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Geriatric Practice:Geriatric Practice:Challenges for TechnologyChallenges for Technology
Peter A. Boling, MDPeter A. Boling, MD
Professor of MedicineProfessor of Medicine
Virginia Commonwealth UniversityVirginia Commonwealth University
Selected Problem AreasSelected Problem Areas
Physician-agency regulatory interfacePhysician-agency regulatory interfaceMany providersMany providersMany different formsMany different forms
Information sharing across settingsInformation sharing across settingsMany providersMany providersMany embedded data systemsMany embedded data systemsMuch costMuch cost
Formulary chaosFormulary chaos
Bombarded!Bombarded!
Managed care discounts and carve-outs
JCAHO
CredentialingFormularies
Pharmacy management services
Super groups and specialty centers
OVERHEAD
Standards & guidelines
Compliance
Discontinuous “Non-System”Discontinuous “Non-System”
Medicare Medicaid
Medicare + Choice
LTC Insurance
Medigap Medicare Drug Benefit
Medicare’s Prospective Medicare’s Prospective Payment ModalitiesPayment Modalities
Home Care
Nursing Home
DRGs RUGs HHRGs
Hospital
Physician Regulatory Interface Physician Regulatory Interface and Signature Authorityand Signature Authority
A Physician’s NightmareA Physician’s Nightmare
Drug Plan CPhysician
Medicaid HMO
LTC Ins.
Medicare PSO
Drug Plan A
MedicareHMO #2
Drug Plan B
MedicareHMO #1
Medigap plan
MSA
Physicians’ OrdersPhysicians’ Orders
Home health agency (reimbursed)Home health agency (reimbursed)Form 485, initial & every 60 days, + changesForm 485, initial & every 60 days, + changes
Home medical equipmentHome medical equipmentCMNs (11 types)CMNs (11 types)Special forms: motorized devices (scooters)Special forms: motorized devices (scooters)
Handicapped parking tagHandicapped parking tagDo Not Resuscitate orderDo Not Resuscitate orderDisability, Work excuse, FMLADisability, Work excuse, FMLA
Physicians’ OrdersPhysicians’ Orders
Supplies (Medicaid and other)Supplies (Medicaid and other)Diabetic supplies (Medicare)Diabetic supplies (Medicare)Pharma discount programsPharma discount programsPharmacy ordersPharmacy orders
Prescriptions (handwritten)Prescriptions (handwritten)FAXes from mail-away companiesFAXes from mail-away companiesControlled substancesControlled substances
Clinical Data Sharing Clinical Data Sharing Across SettingsAcross Settings
Post-acute Care InformationPost-acute Care Information
Hospital discharge summaryHospital discharge summaryPhone callPhone callLetterLetterE-mailE-mail Intranet data within a health systemIntranet data within a health systemPatient or family recollectionPatient or family recollection
Provider Dependent
The Personal Data ChipThe Personal Data Chip
Is the data correct?Is the data correct?Human errorHuman error Intentional falsificationIntentional falsification
Is the data secure?Is the data secure?Gets lost, stolen, etc.Gets lost, stolen, etc.
Who decides what goes on it?Who decides what goes on it?Choice of data types and elementsChoice of data types and elements
Who decides what format is used?Who decides what format is used?
The Central Data FileThe Central Data File
Is the data correct?Is the data correct?Human errorHuman error
Is the data secure?Is the data secure?AccessAccess
Who decides what goes in it?Who decides what goes in it?Choice of data types and elementsChoice of data types and elements
Who decides what format is used?Who decides what format is used?Many existing systems ($$ Billions)Many existing systems ($$ Billions)
Health DataHealth Data
HospitalHospital Amb. Amb. CareCare
Assist.Assist.
LivingLiving
HomeHome
HealthHealth
NursingNursing
HomeHome
InfoInfo ++++++++++++ ++++++++++ ++++ ++++++++ ++++++++
ChartChart OneOne SeveralSeveral NoneNone SeveralSeveral OneOne
Drug Drug MARMAR
YesYes NoNo MaybeMaybe NoNo YesYes
FormForm NoneNone NoneNone NoneNone OASISOASIS MDSMDS
Informatics ProblemsInformatics Problems
Similar items do not cross walk wellSimilar items do not cross walk wellSoftware programs do not interface wellSoftware programs do not interface wellOrganizations use proprietary systemsOrganizations use proprietary systemsData in EMR transfers poorly to paperData in EMR transfers poorly to paperData in EMR often limited in readability Data in EMR often limited in readability
and information content; designed to and information content; designed to satisfy regulators not help clinicianssatisfy regulators not help clinicians
HIPAAHIPAA
Misinterpretation (predictably) widespreadMisinterpretation (predictably) widespreadProviders & staff fear, resist sharing dataProviders & staff fear, resist sharing dataHealth care is therefore more difficultHealth care is therefore more difficultLack of information leads to Lack of information leads to
ErrorsErrorsCostly redundancyCostly redundancy
Corrective action is neededCorrective action is needed
Medicare Physician PaymentMedicare Physician Payment
RBRVS based on Relative Value UnitsRBRVS based on Relative Value Units Each service valued based on average total costEach service valued based on average total cost
Work RVUsWork RVUs Pre-visit workPre-visit work Intra-visit workIntra-visit work Post-visit workPost-visit work
Practice Expense RVUsPractice Expense RVUs Malpractice RVUsMalpractice RVUs
99214 – Two Scenarios99214 – Two Scenarios
5 5
2530
8
17
0
10
20
30
40
50
60
Pos-visit
Intra-visit
Pre-visit
Generalist
Geriatrician
Distribution of Visit TimesDistribution of Visit Times
0
5
10
15
20
25
30
35
12 14 16 18 20 22 24 26 28 30 32 34 36
Generalist
Geriatrics
Medicare Part D (Drugs)Medicare Part D (Drugs)The Formulary ProblemThe Formulary Problem
Mr. Smith sees the doc; they talk about Mr. Smith sees the doc; they talk about condition, make decision, write prescriptioncondition, make decision, write prescription
At pharmacy: “not first tier on your plan”At pharmacy: “not first tier on your plan” Patient wants lower cost option if possiblePatient wants lower cost option if possible Pharmacist calls doctor, “need alternate choice”Pharmacist calls doctor, “need alternate choice” Staff pulls office chart, leaves for doctor laterStaff pulls office chart, leaves for doctor later Doctor makes second decision, calls pharmacyDoctor makes second decision, calls pharmacy Pharmacy calls patientPharmacy calls patient Patient returns, gets medicinePatient returns, gets medicine Elapsed time: 2 to 4 daysElapsed time: 2 to 4 days
Medicare Part D PBMsMedicare Part D PBMsWhich Formulary for This Patient?Which Formulary for This Patient?
PlanO
PlanM
PlanL
PlanF
PlanG
PlanJPlan
K
Plan N
PlanB
PlanA
Plan I
Plan D
PlanC
PlanH
PlanE
PhysicianOffice
The Systems Interface ProblemThe Systems Interface Problem
HME #4
HME # 5
HME #2
HME # 1HME #6
HME #3
HHA #4
HHA #1
HHA #5
HHA #3
HHA #2
DM #2
DM #1PBM #1
PBM #3
PBM #2
PBM #4
Physician Offic
e
Hospital #1Hospital #2
Advanced Chronic IllnessAdvanced Chronic Illness
Chronic Diseases & Costs (1999)Chronic Diseases & Costs (1999)
0
2000
4000
6000
8000
10000
12000
14000
16000
$
65-69 70-74 75-79 80-84 85+
Age Bracket
Zero
One
Two
Three
Four +
Medicare Expenditures (1999)Medicare Expenditures (1999)by Subgroupby Subgroup
Top 1 percentTop 1 percent
Top 5 percentTop 5 percent
Top 10 percentTop 10 percent
12.8 percent12.8 percent
35.9 percent35.9 percent
53.8 percent53.8 percent
Rank among Utilizers % of Total Medicare Expenses
People With Advanced Chronic IllnessPeople With Advanced Chronic Illness
Roughly 5-10 million peopleRoughly 5-10 million people Need advanced primary care case managersNeed advanced primary care case managers Do not need “disease state management”Do not need “disease state management” Need mobile medical providersNeed mobile medical providers
House callsHouse calls Nursing home and assisted living visitsNursing home and assisted living visits
Need integrated health careNeed integrated health care Use 50% of health care resourcesUse 50% of health care resources Are an underserved, marginalized populationAre an underserved, marginalized population
What Might HelpWhat Might Help Accurate open formulary database on webAccurate open formulary database on web Don’t create thousands of software solutions for Don’t create thousands of software solutions for
small portions of this messsmall portions of this mess If there is a mandatory central clinical database, If there is a mandatory central clinical database,
make it broadly inclusivemake it broadly inclusive Educate providers accurately about HIPAAEducate providers accurately about HIPAA
If necessary, pass clarifying legislationIf necessary, pass clarifying legislation Avoid creating walled cities of informationAvoid creating walled cities of information Substantial restructuring of Medicare and Substantial restructuring of Medicare and
MedicaidMedicaid Incentives for providers the engage in chronic careIncentives for providers the engage in chronic care
Peter A. Boling, MDPeter A. Boling, MDProfessor of MedicineProfessor of Medicine
Virginia Commonwealth Virginia Commonwealth UniversityUniversity
[email protected]@hsc.vcu.edu
804-828-5323804-828-5323
