Sorry I haven't written...

It's been awhile since I started writing this so just to get you up to speed on where I am in building shangri-la...I'm now at a healthcare technology company and I've joined a group of truly innovative, cutting edge developers who understand and practice systems and design thinking.  They have built this platform to manage clinical data flow between the various healthcare delivery system participants, using a social (read: community) networking model.  What is fundamentally different is how they have structured the underlying data model.  The base model is the healthcare community consisting of multiple healthcare enterprises (rather than the base being an individual provider, hospital or payor).  From there, they have thought about how the end-user (consumer, if you will) of the data would access the data, where they would access the data and why they would access the data.  As a result of taking into account the community orientation and the end-user perspective, the platform consists of three major components, which I believe could apply to any HIT design:  a data integration bus, the longitudinal patient record and the communication tools.

First, you need something that can (1) take in data from a variety of sources, (2) be flexible but systematic in consuming the data, (3) have probabilistic patient matching, (4) normalize the data to fit a defined nomenclature standard and (5) create a longitudinal patient record.  All 5 of these functionalities are what is incorporated in the "integration bus."  The platform is able to collect administrative and financial claims data from payers, clinical data from laboratories, pharmacy claims data from PBMs, radiology images and reports from radiology providers, CCDs from EMRs, and patient-derived data from a PHR.

The data is then organized into a longitudinal patient record, which requires the platform to run the data through a probabilistic patient matching algorithm and a data normalization program.  Once the data has been attributed to the correct patient and the data normalized, the data can be subjected to a variety of computable, evidence-based, clinical guidelines, in order to make sense of the data - "transform data into knowledge."  The platform is able to risk stratify the population by running the data through the Johns Hopkins ACG risk model and assign disease condition markers to patients, which in turn can generate evidence-based care plans, based on the disease condition.

Finally, through these various applications, working on the longitudinal patient record and creating care plans, the platform can generate workflows to distribute the tasks from each of the care plans and involve and inform all of the members of the care team.  The data and tasks are available to access by the end-users securely, via the web, using any browser, smartphone or tablet.

Also, unlike most other platforms out there in this care coordination/medical management space, they have included the patient as part of the care team - so he/she can also get assigned tasks based on the care plans and the patient can track his/her progress with the plan as well.  The patient is also able to send secure email messages to his/her providers, order refills, make appointments, track clinical results (e.g., lab data), obtain health educational information, and communicate his/her care plan to other family caregivers.

So far, it's been a blast to be working with this group of technologists, who not only get the technology, but are also keenly aware of the people that will be using and benefiting from their work.

We are currently implementing this platform in a Medicare Advantage plan, to go live in January, 2013.  This project will also take advantage of the medical management capabilities of the platform - including all of the regulatory communications, the quality measurement and reporting and the tracking of operational measures associated with medical management, including concurrent review.  Will let you know what happens on go live.

hello world

thanks for tuning in.  by way of introduction, i am a former practicing surgical sub-specialist.  after practicing 5+ years in an academic setting, a private two-person practice, an hmo staff model and an ipa - i found that there is no "perfect" practice.  the frustrations of working in the healthcare system, trying to help my patients were so great that i needed to find some way of fixing these systemic problems.  i realized that caring for patients one at a time would not enable me to change the system.  so i packed up my scalpels and left clinical practice and headed off to an illustrious career in health plan administration as a medical director/chief medical officer.  if you can't beat'em, join'em, right?  or so i thought.

guess what?  health plans are all screwed up also!  quelle supris!  while a chief medical officer (CMO) is supposed to oversee a health plan's clinical programs, including utilization management (the unit that approves/denies requests from providers for healthcare services that require authorizations), pharmacy (the unit that approves/denies requests from providers for drugs that require pre-authorization), quality (the unit that is supposed to assure quality healthcare services through auditing, credentialing and conducting quality studies and implementing quality improvement projects) and grievances & appeals, the reality is that the CMO is mostly a figurehead with very little ability to actually improve the healthcare delivery system.  in fact, after having worked in health plans for 5+ years, i have come to the realization that health plans are the cause of (not the solution to) our healthcare problems today.  [yes, i may be a little naive and polyannish - but hey, that's my midwestern upbringing]

of course, it's not their fault.  it's really no one's fault, right? - it's just the way the system was set-up.  [there is actually some truth to that - more to come in later posts]  health plans are in the business of keeping themselves in business.  self-preservation sustains the industrial inertia that keeps the status quo so firmly entrenched that it suffocates innovation in healthcare.

to be fair, self-preservation applies to just about everyone in healthcare and that's another reason why health "reform" is so hard.  physicians are doing their best trying to keep their heads above water.  hospitals are fighting just to stay open.  employers "victimized" by ever-increasing health plan premiums for their employees don't know any better and simply shift the costs to their employees.  and we, as consumers, are left holding the bag, powerless to change the way we're being treated by the healthcare "system."  finally, we now have government trying (again) to make some inroads into the healthcare mess.  we'll keep our fingers (and toes) crossed to see if anything substantive comes of it.

stay tuned for further posts.