Tag: Patient Trends

EHR Records Find Almost 20 Percent of Patients with Hypertension

Expanding blood pressure screenings to non-primary care settings can help identify more patients with hypertension, and could contribute to better hypertension control and management.

That is the finding of a Kaiser Permanente study of more than one million patients’ electronic health records published in the Journal of Clinical Hypertension.

The researchers analyzed the records of 1,076,000 Kaiser Permanente Southern California patients seen over a two-year period in primary care settings and non-primary care settings, including optometry, orthopedics and urology. The study reported the prevalence of hypertension and compared the characteristics of those patients identified with hypertension in a non-primary care setting to those identified in primary care settings.

Of the patients studied, 112,000 were found to have high blood pressure by the end of the two-year study period. Of these, 83 percent were diagnosed in a primary care setting and 17 percent in a non-primary care setting. The main non-primary care specialties to first identify a high blood pressure reading were ophthalmology/optometry with 25 percent, neurology with 19 percent, and dermatology with 13 percent. All staff members conducting blood pressure screenings in these clinical settings were certified in blood pressure measurement to ensure consistency in screenings.

According to the researchers, the number of false positives were comparable between both settings, suggesting that blood pressure readings in non-primary care settings were as accurate as those taken in primary care settings. Patients who were screened in non-primary care settings and found to have high blood-pressure readings were sent back for follow-up visits with their primary care provider.

“Patients who do not see their primary care providers on a regular basis may have hypertension that goes unrecognized,” said study lead author Joel Handler, M.D. “For this reason, expanding hypertension screening to non-primary care settings may be an opportunity to improve early hypertension recognition and control.”

The study indicated that patients identified with hypertension during non-primary care visits were more likely to be older, male and non-Hispanic white. In addition, these patients were also more likely to smoke and to have chronic kidney disease. Researchers also found that patients with an initial high blood pressure identified during non-primary care were less likely to be obese compared to those with an initial high blood pressure identified during a primary care visit.

Docs Not Even Close to Meeting Digital Needs of Patients

The majority of patients would like to have digital services from their physicians such as online appointment scheduling, bill paying, and access to lab results, yet only about one primary care physician in three offers such customer service.

That is the finding of a new survey from TechnologyAdvice, a Nashville-based company that provides independent review and analysis of enterprise technology products.

“Primary care physicians are reporting some of the highest rates of EHR adoption to comply with government regulations and to receive incentives from Meaningful Use, but a significantly lower number of patients claim to have access to these patient portal services,” said TechnologyAdvice Managing Editor Cameron Graham, who authored the survey. “The issue here may not be implementation of digital services, but instead a lack of patient awareness. If physicians are offering these in-demand digital services, a more proactive approach to promoting them is needed and could create an advantage in attracting and retaining patients.”

Sixty percent of patients surveyed said digital services like online appointment scheduling and online bill pay are either “important” or “somewhat important” when choosing a physician. However, when asked what services their current physician provides, less than one-third of patients indicated they have access to either online bill pay, online appointment scheduling, or the ability to view test results and diagnoses online, which are the top three services that patients report wanting the most.

In addition, 68.6 percent of respondents said it was either “somewhat important” or “very important” that a physician follow up with them, yet only 30 percent of respondents reported receiving a follow-up that wasn’t related to bill pay.

Patient age also appears to influence what services are expected from physicians. Notably, every digital service listed on the survey was in greater demand among younger respondents. For example, 41.2 percent of patients between the ages of 25-34 said they would like their physician to offer online appointment scheduling, while just 13.5 percent of respondents over 65 said the same. The results also showed that 48.4 percent of the youngest respondents (18-24 year olds) would like to use a smartphone app to schedule online appointments.

Healthcare hiring boom will bypass hospitals

The healthcare sector of the U.S. economy will be hiring at a faster pace in 2015 as a healthier economy and shrinking uninsured population fuel an uptick in demand for routine and discretionary services. The era of hiring restraint—fueled by the recession and the steady rise in high-deductible plans—appears to be ending.

The hiring binge will be uneven, though. The outlook for growth in hospital employment—healthcare’s largest employer—is modest at best. Many hospitals will be reducing head counts. Others are holding the line on adding new employees since the federal government plans to keep a tight rein on reimbursement while private insurers are pushing more participation in risk-based contracts. Hospital margins shrank over the past year as rising labor costs ate into a slower-growing top line.

Hiring at outpatient facilities and ambulatory surgical centers, on the other hand, is expected to continue its rapid growth as technological changes and financial pressures push the locus of care from inpatient to outpatient settings. Home healthcare’s need for personal aides will continue to mushroom.

And beneath it all, healthcare human resource departments will continue to face a major skills gap, especially when it comes to filling nursing positions. That problem will worsen as hundreds of thousands of aging baby-boomer nurses retire. New delivery models, which are expanding the need for people steeped in population health management, patient outreach and care coordination, exacerbate the problem.

Hiring across healthcare grew at less than 2% a year since the 2009 recession because of a long, anemic recovery. But the pace picked up as 2014 drew to a close. The sector’s monthly hiring more than doubled over the course of the year, finishing with 14.9 million jobs, up 2.1% from the end of 2013.

The year-end pace of hiring will likely continue this year, said Ani Turner, deputy director of the Center for Sustainable Health Spending at the Altarum Institute. “I don’t see any reason why it’s going to drop off,” she said, citing the Patient Protection and Affordable Care Act creating more households with health insurance and a falling unemployment rate giving people more income to spend on healthcare.

But healthcare’s largest sector—hospitals—is the outlier. Facing continued financial pressure from public and private payers, hospitals are intensifying their efforts to reduce their largest expense: labor. “I think we’re going to see pockets of layoffs,” said Jennifer Stewart, managing director of research and insights at the Advisory Board Co.

It’s already happening at Denver-based Catholic Health Initiatives, which in December announced it would eliminate about 1% of its 90,500-person workforce. The 92-hospital system said the move was in response to its poor financial performance. “The CHI workforce reduction was limited to about 1,000 positions,” the system said in a statement.

It’s a microcosm of the sectorwide trend. The Bureau of Labor Statistics projects hospital employment will grow by 815,000, or 17%, over the next decade. But overall healthcare employment will grow significantly faster—29.4%—with the much smaller home health and skilled-nursing facility sectors each adding almost as many jobs as hospitals. Hospital employment will fall to 25.5% of the sector’s jobs in 2022 compared with 28.2% in 2012.

That leaves hospital recruiters with a new problem—a growing shortage of experienced registered nurses to replace older nurses and to fill slots in care coordination, a fast-growing specialty. The nation will need a million new registered nurses by 2022, according to personnel placement firm NAS Recruitment Innovation.

Carolinas HealthCare, based in Charlotte, N.C., increased by 15% the number of advanced-practice nurses and other practitioners last year as the system worked to expand its primary-care capacity. The number of advanced practitioners Carolinas employs has doubled in the past five years to 741.

“We’re focused on meeting our patients where they want to receive assistance,” said Debra Plousha Moore, chief human resources officer for the 22-hospital system.

While it has no overall projection for hiring this year, Carolinas did eliminate 100 executive- and management-level jobs as part of an effort to reduce operating expenses by $110 million annually. “There is clearly increased pressure for hospitals to improve their bottom lines,” said John Klare, a managing director and healthcare practice leader for Navigant Healthcare.

Post-acute-care companies, which continue to expand, will pick up the slack in healthcare hiring. It will be concentrated in the home health field, which grew 4.3% last year to 1.3 million jobs. “You’re seeing a trend across the states, especially for the Medicaid populations to … move patients out of skilled-nursing facilities and get them into a home,” said Toby Wann, founder of Nashville-based equity research firm Obsidian Research Group.

FirstLight HomeCare, a Cincinnati-based provider with more than 120 franchises across the country, added 500 caregiver jobs last year and expects to add a similar number this year. “Our outlook for hiring is very bullish, both at new offices and at existing offices,” said CEO Jeff Bevis. “Demand has certainly increased the latter part of 2014 going into 2015 compared to where we were this time last year.”

Skilled-nursing and residential-care facilities—which saw anemic growth of only 1% last year, bringing total employment in the sector to 3.3 million jobs—face a mixed employment picture in 2015. While home care is often touted as being more cost-effective, it increases the demand for nurses and nurses’ aides.

“Home care is less efficient than skilled nursing because you have a one-on-one care model,” said Fred Benjamin, chief operating officer at Medicalodges, a Coffeyville, Kan.-based long-term-care provider. “Therefore, you need more people.”

But given the overall shift toward home care—the American Health Care Association, which represents long-term care and post-acute providers, projects 27 million people will be receiving long-term care, including home health services, in 2022, up from 6 million currently—the hiring pace at nursing homes may slow.

“We don’t foresee any reductions in our workforce in 2015,” said Gerald Coggin, senior vice president for National Health Corp., a Tennessee-based operator of 73 skilled-nursing facilities in 10 states. “By the end of the year, once we get all of our new building projects completed, we could add approximately 250 to 400 new employees.”

To Obsidian Research’s Wann, that translates to very different recruitment pressures on the home health and nursing-care segments of post-acute care. “You probably will see a little pressure to raise wages on the home-health side,” he said. “Conversely, on the skilled-nursing side, I don’t see much upward pressure in terms of wage rates in the skilled-nursing facilities.”

The hunt for qualified physicians interested in primary care will continue to dominate the physician employment landscape in 2015. The Bureau of Labor Statistics projects total physician employment will grow only 18% to 814,700 positions in 2022, significantly below healthcare as a whole. But filling those extra slots will be exacerbated by the baby boomer retirement wave among doctors, just as it will be with nurses.

Phillip Miller, vice president of the Irving, Texas-based physician-recruitment firm Merritt Hawkins, notes 66% of oncologists are 55 or older, as are 60% of psychiatrists, 54% of cardiologists and 52% of orthopedic surgeons. “Now that the stock market has rebounded, we do anticipate an unprecedented wave of retirements that the industry is not prepared for,” he said. “It’s like a tsunami lurking off shore.”

Yet specialist recruiting isn’t the major problem faced by Dr. Matthew Gibb, chief medical officer at the Carle Foundation, an integrated health system with a 393-bed hospital in Urbana, Ill. “We’re seeing the biggest difficulties in our primary-care recruiting,” he said. “There’s a lot more competition for primary-care physicians both nationally and regionally.”

His solution? Signing bonuses, educational loan repayments and a $10,000 to $20,000 boost in the current starting salary of $190,000.

“We’ve placed a high emphasis on coordinated care, team-based care and population health,” which is attracting candidates, he said. “The employed model doesn’t seem to bother our recruits.”

You can show patients test results, but will they understand them?

With the increasing adoption of electronic health records, more patients are able to view their lab results electronically outside of clinical consultations, but a study suggests that access doesn’t mean patients understand what they’re seeing.

A team at the University of Michigan schools of Public Health and Medicine discovered that people with low literacy skills and low numerical comprehension were less than half as likely to identify if a lab result was inside or outside the standard range. They were also less capable of determining, based on the test values, whether or not they should contact their doctor, researchers said.

“We can spend all the money we want making sure that patients have access to their test results, but it won’t matter if they don’t know what to do with them,” Brian Zikmund-Fisher, associate professor of health behavior and health education at the university’s School of Public Health, said in a release. “The problem is, many people can’t imagine that giving someone an accurate number isn’t enough, even if it is in complex format.”

Through an Internet-administered survey, the research team asked more than 1,800 adults between the ages of 40 and 70, of whom nearly half were diabetics, to respond as if they had Type 2 diabetes. They were shown lab test results for hemoglobin A1c—a common measure for checking blood sugar—along with other blood tests, in addition to being measured on their ability to apply simple mathematical concepts and health literacy skills.

Of those who were assessed as having higher numerical comprehension and literacy skills, 77% could identify levels that fell outside of the standard or acceptable range. But of those with lower numerical comprehension and literacy skills, just 38% could do so. Those with higher scores on the numerical comprehension and literacy tests also were more sensitive to the test results insofar as knowing when they should consult with their doctor.

One motivation behind providing patients with access to their own data is to help them manage their own healthcare, but more research is necessary to decide how best to display this information, according to Zikmund-Fisher.

“Improving how we show people their health data may be a simple but powerful way to improve health outcomes,” he said.

The study, reported this month online in the Journal of Medical Internet Research, was supported by a grant from the University of Michigan Risk Science Center.

WellPoint to change name to Anthem

WellPoint, one of the largest investor-owned health insurers in the country, is looking to rebrand itself as Anthem, pending shareholder approval.

Joe Swedish, WellPoint’s CEO, told Modern Healthcare the insurer was making the change to better connect with consumers in a “radically changing” healthcare environment. After surveying 55,000 people about their healthcare preferences, officials said they found brand was at the top of consumers’ list, along with price and provider network.

“We’re dealing with a consumer-oriented industry that now is being put in a position to make healthcare decisions for themselves and their families that is based around more information around access, quality and price,” said Swedish, a former health system CEO. “We have to demonstrate a brand that gives each person a value proposition.”

Swedish also said the Anthem name will hopefully eliminate brand confusion among its 48,000 employees and large provider network, in addition to its millions of members. The insurer, which operates Blue Cross and Blue Shield plans, took on the WellPoint name in 2004 when WellPoint Health Networks and Anthem merged. However, most of its plans carry the Anthem name, including in California, Virginia and Connecticut.

“This will help tremendously in aligning our relationships” with all stakeholders, Swedish said.

WellPoint, based in Indianapolis, had 37.3 million members as of June 30.

The company has moved more aggressively than Aetna and UnitedHealth to participate in the state and federal health insurance exchanges created under the healthcare reform law. In the second quarter of this year, the insurer added 769,000 exchange members, predicting profit margins for exchange plans will range between 3% and 5%. Swedish said he also expects the Anthem name “absolutely will help” WellPoint as it ramps up its exchange efforts.

The name change is believed to go into effect by the end of this year. Shareholders must approve the move and will have a chance to do so at a special meeting on Nov. 5.

Why Physicians Are Turning To Startups

To appreciate the potential impact of the startup movement on health and medicine, you really need look no further than Drs. Rushika Fernandopulle and Farzad Mostashari (disclosure: I was colleagues with both at college and later at MGH).

Both are passionate about transforming healthcare – Fernandopulle has an M.D. and a public policy degree from Harvard, and was the first executive director of the Harvard Interfaculty Program for Health Systems Improvement; Mostashari served as Assistant Commissioner for NYC’s Department of Health, and more recently as the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services in the Obama administration.  Both are committed to improving the delivery of patient care.  And both have deliberately chosen to pursue their vision by creating a company as the vehicle to deliver the change they each believe in.

“The world of start-ups may not be the usual path for those leaving a senior federal post,” wrote Mostashari about his new direction, “but it’s the right decision.”

Last month, Mostashari founded Aledade, which seeks to enable independent, primary care physicians to establish accountable care organizations.

A few years earlier, in 2010, Fernandopulle co-founded Iora Health, an innovative model of direct primary care, and continues to serve as CEO.

Explains Fernandopulle,

“As a practicing physician it soon became obvious our current model of care delivery does not work; instead of simply complaining about it I felt I needed to try to fix it, but got frustrated trying to do it within existing health systems, and found studying the problem (in academics), working through the government, and consulting was not effective. I decided that the best way to make change happen quickly was to simply strike out myself and just do it- being an entrepreneur allows you to break what others think are the rules (they aren’t) and take change into your own hands.”

Fernandopulle and Mostashari aren’t alone – across the country (and the world), physicians from every specialty are creating, joining, or hoping to join startups.  While many of these doctors are fairly junior, and have little (if any) substantive clinical experience, some are more seasoned – HealthLoop’s Jordan Shlain comes to mind, for example.

While the motivation is probably slightly different for each physician-entrepreneur, I suspect that the common theme is a deep-seated passion for explosive, tangible real-world impact – and the optimism and conviction to believe you can achieve this.

Passion: Participation in the startup is an expression of a heartfelt conviction – it’s not a job, a way of getting paid, but rather a form of self-actualization.  This is the John MacKay, Richard Branson, Howard Kurtz, and Mark Zuckerberg view of the world – not that of Valeant’s Michael Pearson and the “Outsider,” spock-like CEO’s William Thorndike lionizes, nor the middle manager phenotype that Monster.com famously mocked.  (Then again, Scott Adams, of Dilbert fame, has argued it’s misguided to follow your passion, suggesting you tend love what you’re successful at, not successful at what you love.)

Explosive: “Startup” is used here explicitly in the Paul Graham, Startup=Growth sense – generally VC backed, formed with expectation and intention of hitting a phase of exponentially accelerating growth.  Most new companies (think local dry cleaners and restaurants) aren’t startups, in this sense (though occasionally they hit it big; the EMR giant Epic, for instance, grew gradually and famously never took a penny of VC funding).  In contrast, companies started by doctors like Fernandopulle and Mostashari are supported by A-list VCs (Polaris, Fidelity Biosciences [disclosure: I spent some time with this firm about eight years ago], Venrock) precisely because of the aspiration for explosive growth.

Tangible, real-world: The goal of Aledade and Iora Health isn’t to come up with a brilliant idea validated by publication in a top-tier scientific journal or think tank white-paper, but rather to tether a promising idea to successful implementation, as demonstrated by adoption in the market.  Startups – as I argued in 2005 – represent, in a sense, the purest distillation of the translational research ideal.

Impact: Perhaps no aspect of startup culture has been more lampooned than the idea that you’re trying to dent the universe, disrupt, revolutionize, and make the world a better place.  Turns out: it’s true – most entrepreneurs truly are striving for outsized impact.  Similarly, many physicians were drawn to medicine because they saw in it an opportunity to make a difference; startups, it would seem, represent a natural vehicle for this ambition.

Optimism and conviction: These qualities – which I might summarize as “startup=applied hope” — represent my favorite aspect of silicon valley, and arguably capture its most distinctive, compelling, and essential features.  There’s a pervasive sense of possibility out here, a belief that a smart, motivated group of people can, must and will change the world.   While such fervent, almost religious optimism can be both excessive and dangerous (see here and here), in moderation it can also be enormously attractive – and for many physicians, ego-syntonic.

With so much going for startups – not to mention the ever-increasing number of digital health accelerators, incubators, and translational centers that now dot the landscape (I’ve been very impressed by the experiences I’ve had with Rock Health, the UCSF Center for Digital Health Innovation, and the MakerMD community, and I’ve been privileged to be a co-founder of the MGH/MIT Center for Assessment Technology and Continuous Health [CATCH]) – the real question may be why more physicians aren’t leaving for startups.

Four factors may stand in the way:

  • Professional pressure to stay in the system.  Many early career physicians contemplating entrepreneurship are counseled by colleagues not to “throw away” their training, and to remain in clinical medicine.  While the idea of academic physicians urging young doctors to become…academic physicians is hardly new, entrepreneurship may be seen to represent a double disappointment – leaving the fold, and joining the private sector.

  • Institutional pressure to surrender all (promising) IP to the university or hospital.  The flip side of the first challenge: many institutions, perennially on the hunt for new sources of revenue (especially in the context of a tight NIH budget) pounce on any physician advancing a promising idea – see this 2012 Boston Globe story involving a doctor from MGH.  I’ve been amazed by the amount of feedback I’ve received from fellow physicians about this specific concern.  I suspect many academic leaders may  inadequately appreciate the extent to which their own institutional policies may be damping the exact entrepreneurial spirit they’re trying so intensively to cultive.
  • Concern from potential collaborators and (especially) investors that physicians are more likely part of the problem than part of the solution.  I’ve heard some well-known technology-focused VCs here in the Valley suggest doctors are too enmeshed in the system to develop radically disruptive solutions — though many of these same investors have also gone on to fund companies with physician founders or co-founders.  As I’ve long argued (here, too), physicians can bring unique insight to the problems of their profession, and are often more motivated than anyone to drive change.  I believe deeply in the value of what Eric von Hippel’s, “field discovery,” in Aenor Sawyer’s “front line innovators,” in Judah Folkman’s “inquisitive physicians.”


  • Inertia:  The challenge of change may be the most difficult problem to solve.  Especially as their careers start to accelerate, physicians tend to be both extremely busy and reasonably well-paid (certainly compared to the salary they’d likely pull at a newly-funded startup).   It’s hard to leave something you know well, and that you’re good at, at that you’ve invested so much time in, and leap into the unknown – to say nothing about the open architecture (most startups have not gotten Maria Konnikova’s brilliant New Yorker memo) and brogramer culture.  Not surprisingly, many physicians who ultimately leave medicine to become full-time entrepreneurs do so gradually, or else make the decision before they even enter clinical practice.

Despite these concerns, and others, the draw of entrepreneurship in medicine may prove too overpowering to restrain.  As Fernandopulle summarizes,

“When I decided to strike out on my own it was seen as crazy, and there were very few physicians doing it. Now I see more and more (mainly younger) doctors deciding to leave full time practice and spend some or all of their time in startup companies. They sense the huge opportunity to remake the health care system, and people with both a clinical perspective and credibility and system/business skills will be key to building new tools and models.”

I share Fernandopulle’s enthusiasm — I’m tremendously optimistic about the potential for synergy and the opportunity for impact that physicians have at startups.  So much so that (disclosure) I’ve recently changed jobs, and this very week, joined a silicon valley startup, DNAnexus, as Chief Medical Officer, where I’ll get to focus on a topic that’s animated me since I read Eighth Day of Creation in high school: delivering upon the collaborative, patient-inspired vision of genome-enabled (really, data-enabled) medicine.

My former biotech colleagues have no doubt concluded that the world is already a better place.