HHS says few states have taken them up on an offer to receive federal funding for data-mining, which would allow their Medicaid fraud units to search claims. States say they don’t need it, even though the improper payment rate has nearly doubled as the number of enrollees surges.

A 2013 HHS rule allowed state Medicaid fraud control units to use federal funds for the audits, which the agencies previously had been explicitly prohibited from doing.

Only California, Indiana, Louisiana, Michigan, Missouri and Oklahoma have been granted permission to conduct the data-mining. Florida’s Medicaid fraud control unit received approval from the CMS to conduct data-mining as part of a Section 1115 waiver in 2010.

Earlier this year, the CMS revealed that the Medicaid improper payment rate has jumped from 5.8%, or $14.4 billion, in fiscal 2013 to 9.78%, or $29.12 billion, in fiscal 2015.

Richard Stern, director of the Medicaid Fraud Policy and Oversight Division in HHS’ Office of the Inspector General, said he wishes that other Medicaid fraud control units would get on board as increased use of data-mining could be an effective tool to reduce improper payments, especially those relating to fraud.

Still, many of the states reached by Modern Healthcare said they believe their state Medicaid agencies or health departments are producing enough leads from their own data-mining efforts for them to pursue.

“We’ve yet to encounter a situation beyond (our Medicaid agency’s) capacity to provide timely information that would necessitate the extensive investment in personnel, infrastructure, and equipment to essentially duplicate those resources,” said Josh DeVine a spokesman for Tennessee Bureau of Investigation.

Spokespeople for fraud units in Arkansas, Colorado, Massachusetts, Ohio, South Dakota, Texas and West Virginia made similar remarks.

State Medicaid fraud units in Hawaii, New Jersey and Rhode Island are evaluating how data-mining could benefit them, while a spokesman for New York said it may soon seek a waiver with HHS’ OIG.

Some said they want to see how other states fare before enlisting the HHS’ help.

“We are hoping that larger states can make progress in developing a road map for effective implementation before we commit to a specific data-mining strategy or technology,” said Carl Kanefsky, a spokesman for Delaware’s Justice Department.

Article source: http://www.modernhealthcare.com/article/20151216/NEWS/151219895

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Consumerism has been a trending topic in healthcare for several years. Some warned that the increase in consumer research could negatively affect doctor-patient relations, as patients felt empowered to challenge practitioner wisdom through their new found online knowledge. While others extolled the benefits of it, as it might force doctors to take a hard look at their off-the-shelf treatment plans and come up with better solutions for patients.

Consumerism was born, but not fully baked. Fast-forward to last month, and we see consumerism expanding in healthcare quickly. Geisinger announces refunds for unsatisfied customers! It’s shocking! It’s alarming! It’s… nothing new, especially if you’ve been living in the world of the consumer.

But, traditional consumer-oriented industries and healthcare are different. Simply modeling tactics in healthcare after tactics in other industries won’t work. I’m not looking to sign up for a loyalty program with my urologist anytime soon. Instead, valuable lessons can be learned by looking at this from a higher level. Rather than looking at other consumer-oriented industries’ tactics, looking at strategies and processes can give us better insight into what will make a greater impact on the future of the healthcare experience.

The First Step: Understand the Journey

To maximize the patient experience, you have to first understand the full patient experience. It’s not enough to look at a particular point in time, you need to look at the whole process.

The healthcare patient journey isn’t that far off from the journey of consumers in other industries, but there are important differences.

The healthcare consumer and retail consumer journeys follows a similar path, but the tech opportunities differ greatly.

In many industries, the need and research phases see the highest investments in digital technology, but for healthcare, digital technologies can have a great impact on the lives of consumers further down the path. While many consumer brands step away at the point of purchase; healthcare, and its supporting technologies, can often do the most good starting at the point of care.

Step 2: Consider Purpose

Once you have an understanding of the consumer journey, the next task is to define your organization’s purpose and determine how it shapes your interactions with consumers as they move through the process, and interact with your brand both on- and offline. The purpose should be communicated by the way your employees interact with patients, as well as reflected in your online presence. A clear purpose will help you focus on the right strategies and tactics for your business, and keep you from getting distracted by fads and flashy ideas.

If we look back at the Geisenger example, we can ask how that fits with purpose. If the purpose of the business was to maximize revenue, it wouldn’t fit. A higher purpose such as, “Improving the lives of community members” fits better. A community-oriented purpose might have improved patient experience as a strategy, and refunds for dissatisfied patients as a tactic.

Step 3: Create Purpose-Driven Tactics for Every Phase of the Journey

Once we have a consumer journey mapped out and a purpose identified, we can start to map out the strategies and tactics that will support our purpose throughout the consumer’s journey.

For arguments sake, let’s assume your purpose is the one outlined above: “Improving the lives of community members.” If we look back at our consumer journey, we can start to think through the strategies and tactics that will make a difference in the lives of community members. From a technology standpoint, in 2016, consider the following for each phase to support your purpose and enhance the digital patient experience:


In traditionally consumer-centric industries, generating needs is a common practice. Did you need a phone that could connect to the internet in 1995? Do you now? In traditional healthcare, generating needs is less common. In community-driven healthcare, generating needs will be an important task. You will need to do more to ensure that the population is aware of its needs.

The technology is still pretty light in this phase, but there are a few supporting tactics that healthcare companies can leverage to generate and understand general and individual patient needs. For example, you could use your CRM or EHR system to email surveys to patients to gather need-based data to better serve and understand your patients. The data gathered from these surveys can help you identify potential patterns among patients to identify needs, and also use the data to better personalize each patient appointment and experience. Healthcare companies can also use their CRM or EHR systems to send out emails to patients to notify them of flu shot availability, or promote wellness programs.


As we continue in the shallow(ish) end of the technology pool, the research phase is all about web presence.

Reflecting on our example purpose — Improving lives of community members — a website can help consumers as they research by providing the right content. A content strategy should support tools that increase health knowledge and strengthen health literacy of the community. Following this purpose, your website should help consumers understand conditions and recognize when they need to make an appointment. It should also provide them with the information they need to get a feel for what it will be like to work with your practice and whether the practice will be a good fit for them.


On the surface, the booking phase seems to be one that is particularly inward looking. The way in which it supports a health system is obvious (more appointments = more money), how it supports the community at large is less so. However, this phase is essential to improved community care and patient experience, as booking can be a major obstacle to an individual’s ability to receive care. Health systems have begun to make the process of booking easier on patients within an EHR, but for the community at large, and potential new patients, the process is still cumbersome.

Removing barriers to entry by providing a new mix of appointment booking options can greatly improve the health of the community. The mix of tools for booking appointments should shift from the phone-only system that exists in many practices to a system that supports digital tools. Yes, booking through a website, but also chat on that same website, as well as text to schedule and potentially even integrations with third party chat apps like WhatsApp or Facebook Messenger. Third party apps may sound wild, but a similar tactic has been working in China through WeChat for the past year. As the demographics and usage preferences of the healthcare audience shift, this type of pattern will become more commonplace.

When it comes to care, the health of the community can be improved by extending the reach of a health system. This can mean a number of things, including an expanded role for telehealth. Video chat has gained momentum recently and should continue to do so, particularly for preliminary evaluations, as it allows doctors to reach patients quickly and also in areas that may not be readily accessible to healthcare services.

When a patient is actually in the office, it’s important to consider the shift in the doctor’s role. Doctors and their teams can no longer simply be practitioners, they must also be educators. Appointments should turn into education sessions. Instead of quickly jumping to a prescribed approach, doctors should use tools to explain options clearly. Every room now has a computer and a screen in it, it’s time to turn those outward and use them to facilitate explanations of options. Other new tools used to display 3D models of the body will also become important.


After the appointment, the real work begins. Patients are expected to do more on their own than ever before, and they need to be educated and prepared to take on the balance of care that occurs outside a clinical setting.

This can mean a number of things. To begin, better sharing of appointment notes, apps for tracking progress, and improved communication between appointments can help prepare patients. Native and web apps can facilitate much of this work, and the right strategy depends on the usage patterns of your audience. The key is to find the right tactics to connect with and enable consumers.

Step 4: Observe and Optimize

Perhaps the best thing healthcare can adopt from consumer-centric industries in 2016, is to never stop learning and improving. Collect data, conduct user research studies, find out what works and what doesn’t. The tactics mentioned above are a great starting point for a single purpose next year, but the key to deploying the right tactics for your consumers is to never stop learning and improving.

Article source: http://www.healthcareitnews.com/blog/enhancing-patients-digital-journey-2016

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People over the age of 60 are likely to be driving the healthcare market around the world in less than five years, according to global research firm Frost Sullivan.

By 2020, Frost Sullivan estimates 22 percent of the world’s population will be age 60 or older. In order to encourage independent living, IT service providers need to support the development of smart homes and communities that leverage technology-based solutions for the aged, researchers conclude.

The report identifies three anticipated market trends that could help aging people participate in their healthcare:

  1. High adoption of remote monitoring devices, which are useful for personal physicians, nurses and family, will help all senior citizens who prefer to stay in their own homes.
  2. Information and communication technology-based assistive technologies, including computer-based or other electronic communication aids, object locators and reminder systems, will also gain traction.
  3. Employing robots as a support system will emerge as an excellent aged care model.

The aged population’s requirement for specialized medical technology will create strong long-term opportunities for wireless network, IT service and software solution providers, researchers point out, so, service providers are making concerted efforts today.

“Wearable devices are increasingly becoming an integral part of senior citizens’ lifestyle,” said Frost Sullivan Information Communication Technologies Senior Research Analyst Shuba Ramkumar, in a news release. “While it is true that a wearable device or global positioning system tracker does not in itself provide better care, it can facilitate remote monitoring of senior citizens and help prevent major accidents. For example, it can prevent a patient with memory loss or dementia from going outside and endangering themselves.”

However, seamless connectivity, irrespective of whether it is low/high bandwidth or short/long range, is important for the accurate functioning of the aged care ecosystem, Ramkumar added. Even the smooth operation and integration of assisted living technologies in the healthcare sector is dependent on the resolution of connectivity, data privacy and regulation issues.

Today, the need to certify some community and technology devices for deployment and restrictions on the use of data collected by devices prove to be major obstacles for the end-user market, according to the report. Nevertheless, development of stringent data security regulations and partnership with healthcare technology companies can help overcome some of these challenges.

“IT service providers must collaborate with large private and public aged care providers to design and deploy solutions that integrate with the healthcare system,” said Ramkumar. “For residential care communities, they should also provide end-to-end Internet of Things platforms to enable communication between smart devices for monitoring patient activity. These solutions are necessary to integrate home/residential care systems with the central healthcare system to facilitate automated healthcare delivery.”

The Frost Sullivan report supports the same concepts Eric Dishman, director of health innovation and policy at Intel, has been talking about and advocating for years.

As he sees it, the graying of the Baby Boomers offers and requires new ways of delivering care, and at the same time it presents new market opportunities.

Back in 2004, when Dishman testified before the U.S. Senate Special Committee on Aging, he noted the world was graying rapidly, and healthcare was yet to come up with healthcare innovations needed to care for seniors, and particularly to care for them “in place” – in their homes.

He called on senators to use their imaginations.

“Imagine a pair of socks that can detect swelling in an older person’s feet and relay the change to a caregiver. Picture a “smart” cat that can calm an agitated Alzheimer’s patient by purring at their bedside. Envision tracking devices for the soles of shoes that can monitor an older person’s gait for irregularities, and ultimately prevent a crippling fall. These are just a few of the innovations that promise to transform the aging services field — from an overburdened safety net to a highly efficient preventative system.”

Article source: http://www.healthcareitnews.com/news/healthcare-it-ready-boomers-coming-age

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Seeking to better align health IT standards with health information management practices, three industry groups joined forces for a new report aimed at speeding standards-based interoperability.

call Health IT Standards for Health Information Management Practices, a “first-of-its-kind” report that’s meant to be a guide for those HIM and health IT professionals working to develop interoperability standards.

It aims to enlighten standards developers about information management practices and show how to better align them with health information technology. It will also serve as a roadmap of sorts for the development of standards to support information governance, including efforts in the U.S. and abroad to ensure semantic, technical and functional interoperability among information systems.

“To achieve interoperability, HIM and HIT professionals must each share their perspectives and determine how to bring the pieces together into a cohesive program that allows information to be used effectively throughout its lifecycle,” said AHIMA CEO Lynne Thomas Gordon, in a statement. “This inaugural collaboration with IHE has produced a great resource for our industry, and we’re excited to continue our work together.”

AHIMA, HIMSS and IHE International developed the white paper as part of AHIMA’s information governance initiative. In a unique collaboration, vendors and HIM professionals worked together on the report to help ensure interoperability is approached with the HIM perspective in mind and to promote standards-based “rules of the road” for electronic health records and other health IT.

The white paper offers an overview of HIM practices related to information governance; detailed analysis of HIM business requirements and best practices; five use cases derived from these business requirements and best practices for the information availability; a glossary of key terms; an initial gap analysis of existing HIT standards to support HIM business requirements under three governance principles (information availability, integrity and protection) and recommendations for HIM community and standards development organizations for further standardization of both HIM practices as well as capabilities of HIT products.

The collaborative “allowed us to share valuable knowledge on standards development and health information exchange as we developed this white paper,” said Mari Greenberger, director, informatics at HIMSS, in a statement. “Building on our current efforts in defining and developing use cases for secure exchange of health data, HIMSS recognizes the importance of and need for this ongoing alignment to provide information that is useful and drive meaningful outcomes to the healthcare community.”

Article source: http://www.healthcareitnews.com/news/himss-ahima-ihe-map-data-governance-strategies

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Should VA opt for a commercial EHR?

On October 28th, 2015, posted in: Industry News by

While the Veteran Affairs Departments homegrown electronic health record system is entrenched at VA outlets around the country, the once cutting-edge EHR appears to be under fire this week.

MITRE Corp. said that the EHR, called the Veterans Health Information Systems and Technology Architecture (VistA), is “in danger of becoming obsolete,” within a 4,000-page report it issued late last month.

The report suggested that the Veterans Health Administration CIO, in partnership with the VA CIO, should oversee a comprehensive cost-versus-benefit analysis among commercial off-the-shelf (COTS) EHRs, open source options, and continued in-house custom development of the VistA iteration currently in use.

“The analysis should take into account all the complexities of the VistA architecture and infrastructure and known issues with performance, scalability, extensibility, interoperability, and security,” the report said. “It should also address full life-cycle costs, including development time (based on recent delivery trends), availability of development resources, maintenance and licensing costs, and infrastructure costs.”

What’s more, VA officials are expected to testify this week in front of a congressional committee, defend the system, and oppose suggestions to scrap it in favor of commercial solutions much like what the Defense Department did when it awarded Cerner, Leidos and Accenture the massive contract this summer, Politico reported.

“VistA is a great big Buick with whitewall tires and tail fins that gets about 8 miles to the gallon,” said Rep. Phil Roe (R-Tenn.), a physician and member of the veterans committee, who noted that the VA is spending 80 percent of its IT budget on maintenance, according to Politico. “It gets you from A to B, but will it last 20 years?”

Another question likely to arise is whether or not VistA will ever be truly interoperable with the commercial EHR DoD announced it would implement this summer.

MITRE’s report said that VistA’s problems “stymie interoperability between Veterans Health Administration facilities as well as with DoD and non-VA providers.”

The DoD in late July awarded a $4.3 billion contract to the team of Cerner, Leidos and Accenture, which edged out two other teams, one being Epic and IBM, the other consisting of Allscripts, Computer Sciences Corp. and Hewlett-Packard.

Prior to that DoD and VA were working on a joint electronic health record system, dubbed iEHR, that fizzled out in early 2013.


Article source: http://www.healthcareitnews.com/news/should-va-opt-commercial-ehr-emr-vista-dod-cerner-iehr

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