Tuesday, June 30, 2020

Patient-centered care in an interoperable environment

The final rule on interoperability from the Office of National Coordinator of Health Information and Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS) were issued early in March of 2020 and were nothing less than a landmark; however, just weeks later, the interoperability rules were pushed back as US healthcare streamlined all of its resources to battle the COVID-19 pandemic.

The interoperability mandates that would have nudged healthcare into a truly digital era became an afterthought as the country dealt with a crippling pandemic. The paradox is that COVID-19 has highlighted the critical need for exactly what the rule would have encouraged: the advancement of interoperability for care coordination and greater data sharing across healthcare organizations.


Interoperability is critical to the fight against COVID-19


Although CMS has only announced a delay in enforcing the rule, the need for making healthcare data interoperability has only become more obvious. Had interoperability gone into effect earlier this year as planned, many healthcare organizations would have been able to securely share the data they have around their patients for seamless care coordination. Data flowing across geographical borders would have been extremely useful in detecting risk factors, identifying resource shortages, and pharmaceutical development.

So far, the current healthcare system is only slightly better than a patchwork of different data systems, and COVID-19 has exposed these gaps. While we have pivoted our efforts to combat the pandemic, the success of these containment measures will heavily depend on the timely exchange of critical information. Healthcare’s response to the pandemic will rely on the effective collaboration of healthcare providers, community health organizations, labs, and insurance companies to test patients, identify patterns of infection, and design ways to improve these activities over time.


Creating a foundation for impactful health innovation


Technology in healthcare has continued to evolve, but the siloed nature of data systems and archaic practices of sharing data thwarts much of the potential positive impact. However, with the COVID-19 outbreak, the stress on frontline healthcare workers to assess a patient’s healthcare history and prioritize them based on their risk has increased dramatically. A patchwork of systems or makeshift data exchange infrastructure will not suffice.

Although electronic health records (EHRs) have been around for a long time now, data from other systems often doesn’t flow into the EHR. As a patient moves from facility to facility in the continuum, the information rarely moves with them, except for physical notes. Implementing interoperability among systems would allow real-time, patient-centered care.

Critical patient information can be delivered to providers to understand more about their patients, their risk profiles, their travel history, previous episodes and more. The quick access to data would be useful in reducing redundancy in tests and procedures and helping the patient receive more rapid care. Additionally, interoperability among providers can ensure that all physicians are accessing information that reflects real-time changes and can better coordinate care among themselves for the patient.

Interoperability can be significantly helpful in reducing patient-facing tasks such as filling out forms repeatedly or explaining their medical history to every new provider. Access to updated and real-time information can result in faster and more efficient treatment and better patient experience of care. In addition to that, the new ONC interoperability rule encourages healthcare organizations to let patients have ownership of their own health data. The patient is the common entity in all healthcare encounters, and it’s important that they have access to their information and that their providers have access as well, because they are ultimately the ones coordinating all of their care.


The road ahead: advancing interoperability for the future


The Coronavirus outbreak demonstrated the importance of the ONC rule. While it’s only an idea of what critical data capabilities we need for future crises, we know that a strong data infrastructure could help in being more precise in our response. Interoperability will ignite significant and sustainable change in healthcare quality, delivery and payment and we need to make sure that individual health systems are connecting in an interoperable as well as an effective way, with a strong, scalable infrastructure backing it up.


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Monday, June 29, 2020

Written employment contract updates for physician practices to consider in the wake of COVID19

Many physician practices have reopened and are trying to get back to “business as usual”. However, it is essential that physician practices take the time to review whether their employment agreements served them well during the pandemic, and what changes might be needed. This is especially important given that we may yet face a second wave of COVID-19.

Most physician employment contracts contain a provision requiring parties to a contract to agree to any modifications in writing. However, as a result of COVID-19, medical practices facing closures and forced service reductions found themselves in a dilemma. How could the practice afford to continue paying full compensation to physician employees with no/reduced revenue? It should be noted that although many physician practices received loans and grants as a result of the COVID-19 pandemic, most practices received inadequate support and the majority of employment decisions came before funding was even available.

Unfortunately, physician practices largely did not follow their written contracts when faced with the challenges of the pandemic. A lot of employers (including large institutions) unilaterally modified their contracts verbally, via email, or a written memo to all employees. Although most employees went along the proposed modifications, others sued their employers for breach of contract.

Of those employers that complied with their contracts, most entered into proper written amendment with their physician employees. Where an agreement could not be reached by the parties, some employers provided notice of termination without cause and paid out the contract term. In other cases, giving notice to the employee brought the parties to the table and an agreement was ultimately reached. Unfortunately, there were some employers that summarily terminated employees who refused to sign amendments and still others who fabricated grounds for termination to avoid their obligations. These unscrupulous employers will likely face litigation as a result of their actions.

From the perspective of an employer, the world has changed. In order to be prepared, physician practices should consider the following updates to their written employment contracts:
  1. Employers should give themselves the right to unilaterally modify compensation. It should be tied to certain events (such as a closure or reduction in services below a fixed amount), and all employees should be treated the same across the board. Employers should clarify when the reduction will end based on objective measures, such as a return to a certain volume of collections, patient volume or similar measurement. Offering a repayment plan to employees or a chance for employees to earn additional income is also a very welcome approach.
  2. Employers should give themselves the right to terminate a contract more quickly when certain events occur, such as a closure of the practice or perhaps a reduction of practice volume below a certain amount. I prefer that termination not be immediate and that a reasonable notice period be provided, but lengthy without cause provisions (i.e 180 days) are inadvisable.
  3. Employers may need to have the right to assign employees different hours and locations in the event of certain specific circumstances. I am always in favor of specificity in a contract as it relates to schedule/location in order to reflect the parties’ understanding; however, the pandemic made it clear that employers made need the right during a crisis to close locations and/or modify clinic hours, and thus the need for flexibility becomes key.

When COVID-19 hit, many physician practices elected to immediately terminate/furlough their physician employees without regard to what the written employment agreement required. It’s important to remember that a contract generally can only be terminated in accordance with its terms, so a physician practice that wants the ability to furlough its physicians or immediately lay them off must revise its contract to allow for such an approach. Again, I suggest the conditions when some provisions may be used be specifically described so as to make the contract as reasonable and fair as possible to both sides.

Every physician practice must think about the challenges it faced (and may still be facing) during the pandemic and what contract provisions could be helpful. Practices should revise their contracts now with practical solutions for potential disaster that could occur in the future, whether related to health, natural disaster or even war.

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Wednesday, June 24, 2020

Physicians are needed for jobs outside of patient care

Physicians choose to take nonclinical positions for a variety of reasons, including to take on a leadership role, concentrate on a particular interest, or address burnout. Nonclinical jobs are available in a number of industries and sectors. Pharmaceutical companies, consulting and professional services firms, the federal government, nonprofits, and other types of organizations can benefit from a physician's medical expertise and patient care experience.

Doctors are not "leaving medicine" by taking a job that doesn’t involve directly diagnosing and treating patients. Rather, they are merely using their skills and expertise in a different way. They help to prevent and manage disease and promote overall health of both individuals and populations. Precisely how they accomplish this depends on the type of organization and specific role.

The following five responsibilities are some of those for which physicians tend to be needed outside of patient care.


1. Analyzing and interpreting


Physicians are in a unique position to be able to analyze health-related data and apply it to a policy, plan, situation, or product. This is due in part to our deep understanding human biology and the pathophysiology of disease. Just as important, though, is our ability to interpret data in a clinical context. This combination allows us to not only come to accurate conclusions, but to apply them appropriately.

Drug safety physicians with pharmaceutical companies analyze adverse event data. Managed care medical directors interpret medical study results to develop clinical coverage policies. There are just a couple of the many examples of doctors analyzing and interpreting medical and health-related data in nonclinical roles.


2. Disseminating and communicating


A significant portion of our medical education is spent learning to be good communicators. We're taught to how to ask the right questions, empathize, deliver bad news, and explain complex topics in lay terms.

Communication skills aside, a medical degree garners some amount of immediate respect in many contexts.

Physicians are called upon to disseminate and communicate health-related information in various contexts. Medical writers convey scientific information through publications. Medical science liaisons communicate similar information verbally. Medical directors of numerous organizational types disseminate relevant medical data to both internal and external stakeholders.


3. Prioritizing and strategizing


A patient evaluation in a clinical setting may reveal a laundry list of signs and symptoms. Physicians rely on their ability to prioritize in order to address the most pressing needs and concerning findings first. Similarly, an overall management strategy is needed to effectively treat complex diseases, making proficiency in strategizing crucial to effective patient care. In a nonclinical setting, physicians may be involved with several company initiatives at one time. Prioritization prevents fires from starting and drives the organization toward its goals.

Physician leaders are instrumental in developing strategy for companies whose products or services impact patient care or human health. For example, a management consultant evaluates the challenges of client companies—which are often healthcare organizations - and recommends strategy to address them.


4. Promoting and protecting


As physicians, we're adept at empowering our patients to make smart decisions about their own health. Physicians in nonclinical roles promote and protect on a population level. For example, the medical officer at a health department oversees use of funds, personnel, and other resources to promote and protect the population’s health.

Many physicians are involved in professional associations, advocacy groups, or nonprofits aimed at ensuring that we're able to meet our patient's needs. Those who enjoy this professional involvement may find fulfillment in a nonclinical career with a similar focus.


5. Improving and innovating


You might struggle to recall a recent day at work in which all your technology worked perfectly, your clinic’s processes ran flawlessly, and your patients followed your recommendations exactly.

There is ample room for improvement and innovation in medicine and in our broader healthcare system. Nonclinical physicians are armed with the experience and expertise necessary to innovate and guide improvements. Physicians working for biotech startups, health IT companies, or in pharmaceutical research do so with a focus on product development. Those working within the professional services sector direct innovation through process improvement and other intangible innovation.

Physicians are indispensable for much more than patient care

Our knowledge and experience as physicians equip us to provide significant value far beyond individual patient care. The examples above are only a few of the ways in which we can contribute to improving the health of individuals and populations through the products, services, and solutions that organizations of many types provide.

It's far too common to hear about physicians who are considering a nonclinical job simply because they are burned out or frustrated by aspects of clinical work. Practicing our profession in a nonclinical setting should be a strategic career decision driven by the benefits that our skill sets can provide beyond a traditional patient care setting.


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