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2008 - The Year in Review

Image2008 accelerated “doctor-squeeze” – a relatively recent phenomenon that financially and emotionally pressures doctors between government and insurance mandates, and patient expectations. Costly technology purchases could no longer be postponed by doctors in 2008, even while an ugly recession eroded patients’ ability to pay. And, insurance restrictions on care delivery further zapped physician morale.
“I feel like I’m actually hurting patients with some scripts I write because I’m limited to the drugs their insurance will pay for, and if I write outside the formularies in order to give them the drug they actually need, patients do without because they can’t afford the medicines,” says one cardiologist who asked to remain anonymous for fear of insurance company backlash. Yet, the much-hailed, oft-hated “pay for performance” measurements reigned supreme.

According to Marc Schillerm, founder and Managing Partner of Rain Partners, LLC, a research, knowledge‐transfer and advisory services firm that serves biopharmaceutical and healthcare clients, the most significant technical developments fell into two primary areas:

1. The US Govt. “That’s right, I’m not kidding. 2008 has been a landmark year for the US government and its push to bring the benefits of technology to the healthcare arena,” he says. Two initiatives stand out in particular:
      (a) The FDA’s Sentinel System/Initiative, a cooperative distributed database to track 100 million patients by 2012, has brought about a shift from PASSIVE to ACTIVE Pharmacovigilance (the fancy word for drug safety).
      (b) ePrescribing to Medicare. With the US Govt in the lead, and an essentially free solution for physicians, we are now well on the way to reducing the incredible suffering due to preventable adverse events. Taken together these technologies will be saving lives, saving money and improving healthcare delivery for Americans. That’s a significant development.

2. The New Generation of Search Engines focused on Healthcare. “Plain old vanilla search as we know it will soon disappear in health and medical matters,” he says. 2008 has seen the introduction of several very different and very unique search engines that provide a completely new user experience. Two especially interesting engines to watch include: Helia and Medstory (purchased by Microsoft for 1.5 billion). Google has introduced sub-categorization and tags in health.

That’s the thing about change, it’s constant. And arguably better change is on the way in 2009.

Lorraine Fernandes, vice president and Healthcare Industry Ambassador at Initiate Systems, says the exchanging/sharing of information in 2008 “across the parking lot and down the road” has become a major market driver as a result of relaxation of the Stark law and the shift to consumer centric care and business models that are addressing physician connectivity and retention. She says this market driver specifically impacts portal and EMPI/Record Locator Service vendors as this technology is required. Additionally, because lab, radiology, medication and other clinical data will be viewed through portal technology, organizations have become more conscious of consumption of electronic or digitally imaged information.

“These local initiatives will have a far more immediate impact on reducing costs and improving patient safety than the regional, state, and national data exchange initiatives,” explains Fernandes. “And, they will accelerate as they can be an interim or final step to advancing electronic medical records in light of our economic crisis.”

As for 2009, Fernandes believes the discussion around privacy and patient identification will continue to heighten, especially with more data sharing, and the recently released Rand report on patient identifiers. “While Congress has forbidden all Federal staff from engaging in any debate, the time has come for a very open debate with scientific studies to finally resolve the identifier issue in the context of safety, privacy, and quality,” she says.

For sure, 2009 will be filled with heated debate and slow but mandated physician compliance – but some of those mandates will come from patients this time around.

“E-prescribing will explode, with more patients demanding it and more physicians adopting, thanks to CMS incentives,” predicts Michael Burger, director of Clinical Product Management at Sage Software Healthcare. “EHR adoption will remain slow but steady, despite the country's economic woes and HIT vendor consolidation will continue. Federal HIT spending will stall in Congress because of budgetary concerns. HIE/RHIOs will need to find a sustainable business model.”

Enter the Patient
“Demand for consumer/physician interaction over the Web will explode, with tech-savvy consumers demanding the ability to schedule appointments, request refills, review record summaries and complete forms online,” adds Burger.

This should come as no surprise, given patient dissatisfaction with physician phone systems. Other changes have been long in the coming as well.

The ability to create pictures of a patient’s internal anatomy and convert them to film through diagnostic imaging has undisputedly revolutionized the way diseases and injuries are detected, diagnosed and treated. But with diagnostic imaging usage at an all time high, and a cost rise from $6.89 billion to $14.1 billion between 2000 and 2006, according to Michael Mardini, vice president of Medical Imaging for Nuance’s Healthcare Division, the process is under tight scrutiny, and changes are expected in 2009.

“Relying on Radiology Benefit Management (RBM) Programs is a solution, however, it is not the best solution to address exam appropriateness and cut radiation costs,” says Mardini. “In 2009, we will see doctors move towards a point-of-service model where order decision support tools are used by the doctor at the time they order their patient’s diagnostic exam. Not only will order decision support allow radiology departments to move away from RBM Programs, which are meant to contain costs for insurers, not serve patients, but doctors will have real-time access to clinical recommendations and exam options that align with their patients’ indications.”

He says 2009 will see the expansion of automated, electronic, decision support tools to help doctors order smarter which will control costs, and “more importantly improve overall patient care quality by ensuring the most appropriate exam is ordered the first time around.”

Better Electronic Records in the Works
EMRs are also up for a 2009 shake-up as systems move further beyond over-stuffed manila files. “We’re all familiar with the overstuffed manila folder decked out with stickers, tags and paper clips, and we’re not the only ones concerned that it is responsible for keeping our health records safe and up to date,” says Keith Belton, senior director of Product Marketing for Nuance’s Healthcare Division. “A 2004 Federal mandate requires all patients have electronic medical records by 2014. However, many doctors are hesitant to switch to an EMR because productivity may be lost due to the time required for technology adoption and data input via the keyboard.”

The speech-driven EMR, powered by companies such as Nuance Communications, eliminates this concern by enabling doctors to create patient documents via voice. “By speech enabling the EMR, patient records are created and available in near real-time; are complete with better notes as they are not limited to click-box templates; and, drive improved care for the patient and benefit doctors who are compensated on a pay-for-performance scale by facilitating more detailed documentation,” says Belton. “The speech-driven EMR also delivers powerful ROI by eliminating the need for transcription services, in-house and outsourced, while streamlining the entire clinical documentation process.”

Indeed, the concept of the EMR is changing every day. In 1997, an EMR was an application that eliminated transcription for office visit notes and certain procedure reports. In 2003, the EMR was expanded to include paper documents (faxes, scans) and messaging. “As we move into 2009, the government and consumers are pushing to interconnect different EMRs with the PHR (Personal Health Record), to create a longitudinal health record (EHR), and the concept will continue to evolve,” says Joe Rubinsztain, founder and CEO of gMed, an EMR provider to specialty practices.

Changing Tools
Physician handhelds are also undergoing serious and useful upgrades. One example: Motion Computing’s 2008 moves. This year Motion added some significant updates which include a Smart Card reader and EasyConnect USB/Ethernet module, as well as a Carry Sleeve that allows the user to easily transport, charge and utilize the C5 while away from the office or standard docking station.

Then there’s the influx of Apple’s iPhone in the medical sphere. The free Epocrates Rx software, designed specifically for the iPhone platform, was available at the launch of the Apple App store in July. The professional drug guide was an immediate hit with physicians, and is continuously ranked as one of the most popular apps in the health and fitness category.

Epocrates provides on-demand drug information for healthcare professionals to reference during a patient consultation. In a clinical scenario, a physician can use the iPhone with Epocrates to look up the correct dosing for a new medication, or enter a patient’s list of drugs to check for potentially harmful interactions. A standout feature for many physicians is the pill identifier tool, which has been central to solving mystery pills patients bring in or cannot recall by name.

According to Jeffrey Wolf, CEO of GenerationOne, one of the most significant advances in the med tech field in 2008 is the emergence of integrated mobile collaborative care solutions. These consumer-facing mobile technologies deliver real-time intervention, interactive communications and targeted clinical decision support via cellular phones and other mobile devices to drive real change in patient behaviors.

“The convergence of existing clinical wireless solutions with mobile technologies that make use of data collected from medical devices such as blood pressure gauges and glucometers, as well as data entered by the user via their phone’s keypad, holds great promise for closing the gaps in traditional disease management and wellness programs,” says Wolf. “In particular, they address the key issues preventing these programs from achieving maximum results, such as non-compliance with prescribed therapies for controlling chronic conditions.”

Mobile collaborative care solutions leverage the immense popularity of cell phones to collect data and deliver actionable information back to patients and providers based on advanced protocols and scripts that tie into evidence-based best practices for a range of chronic conditions. They can be customized according to the specific health needs of the targeted population, enabling focused patient health management.

“We fully expect these integrated mobile solutions for collaborative care to continue maturing throughout 2009, as health plans, employers and providers realize the immense benefits they deliver in terms of facilitating the behavioral changes that are key to effectively controlling and even preventing chronic conditions,” says Wolf.

In a nutshell, 2009 means more out-of-pocket expense for physicians as they struggle to keep up with mandate and technological changes. The good news is that these investments are more likely to finally deliver a pay-off for doctors in 2009.
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