Barely a day has gone by recently, that the Affordable Care Act (ACA), Accountable Care Organizations (ACO), or the Centers for Medicare & Medicaid Services (CMS) have not been in the news.

In the broadest strokes, the Accountable Care movement attempts to shift the health payment system from a pay-for-service (fee based) system, to a pay-for-performance (outcomes based) system. Of course, for hospitals that want to accept Medicare and Medicaid, these reforms are mandated. But the overall approach affects almost all practices, regardless of status or whether you are an ACO.

Part of the reason that these policies aren't going anywhere is that early data shows they're working. In 2012, ACOs established in the Medicare's Shared Savings Program generated nearly $400 million in savings, the Centers for Medicare & Medicaid Services said in a statement released last week. 

Despite the laws, it's not always clear how to use telemedicine to improve outcomes in a pay-for-performance system. Interestingly, telemedicine and telehealth has been identified as a key tool in compliance with Accountable Care. It is even written into CMS' final rule for the Medicare Shared Savings Program: accountable care organizations must "define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies." 

So here are 7 ways telemedicine can help you comply with Accountable Care: 

1. Telemedicine makes care coordination possible and effective. Just changing incentives is not enough to improve outcomes. As the New England Journal of Medicine reports, "Merely aligning financial incentives will not improve quality and reduce costs for episodes of care... True coordination of care is required to ensure the best possible outcomes." Telemedicine makes this kind of care coordination possible and effective, particularly in a hybrid store-and-forward context that adapts to provider parameters.
2. Telemedicine makes transportation less necessary. Whether home monitoring or distance consults, telemedicine can save costs of unnecessary visits and lengthy transportation. When payment is linked to outcomes, even saving a patient or provider a single trip can make a big difference over an organization.
3. Telemedicine leverages provider time. In an age of provider shortages, telemedicine can make each provider's minutes count as much as possible. Through consults, collaboration, and even remote patient visits, provider time is leveraged. 
4. Telemedicine can decrease readmissions. Because telemedicine can help the right at-home care to happen, clarify which provider is responsible, and make sure patients follow through, telemedicine has been shown to have a strong effect on decreasing readmissions.
5. Telemedicine can drop length of stay. Data shows that care coordination, especially the kind of collaboration supported by telemedicine, is one of the strongest ways to drop length of stay. And length of stay is a key outcome in Accountable Care.
6. Telemedicine improves access to care. Telemedicine can improve access for the underserved in rural, urban, or Veteran populations. Especially as provider shortages worsen in different parts of the country, and for different specialities, this kind of access to care is proving crucial in keeping costs down and meeting patient needs.
7. Telemedicine supports good patient care, regardless of political climate and payment changes. Truth be told, many of our colleagues have been using telemedicine to improve the ways they care for patients -- regardless of whether it's rewarded by the current political context. We think that's good practice, in every election cycle.

Click here for our free guide on the pros, cons, and ROI of telemedicine options:

Image courtesy of chelseastirlen on flickr.com, used under Creative Commons rights.

As we transition out of the holidays and into the new year, we start to move faster. Our days are busy, we're preparing for yearlong projects, and patients are packed into the schedule following vacations.

In our practice, we've noticed that as we start to move faster, details suffer. The first detail to go? HIPAA compliance. And despite our prioritization of patient care, HIPAA violations are no minor consideration, as we all have come to know. 

So as the 2014 kicks into gear, we wanted to share our favorite easy tips for staying HIPAA safe and compliant.

3 simple ways to stay HIPAA compliant:

• Only use apps that promise HIPAA compliance. Some apps may feel safe, or even say they are "secure", but unless they explicitly promise they are HIPAA-compliant or HIPAA-secure, we'd be wary.
• Focus on patient communication. Patient communication is one of the places where providers tend to get a little lax with their HIPAA considerations, just because it feels like regular communication. But a few simple practices can keep your patient communication simple, personal -- and HIPAA safe. 
• Check your email settings. Although email can't be used for medical collaboration, we use it for so many things that HIPAA complications can sneak in. So we created a guide to make sure your settings help you, rather than hinder.  

We've found that small ways of keeping on top of regulatory issues end up keeping us on track even better than more intensive strategies. So keep it simple -- and stay HIPAA safe. 

Telemedicine can bring HIPAA issues, but doesn't have to. Get our guide here:

The phrase "concierge medicine" conjures up visions of white glove treatment, house calls to yachts, and luxury medical experiences. Some even suggest that these luxury, tailored, out-of-pocket approaches may be unethical because they divert resources from the rest of the medical system.

New models, however, are demonstrating that concierge medicine is not just for the elite. As we detailed in our last post, concierge medicine is, at its core, a direct payment model. Rather than providers caring for patients and collecting payment primarily through government or insurance programs, providers provide care and arrange payment directly. These models are sprouting up in a variety of contexts and with a wide spectrum of payment structures -- but all are beginning to prove that concierge medicine -- or at least some kind of direct care and payment model -- may be used more broadly.

One model, often termed "direct primary care", is being used for everyone from tech entrepreneurs to long-haul truckers. Sherpaa and Qliance are two companies that are providing primary care plans for as little as $50 per month, often in combination with insurance coverage for further treatment. “The concierge model carries a lot of baggage in being health care for the wealthy,” said Dr. Erika Bliss, a family physician and Qliance’s chief executive. “We want to grow this and bring the price point down to average Americans.” The outcomes have been very promising in decreased costs, increased patient satisfaction, and improved health outcomes.

In an age of physician shortages (especially for poorer patients), healthcare provider burnout, and inflated costs, researchers and government officials are seeing opportunity in direct care. An even more populist model, which is also being looked at as a possible opportunity, are clinics in major US cities that meet the needs of the uninsured, especially Spanish-speakers. These clinics offer offer round-the-clock-hours, cultural and linguistic fluency for recent immigrants, and upfront pricing that assumes a lack of insurance -- all things that make these solutions perfect for many. It is reported that "Health officials see in the clinics an opportunity to fill persistent and profound gaps in the county’s strained safety net, including a chronic shortage of primary care physicians."

Of course, there are concerns that the standard of care with low-income clinics and even direct primary care models could suffer. Some patients may not have coverage for specialists or hospital services. Some doctors may not have admitting privileges at local hospitals. And many worry that patients with more severe health needs or more limited funds may not actually end up with the care they need. That said, models like Qliance's and Sherpaa's do seem to be meeting some significant needs, and we'll likely see plenty of innovation in this direct care model in the years to come.

Telemedicine is crucial in a direct care model. Get our guide to your options:

Daniel Diaz was peeling an avocado recently and cut himself. Five stitches later, the hospital billed him $3,355.96.

Daniel's case is far from unique. Hospital charges are skyrocketing -- California Pacific Medical Center’s prices have doubled in the past 8 years. And although recent news has focused on insurance, costs and pricing models are proving to be one area of both concern and opportunity in the medical community.

High hospital costs are symptomatic of a system that isn't aligning care with costs. Finances are evermore opaque, bills don't seem to match the service provided, and patients -- not to mention providers -- seem frustrated and disillusioned. But true costs are not necessarily driving high prices. As the New York Times reports, "The main reason for high hospital costs in the United States, economists say, is fiscal, not medical." And it is hospital costs, not doctors' fees, that are the majority of the costs billed to patients.

So healthcare providers are often stuck in a system that doesn't make sense to patients, and doesn't prove rewarding (financially or medically) to the provider. It is in this context that some providers are exiting the system entirely, cutting ties to insurance and sometimes hospitals, and moving to a "concierge medicine" model. “When I decided to abandon insurance, I didn’t want to lose my patient base and make it unaffordable,” Dr. Stanford Owen, a physician who recently switched to the model, said. “I have everything from waitresses and shrimpers to international businessmen. It’s a concierge model, but it’s also the personal doctor model.” 

Concierge medicine is defined in this article as "a growing subset of medicine where patients pay doctors anywhere from $1,500 to $25,000 a year to receive personalized attention and care." It is a model that lets providers drive care, charges patients a truer cost for the care they receive, and may decrease costs overall. While concierge medicine is often associated with "white glove" treatment for the ultra-rich, the model is most basically a model in which doctors cultivate a direct care and payment relationship with patients, circumnavigating the insurance system.

In many ways, concierge medicine (especially in the humbler family doctor model) solves many of the problems we see in healthcare today. That said, it has its limitations, especially when it comes to specialists. “The vast majority of patients I see have very little money and are very, very sick,” Dr. Lahita, an autoimmune specialist, said. “It would be unconscionable for me to take cash. I’d limit my practice, and it wouldn’t be wise.”

We'll be exploring more about the concierge medicine model this month. It may not be the definitive answer to any of medicine's problems, but we certainly salute the brave physicians that are experimenting with a new model -- failures and successes included.

Concierge medicine makes medical collaboration crucial.  Get our guide:

This post was originally published on July 24th. Since this piece of our website was not working for all viewers, we're republishing some selected posts this week. 

Protecting patient privacy is a good thing. If a patient's medical information gets into the wrong hands, it can make it hard to get a job, complicate relationships, and have financial consequences -- so privacy and HIPAA are important and serious.

But the truth is that HIPAA is causing healthcare provider burnout. As we've talked about in other posts, up to half of physicians are burned out, which has real ramifications: physicians experiencing burnout are more prone to errors, less empathetic, and more likely to quit practicing altogether

And HIPAA is one factor contributing to this burnout, by:

• Disconnecting you from patients. HIPAA-induced wariness about sharing information with patients or patients' families can start to create barriers to interacting.  With so many rules about what is allowed to be shared, to whom, and when, some providers shut down.
• Wasting time with extra forms and EMRs. Most providers report that paperwork (even if it's electronic "paperwork") is at an all-time high, and HIPAA is a strong driver.
• Causing anxiety about getting in trouble. These days, even a simple conversation, phone call, or (gasp!) text message can start to feel hugely risky. That stress contributes to the overall stress of providing healthcare and accelerates burnout. 

So what is to be done? Well, there's a lot you can do, actually. First of all, when you acknowledge the ways HIPAA creates challenges in your practice, it makes you less likely to blame the people around you. Second, when you notice ways that HIPAA is making connection difficult, you can address it in your workflow. For instance, many of ClickCare's users tell us that ClickCare saved them a lot of stress -- as well as time -- because they didn't have to "reinvent the wheel" around HIPAA-safe collaboration. And finally, when you accept that HIPAA rules and constraints might be creating a feeling of disconnection with patients, you can get creative about ways to connect with them even within those constraints.

As with most things, the first step is recognizing the dynamic. Like William James said, "Acceptance of what has happened is the first step to overcoming the consequences of any misfortune." HIPAA is no exception. 

For an overview of the HIPAA/HITECH Omnibus Rule 2013, click the button:

Let us know your comments about the blog article, and tell us which topics you would like us to write about in future blog articles.

This post was originally published on July 24th. Since this piece of our website was not working for all viewers, we're republishing some selected posts this week.  

Working with the doctors and nurses I see every day is one of my favorite things about this work. I also observe a lot of folks working together, and the frustrations and successes I have been seeing made me want to look in the literature for other perspectives on medical collaboration. I found many articles, but two of them really struck me. 

The first was about teamwork on inpatient medical units and the second discussed barriers to nurse-physician collaboration. They made some pretty stark observations about the ways healthcare providers are failing to work together effectively -- and why. 

Sure, we're working in teams and we're trying hard. But working in a team is not the same as working together in a team.

These studies found 4 key barriers to medical collaboration:

1. People aren't in the same place at the same time. This may sound obvious, but the fact that medical teams are working in different buildings, across organizations, and over different shifts creates a unique communications challenge. Communications systems that ignore this challenge (like video conferencing systems or pages in hospital hallways) ultimately fail. 
2. Common systems don't work. Healthcare providers report that the communications systems they're expected to use don't facilitate collaboration or coordination of care. Whether it's an EMR, a paging system, or telephone calls, providers are frustrated with the current options. They're old technologies that don't match the pace, aspirations, or reality of healthcare today. 
3. Coordination of care is basic, and not happening. You would think that the question, "who is taking care of this patient?" would be pretty basic. But providers report that coordination of care is taking up increasing amounts of their time and happening poorly. So poorly, in fact, that knowing who is taking care of a given patient is becoming a daily challenge.
4. The "cockpit approach" doesn't work. Well, to be more specific, it does work -- 10% of the time. In a few specific situations, like in ERs and NICUs, applying learnings from airplane cockpits works (e.g., using checklists). But as Zwarenstien and Reeves point out, 90% of medicine takes place outside of this type of setting. The rest of medicine involves fluid teams, long-term and complex problems, and takes place in different locations and different times. That means that the cockpit construct doesn't help much, and these teams are left without a solution.

These barriers are familiar to me, both in our own hospital setting, and in the experience of many ClickCare users. The good news is that time and time again, I've seen creative, courageous nurses, aides, and physicians overcome these barriers, creating better patient care and a better provider experience.

What ClickCare's users taught me about breaking through to medical collaboration: 

1. Accept that this is your problem, even if it's not your fault. We may not have caused these difficulties in collaboration and communication, but we're suffering from them. The good news is that we've noticed ClickCare users getting a lot of satisfaction and stress-relief from collaboration. It wasn't their fault that it wasn't happening in the first place, but it did benefit them to make it happen.  
2. Experiment. There isn't a one-size-fits-all solution for collaboration, and so we have to experiment with figuring out what can work for us. The thing about experimentation, though, is that new efforts may not work right away. In the words of Seth Godin, "Anyone who says failure is not an option has also ruled out innovation." 
3. Choose a communications technology that works for you, even if not everyone is using it. As human beings, we have a tendency to wait for permission, to wait for standardization, to wait until we find out what everyone else is doing. But given the slow rate of change in the medical world, we have to take change into our own hands. Even if not everyone has adopted a new technology, it could easily be the right thing for us, for our organization, and for our patients. 

Trying hard is something that comes naturally to me. I may not have been the fastest player on the football field, but I was the one that hustled the most.

Practicing medicine has often been about trying hard, as well: long hours; fascinating research; late-night visits to post-surgery babies on the way home from dinner with my family. 

But in recent years, as medicine has become increasingly regulated, I notice a trend toward the legislation of hard work. Patient satisfaction went from a feeling to a metric. Collaboration about serving our patients went from a chat in a hospital hallway to a Powerpoint with "tips" on shaking hands and what to say in the exam room.

Combine this kind of profit-seeking approach with healthcare providers that work hard and care harder… and you've got a recipe for burnout and frustration. Providers suffer, medicine stagnates, and patient satisfaction ends up lost in the shuffle.

So I've started doing the only thing I can in this environment: do the right thing in the moment. I've started thinking of it as Zen and the Art of Patient Satisfaction, in fact. Forget the rules. Forget whether this is your first patient or your fiftieth. Forget whether you need to be more productive or have a higher patient satisfaction rating or whether you've been sued before.

Stop trying so hard. 

As Eugen Herrigel says in the famous book Zen and the Art of Archery, "The man, the art, the work -- it is all one.” That moment when patient, provider, and collaborators are all in the moment and truly being responsive to each other: that is Zen and the Art of Patient Satisfaction. And the satisfaction belongs to every single person involved in the care -- as long as they're present. 

Something happened in the last couple of decades of practicing medicine. On one hand, it's become increasingly difficult to care for our patients: we see 5 patients in the time we used to see 1; it's impossible to navigate insurance companies' rules; and hospital regulations seem to tie our feet and ask us to jump.

At the same time, medical administrators use "patient satisfaction" as the metric of success, and so regulate provider actions in service of that metric: sit down when you're speaking with patients; talk about feelings; talk about facts; thank the patient for choosing our hospital. Oh, and see more patients.

Somehow these formulaic demands feel both overwhelming and insufficient. We agree that patient satisfaction is fundamentally important. But we disagree that the route to patient satisfaction -- when up to half of physicians show signs of burnout -- is more rules, more sticks, and more carrots.

We'd like to propose something revolutionary: that patient satisfaction starts with provider satisfaction. Our experience is proof, the studies back it up, and our patients seem to echo the sentiment. So, in service of that… 

5 reasons that patient satisfaction starts with happy, satisfied providers:  

1. Compassion fatigue can disable us. Compassion fatigue (sometimes called Secondary Traumatic Stress) is a documented condition, common in caregivers and healthcare providers. When compassion fatigue occurs, disconnection, negativity, and even inefficacy in regular work is the result. A lack of support, pervasive stress and pressure, and isolation are all causes -- the exact things that inspired us to start ClickCare -- and are things that persist in so much of healthcare. 
2. Happy providers communicate better. We all know that providers that communicate well have happier patients. But you might be surprised to find out that if we're happier, we'll communicate better. In fact, a study from the University of Arizona showed that happy people have deeper, more substantive conversations, something that patients seem to crave. 
3. Burned-out providers become unable to do even the basics. One recent study shows that providers with burnout are detached, have a low sense of empathy, and even lie and cheat.  So while sometimes we think of self-care or avoiding burnout as a selfish thing, it's very clear that getting what we need as providers is the most altruistic thing we can do. 
4. Will power and good decision-making plummet when exhausted. There is a really fascinating set of research that shows that will power and good decision-making are linked. And the more decisions we are required to make (or the more will power we use), the more that "muscle" becomes exhausted. Once exhausted, our will power and decision-making become very poor -- until we recharge, rest the muscle, and are ready to use it again. As every healthcare provider knows, a day in the office is an endless series of complex decisions. And when we're not given the space or support to rest from that complexity, the evidence shows that we'll perform poorly.
5. Finally, providers actually need the same things patients need. So often, providers and patients are pitted against each other in a "zero sum" model of medicine: it is assumed that if the provider is getting what she needs then the patient won't, and vice versa. In fact, however, as elaborated in this New York Times article, providers need many of the same things that lead to patient satisfaction. Both patients and providers need more time in the exam room, better communication, simpler regulations, less rush, and more authentic interaction with each other. So it's actually a win-win.

For us, the simplest pleasure as healthcare providers is communicating with patients. Whether it's digging into the "problem behind the problem," hearing about jobs or kids, or finding a simple explanation for a diagnosis... these conversations are the best parts of our day. 

So it's scary to hear about all of the HIPAA violations that come from the simple act of communicating. As we wrote in this post, fines keep increasing and enforcement is now a "will happen" thing rather than a "could happen" thing.

ClickCare's primary purposehttp://www.clickcare.com/about-us-mission-statement.php is to help healthcare providers communicate with each other. But we know that providers also use ClickCare to communicate with patients. So we want to make sure that whether you're using ClickCare or communicating through another medium, you're doing so easily, quickly -- and securely.

3 ways to keep your patient communication safe from HIPPA violations:  

1. Never let patient photos into your camera roll. Increasingly, smartphone apps (with the exception of ClickCare) pull from your camera roll-- sometimes even sharing pictures without your knowledge. And even if that doesn't happen, your camera roll only has one layer of security -- the login password on your smartphone. So when dealing with patient photos, we recommend using a secure app like ClickCare that doesn't ever save photos to your camera roll. You'll know your pictures are safe, and used only for your purposes. 
2. Don't use emails or text messages -- period. Email and text messaging have become so common that many healthcare providers end up sending updates or photos via email -- or requesting that patients do the same. Unfortunately, HIPAA violations arising from email or text are increasingly audited and fined, so even with "secure" email, you should never send or recieve patient information this way. There are just too many points in the system where you could be unknowingly violating HIPAA.   
3. Enlist your whole community in secure communication. We tend to have a pretty inclusive office culture. Obviously, everyone from our receptionist to the young man that picks up mail are crucial parts of our communication with patients. That said, only certain members of the community are allowed access to patient information. So make sure to log out of EMRs or other secure programs when you're done using them, and make sure everyone helps keep physical files in the hands of the people allowed to see them. 

My favorite Italian restaurant in our town is a little place called Nick's. Like most good eateries, this one is always packed with a wide swath of folks from our community. And among the families sharing platters of pasta is usually a patient or two.

I'm always grateful for this kind of informal communication with patients. I get to ask after their nose or thumb or hip… and usually inquire about that trip they were about to take when I saw them, or their son that played quietly in the corner of the exam room. I never thought much about these interactions until my daughter commented on it.

"Dad," she said, "How can you possibly remember all of those details when you see so many patients?" I shrugged. Being familiar with the details of my patients' lives is as much a part of my job as being able to do a flap effectively.

I take my ability to remember these things for granted, for the most part. I expect myself to remember a patient's name, condition, family, job struggles, and point of view. I expect myself to recall details of decades-old cases in my communication with patients. And I expect myself to remember an interesting case to share with young students.

Or, at least, I thought I did until I heard this TED Radio Hour on Memory. One quote from Scott Fraser, a forensic psychologist and expert on memory, stood out to me in particular:

"We all have to be very careful. All our memories are reconstructed memories. They are the product of what we originally experienced and everything that's happened afterwards. They're dynamic. They're malleable. They're volatile, and as a result, we all need to remember to be cautious, that the accuracy of our memories is not measured in how vivid they are nor how certain you are that they're correct."

There are reams of research (not all of it useful) on the best methods for communication with patients, like this piece on whether patients actually prefer a patient-centered style. But no matter what your approach, it's crucial to be able to remember the details of what happened as you communicate. I have not found EMRs to be useful aids, as they're not searchable and the information is organized in such a way that I can't seem to pull out the story of the patient.

I do think it's likely that my memory for patients is trained, and thus better than average in this context, but I also know that it can be immensely valuable to have tools that help me remember a patient's full story accurately. Although I hadn't realized it, I have been using ClickCare as a tool, not just for collaboration, but for remembering full cases. That better "remembering" has also led to better communication with patients (as well as with other colleagues and with students.)

So while I can usually remember my patients when I see them in Nick's, I'm incredibly grateful to have ClickCare on my iPhone to help me out when I need to remember a nuance about a case -- wherever I happen to be when I need that information.