Geriatric Practice: Challenges for Technology

1. Geriatric Practice:Challenges for Technology Peter A. Boling, MD Professor of Medicine Virginia Commonwealth University

2. Selected Problem Areas • Physician-agency regulatory interface • Many providers • Many different forms • Information sharing across settings • Many providers • Many embedded data systems • Much cost • Formulary chaos

3. Bombarded! Managed care discounts and carve-outs Super groups and specialty centers Compliance OVERHEAD Formularies Credentialing JCAHO Standards & guidelines Pharmacy management services

4. Discontinuous “Non-System” Medicare + Choice Medicare Medicaid LTC Insurance Medigap Medicare Drug Benefit

5. Medicare’s Prospective Payment Modalities Nursing Home Home Care Hospital DRGs RUGs HHRGs

6. Physician Regulatory Interface and Signature Authority

7. A Physician’s Nightmare MSA Medicare HMO #2 Drug Plan B Medicare HMO #1 Drug Plan C Physician Medicaid HMO LTC Ins. Drug Plan A Medigap plan Medicare PSO

8. Physicians’ Orders • Home health agency (reimbursed) • Form 485, initial & every 60 days, + changes • Home medical equipment • CMNs (11 types) • Special forms: motorized devices (scooters) • Handicapped parking tag • Do Not Resuscitate order • Disability, Work excuse, FMLA

9. Physicians’ Orders • Supplies (Medicaid and other) • Diabetic supplies (Medicare) • Pharma discount programs • Pharmacy orders • Prescriptions (handwritten) • FAXes from mail-away companies • Controlled substances

10. Clinical Data Sharing Across Settings

11. Post-acute Care Information • Hospital discharge summary • Phone call • Letter • E-mail • Intranet data within a health system • Patient or family recollection Provider Dependent

12. The Personal Data Chip • Is the data correct? • Human error • Intentional falsification • Is the data secure? • Gets lost, stolen, etc. • Who decides what goes on it? • Choice of data types and elements • Who decides what format is used?

13. The Central Data File • Is the data correct? • Human error • Is the data secure? • Access • Who decides what goes in it? • Choice of data types and elements • Who decides what format is used? • Many existing systems ($$ Billions)

14. Health Data

15. Informatics Problems • Similar items do not cross walk well • Software programs do not interface well • Organizations use proprietary systems • Data in EMR transfers poorly to paper • Data in EMR often limited in readability and information content; designed to satisfy regulators not help clinicians

16. HIPAA • Misinterpretation (predictably) widespread • Providers & staff fear, resist sharing data • Health care is therefore more difficult • Lack of information leads to • Errors • Costly redundancy • Corrective action is needed

17. Medicare Physician Payment • RBRVS based on Relative Value Units • Each service valued based on average total cost • Work RVUs • Pre-visit work • Intra-visit work • Post-visit work • Practice Expense RVUs • Malpractice RVUs

18. 99214 – Two Scenarios Geriatrician Generalist

19. Distribution of Visit Times

20. Medicare Part D (Drugs)The Formulary Problem • Mr. Smith sees the doc; they talk about condition, make decision, write prescription • At pharmacy: “not first tier on your plan” • Patient wants lower cost option if possible • Pharmacist calls doctor, “need alternate choice” • Staff pulls office chart, leaves for doctor later • Doctor makes second decision, calls pharmacy • Pharmacy calls patient • Patient returns, gets medicine • Elapsed time: 2 to 4 days

21. Medicare Part D PBMsWhich Formulary for This Patient? Plan E Plan C Plan A Plan B Plan D Plan M Physician Office Plan F Plan N Plan L Plan G Plan H Plan O Plan J Plan K Plan I

22. The Systems Interface Problem HHA #1 HME #3 HME #2 HHA #2 HME # 1 HME #6 HHA #4 HME #4 HME # 5 HHA #3 Physician Office HHA #5 DM #2 PBM #2 PBM #3 PBM #1 DM #1 Hospital #2 PBM #4 Hospital #1

23. Advanced Chronic Illness

24. Chronic Diseases & Costs (1999)

25. Top 1 percent Top 5 percent Top 10 percent 12.8 percent 35.9 percent 53.8 percent Medicare Expenditures (1999)by Subgroup Rank among Utilizers % of Total Medicare Expenses

26. People With Advanced Chronic Illness • Roughly 5-10 million people • Need advanced primary care case managers • Do not need “disease state management” • Need mobile medical providers • House calls • Nursing home and assisted living visits • Need integrated health care • Use 50% of health care resources • Are an underserved, marginalized population

27. What Might Help • Accurate open formulary database on web • Don’t create thousands of software solutions for small portions of this mess • If there is a mandatory central clinical database, make it broadly inclusive • Educate providers accurately about HIPAA • If necessary, pass clarifying legislation • Avoid creating walled cities of information • Substantial restructuring of Medicare and Medicaid • Incentives for providers the engage in chronic care

28. Peter A. Boling, MDProfessor of MedicineVirginia Commonwealth University pboling@hsc.vcu.edu 804-828-5323