What is Driving Health IT Right Now?

By Joe Wivoda, Chief Information Officer

WARNING: The following is a rant and a plea for a change in direction in health information technology (HIT). I would love to hear what others think. What drives us in HIT? Is it regulation, the vendors, the patients, or quality? 

The Centers for Medicare and Medicaid Services (CMS) just closed the comment period for the Notice of Proposed Rulemaking (NPRM) for the Meaningful Use Stage 2 delay. For many of us the biggest question about the NPRM is what does "implementation" mean in the rule? Does it mean that if the vendor is charging a ridiculous amount for the 2014 version, and we found out after the budget process was complete, we have a delay in implementation? We spend so much time thinking about ways to simplify our lives, whether it is taking advantage of a proposed rule, filing for an exception, or implementing the "low hanging fruit" of the meaningful use menu objectives. I asked myself "What is really driving us in health IT?" Or, more importantly, "What should be driving us?"

Prior to the economic collapse and subsequent American Recovery and Reinvestment Act (ARRA) of 2009, HIT was focused primarily on making incremental improvements and slowly implementing clinical systems. The "stimulus" and associated HiTECH Act provided significant impetus to hospitals and clinics (but not elder care, homecare, hospice, behavioral health, the list goes on) to fully implement and adopt electronic systems in health care. Further, money was allocated to support this effort in the form of the regional extension program and workforce development. These steps certainly moved the needle, and as of today we have 93% of hospitals that have received payment for Meaningful Use!

Achieving Meaningful Use does not necessarily mean you are effectively utilizing an electronic health record (EHR), or even that you are using it properly, but the Office of the National Coordinator for Health Information Technology (ONC) and CMS have steadily made improvements to the requirements such that we are being forced to use EHRs to benefit patients. I see so much complaining and hand-wringing over the Stage 2 requirements around patient engagement and transitions of care, even before attempts were made to reach the measures! Is it really that painful and difficult to get 5% of our patients to look at their health information electronically? Shouldn't we agree that electronically sending summaries of care for patients transferred to other facilities is the right thing to do for ALL patients, not just 10%?

I do agree there are barriers to achieving the Stage 2 objectives, but they can be overcome. Vendor performance is probably the most difficult to overcome, and that is the purpose of the NPRM that allows hospitals and clinics to delay Stage 2 or even go back to 2013 Stage 1 measures this year (assuming it goes through). We need to break the cycle of talking about how we need to implement technology, bring up barriers, react to legislation of finances, and finally make incremental changes. Those of us who work in health IT need to stop making decisions based primarily on what the government or the payers say: We need to listen to the patients!

If we focus on patient safety, patient satisfaction and quality measurement, we will not have any problem meeting the requirements for Meaningful Use or payment reform. Stage 3 of Meaningful Use will likely require even more patient engagement and quality measures, so why not focus on those now? We will improve the health of our communities and improve the financial stability of our organizations. I challenge all of my HIT colleagues to ask yourself these questions each day:

     "What am I working on that will improve the lives of people in my community?"
     "Are my priorities aligned with our patients?"
     "What information do we need to make real improvements in quality?"

Sure, we will still need to meet the requirements of Meaningful Use, ICD-10, the Chief Financial Officer, a cantankerous physician and others, but we need to do everything through a lens that focuses on patients and quality.

Now that I am done with my rant, I have to go see if the Stage 3 requirements came out yet...

MN eHealth Summit: An exciting change in HIT direction

By Joe Wivoda, Chief Information Officer

In June, Minnesota held its annual eHealth Summit in Minneapolis, and fortunately I was able to attend. REACH, the federally designated Health Information Technology (HIT) Regional Extension Center (REC) for Minnesota and North Dakota, had a booth that I was able to staff, which is something I really enjoy. It gives me the opportunity to talk to new people, and I jump at the chance!

Most conferences I attend are focused on rural, except perhaps the Health Information Management Systems Society (HiMSS) conference (more about that later: some very exciting rural HIT news coming soon!!!). The eHealth Summit mostly had urban and integrated delivery network attendees, with rural being in the minority. During my presentation I asked how many people were rural and a few hands went up. Interestingly, most of the hands were from folks who work at other stops along the continuum of care besides hospitals and clinics. There were behavioral health, home care, school nursing, dentistry and elder services represented. This is very exciting! These providers have been left out of the Meaningful Use program, and do not receive incentives or get REC assistance, but they see the value in HIT and are very quickly adopting electronic health records. The eHealth Summit was always a good opportunity to see what the Big Systems were up to in HIT, but now the entire spectrum of health care services is at the table.

Some of the most interesting presentations and discussions involved non-hospital and non-clinic providers. For example, I attended a standing-room-only presentation on Behavioral Health IT. The conversation quickly turned into a sharing and learning experience for the room of over 100 attendees. Some of the attendees were from chemical dependency treatment centers, and they shared their concerns for CFR 42 Part 2: Confidentiality of Alcohol and Drug Abuse Patient Records compliance, while some mental health providers discussed the difficulties of finding an electronic health record (EHR) that is designed for behavioral health and that can do billing well.

Sure, there were a number of presentations from hospitals discussing how they are putting in the infrastructure for exchange or how they engaged staff in the EHR implementation. It was more interesting for me to see providers that are not participating in the Meaningful Use program to be rapidly implementing EHRs and learning from their hospital and clinic counterparts. This is a fantastic development for HIT, and more importantly, for patient care.

Now if we can just get everyone to start exchanging information and talking to each other.

The Center’s Workplace Wellness Program: Wellness-a-thon

By Kim Nordin, Program Coordinator

The National Rural Health Resource Center is a nonprofit organization dedicated to sustaining and improving health care in rural communities. That, in a nutshell, is what we work for every day at The Center. It’s a no-brainer that we would also work to sustain and improve the health of ourselves. Workplace wellness programs are linked to greater productivity, less sick leave, and a reduction of long-term health care costs. And… they’re FUN! And fun has been linked to employee retention, overall happiness and morale. The Center started a workplace wellness program about three years ago, but with only about 20 percent of our staff still participating, we were in need of a revamp. 

This spring, we rolled out our new workplace wellness program. We call it, “Wellness-a-thon.” The goal was to come up with something that everyone could participate in and something that would encourage us all to work toward wellness. We “walk” across the nation, by individually earning “miles” for various activities from four different categories each week. Our categories are:

1. Fitness/Exercise
2. Mental Health/Mind-Body
3. Safety/Preventative Health
4. Nutrition

Location goals for our 2014/2015 Wellness-a-thon

Each month, we focus on a different category, and offer bonus “miles” for each person who completes the weekly challenge. These challenges are to get people to try something new, to get co-workers to engage in something together, and to consciously work on things to make us healthier. Examples of weekly challenges are, “No high fructose corn syrup this week,” or “Always use the stairs this week” (our offices are on the 4^th floor), or “Workplace humor week - send a co-worker something funny” or “Get your flu shot.” We’re also bringing in quarterly speakers to present wellness topics at our staff meetings. 

Shannon from Whole Foods Co-op in Duluth

presented on nutrition and produce tips at a staff meeting

One way to make our program more fun and interactive was to find reasons to gather as a team. We celebrated National Women’s and Men’s Health Weeks in May and June with a healthy food potluck and daily lunch walks on the lake walk. Just yesterday, 10 of us participated in a 5K walk/run fundraiser for our local YMCA. 

Casual Friday, taking a walk to celebrate National Men’s Health Week. I look shorter than I actually am here. I brought my dog, Truman, to work that day. Fact: Dog friendly workplaces make employees happier and more productive (and I can say, I’ve honestly never worked anyplace where the staff was as productive and happy as they seem at The Center. It must be due to the fact that we allow dogs and our fun wellness program!)

It isn’t “all work, no play” around here. We reward each person with a gift card (to a place where something wellness-related can be purchased) once they reach a milestone (130 miles, up to four milestones per year). We are also rewarding ourselves with a wellness activity we can all do together. This month, we are planning to rent bikes to take a group bike ride on our boardwalk together!

I’m proud of our new wellness program. We currently have over 90% of our staff participating in the Wellness-a-thon, and 15 out of 19 of us have reached our first milestone in three months. Over half of us walked or ran in a 5K together, and we’ve collectively “walked” over 3,000 miles in three months (with each staff person able to earn up to 20 miles per week)! 

One of my favorite things is when I overhear a couple of coworkers planning to take a walk together over lunch, or when someone sends me an idea for a challenge or a staff meeting. It tells me that people are engaged and invested in their health, which is what our wellness program aims to stimulate. It’s the little things that really add up when you’re talking about health and wellness, and I know The Center’s passion, diligence and enthusiasm will keep our workplace wellness program alive! 

Our Sidewalk Shuffle 5K teams, "Rurally Fast" and "Rurally Slow Centerites,"

minus Sally Buck, who was running over after a webinar

New Employee Perspective

By Alyssa Meller, MA, Director of Operations

When asked to write a blog post on my first six months at The Center, I said “Sure! What’s a blog and how do I do that?” I’m not sure that is something a person wants to hear from the new Director of Operations, but this is my first shot at blogging, and I want to get it right.

All kidding aside, I love working at The Center. The first six months have flown by. Each time I think I have my feet under me, ready to tackle the day, something different jumps up, and I’m learning something new. I wouldn’t change that at all. It is how I learn and what I like and thrive on.

Everyone at The Center has been supportive and helped make my transition into this organization go as smoothly as possible. The patience with my asking of many, many questions not once, but often a couple of times, amazes me.  Each person has their own style and unique qualities, and I value that. I find it impressive how The Center’s culture respects each person’s skills and experiences and supports their involvement to further not only the goals of each program but The Center’s mission as a whole.

During the interview process I was asked by a board member what I thought would be the most difficult thing for me if I was hired for this position. I responded, “Allowing myself the patience and time to learn my role, the organization’s style and how to work within the organization’s culture.” Now, I probably didn’t say it that eloquently, but it was what I meant and tried to portray. And I can say allowing myself the time to learn the ropes, the processes and how and when to interact has been my biggest challenge to date. I like to get it right the first time, and that doesn’t always happen when you are new to a position and organization.

As I continue in my role and get out and about, I look forward to meeting and working with each of you, The Center’s partners and friends. I am beginning to understand the depth and breadth of our involvement in sustaining and improving rural health care, not only in Minnesota but nationwide, and I feel honored to be a part of that. 

Fragmented, Affordable Healthcare in Argentina

By Leslie Quinn, MBA, Program Coordinator

My name is Leslie Quinn, and I have been a Program Coordinator at The Center for three years. I recently took two weeks off to complete a capstone project for my Master of Business Administration (MBA) program at the College of St. Scholastica. The capstone was a study-abroad seminar in Buenos Aires, Argentina to observe and engage in cross-cultural and global business settings.

The population of Argentina is 42.6 million; one-third of which resides in Buenos Aires. Argentina is an urban country with only 7.3 percent of the population residing in rural areas. It is one of the Latin American countries that spends the most on healthcare. In 2012, Argentina spent 8.5 percent of gross domestic product (GDP) on total health expenditures. The healthcare system in Argentina is comprised of three sectors: private, social and public. The private sector covers about 10 percent of the population, social covers about 50 percent, and the public sector covers about 40 percent. There is no national health system; it is the responsibility of the provinces.

Every citizen has the right to healthcare in Argentina. If they can’t afford insurance, they receive free care in the public sector. To get an appointment, you must go early in the morning, take a number and wait. The system allows foreigners to receive free care also. Medical tourism is a growing industry as people from industrialized countries seek lower cost care elsewhere.

On my last Delta flight I saw an advertisement for Medical Tourism in Argentina in the SKY magazine

Social

There are two defined structures within the social sector: Obras Sociales Provinciales (OSPs) and Obras Sociales Nacionales (OSNs). There is one OSP for each of the 23 provinces in Argentina and the autonomous city of Buenos Aires. The OSPs provide coverage for civil servants; around 5 million public sector employees and their dependents are covered through the OSPs. There are over 300 OSNs, which are managed by trade unions. We visited the Unión Obrera de la Construcción de la República Argentina (UOCRA), which is the construction workers’ union. Large unions, like UOCRA, have their own hospitals and providers that care for workers and their families.

Construir Salud: Obra Social Del Personal De La Construcción
(Hospital for the construction workers)

There are basic mandatory health services required by law that the insurance plans must cover. Employers provide health insurance, but employees can pay extra for a better plan. The government funds obras sociales for retirees and their families, through the Programa de Atención Médica Integral (PAMI), a Comprehensive Medical Attention Program. Did I mention acronyms are just as popular in Argentina?

Private

There are modern private healthcare facilities in urban areas that provide high quality care. Middle and upper class citizens pay for their insurance. Private insurance plan prices are determined by age and pre-existing conditions. There is a new law that everyone can get insurance with pre-existing conditions, but they will pay more. Argentina has higher rates of tobacco use than the United States, but smoking doesn't affect insurance. There is flexibility to move within the system; many people with private insurance utilize the public providers for surgeries and immunizations. Rare surgeries are provided in public hospitals with no bill or debts, but greater wait times. Pregnant women and children under one year of age receive free care, paid for by the government.

On the best insurance plans, you can get one cosmetic plastic surgery every year. Plastic surgery is common and affordable in a country obsessed with looking young, thin and beautiful; retail stores do not sell plus size clothing. Argentina has become a medical tourist destination for plastic surgery.

Providers

The public system has good doctors, but nursing is not professionalized. There is a shortage of people studying nursing because people think of them as maids in public hospitals. Public facilities have prestige as learning hospitals, so doctors want to work there, but they are not paid well. Public doctors are considered middle class citizens, so they usually work half days in public system and have a second job in the private system. There is a shortage of general practitioners in Argentina as most doctors are specialized. Patients don't need referrals; there is direct access to specialty care. Doctors use paper medical records and prescriptions are handwritten.

The wages in rural areas are three times lower than in urban areas. Doctors don't want to work in rural areas because they are not challenged. Rural doctors work in family practice clinics and it is common for people travel to a big city for major health issues. The rural population has lower standards of living, poorer health, more poverty, and higher school dropout rates.

Results-Based Financing

The 2001 economic crisis in Argentina resulted in a rise in the number of vulnerable people without health coverage and increased poverty. Health indicators, including child and maternal mortality rates, deteriorated in the poorest regions, and national averages worsened. This gave the government the opportunity to strengthen its role in the decentralized, provincial health services.

Plan Nacer, Argentina’s Provincial Maternal and Child Health Investment Program, was introduced in 2004. The program was aimed at increasing access to basic health services to address the causes of maternal and child mortality for uninsured pregnant women and children under six years old. The Plan Nacer program is publically funded and supports the introduction of highly innovative results-based financing mechanisms at the national, provincial and provider levels. The objectives were to reduce infant mortality and to modify the dynamics of financing health services.

The program increased the probability of a first prenatal care visit before week 13 and week 20 of pregnancy. The number of prenatal visits increased, and women also benefited from an improved quality of care, measured by increases in the likelihood of vaccinations and ultrasounds. The improvement in the quantity and quality of services translated into healthier births, an increase in average birth weight, and a decrease in the likelihood of children being born with very low birth weight. Finally, for children under age five, the program raised the likelihood of well-baby checkups.

The Plan Nacer introduced results-based financing mechanisms that promoted a new incentive framework for financing and providing health services that rewards providers for increased healthcare coverage, delivery, and staff productivity. This demonstrates movement away from the traditional healthcare system based on inputs and fixed budgets toward one geared at outputs and results. This is a promising incentive model that could be used by the rest of the world. Lessons from the successful Plan Nacer program can be used to strengthen any public health system.

Sources:
Cortez, R., & Romero, D. (2013). Argentina: Increasing utilization of health care services among the uninsured population. Washington, D.C.: World Bank. https://openknowledge.worldbank.org/bitstream/handle/10986/13289/749560NWP0ARGE00Box374316B00PUBLIC0.pdf?sequence=1