Friday, June 30, 2023

How the marriage of primary care and behavioral health is driving the EHR industry

The U.S. is suffering from a mental healthcare crisis. According to the National Alliance on Mental Illness (NAMI), one in five adults in the U.S. experience a mental health disorder each year, but less than half (47.2%) received treatment in 2021. These data points become even more devastating when you consider that suicide is the second leading cause of death among children age 10- to 14-years-old, with one in six kids age 6- to 17-years-old suffering from a mental health disorder every year.

The silver lining here, if there is one, is that deep-rooted stigmas attached to behavioral healthcare are finally losing their crushing grip on our patient populations as more people openly discuss mental health issues. Another step in the right direction: two years after the pandemic resulted in alarming waves of stress, anxiety, burnout, and depression, our federal government announced a strategy to tackle our national mental health crisis during the President’s first State of the Union address. A major component of the national strategy is the integration of behavioral health into primary care settings to make mental healthcare more accessible across patient demographics.

The marriage of primary care and behavioral health has put a spotlight on our healthcare technology frameworks. The industry's ability to move forward and support the seamless integration of behavioral health care into primary care settings is directly tied to our technology capabilities, from advancing telehealth services to the ever-evolving nature of interoperability. As more primary care practices make behavioral health a core element of the patient experience, medical office software and EHR platforms must catch up with industry trends.


The technological challenges of integrating behavioral health


According to the U.S. Department of Health and Human Services (HHS), “limited technology adoption” is one of the most significant challenges to integrating behavioral health into a primary care setting. The cost-prohibitive nature of comprehensive healthcare IT platforms translates to massive technology gaps between primary care practices and the behavioral healthcare providers they are looking to onboard. The federal government has made clear that this challenge is a guiding principle when creating policies that support the integration of behavioral health services into primary care environments. But government-mandated measures will only take us so far.

EHR platforms and the engineering teams that develop healthcare technology must lean heavily into behavioral health integration trends if we want to fully support mental health initiatives. This begins with making interoperability a cornerstone of our healthcare technology systems. To fully embrace behavioral healthcare and expand mental health services, primary care practices must be able to connect their technology platforms to other healthcare systems, including other healthcare providers, hospital networks, payors, and insurance companies.


Beyond EHR: How technology will drive the healthcare industry forward


The exchange of accurate patient data is integral to achieving an exceptional patient experience, and only possible when our EHR systems are truly interoperable. But creating effective technological frameworks does not stop with EHRs and interoperability. A primary care practice must embrace technological advancements that make behavioral health more seamless.

A perfect example of such forward movement involves telehealth capabilities. Healthcare providers – especially those in the behavioral health space – need reliable and easy-to-use telehealth platforms that not only vastly improve behavioral health accessibility but provide a safe and secure environment for patients to discuss mental health issues and treatments. By building telehealth services into practice management solutions, we are giving practices necessary tools to expand their healthcare delivery models and better care for their patients.

Patient engagement solutions are also key to improving behavioral healthcare offerings. Patients want intuitive scheduling capabilities to set up appointments and digital payment options when paying their healthcare bills. They also want validation from their healthcare providers – just like everyone else, patients want to be seen, heard, and acknowledged by their medical team. One way to demonstrate your practice is patient-centered is by ensuring all patient communications, medical notes, and patient charts include the patient’s preferred name.

Using a patient’s preferred name throughout the practice’s healthcare tech stack can be challenging if a patient has changed their name midway through their relationship with a healthcare provider. Primary care practices need anchor healthcare platforms that allow healthcare providers and admin staff to easily save the new name across various platform functions, integrated apps, and patient demographic settings. Getting a patient’s name right across EHR functions, claims, billing and communications is the first step to accurate patient data.


The next frontier of healthcare: Wholly integrated and interoperable platforms


Addressing mental health issues is crucial to providing an integrated and holistic patient experience. Because mental health disorders often lead to physical ailments – NAMI reports that 40% of patients who suffer from depression have a higher risk of developing cardiovascular and metabolic diseases – behavioral health services can have a major impact on patient outcomes. But it will take more than simply hiring behavioral healthcare providers to integrate behavioral health into primary care environments.

Building a truly integrated and interoperable healthcare landscape means adopting EHR platforms and healthcare technology that supports behavioral health issues. A practice’s ability to address mental health disorders is directly connected to the practice’s technology platforms, from being able to accurately chart patient histories with correct CPT and HCPCS codes to offering best-in-class telehealth capabilities and preferred-name recognition features.

Patient-centric, value-based healthcare systems are only as successful as the technology that underpins our healthcare providers and networks. As part of the healthcare technology industry, it is on us to build and advance EHR platforms and medical office software solutions that support behavioral healthcare needs.


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Thursday, June 29, 2023

AI's role in identifying, treating metabolic conditions

I am a fifth-generation western Kentucky native, and I am told one of my great-grandfathers was the only person enlisted in the Civil War for the Union from Marshall County. I did my pediatrics training at Washington University at the St. Louis Children’s Hospital. I was fascinated during my interview process with far-flung children’s hospitals like Seattle Children’s. In the end, I connected with my program officer Jim P. Keating and decided to stick close to home around Paducah, Kentucky. It made sense to stick close by in a large medical specialty group after residency, but after seven years I decided to do a solo house call practice in St. Louis, Missouri. Concierge medicine was heating up, but I think the industry thought it a bit odd. Back in 2009, I got a phone call from Mayo Clinic asking me to present at the Transform Symposium about “customer experience.” Shortly after that, Brian Dolan from MobiHealthNews called me “the first iPhone doctor” for seemingly having my medical practice rigged up to my iPhone while pulling e-commerce payments.


Status quo medicine was never my thing.


I decided to try my hand at rural solo practice in the very county my great-grandfather was from. The move back to Kentucky was stark. I went from making house calls in several of the most affluent zip codes in the country, to treating families in the least. The thing that impressed me the most about the region after having been gone for such a long time was the sudden deaths of high school friends in their mid- to late 40s. Obesity was rampant. Everyone had a couple of chronic diseases. I didn’t recognize my friends. Something horrible happened while I was gone.

Patients were coming in, eager and just so thrilled that I was even there. I would tell teens and their families what to do during their checkups. Families who never drink water. Families who dislike vegetables. A year later, they would return only to have gained 10 pounds rather than lose any. Then, a patient came in and had lost some weight using one of the consumer apps. I could see the value, but noticed that I didn’t truly provide any of that value. Luckily, Doximity and Healthtap came calling with adviser roles and a full-time telemedicine offer I couldn't refuse. Before I knew it, I was recruiting our team to solve this blind spot of health care: the time in between visits in which patients progress from obesity, prediabetes, and pre-hypertension into full-blown chronic disease.

Today, there is an app for everything. Wearables are ubiquitous. Consumer health mobile programs, employer-led programs, and payer-led programs are available for patients to improve their health. But where is the primary care provider? We are drowning in problems and struggling with burnout. We are expected to hold responsibility for outcomes, but without any prior training (or tools) in affecting health behavior change.

Robert Wilson, MD, put his problem succinctly in this recent episode of the Startup Health Now Podcast. Medical practices are inherently reactive, and the challenge of embedding proactivity into that system is a top priority:

“A lot of primary care providers are not happy with the status quo. We don’t like the fact that we have to wait until someone is sick in order to really impart our clinical judgment. So, we would love to find ways to integrate prevention and risk reduction and all of these things into our daily practice. Especially family medicine. We take care of the whole family. When we impart our advice, it trickles down through the entire family. So, if we have a system of apps or integrations that will allow us to give that information in a more timely manner, that's going to be something much more meaningful.”

I attended a telehealth conference in 2022 led by Eric Thrailkill and his team at the Nashville Entrepreneur Center. I sat in the audience trying to drill down further on the provider problems evidenced by the leaders of medical schools in Nashville. Several themes related to patient-generated data emerged from the noise.

There is a firehose of patient-generated data coming in, but:
  • It’s not filtered.
  • It’s not actionable.
  • It doesn’t fit within my workflow. (I am not getting this information at the right time.)

Then there are patient problems, described succinctly in this infographic from the U.S. Centers for Disease Control and Prevention. Heart disease, cancer, chronic lung, stroke, Alzheimer’s, diabetes, and chronic kidney disease: These are the leading drivers of our nation’s $4.1 trillion in health care costs.

The challenge in primary care is to systematically learn about the entire population, educate the population on their risk, quantify their motivation level, then stratify patient populations into groups. Everything has to fall together at the right time. You must get actionable data to primary care physicians before their patients leave the office. Then, they can implement the provider-led interventions you have created to engage patients throughout this "blind spot" of health care when chronic diseases are progressing.

I am a pediatrician, so the solution to our chronic disease problem has been obvious to me and my fellow primary care colleagues for a long time. The Affordable Care Act is working in reverse to impact hospital costs:
  1. Waiting until a 74-year-old heart failure patient is heading home from the hospital to enlist in chronic disease management or remote monitoring is waiting too long.
  2. Waiting until a 64-year-old patient has been diagnosed with diabetes to then focus on their med adherence data and analytics is waiting too long.

Waiting until a 59-year-old patient with obesity develops diabetes and hypertension and then “managing their condition” with medications and specialist visits is waiting too long.
Waiting until an overweight 42-year-old develops the full picture of metabolic syndrome to then discuss pharmacotherapy is waiting too long.

We need to embed prevention across our entire patient population and automate as many of those processes as possible with algorithms and artificial intelligence to make our days easier, engage our patients, and show them we care.

Today’s patients are ready to live happy and healthy lives in their homes, free of metabolic disease. Now is the time for providers to lead the way by offering engagement programs and provider-led interventions that will create drastic cost reductions early in our rising risk populations.


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Wednesday, June 28, 2023

Common pitfalls in a doctor's first year in practice

Congratulations for making it through medical school and residency, and even perhaps a fellowship, and now you are ready for your first or second job out of school. Finally! You may be clinically prepared, ready to see patients and begin procedures, but are you ready for those first few years from a practice management perspective? In my experience, here are four areas that trip up new doctors the most.


First has to do with contracts.


Negotiate them, find out what you are worth, and know how to slow things down and advocate for yourself well.

Understand the expectations. Are you supposed to supervise advance practice providers (APPs)? Is the compensation and bonus structure easy to understand? Are you supposed to be on call nights and weekends? See patients 34 hours per week in the office? Have certain productivity expectations? Do you have sufficient paid time off (PTO) and continuing medical education (CME) reimbursement? Fully understand what’s expected and see if it’s reasonable or something you need to negotiate.

And find a back door OUT. This will likely not be the job for your entire life, so find a way that you can exit this agreement with a certain notice period – like 90 days, without any strings attached. Then walk through in your mind what would happen if you leave. Is there a tail policy you have to pay? A penalty? A noncompete? Think through all these before you sign.


Second: Pay attention to the fraud and abuse statutes.


You go into practice so well trained about clinical medicine, but often have no clue what business relationships can get you into trouble or what to avoid.Remember this: If it’s too good to be true, IT IS. If someone is giving you money for not much work, if something smells funny, if there is an underlying motive behind it, be cautious. As a physician, you are an especially attractive target for kickback schemes because you can be a source of referrals for fellow physicians or other health care providers and suppliers. Patients trust you. You can at times help your patients decide what drugs they use, which specialists they see, and what services and supplies they get. If you tell them to use a certain lab or certain drug, they do. Companies want your patients and their business and will incentivize you however they can to get business thrown their way.

Be careful with relationships you have with labs, medical director agreements, and any revenue sharing arrangements. Don’t just share space or resources with anyone you refer. There are many well-meaning physicians sucked into fraudulent schemes disguised as legitimate business deals. Usually, the physicians involved were approached by a sophisticated and well-appointed company with a “shiny” proposal and big law firm opinion of support, assuring doctors that everyone else is joining or signing up. Please never believe these assurances. Just remember this: Ask questions and get your lawyer to review it. I promise you it’s money well spent to not have to unwind an illegal deal.


Third: Always protect yourself and have an advocate fighting and reviewing things for you.


Never trust another lawyer, another doctor, or another partner without doing your own homework. Trust, but verify. This is so important. You don’t always have to tell your potential new partner or your employer that you are calling your lawyer for advice. Your communication with your lawyer is privileged and confidential, and they can be a sounding board for you. Many times, I end up writing emails that my clients send, or raise red flags my clients raise, and no one else knows that I exist. If you don’t have a good relationship with your lawyer, find a another one. But think about it when someone says, “This has been vetted by legal.” Who does that lawyer work for? If it’s not you, get your own opinion.


Lastly, know the importance of compliance and how to report problems.


You don’t want to be the office tattle, but what if you start to see something in your first job or two that raises red flags? How do you handle it? If you are working for a small group, make sure they have a compliance plan. Make sure there are some basic audits of the billing and coding in your practice. Hiring your own auditor is a good thing! So many doctors think they know how to bill and code but then end up messing it up, and that can really cost you. Remember that if your partners are messing things up, it can come back on you as a member of the company. If your APPs are billing out under your national provider identifier (NPI) and not following the incident to rules, that comes back on you. So you don’t have a choice to bury your head in the sand. You need to know the basics of compliance.

I know the first year can be hard, but with knowledge of what can trip you up, you can be better prepared to avoid the bumps along the road.


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