Products & Technology

Plugging In

Interoperability isn't just for hospitals and clinics any longer; HME providers' referral partners want and need to connect with them. Are you ready?

• By Holly J. Wagner
• Apr 01, 2019

While you go through your day helping customers and managing your business, an army of data crunchers and programmers are working like an electronic beehive to connect all the information doctors, hospitals, clinicians and pharmacists feed into the healthcare system.

Add to that what patients are feeding into their CPAPs, inhalers, cardiac monitors, glucose meters and pretty much everything else that can be measured electronically, and you have the makings of a seamless, end-to-end connected care system — or a confusing, vulnerable healthcare disaster.

Actually, you have both. Technology is bringing previously unimagined capabilities to medicine — especially remote monitoring and caregiving — but the pace of digital technology advancements also carries the risk of system failures or breaches and data security.

“The future of healthcare is connected. Whether it’s connectivity inside a hospital, between health systems, or from the hospital to the home — connected care is transforming care delivery and improving patient outcomes and clinician efficiencies,” says Tim Murphy, business leader of new business solutions at Philips Sleep and Respiratory Care.

You may feel removed from all those bytes of heart rates and sleep disruptions flying around cyberspace, but if you’ve ever filled an e-scrip, you are dabbling in connected care. Some of the devices you provide are likely subject to remote monitoring, and the more information home medical devices capture and transmit, the more opportunities there are for DMEs, especially in an era of bundled care, to shine.

Pressure to integrate and streamline medical care and records is coming from many directions: payers, government, hospitals and caregivers are all on the list. To the extent that patients have adapted to the digital age, they also expect the benefits of those technologies to be part of their healthcare. That pressure creates opportunities for DMEs to add value.

“If you are an accountable care organization and you are at risk for covering the lives you treat on a day-to-day basis, your interaction with those patients on a face-to-face is a very tiny portion of your time with them. So anything HMEs can do to leverage the power of automation and data collection to monitor how those patients are doing with their therapy, that’s tremendously powerful to referral sources,” says Nick Knowlton, vice president of business development for Brightree LLC. “Once the referral sources understand that they can get this kind of data on these patients from HME providers, it’s an uplift to their perception of the job that HME providers do on a daily basis to help take care of their patients. It’s more end-to-end. You are more of a partner in care delivery than a commodity from whom they get medical equipment.”

IT STARTS WITH THE PRESCRIPTION

“The vision for a completely connected care pathway exists, but it’s still in its early days,” says Chris Hogg, chief commercial officer at digital monitoring company Propeller Health (recently acquired by ResMed). “The strongest links in the chain at the moment are between the physician and pharmacist, via electronic health record (EHR) technology, and between the patient and their individual device, because consumers are already using smartphones and other technology to manage their health. We need to do more work to bridge the gap between provider and patient, and we expect to see those links become much stronger in the next five to 10 years.”

Government got behind e-prescriptions for medications as part of electronic health records efforts, but stopped short of including DME prescriptions in the requirement, says Knowlton. So while doctors have been e-prescribing medications for about 15 years, the trend is just catching up in DME. Without a government mandate, it may fall to DMEs to sell the benefits of e-prescribing to doctors, Knowlton says, noting, “Those conversations are going pretty well as long as you explain to the physician why you’re doing it and how it is going to help them and benefit patients under their care.

“HME providers are able to go have a tough conversation with a referral source and say, ‘I want you to do this electronically because I can’t sustain an operation where there is so much cost involved in cleaning up every order.’ They are having really good conversations with that. They are also putting some of those cost burdens back on referring providers — ‘Hey, if I’m going to be your supplier, you have to send me clean orders or I’m going to bill you for that which I do not get reimbursed.’”

Getting doctors on board is easier when it’s aligned with ERM they are already doing for medications. “Some of the technologies we push for to move e-prescribing forward are actually embedded in a physician’s native workflow,” Knowlton says. When DMEs approach them for e-prescriptions, “Light bulbs just go off for them. It’s like, ‘OK, diverting ourselves to a fax-based workflow is a distraction. If I can order home medical equipment from my EHR and it’s right next to where I order lab tests or medications for a patient, ‘ actually it’s better aligned with their workflow and the things they do every day.”

PILOTING BY REMOTE

Prescriptions are just the beginning of e-medicine. Remote monitoring caught on in the sleep segment, but digital technology has accelerated its spread and acceptance in many other areas. ResMed already monitors millions of CPAP patients’ equipment, and Philips monitors another 9 million patients, the company reports.

“Philips connected solutions enable the care of more than 9 million patients with cloud-based patient monitoring systems, bridging care from the hospital to the home. For example, with Philips connected technology, HMEs have the capability to streamline workflows and coordinate care across an entire care team,” Murphy says. “This technology not only improves the patients’ lives with advanced remote monitoring, it also improves cost efficiencies. Our cloud-based systems have enabled customers and home health providers to securely manage patient records, allowing them to identify at-risk patients, share data across the entirety of the care team, even with payers, and automate operations.”

Experts agree the remote monitoring trend is gaining steam. Daytime oxygen and breathing aids were the obvious next step after sleep, but many more conditions and medications are likely to see more remote monitoring and, eventually, care. “If chronic conditions, one of the big six that payers look at, can be treated remotely or help that patient stay out of the hospital remotely, they are going to take advantage of it because taking care of patients in the home is the cheapest care setting,” Knowlton says.

“The number and type of medicines that have a digital component is sure to expand. In fact, we envision a future where almost all medicines have a digital component to them in the same way that the banking, hospitality, transportation and many other industries have become ubiquitously digital,” Hogg says.

Propeller Health is a tech company that is jumping into that niche. The company offers a sensor set and monitoring app that works with most inhaled medications, usually at no cost to the patient, the company says. “We also have a long way to go in terms of making digital medicines an expected and integrated part of the care process,” Hogg says. “At Propeller, we’ve been most successful when we can partner with a physician or pharmaceutical executive who truly believes in the future of digital health and will work within their organization to fully integrate digital into existing processes.”

Like Google or Facebook, the information gathered is as much a part of the business model for health companies as any fees that insurers, drug companies or users pay. In exchange for the data they glean, many companies offer the monitoring service to patients for free. The data will help them refine existing services and develop new ones.

Knowlton predicts wound care will be a big growth area soon, because the technology to manage wounds remotely is already in use. “Remote monitoring might be working its way into the HME space business line by business line,” he says.

“Wound therapy in general is going to be a big one. Not just because the capabilities are here to do similar things with wound vacs as with other connected devices,” he says. Payment reform initiatives coming to Medicare-certified home health services are helping drive the sophistication of remote wound monitoring — wound image factoring, remote diagnosis and assessment that he thinks will create even more opportunities for DMEs to distinguish themselves. “I would venture to guess that we are going to see some upticks in how the HME providers go hand in hand with helping treat those situations, how they play a role in a patient’s care in the home and how they monitor treatment progression,” he says.

Murphy agrees the increase in chronic condition diagnoses is taxing physicians’ time and increasing patient workload. “Remote monitoring not only allows clinicians to stay involved with their patients’ therapy programs after they have left the hospital, but this kind of technology can also flag potential adverse events in real time, helping doctors to check in with their more at-risk-patients and enabling HME providers to better manage their patient populations.”

FLIRTING WITH PANDORA

Remote monitoring is a boon to medicine, but like many new technologies, it’s a Pandora’s box of potential issues. Often, the device agreements are much like Apple or Facebook user agreements, with information about what the device is monitoring and sharing buried deep in fine print that most people never read. Your CPAP patients may know their machines are transmitting information to their doctors, but not realize it’s also transmitting to the manufacturer or their insurer. And those services are moving across public networks, exposing them to potential risks.

A 2017 report by Trend Micro found that more than 100,000 healthcare devices and systems were exposed directly to the public Internet, including EHR systems, medical devices and network equipment. According to the Government Accountability Office (GAO), more than 113 million care records were stolen in 2015. A separate study conducted that year estimated that cyber attacks would cost the U.S. healthcare system $305 million over five years. That’s a big incentive to protect the data.

In late February, Sen. Mark Warner (D-Va.) sent a letter to healthcare industry trade groups, asking for ways to improve cybersecurity in the industry. Warner asked stakeholders whether or not they have inventories of all the connected systems in their facilities; what steps they take to protect them; how system patches are tracked; how many of the organizations are running on outdated systems; and asked the organizations to share best practices and make recommendations.

“The increased use of technology in healthcare certainly has the potential to improve the quality of patient care, expand access to care (including by extending the range of services through telehealth), and reduce wasteful spending. However, the increased use of technology has also left the healthcare industry more vulnerable to attack,” Warner said in an announcement. “As we welcome the benefits of healthcare technology we must also ensure we are effectively protecting patient information and the essential operations of our healthcare entities.”

Recent Department of Health and Human Services (HHS) actions are focusing on privacy and data security as well as efficiency and interoperability. HHS in February published a proposed rule for medical interoperability with the goal of “seamless and secure access, exchange, and use of electronic health information.”

The proposed CMS rules would require healthcare providers and plans to implement open data-sharing technologies to support transitions of care as patients move between plan types; and give patients free access to their electronic health information (EHI). As with many government actions, the aim is to make costs more transparent on the theory that it feeds competition and reduces costs.

“The whole healthcare industry is going to the coordination-of-care model,” says attorney Jeffery S. Baird, Esq., chairman of the Health Care Group at Brown & Fortunato. “The whole fee-forservice model has come under attack as being very inefficient. Payers are saying ‘we are happy to pay, but you’ve got to show it’s improving the patient’s health and they are not frequent flyers.’”

For DMEs, the biggest legal issues he sees with the connected care tech boom are likely to be payer audits, patient privacy, and potential violations of anti-kickback statutes if a pharmacy shares interoperability software with a referral source to facilitate care (it’s allowable if certain conditions are met).

Remote monitoring can help facilitate audit responses because it provides a record of the patient’s device usage that can be matched up to other data to show patient compliance and how the treatment correlates to results. “I see that as an important issue, that the client information has to be good enough to allow the DME to pass an audit,” Baird says.

Next: “From a HIPPA standpoint, that data needs to go only between providers, those who need to know, and the patient. If the data gets out from the care environment, you have a HIPPA breach,” he says. Privacy rules are the same as for analog records under HIPPA, so the protocols have already been worked out for the mediction prescribing system and most of the pharmaceutical software providers have built them into their business systems.

“Philips HealthSuite (and the cloud-based systems that run on it such as Philips Care Orchestrator and Encore Anywhere) is built on the foundation of international standards and frameworks for integrating privacy and security in the architecture, implementation, and operation of the platform,” Murphy notes. “Philips HealthSuite’s digital platform supports data encrypted end-to-end (in flight and at rest) to avoid tampering and unauthorized access.”

Likewise for Brightree. “You always have to make sure you are in the boundary constraints of privacy, security and consent,” Knowlton says. “A lot of people view interoperability as just technology, but it does involve concepts like privacy and consent and security … There are ample solutions out there for how to navigate that.”

One other possible pitfall for DMEs to avoid: A pharmacy may want to donate software to a nursing home that is a referral source to the pharmacy. “As a result of that donation, is that something of value from a pharmacy to a referral source triggering a violation of the anti-kickback statute?” Baird asks. “The Office of the Inspector General may have to set conditions for that … There is a tendency to want to coordinate software with a referral source.”

Technology isn’t failsafe, but that’s no reason for DMEs to avoid taking a role in connected care. “There will be our share of lawsuits when the technology goes awry. Periodically there will be bad outcomes. The key is to always check and recheck the remote monitoring technology to make sure it’s working, and have liability insurance,” Baird says. “What will happen is, if there is a lawsuit, it’s going to be based on negligence and or product liability. Both of those have been covered by insurers for 100 years.”

That, of course, comes with the same caveat as any insurance policy: “Any time an insurer can deny coverage they will,” Baird reminds. “It’s a game insurance companies play where they will deny coverage. You have to fight it.”

This article originally appeared in the April 2019 issue of HME Business.