application processing time, and expected benefits processing.

The biggest lesson learned? “We had to make sure our people were properly trained,” Washington said. We had to explain this to our people and to our customers. Once we started doing that, with a training tool in office TV stands, tip sheets at kiosk stations, the few complaints dropped. Communications was the key piece.”

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Guest Contributor: CJ Fulton

There are three things “new” to healthcare that really aren’t new at all: population health management (PMH), the patient-provider relationship, and the emergence of Health applications (mHealth, advanced diagnostic technology, etc).

PMH is hardly groundbreaking. In fact, the practice and proficiency of payers stratifying populations by risks, identifying high-cost conditions, and deploying member engagement strategies around disease management date back to 1929 in the U.S.

Patient-provider relationship? Well, it doesn’t have a Facebook flashback movie per se, but I did find a movie scene from 15 years ago that I think articulates this relationship and its history perfectly…

Lastly, new technologies have sustained a perpetual momentum in an industry where rapid change is accepted and expected. With tech change, apps are written on open source platforms where APIs can be layered with multi-directional fluidity.  But caveat emptor: some health-tech companies are repackaging old methodologies, evangelizing, and attempting to retrofit their old square-peg platform into your new care circle.

No, the three aspects aren’t new, but the alignment and integration of PMH,  the patient-provider relationship, and the emergence of heath IT have created a sort of healthcare  Industrial Revolution.

Mapping systems of data (not siloes), managing relationships, and dispersing data in real-time on harmonized, open platforms is a capital investment that must provide significant financial and clinical ROI for every dollar spent. With the help of a Pioneer ACO and a Top 5 Hospital MSSP ACO, I have compiled a shortlist of ACO-360⁰ questions that will help you select an ACO platform that allows stakeholders to access their “internet of care things”:

1)      Vendor viability and covering the basics to understanding their current business risk

A.      Customer reference checks

B.      Total revenue, operating margin, debt-to-equity ratio, R&D budget


2)      Application Functionality

A.      Have the vendor list national standards and sources used in assessments, care plans, particular interventions, etc.

B.      Have the vendor prepare a brief narrative on how the ACO could use their platform in your care delivery enterprise (related to configuration hierarchies and role-based security).

C.      Include two use cases: one that incorporates the lowest hanging fruit, and one for outliers to capture how the platform handles complexity


3)      Technical Evaluation

A.       Must have a correspondence engine: secure texting/email.

1.       Security protocols?

2.       Capability for importing address books?

3.       How are incoming patient emails or texts handled?

4.       How do you maintain phone numbers for texting?

5.       How do you store texts and/or email?  Is the content ever purged?

6.       Is there a process by which care team members agree to establish a text and/or email relationship with a patient?


B.      Care Snare Alerts

1.       Have the vendor describe the capabilities and functionality of platform rules engine

2.       Ask if the ACO can determine whether alerts are platform generated or rules engine generated?

3.       How would alerts be coordinated with those already in place at the ACO?

4.       What options are available for alerting? Email, phone, text, page, other.

5.       Briefly describe how alerts are incorporated into user workflow?


4)      Integration

A.      Population Risk Management. Import or proprietary number that can be customized?

B.      EHRs – What current integration do you have with EHRs?  Please be specific in terms of the vendor/product and specific data imported and/or exported (e.g., ADT)

C.      Do you currently integrate with any other ambulatory physician practice management platforms/EHRs?

D.      Clinical Data Repositories (CDRs) – Do you currently integrate with any vended or proprietary CDRs?  If not, please address future plans within the product direction section of ACO’s vendor evaluation.

E.       List all formats which you currently support in integration including, but not limited to:  HL7, CCD, CCDA, XML.

F.        Please describe how you reconcile MPI.

G.     PCP Attribution – Please describe how you handle PCP attribution, challenges you experience, and customer sites where PCP attribution is in productive use.

H.      Assessments – please describe the ACO assessment engine in terms of capabilities, current customer usage, and future development plans.


5)      Product Direction

A.      Please describe lab, claims, PACS, medication coordination module, specifically addressing drug-to-drug interaction, pharmacy notifications, and med reconciliation.

B.      What is the current version and release number?  When is the next planned upgrade?  How frequently do you deliver upgrades or product enhancements?

C.      Are all hosted clients upgraded to the newest release at the same time?

D.      Are hosted clients permitted to be on different versions or releases of the product?

E.       Is platform Meaningful Use certified for Stage 2?  Stage 2 requires providers to exchange information electronically with other providers, hospitals, patients, laboratories, pharmacies and public health agencies.


6)       Cost/Value Proposition

A.                  Include TCO and 3-year cost matrix as applicable

B.                  How many resources (FTEs) are required from ACO to support an enterprise platform implementation?  Please briefly indicate what skills are required.

C.                  What resources (FTEs) are required from the ACO to configure and support platform post-implementation?

D.                  Does Vendor provide consulting services?  If so, at what hourly rate?  Do customers typically require consulting assistance?


CJ Fulton is the Director of ACO and Government Consulting for ZeOmega, a leading provider of software for integrated care management.  He brings over 18 years of experience in HIT, population health design, and innovating new health care models for payers, providers and value-based care organizations. CJ and ZeOmega will be exhibiting at HIMSS, February 23rd-27th at Booth #4373. To read more from CJ’s blog, go

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The Department of Health and Human Services is currently working toward “a more seamless and streamlined way to capture the info necessary for value-based payment and ACO.”
A recent town hall session at a Kentucky regional extension center gave officials at ONC the opportunity to connect with attendees to discuss ICD-10, accountable care changes, and health information exchanges.
Also on hand were top officials from the Centers for Medicare and Medicaid Services (CMS).
Although no specific timeline was provided, officials from both CMS and ONC agreed that Stage 3 of Meaningful Use should provide incentive alignment opportunities.  The requirement for Stage 3 criteria and incentives are expected later this year.

via Healthcare IT News

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Carequality, being touted as a kind of second generation interoperability platform, was introduced at HIMSS14 as “an industry-driven collaborative focusing on interoperability needs that will allow current and new networks to interconnect.” Mariann Yeager, the executive director of Healtheway touted the promise of enhaced interoperability as the way forward for more effective health information exchanges (HIE).  Carequality is seen as the next step of standardization in interoperability, and thus far includes 24 different organizations.

Included in that collaborative is the Alaska eHealth Network which looks aheead to a time when consumers have access to their own health data similar to the way that consumers now can access their credit history.  The benefits will likely be to both physician and patient, and ultimately result in a more engaged healthcare consumer.

via Healthcare IT News

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The Congressional Budget Office (CBO), projected an $8 billion surplus under the risk corridors program over the next ten years.  These figures take into account the $500 million estimated loss, which resulted from changes to the Affordable Care Act that allowed Americans with canceled policies to be granted a hardship exemption to the individual mandate.

The CBO based their projections on Medicare Part D prescription drug program.

The fallout from last year’s government shutdown threatened to tie the Affordable Care Act’s risk corridors to a one-year increase of the debt ceiling.  Congressional Republicans have been attacking the effort to soften financial risks of insurer’s selling plans in the first year of newly rolled out health marketplaces.

Via Modern Healthcare

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Two of the key promises of the health IT implementation push are the promise of enhanced workflow efficiencies and technology-driven cost savings.

Under the state of Washington’s Emergency Department Information Exchange (EDIE), the Washington State Health Care Authority recently reported a projected $31 million in cost savings by reducing unnecessary ED visits by Medicaid patients by up to 23%.

The EDIE also allows any ER physician view patient’s treatment plan and provides hospital’s social work staff to receive email notifications that pertain to their patients.

The idea for the EDIE first started when a social worker in Idaho began tracking high-utilization populations, with the goal of improving their care.  Salt Lake City-based Collective Medical Technologies developed the EDIE platform.

Via Healthcare Informatics

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Vermont Information Technology Leaders (VITL), the health information exchange (HIE) in the state of Vermont, plans to speed along their efforts at boosting interoperability after inking a deal with Orion Health.  The resulting integration platform will utilize Aetna’s Medcity HIE, the basis of the VITL.

EHR vendors will be able to automate meaningful use compliant accessibility under the soon-to-be integrated platform.

The VITL connects all but one of Vermont’s 14 hospitals, as well as three hospitals in neighboring states and more than 160 physician practices.

Via HIE Watch

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A recent study at the University of California San Francisco and the University of Washington revealed a significant uptick in medication adherence for diabetic patients who used an online portal to refill prescriptions.

The study looked at 18,000 Kaiser patients over five years. Individuals who requested statin refills solely via an internet-based portal increased medication adherence by 6% and decreased their risk of higher cholesterol levels by 6%.

Of the more than 9 million Kaiser patients currently covered, 4.1 million utilize an online portal.

Via Healthcare IT News

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A new accountable care initiative is underway as of January 1st, 2014 in the city of Denver. Physician Health Partners and Cigna will cover 27,000 individuals, with care provided by 300 primary care physicians.

The launch of the new collaboration brings the number of Colorado residents covered by one of Cigna’s ACO partnerships to more than 75,000.  There are 86 additional Cigna-backed ACOs providing health coverage across the US.

As with some other ACO agreements, the triple aim of accountable care — patient satisfaction, cost savings, and enhanced quality of care —take focus, under the care of a physician’s group, in this new ACO effort.

Via Business Wire

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