Indian Healthcare going thru a paradigm shift

Indian Healthcare is going thru a paradigm shift right now. It is moving from fragmanted to consolidated. Its moving from Transaction based Healthcare model to a Healthcare contract.

Large consolidated hospital chains are emerging in the private sector. Clinic networks, Lab networks and Pharmacy chains are also emerging on the scene. Govt is also catching up with the modernisation of its hospitals and PPP. Health Insurance is begining to follow patients even after they leave the clinic and some systems are emerging to manage their health and disease in the society as well. However all this is happening on the brick&mortar side of the healthcare. What about technology, people and process?

TECHNOLOGY:
Is technology catching up at the same pace as brick&mortar? Are these networks/chains having the required technology infrastructure in terms of software, hardware and IT networks? Is the budget being allocated for the technology infrastructure? For a good IT setup, Indian hospitals have to get into a habbit of allocating 10% of their budget to IT.

There is a need to develop a Healthcare-IT platform specifically for India. A platform that will include HIS+EMR+ERP and will be hosted, so that every clinician, administrator or manager can use it over the web. Software as a service [SaaS] model can become a reality now in India because internet bandwidth is becoming available everywhere through fixed lines, mobiles and DTH. The SaaS moel is economically viable because it converts the Capex into Opex. Also there is no entry or exit barrier.

Current HIS/EMR are force fit to the unique requirements of the Indian Healthcare. Either they are imported and dont include the special needs of Indian business. Or they are home grown and dont recognize the global aspirations of Indian hospitals/clinics.

Public Health informatics is still a far cry!

PEOPLE:
Is there trained manpower available to run this show? we need people trained and experienced in Healthcare + IT + Management skills. Atleast 30% of the people should have all the 3 skills in the same brain and the rest can start from one descipline and acquire the other 2 in time.

I think the real change will happen when our Medical colleges restructure their courses to include management and IT as an integral part of the education curriculum. Some Healthcare Management institutes have taken the first step towards including some part of IT in the curriculum, but there is a long way to go before the model matures.

We need to have short term, medium term and longterm approach to the people issue. Do we have anyone thinking in this direction!

PROCESS:
Awareness about NABH, JCAHO and ISO standards is emerging in large hospitals. More because they want to look attractive to the MNC Health insurance, so that medical tourism can be routed this way. However the culture of Quality is yet to percolate down into the psyche of the Indian Healthcare. This will take time to happen and will require a significant push from central bodies like QCI.

The need of the hour is to define key performance indicators [KPI] for clinical, admin and management aspects of healthcare. Some standard mechanism has to emerge for KPI measurements, analysis, publication and debate. Some healthcare body has to take the lead for KPI in Indian healthcare. Unfortunately very few even understand the concept of Healthcare KPI.

During my recent lecture I asked the Healthcare management students if they are measuring their processes, and most of them could just draw a blank!

Disease Management Thru Mobile Platforms

• Disease management is emerging as the next big thing in Healthcare-IT. It is catching up in both US healthcare as well as Govt run healthcare systems in commonwealth countries like Canada, UK, Singapore, Australia etc. India should not be far behind.





• The prime reason for interest in disease management is due to rapid increase in chronic diseases owing to adoption of unhealthy lifestyles.





• Improvements in laboratory technology have enabled better monitoring of physiological and pathological markers.





• The disease can be monitored from predisposition stage itself.





• IT products for Disease management are few and far between. But leveraging the mobile technology can catapult the Disease management into the forefront of everyday life.
  Mobile platforms are ubiquitous in nature and are very personal to the patient and the doctor. Any Disease management program run by using mobile platform should be an instant hit.





• However the open question that remains is that who will pay for the program initially i.e. Disease Registry and Disease Management Program. Although the data generated by the program is expected to pay for the program over time, but initially there is no data and no value can be derived from it until much later.





• Governments, Mobile platform companies, Health Insurance companies and Pharma companies accrue the maximum benefits. They should be in a position to pay for the program initially and reap the rich benefits from the data collected over time.





• Governments are paying for the program in some commonwealth countries, whereas some Insurance companies are already investing in CDM in USA. It will be interesting to see who takes the lead in a country like India where the gold [data] lies at the bottom of the social pyramid!

Fallout of Obama's EMR incentive package

Obama’s incentives package has put power in the hands of Physicians. So what is expected to change:

1. Pharma co: Physician’s reliance on pharma companies for drug education updates will reduce because they will get direct access to latest version of electronic drug databases in the EMR. Many EMR will have CPOE and Medication Management built into it, which will guard against unnecessary/incorrect prescriptions. Cross-selling and Up-selling of drugs will get minimized. However the drug compliance will go up in chronic disease management.
2. Insurance: Private sector Health Plans will have to compete with Public sector Health Plans for their bread-and-butter. US has a very large aging population [Baby Boomers].
3. Hospitals: Will have to figure out how they can increase their Medicare and Medicaid practice. They will also have to depend more on Physicians that already have a greater mix of Medicare and Medicaid practice.
4. CDC: Public Health initiatives and Disease Surveillance will gain power because they will start getting valuable Public Health data through Medicare and Medicaid. So far private enterprises didn’t want to share member/patient/outcomes data.
5. Healthcare Economics: will shift towards measuring clinical outcomes rather than business value. Public Health, Disease Management and Preventive Medicine will gain because US has a very large aging population [Baby Boomers].
6. M&A: New business models and major consolidations should be expected. I can see Pharma companies and Insurance companies buying out EMR/EHRS, Healthcare-IT companies [which one, I keep guessing..].

Initially I was skeptical about what 1 President can change. However Obama is surely exercising the power vested in the highest office of US. This looks like the dawn of a new era in US Healthcare.

Physician Practices become a large Healthcare-IT market in USA

As per my study here is a summary of Obama’s EMR and EHRS Incentive package:

1. $ 2B for developing standards, EMR installation grants and EHRS @ RHIR [I guess new name for RHIO]
2. $ 21B as incentives on EMR adoption. This is the net cost after anticipated savings of $ 15B are subtracted from the total spend of $ 36B on incentive payments.

Incentives will be given to providers with:

1. Use of a certified EMR product complete with ePrescribing capability as determined appropriate by the Secretary of HHS
2. The EMR is connected to the EHRS/ HIE for the electronic exchange of PHI
3. Complies with submission of reports on clinical quality measures
   

The incentives are for the ambulatory space and are paid on a per Physician basis. Hospitals are not eligible with certain exceptions. Provider can claim this incentive thru Medicare or Medicaid depending on their practice mix.

MEDICARE:

1. Physicians operating in a "provider shortage area" will be eligible for an incremental increase of 10% in their bonus payments.
2. Physicians operating entirely in a hospital environment, such as anesthesiologists, pathologists and ED physicians, are ineligible.
3. Beginning in 2015, physicians not demonstrating meaningful use will have their Medicare fee schedule reduced.

For further details you can refer FAQs on AllsrciptsMisys website; There is a table that gives the details of the amount physicians will receive each year through Medicare.

MEDICAID:

A healthcare provider is eligible for incentive payments from Medicaid who:

1. is not hospital-based and has at least 30 percent of the professional’s patient volume coming from Medicaid patients;
2. who is a pediatrician, who is not hospital-based, and who has at least 20 percent of the patient volume coming from Medicaid patients;
3. practices predominantly in a FQHC or rural health clinic and has at least 30 percent of the professional’s patient volume coming from Medicaid patients;
4. is a children’s hospital, or an acute-care hospital that is not described in clause (1) and that has at least 10 percent of the hospital’s patient volume coming from Medicaid patients.

Incentive payments will be based on a calculation that factors the physician’s Medicaid mix in combination with up to $25,000 the first year and $10,000 each subsequent year for five years, all multiplied by 85%. The highest potential for Medicaid payments is $63,750. Additionally, physicians filing under Medicaid must first demonstrate EHR usage by 2015 and will not be eligible for payments after 2021.

HOSPITALS:

Eligible hospitals such as children’s hospital, or an acute-care hospital can get $2 million base payment plus a figure derived from the discharge volume.

Critical Care Hospitals are not eligible for the incentives described above. Instead, they will be allowed to expense the acquisition cost of Health-IT in a single year for Medicare payment instead of depreciating it over a number of years.

For eligible hospitals not demonstrating meaningful EHR use by 2015, three-quarters of the anticipated percentage increase in the fee schedule shall instead be reduced by 33 1/3 percent for fiscal year 2015, 66 2/3 percent for fiscal year 2016, and 100 percent for fiscal year 2017 and each subsequent fiscal year. This reduction will be reevaluated each year, and a hospital can return to a normal fee schedule as soon as EHR use is demonstrated.

ADVANTAGES:

1. Therefore the Small Physician practices suddenly have become a very large Healthcare-IT market in USA! The power base has shifted. I remember the book ‘Power Shift’ by Alvin Toffler.
2. Obama has put life back into Public Sector Health plans - Medicare and Medicaid! WOW This is the work of a genius.

Above is a simplified version of the incentive package. There is more devil in the details. For those who want to go deeper, there is a good analysis provided in FAQ on AllscriptsMisys website.

Disease Registry and Disease Management Program for Emerging Markets - Conceptual

Data Capture for building a Disease Registry in emerging markets like India is always a challenge. Electronic systems can come to the aid of healthcare professionals to collect credible data from data sources. However technology has to be used where it makes most sense. For example electronic data capture directly from field maybe a far cry. So just make the healthcare workers collect clean paper data and let a BPO unit do the data entry.

Primary Data capture:

• Paper data – transcribed by data entry operator


• Mobile – SMS or email sent by MPW


• Mobile – SMS or email sent by Patient


• Mobile – Voice call done by Patient to a call centre that records the data
  

PHC/ Hospital sends the collated data to State level Disease Registry via:

• DTH linkup to Satellite and linked to the Registry


• Broadband linkup to the Registry
  

State level Registry is linked up to the Central Registry via Satellite

Full Redundancy can be built by Broadband and GPRS linkup to make sure alternative route is available if one fails.

Enterprise Master Person Index [EMPI] software along with the Registry will make sure that duplicate entries are not present. EMPI decides this based upon complex statistical analysis of parameters such as – name, age, sex, address, ration card number, DL number, any other identification number etc.

Once the Disease Registry has been built the Disease Management can also be one. Standard Care Plans can be pushed from the central location and the local doctor can customize it for the individual needs of the patient.

• Standard Care plans are pushed down from National level Registry to State level Registry to local hospitals.


• Care plans can be customized by local doctor.


• Clinical decision support software can help the doctor customize the care plan for the patient based upon combination of key indicators such as HBA1c levels, age and drug prescriptions of a Diabetic.


• These customized care plans can be pushed to the patient via paper mailer, mobile – text and voice.


• Patient Relationship Management software can keep track of care plan and drug compliance via reminders and alerts on mobile SMS, voice and mailers


• Call centers managed by nurses can also keep track of care plan and drug compliance of patients

Are we measuring enough?

Every industry measures its processes. In fact Automobile industry went to the extent of measuring and standardizing each step such that they almost removed the waste and called it 'Just in Time'.

Unfortunately healthcare hasn't developed the culture of metrics or KPI yet. But believe me its high time we started doing it, because the capex and opex is beginning to spiral out of control.

Biology is not 2+2=4. In Healthcare we cant standardize everything as the Automobile industry, because we deal with human body with so many variations. Worst of all god didnt give release notes and users mannual! However we can measure each standard step in the clinical process and consolidate it every week, month or quarter. We need to start measuring the key performance indicators [KPI] of our hospitals. This will help us find out if our resources are productive and utilized. It will tell us when we need to add more resources. It will also tell us if there is any spare capacity which we can use. We can also track errors in the process.

Operational KPI have direct bearing on Financials of a hospital. I recomend the following KPI at practice, department, hospital and population level:

• Productivity - Time taken per unit of work - measure for People, Equipment
• Utilization - Time effectively used vs. time available - measure for Beds, People, Equipment
• Defects - number of process errors reported
  

Time is a common dimension accross e.g. by week, by month, by quarter..

Ideally activity based costing should also be done in a hospital. However in absence of the granular data, at least department level operational data aggregation should be done. They say unless you measure you dont know how far you are in the path.