As an example, I learned last week at the HIMMS 2013 conference that one pilot project of at-home wireless glucose monitors at several hospitals reduced readmission rates for diabetics between 19 and 65 percent, thus cutting care costs and reducing serious episodes of illness. But several hospitals discontinued the effort when the pilots were done because they saw their admissions decline, noted Dr. Wayne Guerra, a physician who relayed the findings at the conference. (Guerra, marketing chief at mobile health app maker iTriage, is involved in the creation of the Mobile HIMSS Roadmap, which is meant to help hospitals deliver on patient engagement via wireless and mobile devices.)
Admissions are where health providers make their money. The feds know this, which is why Obamacare is changing the incentives. For example, Medicare reimbursement rates for a follow-up in-person consultation will be $165, but $195 if over the phone or through electronic means such as patient portals. That's a small step to change the incentives, but it doesn't pay for regular communications via electronic means. And, Guerra notes, "doctors are avoiding electronic due to the high cost and complexity of the electronic communications systems. They tend to use the phone or do in-person for the follow-up."
Likewise, "providers aren't paid to use the data from personal devices, so the economic issue hinders formal use," said Dr. Mohamad Ali, the Mobile HIMMS Roadmap task force's chairman and an assistant medical director at Wexford Health Sources in Pennsylvania. There are also legal issues as to how providers should treat patient-supplied data -- basically, at what point does it become part of the formal medical record and thus data that the provider is liable to monitor and act on? The MU2 regulations don't address the economics or legal issues. The result is that the current system "discourages patient self-monitoring and participation," says David Wierz, another road map task force member who is also principal of the health IT consultancy OCI Group.
Obamacare is changing the economic model in stages, with the goal being that providers are paid a flat annual fee per patient, which is supposed to encourage wellness care by making it too expensive to let patients fall ill -- the opposite of today's predominant fee-for-service model. But even organizations committed to the change will find it tricky to navigate the shift, as big-dollar treatment revenues disappear and an annuity payment takes its place, noted Julie Vilardi, a nurse at Kaiser Permanente involved in its technology transformation efforts. It's the same problem IT vendors face in moving from selling big-ticket software and systems to selling cloud services: There's a cash flow gap, often when the necessary investment in the new technology is biggest.
Ignorance of today's technology and user base
I heard it multiple times at the HIMSS conference: "Who will train patients how to access the patient portals on their computers?" Many in health care -- both in IT and in the medical provider ends -- seem to have missed the last decade, the rise of electronic banking and e-commerce (which aren't that different from patient portals), the universality of the Web, and the rise of mobile devices and apps.
"The patients already know this; it's health care that needs to catch up," Vilardi said. Her organization has 6 million members, two-thirds of whom use Kaiser's patient portal to email their caregivers, make appointments, refill prescriptions, and even choose their doctors. The federal MU2 requirement is that 5 percent of patients have such electronic interactions each year -- a percentage that was reduced from the original but still-low 10 percent target.
Yet in session after session, I heard the assumption that users were too stupid or ignorant to use such systems. At the same time, while slick mobile apps and Web portals were demonstrated all over the HIMMS show floor, I saw multiple health care organizations demonstrate their own ignorance about current technology -- the very people designing the systems for patients to use.