Technology disruption: ‘It’s not always this crazy’

Americans have always seen technology, and technological advances, as great drivers of change. Technologies that, at one time or another, seemed to have “changed everything,” are all around us – in our cars, on our desks, and in our hands. We call these things “disruptive technologies,” knowing that the people who create, acquire, and use them have a way of making life more challenging – at least temporarily – until the rest of us catch up.

As we enter 2014, it appears that in healthcare, it is not technology that is disrupting everything else, but ideas on how best to harness and use it that are disrupting technology instead. With the help of Wayne Easterwood, chief information officer at Centerstone Research Institute (Nashville, Tenn.), let’s have a look at why 2014 is more likely to be about “technology disruption” than about “disruptive technology.”

1) Meaningful Use

More than four years ago, when all of us first heard the term “Meaningful Use,” it all seemed so clear, so elegant. The nation’s health providers, under the leadership of the Office of National Coordinator, would begin a three-step journey, moving ever closer to a shared and very integrated vision of the health information infrastructure of the future.  Phase one would entail implementing EHRs and focus on collecting the required data. Phase two would focus on expanding data exchange at transitions of care, while phase three would make data interchange common.

Today, realizing the vision for Meaningful Use of electronic health record technology remains a concern for behavioral health CIOs like Easterwood. However, he remarks, “meeting the MU criteria alone are not the primary concern.” Instead, he’s concerned most about “dealing with all of the specific changes that Meaningful Use is driving.” Behavioral health organizations with eligible providers, like his employer, “did what we could to access year first-year funds, which are really all about getting systems set up and getting data into your system.”

The challenge with the second year of MU “is all about having the data to extract out of your system and share with caregivers,” he says, noting the near-term goal of sharing within the behavioral health environment itself. While achieving MU targets is a goal that can translate into incentive dollars, Easterwood sees MU as “a directional thing, something that points you beyond the numbers into how you coordinate care.” MU also raises practical questions:  “If you do scripts, for example, how do you get that data out of the EHR and into the therapists’ system?”  

With hospitals becoming more and more focused on the causes and costs of readmissions, the behavioral health field has an opportunity to stand out. “We’re really good at coordinating care, doing case management, and supporting behavioral change,” he maintains. However, medicine hasn’t necessarily taken note of that because behavioral health providers “haven’t been very connected to hospitals” and many in medicine haven’t yet realized the role that behavioral health conditions can play in increasing care costs.

While there is a clear opportunity for behavioral health providers to shine, hospitals aren’t just waiting for them to come in and save the day, he explains. A key factor in hospitals’ decision to work with another system of care like behavioral health is the degree of difficulty involved, not just in exchanging the health information needed to manage chronic diseases and comorbidities, but also in bridging a sizable cultural divide: “You’re dealing with primary care or hospital culture, a culture that we’re not really getting into yet. We’ve got a lot of work to do.”

Easterwood worries that hospitals, when faced with the challenges involved in coordinating, accessing, and managing interoperable behavioral health data from multiple providers will “stand up their own systems for behavioral health.” So, although MU is driving all providers “in the overall direction of care coordination and value-based care,” many organizations are hesitating, preferring to see someone else make the move – and take the risk – first.  “Everyone is really hanging on to their traditional models until they’re getting forced to move ahead,” he says. 

The sticking point isn’t so much in what the MU criteria say. “MU is always challenging you to do things in one prescriptive way, using the official Continuity of Care Documents (CCDs), making sure that you count properly, ensuring that you follow all the rules.”

What’s got people – and technology – so disrupted is what the criteria don’t say. “It’s a challenge to the vendors to build systems that really simplify reporting – that enable customers to collect consistent information through their workflows, then generate reports and quality measures with consistency and integrity,” says Easterwood.

MU quality measures, in particular, pose a big challenge. “These are one of the things that makes Meaningful Use tough,” he acknowledges. Like many behavioral health organizations, Centerstone employs a lot of part-time psychiatrists. Getting these busy providers aligned around MU requirements, EHR systems, and clinical workflows is one challenge; ensuring that they’re regularly assessing and then recording data for required measures is another; and then combining that data together and getting organizational quality measures reported is a third.

2) ICD-10

Another major concern is the looming deadline for conversion to ICD-10 coding by October 1, 2014.  “The key,” he says, “is transitioning it with our payers” amid a swirl of other payment system changes involving fee-for-service care, managed care and other, future payment systems.

Meeting the ICD-10 deadline – and keeping claims-related cash flowing in - means that, for some period, Easterwood’s team must be able to send claims to payers “in parallel,” using two coding systems: the outgoing ICD-9 system and the new ICD-10. Exactly when any payer transitions to ICD-10 is up to that payer to decide. Provider organizations can only be ready when the time comes.

Doing a quick bit of math in his head, Easterwood outlines the ICD-10 transition process for Centerstone, beginning with care authorizations: “If I back up three months [from October 1], I’ve got to coordinate my new authorizations. I have to manage that transition as old authorizations run out and new ones kick in.”  New authorizations that extend into the transitional period must be processed in parallel, using both coding systems.

“Then,” he continues, “I have to coordinate with major payers.” With 60 to 70 percent of Centerstone’s business involving Medicaid, this means coordinating with three to five managed care organizations per state. Each MCO currently uses electronic forms associated with ICD-9 codes, but must transition to new forms when the ICD-10 switch is made.

Coordinating the coding/forms switchover with a Medicaid payer is difficult “because they’ve got so many providers to work with,” says Esterwood. “It’s a huge effort for them to determine when they will make the change and then exactly how. Our job is to be staged and ready to go when that day comes.”

Similar coordination efforts also involve commercial insurers and Medicare. Authorizations, claims, submitted in parallel using the ICD-9 forms/codes until the ICD-10 switch is made.

“It’s not always this crazy on a national level,” he suggests, noting that 2014 is a pivotal year.

3) Service delivery

While Easterwood makes clear that all of the disruptive changes rippling through health information systems are “directionally right and understandable,” he feels a genuine element of uncertainty. Though new requirements are disrupting technology platforms today, technology will soon resume its disruptive role, impacting not only “the patient side, but the expense side as well.”

“Things are ripe for a disruption around some new innovative technology model,” he suggests, noting that such a model could “blow up” the office-based, face-to-face clinical service model. In his view, the traditional model faces too many lingering challenges – accessibility and transportation problems, reimbursement challenges, high operating costs. “You can’t optimize based on brick and mortar,” he states.

“The right technology mix could really improve our ability to maintain clients where they are, improve the quality of life they aspire to; yet be disruptive to folks delivering services the traditional way.”