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Monday Morning Update 4/28/14

April 26, 2014 News 9 Comments

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Cover Oregon waves the white flag and shuts down its $248 million health insurance exchange website without having enrolled a single citizen. The state will convert the site for Medicaid enrollment for an additional $35 million (federal taxpayers will pay 90 percent of that) and everything else will be turfed off to Healthcare.gov. The only winner is Oracle, which was paid $134 million even though the state says the company failed to deliver what it promised. The folks who run Cover Oregon, who seem to think their credibility emerged unscathed, say it would have cost $78 million to fix the disaster it oversaw but only $5 million to piggyback onto Healthcare.gov, which it could have done on Day 1. The money Cover Oregon wasted, like that of other states that decided they could build their own sites slightly less incompetently than the federal government, is pretty much gone since the site was to have paid for itself via a tax on insurance company sales.


Reader Comments

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From The PACS Designer: “Re: Google Ara. Google’s approach to the next smartphone will be a modular one called Ara from Google’s ATAP (advances technology and projects) group. By allowing the Android phone to be constructed to a controlled style, it will let developers limit what a user can do with the smartphone. This should be of interest to those who want to reduce BYOD usages in institutional settings.” It’s an interesting approach, like taking tablets back to the IBM-compatible PC days when you could buy components from anybody and just plug them in. I suppose the upside is that your phone will have a long life cycle since it’s really just a core board that accepts components. On the downside, Google excels at building ugly, frustratingly non-standard products (Gmail) and Apple and Samsung phones are selling just fine even if they are rendered obsolete after only two or three years. Not to mention that Google has no retail stores from which to sell and support consumer hardware. I’m no expert, but this project has “bust” written all over it, which seems to be a regular occurrence among the Googlers these days.

From Ex-Epic: “Re: Epic. Has been sending a team of people to Denmark (Copenhagen) for a few months now on regular sales/early stage implementation meetings. Haven’t seen it mentioned here with the other international sales mentioned lately.” I mentioned in November 2013 that Epic would be providing systems for all of eastern Denmark.


HIStalk Announcements and Requests

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Most poll respondents don’t think any differently about HHS after it released Medicare physician payment information. New poll to your right: do you use an activity tracker such as FuelBand or Fitbit at least five days per week? My sense is that the wearables fad is over – the devices don’t measure a whole lot given their cost and walking still isn’t fun or practical for many people – they don’t need discouraging electronic reminders that they failed to meet their goal.

Listening: new from Stream of Passion, because I can go only so long without needing some Dutch progressive-opera metal (fronted by a female singer from Mexico for some reason.)

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I support DonorsChoose projects that help classrooms in need, and in return, I get nice thank-you emails and photos from the teachers who appreciate the support. I realize I haven’t mentioned the most satisfying part – receiving letters from the students themselves. This particular project was for remanufactured toner cartridges and file drawers for a total cost of $187 as donated by HIStalk on behalf of readers. One of the students said, “I’m grateful that you donated to us because some teachers don’t have any printing supplies and my teacher was one of those people, but now he’s not, so I’m thanking you.” This is from a highest-poverty school in Mississippi, where the teacher (Mr. Delperdang, a Teach for America teacher )was spending his own money printing classroom materials from home.  


Upcoming Webinars

May 1 (Thursday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 2 – Build-Measure-Learn to Get Value from Healthcare Data. Sponsored by Premier. Presenters: Alejandro Reti, MD, senior director of population health, Premier; and Alex Easton, senior director of enterprise solutions, Premier. Once you deploy an enterprise data warehouse, you need to arrive at value as quickly as possible. Learn ways to be operationally and technically agile with integrated data, including strategies for improving population health.


Acquisitions, Funding, Business, and Stock

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From the Cerner earnings call:

  • The company’s backlog increased to $9.24 billion. For non-investment types, “backlog” refers to products or services that have been sold, but whose revenue hasn’t been recognized due to accounting principles. In non-manufacturing businesses like healthcare IT, backlog is a good thing because it represents sales that haven’t shown up as income yet but will down the road. Backlog isn’t positive for manufacturers because it means your factory isn’t cranking out widgets fast enough, meaning you’ll need to make big capital investments to increase capacity or else your customers will find another vendor.
  • Sales revenue increased 4 percent, but the big jump was in services at 25 percent. Cerner is very good at generating that kind of recurring revenue without having to go through the grueling process of finding new customers, especially ones who are also considering Epic.
  • The company sold zero new ITWorks or RevWorks deals, and in fact “have not added a full RevWorks client in recent quarters.” Cerner just can’t seem to get anything right when it comes to financial software and services.
  • 25 percent of the quarter’s bookings were to non-Millennium customers. That’s a big deal – obviously the company is taking business away from someone else’s customers.
  • The company says the ICD-10 delay will give a slight boost to its revenue cycle business because some prospects were on a software hold while focusing on ICD-10. They didn’t mention that if that’s true, business will take the same slight downturn next year when ICD-10 looms again.
  • Revenue from sales outside the US dropped 16 percent, mostly because of reduced low-margin hardware numbers.
  • Cerner’s highly publicized deal with Intermountain Healthcare was summarized as pushing trigger events in front of clinicians, with the challenge being to turn the processes Intermountain has developed into “self-contained diagnostic, treatment, outcome, and reimbursement containers” that “replaces the claim in the fee-for-service world” and that can be used in non-Cerner systems. Sounds great if it works, which has never been the case in any example I can recall where a big-name hospital’s rules were benevolently sprinkled down like holy water on bowing masses of less-blessed hospitals.
  • The company mentioned HIMSS exhibits that showed “elegant graphs that purport to provide great insight into the data,” but that unless you can put that information in front of the physician in real time, “you’re just reporting the news vs. making the news.” That sounds inherently true, but the reality isn’t quite that dramatic – a hospital could use an analytics system to find potential areas of improvement (right down to the individual physician) and then use its order entry/clinical decision support system to build in guidance make it easier for physicians to do the right thing. Hospitals have plenty of capability built into the systems they already own without chasing yet another Intermountain project that seems to work for nobody except Intermountain. Every hospital I’ve worked in had plenty of information that could have improved outcomes and cost – what they lacked wasn’t technology, but rather the willpower to make the significant percentage of cowboy doctors follow the agreed-on rules. They needed competence and leadership, not more information to ignore.
  • Concluding the Intermountain hype was a statement saying that the most exciting part of the partnership is to sell Cerner consulting services.
  • The company still claims it can steal some Epic clients who have reached EMRAM Level 7 “because they don’t feel like the solution they have will suit their future needs.” I would think the best chance of that happening would be to undercut Epic’s maintenance costs, but Cerner didn’t mention that.
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Tee Green, CEO of Greenway Health, provided HIStalk with this statement regarding the departure of President Matt Hawkins (above),who came over from his previous role as CEO of Vitera when Vista Equity Partners bought Greenway and combined the two companies in November 2013:

Matt Hawkins was instrumental in driving the growth and operational efficiencies at Vitera Healthcare, helping position that organization to combine with Greenway Medical Technologies and SuccessEHS to form the company Greenway Health is today. As Matt prepares to assume a new leadership role outside of Greenway, we’re very excited for him and wish Matt and his family nothing but the best. As Greenway moves forward, our priorities remain the same: to continue supporting and enhancing our solutions and to help our customers remain efficient and financially strong as they deliver care that improves the health of their patients and whole patient populations.


Sales

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Texas Health Resources will deploy the AirStrip One clinical mobility solution throughout its system.


People

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Joshua Seidman, PhD (Evolent, ONC) joins Avalere Health as VP of the newly created Center for Payment and Delivery Innovation (according to the press release) or Center for Delivery System System and Payment Innovation (according to his LinkedIn profile.)

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KentuckyOne Health (KY) names Doug Jones (Providence Health & Services) as regional CIO.


Government and Politics

The AMDIS listserv brings up an interesting CMS attestation calculation quirk: any measure that requires “more than” a specific percentage actually requires the next-higher whole number percentage. You fail if you hit 50.4 percent on a measure that requires “more than 50 percent” since CMS rounds down to 50 percent and you didn’t exceed that. It’s bizarre that they round numbers at all.

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The HIMSS EHR Association offers its comments to ONC’s proposed 2015 EHR certification criteria:

  • Early notice of proposed changes helps vendors prepare, but doesn’t address the real problem — certification rules are changed too often.
  • Vendors would have less than a year to build 2015 requirements into their products, so they want the edition labeled as 2016 rather than 2015.
  • Vendors can’t spend all of their time chasing certification requirements – they also have to consider customer requests and other government-mandated changes.
  • ONC underestimates the cost for vendors to keep up with its requirements – EHR says the real cost numbers are 10 times those ONC puts out and the 2015 criteria will be more than 15 times more expensive than ONC claims.
  • EHRA doesn’t think certification should be required for anything other than providers collecting HITECH money – certification should not be broadly expanded.
  • EHRA says it’s not reasonable to put the electronic clinical quality measures in 2017 edition certified software – there’s not enough time left.   

Innovation and Research

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Brigham & Women’s Hospital (MA) will hold Pilot Shark Tank on Monday, where entrepreneurs are invited to pitch their ideas to hospital doctors and nurses who can approve a pilot project. Finalists are CareMon (3D optical patient monitoring), Constant Therapy (iPad-based stroke rehab therapy), Healo (remote monitoring of wound healing), Home Team Therapy (PT programs for home), MySafeCare (patient and family reporting of safety concerns), Revvo (bio-adaptive exercise bike), Tenacity Health (peer health coaching), Twine Health (collaborative chronic disease management), VerbalCare (patient-caregiver communication), and Vital Score (Apgar-like scoring of unhealthy behaviors that contribute to chronic illness).


Technology

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In the least-surprising news of the week, Google+ goes comatose as its leader quits, its teams are reassigned, and the groups working on its Hangouts and photo features are moved under the Android operating system. Only Google could have designed product even clunkier and more confusing than Facebook except without the first-mover advantage and network effect that keep Facebook popular (at least for now.) Nobody wanted to use it as a Facebook alternative, so maybe at least some of its expensively developed parts can be salvaged for something useful. People wants EHRs to be as simple to use as Facebook, so maybe Google could drag up the moldy source code for Google Health and kludge something together that would turn two flops into one success.

Most electronic hospital  equipment can be taken over by hackers,according to a study by healthcare provider Essentia Health: IV pumps can be changed over the network, Bluetooth-powered defibrillators can be triggered at will, and unsecured medical images can be viewed by anyone, for example. The Essentia team also found that they could reboot some devices to force them back to factory defaults and that many pieces of equipment are connected directly to the Internet instead of being inside the firewall, allowing any hacker to simply plug into an available hospital jack and start finding devices to hack. A key finding is that EHRs accept data from unauthenticated devices, so bogus information could cascade into more harmful treatment decisions.

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More speculation on why Nike stopped manufacturing its FuelBand activity tracking hardware: the software portion (NikeFuel) may end up on Apple’s iWatch or other wearable platforms.


Other

Security experts say the hacker network that calls itself Anonymous may be responsible for a series of cyberattacks launched against the website of Boston Children’s Hospital (MA), which left patients and clinicians unable to use the hospital’s portal (the site is down as I write this Saturday afternoon). The group had demanded that the hospital fire the head of its child abuse prevention unit after a high-profile custody battle in which the hospital filed medical abuse charges against the parents of a 15-year-old female patient who was later placed in the state’s custody. Anonymous found itself embarrassed two weeks ago when it launched attacks against Israel-based sites, but Israeli hackers launched a counterattack by tracking the IP addresses of the Anonymous members and hacked their computers, including hijacking their webcams to snap and publish photos of the not so Anonymous members.

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Athenahealth announced last week that it was dropping its membership in the HIMSS EHR Association, which it says “ostensibly” represents EHR vendors in federal policy debates. The company says it “never really belonged there in the first place” because EHRA is dominated by non-cloud EHR vendors and athenahealth isn’t really an EHR vendor but rather a services company (a debatable point.) Athenahealth (a) doesn’t like that EHRA pushes for more vendor-friendly federal policies (longer timelines, lower bars) and (b) wants CMS to name vendors whose customers seek hardship exemptions while EHRA “presses just as hard to protect its members from the consequences of their failures by opposing any such disclosure.” EHRA decided not to wage press release warfare with athenahealth, but says its membership diversity creates value and credibility and while it’s sorry to see athenahealth leave, some of the company’s statements are incorrect (specifically the one claiming that EHRA opposes hardship exemption transparency, about which I could indeed find no stated EHRA position.) Athenahealth also says it takes too much time to explain to people why it regularly disagrees with its own trade association. My opinion: athenahealth voluntarily joined EHRA hoping to gain something from it (DC influence, publicity) and is quitting for the same reason (publicity and hoping to differentiate itself competitively from its former fellow members, especially after ATHN announced unimpressive quarterly result last week). Customers don’t care one way or another, and with the company’s size, it can do its own Washington glad-handing. Every member of CommonWell Health Alliance (except Sunquest) is also a member of EHRA, so maybe athena should storm off from that group as well.  At some point, a large, publicly traded company crosses the line from “disruptor” to “disruptee” and athenahealth may be getting close.

ECRI Institute’s listing of healthcare IT data integrity as the #1 problem facing healthcare organizations includes specific examples: data entry errors, missing or delayed delivery, accepting incorrect default values, copying and pasting, using both paper and electronic systems, and incorrectly attributing device data to the wrong patient. It recommends assessing clinician use, improving testing, offering better training, and giving users an easy way to report system problems they see.

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Athenahealth’s Jonathan Bush and business writer Stephen Baker team up to write Where Does It Hurt?: An Entrepreneur’s Guide to Fixing Health Care, available May 15. Sounds interesting except that JB’s incessant verbosity makes it tough to convince free milk drinkers to plunk down cash to buy the cow.

Strange: a New York doctor is sued for stiffing the Scores strip club for $135,000 worth of lap dances in four visits over 10 days. He claims he was drugged by club employees and disputes that he was even present despite security camera video suggesting otherwise. A Scores spokesperson said of the cardiologist, “If I had five dancers dancing for me, I’d be in the ICU. He’s a heart doctor – I guess he’s got a good heart.”


Sponsor Updates

  • Liaison Healthcare enhances its EMR-Link EHR interoperability solution with Meaningful Use Stage 2 capability.

Switching from a Cloud-Based EHR Vendor

I mentioned a while back about hearing from a physician practice that was finding it next to impossible to extract EHR information from their cloud-based EHR to move to a different system. I offered to write about the experience from the points of view of both the vendor and the practice. Here is a summary of the communication, which should provide lessons learned for both customers and vendors.

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From Matthew “Toby” Cox, MD, MPH, Families First Pediatrics, South Jordan, UT

  • We started with ADP AdvancedMD in April 2011, but found it didn’t meet our needs and we are switching to the peds-specific PCC EHR.
  • ADP Advanced MD claimed on their website that they won’t hold data hostage – they will provide an encrypted hard drive with all data plus mapping and documentation within one week for $1,250.
  • We paid $1,250 on January 30, 2014 and received a thumb drive several weeks later. The new vendor, PCC, says the new information is a comma-separated value file that makes no sense.
  • After several weeks of getting no response, ADP AdvancedMD (whose national headquarters is less than a mile from our practice) sent a technician, who said the file the practice was given was incomplete. Another file was supposed to be sent, but wasn’t.
  • Three months later, we still have no usable data and the ADP AdvancedMD representative suggested pulling up every patient chart and printing a PDF.

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Response from Jim Elliott, VP of marketing, ADP AdvancedMD

  • The delay was due to a process issue that has been resolved.
  • The ADP AdvancedMD rep hand-delivered the 4.5GB data file that can’t be split into smaller files readable by Access or Excel because records are sorted by date of service and that would break up a patient’s chart.
  • The practice had set up templates and each field they used can only be defined by the practice since the system doesn’t “know” how they are being used.
  • The new vendor, PCC, understood the layout and required no further changes.

From Dr. Cox

  • Nobody from ADP AdvancedMD told us in training that when we added items to templates that we were adding “codes” that would complicate the data extraction process.
  • Our last EHR conversion from another vendor at least gave us individual patient PDFs that could be accessed by a menu button – not ideal, but usable.
  • The practice management data extract from ADP AdvancedMD was perfect. Only the EHR information is a problem.
  • I asked ADP AdvancedMD during their sales pitch about our access to our data if we decided to leave since it seemed unusual that they were offering a month-to-month contract. Their salespeople said we would have access to the data and be provided a hard copy of it. I was not savvy enough at that time to probe deeper into this as I took their word for it (dammit Jim, I’m a doctor, not a computer data specialist!)

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From a programmer at Physician’s Computer Company (PCC)

  • We never indicated to ADP AdvancedMD that we found their extract usable. The limited guidance we received was weeks later and only after repeated requests.
  • We do vendor conversions every week and have done every major vendor. This is the only one that we have not been able to convert.
  • Anyone on ADP AdvancedMD who thinks they can switch vendors is deluded.
  • Here is a consecutive snippet … it’s the same date of service for the same patient, but it’s a random mix of stuff.

From Dr. Cox to ADP AdvancedMD

  • If you were handed that data file, how would you import the information into Advanced MD step by step?
  • Has anyone every successfully imported that information into another system?
  • Is a bulk export to an industry-standard layout (CCD/CCR/CCDA) possible?
  • Can a mass export to PDF be done as a last-ditch effort to get patient information into their new system?

From Jim Elliott to Dr. Cox

  • There were communications gaps between the two vendors. ADP AdvancedMD spoke to PCC’s technicians and understood that the new vendor had everything needed to convert.
  • ADP AdvancedMD is still a few months away from delivering the capability to bulk export to CCD or CCR, but it can be retrieved from individual patient records.

The practice’s information is still not available in their new system three months after their initial request and payment and Dr. Cox is worried about the clinical impact to patients of missing three years’ of their data.

My suggestion: regardless of whether your EHR vendor is a traditional or cloud-based one, ask them now (not later) for the names of former customers who successfully migrated off their platform with all data intact (which will prove that it’s at least possible). Or, far less desirably, ask for a sample extract with documentation.

I’ll also ask the technical folks who work for EHR vendors to weigh in on the data snippet above. Would your company be able to migrate intact, complete patient records using a file with that layout? It looks to me as though the individual items are identified using free text and non-standard codes that would be meaningless outside the source system.


Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

More news: HIStalk Practice, HIStalk Connect.

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Currently there are "9 comments" on this Article:

  1. Nicely done Mr Green. More telling than your nice words will be whether Vista Equity places Hawkins at another portfolio company…

  2. We are currently converting from a large number of different vendors into Epic. The data extraction ranges from HL7 to PDF to pipe-delimited files to “here is access to our database, you figure it out.” There is usually a rhyme and a reason to the data but there is also some stuff that just cannot be used in a meaningful way (I used that word meaningful on purpose). So first glance at the file above looks like what we have gotten from other vendors and it just has to be massaged a little.

  3. If I was a betting peson, add Massachusetts to the states who failed miserably with their HIE. It is so bad that that we now have people who had insurance and signed up without insurance! They will be covered by the state until July, maybe! So our Medicaid enrollment is growing because of the incompetency, at the taxpayer expense. Go Obamacare!

  4. Really detest how folks like to equate any problem with a state’s own incompetency to Obamacare. Get real – states such as OR and MA frankly screwed up in defining their requirements and managing their contractors. Even the Feds screwed up here. But to blame it on a legislative act… Just bizarre.

    Great reporting on the EHR conversion issue and brings to light the struggles that many orgs are having moving from one system to the next. Points to one of the biggest problems w the HITECH – incentivizing the adoption of tech that was not yet ready for prime time and a mkt not wise enough to know the difference.

  5. “Points to one of the biggest problems w the HITECH – incentivizing the adoption of tech that was not yet ready for prime time and a mkt not wise enough to know the difference.”

    +10000

  6. Can anyone produce the actual documentation about the CMS attestation issue. I know a CIO that would be very interested, and would want some hard proof.

  7. I think you may be jumping the gun on calling the Google Ara a bust. ATAP projects are not always intended for consumer use. They are more experiements to see what they can do and what is viable much like concept cars at an auto show.

  8. This is Chip Hart, Director of Pediatric Solutions, from PCC. I am very reluctant to respond here because I have no interest in getting into a spitting match with a vendor on-line.

    However, the fact is that although we have successfully converted EHRs and PMs from dozens of systems over the years, we have never received a ‘data dump’ like this before. It is, effectively, unusable. I don’t see how even **AdvancedMD could import its own data**. [Tim, above: there is very little rhyme/reason and much of the context of the data is missing.]

    Again, rather than finger point here, I will simply ask this question:

    Has anyone out there had a successful AdvancedMD data conversion? Secrets, hints, guidance, even commercial solutions are all welcomed. We tried working with the local AMD expert and didn’t get anywhere. You can reach me at chip@pcc.com.

    Data conversions are going to be a growth industry over the next decade and I think many practices are going to be shocked to learn how their cloud-based solution has them locked down.

    Thanks.

  9. I forgot to add: it is ONLY the EHR side of AdvancedMD that we have a problem with. The billing side has a very nice, one-click data extraction function that provides exactly what a practice would need to transfer the PM side of the business. We understand from this process that the EHR is a completely different product and behaves accordingly.







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