Month: September 2019

The applications of smartphones in medicine are vast; they can be seen impacting patient-clinician communication, advancing patient care, diagnostic and monitoring tools, promoting access to medical education, and expanding research efforts ^[1].

The most straightforward impact of smartphones in the medical setting can be observed in the ways in which they have enabled real-time messaging, communication, and information retrieval. A 2012 Manhattan Research/Physician Channel Adoption Study found that nearly 90% of physicians own and use smartphones in their workplace ^[2]. Conveniently, smartphones integrate both computing and communication features, making information like drug and diagnostic data easy to access and impart at the point of care ^[2]. This technology has been shown to improve communication and care coordination between healthcare providers, in particular, on inpatient wards ^[3]. Additionally, the integration of smartphone data collection and interfacing capacities with Electronic Health Record (EHR) maintenance has proven to be a key component of medical homes and enhanced patient-clinician communication ^{[1, 2, 3]}.    

Notably, the most popular and well-elucidated usage of smartphones in medicine can be seen in the myriad of patient monitoring and diagnostic smartphone applications (apps) and their Bluetooth and/or hardwired extensions that effectively convert smartphones into medical devices ^[3]. The implications these apps and their portable extensions hold for patient monitoring and diagnostics have already proven to be significant in the field ^{[2, 3, 4]}. A few of the most striking examples include the use of smartphones as single-lead electrocardiograph (ECG) devices, safety monitoring devices for patients with dementia, non-invasive (flashlight-based) anemia detecting devices, real-time heart disease and diabetes monitoring technology, and as Doppler devices that measure blood flow ^{[1, 3, 5]}. Without question, smartphones may promote early detection and enhanced treatment/monitoring for any number of conditions and have already proven promising in increasing access to select medical services in under-resourced territories and nations ^{[3, 4]}.

Although less studied, health apps for the layperson and physician/medical student reference apps also utilize smartphones for medical purposes ^[3]. For instance, diet, weight loss, and fitness apps are the most commonly downloaded among adult users and employ smartphone-integrated features as health tools, such as the accelerometer and GPS in smartphones as pedometers and navigators ^[3]. Meanwhile, other apps can promote mindfulness practices, help women track their monthly cycles, and aid patients in accessing practical healthcare information and reminders ^{[1, 2, 3]}. Despite the lack of data on the use of physician/student reference apps, one study claimed that over half of Epocrates users (an app designed to disseminate reference information on drugs, diseases, diagnostics, and patient management) reported that it helped reduce medical errors ^[3]. Accordingly, the role of smartphones in medical education is expected to rise, especially as we witness the increasing use of similar technology, such as in many universities across the country where students are issued iPads in place of medical textbooks ^{[1, 3]}.

Even so, concerns over smartphones’ potential risks pervade clinical contexts: from the dangers of physician distraction to perceived unprofessionalism by patients and colleagues to a general lack of proper financial and techno-sociological integration into medical settings ^[3]. One present-day challenge is the deficiency of smartphone-literacy more commonly, but not exclusively observed in elderly physician and patient populations ^[4]. What’s more, skeptics of the surge in smartphone-based data collection point to the risk of ‘clinician data-overload,’ underscoring the necessity for effective medical smartphone-based data integration strategies to identify clinically relevant information ^{[3, 4]}. Additionally, although the potential of smartphone advances to reduce healthcare costs is highly promising, current provider reimbursement models typically rely on in-person consults for billing purposes, highlighting the need for proper financial integration and coordination of smartphone technology ^{[2, 3]}. Yet another concern raised by the arrival of seemingly countless health apps is the reliability of the information they disseminate and are premised upon, calling attention to the need for strengthened regulations (already underway by the FDA) ^{[4, 5]}. Relatedly, ensured confidentiality of personal medical data indicates the need for enhanced HIPAA-compliant and secure technology regulations for smartphone-based apps, also currently underway ^{[2, 3, 4]}.

Indeed, continued research and analysis into the role of smartphones in all aspects of medical applications will pave a path towards their streamlined, effective integration and usage. In short, as we continue to observe advancements in areas such as telemedicine, patient care, and remote research capacities facilitated by this technology, the omnipresent role of smartphones in medicine cannot be understated.

^[1] Batista, Michael A, and Shiv M Gaglani. “The Future of Smartphones in Health Care.” AMA Journal of Ethics 15, no. 11 (January 2013): 947–50. https://doi.org/10.1001/virtualmentor.2013.15.11.stas1-1311.

^[2] Ventola, C Lee. “Mobile Devices and Apps for Health Care Professionals: Uses and Benefits.” P & T : a peer-reviewed journal for formulary management. MediMedia USA, Inc., May 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029126/#b1-ptj3905356.

^[3] Ozdalga, Errol, Ark Ozdalga, and Neera Ahuja. “The Smartphone in Medicine: A Review of Current and Potential Use among Physicians and Students.” Journal of Medical Internet Research. Gunther Eysenbach, September 27, 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510747/.

^[4] “Smartphone Medicine.” The Journal of Healthcare Contracting, n.d. http://www.jhconline.com/smartphone-medicine.html.

^[5] “HemaApp Screens for Anemia, Blood Conditions without Needle Sticks.” UW News, n.d. https://www.washington.edu/news/2016/09/07/hemaapp-screens-for-anemia-blood-conditions-without-needle-sticks/.

Passed with bipartisan support in 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is healthcare legislation primarily aimed to replace the fee-for-service (FFS) model with a physician payment framework that promotes quality-over-quantity care. The law does so by repealing the Sustainable Growth Rate reimbursement formula for updates to the Physician Fee Schedule and replacing it with new models for determining yearly payment rate updates for physicians’ services. Among an array of changes to Medicare and Medicaid, MACRA also temporarily extended the Children’s Health Insurance Program (CHIP) and increased premiums for Part B and Part D of Medicare for beneficiaries with income above certain thresholds ^[1].

Under MACRA, the Quality Payment Program (QPP) was established to help move the healthcare industry towards the goal of value-based care. The QPP utilizes new quality reporting mechanisms in conjunction with streamlined quality measuring schemes previously implemented by the Centers for Medicare and Medicaid Services (CMS). The program is composed of two payment models, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). To facilitate a transition from FFS to quality-based payment, a period of positive pay increases for clinicians was established from July 1, 2015 to December 31, 2018, in the amount of 0.5% annually. The fiscal start of MIPS (based on the 2017 performance year), as well as incentives for participating in APMs and Advanced APMs, formally began on January 1, 2019 ^[2].

MIPS administers either positive or negative payment adjustments for clinicians whose practices are reliant on the FFS reimbursement model. Qualifying professionals (physicians, nurse practitioners, physician assistants, and clinical nurse specialists) who chose to participate in this program see annual payment increases or decreases depending on performance metrics. The law consolidates and streamlines three previously implemented quality reporting schemes within MIPS: Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VM). Under MIPS, CMS will calculate a score from 0 – 100 for participating professionals based on four categories:

1) Clinical Quality

2) Advancing Care Information

3) Cost

4) Improvement Activities

The Clinical Quality category employs metrics previously reported under PQRS, the Advancing Care Information category utilizes measures formerly under the Electronic Health Record (EHR) Incentive program, and the Cost category uses metrics previously under the VM scheme. The Improvement Activities category recognizes providers for efforts that contribute to advancing patient care, safety, and care coordination. The maximum negative or positive payment adjustment is 4 percent in 2019 and will gradually increase to 9 percent in 2022 and beyond ^[3].

MACRA promotes participation in private payer and Medicare APMs. Beginning in 2018, eligible providers who chose to participate in an APM and receive at least 25 percent of their Medicare revenue through an APM earn a 5 percent bonus. To incentivize participation in APMs, the threshold for receiving the 5 percent APM bonus will increase to 50 percent of Medicare revenue in 2021. The threshold will continue to rise over time, reflecting CMS’s commitment to move toward quality-based payment schemes.

In order for providers to qualify for a payment track entirely separate from MIPS, an APM must be considered an Advanced APM by meeting the following criteria: 1) employ certified EHR 2) utilize quality-based metrics commensurate to those of MIPS 3) require clinical providers to bear more than nominal monetary risk for financial losses or operate as part of a medical home ^[4]. Finally, to address the unique payment integration challenges faced by small and rural practices, MACRA allocates $20 million annually to provide technical assistance to practices with 15 or fewer MIPS-eligible clinicians ^[5].

^[1] “2015-HR2.” CMS.gov Centers for Medicare & Medicaid Services, April 17, 2018. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/2015-HR2.html

^[2] “Medicare Access and CHIP Reauthorization Act of 2015.” American College of Cardiology, April 28, 2015. https://www.acc.org/latest-in-cardiology/articles/2015/04/28/15/59/medicare-access-and-chip-reauthorization-act-of-2015-what-you-need-to-know.

^[3] “2018 MIPS Strategic Scoring Guide.” American Medical Association. AMA, 2018. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/physicians/macra/2018-mips-scoring-guide.pdf.

^[4] “Innovation Models.” Innovation Models | Center for Medicare & Medicaid Innovation, n.d. https://innovation.cms.gov/initiatives/#views=models.

^[5] “Quality Payment Program: Small Practice, Underserved, and Rural Support.” Physician Payment, March 14, 2019. https://www.aafp.org/practice-management/payment/medicare-payment/macra-101/qpp-surs.html.