In medicine, we're called on to help people do what they love to do. Healing, in a generic sense, is important, but what that means depends on the unique individual.

For a quilter, we want to make sure she can see and use her hands well enough to piece the colored fabrics that help her express herself: her ability to run may not matter to her. For an athlete, it matters whether they are back in the game 8 days from now (just after playoffs) or 6 days from now (just in time to win the big game).

And for a singer in the Metropolitan opera, to belt her piece on command is crucial, whether she's just come down with a cold or not.

The New York Times recently took a look at the house doctors who volunteer to care for the Met's performers on a nightly basis: "The doctors’ job is to minister not only to the strained larynxes and occasional fractures of the cast and crew, but also to treat members of the audience, who are most commonly felled by preperformance overindulgence in wine and rich restaurant food."

In so many ways, we are all the "house doctor" for an extraordinary person. Whether a stay at home mom, a great grandmother, a construction worker, an opera singer, or a pro golfer, we all have crucial roles we play and ways we need for our bodies to support us in doing so.

Pay-for-performance models and managed care are interesting because, despite their flaws, they relate to this truth. Our job as medical providers is to help people get better so they can do the things they want to do.

If you're looking for a telemedicine solution to help you get the lead back on stage, the mom back to running with her kids, or the quarterback back to practice, get our guide to the options here:

When I first started practicing, there certainly wasn't as much talk about technology. Now we're all thinking about BYOD, iPhones, EMRs, EHRs, and big data.

But there has always been discussion of how to use the tools available to us to make research stronger, care easier, and medicine better. And for decades, I've been experimenting with the best ways to use tools like telemedicine to support medical teams in caring for complex patients - facial deformities, handicapped children, spinal bifida and everyday care. Especially in the early years of computers in medicine, it was not always easy to get the team on board. There were a lot of long meetings, backtracking, and mistakes. So I learned some lessons the hard way about how to work on teams, integrate technology, and ensure great outcomes.

My 5 hardest earned lessons on using technology for medical teams, especially in managed care settings:

1. Explain your technology choice and the reasons for your decision. Be open and honest with full disclosure of the pros and cons so teammates don't feel like they've been forced into a particular choice.
2. Enlist the support of a champion. Find a person on the team with idealism and energy -- and show them how these new tools will help leverage everyone's efforts.
3. Support the weakest link. After all, it is a team, and a team is only as strong as its weakest link. There are team members who preceded the information revolution. Often presenting themselves as proud of their computer illiteracy, they often strongly wish to be part ot the new age. So rather than leaving them behind, make them part of the solution.
4. Make sure the technology helps solve the team's problem. We're all human, and it's hard to care about someone else's agenda. So if the technology solves the government's or joint commission's problem (as opposed to the team's or patient's problem), you'll struggle to get anywhere.
5. Choose technology that is quick, on demand, detached from schedules, and delightful. Information overload has numbed minds, pained wrists, and strained eyes. The wrong technology for the wrong reasons (any reason that does not take care of the provider and patient first) will never work. Security is paramount, but when doubt, err on the side of simplicity.

Click here to get a rundown of telemedicine options and what to look for in a solution:

HIPAA, of course, will not let us share why we am here, but we are in a hospital atrium waiting area, waiting. 

This particular hospital is one that I visit only infrequently and is not my primary hospital. (That sentence alone is a whole story that illustrates the changes in medicine.) I run into old friends: the type of friends that only a long and loving career in medicine can nourish.  Nurses, advanced practice nurses, physicians.  Friends who help each other take care of our patients.  Friends who put the patient first. Good old fashioned medicine.

Our multifaceted heathcare system would have it otherwise. It is not efficient to talk. It is not documentable to console and encourage each other. But we do it anyway. We remember the experiences we share, and we remember the lessons learned. Real learning from real experience is not always in the clinical guidelines binder and an evidence base for the situation we were in -- cannot be found -- because it does not exist.

It is not a world of the 80:20 rule, Pareto efficiency, or here which would be easier for the financial side of our brains to manage. It is 100:0. Alive or dead; healthy or well.  Things end up in between, but, the intent needs to be absolute and perfectionistic.

Managed care is important. But as we move into an age of "value-based" medicine, we must ask: “Whose values?” Are they those of Maimonides and Hippocrates?  “Is efficient care the best care?"  Mostly yes, sometimes no. Because of the erection of silos around us, communication becomes vital for the patient to survive. We will never return to the days of a cottage industry, but we have the opportunity to supersede the limitations of industrialized medicine.  iClickCare strives to reestablish the communication, conversation, satisfaction, support, and good care that is intrinsic to our professions. Hybrid Store-and-Forward® telemedicine brings back the best of working together, while taking advantage of the concept that "no one of us is as smart as all of us."  Of course, the “all of us” welcomingly includes our committed and public policy makers and the members of our team who administer.  

And finally, if you are a patient (and we all are), take an active part in reestablishing your role and responsibility in the process. Move back, intellectually, to the "good old fashioned" time when you paid the doctor directly after discussing the options best for you.  It can be done again -- and we create it by our expectation and commitment to make it happen.

Those principles of the past can be massively empowered by using the technology of now and of the future.

A sure way to form a bond with any medical provider is to share "war stories" of your EMR / EHR. Whether a specialist or a generalist, and across the spectrum of care, providers struggle with the heavy burden that this technology has created. 

EMRs with poor user interfaces, no collaboration mechanism, and formats that force counterintuitive thinking are hugely detrimental to providing good patient care. They contribute to the shrinking time we have with each patient and, as the article explores, can contribute to making mistakes. 

Things get even worse when you look at the performance of most EMRs / EHRs in managed care system. When the hospital system or ACO is responsible for the full scope of performance and efficiency for each patient, the losses that bad tech causes become compounded. There is an ever-worsening shortage of providers; how can we rationalize even a 20 minutes loss in their time each day due to bad tech? 

So what are providers and administrators to do? Well, we certainly don't have all the answers, and we know first-hand how frustrating technology can be. But here are 4 things that our colleagues have found to make technology in medicine a blessing, rather than a curse: 

1. Invest in well-designed technology. Some products invest more in the design of the interface and functionality of the tool. Demand that the tool that helps you care for patients is elegant, easy to use, and helps you do your work in the ways you want to do it.
2. Change how you work. As Robert Wachter said in the New York Times recently: "In health care, changes in the way we organize our work will most likely be the key to improvement... It means creating new ways to build teamwork once doctors and nurses are no longer yoked to the nurse’s station by a single paper record. It means federal policies that promote the seamless sharing of data between different systems in different settings."
3. Figure out if there is just a lag time. The New York Times article above also mentioned what Erik Brynjolfsson, a management professor at M.I.T., described as “the productivity paradox” of information technology, in which there is a delay between adopting a new technology and experiencing the benefits from it. This is a reality to some extent, so patience can be helpful -- as long as you're not waiting for a gain that is never going to happen.
4. As we shared in this post, you are not setting yourself up for success if you make huge investments in hardware. We recommend investing in software (which can be updated, and is generally the lowest portion of costs) rather than hardware which gets obsolete quickly. Use the equipment you already have, the spaces already available to you, and just start. 

One way to deal with poor technology at work is by bringing the tools that work for you, on your own phone / device: Bring Your Own Device (BYOD.) The challenge here is whether you'll run afoul of HIPAA. Click below to learn easy ways to stay secure. 

A recent New York Times article tells the story of Jerome Pate, a homeless man who visited the Emergency Room 17 times in 4 months last year. He would go if he was sick. And he would go if he was cold, or drunk, or hungry, or suicidal. In other words, he had a lot of visits, for minor or nonexistent medical problems, with a serious root cause (in this case, his homelessness). Mr. Pate was a super utilizer. 

“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a county health official who helps run the experiment here. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.” This type of pattern would have actually been a cost center in the old medical system. When you're paid by the visit, many visits for small or nonexistent problems actually work in favor of the hospital in terms of profit.

In an age of penalties for readmissions, and pay-for-performance being the rule of the day, this is not a strategy that works.

More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect. For those patients, as well as for Accountable Care Organizations and managed care hospital systems, super utilizers can be a major source of costs -- as well as care that doesn't really meet the patient's needs.Some people have expensive problems that are only solved by many hours of a single specialist. But some of the largest shares of spending are actually from the super utilizers who are racking up costs with very simple problems.

Hospitals and providers who use iClickCare have been finding that the needs of super utilizers can be best met with the support of telemedicine. When providers collaborate across the spectrum of care, it is much easier to deal with patients who have nonmedical issues exacerbating or causing their primary compliant. It allows providers to communicate on their own time, across buildings, and spanning visits.

Here are 3 ways telemedicine and medical collaboration can help you care for super utilizers and make sure costs are contained:

• Stop people from falling between the cracks. With Mr. Pate, for instance, the hospital's procedures and systems made it so that each time he came in, the ER team assessed and/or treated him for the medical concern he presented with. Even if the providers in the ER were aware of the nonmedical issues he was facing, they had no good way to connect him to the services he needed -- services that may have prevented him from circling back to the ER the very next week. With a medical collaboration platform like iClickCare, an ER doc could leave a question or consult for a health outreach or social service worker at 3am and that other provider could connect with the patient or the original doctor the next day.
• Create a broad treatment team. Because medical collaboration lets you create a treatment team across the spectrum of care, the components of a patient's problems that are less directly "medical" can be cared for. A collaboration in iClickCare, for instance, can include teachers, health outreach workers, social workers, the ER doctor, a specialist, and a primary care doctor. All sharing their thoughts and questions on their own time, in a single place.
• Resolve the root problem the first time. In Mr. Pate's case, he was 17 visits in and his root problem -- his homelessness -- still hadn't been addressed. It is better care (and more cost effective) to buy a person a pair of winter boots than to amputate a diabetic's foot. And a telemedicine platform can allow providers to get to the root of the problem through collaboration and continuation of care -- without allowing things to get bad, painful, and expensive. 

For our complete Quick Guide on telemedicine, click here: 

Recent news reports indicate that the Ebola crisis is almost over. There remain some very serious threats and infections, including that of these workers for Partners in Health. And, of course, completely erradicating the disease is likely impossible. That said, the last known Ebola patient was released from a hospital in Liberia (the original epicenter of the epidemic) 13 days ago. And 7 days ago, the WHO and UN indicated that the entire outbreak could be over by the summer.

The World Health Organization, as quoted by the New York Times, said: "The Ebola outbreak that has claimed nearly 10,000 lives over the past 15 months could be halted by the summer, but only if international financial support is sustained."

It has been a devastating crisis that has taken a terrible toll -- and infections and deaths do continue. But, to be sure, it could have been much, much worse. Early statements by infectious disease experts demonstrated that this crisis, and this disease, are among the worse (or at least had the potential to be so) in humankind's experience. 

So with the end of the Ebola crisis in sight -- something that seemed impossible just a few months ago -- we gather some key lessons for managed care, hospital systems, ACOs, and every medical provider:

• Celebrate wins. So much attention was paid at the start of the crisis, but now that human ingenuity, hard work, and collaboration have led to near elimination of the crisis, you can barely find news stories about it. This is a destructive cycle. We've found that the most successful hospital systems respond in a crisis -- but also celebrate when things have gone right.
• Develop resources and systems to support the long fight. As the WHO and UN share, success is within reach, but only if funding and resources continue all the way to the end of the fight. Whether it's implementing a telemedicine system or treating a single patient, good care necessitates seeing the work through to the end. (And sometimes this means long past the point of discharge.)
• Collaborate. The battle against the Ebola crisis showed collaboration across sectors, across geography, and at all points on the spectrum of care. An extraordinary outcome was achieved in this case, and we believe that it is because of the collaboration of many, not the insight of the few.

Thank you, thank you, thank you to all of the men and women, government officials and healthcare providers, families and patients who worked and fought to get to this point. And may we all contribute to seeing this through to the end.

For other stories of medical collaboration from around the world and across sectors, get our Quick Guide to medical collaboration: 

Last week, the Centers for Medicare & Medicaid Services made an announcement that is really significant, but perhaps not surprising. They are launching a program that will further cement managed care and even more deeply link performance and payment -- the Next Generation ACO Model.

It is designed for ACOs that are experienced in coordinating care. The announcement notes: “It will allow these provider groups to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.”

Part of the announcement is the expansion of telehealth services. This further cements the use of iClickCare, not as flourish or a "nice to have", but as a routine way of taking excellent care of patients. As the American Telemedicine Association clarified: “The decision is particularly significant because under this new model, Medicare telehealth services can be covered without regard to longstanding rural and institution restrictions, requiring a beneficiary be located in a rural area and served at a health facility. For the first time, telehealth coverage will be extended to 80 percent of Medicare beneficiaries living in metropolitan areas and from any service originating site, such as their home.”

Only 15 to 20 ACOs are expected to participate, but the message is becoming increasing clear:

Reward and risk are, increasingly, being transferred to the provider.

Are we moving back to a time before Medicare existed? Of course not but it seems that there is more recognition that the provider and the patient are part of the solution rather than part of the problem. We wonder why this is being approached in such a small way, but we also recognize that it only takes the tiniest of sparks to start a bonfire that will last the whole night.

iClickCare welcomes the opportunity to help ACOs reduce risk. More than care coordination, real risk reduction requires collaboration, which is iClickCare’s core mission. The deadline for a letter of intent for the Next Generation program is May 1, 2015, just 45 days away. If you are applying, contact us and we'll explore how we can support you. 

The benefits and savings of iClickCare have existed for decades. Now, the difference is that this type of coordination of care and strategic collaboration are indispensable -- and supported by the government. Now, more than ever, is the time.

As telemedicine becomes more important for managing risk, coordinating care, and decreasing the costs of care, you can try iClickCare for free: 

Last weekend, I visited Philadelphia to see my daughter. As I walked along one cobblestone street, I noticed a metal plaque with four interlinking hands on some of the oldest homes. It was familiar to me, and in reminding myself of the history of these placards, I realized something fundamental about the changes in medicine.

But let me back up. In fact, let me back up to Benjamin Franklin in 1752. In response to the horrific fires in the young city of Philadelphia, Benjamin Franklin put together a “contibutionship” to take care of rebuilding after the fires. Modeled after a London firm, policyholders of this contributionship formed a mutual insurance company to share burdens in the case of fire. A contributionship member placed a medallion or plaque on the house. When a fire occurred, the paid firemen raced to the scene and put the fire out. If there was no medallion, they watched the property burn. Of course, risk was managed: there could be no trees on the property of the houses with medallions.

Capitated care, managed care, accountable care are all built on the same principle. Benefits (care) are given, but risk is shared by everyone involved. The only difference is that there are a lot more middlemen and statisticians in the healthcare system. And rather than each member paying directly, the member pays taxes or a premium to the government or insurance company.

Management of that care involves finding a better way to decrease costs. Instead of requiring no trees on the property, healthcare management focuses on efficiencies and expensive outcomes. iClickCare focuses on both the quality and savings of coordinated and collaborative care. Everyone “at risk” -- institutions, providers and patients themselves -- can contribute to the outcome by safe handoffs, time saved, and decreasing waste.

The nearly unspoken caveat is that everyone must behave differently. Not only the providers need to change, the patients need to do so as well. An excellent commentary on that piece by Christensen, Flier and Vijayaraghavan is here.

So as these concepts become even more crucial for us all to move towards sharing the burden of disease, managing risk, decreasing costs, and providing good care, these are the definitions that will be crucial:

• Capitated care:  By the head. The payment for insurance to care for a member for a fixed fee per year.
• Managed Care:  Adding tools such as approvals for procedures, a panel of physicians, and occasionally rationing of services. Remember the rule about trees in the contributionship? HMOs have those kinds of provisions.
• Accountable Care Organization:  An organization which pays by capitation or fee for service, but adds penalties and rewards based on quality measures from the Centers for Medicare and Medicaid Services.
• Managed Medicaid:  A healthcare payment system by states which enrolls the poverty stricken in a capitated plan. Payments to providers can be fee for service or capitated.
• Prepaid Health Plans:  Same as above. Prepaid group practices developed from 1930 through 1960.
• HMO (Health Maintenance Organization):  A prepaid health plan but based on the Health Maintenance Organization Act of 1973. Payment for services is only made within the network of the plan after referral from a primary care provider.
• PPO (Preferred Provider Organization):  A prepaid heath plan in which the patient is able to make self referral within and without of the network of the plan.
• EPO (Exclusive Provider Organization):  A hybrid of HMO and PPO. The patient selects the provider without a primary care referral, but the care must be exclusively within the network of the plan.
• BPCI (Bundled Payments for Care Improvement):  Not prepaid, but retroactively paid services to groups of providers to force alignment of incentives. A managed care program with retroactive payments instead of prospective payments. 

When all is said and done, though, medicine should come down to a partnership with the provider and the patient. The doctor, the nurse, the aide and the therapist are a team with the patient and for the patient. Any system will only work when it is also really bought into by the patient. For as Benjamin Franklin said when referencing fighting fires: “an ounce of prevention is worth a pound of cure."

Tools like iClickCare can support a Managed Care system by improving the way that coordination and collaboration happen. See how iClickCare can work for your organization with a free 2-week trial:

Managed Care, ACOs, and Pay for Performance systems have all been circulating in our world for years now. But for many hospital systems and long-term care facilities, adoption and management of these practices has been uneven. And research is showing that some ACOs are floundering to succeed in this new system.

That is about to change, one way or another. Managed care and pay for performance are here to stay, especially in long-term care settings.

Recent reports document that Medicare wants 30% of all payments to go through models like ACOs by the end of next year, and 50% by the end of 2018, up from about 20% now. Of course, there are already incentives and for performance in place, such as penalties for hospitals when patients get readmitted. These nudge providers to improve care, even if they’re still getting paid in a traditional fee-for-service system. The government wants 90% of all Medicare payments to include such incentives by the end of 2018. 

The government's first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016.  Then, alternative payment models need to get to 50% by 2018. So what does this mean?

In alternative payment models, providers are accountable for the quality and cost of care for the people and populations they serve. This of course moves away from the old way of doing things, which amounted to: “the more you do, the more you get paid.” In a Patient Centered Medical Home model, instead of doctors working separately in their own silos, care coordinators oversee all the care a patient is getting.  That means patients are more likely to get the right tests and medications rather than getting duplicative tests, procedures, etc. These medical homes typically offer patients access to a doctor or other clinician 7 days a week, 24 hours a day including through extended office hours on evenings and weekends.

The second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018. Most providers will be tying at least some of their payments to quality and value— even those who are not yet ready to fully transition. Providers will need to link nearly all payment to quality and value, in some way, to see that we are spending smarter. 

As Murphy-Barron's and Fitch's paper summarizes: "Provider organizations need to be aware the managed long-term care plans are funded using a capitation mechanism in which they receive a lump sum per member from which they must pay most long-term care and other ancillary expenses. The risk shifts from the Medicaid program to the plan. Running a successful managed long-term care plan therefore requires significantly more investment in risk management, financial management, and strategic planning than do fee-for-service arrangements."

We're, of course, always advocating for the use of "good old fashioned" common-sense medicine as well as savvy use of technology to support these changes. But the one thing we know for sure is that it will take all of our efforts to find the way forward. 

Take a look at this 60-second video to see why we think telemedicine can help:

There have been a lot of exciting articles recently about the advantages of replacing some in-person visits with telehealth visits.  

For instance, these stories on using telehealth services to cut costs and improve care have stood out to us as models: 

• Veterans have been getting telehealth appointments for services like therapy, enabling the VA to leverage capacity and allow some vets increased privacy and ease.
• Prisons are finding telehealth crucial in decreasing risks and cutting costs.
• This study found that telehealth visits costs $40-$50 per visit, as compared to $136-$176 for a conventional visit.

Because "telehealth services" are often defined as video conferencing, there is a gaping hole in the process. When the initial visit fails to get the expected results, it can actually end up less efficient for all parties.