Pain Points and Concerns in Healthcare

Part
01
of fifteen
Part
01

Pain Points - Clinicians in Hospitals, Outpatient Centers, Doctors offices.

Pain points and concerns of clinicians in settings such as hospitals, outpatient centers, and doctor's offices include electronic health record (EHR) usage, patient record-keeping and communication between the involved parties and care providers (a key factor in ensuring patient safety), MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and regulatory requirements in general, and general feelings of burnout.

The focus of our research is mainly on the post-acute, long-term, and ambulatory arenas, excluding general primary care physicians. Some results are related to physicians in general, though since the hospital or outpatient setting (included as the focus on this request) tends to encompass a large part of healthcare providers/clinicians, it seems reasonable that these are applicable.

1. Electronic Health Record (EHR) Usage

Challenges clinicians face with Electronic Health Record (EHR) usage include limited interoperability, difficulty in handling burdensome requirements, a lack of EHR usability, and reduced face-time with patients. Details of each of these are provided in an EHR Intelligence article from August 31, 2016.

Limited Interoperability:
EHR systems are used by "over 90%" of the healthcare industry, and the focus has shifted to exchange of health data between EHR and other systems, though with only minor progress. Exchanging health information from one clinician or hospital to another is limited, putting patient safety at risk, especially in emergency situations.

Difficulty in Handling Burdensome Requirements:
After EHR adoption, Medscape found that patients described a "48%" decrease in clinician workflow in a 2016 report. Reporting in EHR is often complex and burdensome for clinicians, with the "EHR Incentive Program out of the Centers for Medicare & Medicaid Services (CMS)" exemplifying a report measure with difficult guidelines. Strict standards in documenting records and engaging with patients often inhibit the clinicians from focusing on a patient's immediate health needs.

Lack of EHR Usability:
When completing tasks in EHR, clinicians find that the system is counter-intuitive and can slow down productivity. Lack of usability is a "primary pain point" for clinicians, as reported in a Frost & Sullivan study.

Reduced Face-Time with Patients:
EHR hinders engagement between the doctor and the patient, with system computers cutting into important face-to-face time and getting in the way of relationship-building. Medscape's 2016 EHR study reported that "57%" saw limited clinician-patient interaction time with the system in the way. Also, "50%" found EHR usage detracted from the total patients the clinicians could see each day.

2. Patient Record-Keeping and Communication Between the Involved Parties and Care Providers

Known as "telling the patient’s story," clinicians find that communication between involved parties and care providers is a key pain point. The exchange of patient healthcare information between responsible parties is a point of contention for physicians, because information can be difficult to sort through when looking for important data (known as "information foraging"), communication between healthcare providers must be "rapid-fire" quick, there is a medical jargon overload, and a lack of structure in communicating between parties.

Patient transfers are a concern for clinicians for the patient complexity, difficulty in identifying a best-scenario healthcare setting, increasing financial pressure, and obstacles to efficient communication between involved parties and care providers. A survey conducted by Philips and Regina Corso Consulting finds that healthcare data is becoming increasingly important in maintaining patient safety, with "74%" of clinicians and nurses saying that a lack of patient data during in-hospital transfers puts patients at risk.

3. MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and Regulatory Requirements

MACRA (Medicare Access and CHIP Reauthorization Act of 2015) governs how physicians are compensated based on patient healthcare outcomes and the quality of clinicians in treating patients. While it was initially widely accepted by physicians, it has been found to hinder smaller clinics with fewer resources and favor larger hospitals with a vast amount of staff and healthcare capabilities.

MACRA strains physicians financially and administratively, as it requires clinicians to track their quality of care. According to Ropes & Gray in 2017, "physicians must purchase and maintain costly information systems, including EHR" in order to reach performance goals. Clinicians find it to be costly and time-ineffective.

4. General Feelings of Burnout

A Physicians Foundation survey finds that "30.6%" Primary Care Physicians describe feeling burnt out. Of the PCPs surveyed, "29.0%" said they feel that they are overworked and overextended. PCPs who feel that they are at a full patient workload capacity account for "52.2%" of those physicians surveyed. A general feeling of burnout is a theme with clinicians regarding pain points.

Summary

In summary, the key pain points and concerns of physicians in settings such as hospitals, outpatient centers, and doctor's offices include electronic health record (EHR) usage, patient record-keeping and communication between the involved parties and care providers (a key factor in ensuring patient safety), MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and regulatory requirements in general, and general feelings of burnout. These are the major trends and key findings found during research.
Part
02
of fifteen
Part
02

Pain Points - Chief Information Officers in Hospitals, Outpatient Centers, Doctors offices.

The short answer is that many CIOs in US hospital settings cite security and privacy, data management, compliance, expanding responsibilities, limited resources and administrative barriers as major concerns or pain points. However, I did not find information specific to the post-acute and long term care ambulatory management spaces. This is based on a consolidation of healthcare and technology news, reports by healthcare consultancies, and reports by companies providing healthcare services published between late 2016 and late 2017.

Security and Privacy

Security was the top challenge facing healthcare CIOs in 2016, as voted by 22 experts in a survey by healthcare data service provider Royal Jay. Changing regulatory requirements and the increased sophistication of cybercriminals has increased the risk of data security breaches in healthcare. CIOs are focusing on investments into protecting hospital data despite the high costs involved and difficulty of evaluating the value of different technologies to achieve this end, and recognize the need to educate or sensitize staff to cybersecurity risks.

MANAGING DATA

ELECTRONIC HEALTH RECORDS
Improving the interoperability of electronic health records (EHRs, also known as electronic medical records) and the integration of legacy systems are among the top challenges facing healthcare CIOs in 2016, according to the Royal Jay survey and a survey of healthcare CIOs conducted by Spok, a clinical communications solutions company. More reports from 2017 confirm this is a continuing concern, especially in optimizing information systems. Further concerns about EHRs include ensuring staff have access to as complete a picture of a patient as possible, consulting staff in various hospital roles on implementation, collaborating with vendors to develop solutions to improve accessibility by patients, and the integration of EHRs during mergers and acquisitions.

Telemedicine capabilities, or providing remote patient diagnosis and treatment, is one of the key benefits of implementing EHRs. CIOs identify a range of concerns in this respect, including improving interoperability across the care continuum (outside and within, and before and after hospital treatment), promoting innovation (by sending patient experience data directly to the FDA and facilitating inter-clinician communication), and seeking innovation funding to leverage on the potential of EHRs to meet the above goals.

LEVERAGING ON DATA ANALYTICS
Healthcare organizations are also increasingly conscious of possibilities of improving care using data insights. Most hospital CIOs recognize the importance of sound data management strategies, with the aim of increasing trust in organizational data, according to a 2017 Healthcare IT News article. However, the same article states that CIOs are facing challenges with implementing hospital-wide data governance due to varied buy-in from hospital leadership, differences in how data measures are defined, conflict and disagreement between departments and challenges due to time and unforeseen costs. Hospital staff may also struggle with information overload and burnout due to the tiresome and tedious technical work systems such as EHRs demand.

Compliance with regulations

Maintaining compliance in the face of changing and complex regulations is a commonly cited pain point of hospital CIOs. The complexity and ambiguity of Meaningful Use compliance regulations and expectations, in particular, was identified as a challenge. Meaningful Use is the concept of using certified electronic health record technology to achieve a variety of goals, including improve quality, safety, efficiency, and reduce health disparities, as well as engage patients and family and improve care coordination, public health, and maintain the privacy and security of patient health information. It was claimed that these nebulous regulations are tough to meet throughout the key stages of a big project like EHR implementation which include implementation, stabilization and optimization.

Expanding Responsibilities

The consumerization of technology, among other shifts in healthcare and technology, have resulted in the bloating of tasks handled by hospital CIOs. Duties can span from managing operations and overseeing integration during mergers and acquisitions, to crafting long-term strategies and supervising many product life cycles with limited resources. A CIO interviewed by Boardroom Insiders states that the role involves being "a strategist, a visionary, a salesperson" to "create collaboration across multiple lines of services". Many have observed a shift in their main role, from applying expertise in technology and overseeing procurement, to matching operational change to technology; one CIO uses “orchestra conductor” as an analogy for the latter. Yet another cites a transformation from technical and financially-driven projects to clinical and business-critical projects. Yet the persistent challenges for CIOs in spite of this new context remains the balancing of regulation and innovation, and of time-sensitivity and resource allocation.

Limited resources

CIOs face resource constraints that constitute two faces of the same coin. On one hand, they must work within a limited budget. A poll of more than 100 CIOs and CMIOs by Dimensional Insight, a developer of business intelligence tools, revealed that 70% of respondents said limited resources have hindered the momentum of their data governance initiative, while 57% said resource scarcity was the biggest challenge they face. On the other, they face difficulties minimizing and justifying expenses. For example, hospital CIOs are pursuing te adoption and buy-in of mobile applications, but the Spok survey found that 54% of participating CIOs continue to consider mobile adoption and buy-in a challenge. Almost half of them cited funding as a top challenge for rolling out secure texting between physicians. There are limited insights on the benefits of particular technological investments as hospitals have no standard or effective way to asses either potential returns on investments, or the efficiency with which a particular technology is being used. CIOs also have to confront a management approach which places more emphasis on short-term than long-term returns on technological investments. Ancillary concerns include achieving success with new payment models, and addressing the talent gap due to a lack of human resources with the requisite IT skills.

Administrative barriers

Discrepancies in governance processes between organizational departments continue to be a concern for hospital CIOs. The Dimensional Insight poll found that 71% of the CIOs polled claimed to experience discrepancies between measures (such as those of clinical or financial data) across departments. Half said there were discrepancies across clinical departments, such as differences in definitions used, which may be organizational, or industry-derived. Obtaining buy-in from physicians and hospitals for technological investments and implementation, as mentioned briefly in several of the above sub-sections, also continues to be a key issue.

Conclusion

The top issue for CIOs in US hospitals is the protection of hospital data, perhaps unsurprising as the threat of cybersecurity breaches in healthcare is both high and increasing. Following this, CIOs are broadly focused on addressing issues relating to implementing and integrating EHRs and other mobile patient services, maintaining compliance in the face of complex and evolving regulations, securing buy-in and the necessary resources for implementing technologies, and battling the heterogeneity of department-specific protocols and governance practices.
Part
03
of fifteen
Part
03

Pain Points - Chief Medical Officers in Hospitals, Outpatient Centers, Doctors offices.

We were able to compile a list of "pain points" faced by Chief Medical Officers (CMO) based on pre-compiled lists of "top" concerns. We found that one of the more pervasive pain points—as it's featured under each heading below—is the complicated health IT system that takes CMOs away from their actual work causing them to spend hours in training. This often leaves many feeling burnt out and demotivated to do their work. It also takes many physicians away from their patients.

PAIN POINTS IN HOSPITAL SETTINGS

1. "Harnessing Performance Data for Change"
While many organizations are "confident in their ability to access data," this confidence is not reciprocated when "leveraging that data to drive action across the organization." CMOs often find themselves sitting with large amounts of data and not knowing what to do with it.

"Combating physician burnout and change fatigue," is a pain point faced by many CMOs. As the health industry continues to change at a rapid pace, many physicians are feeling the pressure to keep up. According to The Advisory Board Company, these changes are "causing unprecedented burnout among physicians."

3. Complicated Health IT Systems
According to the Electronic Health Reporter, Chief Medical Officer, Dr. Donald Burt, the biggest Health IT pain point is that physicians are forced to use hospital systems that are not "designed with physician users in mind." Physicians often have to spend hours, sometimes days, away from their work in systems training. Another pain point, by CMO, Dr. Trishan Panch, is "a health system’s inability to scale care management resources." Dr. Trishan Panch states that the care management resources are able to improve outcomes when patients are involved, however, there are limitations "(i.e. human interaction via phone or in-person)" which only engage a small portion of the patient population.

4. Failure to Diagnose
According to the Sullivan Group, one of the major pain points for many CMOs is "the failure to diagnose." This is evident as "three-quarters of funded safety projects have a ‘failure to diagnose’ focus."

PAIN POINTS FOR OUTPATIENT CENTERs

According to CMO feedback, there needs to be greater "problem-solving on access to mental health resources."

2. Housing vs. Treatment at Emergency Departments
In this instance, a shift needs to be made away from housing patients in emergency departments to treating patients in emergency departments.

3. No Standardization of Assessments
There is no uniform way of doing assessments. According to CMO feedback at the Institute for Healthcare Improvement forum, healthcare organizations need to "incorporate and standardize best practice," across the board. This can be done by defining common goals and providing support to organizations and providers through better communication, clear expectations, and providing tools.

4. Lack of Inter-Organizational Trust
Developing trust comes into play once a shared mechanism for standardization is put in place. This will foster organizations and providers to "[s]hare knowledge, new ideas, and wisdom with
transparency and honesty."

5. Lack of Ambulatory Quality Strategy and Infrastructure
According to The Advisory Board Company, "[d]eveloping an ambulatory quality strategy and infrastructure" is an area that needs improvement. Many CMOs feel that they have great "performance improvement efforts," but they do not have "the same span of control, infrastructure, or leverage," when it comes to influencing post-acute care facilities.

6. Need for Better Metrics to Prevent Readmission
According to an article by Hospitals and Health Networks, CMO, Dr. Brent Wallace states that incentives are mostly based on what is important to the doctors or hospitals, and very little on the patient. Wallace believes that health care metrics need to be more patient-centric and, for example, look into "specific socioeconomic or behavioral reasons," that bring patients back into hospital beds.

CMOs feel more pressure as a result of the Hospital Readmissions Reduction Program (HRRP), "a national mandatory penalty-for-performance program." The main critiques CMOs have of this program is that the penalties are too high and that hospitals do not have the ability to influence patient adherence.

PAIN POINTS AT DOCTORS OFFICES

According to an article by Dr. Eric Bricker, trained internal medicine physician and Chief Medical Officer of Compass Professional Health Services, many physicians face the following challenges:

The Medicare Access and CHIP Re-authorization Act (MACRA) plays a role here. MACRA ensures that healthcare reimbursements are based on value rather than volume, and this shift has created many documentation issues for practices and CMOs, alike.

Prior authorization requirements have increased over the years. For example, in 2007, 8% "of drugs in private drug plans covered by Medicare Part D required prior authorizations", which went up to 23% by 2015.

3. "Lack of Negotiating Power with Payers"
As payers consolidate, physicians find themselves with "declining reimbursement and narrowing provider networks." Physicians are now finding themselves "a 'take it or leave it'" situation with payers.

With the increasing workload and frustration of not being able to spend enough time with their patients, many doctors are starting to find it difficult to stay motivated.

Patient satisfaction scores play an increasingly important role "in how physicians are treated by their employers and insurers." Patients now enter their doctor's office with a long list of self-diagnosis from information they have found online. They request numerous tests and responses to their findings. This makes the doctor job even harder and added to the pressure is that sites such as "Yelp, RateMDs, and HealthGrades.com," provide ratings and reviews by patients regarding their experiences with named physicians.

SUMMARY

The most notable pain points experience by CMOs are that all the rapid changes occurring in the healthcare system are causing them to spend more time away from their patients and their work. In their efforts to keep up with all these changes, which are predominantly systems based, many CMO's are starting to feel burned-out and demotivated.
Part
04
of fifteen
Part
04

Pain Points - Patients in Hospitals, Outpatient Centers, Doctors offices.

Waiting times, healthcare costs, poor communication, confusing prescriptions, and an over-complicated health insurance system are major pain points and concerns facing patients in a hospital setting. Below you will find details of our findings.

METHODOLOGY

In order to answer this question, I first searched for pre-compiled data on pain points and concerns of patients in a hospital setting, such as lists or academic papers published in the last 24 months specifically focusing on the US, and particularly focusing on post-acute and long term care ambulatory management spaces. I found that there is no pre-compiled data available; I believe that this is because the data has yet to be collected. I then extended my search to look for individual pain points and concerns discussed in online articles, news reports and online healthcare publications. Finally, while I initially focused my search on data relating to post-acute and long term care ambulatory management spaces, I found that data on this area published in the last 24 months was fairly sparse. I believe that this is because it is quite a specific area of investigation. So for this reason, many of the pain points relate to patients in the hospital setting in general, with reference to post-acute and long term care ambulatory management spaces where possible.

PAIN POINTS/CONCERNS

— WAITING TIMES

Patient waiting times in the doctor's office are a major pain point for patients in the US. In fact, in the last three years it has been recorded that physician wait times in large metropolitan markets have risen by 30%.

— HEALTHCARE COSTS

Rising costs are also a major pain point. Patients are concerned over rising costs of healthcare, and are making decisions based on this. Research shows that "employees' health premiums have been rising at about twice the rate of annual salary increases". This puts into perspective how rapidly healthcare costs have become a problem, even for those who can afford their premiums. In addition to this, it is suspected that the brand-name drugs, which account for 13% of US prescriptions, are driving up these costs. This has lead to further issues relating to this concern. Patients are reporting not filling their prescription (25%) or skipping doses (19%) because of medication costs. Not filling their prescription often comes as a result of the patient arriving at the pharmacy with their prescription and finding that the medicine is out of their budget.

— POOR COMMUNICATION

In terms of long-term settings, poor communications is a major pain point. It has been found that 1 in 3 chronic patients do not understand their illness. Research shows that as much as 30 to 40 per cent of patients with a chronic illness have difficulties understanding the health information available on their own disease, and find it difficult to interact with health care professionals." In addition to this, this NY Times article also supports the fact that being ill-informed is a pain point for patients, particularly those with serious illnesses.

— CONFUSING PRESCRIPTIONS

Prescriptions being thought of as confusing are another major pain point to patients. Misunderstandings and unclear communication surrounding what dosage to take at a given time, and uncertainty as to whether or not they properly took their medications, has lead to 20% of US prescriptions never filled, and 50% not taken properly. In addition to this, many patients voice concerns that they do not understand why the have been prescribed a particular medication.

— OVER-COMPLICATED HEALTH INSURANCE

Over-complicated health insurance has become an increasingly prominent pain point for healthcare patients. Health care insurance is referred to as a maze, in which there is limited information available to guide patients to help them understand what exactly they are covered for, and this causes great anxiety. There is a great body of anecdotal evidence of patients facing large unexpected bills as a result of not fully understanding their healthcare insurance. Complication-facing patients regarding their healthcare insurance has become a common problem facing Americans.

CONCLUSION

To sum up, I have found that waiting times, healthcare costs, poor communication, confusing prescriptions, and an over complicated health insurance system are major pain points and concerns facing patients in a hospital setting.
Part
05
of fifteen
Part
05

Pain Points - Clinicians in US Healthcare Systems

Clinicians today are facing a wide array of pain points in the industry, ranging from patient reviews and awareness to burnout or the over-presence of administrative duties. As more clinicians are tasked with completing copious amounts of paperwork, the amount of medicine that they actually get to practice is beginning to decrease, leading to large amounts of stress. Additionally, the pressure for positive patient reviews online by other administrative persons in the health care system is causing clinicians to feel as though they must provide unnecessary care or over-treat patients in order to secure a positive patient review. Below you will find a breakdown of five major pain points that clinicians are facing in the U.S. health care system, as well as the effects of these concerns on clinicians.

Lack of Preparedness

More often today, clinicians working in long-term care or chronic care management are finding that they are unprepared for handling the patient's situation adequately. According to the Commonwealth Fund National Survey in 2016, around 25% of clinicians do not feel fully prepared to care for patients with chronic diseases. As the number of patients that are suffering from a chronic disease continues to grow, this problem is only going to worsen. In 2016, around 58.5 million U.S. adults were suffering from some sort of chronic illness, and this number is only expected to grow in future years. Although there are efforts out there to increase education for clinicians attending to patients that require long-term care due to chronic illnesses, this still remains a major area of struggle for doctors everywhere.

Lack of Motivation & Burnout

Perhaps the largest area of concern for clinicians today is the lack of motivation for working anymore. Much of this is due to the time spent doing administrative work, as opposed to practicing actual medicine on patients. Clinicians did not originally plan on going into the medical field to carry out organizational or administrative work, and so this information often becomes either neglected entirely or is taken on by physicians who then end up lacking in the provision of patient care. Although administrative work is required for any position in the medical field to some extent, it should not be the job entirely. In 2016, 54% of clinicians reported losing enthusiasm for their work, an increase of 10% from 2015, due to the lack of medicine that they can practice because so much administrative work needs to be completed. Additionally, the same percentage of physicians also reported signs of burnout in 2014, an 8% increase from 46% in 2011.

Conflicts with Patient Reviews

The use of online platforms such as Yelp and RateMDs has had many negative effects on clinicians that are currently practicing medicine. Through these platforms, any patient can comment and post about their experience with a specific doctor or medical facility. These posts can often be biased or uninformed, leading to a negative connotation to be attached to certain physicians, or even an entire workplace. The pressure that these reviews put on clinicians is also having negative effects. In 2016, 58% of clinicians felt pressure from administrators to improve patient satisfaction and reports on such platforms, by providing unnecessary care or treatments. Additionally, more than 75% of these clinicians felt that the emphasis on patient satisfaction led directly to the overuse of expensive patient testing. The weight placed on patient surveys online and through other methods has led to the unnecessary testing and treatment of patients for conditions, which in turn is leading to more expensive patient bills that only further upset the patient.

Disruptions from Self-Informed Patients

The use of technology and the internet by patients to self-treat or self-diagnose their symptoms prior to visiting a doctor is causing major issues for clinicians, as well. Just like with online review platforms, the use of Google searches by patients is providing individuals with the power to arrive at appointments with information in-hand that is oftentimes incorrect, leading to dysfunctionalities between patient and doctor. Patients are now starting to view doctors simply as advisers, rather than actual medical personnel that can help them. This sort of setup leads to orders for unnecessary diagnostic tests and medications just to ease the mind of the patient, which also leads to heftier patient bills. To make it worse, around 25% of patients do not follow the treatment prescribed by clinicians, as they feel they have more information at their fingertips online than they receive in a medical office. As patients begin to feel like they can do more on their own than a clinician can provide them with, the job dissatisfaction of doctors continues to grow.

Financial Burden of Re-certifications

In an attempt to keep clinicians up-to-date on best practices and current drugs on the market for patients, medical personnel are often required to seek the re-certification of their medical licenses. This process often proves to be extremely expensive, which adds to the stress put on doctors by all of the previously listed stress points. Additionally, many clinicians are feeling as though the process by which to obtain a re-certification is twisted and contradicting. The money that goes towards paying for certifications from an organization often is used to promote the use of study materials or exams that are required for the certification itself. This process proves to be of high-stress for clinicians everywhere.

Conclusion

The constant pressure by administrators and patients to provide quality patient care is leading to a decrease in patient happiness and greater amounts of stress on clinicians. As more patients are walking into offices with ideas already in mind, the care provided is only being judged on what is going wrong. With the increase in administrative work that clinicians are being tasked with completing, it is becoming increasingly difficult to meet all needs of the patient and the medical facility. If workloads are not decreased and patient expectations are not put in place, the dissatisfaction and struggle of clinicians in the U.S. health care system will only continue to grow.
Part
06
of fifteen
Part
06

Pain Points - Chief Information Officers in US Healthcare Systems

Chief Information Officers (CIO) in US healthcare systems face numerous challenges. The pain points and concerns of Chief Information Officers include business intelligence, electronic medical records (EMR) adoption, security/privacy, data migration to cloud, patient portals, optimization of IT systems, talent gap, and mergers and acquisitions.
After an extensive search through industry reports, organizational surveys, press releases, and other trusted media sites, information pertaining specifically to post-acute and long-term care ambulatory management spaces was not found in the public domain. The pain points identified in our list are the overall general concerns and challenges faced by a healthcare CIO, usually in a hospital setting.
Chief Information Officers have various administration, IT and hospital network issues to deal with in the country’s healthcare system. CIOs are no more responsible with just the back-end functions of the healthcare organization but must also deal effectively with clinical leaders. The major challenges, pain points, and concerns that a CIO faces are listed below.

1. Business Intelligence

A major challenge that CIOs face is the business intelligence that is needed, along with the proper analytics, to support the smooth transition of systems to value-based models like patient-centered medical homes and accountable care organizations.

2. Electronic Medical Records (EMR) adoption

A number of healthcare systems in the country have experienced a drawback with defragmenting electronic medical records due to the interference of meaningful use. CIOs today are doing their best to work on a single-patient portal in order to help patients view their records all in one place. Challenges are met when the staff is being made aware of their workflow changes and are engaged in the “transition to an electronic platform”. According to Darren Dworkin, the CIO of Cedars-Sinai Medical Center, the largest improvement that can be made is in the area of creating choice. In order to be distinguished as a platform, a leveraged open APIs needs to be built through creating choice.

3. Security and Privacy

Security and privacy are considered as major challenges for CIOs. Over the past decade, healthcare systems have been undergoing a series of changes from regulatory requirements to technology advancements and IT sophistication. The system is becoming more and more complex in terms of information security. CIOs find keeping up with regulatory aspects of healthcare reforms to be difficult and expensive. With every passing month, security issues increase as the need increases to keep systems up-to-date with technology. Health data theft has also been posing a problem of late to CIOs of large healthcare organizations. Cybersecurity spend, data theft, and social engineering are other top concerns.

4. Data Migration to Cloud

Healthcare systems store large amounts of data like patient records, medical images, appointment summaries, and backup data in times of emergencies. When migrating the enormous data to the cloud, there are a number of technical challenges that can be faced, for example, resource exhaustion, data lock-in, bugs, and unpredictability of system performance. CIOs need to oversee this entire process to ensure the smooth transfer of data.

5. Patient Portals

Patient engagements and patient portals are critical themes of what healthcare systems are working on currently. According to Brent Snyder, the CIO of Adventist Health System, the vendors who provide portal solutions are not keeping up-to-date with technological advancements and are lacking in the degree of connectedness that the patients are looking for.

6. Optimization of IT systems

It is one of the primary duties and top priorities of a CIO to ensure that the healthcare organization is getting as much value as possible from their EHR investments. Today, healthcare organizations are working to utilize all possible EHR capabilities in order to provide multiple services to their end-users (patients, clinicians, health systems, and internal systems). These multiple services have a direct impact on the hospital’s value and outcome and thus, needs to be managed precisely to obtain maximum ROI.

7. Talent Gap

While healthcare systems are in a constant process of being digitized, the IT talent, however, is not up-to-date. With the growing demands of technology, IT business leaders are finding it difficult to hire employees with the preferred know-how and skills. Based on the 2014 HIMSS Workforce survey, about 70% of respondents admitted that the lack of skilled talent is the biggest concern.

8. Mergers and Acquisitions

Due to mergers and acquisitions, healthcare systems would generally need to have their information systems and EHRs integrated, which is often a difficult and painful procedure. CIOs need to prepare long-term roadmaps in order to reach an optimally “merged technological environment”. In doing so, there are numerous ways for the system to become disconfigured leading to fragmentation. CIOs must have the vision to deal with this challenge and also anticipate the frustration from other business leaders.
CIOs plan on focusing their attention on the following additional aspects as well,
Integrating healthcare communication systems.
Standardization of technology.
— Decreasing the number of technology vendor partners.
— Communication of critical test results in a timely method.
Improving cellular and Wi-Fi coverage on hospital grounds.

Conclusion

To wrap up, we have identified the overall general pain points and concerns of a healthcare CIO. The pain points include business intelligence, electronic medical records (EMR) adoption, optimization of IT systems, talent gap, security/privacy, data migration to cloud, patient portals, and mergers and acquisitions.

Part
07
of fifteen
Part
07

Pain Points - Chief Medical Officers in US Healthcare Systems

Through my research, I was able to find a significant amount of information about the pain points of Chief Medical Officers in US healthcare systems. Some major challenges faced by post-acute and long-term care ambulatory management professionals include the challenge of adopting and implementing the Medicare Access and CHIP Reauthorization Act (MACRA), establishing proper reporting and data management systems, developing relationships between specialist and post-acute care and ambulatory providers and managing the cost of ambulatory healthcare.

Adoption and Implementation of MACRA

MACRA is one of the major pain points of Chief Medical Officers in US healthcare systems, especially in the post-acute and long-term care ambulatory management spaces. MACRA is a bipartisan legislation signed into law on April 16, 2015. A result of MACRA is the Quality Payment Program, which offers two payment tracks and seeks to improve quality of care. MACRA will transition the US healthcare system from the "traditional fee-for-service payment model to new risk-bearing, coordinated care models."
Initially, post-acute care was not included in many CMS programs, but this sector is now faced with the challenge of adopting the system of electronic record-keeping and being held more accountable for the outcome of the patients' care.

ESTABLISHING PROPER REPORTING AND DATA MANAGEMENT

Another challenge faced by Chief Medical Officers is getting up to speed with the integration of technology that will allow organizations to connect with and share data. Reporting under MACRA requires that data be submitted for review in order to qualify as advanced alternative payment models (APMs) under MACRA. Many networks can face challenges if they have not invested in integrated care pathways, care management and transition resources, and information systems.

Developing RELATIONSHIPS BETWEEN SPECIALIST AND POST-ACUTE CARE and AMBULATORY PROVIDERS

Due to the transfer of care from one health care provider to the next, it is imperative that executives establish relationships, processes and infrastructure to achieve coordination and control with trusted post-acute care partners. Doing so will ensure improvement in tracking patient outcomes. According to Michael N. Abrams, "Fifty percent of hospitals refer patients to 18 or more post-acute providers, and some hospitals send patients to as many as 30 or 40 different facilities. In such cases, patients generally fall back on factors like proximity and word of mouth."

Relationships with specialists and post-acute care providers are likely to be key in identifying cost-saving opportunities within the system.

Managing cost of ambulatory healthcare

Times are changing, and so is the way individuals receive healthcare services. According to Mary Johnson with the University of Minnesota Health, "Ambulatory care is poised to change dramatically through the use of virtual care applications. We will be able to communicate with and assess patients in many more ways, such as via technology that enables virtual physiological monitoring." The changing landscape of healthcare industry means that more and more out of clinic options are available for patients who need a variety of healthcare services. In turn, the need to maintain physical space will reduce along with costs of extra staff needed to keep these facilities running. This will also allow more time and attention to take care of urgent in-clinic patients while also providing care those who may not need to or have the availability to visit the office.

SUMMARY

The challenges of adopting and implementing MACRA, establishing proper reporting and data management systems, developing relationships between specialist and post-acute care and ambulatory providers and managing the cost of ambulatory healthcare can prove to be major pain points for Chief Medical Officer in the acute care and ambulatory healthcare management spaces. Actions to be taken in order to overcome these challenges include: 1.) Quick adaptation to data-driven tracking and reporting tool to ensure compliance with new healthcare policies. 2.) Establishing coordinated efforts with other healthcare providers to ensure consistency of patient care. 3.) Understand the changing landscape of healthcare and technology and be open to alternative virtual healthcare solutions.
Part
08
of fifteen
Part
08

Pain Points - Patients in US Healthcare Systems

Patients in the US healthcare system are facing several pain points and concerns. This especially holds true in the post-acute and long-term care ambulatory management spaces. The main challenges in front of the US healthcare system are the growing cost of healthcare, access to primary care with respect to appointments, quality of interaction, quality of skilled nursing facilities, and safety concerns in long-term care. A detailed discussion of these pain points is as follows:

RISING COST OF HEALTHCARE

As the healthcare premiums rise twice as much as the rate of the annual salary hike, more and more employees are enrolling in high deductible benefit designs. These designs are causing more consumerism that is considered new for many people. 13 percent of prescription drugs are branded and thus costly. Tests such as MRI scans increase the cost of healthcare. This test could cost from $470 to $13,000, depending upon the place from where it is being performed. In a survey, 65 percent of people responded that the healthcare system is too expensive for them. There are several misconceptions among those aged 40 years old and above about the number of long-term care services they'll likely need and their costs.

ACCESS TO PRIMARY CARE

Primary care is becoming inaccessible to a large population due to an increase in demand. In large metro cities, the average time for an appointment with a physician has increased by 30 percent in the last three years. Patients often end up visiting emergency rooms that are the least cost-effective option for them. Further, in a survey, 11 percent of patients and 14 percent of physicians responded that the quality of healthcare services are seriously affected by a lack of quality interaction. Poor ratings for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) have been associated with increased wait times to see the doctor despite having a scheduled appointment.

Insurers often decide the reimbursement based on the patients' waiting experience in scheduled appointments. Longer wait times for appointments and limited hours of service are the reasons that individuals (particularly uninsured) find ambulatory care offices accessible. In the case of critical illness, high-quality relationships and communication are the top priorities of patients and their family members.

QUALITY OF CARE DATA REGARDING SKILLED NURSING FACILITIES

Post-acute facilities in the form of skilled nursing facilities provide a great help to the patients after their discharge from hospitals.
A patients’ perception rather than their own experience often plays a more important factor in their expectation and choice of quality healthcare services. However, there is great concern about the quality of services these centers provide to the patients for their post-acute treatment. It has been found that most hospitals give patients a list of skilled nursing facilities without giving a description of the quality of services that each and every facility provides. This leave patients unable to make informed decisions about the choice of their post-acute care.

SAFETY CONCERNS IN LONG TERM CARE

Long-term care is the setting that includes skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals. These facilities are used for patients who don’t require hospitalization but cannot be treated at home. There are concerns regarding the safety of patients in long-term care. Patients in skilled nursing facilities are prone to adverse events that are often preventable and usually end up in hospitalization. Further, rehabilitation facilities reported even greater adverse effects in older patients such as medication errors, healthcare-associated infections, delirium, falls, and pressure ulcers. It has been found that long-term care populations often suffer from adverse drug events. Issues related to communication problems are also considered to have played an important role in the occurrence and consequence of adverse events and patients’ satisfaction.

CONCLUSION

To wrap it up, the US healthcare system should address the concerns of patients in the areas of rising healthcare costs and insurance, issues related to difficulties in getting an appointment, wait times, safety, and quality issues with nursing care facilities and long-term care.
Part
09
of fifteen
Part
09

Pain Points - Clinicians in the Home Care System

Clinicians in the home care system are vital to long-term patient recovery. However, home care has several flaws that prevent clinicians from offering comprehensive treatment plans to their patients. The biggest pain points for clinicians involve the transition of a patient from primary care to home care, specifically the amount of information that travels with the patient throughout their recovery process. There are large information and data gaps as a result of a lack of evidence-based practice, accessible medical data, real-time data sharing, and communication between providers that lowers the quality of home care. In addition, inflexible and misinformed regulations prevent clinicians from making changes that might otherwise help solve some of these issues.

Lack of Evidence-based Practice

The lack of evidence-based clinical practice in the home care system creates a large pain point for clinicians. A large portion of home care services still rely on traditional clinical methods, some of which have been proven ineffective or even harmful. It is estimated that about 30% of healthcare spending goes towards services that are either redundant or ineffective. This equates to about $750 billion out of $2.5 trillion that is potentially being spent inefficiently. Additionally, whether a clinical practice is effective or not, only 15% of clinical practices are actually based on clinical trials. Neglecting to use evidence-based clinical practices has also led to an estimated 98,000 people dying each year from preventable medical errors. This could be key area for improvement since research has shown that outcomes for clinical care based on rigorously designed research studies are 28% better than traditional methods.

This lack of attention to research has also created a crack in the foundation of the whole home care system. It affects every part of the clinician's experience as a healthcare provider. From the regulations to the IT system to management staff, everything is built around traditional practices, making it very difficult to change the very practices the whole system was built around.

Regulatory Restrictions

Due to the nature of home care services under Medicare, reimbursement of services requires heavy amounts of documentation showing that services abide by regulations. That means with this payment process, the clinician must consider Medicare requirements as soon as treatment begins. The amount of constricting regulation means that, often times, focus strays away from keeping clinical staff and organizational practices up-to-date and instead on payment criteria. Instead of updating practices to improve patient outcomes based on new research, clinicians' responsibility goes to keeping up an income stream to keep their business running. Due to inflexible or slow changing requirements, the entire system of home care becomes outdated and limited. This creates a contradicting situation for clinicians: either risk losing reimbursement for increasing patient well-being or risk patient well-being to be able to continue caring for them.

Lack of Accessible Medical Data

Falls are considered at the top of potentially preventable events that lead to ER visits and hospital re-admission. A patient's risk of falling can be determined from several sources including previous rehabilitation notes, medication's effects on balance, weight-bearing status, and patient's education level. When dealing with patients with a risk of falling, a pain point for clinicians is the amount of information they have access to about the patient. They form a care plan in the beginning without much of the vital information that could be used to lower fall risk. Part of the issue is the lack of updated medication lists in Electronic Healthcare Records (EHR). The data on the EHR is often out-of-date, inconsistent, or missing. There is also a general unavailability of relevant information available due to a lack of IT solutions to support this type of data. This creates a lot of difficulty for clinicians to provide error-free care to their patients and leads to preventable accidents such as falls.

Lack of Real-Time Data Sharing

Despite the home care system's need for real-time data to keep patient care as efficient as possible, much of the data is concentrated in primary care. For example, current hospital prescribing and pharmacy systems don't have automatic functions to transmit the data to home care systems. The lack of data results in a less than robust home care system. In a clinical home care workshop, all stakeholders in the discussion on real-time data agreed on the benefits it would bring. It would improve the patient experience, minimize patient safety risks, and improve efficiency.

Lack of Communication Between Providers

A lot of pain points associated with the transition of care clinicians have to deal with are associated with poor communication and information sharing between health care providers. Hospital discharge is considered one of the most dangerous transition periods for the patient. In a comprehensive study done on patient outcomes after being discharged from the hospital, it was estimated that 23% of patients experienced an adverse event, 72% of those were due to adverse drug events. Additionally, 50% of the events could have been prevented, largely by better and more timely communication of essential patient information between providers. This information inconsistency is largely focused on medication lists. Adverse events are most commonly tied to medication changes made while in the hospital. These changes are frequently not communicated to home care organizations and clinicians. One study showed that around 14% of elderly patients have at least one medication discrepancies at discharge. Of these patients, 14% were associated with re-hospitalization within 30 days, compared to only 6% that didn't experience any medication discrepancies.

Conclusion

Though clinicians in the home care system experience many pain points in their efforts to care for their patients such as regulatory restrictions, the majority of their issues stem from a lack of communication and transfer of information with the rest of the healthcare system. Their biggest hurdles fall under the umbrella of not having sufficient or updated information on their patient that is vital to ensuring patient safety. Lack of evidence-based practice, accessible medical data, real-time data sharing, and communication between providers are all pains that the clinicians in the home care system struggle with when providing healthcare to their patients.
Part
10
of fifteen
Part
10

Pain Points - Chief Information Officers in the Home Care System

I have identified you a list of major pain points and concerns of Chief Information Officers. Unfortunately, there was limited information published specifically targeted to home-health CIOs . There was no information published specifically regarding CIO's in the post-acute and long term care ambulatory management spaces.

1. INTEGRATION AND OPTIMIZATION
In the Deloitte report, Chief Information Officers have expressed major concerns regarding the integration of healthcare technology into non-traditional settings such as patient homes. Integration is required throughout the company's operation from scheduling & tracking to informing long term care strategies. The most recent integration issues faced by home health CIOs involve combining agency EMR systems with other health care systems. The primary goals of the CIOs are to bring together disparate systems and streamline productivity in a cost effective way.

2. REGULATIONS
The major regulatory concerns of home health Chief Information Officer's involve Meaningful Use requirements. These regulations effect company operations from recording patient information to exchanging summary care records. In July 2017, the home health industry saw the first major change in the way it's regulated in over 30 years. CIOs are responsible to become compliant with these new regulations that will affect their companies eligibility to participate Medicare and Medicaid programs. The regulations are predicted to effect the way that home health agencies manage and care for over 5,000,000 patients.

3. RAPID CHANGING TRENDS
Chief Health Information Officers are having to adapt to rapidly changing trends. Along with increased telehealth service demand, CIOs are having to focus on mobile solutions much more than they have in the past. The dominating platform has been the internet and is now shifting to mobile devices. It is predicted that very soon platforms will be dominated by automated intelligence like Alexa and Google Home.

4. CYBERSECURITY SPEND
Chief Health Information Officers are having to stress over cyersecurity budgets. 42% of cyber attacks are related to healthcare. In 2016, the cost of an average cyberattack on a hospital was "$3.5 million, but according to a HIMSS survey, 46% of hospitals spend less than $500,000 annually on cybersecurity. A PwC analysis put these numbers in a more micro perspective: While a data breach can cost a hospital $200 per health record, about $8 is spent protecting that same record."

5. MANAGING THE DATA DELUGE
Chief Information Officers in healthcare struggle with data collection. A recent "Stoltenberg Consulting Poll found 51% of healthcare IT leaders believe the most significant barrier to hospital data analytics is not knowing what data to collect or how much of it" Organization of data is also another key pain point.

6. MERGERS AND ACQUISITIONS
Chief Information Officers in healthcare struggle to "develop long-term roadmaps to reach an ideal merged technological environment, which can become jolted and disconfigured when another organization comes into the mix." CIOs mus integrate systems without creating excess fragmentation or redundancy.

7. TALENT GAP
According to the most recently available HIMSS Workforce Survey released in 2015, "nearly 70% of providers said the lack of qualified talent was the biggest challenge to achieving a fully staffed department and 30% said they scaled back or put an IT project on hold due to a shortage in staffing."

CONCLUSION
Chief Information Officers in the home health industry are facing massive shifts in the way their companies are regulated. In 2017, the industry saw its first large regulation change in over 30 years. They are also concerned about issues they face when integrating health care technology into patients home settings. Rapidly changing trends are presenting issues in the way CIOs are managing and developing their solutions.
Part
11
of fifteen
Part
11

Pain Points - Chief Medical Officers in the Home Care System

Home care is a diverse array of healthcare services administered in patients' homes for the post-acute and long-term treatment of illnesses or injuries. Our research indicates that Chief Medical Officers (CMOs) in the home care system primarily face four pain points. They are described in greater detail below.

POLITICAL environment

The political environment is a critical pain point due to the uncertainty it causes in terms of funding. Although the home care industry generated $93 billion in revenue in 2017, many Americans don't have private insurance and can't afford to pay $4,000 per month for out-of-pocket home care services. More than 5 million seniors and young people with disabilities received home care through Medicaid and Medicare in 2016. This reliance on government entitlement programs creates uncertainty, because Congress regularly debates their funding. For example, throughout much of 2017 Republicans attempted to repeal and replace the Affordable Care Act, which would've drastically cut funding for Medicaid. If funding for Medicaid or Medicare is reduced, CMOs in the home care system will, in turn, be forced to cut services, reducing their revenue.

In addition, CMOs must remain aware of regulatory reform efforts, like the July 2017 changes introduced by the Centers for Medicare & Medicaid Services to redefine enrollment requirements and increase the rights of patients and caregivers in the home care system. The substance and direction of healthcare reform can drastically change every two years, depending on the results of mid-term and presidential elections. As a result, CMOs in the home care system must closely track developments in the political environment.

TECHNOLOGY adoption

The adoption of new technology is driving innovation in the home care system. Patients are now expecting healthcare providers to offer more on-demand services than ever before, including in a virtual setting, but the industry has struggled to adapt in this ever-changing landscape. Three recent studies by HITLAB, a digital health innovation laboratory, found that 95% of respondents went back to a paper-based approach after failing to implement a digital product intended to optimize scheduling care. Caregivers have also advocated for more automated home aide selection tools. Additional obstacles include improving digital product's functionality and building consumer trust in virtual health services.

staffing

Staffing poses a particularly challenging pain point to CMOs in the home care system. The most pressing issue is the ongoing nationwide shortage of home health aides, largely due to inadequate pay. In 2016, the average salary for a home health aide was $22,170 with limited benefits. Russ Knopp, co-owner of Comfort Keepers, a medium-sized home care provider, addressed this issue by saying, "[Home health aides] could go to Target and make $1 more an hour. They do this because they're kind, caring and compassionate people." This pain point will worsen when baby boomers reach retirement age, increasing the demand for home health aides by an estimated 40%.

COMPETITION

CMOs in the home healthcare system face heavy competition for customers since there are over 400,000 home care businesses in the US. Consequently, CMOs must adequately address the other three pain points to ensure they can compete in this market. However, the home care industry holds promising potential, given its 4% growth from 2012 to 2017 and the potential for increased demand in the immediate future.

CONCLUSION

CMOs in the home care system face four pain points: political environment, technology adoption, staffing, and competition. Any failure to address one of these issues could prove disastrous for a CMO in this industry. However, if overcome, the home care system has strong potential for growth due to the coming uptick in demand for these services.
Part
12
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Part
12

Pain Points - Patients in the Home Care System

The main pain points for patients in home health care settings include communication issues, language or cultural barriers, inconsistent quality of care, scheduling issues, and lack of compassion. While there was limited data available specific to post-acute or long term care ambulatory management spaces, there were consistent reports regarding the complaints among home health care patients in general.

Despite an exhaustive search through government databases and healthcare industry sources, information regarding pain points or concerns of patients specifically in post-acute home health care or long-term care ambulatory management settings proved largely elusive. The Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCAHPS) offers some insights to the satisfaction ratings among such patients, but this survey indicates that patients are largely satisfied with their overall experience.

HOME HEALTH PATIENT SATISFACTION
Patients prefer the option of having home health care over in-patient care. Studies have shown that patients who recover or receive rehabilitation at home offer higher satisfaction scores than those who receive in-patient care. These patients are not only more content, they are more likely to adhere to their care management plans, leading to improved overall health and satisfaction. New Mexico-based Presbyterian Healthcare Services offers a hospital-at-home option, which over 92% of its patients choose.

In terms of post-acute home care, which is often provided by a home health agency, patients are generally quite satisfied with their care. The Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCAHPS) measures patient experience receiving care from Medicare-certified home health agencies (HHA). It looks at four specific areas: professionalism, communication, discussion of medications/pain/home safety, and overall care. In 2016, patients ratings were 83-88% across these four areas, and 78% would recommend their HHA to a friend or family member.

According to a 2016 study in the publication Home Health Care Management & Practice, which analyzed data compiled from the CMS 2010 to 2012, patient satisfaction with home health services was relatively high at that time as well, indicating some degree of consistency over the years. Fully 88% of patients said their home health team treated them in a professional manner, 85% reported good communication from the team, and 83% reported receiving information from their team members regarding their medications, pain management, and home safety issues. In addition, 84% of patients rated their home health agency 9 out of 10, and 79% said they would recommend the agency to a friend or family member. Of course, these satisfaction figures would indicate that there is a segment of this patient population that is unsatisfied with these factors, and that dissatisfaction is seen in the pain points we have identified.

PAIN POINTS
A 2016 article from Shield HealthCare outlines ten pain points identified by Home Care Pulse for patients in home health settings:
1. Multiple caregivers causes confusion for the patient
2. Caregiver Tardiness
3. Inconsistent care quality with nurses of varying experience levels providing care
4. Caregivers doing personal things during patient care time, such as texting or making phone calls
5. Lack of training for caregivers
6. Cultural differences and language barriers
7. No discounts for long shifts
8. Pay schedules can be inconvenient with patients preferring various payment structures (e.g. weekly versus monthly)
9. Time and a half charges
10. Lack of communications when caregivers call in sick.

Many of these findings are borne out in other studies and industry sources. An article at Aging In Place reiterates some of these patient concerns in its examination of why home health companies may fail. Reasons for failure may include inexperienced staff, a lack of empathy on the part of a caregiver, lack of professionalism (calling in sick or making phone calls while on duty), cultural and language barriers, and inconsistent care quality.

Post-acute healthcare management software solution provider CompliaHealth outlines similar client complaints, offering HHAs advice on combating these problems. Also, an article at Home Health Solutions Media reiterates some of these issues.

• Communication: Lack of communication and miscommunication are among the top pain points for patients and their loved ones in home health care situations. Patients complain about not knowing which caregivers are coming, when they will arrive, what they will do, whether they will pick up needed medications, and schedule changes without notification. Having multiple caregivers often results in communication confusion. Family members want more information on how their loved one is doing or issues that may need their attention. Language barriers are also a consistent area of frustration for home health clients. Proper staff education can be a solution to this problem.

• Inconsistency in caregiver training or skills: Home health patients complain when the quality of care they received becomes inconsistent when caregivers of varying experience levels provide care. Conflicts arise when caregivers cannot manage certain tasks.

• Lack of compassion: A common complaint among patients is the feeling that their caregiver does not truly care about them, which may be exhibited by rushing through tasks or spending time on personal tasks such as phone calls.

• Scheduling problems: One of the top complaints among home care clients is in relation to scheduling. Lack of punctuality, timing issues, or accommodating client needs and respecting their time are among the pain points described.

CONCLUSION
In conclusion, home health care patients offer relatively high satisfaction scores for their overall care experience. However, some consistent complaints among these patients include communication issues, language or cultural barriers, inconsistent quality of care, scheduling issues, and lack of compassion.
Part
13
of fifteen
Part
13

Overview - Value Based Care: United States

Overview

The need to increase patient value focused on health outcomes over cost, necessitated the introduction of Value Based Healthcare (VBHC). VBHC is a healthcare delivery model that ensures patients receive top-notch healthcare services by tying payment of healthcare providers to the quality of healthcare given to a patient, ultimately rewarding healthcare providers for efficient and effective services. Using the VBHC model ensures that healthcare providers receive rewards for improving patients health, reducing the effects of chronic diseases and ensuring healthier lives with visible evidence. As opposed to the traditional fee-for-service model that mostly focuses on paying healthcare providers based on number of procedures carried out or amount of patients attended to, the VBHC focuses on value offering to patients aimed at providing exceptional healthcare services, improving population health management, reducing healthcare cost, ensuring pro activeness in healthcare, encouraging accountability in healthcare and encourage better patient engagement.

Types of value based healthcare models

This model of VBHC is based on a network of healthcare providers including physicians and hospitals that provide a coordinated, high quality healthcare to beneficiaries. This model which was designed by the Centers for Medicare and Medicaid Services (CMS), guarantees timely quality care, elimination of redundant services and reduction of medical errors. Since health care providers volunteer to participate in this model of VBHC, the network of providers adopt a savings sharing payment method as long as the ACO is able to provide high quality healthcare and reduce cost. Participating healthcare providers under this model also assume shared financial risk in cases of losses and may have to repay Medicare where they are unable to provide value based care to patients.

Bundle Payments — This model of VBHC also known as an episode-based payment accepts single payment for all services provided on an entire episode of care. It adopts a collective reimbursement of expected healthcare services cost for the treatment of a particular condition that requires multiple services embedded including multiple physician visit or several procedures. This payment also carries its own risk since the expected cost is estimated before the healthcare services are provided to the client. If the cost of the services is lower than the bundled fee the healthcare providers keep the savings and if otherwise the provider absorb the loss.
Patient-Centered Medical Homes (PCMH) — This model of VBHC provides healthcare services through one primary physician with an aim of providing centralized services to manage various needs of a patient. This model requires healthcare providers to obtain the PCMH certification which requires them to conform to delivering services including personal care management, care coordination, quality care and when acceptable by the patient a one-on-one relationship with care providers.

Summary of the benefits of VBHC

(a) Reduction of amount spent by patients to acquire high quality healthcare.
(b) Improvement in the ability of healthcare providers to provide efficient healthcare services and improve patient satisfaction.
(c) Ability of payers to control cost with fewer claims.
(d) Improvement of society health and reduction in amount spent of healthcare.
(e) Reduction in risk of loss of lives as more attention is paid to patients.

Role of technology in VBHC

The VBHC model has been designed to rely heavily on data, making it equally analytical and medical which will require the on boarding of software algorithms, monitoring big data as well as data scientists whose job will mostly be to make sense of all data gathered from the implementation of the VBHC as well as the evaluation and measurement of health outcomes. Technology will play a crucial part in the effective collection, aggregation and analysis of quality data to aid error free monitoring, evaluation and reporting in VBHC.

Conclusion

VBHC promotes the improvement of healthcare services with special emphasis on an increased value in healthcare services provided to patients by focusing on healthcare outcomes over cost. While benefits of the model such as reduction in amount spent by patients and increase in the provision of healthcare services are both enticing and promising, it is also faced with challenges such as inability to understand the complex financial risks and lack of resources to adequately report, validate and use data.
Part
14
of fifteen
Part
14

Overview - Electronic Health Records Implementation: United States

Electronic Health Records (EHR) are currently widely used in the U.S. Although Electronic Health Record systems have been available as far back as the mid 1960s, they were not widely implemented until the introduction of the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009, which offered incentive payments through Medicare and Medicaid for those office-based practices and hospitals that adopt an EHR system as a means of improving quality of care.

The implementation of EHR steadily grew from 20.8% of physicians in 2004 to 86.9% of physicians in 2015 (the year of the last available statistic). Implementation of EHR has not been universally implemented due to user resistance, lack of education and training, and concerns arising from data security.

While the majority of the information we gathered was from the last 2 years, there were some data points that we were unable to gather from recent sources. In particular, older resources were used to provide a more thorough overview of some important aspects the implementation of Electronic Health Records Systems in the U.S.

We have arranged the following overview of the U.S. EHR implementation, which has been arranged into the following three categories: explanation of EHR systems, history of the EHR implementation processes in the U.S., and main challenges to the implementation of EHR systems.

background information

Electronic health records (EHR) are electronic medical records that include information on the total health of a patient, in addition to clinical data, medical history and treatment data. EHRs differ from the traditional medical records (diagnoses, lab reports, visit notes, and medication directions) which are created on paper and filed manually.

Beginning in the mid-1960s, Lockheed and other technology vendors started to develop electronic clinical information systems, including some catering specifically to hospitals and medical practices.

EHR create a synthesized patient record, including all relevant information, stored electronically on local or cloud-based platforms. This allows the physicians to easily access, amend and transfer patient information from clinics to hospitals. However, the implementation of these systems in medical practices can be a complicated process.

In order to adopt these systems, the first step is to conduct an assessment of current practice goals, needs, and financial and technical readiness. Once these details are identified, practices must select appropriate systems, introduce the system to the practice staff and users, conduct training and finally install the system into the local computer system. To ensure the success of the use of EHR systems in medical practices, practices are encouraged to conduct pilot activities and establish periodic quality control and improvement processes.

History of the EHR Implementation Processes in the U.S.

Though available a decade earlier, EHR began to be used in the U.S. in the 1970s, with the Department of Veteran Affairs began its Decentralized Hospital Computer Program (DHCP). High costs prevented these systems from being universally adapted by medical practices and smaller hospitals.

Nonetheless, the emergence of web-based software in the early 2000's encouraged the development of similar systems, catering to the medial community. The ability to access information remotely or store on a remote-system made the electronic method of keep records more appealing and ultimately more affordable for physicians to implement into their practice, implementation of these systems was very slow.

In 2009, as part of a federal initiative to improve healthcare quality, the Health Information Technology for Economic and Clinical Health (HITECH) Act gave healthcare providers incentives to adopt EHR systems. Specifically, the HITECH Act incentivized payments of public funds for Medicare and Medicaid benefits to those offices using EHR systems, noting that these platforms allowed for improved quality of care to be given to patients as a result of increased accessibility to records. Clinical practices were eligible to receive up to $44,000 over five years to help offset the costs of implementing and using EHR systems. Between 2011 and 2017, more than $12.54 billion in Medicaid EHR Incentive Program were made, signaling the impact of this program in driving adoption rates.

The increased commercialization of EHR software, in addition to the federal incentive programs, spurred an increase in the adoption of EHR systems in the U.S. Indeed, information from HealthIT.gov and the CDC reports the following adoption rates of EHR systems in the U.S. by year:
2004 – 20.8%
2005 – 23.9%
2006 – 29.2%
2007 – 34.8%
2008 — 42%
2009 – 48.3%
2010 — 51%
2011 — 57%
2012 – 71.8%
2013 – 78.4%
2015 – 86.9%

While the trend in EHR adoption is increasing in the U.S., barriers continue to exist for universal adoption of these electronic systems in hospitals and medical practices.

Main Challenges to the Implementation of EHR Systems

Cost was among the largest barrier to adoption of EHR systems during the end of the 20th century. For example, in the 1990s the cost of implementation of an EHR in Kaiser Permanente health system was over $4B. Nonetheless, costs have decreased significantly due to the increased availability of these systems, allowing this barrier to be overcome.

The remaining challenges to EHR adoption across U.S. hospitals and medical practices include: human resources, hardware availability, network capacity, data accessibility and public perception.

Human resource barriers include: user resistance, lack of computer skills, and the additional workload EHR systems create on clinical staff. This has largely been associated with lack of training resources for potential system users.

Challenges associated with hardware and software include: lack of IT support resources, and concerns that these systems will become obsolete, limited ability to use software across of systems, ease of use, and lack of appropriate infrastructure for integration of EHR with other existing information system. Similarly, network capacity barriers include: lack of internet, lack of network infrastructure, and slow network speeds.

Data is the basis of these systems, but the main associated challenges include: lack of health information data standards, data security concerns ad data accuracy.

Finally, public doubt in the security of confidential data stored in electronic systems has further hindered the adoption of EHR systems.

Conclusion

Electronic health records have been increasingly implemented across practices and hospitals in the United States. Data from the last available year, 2015, indicates that these systems are used in over 86.9% of practices in the United States. However, significant challenges to implementation arise from human resources, hardware, software and network resources, and public perception of the security of highly confidential data.
Part
15
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Part
15

Overview - Home Care Management in the US.

Home healthcare provides a variety of sources like wound care, patient and caregiver education, injections, and nutrition and intravenous therapy in the patient's home. Typically, such care is provided after a patient has had an in-hospital stay or emergency care visit.

Methodology

After extensive research of all publicly available databases and statistics, we were unable to find vital data from the last two years that was required to provide a proper overview of home care management in the United States. However, relevant and important sources used were from 2014, because they provided useful and authoritative information.

General Statistics

As of 2014, there were approximately "67,000 paid, regulated long-term care service providers" in the U.S. supporting approximately nine million people in a variety of care environments. They were broken down into the following groups: "4,800 adult day services centers, 12,400 home health agencies, 4,000 hospices, 15,600 nursing homes and 30,200 assisted living and residential care communities".

Nearly half or 46.6% of home health agencies are located in the southern states and, overall, 84.6% can be found in urban areas. Of the 12,400 agencies, 80% are under for-profit ownership. Home healthcare agencies typically support fewer than 500 patients. Though this figure is dated, an average 427 patients were helped by home care agencies in 2013. Most agency patients are long term with 41.7% of agencies "discharg[ing] 100 patients or fewer" each year. Only 31.3% "discharged more than 300" patients.

There are several home healthcare roles including nurses, home health aides, aids that provide personal care, and nursing assistants. There are two industries associated with these workers, home healthcare services and services for people with disabilities."

Of the 1.5 million full-time equivalent nurses working in these five sectors in 2014, one-tenth or 150,000 worked for home health service providers.

The Bureau of Labor Statistics reports 911,500 home health aides were employed in 2016 with 45% or 410,175 working for "home healthcare service" providers. Of the 2,016,100 personal care aides, 15% or 302,415 working for "home healthcare service" providers. The number of jobs across a range of employer types was 2,927,600.

The average 2016 pay for personal care aides and home healthcare aides was $22,170 a year or $10.66 per hour.

Education requirements can vary between employer types, however, if working for a certified home healthcare provider an aide must have received formal training and passed the appropriate test.

Most home care and personal care workers are women (9 in 10), and the average age is 45. People of color make up 50% of home care workers and one quarter of home healthcare workers were born outside the US though 90% are US citizens.

HOME CARE MANAGEMENT

The home care industry, which has already "doubled in size" from 2004 to 2014, is expected to continue its growth trajectory with an aging population expected to reach 88 million people over 65 years of age by 2050. As at 2014, home healthcare generated $71 billion in revenue.

Home healthcare agencies need to meet standards set by Medicare and Medicaid with 72% of their patients have their care paid for by government programs. With payment reforms, home care agencies are likely to see more referrals for their services. It also aligns with the desire for personalized care and "on-demand" or "direct-to-consumer" services. Consensus is divided on how this can be best aligned and whether there is a need to modify the payment proportions already in place with Medicare. Discussion is also occurring on what services can be covered under home health support.

Home health service providers have an opportunity to grow their businesses but will need to meet a number of challenges if they wish to do so. This includes being able to demonstrate to government that they offer value for money and quality services. Payers will likely require closer vetting of agencies and may well look towards favoring agencies who can ensure 24/7 care and coverage across broader geographical areas.

Challenges for agencies themselves include staff availability, the risk of injury on the job and, at worst, potential for patient neglect or abuse. The latter can be addressed by ensuring regular contact with nurse liaisons and having appropriate health management plans in place and regularly reviewed.

Mitigating those risks also includes increasing wages which dropped between 2005 to 2015 by 10 cents an hour, to $10.11. The current hourly rate is $10.66 and, given that most aides work part-time, their median income is only $13,300.

The employment pool for aides is also reducing with labor force participation anticipated to increase by only 2 million from 2014 to 2024, whereas the participation rate from 2004 to 2014 was 6.3 million. Improving pay and job quality would provide incentive to potential employees. Reducing the risk of injury is also important from both a business perspective with workers compensation claims but also to the employee. As many as 26% of aides are without health insurance. Providing the necessary tools and training to help aides minimize their risk of injury, as well as a competitive wage, makes sound business sense.

Future Characteristics and Roles

The Medicare Home Health Agency of the Future,” says that filling critical roles in the healthcare system is reliant on the need for future home health agencies to strengthen characteristics and capabilities. There are four characteristics that they need to possess: they must be person and patient-centered, seamlessly coordinated and connected, offer high-quality patient care, and they must advance technologically to allow patients to receive more intensive services and connect with healthcare professionals. They need to meet three critical roles: primary care partners, post-acute and acute care support, and long-term, home-based care partners.

CONCLUSION

Today’s home healthcare workforce is composed mostly of nursing assistants, home health aides, and personal care aides. There are a number of opportunities and challenges for home care management in the US at the moment, including staff shortages and the need for greater alignment between agency and provider or payer. It has been recognized by government and stakeholders and discussions are underway on how to better meet the needs of patients who want to receive after hospital care in their own homes.
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