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Readers Write: The Key to Transitioning from PQRS to Risk-Sharing Agreements

September 29, 2014 Readers Write No Comments

The Key to Transitioning from PQRS to Risk-Sharing Agreements
By Mason Beard


If you, Dr. X, report on quality for your Medicare patients, you’ll get a nice bonus. That’s how PQRS started out—a purely pay-for-reporting initiative.

The bar for this program was set fairly low to encourage providers to meet the requirements. But in its crafty way, the federal government has steadily shifted the program away from the carrot and toward the stick. In fact, the incentive phase of the program ends next year. Providers who don’t measure up will simply experience the stick. In other words, the government has moved its focus from reporting to performance.

I don’t want to paint CMS as conniving to punish poorly performing providers. The truth is that PQRS has been a very successful program and is driving an important focus on the quality of care delivered to Medicare beneficiaries. Another quite evident truth is that CMS is not stopping here.

CMS isn’t just creating government programs and regulations; they’re trying to change provider behavior to rally around outcomes reporting and better care. They’re pushing providers inexorably toward value-based reimbursement (VBR). Reading the tea leaves of what’s happening with PQRS—and considering the proposed Merit-Based Incentive Payment System (MIPS)—the government is going all in on this.

Technology can help providers who are doing PQRS reporting prepare to move successfully into more sophisticated VBR arrangements. From the beginning of PQRS (PQRI at the time), it was evident that providers would need HIT tools to help them track, measure, and report on quality measures. PQRS has been around long enough that there are now a variety of tools providers can use to help them fulfill this requirement.

Not all of these tools can help providers meet PQRS requirements and transition to more sophisticated VBR arrangements using the same infrastructure. Make no mistake — such a transition is essential. To manage it successfully, organizations don’t need a point solution, they need a platform.

Here’s why. The new PQRS, the MIPS of the future and other VBR arrangements don’t focus on reporting outcomes; they focus on improving outcomes. The only way organizations will be able to improve outcomes is by implementing what I call the 4 As:

  • Aggregation. Providers need to be able to gather clinical and administrative data from the disparate technologies across their system.
  • Analytics. Providers need some level of analytics to understand their population, identify gaps in care, and assess risk.
  • Action. Providers can’t just aggregate data and analyze it and then not do anything about it. They need some system in place to engage their patient population (via care management workflows, automated outreach, reminder letters, etc.) and fill gaps in care.
  • Accountability. They need to be able to prove the value back to the stakeholder. Simply put, this means reporting the outcomes for a variety of initiatives to CMS and other payers.

It’s important to note that PQRS point systems only address the fourth A: accountability. (Even then, they may not have the flexibility to adapt to the various reporting initiatives that will be required by multiple payers as time goes on). If a PQRS solution only addresses the fourth A, it can’t prepare an organization for risk. It doesn’t create processes that move the organization away from a fee-for-service world.

A platform, on the other hand, enables provider organizations to enter the value-based world. Performing PQRS reporting on a platform is the perfect starting point. As providers fulfill the PQRS reporting requirements, they can layer in processes that help them transition from a reporting workflow to a more proactive workflow focused on population health management. With the aggregated data and intelligence they build up around their performance in the process, they become equipped to enter into VBR arrangements with commercial payers.

A platform delivers an easy, turnkey way to branch out from PQRS to address other, more sophisticated payer initiatives. The time to plan for this transition is now because the stakes are rising. Every plan—both government and commercial—is developing some kind of risk- or performance-based initiative. With a platform, providers don’t have to take the plunge immediately. They can first dip their toes in the waters of PQRS and then move steadily into a world of improved outcomes and value-based reimbursement.

Mason Beard is senior vice president of solutions and co-founder of Wellcentive of Alpharetta, GA.

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September 29, 2014 Readers Write No Comments

Readers Write: EHR Divorce Rates on the Rise – Four Factors that Predict Electronic Health Record Adoption Success

September 29, 2014 Readers Write No Comments

EHR Divorce Rates on the Rise – Four Factors that Predict Electronic Health Record Adoption Success
By Heather Haugen, PhD


Despite healthy growth in the implementation of EHRs, the lack of effective adoption plans is impeding their intended purpose of helping healthcare providers improve care.

In 2013, nearly six in 10 hospitals have adopted at least a basic EHR system. But not all EHR users are happy with their purchase. In fact, 30 percent of hospital executives admit they are dissatisfied with their system, and 30 percent of current EHR solutions are replacements of another product.

Research reveals that a myopic focus on the go-live event is the root cause of low EHR adoption rates and increases the chances of organizations’ divorcing their EHR vendor. In contrast, those healthcare leaders who focused on the processes and discipline required to achieve adoption and maintain it over the long run were more likely to achieve the clinical and financial outcomes they expected from the EHR.

EHRs have the potential to improve both patient care and work efficiencies in delivering care, but these outcomes are only possible when clinicians adopt the best practices and workflow needed to continually improve how the system serves the organization.

The research published in “Beyond Implementation: A Prescription for Long-Term EHR Adoption” revealed four key factors that predict EHR adoption:

Engaged Clinician Leadership

Engaged clinician leadership is the most important predictor of successful EHR adoption. IT leaders are often given primary responsibility for the organization’s EHR system. While their skills and experience are necessary for functionality of the EHR system, the input and expertise of nurses, physicians, pharmacists, and other clinical staff is essential to driving staff’s proper use of the EHR and improved clinical and financial outcomes.

Moreover, leaders of EHR adoption efforts need to be highly engaged through and beyond go-live. While this may seem like a given, competing priorities make it difficult to maintain the degree of engagement required after the go-live event. When comparing organizations with successful implementations and those who have become dissatisfied with their system, our research shows that engaged leaders:

  • are well informed and aligned in how they communicate the value of the EHR;
  • empower clinicians to make decisions about how the EHR should be implemented and used;
  • understand the degree of change required and set priorities appropriately; and
  • stay engaged for the life of the application.

Effective Training to Ensure Proficient Users

The way in which clinicians and users are trained impacts their level of proficiency. In healthcare, we often use traditional methods – one-time “training events” that occur at a certain time and place. The trainers focus on teaching the hundreds of features and functions available in the system over multiple days with the goal of reaching “mastery” by the session’s end. But this is an ineffective, insufficient, and unrealistic method.

Bill Rieger, CIO of Flagler Hospital (FL) originally thought that implementing his health system’s new EHR would include traditional, classroom-style training. This approach required training sessions to begin a full six months prior to go-live due to limited classroom space and a large clinical staff. By making the switch to using scenario-driven simulations – a hands-on method – the hospital was able to begin the initial training program just six weeks prior to go-live, resulting in increased retention and a more successful launch.

Simulation-based training that focuses on helping users become proficient in new workflows and best practices results in dramatically better outcomes compared to traditional training and takes about half the time. This style emphasizes an accumulation of experience over time. It happens continuously in the specific work environment and leverages role-based content to provide a level of individualized fluency. Critical thinking skills and retention of content improve significantly when the goal is proficiency, in contrast to attending a more passive training event.

Measuring for Improvement

Defining metrics to track proficiency in EHR use and communicating them with clinicians is another critical step for adoption. Without it, improper use of the system is more likely to continue. Through a process of peer-to-peer auditing and regular progress reports, clinicians can track their performance and improve in necessary areas – ultimately enhancing patient care in the process.

In addition to providing feedback for clinicians, measurement can help optimize the EHR platform. For example, if simulation reports reveal that a large percentage of users click in the wrong area when completing a certain task, it would indicate a point of non-intuitive design. Armed with such data, the EHR vendor may be able to modify the system for improved use.

Adequate Resources and Prioritization Beyond Go-Live

A focus on the people, processes, and evaluations to improve adoption over the lifecycle of the application is required for long-term success, yet very little attention is typically paid to sustainment efforts.

Even when a new EHR is well accepted by clinicians and they become proficient in the application, adoption is a process that can never be finished for two reasons:

  • There will always be new clinicians and residents entering the healthcare organization. An organization with a successful EHR program will ensure that these individuals receive every bit of guidance and have the ability to be just as successful in their use of the EHR as those clinicians who had been present at the go-live event.
  • EHR systems will always be subject to upgrades and changes. While the changes are meant to enhance the system, they will do more harm than good if end users do not receive the appropriate level of guidance when being introduced to new workflows and processes. 

Too often, people that are recruited to work on EHR adoption efforts eventually revert back to their previous roles and work on their former projects, leaving the organization without proper resources to account for this inevitable cycle brought on by time and turnover. Flagler Hospital overcame this tyranny of time by keeping implementation committees in place and by focusing on long-term, ongoing education even through multiple EHR upgrades.

Moving from an EHR implementation focus to an EHR adoption focus requires a significant overhaul in how we think, how we lead, and how we behave. Now is the time for healthcare leaders to evaluate their organization’s performance in these four key areas that predict EHR adoption.

Heather Haugen, PhD is managing director and CEO at The Breakaway Group, A Xerox Company of Greenwood, CO, which recently delivered an HIStalk webinar on this topic that can be viewed as YouTube replay.

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September 29, 2014 Readers Write No Comments

Curbside Consult with Dr. Jayne 9/29/14

September 29, 2014 Dr. Jayne No Comments


As a CMIO, I often feel my attention is all over the place. I’m dealing with clinical documentation needs for various constituencies while trying to ensure compliance with a host of federal, state, and other quasi-regulatory standards bodies. I’m also trying to implement tools to measure patient, physician, and employee satisfaction while maintaining my sanity in what seems like an upside-down healthcare world.

Given that background, you can’t imagine the serendipity I found when Dr. Andy’s recent CMIO Rant coincided with my weekend project to review E&M coding.

Due to some discrepancies in coding volumes after a recent ambulatory EHR upgrade, our compliance officers asked for a thorough review of the system’s E&M calculation tools. There are quite a few nuances to how the system codes and we’ve also had some recent coding education outside of the EHR, so I wasn’t convinced we weren’t dealing with another variable.

Our system is flexible and allows physicians to choose either 1995 or 1997 guidelines for each encounter. What if the recent coding class had physicians making different choices than they did previously? What if they were scared by the gloom-and-doom predictions of a RAC audit and undervalued their documentation?

I had been sitting for several hours with my trusty-rusty paper coding review forms, scoring visit documentation based on the guidance from our coding and compliance team. Once a visit was scored, I compared the results to the EHR’s calculations. Our EHR breaks down its coding suggestions parallel to E&M guidelines, so it is fairly easy to compare the bullets it counted vs. what I counted on paper.

Fortunately, our system does not advise on the level of Medical Decision Making, but rather requires providers to select that coding component. I can’t imagine how controversial the review would be if the EHR was prompting it.

There’s so much going on with HIStalk I tend to get behind from time to time. When I couldn’t handle any more bullet-counting, I took a break to catch up on HIStalk Connect and HIStalk Practice. Imagine my delight when I found Dr. Andy’s response to the AMA’s comments on EHR design. His first counter-request for the AMA is for them to help us fight “regulations that require overly detailed physician documentation, like the CMS E&M coding guidelines, which really set a floor of complexity below which we cannot sink.”

I laughed out loud, as I do every time I receive an email from CMS advocating their brand of “administrative simplification,” which has to be the biggest oxymoron ever. Just that morsel would have been enough to make my day, but then he covered their seemingly contradictory request for EHRs to lower cognitive workload while requiring them to enable dozens more tasks than we ever handled on paper. “Massive cognitive workflow” were the words he chose. Having had a 40+ patient clinic day this week, I can attest to the massive nature of the volume of information I had to process to care for them.

Note that I didn’t say data. Data implies the information is in the EHR or another accessible system that I could theoretically review. The reality is that physicians have to handle information on a much broader scale – the patient’s history, family members’ version of the same events, stories about what the patient read on Google, the physical exam itself, in-office testing, and more – on top of the actual electronic data available. Add to that mountain of information the fact that we’re now caring for patients in the office that would have been cared for in the hospital five years ago and it would be easy to become buried.

Reflecting on this massive cognitive workload inspired my new and improved “guidelines” for E&M coding. I didn’t have enough time (or martini fixings) to flesh out the entire scheme, so let’s confine our thoughts to established patient office visits.

Traditional E&M coding poses five levels of service – 99211, 99212, 99213, 99214, and 99215. The value of the visit (and thus the payments) increase as the level of service increases. Typically 99211 and 99212 are not used to bill actually physician services, so I threw them out. Talk about administrative simplification – I just slashed the number of things I have to think about by 40 percent.

Looking at the rest of the codes and what you have to have to justify documentation in the traditional coding construct, I identified some sample visits that were reflective of the codes even by conservative standards. They fell into nice groupings based on the amount of information the physician had to interact with during the visit. I’m not just talking about information that one would have to review, but also information one might have to deliver. Out of ten charts reviewed for each level of coding, I had a 90-100 percent concordance when using the “information burden” scheme to value my efforts.

Here’s how it works.

99213 – Now called “Mild Information Burden”

  • Patient has fewer than three issues he/she wants to be seen for today.
  • Patient has been seen at fewer than three healthcare facilities/providers in the last three months.
  • None of today’s issues will cause death or serious consequences if left untreated.
  • Determination of proper treatment requires review of fewer than three data sources (EHR, clinical data warehouse, HIE, antibiogram, CDC bulletin, guidelines website, Sanford guide, discussion with colleague, etc.)
  • Treatment requires fewer than three instructions, outside orders, or documents (patient education handouts, prescription, therapy order, referral, prior-auth, FMLA papers, etc.)
  • Visit requires less than 15 minutes for documentation.

99214 – Now called “Moderate Information Burden”

  • Patient has more than three issues he/she wants to be seen for today.
  • Patient has been seen at three or more healthcare facilities/providers in the last three months.
  • At least one of today’s issues will cause death or serious consequences if left untreated.
  • Determination of proper treatment requires review of three or more data sources.
  • Treatment requires three or more instructions, outside orders, or documents.
  • Visit requires more than 15 minutes for completion, including documentation.

At this point, based on my “rules of three” and the two levels of coding, you could quit. However, neither category covers what I had to manage for several patients seen in this week’s clinic. I decided to reserve the highest coding level for those special circumstances, but in keeping with the rules of three:

99215 – Now called “Severe Information Burden”

  • There are three or more non-office personnel in the exam room (patient, family members, children, interpreter, etc.)
  • Patient has been seen by facilities/providers that are members of three or more ACOs.
  • At least one of today’s issues will lead to hospitalization in the next three months.
  • There are three or more possible ways to treat one of today’s issues, depending on the patient’s insurance status and/or ability to pay for non-covered services.
  • More than three separate logins and passwords are required to access the data needed to care for the patient.
  • Visit takes long enough that it requires cutting three or more subsequent appointments short in order to catch up.

Maybe it’s just me, but those rules would be much easier to follow than what we currently have. I’d rather use my cognitive skills to deliver quality care and build relationships with patients than to remember whether I’m supposed to be documenting by organ systems or body areas. What does “expanded problem focused” mean anyway? Or “detailed”? I like to think that all my visits are detailed, if not comprehensive. Current E&M coding turns those perfectly good words into something incomprehensible.

Give it a shot – pull a couple of visits and see whether my proposed coding system holds up under the stress of your clinic day.

Do you dream of a world without E&M coding? Email me.

Email Dr. Jayne.

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September 29, 2014 Dr. Jayne No Comments

Morning Headlines 9/29/14

September 28, 2014 Headlines No Comments

HealthKit support added to WebMD, Carrot Fit, Yummly, more

A week after a bug forced Apple to pull HealthKit from its iOS 8 release, the feature is back up and running with a growing list of optimized health apps feeding data into it.

Citizen Hackers Tinker With Medical Devices

The Wall Street Journal covers the concerning rise in consumers hacking their own medical devices to add functionality that the FDA has yet to approve.

Deaths fall ‘with use of software’

In England, death rates drop at two NHS hospitals after a risk score-based alert system was implemented that monitors vital signs, calculates an “early warning score,” and then alerts nurses when the score trends outside of an acceptable threshold.

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September 28, 2014 Headlines No Comments

Monday Morning Update 9/29/14

September 27, 2014 News 3 Comments

Top News


Apple’s HealthKit health data aggregation system and the apps that use it go live after being pulled previously from the initial iOS 8 rollout due to unspecified bugs. Some HealthKit-powered apps that are back in the App Store after the iOS 8.0.2 update are FitPort, MyFitnessPal, WebMD for iPhone, and Carrot Fit. HealthKit allows iPhone-collected fitness measures to be forwarded to other iPhone apps, brokering the exchange using the phone owner’s permissions of allowable data sources and destinations. That might be the most significant aspect of HealthKit – the consumer-patient is in charge of the collection and movement of information about them.

Reader Comments


From Ben and Jerry: “Re: Chuck Podesta. Gone from Fletcher Allen, now CIO of UC Irvine Health.” Verified per his LinkedIn profile.

From WisconsinBeerGut: “Re: Epic to Cerner conversions. I’ve worked for Epic and consulting companies and I’m not aware of any clients that have replaced Epic. Some mergers to watch that involved Epic and non-Epic users are NorthShore-Advocate in Illinois and UAHN-Banner in Arizona.” Given Epic’s cost, you’d have to really hate it to contemplate spending money to replace it. That’s not the only reason that it keeps users, but it may be significant one.

From Ex-Epic: “Re: Cernover. Judy prides herself on the fact that Epic has never lost a customer to Cerner or any other vendor. There have been some small scale de-installs for various reasons unrelated to dissatisfaction with Epic and those of course get swept under the rug, but to my knowledge (and according to Judy) there has never been an Epic to Cerner move.”

From AtUGM: “Re: Epic’s app exchange announced at UGM. It envisions that hospitals will sell their self-developed apps. My organization has discussed this with Epic, but Epic hasn’t provided any way to do it other than as a spin-off, which we’re loath to do. Eclipsys had an app exchange and I don’t think it went anywhere. It would be great if you wrote a feature discussing these app development opportunities with the big companies and what it would take to actually be useful to those of us in the industry.” I assume that vendor-specific app stores work like Apple’s – the vendor skims 20-30 percent off the top and sells apps that meet their published requirements. I would be interest in hearing about anyone who’s actually bought an app from a healthcare IT vendor’s store. I would be worried about paying a lot for something that might be poorly supported or that won’t be enhanced regularly.

HIStalk Announcements and Requests


Most poll respondents like the idea of a 90-day MU reporting period for 2015 instead of the 365-day version that is official for the moment. New poll to your right or here: is it OK for an EHR vendor to block system access to a late-paying practice or hospital? Leave a comment after voting with your thoughts.

Last Week’s Most Interesting News

  • Intermountain Healthcare joins the Cerner-Leidos-Accenture DoD EHR bidding consortium.
  • Hospital operator HCA announces its intent to acquire physician systems vendor PatientKeeper, signaling that it will remain a Meditech clinical system customer.
  • A government report exposes HHS-CMS infighting and incompetence as went down in flames at its launch last October.
  • ZirMed acquires predictive analytics vendor MethodCare.
  • ONC Chief Science Officer Doug Fridsma, MD, PhD resigns to become president and CEO of AMIA. 

Acquisitions, Funding, Business, and Stock


Oncology data vendor COTA closes $3.7 million of a planned $7 million funding round. Most of the folks involved are from Hackensack University Medical Center’s cancer center.

Meditech finally issues its 2013 annual report that was due 11 months ago but was held up following revenue recognition changes. Revenue was down a bit from 2012 at $580 million, but net income rose to $133 million (that’s an enviable margin). Neil Pappalardo owns nearly 41 percent of the company, or about $680 million worth. The directors and officers of the company have been around forever, with the newest hires among their ranks having joined the company 24 years ago.



FCC Director of Health Initiatives Matt Quinn leaves the agency for a job with Intel.

Announcements and Implementations


CareSync announces version 2.5 of its personal medical records system, which adds the ability to collect and track information from 80 health and fitness apps such as Fitbit and Withings blood pressure cuffs.

CVS Health announces new MinuteClinic affiliations with University of Maryland Medical System, UTMB, and UAB.

Government and Politics

An investigation finds that HHS paid WebMD $14 million to promote the Affordable Care Act.



Glucose monitor manufacturers and the FDA express concern that the technologically sophisticated family members of diabetes patients are hacking the devices to make them more useful, partially because FDA takes forever to approve manufacturer-requested changes. A group of engineers, many of them parents of diabetic children, modified a glucose monitor to send readings to a website so that parents can monitor their children who are away on sleepovers.


A Premier study of ACOs finds that while most are improving care using basic internal systems such as EHRs, patient registries, and data warehouses, they struggle with bringing in data from external sources and providing patient-facing technologies. The key obstacles are interoperability problems and cost.

Penn Medicine (PA) has developed 75 apps, including the MedView physician portal and new Connexus patient data display app.

Weird News Andy provides a non-weird item: US hospitals aren’t prepared to handle Ebola-related patient waste since no disposal packaging has been approved, causing waste management companies to refuse to accept it. Emory University Hospital finally convinced Stericycle to accept 40 bags of infectious waste by first autoclaving it, but only after CDC brokered a deal.

Death rates dropped at two English hospitals that moved from paper-based vital signs charting to using the VitalPAC electronic system that provides warnings when patients are deteriorating. The hospitals developed the “early warning score” software with a vendor.

Here’s the more traditionally odd Weird News Andy article, which he titles “Give It a Shot.” The state nurse’s union sues Brigham and Women’s Hospital for requiring employees to get a flu shot after voluntary efforts failed to move the needle (pun intended) above 77 percent participation vs. 90 percent success in peer hospitals. State law prohibits hospitals from requiring employees to get a flu shot even though several hospitals require it as a condition of employment.  

Healthcare Analytics Summit 14 Report 


I attended Health Catalyst’s Healthcare Analytics Summit 14 last week, my first visit to Salt Lake City. Note: in the interests of disclosure, the company comped my registration fee although I paid my own expenses otherwise. I took the photo above from my room’s balcony, by the way – a very brief rain shower kicked up on a sunny afternoon and created a double rainbow over the City-County Building.

The Health Catalyst folks were hoping for around 100 attendees and ended up with 500. The event was held in a beautiful five-star hotel, the Grand America, which had surprisingly reasonable prices and outstanding service. Rooms, food, and meeting facilities were excellent.

Salt Lake City apparently is not quite as Mormon Church-driven as I naively expected since you can actually get ethnic food and alcoholic beverages, although some odd rules are in place (as explained to me, you can’t order drinks without buying food, so you pay $2 for a bowl of peanuts to allow you to order a beer). Good restaurants were an easy walk away, everything from tapas to tacos (my choices: Green Pig Tavern, Eva, Himalayan Kitchen, Caffe Molise, and Tin Angel Cafe). It’s a lot smaller city than I would have guessed – around 200,000 residents – and the mountains create an attractive backdrop. I checked out a rehearsal of the Mormon Tabernacle Choir that was inspiring. The weather was a lot hotter than I expected. My overall impression of the city was favorable, although since I don’t ski, I’m not sure I would have a non-business reason to return.


The event logistics were unparalleled. Plenty of Health Catalyst folks were on hand to direct people, answer questions, and even run a Genius Bar-type setup to help attendees use the cool app developed for the conference, which allowed interactive voting, reacting to speakers, and connecting with fellow attendees. I happened to chat with the guy whose company developed the app while walking to a session and he said it was built specifically for this conference. If it can scale, it would be pretty cool for larger conferences as well.

Presenters included Glenn Steele, Jr. MD, PhD, president and CEO of Geisinger Health System; James Merlino, MD, chief experience officer, Cleveland Clinic; Mike Leavitt, former Utah governor and former HHS secretary; Ray Kurzweil, director of engineering, Google; Penny Ann Wheeler, MD, president and chief clinical officer, Allina Health; and Charles Macias, MD, MPH, chief clinical systems integration officer, Texas Children’s Hospital.

A bizarre press restriction prevents me from even mentioning the name of the keynote speaker, although you can see it here. That’s too bad because I would have gushed about how entertaining and surprisingly relevant he was, and my fellow attendees seemed to agree given their highest rating of his keynote from all of the first day’s sessions. It was a bold choice by Health Catalyst. I enjoyed his talk more than any keynote I’ve ever heard. He would make an outstanding HIMSS keynote presenter, much better than the drones they’ve propped up on stage lately.

My least-favorite speaker was Mike Leavitt, who always struck me as a lightweight political journeyman turned opportunistic lobbyist. He rambled and misspoke to the point that I was checking email for most of his presentation. Everybody else did a great job, although I might have dialed back the presence of Health Catalyst people on the podium a bit if the intention was to engage attendees who don’t necessarily have a Health Catalyst connection. It got a bit confusing since three of the folks involved are from the same family (Burton) and were introduced with both past and present titles as the company made changes over the years, so I couldn’t keep track of who’s who as they came and went from the podium over the two days. I didn’t get a whole lot from the three breakout sessions, so for me the value was in the keynotes.

Health Catalyst used information collected from the app to announce some interesting (and sometimes creepy) facts gleaned from audience responses, such as that Android users were most likely to blow off the breakout sessions after attending the keynotes. Every session included several instant poll audience questions and a team of analysts presented the results immediately as the presenter paused. That was pretty cool and a nice touch to connect presenters with the audience.


I should also note that this was neither a user group meeting nor a selling opportunity. The presenters for the most part were vendor-neutral and talked about using data in general, not Health Catalyst’s products in particular. I also applaud the company for really thorough preparation right down to the minor points of quality of the handouts, stage setup, and food and break logistics. Also a high point was distribution of an internally written book that I’ll be reading cover to cover. They really have a lot of good information to share that transcends their products alone.

Some of the memorable points of the conference from my perspective:

  • It’s clear that the hasty move to electronic medical records and health apps is creating more data than anyone understands. We’re at the exploratory stage, trying to figure out which of thousands of data points are relevant in predicting outcomes or triggering interventions. This is exciting. We are surrounded by data that we don’t yet know what to do with, but the first glimmers of success are coming out.
  • A lot of people, including many of healthcare’s leaders, aren’t convinced that the industry should be data driven. Not only does the “medicine as an art vs. a science” argument arise, but leaders often have personality types that value bold decisions based on emotion, history, gut instinct, leading through relationships, and valuing consensus over facts. As was said several times in the conference, it takes courage to use data, especially when it tells us something we don’t want to hear or that requires unsavory actions.
  • Becoming a data-driven organization requires two attributes. The first is fairly simple from the non-IT point of view – collecting and analyzing the information. The second is having the organizational willpower to do something with it. Facts alone don’t change anything – leadership is required.
  • Better care costs less. Analysis nearly always shows that the highest-cost organizations deliver lower-quality care. The upside of this is that we can improve care and outcomes without spending a penny more than we already do as a society, provided we have the will to do it.
  • As the unnamed keynote speaker pointed out, people mimic those who are having success. The organizations improving care and reducing cost through the use of data will find their competitors raising the bar by doing the same. Nobody wants to be in the higher percentiles of cost or the lower percentiles of quality, so as competitors eye each other warily, it’s likely that they will raise the boats for everyone.
  • Everybody has a data warehouse. Most of them don’t provide useful information.
  • You can’t selectively intervene on individual patients by using claims data. By the time you take action, the high-cost patients have costs trending back down and you’ve missed the opportunity.
  • People seem to love QlikView as a data analysis and presentation tool. I noticed several presenters from provider organizations were using QlikView dashboards.
  • An interesting thought from one presenter: “We don’t take a quality assurance or compliance approach.” In other words, it’s not effective to chase the 2.5 percent of outlier providers. Instead, move the 80 percent even higher since improving the already-good majority has a much greater overall impact.
  • The maturity progressions looks like this: data reporting –> data analysis –> decision support –> predictive analytics.
  • “Predictive analytics without actions an interventions are useless.” You can predict things you don’t care about or are reluctant to act on.
  • The most relevant health factors involve socioeconomics. Healthcare delivery organizations can’t fix those.
  • The wisdom of crowds still has value even in an analytics-driven organization.

I give this conference a high grade. The logistics were superb, the size and scope was just right, the value was significant, and the speakers were well chosen and interesting.


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

More news: HIStalk Practice, HIStalk Connect.

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September 27, 2014 News 3 Comments

Morning Headlines 9/26/14

September 26, 2014 Headlines No Comments

Intermountain Healthcare Partners with Cerner to Provide Clinical Governance for Leidos Partnership for Defense Health

Intermountain Healthcare joins Cerner, Accenture, and Leidos on their joint-bid to win the DoD EHR deal, making Cerner the only vendor with a prominent health system listed as a contributing member.

Premier, Inc., eHealth Initiative survey suggests many ACOs lack mobile applications and face high costs

A survey of 62 ACOs find that 95 percent are experiencing significant problems integrating data across disparate systems, and that 90 percent cite cost and ROI of health IT solutions as a barrier to adoption.

Workgroup for Electronic Data Interchange ICD-10 Survey Results

A survey of 514 providers, vendors, and payers finds that while some progress has been made in preparation for the ICD-10 transition, most organizations have slowed, or completely halted, preparation efforts.

MEDITECH: Form 10-K Annual Report

After an 11-month delay in financial reporting due to revenue recognition issues, MEDITECH files its 2013 year end results: revenue fell three percent to $579 million, while net income rose slightly to $133 million.

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September 26, 2014 Headlines No Comments

DoD EHR Update from Dim-Sum 9/26/14

September 25, 2014 News 2 Comments




Between 2000 and 2003, Harvard Business School published a case study on Toyota industrial engineering processes in a hospital. Toyota collaborated with Beth Israel and LEAN Healthcare was born – now that was a great and interesting collaborative. Well defined and the results were quantifiable!

Collaboratives can add value; even ones that may not sound great at first could prove to define and refine standards, improve care, and actually enable better quality controls for care. If you like collaborative approaches, take a look at what has been done between Deloitte and Northern New England Accountable Care Collaborative (NNEACC). The solution is called Insight. After mentioning that new collaborative, I cannot help but remember a strange and poorly constructed one. How can anyone forget the ill-fated relationship between Philips and Epic that ended in 2006?

I can think of one specific collaborative that has promised the world and delivered almost nothing (see NwHIN). However, after a cursory read of the DHMSM Team Leidos article about a collaborative effort linking Cerner’s mega client Intermountain Health on governance structure, I began to think of what other collaboratives I would want to accentuate and/or at least commoditize so that I might differentiate my team to compete for the DHMSM opportunity. IBM will certainly throw in an Epic-esque client that has provided the groundwork for improvements across the Epic stable of solutions. I even think CSC and Allscripts might find their favorite client pet co-development.  I think I like Collaboratives.

One has to wonder, what was the primary edict for the collaborative, and what measurable outcomes have been reported – indicating value? To what extent have the monies invested into the collaborative been shown to improve profitability or improve PQRS results? I am not against collaboratives so much as I have a real desire to understand how some of them were stood up and made financially viable, why some dissolved, and most evolved with grand entrances into the market only to die a death of irrelevance. I think I like Collaboratives.

I for one like the New York eHealth Collaborative and the Massachusetts eHealth Collaborative, and not just because they have the word collaborative in their name. I think they are practical entities that leveraged historical regional extension centers, where money was initially provided by public funds and, through attrition and maturation of models and adoption challenges, the collaboration actually had to collaborate. They had to collaborate to survive. These collaboratives had to figure out smart ways to make their collaborative viable. Their challenge, unlike Intermountain Health (for Cerner) or Kaiser (for Epic), is that they had to work with disparate and competing entities, clinicians that were not incented by what their crosstown rivals did. The collaborative’s cross regions that did not in and of themselves support huge populations, and yet they wanted to know how their colleagues worked in other parts of the state, in rural, suburban, and urban environments.

Sounds remotely like the military HIT that we have grown to appreciate and fear. I like those collaboratives because they have to work together even though they are in a “coopetition” mode. (They were built to compete, to differentiate their medical specialty, and yet they know that cooperation has to occur for a peaceful co-existence and patient-first mentality. Thus the term “coopetition.”)

Honestly, I wish Team Leidos, Accenture, and Cerner would chat up their HealtheIntent population health tool, and what can be done to improve care coordination, quantify targeted chronic-disease management, improve appropriate care measurements, lower readmissions, and provide dynamic quality measures that actually act as a catalyst for patient engagement. Maybe Team Leidos could express its thoughts on how to turn prescriptive, descriptive, and predictive analytics into actionable analytics – impacting care and quality of life? Why not share its philosophical thoughts on data liquidity and how that could be the conduit for improved EHR and research data mining? Take the time to share their approach to research – we know IBM will reference Judith’s Cogito – so compete.

Maybe I am being harsh. I guess I am all too aware of how collaboration in the federal government has not always worked out very well. The best example of a collaboration was between the VA and DoD to share – or rather to transition – the EHR for a service member en route between active duty into veteran’s care. The best analogy: “Imagine spending the day as a cub scout during a camp out, eating gummy bears, enjoying hot dogs roasted over an open flame and masticating pounds of beef jerky on the three-hour canoe trip!” That was the planning for the debacle between DoD health and VA health – now imagine being stuck in the tent all night with those boys – that is pretty much the result of DoD/VA EHR interoperability – a smelly tent!  Not sure if there is a lesson in that story, but after reading it aloud, I smiled.

The good news is that at least DHMSM competing teams are looking to grab practical experience and applying it to the DoD HIT environment. Any collaboration with organizations that embrace HIT standards is a great thing. Any collaboration that shows that the HIT development vendor actually possesses a veracious understanding of governance structure – bully for them. Any collaboration that can accentuate the divine path to full-on proactive adoption, well then … that is Heaven. I like the move, and expect to see a lot more collaborating.

Inasmuch as I like the collaboration with Intermountain Health, I really would like to hear more about lessons learned from Accenture’s effort in Singapore. Cerner should express lessons learned from its NHS efforts. After all, Cerner had to work with Fujitsu (sort of the equivalent of our service integrators in and about the Beltway). Fujitsu is a less-than-stellar example of HIT consulting talent that was appointed by the NHS to implement, integrate, and manage the regional program. Maybe a white paper on nexus process and data touch points that could improve continuity of care with an eye on improving outcomes and lowering readmissions would be helpful and germane.

DHMSM is about transition and data liquidity. The DoD will not get excited with the commercial version of efforts to move from fee-for-service to value-based care. However, the DoD will perk up and pay attention to care coordination – so focus on the client and similar client experience and their deficits, lessons learned, and what new approaches improved adoption and workflow. One should remember that the DoD has stated on several occasions – mostly during Hill meetings – that the DoD does want to be more innovative like Kaiser (code for Epic). Cerner probably sees Intermountain Health as its Kaiser, so why not leverage that as a collaborative? I just hope Cerner can provide the depth of white papers and analysis of pre- versus post-Cerner in Utah and a lesser extent Idaho. That would be good news for the DoD.


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

More news: HIStalk Practice, HIStalk Connect.

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September 25, 2014 News 2 Comments

News 9/26/14

September 25, 2014 News 1 Comment

Top News


Intermountain Healthcare (UT) joins Cerner and Leidos in their bid for the DoD’s new EHR system. Intermountain will provide clinical governance of solutions and workflow to be proposed for the $11 billion Defense Healthcare Management Modernization Initiative (DHMSM). Intermountain is in the process of implementing Cerner’s EHR and revenue cycle solutions across its 22 hospitals and 185 clinics. The move is no doubt yet another feather in the cap of Cerner President Zane Burke, interviewed this week in the local paper: “It’s a really interesting time. We have a lot of work left in front of us, but I love the position we’re in and the clients that we have on the journey with us. It’ll be a lot of fun.”


Dim-Sum, HIStalk’s intrepid DHMSM insider, shares always entertaining and thought-provoking insight into the Intermountain “collaborative.” A snippet:

“After a cursory read of the DHMSM Team Leidos article about a collaborative effort linking Cerner’s mega client Intermountain Health on governance structure, I thought of what other collaboratives I would want to accentuate and/or at least commoditize so that I might differentiate my team to compete for the DHMSM opportunity. IBM will certainly throw in an Epic-esque client that has provided the groundwork for improvements across the Epic stable of solutions. I even think CSC and Allscripts might find their favorite client pet co-development. I think I like collaboratives.”

Reader Comments

From Chris Jaeger, MD: “Re: Sutter Health’s HIE discussions with Orion Health. As Sutter Health’s CMIO and executive sponsor of its HIE efforts, I can state without a doubt that the following post is false:
From Deal Breaker: “Re: Sutter Health. Stops discussion with Orion Health after its HIE project goes on for nine months. …”
Our collaborative relationship with Orion and related HIE efforts have never stopped – to the contrary, we continue to make great progress while also actively planning the next phases of establishing robust data exchange with those that share in the care of our patients.”

HIStalk Announcements and Requests

This week on HIStalk Practice: Athenahealth looks for the next great startup. TekLinks partners with Greenway. Doximity goes live in Utah. Physician practices in Texas take home quality improvement award for use of HIT. Physicians feel slighted by CMS thanks to attestation "glitch." costs more than originally thought. Physician executives have options when it comes to standing desks. Thanks for reading.

This week on HIStalk Connect: Dr. Travis analyzes the non-traditional roles that cloud-based computing has found in healthcare thus far, and speculates on its future. Researchers in Paris are working with 3-D video cameras to create virtual reality-based surgical training aids. Virtual visit provider Teladoc raises a $50 million Series C.

Acquisitions, Funding, Business, and Stock


Allscripts and Citra Health Solutions (formerly Orange/MZI) announce a partnership to make their services available to each other’s customers. Citra, which provides consulting services and technologies for providers and payers, unveiled its new name and branding at the Allscripts user group meeting last month.


ZirMed acquires predictive analytics vendor MethodCare and announces plans for a Chicago-based Healthcare Analytics Center of Excellence led by MethodCare staff. Moving forward, MethodCare will operate under the ZirMed name.


Conifer Health Solutions agrees to acquire physician practice business solutions vendor SPi Healthcare for $235 million. SPi CEO John O’Donnell will join Conifer’s senior management team, reporting to President and CEO Stephen Mooney. The transaction is expected to close in Q4 2014.



North Philadelphia Health System (PA) selects Medhost’s inpatient EHR for implementation at St. Joseph’s Hospital and Girard Medical Center.


Beaufort Memorial Hospital (SC) selects the Access Passport online forms solution to take its paper-based accounts payable, human resources, and administrative documentation processes digital.

Announcements and Implementations


Community Hospital (NE) goes live on a patient portal from Relay Health.


Children’s Healthcare of Atlanta joins the Georgia Health Information Network. CHOA has integrated GaHIN’s Georgia ConnectedCare product into its Care Everywhere HIE application, which it launched earlier this year to facilitate data sharing with other providers using Epic.


Kennedy Health System (NJ) adopts the MedAptus Professional Charge Capture Solution for hospitalists at its three acute-care facilities.

image announces the availability of the MyMedicalRecords PHR to its customers. The PHR will offer travelers access to their medical records and such documents as passports, birth certificates, immunization records, and insurance policies.

Practice Fusion announces that its customers will soon be able to order, manage, and receive lab test results within its EHR through Quest Diagnostics. Physicians will also have the option to share test results with patients through the Patient Fusion portal.

Research and Innovation


A survey of 62 ACOs reveals that poor interoperability between organizations remains a big barrier to improving clinical quality. Additional findings include:

  • 100 percent of respondents find access to data from external organizations challenging.
  • 95 percent find interoperability of disparate systems to be a significant challenge.
  • 90 percent feel the cost and ROI of HIT has become a key barrier to further HIT implementation.
  • 88 percent face significant obstacles in integrating data from disparate sources.
  • 83 percent report challenges integrating technology analytics into workflow.


WEDI releases the results of its ICD-10 Industry Readiness Survey, which finds that vendors, payers, and providers have made some progress in preparing for the October 1, 2015, transition, but not nearly as much as likely needed for a glitch-free switch.



Jim Dowling (QuadraMed) joins Qpid Health as vice president of sales.


Michael McDermott, MD (Radiologic Associates of Fredericksburg) takes on the role of CEO at Mary Washington Healthcare (VA) beginning January 1, 2015.


Bob Taylor, DO (Greenway) joins Clinical Architecture as CMIO.


Ryan Witt (Juniper Networks) joins ClearDATA Networks as vice president of growth and innovation.


Steven Steinhubl, MD (Scripps Translational Science Institute) joins Vantage Health as chairman of the board.



This article covers the debut of Spruce, an app that lets users privately share photos and medical information with dermatologists, and then receive in-app treatment. Baseline, Cowboy Ventures, and Kleiner Perkins Caufield & Byers contributed $2 million to the launch in initial seed round financing.



Samsung, the Children’s Fund, and Columbia University announce at the 2014 Clinton Global Initiative Annual Meeting a two-year partnership to develop the Samsung Innovation Center at the Children’s Health Fund. The center will focus on advancing access to and quality of healthcare for medically underserved children through telehealth and other strategies.

Sponsor Updates

  • Intellect Resources describes Ochsner Health System’s (LA) challenges and results of its Epic implementation.
  • Connance will share how the University of Rochester Medical Center increased its charity care dollars while reducing bad debt during the HFMA Region 2 Fall Annual Institute October 22-24 in New York.
  • ReadyDock discusses the vulnerability of mobile devices to virtual and pathogenic attacks in a recent blog post.
  • Aprima and First Databank offer electronic prior authorization through Surescripts connection.
  • Etransmedia shares how a pediatric cardiology practice was able to reallocate resources after working with Etransmedia’s RCM team to automate its front office.
  • Billian’s HealthDATA shares 10 recent healthcare CIO placements.
  • CareSync rolls out V2.5, which combines wearables data with medical records using integrations through Validic partnership.
  • Craneware will host its first Revenue Integrity Summit October 14-16 in Las Vegas.
  • Greenway becomes the first ambulatory information provider to have a solution recognized as a Validated System by Healtheway’s eHealth Exchange Product Testing Program.


EPtalk by Dr. Jayne

Our hospital recently hosted a healthcare career day for middle school students. We’re in an economically depressed part of town with some serious socioeconomic issues, yet fully realize we’re going to need dedicated and well-educated healthcare workers to deal with the challenges we’ll continue to face. The goal of the day was to expose them to various opportunities either directly in or supporting healthcare. They were able to visit various areas of the hospital, including sterile processing, the laundry, patient care floors, engineering, and an operating room.

Some students were grossed-out by the idea of direct patient care, but were interested in engineering or IT, which is a good thing. It takes an army of people to keep an institution of our size going and often those jobs are independent of patient census or case mix, which is a good thing for job security. The highlight of the day for many was being able to see one of the air ambulances land and speak with the flight crew.

As a member of hospital administration, my role was to shepherd a group of students through various stations set up throughout the hospital, where they could talk directly to staff and learn about their jobs and how they contribute to the healthcare team. As is predictable with students in that age group, frequent questions included: “What’s the grossest thing you’ve ever seen? What’s the worst injury you’ve ever seen?” My favorite question was, “Is the stuff that happens on Grey’s Anatomy really true?” which made me wonder why a parent was letting a 10-year-old watch a show about sex-crazed doctors.

At one point, the air ambulance pilot received a question about emergency situations. He told the student his question was in the top 10 list of things he didn’t want to experience, to which the student responded “What’s number one?” I had to give him full credit for that one. I kind of tuned out after that because I was thinking about what I’d put on my own top 10 list of things of things I never want to happen.

I’ve experienced some things in my IT and practice careers that would definitely make that list:

  • Someone accidentally activated the fire suppression system at our corporate data center. Because we were using Halon, the building had to be vented by the local fire department with their positive-pressure ventilation equipment. This took about eight hours for a building the size of our data center. Unfortunately, our “hot backup” failed due to a defective network switch, requiring all practices to go to paper.
  • A local road crew cut the T1 line to my office. Luckily, we equipped key staff with wireless cards and network hot spots, so it wasn’t that big of a deal.
  • With my first EHR, the clinical documentation workflow went through a “locking” process as the provider finalized the note. This was after the provider reviewed the documentation on screen. Unfortunately, during the locking process some kind of character limit went into effect, causing the documents to truncate. When patients returned for their follow-up visits, their plans (at the bottom of the documents) were missing critical elements. Nothing makes your blood run cold like reading “Counseled patient on…” and having that be all that remains of your highly detailed patient plan.
  • Vendor sunsets a product that actually supports your workflow and that your staff likes, transitioning you to a product that is not yet ready for prime time. This has now happened to me twice.

None of these are quite as scary as having rotor failure on your helicopter or having the landing pad collapse underneath you, but in our world they’re pretty unnerving. What’s on your top 10 list of things you never want to happen? Email me.


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

More news: HIStalk Practice, HIStalk Connect.

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September 25, 2014 News 1 Comment

HIStalk Interviews Matt Scantland, Co-Founder, CoverMyMeds

September 24, 2014 Interviews 1 Comment

Matt Scantland is principal and co-founder of CoverMyMeds of Columbus, OH.


Tell me about yourself and the company.

My partner Sam Rajan, who’s a pharmacist, and I started CoverMyMeds to address prescription abandonment. We learned about the problem when we built a prior authorization system for a health plan. 

The idea for CoverMyMeds came to us when we looked at the fact that from the perspective of a doctor, it really doesn’t matter how good the prior authorization process is for any one health plan. It’s just one of dozens that the doctor needs to navigate. The idea of CoverMyMeds was, let’s create one-stop shopping so that the doctor can use one process to submit a prior authorization for any drug to any health plan.


Your Inc. 5000 numbers are pretty impressive with $19 million in 2013 revenue and 73 employees. Did you plan for that or did you just happen to hit on a niche that took off?

We’ve been thrilled with how things have gone. We’re growing over 100 percent a year since we started. We’ll do about $50 million in sales this year and have about 130 employees.

I wouldn’t say it’s any genius on our part. The prior authorization process is just incredibly painful for everyone that’s involved. The doctors and also the health plans have been looking to improve this process for decades. Working for them, we were the first to be able to create an electronic process that scales.


It seems you would have competition from someone like Surescripts if business is that strong. Do you have competition?

Surescripts launched a product at the beginning of the year that’s a little bit different than ours. Whereas our process works for any payer, whether the payer participates electronically or not, Surescripts is launching something that works just with payers that connect to Surescripts.

So far, because the PA process has not been something that’s electronic in the past, the value proposition of our service has tended to be much stronger for the participants, where with one integration in the electronic health record or in the pharmacy dispensing system, the PA can be submitted to any payer. We also lead the industry in connecting electronically to the payers, but the process works across the board.


It’s a fascinating business model that drug companies to pay for the service, which they fund from the revenue of what otherwise would have been unfilled prescriptions. Nobody who uses the service pays for it. How do you get the word out to doctors and pharmacies that it’s available and it’s free?

Being free helps. [laughs] You’re right, the drug companies and now the health plans pay for our service. This is a business that has what we call network effects, which means that the more people that use it, the better it gets for everyone.

We have a huge pharmacy network. Almost every pharmacy in the country, including the big chains, uses our service. When they initiate a PA, if the doctor’s office isn’t already a user, we invite them to become a user. Over time, we’ve built that physician network to more than 100,000 distinct providers. It creates that viral process that allows us to grow quickly as a network business.


You’ve connected electronically to EHRs and pharmacy systems. Is that work finished?

That’s really the future of our company, but it’s pretty new. We started in the pharmacy, which is where the PA process begins today. All over the country, the first time anyone tends to think about the prior authorization is after a claim rejection in the pharmacy. 

Today, we’re integrated into almost every pharmacy in the country, right inside the pharmacy management system. We’re looking to do the same thing in the electronic health records, although that’s a new area for us.

We announced a partnership with DrFirst, where we’ll make the PA process available at the point of prescribing. We’ll also connect those pharmacies into the DrFirst system so that PAs initiated in the pharmacy can be sent to DrFirst’s doctors electronically. We’re also working with most of the other electronic health records, so I’m trying to do that same type of an arrangement. We’ve come up with a financial model where we can actually pay the EHRs to do that work. One integration is something that works across the board for every payer.


You offer APIs and also widgets for web pages of both health plans and manufacturers, which is pretty smart to get people to have access to your service through the other sites of the companies that you work with. How much technology is involved in what you do?

CoverMyMeds is really a software company. We don’t do any actual PAs ourselves. Instead, we provide the tools that let providers automate their process in a self-service way.

We provide the APIs. That’s been the main driver of our growth for both the pharmacy management systems to do the integration and then also for the electronic health records. All of those systems can integrate using NCPDP standards or a REST API that can reduce the work effort needed to actually do that integration.


It will surprise people that there’s a company in a very specific, almost obscure niche that has grown so large and is still growing. Do you think you’re under the radar?

Yes. We absolutely are under the radar. But when you look at prior authorization, this is a problem that happens 200 million times a year. This is daily life in a pharmacy or a doctor’s office — 200 million patients that get their claim rejected and potentially will go untreated if this prior authorization process isn’t handled.

While it’s under the radar, it’s really contributing to that $350 billion or so problem of medication non-adherence. In a lot of ways, automating the PA process is the missing value proposition in e-prescribing. It doesn’t make a lot of sense to have an electronic prescribing process if the doctor is just going to then go deal with a fax or a phone call with the health plan. This has become something that’s much more top of mind as life goes on here.


A lot of software startups are trying to find a pain point they can resolve without competing with big companies like EHR vendors. What advice would you have for them?

Listen to customers and solve a big problem. Ideally, do that in a way that doesn’t involve taking a dollar from someone else.

What has really worked well for CoverMyMeds is that this is a way to remove administrative waste from a process without cutting reimbursement to a doctor, pharma company, or health plan. Because it’s truly a win-win for all participants in the market, we have alignment and the help of large companies to make this thing get big.


Your website says you have a chef that creates lunch for employees every day, which is a kind of a Silicon Valley move, but you’re in Ohio. What’s it like working there?

[laughs] We think we’re one of the best places for technology and business people to work in Ohio. We consistently are winning these best workplace awards.

As a software company, we’re nothing without the people. We look at both how do we give a lot more value than our customers expect, and then also how do we give our employees a lot more than they expect? That as a result of that has let us get some great people and then they stick around with us.


As companies grow, there’s always that decision about what comes next – do you acquire somebody, do you get acquired, do you roll out other offerings. Where do you see the company going from here?

Prior authorization seems like a very niche thing. It kind of is, but at the same time, it’s also right at the intersection where a doctor is making a decision about the tradeoffs between the cost of a treatment and its efficacy. We think that that’s a fundamental problem in healthcare.

We have built both the network and the connectivity and then also the relationships with pharma, payers, pharmacies, and providers. We think we can help doctors make more intelligent consumption decisions. We think is a very large opportunity, starting with drug, but helping to get to more personalized medicine in terms of prescribing, and then also other procedures as well.

Because of the growth of the size now, we have a lot of interest from the financial and strategic partners. We’re always willing to listen. We think this is a very big standalone company on its own.


What else could be done with the network you’ve created? You have an athenahealth-type model.

That’s right. We look at athena as a great big brother of the direction that we’re looking to go.

There are very obvious applications. First of all, we’re fundamentally solving the first step in patient adherence, which is get the patient on their drug. The next challenge then is keeping them on the drug. That’s an adherence angle that many of our customers are asking for help with. That’s something that that both pharma and health plans are interested in. We think there are interesting collaboration opportunities there.

The other thing that we’re very focused on right now is helping the electronic health records make this PA process something that happens at the point of prescribing. Right now, if you think about e-prescribing, what you basically have is a shopping cart. The doctor orders a drug and the patient may or may not end up being able to actually get that drug. We think that putting this PA process at the point of prescribing allows it to move from what’s an exception process to something that’s much more decision-supporting for the physician. We’re very focused on helping the doctors and the EHRs achieve that.


Do you have any final thoughts?

I’d really like to thank the HIStalk community and you guys. You’re a huge part of my daily reading list. I don’t think there’s a more credible and important intelligent source as HIStalk in the whole industry. I’d just like to hear from people about what they think.

We’ve been thrilled with how things have gone. In a lot of ways, this business looks a lot more like a consumer Internet company than a traditional enterprise software company because of that network effect. We’re solving something that for a frontline healthcare person is a huge struggle. That’s been one of the most fun things, really, something that truly can impact hundreds of thousands of providers that make their life better. We just celebrated that 10 million patients have now gotten the drugs they needed that they wouldn’t have otherwise. At the end of the day, that’s what keeps us coming in in the morning.

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September 24, 2014 Interviews 1 Comment

Readers Write: The Consultant and the Investor Look at Cerner’s Acquisition of Siemens

September 24, 2014 Readers Write 2 Comments

The Consultant and the Investor Look at Cerner’s Acquisition of Siemens
By Lynn Vogel, PhD


The publication of the recent HIStalk interview with Marc Grossman and a post by Ben Rooks offer a rare opportunity to learn about the different perspectives of consultants and investors using the Cerner acquisition of Siemens as a case study.

Full disclosure: I’ve known Marc (the Consultant) for close to 20 years and I consider him to be one of the top HIT consultants in the business today. I don’t know Ben (the Investor) personally, but was so impressed with his discussion of the MModal acquisition several months ago that I started an email exchange and have deep respect for his understanding of the financial aspects of HIT.

But the perspectives of the Consultant and the Investor couldn’t be more different. Here are some noteworthy excerpts from the Marc Grossman interview and from Ben Rooks’ recent “From the Investors Chair.”

From the Consultant

  • A lot of it’s going to depend on where the Siemens client is.
  • I believe Cerner is buying Siemens for intellectual property. On the patient accounting side, I think they’re also looking at the RCO base that Siemens has, which is a great revenue stream for them.
  • Given Cerner’s history and the industry’s history over the last 20-30 years, Siemens Soarian and Invision product support is going to go downhill.
  • I think they probably won’t sunset it officially for at least 10 years, just because I know Siemens does have numerous contracts which are going out 10 years.
  • Like we’ve seen with many other vendors that purchased other systems, Cerner is clearly not going to put R&D money into two patient accounting systems and two clinical systems if they have an integrated system now.
  • I just don’t see any indication that Cerner is going to continue the development of any of the Soarian or Invision products.

From the Investor

  • Cerner is now the clear sector leader and will enjoy mammoth cross-selling opportunities given the product fit.
  • This was a good use of both the cash hoard Cerner had built up on its balance sheet and its high-multiple stock, allowing the deal to be almost instantly accretive – especially with the $175 million in pre-tax synergies the company guided to in its press release.
  • Cerner’s shares are up almost 10 percent as I’m writing this post, more than twice the S&P — Ms. Market seems to be more excited.
  • The vast majority of analyst commentary has been positive and we here at the Chair are fans of the purchase as well.
  • The only thing that gives me pause as a long time Cerner watcher (and fan) is that the company has zero history of large-scale M&A and the sector has not been kind to such large-scale bets in the past.
  • What’s especially noteworthy here though is that the cultures of the two companies are literally more than an ocean apart
  • That said, the price Cerner paid clearly de-risks the acquisition, and Cerner is known for its strong culture

The Consultant starts with the impact on the client. How the customer base responds will depend on where they are currently with their HIT implementations. Will customer support for Invision and Soarian go downhill now? Will any level of customer support for Siemens’ products last beyond 10 years? Will there be any R&D for Siemens products going forward? Finally, the question about whether Cerner will “continue the development of any of the Soarian or Invision products?”

The Investor is looking at the Siemens acquisition from an almost purely financial perspective. Is this a good use of Cerner’s cash? What’s the impact on the stock price? What’s Cerner’s experience with large-scale acquisitions? How will the cultural challenges be addressed? In general, this looks like a “good deal.”

In some ways, the comparison of these two perspectives underscores one of the major challenges of HIT today. The investors are looking at the money, while the customers are looking for continued product development and ongoing support.

Unfortunately, the boards of most HIT companies are dominated by investors, with little input by those who understand either healthcare or information technology (Ben’s earlier analysis of the MModal situation is an excellent example). What’s missing, specifically?

  1. Looking under the covers. From an IT perspective, the Cerner acquisition of Siemens demonstrates again that acquisitions too often proceed without understand any of the underlying IT challenges. The code bases are different, the database architectures are different, the standards for code libraries are different, etc., etc. Recall the Allscripts acquisition of Eclipsys. A big selling point about this deal was that they were both based on Microsoft tools are architectures. We now know how that turned out. Siemens’ financial products are generally considered to be stronger than Cerner’s, but integrating disparate product suites is a challenge that has eluded almost every previous merger of HIT companies.
  2. Understanding how IT decisions are made by healthcare customers. Boards often have little understanding of the healthcare business and even less about how IT decisions are made in healthcare. It can be a long, slow, and often tortuous process (accelerated certainly by recent federal incentives) with lots of customer concern about long term support (note Marc’s observation that even lab systems typically last a decade or more). As a result, assumptions about how quickly financial returns can be generated are often way off the mark and the result is the demise of the acquired company.
  3. Leverage and financial returns dominate. Cerner is probably looking at the Siemens’ customer base almost as a captive audience, there for the picking and over time replacing their Siemens products with Cerner’s. We can only assume that Siemens reached the same conclusion about the SMS customer base at the time of that acquisition, and we know how that turned out. On the other hand, simply eliminating a competitor over time is a strategy that many companies both inside and outside healthcare have found to be successful. But taking Siemens out of the marketplace may also leave Epic is a much stronger position.

There are lots of discussions about whether the healthcare industry is really all that different from other industries. Even Drucker noted its extraordinary complexity. But when companies make decisions without a deep understanding—at the executive and board levels—about the technology, about what does make the healthcare industry unique, and worry more about the money than the customers (often not realizing that it in the end it is the customers who provide the revenue), we have a better understanding of why the HIT business is so challenging and probably filled more with company failures than successes.

I would argue that one of the solutions here is more Board level input from experienced HIT professionals. Across the industry, we see company boards with investors and occasionally clinicians, but virtually no HIT professional role.

Full disclosure: I was elected to the board of Glytec, an HIStalk sponsor, due to my specific HIT experience from inside the industry. During the course of my term, I have learned an enormous amount from the investors and the clinicians on the board and from the feedback I have received, it seems that my contributions as an experienced HIT professional have been valued as well.

There is an enormous amount of HIT expertise available that companies could use, but seldom do. This includes former (occasionally retired) CIOs, CIOs who are able to serve on boards while continuing full-time IT responsibilities, and consultants, particularly those who have experienced HIT from inside healthcare organizations, etc. Smart HIT companies would do well to take advantage of this talent to contribute to the success of their business.

Lynn Vogel, PhD is a principal with LH Vogel Consulting, serves on the board of Glytec, is a member of Next Wave Health Advisors, and serves as a senior advisor to Sophic Alliance.

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September 24, 2014 Readers Write 2 Comments

Morning Headlines 9/25/14

September 24, 2014 Headlines 1 Comment

New report projects a $5.7 billion drop in hospitals’ uncompensated care costs because of the Affordable Care Act

HHS claims in a report that hospitals will see a $5.7 billion drop in uncompensated care in 2014 due to the ACA, “based on an estimated 10.3 million decrease in the total number of uninsured and an estimated 8 million increase in the number covered by Medicaid.”

DMH may be on the hook to repay $900K: Government audit uncovers failures of compliance for year 2011-12

Drew Memorial Hospital of Monticello, AK will likely have to pay $900,000 of its Stage 1 MU incentive money back to the government after failing to pass an MU attestation audit.

Hospitals Cut Costs by Getting Doctors to Stick to Guidelines

Researchers from Christiana Care Health System (DE) found that they were able to cut costs associated with non-recommended use of cardiac monitors by 70 percent after embedding American Heart Association protocol reminders in their EHR.

A Health Care Success Story

Farzad Mostashari, MD and his investment partner Bob Kocher, MD co-author an op-ed in the New York Times highlighting the cost savings and improved outcomes seen in the small community of McAllen, TX, once famously pinpointed as the most expensive place in the US to receive healthcare, since its physician practices formed an ACO.

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September 24, 2014 Headlines 1 Comment

Morning Headlines 9/24/14

September 24, 2014 Headlines No Comments

HCA to Purchase PatientKeeper

164-hospital health system HCA acquires PatientKeeper, which it will roll out as an overlay for physicians using its legacy Meditech system.

ACO bill expands telemedicine use

Diane Black (R-TN) and Peter Welch (D-VT) introduce bipartisan bill H.R. 5558, the ACO Improvement Act, which would enable ACOs to expand remote patient monitoring platforms, and allow them to use “share-and-forward” technologies that improve medical image sharing.

Philips Plans Breakup to Focus on Health, Consumer Goods

Royal Philips will split itself into two companies, one focused on lighting, which generates $9 billion in sales annually, and the other on consumer goods and healthcare, which generates $19 billion.

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September 24, 2014 Headlines No Comments

News 9/24/14

September 23, 2014 News 1 Comment

Top News



Hospital operator HCA announces that it will acquire privately held physician systems vendor PatientKeeper. Terms were not disclosed. I spoke to PatientKeeper President and CEO Paul Brient ahead of the announcement. “HCA is a longstanding customer of our view-only portal, our clinical review tool,” he said. “Now HCA will deploy all of our software – CPOE, clinical documentation, and medication reconciliation – over top of their Meditech systems. They will invest to make it even more useful to their doctors.” Brient will serve as CEO of PatientKeeper, which will be operated as a wholly-owned subsidiary of HCA. Its 160 employees will continue to work from company headquarters in Waltham, MA, supporting the company’s 58,000 physician users. The acquisition is expected to close by the end of the year.

Reader Comments

From Garbanzo Being: “Re: HCA. Will remain on Meditech and not transitioning to Epic or Cerner as has been rumored. PatientKeeper helps extend the life of Meditech for HCA.” HCA didn’t say that specifically, but PatientKeeper President and CEO Paul Brient hinted to me that HCA likes PatientKeeper over Meditech better than Epic, suggesting that its Epic experiments have concluded and the go-forward platform will be Meditech. He didn’t mention whether HCA will do a Meditech 6.0 upgrade, the challenge of which sent them sniffing around Epic in the first place.


From King Biscuit: “Re: Office Practicum. Announced to clients that they acquired EHR/PM vendor Odd since OP is a small company and it’s a competing product. The email suggests a move away from a pediatrics-specialty product and possibly a wholesale platform change.” I don’t know anything about except that it founded by Packy Hyland, who also founded Hyland Software (now Onbase by Hyland).

From Shannon: “Re: 3M’s CAC 360 Encompass R2 (Release2). Has numerous major problems. Coders not happy using it. 3M is currently merging their 2 NLP platforms — will this be too late for ICD-10 implementation date? Will the other CAC vendors be able to capitalize on this weakness?” Unverified.

From Deal Breaker: “Re: Sutter Health. Stops discussion with Orion Health after it HIE project goes on for nine months. Is this the reason there are not any US reference sites for Orion all accounts travel to Canada and New Zealand?” Unverified. I think a site visit to New Zealand would be pretty great since I’ve heard it’s spectacular there and they (unlike much of the world) love Americans.

From All Hat No Cattle: “Re: Cernover. Don’t forget that Integris in Oklahoma (12 hospitals) is moving to Epic, too. Care New England in RI now Epic outpatient. How long until CHI moves across to Epic for their remaining sites on Cerner like KentuckyOne?” I tried to muster an argument that at least some sites have moved from Epic to Cerner, but I was just speculating since I couldn’t name any. The Cernover list is a bit one sided, so chime in if you know if an Epic-to-Cerner move that wasn’t triggered by a health system acquisition and standardization.

From Bob White: “Health 2.0. Lots of innovative companies there, although they all start to sound alike after a while.” The conference gets lots of people excited even though 95 percent of the startups there will sink without a trace because they aren’t that sharp, are underfunded, are poorly managed, or let their technology arrogance override their healthcare ignorance. I wish them all well, but I don’t have the patience to watch Darwinism in action as they desperately try to find pilot sites, customers, or acquirers before they run out of runway. My interest picks up once they hit $5 million in annual revenue because once they get that big they probably won’t disappear entirely.

HIStalk Announcements and Requests 


Welcome to new HIStalk Platinum Sponsor ZeOmega. The Plano, TX-based company, founded in 2001, offers the Jiva population health management platform to payers, providers, and value-based care organizations. A recent client success is Indiana health plan MDwise, which reduced readmissions by 66 percent and length-of-stay by 65 percent, saving $6.5 million per year with Jiva. Jiva is scalable and stable with redundancy and recovery built in and the new release adds more capabilities to support accountable care and value-based health delivery models in integrating workflow, analytics, content, and communication capabilities. The folks there would be happy to do a demo for you. Thanks to ZeOmega for supporting HIStalk.


September 25 (Thursday) 1:00 ET. Using BI Maturity Models to Tap the Power of Analytics. Presented by Siemens Healthcare. Presenters: James Gaston, senior director of maturity models, HIMSS Analytics; Christopher Bocchino, principal consultant, Siemens Healthcare. Business intelligence capabilities are becoming critical for healthcare organizations as ACOs and population health management initiatives evolve in the new healthcare marketplace. The presenters will explain how BI maturity models can help optimize clinical, financial, and operational decisions and how organizations can measure and mature their analytics capabilities.

September 26 (Friday) 1:00 ET. Data Governance – Why You Can’t Put It Off. Presented by Encore, A Quintiles Company. Presenters: Steve Morgan, MD, SVP for IT and data analytics and CMIO, Carilion Clinic; Randy Thomas, associate partner, Encore, A Quintiles Company. In this second webinar in a series, “It’s All About the Data,” the presenters will review the pressing need for data governance and smart strategies for implementing it using strained resources.

Acquisitions, Funding, Business, and Stock


Royal Philips NV announces plans to split into two companies – one devoted to lighting, the other to healthcare and consumer goods that will operate under the HealthTech name. The announcement follows in the footsteps of similar moves made by rival Siemens last year.


Community Health Center of Southeast Kansas and Health Partnership Clinic (KS) select eClinicalWorks EHR and RCM for their 12 combined clinics.

Catholic Health Services of Long Island (NY) chooses Connance predictive analytics and vendor management technology.

Sheltering Arms Rehabilitation Center (VA) deploys Strata Decision’s StrataJazz as its financial platform.

Announcements and Implementations


North Country Hospital becomes the first in Vermont to go live on the state HIE. Larger hospitals like Fletcher Allen Health Care will be online by the end of the year.


Waterbury Hospital (CT) integrates TigerText secure messaging into its Cerner EHR. The hospital has also been in the news due to rumors of a possible takeover by Tenet Healthcare Corp.

Surescripts announces the addition of four pharmacies and three EHR vendors to its Immunization Registry Reporting service.


The Bronx RHIO selects Direct secure messaging services from DataMotion for its affiliated healthcare organizations. The Visiting Nurse Service of New York and SBH Health System (NY) are among the first to use the service.


Zynx Health launches the ZynxCarebook mobile platform to help streamline coordinated care efforts between inpatient and after-care providers.

Government and Politics


White hat hackers from the HHS inspector general’s office report that their attempts to break into earlier this year alerted them to a “critical vulnerability.” Their attempts to exploit it were thwarted due to defenses already in place.


Representatives Diane Black (R-TN) and Peter Welch (D-VT) introduce the ACO Improvement Act. If passed, the act would permit ACOs to use remote-patient monitoring and store-and-forward technologies for delivery of images to providers far away.


Alaska’s Department of Health and Social Services files a lawsuit against Xerox for "failing to timely and adequately implement the [Medicaid payments] system and failing to timely and accurately pay Alaska providers." The state is seeking $46.7 million in damages, and has already shelled out $154 million in advance payments to providers to help see them through the Xerox delay.

Research and Innovation


Ali Parsa, MD creator of the UK-based Babylon subscription health service, announces that he is prepared to take the Babylon app to the Middle East and Africa to reach populations with little reliable access to healthcare, but high adoption of smartphones. "We are now looking at parties who have a large customer base, such as supermarkets, big public institutions, mobile phone companies, and newspapers,” he says. "If people can go into Tesco and by an iTunes card, why can’t they buy a Babylon access card?"


image image

Mark Hyman, MD (The UltraWellness Center) joins the Cleveland Clinic as director of its new Center for Functional Medicine. Patrick Hanaway, MD (Institute for Functional Medicine) will serve as the center’s medical director.


Jeff Pate (W Squared) joins Aegis Health Group as executive vice president of business development.


White House CIO Steve VanRoekel resigns to join the USAID, where he will work as a senior adviser in the fight to halt the Ebola outbreak.

image image

Doximity hires Emily Peters (Uncommon Bold) as VP of marketing communications and Peter Alperin, MD (Kelvin) as VP/GM of connectivity solutions.  


Bruce Brandes (Valence Health) is named managing director of Martin Ventures. 


ONC Chief Science Officer Doug Fridsma, MD, PhD resigns to become president and CEO of AMIA.

Announcements and Implementations


Billings Clinic (MT) is implementing just-released Caradigm Quality Improvement to identify gaps in care and make improvements in clinical workflow at point of care.



Construction company DIRTT makes news for using open-source software from the classic video game Doom to design hospital wings and office spaces. CEO Scott Jenkins says the system will help hospitals that want to reconfigure a room’s wall panel quickly for patients with different needs, or to accommodate new technology.


Apple CEO Tim Cook announces that the company’s new “spaceship” headquarters in Cupertino, CA, will be the “greenest building on the planet.” Scheduled to open by the end of 2016, the new HQ will be powered exclusively by wind and solar energy.

CompuGroup Medical locks Full Circle Health Care (ME) out of its EHR system in a billing dispute. The financially struggling practice admits that it stopped paying its maintenance fees 10 months ago after CompuGroup bought its original vendor HealthPort and increased monthly fees from $300 to $2,000. The practice has moved to a new EHR and wants access to its old system for 48 hours to copy patient records that will otherwise be unavailable, putting patients in danger, but says CompuGroup installed a “phone home” kill switch without its knowledge that won’t let the practice log on even in read-only mode. CompuGroup makes the analogy that people who don’t pay their electric bill have their power shut off eventually. Meanwhile, the patients get to enjoy being used as human shields as the vendor and customer bicker. Someone should have read their contract more closely before signing it, I suspect.


Weird News Andy summarizes this story as “Three’s a Crowd.” A Florida woman pays $20,000 to have a third breast added, saying she wants to make herself unattractive to men so she wouldn’t have to date any more (as WNA says, hasn’t she heard of just turning men down?) The real reason is likely her stated dream of starring in an MTV reality show, with possible titles being rich in punning opportunities. WNA notes that the story has been declared a hoax (not surprising given the obviously ‘shopped picture), but that shouldn’t stand in the way of its entertainment value.

Sponsor Updates

  • Arcadia Healthcare Solutions will demonstrate a new version of its Arcadia Analytics solution at Health 2.0 this week. It uses Informatica technology to integrate information from 20 EHR and claims systems to report on reporting for performance management, cost and utilization analysis, and patient outreach and care planning.
  • Amerinet signs a new agreement to offer VitalWare revenue cycle technology to its members at negotiated pricing.
  • Alan Rosenstein, MD, an expert in disruptive physician behavior, posts a PerfectServe article titled “Emotional Intelligence – Understanding Patient, Staff, and Physician Needs.”
  • DocuSign publishes a blog post titled “BAAs and Beyond: Meeting the September 22 HIPAA Deadline.
  • Shareable Ink will work with students from Bentley University on user interface design.
  • Park Place International achieves SSAE 16 Type II standards compliance for OpSus Cloud Services.
  • EClinicalWorks CEO Girish Navani joins a panel discussion at Health 2.0’s annual conference to discuss how technology is improving the patient experience.
  • US News and World Report indicates that 96 percent of Honor Roll hospitals in its “Best Hospitals and Best Children’s Hospital’s 2014-2015” use Wolters Kluwer Clinical Drug Information.
  • Gritman Medical Center (ID) is live on AtHoc’s emergency communication solution.
  • Validic announces a 20 percent increase in its digital health ecosystem with new integrations including hospitals, health systems, payers, pharma, and wellness companies.


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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.



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September 23, 2014 News 1 Comment

HCA To Acquire PatientKeeper

September 23, 2014 News 4 Comments


Hospital operator HCA announced this morning that it will acquire privately held physician systems vendor PatientKeeper. Terms were not disclosed.

HCA Chief Health Information Officer Jim Jurjis, MD said in the announcement, “HCA is investing in advanced, forward-looking informatics approaches to healthcare to improve usability, quality, effectiveness, and efficiency of care. The acquisition of PatientKeeper is an important step in that direction. It gives us important influence in the layer of the electronic record that the doctor sees, creating an innovative platform for workflow improvement.”


I spoke to PatientKeeper President and CEO Paul Brient ahead of the announcement. “HCA is a longstanding customer of our view-only portal, our clinical review tool,” he said. “Now HCA will deploy all of our software – CPOE, clinical documentation, and medication reconciliation – over top of their Meditech systems. They will invest to make it even more useful to their doctors.”

Brient will serve as CEO of PatientKeeper, which will be operated as a wholly-owned subsidiary of HCA. Its 160 employees will continue to work from company headquarters in Waltham, MA, supporting the company’s 58,000 physician users.

Brient confirmed that PatientKeeper will continue to market its products (Charge Capture, Clinical Results Review, CPOE, eSignature, Medication Reconciliation, NoteWriter, and SignOut)  to prospective clients. “There will be no change except the board members will be from HCA,” he said.

The acquisition is expected to close by the end of the year.

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.


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September 23, 2014 News 4 Comments

Morning Headlines 9/23/14

September 22, 2014 Headlines No Comments

Billing dispute leads to blocked patient data in Maine

A small practice in upstate Maine is fighting back after its EHR vendor suspends access to its hosted EHR for falling 10 months behind on its $2,000 monthly maintenance payments.

AMIA welcomes Douglas B. Fridsma, MD, PhD, as New President and CEO

Douglas Fridsma, MD, PhD, and Chief Science Officer with the ONC will leave his position to become the CEO of the American Medical Informatics Association.

W.H.’s Steve VanRoekel to take tech to Ebola fight

White House CIO Steve VanRoekel resigns to join the USAID, where he will work as a senior adviser in the fight to halt the Ebola outbreak.

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September 22, 2014 Headlines No Comments

HIStalk Interviews Michael Oppenheim, MD, CMIO, North Shore-LIJ Health System

September 22, 2014 Interviews 3 Comments

Michael Oppenheim, MD is CMIO at North Shore-LIJ Health System of New York, NY.


What is North Shore-LIJ doing with interoperability and HIE?

I’ll start at the end and then I’ll back up and explain the thinking that led us in this direction. 

We are making a huge investment — time, personnel, and focus — into developing an internal HIE, health information exchange. The reason we’ve done that — and I think a lot of other large integrated delivery networks have come around to this way of thinking — we were very eager participants when New York state initially put out the request for proposals to develop a number of RHIOs within the state. They’ve since consolidated — the HIEs, the RHIOs from across the state — into a single structure, SHINY, the State Health Information Network of New York. 

In the beginning, when you talked about doing internal HIE within an organization, everyone assumed that you were somehow trying to be exclusionist or not participate in the HIE. That’s far from the case. I think the state has come around on that, and many other IDNs have come to the realization that the kind of interoperability that we want to do goes much beyond what the mission and goals of the RHIOs are. 

The RHIOs are very, very much focused on getting as broad a look at patient information as they possibly can. That’s great because they help broker the politics and provide a common playing field for organizations that may be competitors in the marketplace, but are willing to jointly share data through the third party of the RHIO. You create a huge, consolidated record that people can go to and get a comprehensive look at the patient beyond just what they know from their four walls.

But there are a couple of things that HIE has come to mean to some of us that is beyond the scope of what the RHIOs or HIEs are focusing on today. One is around actionability of the data. The second is around not just aggregating and displaying data, but actually literally moving data from point to point without human intervention. 

The user experience with the standard type of HIE implementation is that the clinician first goes to the HIE or the RHIO to look up what history is there about this patient who I’ve never seen before. Then you go and you actually do your clinical documentation and order entry and everything else, in whatever transactional system, whatever EMR you happen to be using for your environment where you’re caring, whether it’s an office- or a hospital-based practice. 

There are two limitations to that in my mind. One is the intrinsic dissatisfaction with having to go to two places to look at data. The second being that the data out in the HIE is not necessarily actionable. I’m ordering a medication in my EMR and there’s a lab test that hasn’t been drawn in my office or hospital, but it’s known in the RHIO. Based on that lab test, I need a dosage adjustment or there’s a contraindication to the medication. My decision support engine doesn’t see that external data. 

Our focus has been on looking at how an HIE can bring data right to the clinician so that he or she can have one place where they do all their work, as well as have more of that data available for a decision support engine or for any rules or analytics or other things that you want to do on your data set, and have it all consolidated. 

We look at the HIE opportunity because internally, we can do a lot more. There’s a lot tighter integration and have a lot more actionability of the data by having an internal HIE that we control, that’s covered by our consents, and any number of other things that are facilitated by having an internal HIE.

We’re an Allscripts shop. We’re using Allscripts TouchWorks in the practice environment and  Sunrise in the hospital environment. We made this decision before the dbMotion acquisition and before some of the newer interoperability tools that they produced. Let’s put that off to the side for a moment.

The workflow that we wanted to enable was what we built so that when a patient comes to the emergency room, we pull a summary from the ambulatory environment. We place it into the Sunrise record, so it’s available and visible to the docs in the hospital. They don’t have to go out and look somewhere else. They don’t have to look at the HIE’s viewer, don’t have to look in the ambulatory record. It’s right there in the hospital environment.

At the same time, we use the data in some actionable ways. We’ve certainly done more sophisticated things than this, but even on the most basic level, we can fire off a notification. We can put a task notification in the task list of the primary care doc to say, do you know your patient is in the emergency room? If and when that patient gets admitted, we fire off a second notification saying, by the way, not only were they in the emergency room, they have been admitted to the hospital.

We begin to start to getting into what’s really business process management around the transition of care and moving the data for the user. Not requiring them to push it via Direct or something else — by sending off alerts and notifications to the primary doc so they can communicate with the hospitalist. That’s just one of the more basic examples.

To us, the HIE is much more of a process orchestration engine, not just simply a repository of data that someone can look at. It’s actionable. It’s delivered to the clinician when they need it, where they need it. That’s been the driving philosophy behind having an internal HIE rather than simply rely on RHIOs or outside entities.

The example I gave involves an ambulatory practice and a hospital. Certainly in some environments where you have a consolidated platform, maybe that’s not the most important use case. But even in hospitals that are using systems that share a record with their ambulatory facility, there’s always going to be other facilities in a large, integrated delivery network that’s not going to be on the common platform. We have nursing homes. We have a home care company. We have numerous other types of business entities that are relying on this flow of data so that their providers can work most efficiently in what we call the home system.

Whatever you’re used to work in, that’s where we want the payload delivered. That’s where we want alerts and notifications and things to arrive. That will be orchestrated through our HIE.


Will HIEs be challenged to provide business value to offset the cost?

If you look at where our future revenue opportunities are going to be, we’re moving away from our fee-for-service world and very much moving to the risk-based contract in a capitated world. We have numerous risk contracts with commercial partners. We’ve just launched our own insurance company, North Shore-LIJ CareConnect.

To us, orchestrating business process, eliminating redundancy by making sure that everybody’s got full access to the full corpus of clinical data, having a decision support engine that sits and looks at data and reacts to data across the entire health system … I couldn’t hand you a document today that says, “Here’s the amount of dollars I expect to improve my pay-for-performance and here’s how much I expect to cut my readmissions and here’s how much I expect to XYZ.”

But conceptually, we are all bought in that our entire financial success of the health system depends on the successful conversion to be able to do capitated and risk-based contracting. We don’t think we can do that without an HIE to coordinate the transition to healthcare managers and care navigators who identify patient activity, figure out who’s been where, get notifications when things happen that shouldn’t have happened, or get notifications when things that should have happened didn’t.

The HIE, for example, has in it the full ambulatory providers schedule. We can find if a patient has an appointment that’s been missed. We can fire off a notification out of the HIE. The HIE is so much more than information exchange.

The HIE platform also has registry function that allows us to load programs into it. If we have a heart failure program, we can either manually or automatically load in that these are all patients with heart failure that are part of this program. Or patients coming in with a certain payer. We can go into that payer registry and then we can make sure we do the right notifications to the right coordinators of those programs as either activity that should happens but doesn’t happen, or activity that shouldn’t happen but does happen, like unexpected specialist visits or ED visits or things like that. 

As an article of faith, we fully believe that in order to truly be able to coordinate care as an integrated delivery network and provide population health and be able to be financially and clinically successful in capitated arrangements or among our own insured population, the HIE has to be a critical enabler of that. I don’t have a specific financial ROI sheet that I can wave and say, “This dollar is going to be offset by that dollar,” but absolutely the direction of how the health system expects to care for patients in a longitudinal way and a holistic way requires this kind of technology.


Do you think the demands of population health management have turned the expectations for HIEs upside down? I’m referring to the RHIO-type organizations.

I’ll answer that in two ways. We’ve always had this intrinsic discomfort, as I started off by saying, that I’m going to look in point A and then point B and then point C, which is why we use the HIE as central consolidation point  to create a single, consolidated, comprehensive record which we can then push forward to the provider just in time as an encounter is about to happen. We anticipated that that kind of clinician reaction had to be overcome. That’s exactly why we did the things we did — get it in their face and not make them go hunt for it.

But how and when will the RHIOs retool? I think they have to. It’s really not as much their onus as it is the onus of the providers who are going to be held to different types of accountability standards to take on the responsibility to go search and find all of that data. That really is putting a tremendous burden on your providers. The value proposition goes up, but it’s on the back of the provider more than it’s on the back of the RHIO to do anything different.

The one thing, though, that I will say … I’ll editorialize a little bit … is that the RHIOs are being fundamentally pulled in the wrong direction on a lot of this stuff. Because at least in New York state, the privacy concerns around the RHIOs are, if anything, driving more and more and more restrictive rules around access to the data, sharing of the data, then sending us data. Within the context of a single organization that we control, we manage the consenting process end to end. There’s a lot more we can do.

When you get out into the state level or eventually the national level, a lot of the good intentions and the good clinical opportunities are potentially going to be stymied by the restrictive practices and policies that are being built around the RHIOs because of the patient privacy concerns. I don’t mean to minimize the privacy concerns. They’re certainly real and legitimate. But what they ultimately translate into from a regulatory statutory perspective, at least in New York state, runs a little bit counter to what we’re trying to accomplish by saying, hey, wherever this patient goes, we’ve got to be able to assure that everyone’s on the same plan of care. Everyone knows what’s already been done. It’s going to be very tough in the governmental RHIOs because of the privacy concerns and what they’re driving from a policy and practice perspective at the RHIO level.


You mentioned your Allscripts implementation earlier. I’m curious about how that’s going, especially now that they’re retooling into a population health management company.

It’s going well. We made this decision before they came forward with their dbMotion acquisition and some of the new tools that they’re bringing forth, which we’re very excited about. We just met with a number of them a few weeks ago. We have a whole bunch of folks coming on site.

We’ve been talking about population health management, trying to understand the respective roles for our internal HIE for what they’re trying to do to bring their products together. The newer front end that they have been talking about which fuses dbMotion with their front end products to make the community data and the local data appear seamlessly to a clinician look like a very, very attractive set of work flows. We are in detailed discussions with them about how we merge some of the things that we’ve done or are doing internally with some of the things that they’re doing, because we did set off on this track a little bit ahead of them.


What are your biggest challenges and opportunities as a CMIO over the next several years?

The HIE is probably one of the biggest. People think of it as a technology — and there is a lot of very, very valuable technology – but the HIE alone, just simply “data comes in, data goes out,” doesn’t accomplish the mission unless you build lots of clinical workflows over it and around it. You’re supporting any number of clinical programs or any number of potential patient flows or workflows. I have a big team focused just on that, which is working on how we take the power of the HIE and apply it to all the various different programs that are growing up around the system. That’s probably one of the biggest.

The other major area for us as a health system is the development of a data warehouse, which we don’t have today. We have a lot of individual analytic tools and products attached to our various EMRs, plus other types of warehousing — cost accounting, things like that.

We still have work to do with our EMR rollout. We still haven’t put physician documentation out beyond the inpatient space, beyond the admission and discharge documents. We still have to build out progress notes, consult notes, and a couple of other things. We still have about 30 percent of our medical group to whom we still have to roll out our ambulatory EMR. Those are all still in progress.

But my overall goal is to look at, as we make this transition to a different model of care, how do we orient everything we’re doing in the EMRs, align it with everything we need to do in the data warehousing space to provide the analytics that are needed to support these programs, and align all that with all of the clinical workflows that we’re building in the HIE to support the population health types of initiatives that we’re doing with the HIE? Making sure that all these three things work together properly, that they don’t overlap each other in what they’re doing, that we don’t leave gaps where I thought the HIE would do that or the other warehouse would do that. To make sure that all of these things align together to support all of the population health programs that we’re engaged in.

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September 22, 2014 Interviews 3 Comments

Curbside Consult with Dr. Jayne 9/22/14

September 22, 2014 Dr. Jayne No Comments


A couple of weeks ago, we performed a major upgrade on our ambulatory system. Officially we’re now ready for both Meaningful Use Stage 2 and ICD-10, with all the bells and whistles installed. As upgrades go, this wasn’t my first rodeo. It went smoothly with only one minor IT concern and no significant incidents for the end users.

Since no good deed should go unpunished, management is now looking to cut our personnel resources for the next one. They can’t seem to understand why several hundred hours of work went into the upgrade because clearly it was “no big deal.” Mind you, these are not old-school IT managers, but members of our ambulatory operations team who want to avoid having super users out of the office.

We rely on the participation of super users, not only from the ambulatory practices, but also from our central business office, central scheduling department, and central referrals department. No one knows end user workflows like the super users who work with them day in and day out. We have detailed test scripts for our internal testing, but we need real-world expertise to tease out the smallest bugs. Like any organization, our users have some creative workflows that we don’t train, and if we don’t have their participation, we won’t find those issues until go-live.

We’ve been using the same upgrade methodology for half a decade, which is usually goes off without a hitch. It’s a belt-and-suspenders approach, with some duct tape and baling wire thrown in for good measure. We do a dry-run upgrade just prior to the super user testing so that we can get our timing down pat for the main event. The upgrade weekend playbook has some elements timed to the minute and there is a single upgrade commander responsible for ensuring every step is completed and communicated.

Because of the need to involve a couple of third-party vendors to handle some data migrations that we wanted to perform while we had the system down, timing for this one was even more critical. There were numerous handoffs among DBAs, access management, application analysts, build analysts, internal testers, and end-user smoke testers in addition to the third parties. Although we don’t make everyone sit on a bridge line and talk through their work and the hand-offs, we do require people to notify the team when they complete a step or if they’re running behind so that we can adjust if necessary.

The lead analyst that usually quarterbacks our upgrades had an unexpected medical issue a handful of hours before we were due to take the system down, so I ended up co-managing it with one of our analysts. This meant being on call overnight for issues, which doesn’t bother me. Once you’ve been on trauma call or managed an ICU full of patients overnight, being on upgrade call doesn’t seem very scary. Still, you never want to hear that phone ring in the middle of the night. Shortly after midnight, I decided to grab some sleep since we weren’t expecting a handoff until early morning.

When the phone rang at 3 a.m., my heart was pounding. The tone in the tech’s voice wasn’t reassuring as she apologized for calling. Apparently the upgrade was running nearly three hours ahead and she wasn’t sure if she should wake someone up to tell them or not. I have to say, seeing an upgrade run ahead, especially by that much, isn’t something you see every day. I shuffled out of bed and we walked through the checklists to make sure nothing had been missed. I cruised the error logs as well. Nothing was amiss, so we had to chalk it up to the production server being faster than our test platform.

We must have our share of either insomniacs or nervous Nellies on our team because a couple of people were showing available on our instant messenger service. They were happy to launch the next few steps early. Despite the call being a non-issue, once your adrenaline is flowing, it’s hard to get back to sleep. I curled up on the sofa with some journal articles, which thankfully did the job. By our 8 a.m. status call, I was rested up and eager for the build and testing teams to get to work.

Even though everyone has remote capabilities, we require the regression testers and analysts to be on site. We’ve learned the hard way that people are sometimes less attentive when working remote on the weekends. Sometimes it’s just better to have two sets of eyes looking at the same screen together (without a WebEx lag or dogs barking in the background) for troubleshooting. It’s a sacrifice for the team to come in, but we try to make it as fun as possible. The kind of team-building you get from an event like this is often priceless. It’s also important for the end user and analyst teams to work closely together and build mutual respect.

In response to the questions about why we spend so many hours preparing and delivering an upgrade, I’m going back through the last couple of months and highlighting some key milestones that may have been riskier with a leaner team. We have multiple people trained to do each task, which was clearly helpful when our quarterback unexpectedly sat out the game. I’m also working to quantify the intangible benefits of having disparate teams work together.

We ended up being able to re-launch the system two and a half hours early, which meant less downtime procedural re-work for the patient care sites that are open on weekends. Due to the diligent prep, we also had fewer phone calls Monday morning than we’ve ever had. That’s got to be worth something as well. The question is whether the Administralians will agree with our analysis. If they don’t, maybe we can let them run the next one and see what happens. We’ve already documented our lessons learned and updated the project plan, so it’s ready to ride.

Ever jumped in when someone said “Cowboy up?” Email me.

Email Dr. Jayne.

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September 22, 2014 Dr. Jayne No Comments

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