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

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

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

Discontinuous Non-System Medicare Medicaid Medicare + Choice LTC Insurance Medigap Medicare Drug Benefit

Medicares Prospective Payment Modalities Home Care Nursing Home DRGs RUGs HHRGs Hospital

Physician Regulatory Interface and Signature Authority

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

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

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

Clinical Data Sharing Across Settings

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

The Personal Data Chip Is the data correct? Is the data correct? Human error Human error Intentional falsification Intentional 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 elements Choice of data types and elements Who decides what format is used? Who decides what format is used?

The Central Data File Is the data correct? Is the data correct? Human error Human error Is the data secure? Is the data secure? Access Access Who decides what goes in it? Who decides what goes in it? Choice of data types and elements Choice 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 Data Hospital Amb. Care Assist.LivingHomeHealthNursingHome Info ChartOneSeveralNoneSeveralOne Drug MAR YesNoMaybeNoYes FormNoneNoneNoneOASISMDS

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

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

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

99214 – Two Scenarios Generalist Geriatrician

Distribution of Visit Times

Medicare Part D (Drugs) The Formulary Problem Mr. Smith sees the doc; they talk about condition, make decision, write prescription Mr. Smith sees the doc; they talk about condition, 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 possible Patient 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 later Staff pulls office chart, leaves for doctor later Doctor makes second decision, calls pharmacy Doctor makes second decision, calls pharmacy Pharmacy calls patient Pharmacy calls patient Patient returns, gets medicine Patient returns, gets medicine Elapsed time: 2 to 4 days Elapsed time: 2 to 4 days

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

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

Advanced Chronic Illness

Chronic Diseases & Costs (1999)

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

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

What Might Help Accurate open formulary database on web Accurate open formulary database on web Dont create thousands of software solutions for small portions of this mess Dont create thousands of software solutions for small portions of this mess If there is a mandatory central clinical database, make it broadly inclusive If there is a mandatory central clinical database, make it broadly inclusive Educate providers accurately about HIPAA Educate providers accurately about HIPAA If necessary, pass clarifying legislation If necessary, pass clarifying legislation Avoid creating walled cities of information Avoid creating walled cities of information Substantial restructuring of Medicare and Medicaid Substantial restructuring of Medicare and Medicaid Incentives for providers the engage in chronic care Incentives for providers the engage in chronic care

Peter A. Boling, MD Professor of Medicine Virginia Commonwealth University