I wrote last week about my new urgent care job. This week I worked a bumper crop of shifts to try to immerse myself in the new policies, procedures, and workflows.
From a clinical standpoint, it’s been terrific. The support team is top notch. I have the option to use a scribe, but I haven’t yet taken advantage of it.
Today was the second-busiest shift that my location had ever seen. I thought I kept my head above water despite having some really ill patients. I had several patients needing procedures or multiple diagnostic tests, so at times we were a little backed up.
I was so busy I barely had time to eyeball my phone. I headed home to put my feet up and was surprised to find multiple emails from patients waiting for me. Apparently my new employer subscribes to an online rating service that allows patients to submit feedback in an attempt to mitigate any negative feedback that might be otherwise posted to online rating sites.
I’m all for patient engagement and receiving feedback, but I wish I would have been warned. Although the email came from the rating service, it’s unclear whether patients can see my email address. Regardless, I would have set up a separate account to handle the traffic.
Even more unclear is what I am supposed to do about feedback that might be negative. At one time we had multiple very ill patients in the office and had even called EMS to transfer one to the hospital. I wasn’t surprised that one of my feedback submissions was about having a long wait. I called for backup when I felt it getting bad (we have flex staff that can swing over from our other locations) but it took time for the float to arrive and pitch in.
Our practice management system tracks all the different times in the patient cycle, from door to doctor to discharge and everything in between. I’m sure my numbers looked pretty bad at multiple times today, but the numbers don’t reflect acuity or case mix. They don’t give you the true picture of what might be going on.
I’m comfortable being rated on the timeliness of my care when I’m in a practice setting with scheduled appointments. I pride myself in running on time and I do well keeping up as long as the appointment slots are on a pretty standard schedule. If you want to grade me on that, I’m game.
However, being graded on being too slow is uncomfortable when you’re in a walk-in setting. It’s not uncommon to have a half dozen patients walk in right after one another. Maybe having multiple patients at the same time who should have really been in a hospital emergency department isn’t that common, but it was my reality.
Thinking through the day, I know I saw patients as quickly as I could, giving the best care possible. My team worked extremely well together, and although people’s lunch breaks were delayed and they were working hard, it felt good. One of the nurses was celebrating her 40th birthday and a member of the management team came to the office with treats. She also brought my official monogrammed scrubs, which made me feel even more like a member of the team.
Although the patients were served faster than they would have been at my hospital’s ED — not to mention that their primary physicians were unable to serve them at all — we didn’t meet their expectations.
I was facile enough with the EHR to run without elbow support, even figuring out a couple of shortcuts. For some reason, my favorite medications are all duplicated, though. With the mad rush we had, there wasn’t time to look at it or resolve it, so prescribing medications is much slower than I’d like it to be. I did get quite a few favorites built on the fly and picked up some tips from the staff at the end of the shift as things slowed down.
I’m waiting to hear back from the owner about what they want me to do with any feedback that wasn’t five stars. In the mean time, I’ve got a new Gmail account ready to receive patient comments rather than having it sent to my personal account. Since I’m only working a couple of shifts a month, I hope the follow-up they expect from me is minimal.
I’m also waiting to hear about their ICD-10 training plan. I’m hoping to get them to hire me to do their training when the time comes. I’ll definitely have the skill set and it might be good for them to be able to have one of their in-house physicians deliver it rather than having to contract it out.
In the mean time, I’m unwinding with a nice glass of wine and recharging before I head into the CMIO trenches tomorrow.
New York Governor Andrew Cuomo signs into law a bill that will delay mandatory e-prescribing requirements for doctors in the state, calling the delay a win for patient safety and explaining, “The fact that many software companies are not ready for e-prescribing could have resulted in patients’ inability to fill their prescriptions.”
West Health publishes a survey of nurses measuring the impact that integrated medical devices would have on patient safety, finding that 90 percent of hospitals report having six or more medical devices that could integrate with an EHR, but that only one-in-three hospitals actually have interfaces in place to exchange data.
New York Governor Andrew Cuomo signs legislation delaying the state’s mandatory electronic prescribing law for one year to March 27, 2016, the same bill he giddily approved in 2012. “This is a victory for patient safety,” said plastic surgeon Andrew Kleinman, MD, president of the state’s medical society. Assembleyman and pharmacist Roy McDonald says 98 percent of the state’s pharmacies were ready to receive all prescriptions electronically, but the Drug Enforcement Administration and EHR vendors waited until too late to begin their preparations.
From Jeff Steiner: “Re: Memorial Hospital at Gulfport. I wanted to respond to a story posted about our hospital’s bond rating change ‘due to a Cerner EHR conversion that inflated accounts receivable and jumped AR.’ Memorial Hospital is in the midst of exciting work and tremendous growth. We are undergoing a $65M expansion project spread over the next two fiscal years (with no planned debt). We are living with revenue pressures from Medicare and Medicaid due to changes in their reimbursement methodology. We’re a busy organization and are facing plenty of market pressures and dynamics like so many of our peers. We wanted to add clarity to the ‘100 days in A/R’ comment. This includes a mix of prior non-Cerner systems and Cerner. This snapshot was a 90 day post live look where MHG was on Cerner’s solutions at our fiscal year end. We look forward to our partnership with Cerner and a very productive relationship.” Jeff is CFO of the hospital.
From Castro’s Cousin: “Re: Banner Health. A high-placed source says it will replace Epic with Cerner at recently acquired University of Arizona medical center and clinics. Official announcement won’t drop until summer.” Unverified, but expected.
HIStalk Announcements and Requests
Sixty percent of poll respondents say they don’t feel welcome and appreciated when interacting with their preferred hospital. Donald says the service he gets is good because it’s a rural area, while OutsourcedMom says she feels too welcome, as in “like a spider’s web of financial ruin.” New poll to your right or here: will ICD-10 be delayed again by Congressional action? I get nervous when I see Congress talking about an SGR fix since that is where an unknown politician slipped in the last delay. It doesn’t matter what the experts think should happen – none of the lobbyists who whisper in Congressional ears have a vested interest in wanting the rollout of ICD-10.
Here’s a generous offer from HIStalkapalooza Gold Sponsor Divurgent. Divurgent gets a bunch of tickets in return for their sponsorship, but graciously offered to donate all but a handful of them them to HIStalk readers who might otherwise be unable to attend if we sell out. I will execute their largesse as follows: if you haven’t already signed up to attend, do it here. I’ll guarantee that the first 50 folks to sign up will get an invitation courtesy of Divurgent, with just one exception: I’m not going to give a bunch of invitations to people from the same company just because a secretary was ordered to sign everybody up. You might think, “Nobody would do that,” but at least two companies signed up 30+ people each to attend, which seems ridiculous since the point is to get a lot of readers there, not to have me (and the event sponsors) pay for someone’s company party. Thanks to Divurgent, who clearly is sponsoring the event to support HIStalk rather than for their own benefit.
I have a few spots left for CMIOs (or physicians working in a CMIO-type role) interested in attending a lunch with peers Tuesday of HIMSS week. It’s near the exhibit hall, so the time commitment is minimal unless you just want to hang out. The signup form is here. Thanks to the company that offered to sponsor the lunch even though I turned them down – it was a nice gesture, but I’d rather spend $500 out of my own pocket than to give the impression that I’ll do anything as long as some company pays – I get those offers pretty often and I usually decline.
Last Week’s Most Interesting News
Apple releases its smartwatch and ResearchKit.
Stanford University says 11,000 people signed up for one of its research studies within the first 24 hours of the release of Apple ResearchKit.
Epic’s Judy Faulkner tells a reporter that she will sign over all of her Epic shares to her private charitable foundation when she dies or decides to turn over control, with her intention being to guarantee that the company will never be taken public.
Two big academic medical centers in the Netherlands stop their implementation of the former Siemens Soarian, expressing concern about how Cerner might handle the product with its Siemens acquisition.
Oregon finally shuts down its health insurance exchange, which due to technical problems never enrolled a single customer despite its $284 million cost.
FDA issues draft guidance on using electronic informed consent in clinical studies.
March 31 (Tuesday) 1:00 ET. “Best Practices for Increasing Patient Collections.” Sponsored by MedData. Presenter: Jason Bird, director of client operations, MedData. Healthcare is perhaps the last major industry where the consumer does not generally have access to what they owe and how they can pay for their services. Collecting from patients is estimated to cost up to four times more than collecting from payers and patient pay responsibility is projected to climb to 50 percent of the healthcare dollar by the end of the decade. Learn how creating a consumer-focused culture, one that emphasizes patient satisfaction over collections, can streamline your revenue cycle process and directly impact your bottom line.
Acquisitions, Funding, Business, and Stock
The Indianapolis business paper profiles Hc1, which just raised another $14.4 million from angel investors, increasing its total to $28 million. The 100-employee company’s revenue doubled each of the past three years and is expected to triple to $35 million in 2016. The company’s Healthcare Relationship Cloud offers collaboration, CRM, and analytics. I don’t see any healthcare experience on the executive team other than the chief medical officer – most of the folks came over from the founder’s previous company, ChaCha, which offers human-guided, text-message based search using freelancers (seemingly unsuccessfully – it looks like not much is happening there and the company has scaled back over the years). Despite a lack of healthcare background, CEO Brad Bostic seems to get it: “When I order a book on Amazon.com, they treat it like a life-or-death situation if they deliver it to me. But if I go to a healthcare situation, where it actually is life or death, I get treated like a number. This is a really big deal. It’s a big game-changer about, how do you treat patients like individuals?”
Eko Devices receives $2 million in new funding and will begin clinical trials at UCSF of its Eko Core digital extension for analog stethoscopes.
The business paper in North Carolina’s Triangle area profiles seven-employee Polyglot Systems, which raised $1.4 million in equity financing as part of its deal with First Databank to distribute the company’s medication instructions. The proceeds will be used to integrate Polyglot’s product with EHRs.
NYU Langone Medical Center names Paul Testa, MD, MPH as CMIO, a position he had held as interim since September 2014.
CTG hires Cliff Bluestein, MD, MBA (Dell Services) as president and CEO.
Announcements and Implementations
Divurgent and Sensato produce a white paper titled “Cyber-Security in Healthcare: Understanding the New World Threats.” It contains an interesting quote from a hospital CIO: “The reason no one bought your service was that, frankly, if we found out about security holes, then we would have to fix them. It is easier to react after the fact than to convince everyone we need to do something before it happens.”
Privacy and Security
Healthcare IT attorney Nicholas Terry says the White House’s draft wording of the “Consumer Privacy Bill of Rights Act” may have HIPAA implications since it no longer specifically excludes HIPAA covered entities, meaning that health systems could become responsible not just for keeping the information they collect private, but for collecting it responsibly. Terry adds that the FTC’s “data minimization” concept may clash with ONC’s interoperability efforts and could limit selling data to third-party brokers. The proposed policy would be enforced by FTC and the attorneys general of individual states. The bill would also preempt the laws of states that may already have stronger privacy laws on the books given that it doesn’t specifically prohibit selling consumer information to data brokers without their permission.
Philly.com’s story on unemployment in the Malvern, PA area originally contained wording suggesting that Cerner is laying people off after its acquisition of Siemens Health Solutions, but for some reason that section of the story was removed and no Cerner reference remains.
A West Health Institute poll of nurses about medical device interoperability concludes (via the mandatory cute infographic) that almost all nurses say they would spend more time with patients if freed up from dealing with medical devices and think those devices should share data with EHRs automatically, while half of the nurses say they’ve seen a medical error due to lack of device coordination. Nurses, not surprisingly, think their own uninterrupted time is the most important factor in improving patient safety and most of them think that manually documenting device information creates errors and delays. West Health calls for ONC to add medical device information sharing to its interoperability roadmap, for FDA and HHS to recognize open standards for medical device communication and to provide guidance to manufacturers, and for Congress to provide “adequate incentives” for developing and using interoperable medical devices.
Stanford physician and author Abraham Verghese says in his keynote to the American College of Cardiology that doctors should rediscover the humanity of practicing medicine and the non-technical benefits of the medical encounter ritual, saying that EHRs have obliterated the stories of patients as the typical ED physician spends nearly half of their time working on a computer. He explains, “EMR has nothing to do with your heart or your patient’s heart.”
The local paper covers the financial woes of Southeast Health in Cape Girardeau, MO. Billing problems caused by the hospital’s Siemens Soarian implementation as well as that system’s $15 million per year operating cost earned it a bond ratings downgrade in 2013. New CIO Mike Nichols is planning to take advantage of the Siemens acquisition to move to Cerner Millennium. The health system spells their name “SoutheastHEALTH” in the apparently misguided belief that marketing by misspelling is the secret to organizational success. You have to squelch the creatively bankrupt marketing people when they babble nonsense like the words they put in the former CEO’s mouth for the hospital’s annual report: “This is not simply an evolution in name alone. We are a far-reaching network of providers and facilities uniting to provide a regional system of healthcare services.” Sounds good except they’re going broke as they lay people off, with the board chair explaining, “Back here, in the old model, we got paid for doing things. In the future, that’s not how a hospital will be paid. Unfortunately, we are sitting in a spot in the middle, because that model hasn’t been explained to us yet.”
Doctors in France protest health reform, unhappy that under proposed changes they’ll be paid by insurance companies instead of having patients hand over cash directly. They say insurance companies will control both doctors and patients and doctors don’t have the clerical staff to manage the reimbursement paper trails. Patients now pay $25 in cash for a visit and are reimbursed by either the social security system or the patient’s insurance company. A doctor who is leading the protest warns that France’s healthcare system, which he says is the best in the world, will “end up like in the UK” where patients who don’t pay upfront don’t mind wasting the doctor’s time “for any old reason.” He adds, “If we change the system, it will be whichever insurance company pays me, who is responsible. The Social Security service will say to me, Mr. Henry, you are prescribing too many antibiotics. You are prescribing too many pills and sending people for too many tests. They will tell me I have to prescribe less. I will no longer be free to ask the question, what is the best thing for the patient’s health? I will no be longer be independent.”
Medicity publishes “The Challenges and Benefits of Interoperability.”
Xerox Healthcare publishes “Survey Says: Your Patient is Unhappy.”
I started my career in retail and then moved on to telecom, then into banking, and now healthcare. They’re different industries, but they are all focused on service.
Oneview is an Irish company. In the last two years, we’ve grown from eight people to 44. We have offices in Pittsburgh, San Francisco, Dublin, Dubai, Sydney, and Melbourne. We’re opening an office shortly in New York. All of our staff are shareholders. We’re energetic, we’re entrepreneurial, we have a passion for innovation, and we just love doing what we’re doing.
Our product empowers patients to be engaged in their care. It also optimizes clinical performance and workflow efficiencies within the hospital. It improves productivity and performance by delivering a good ROI.
Even budget hotels have had to figure out how to meet a minimum standard of entertainment and broadband services. Is that expectation moving into traditionally consumer-indifferent hospitals?
We’re seeing that hospitals are now employing people that have been in the hotel industry. The patient experience now is of huge importance. What we’re also seeing is that there are patient experience officers now at C-suite levels. That’s going to be the norm in the future.
Several companies offer interactive patient systems that use in-room monitors or mobile devices. What makes Oneview different?
We are very much operating in a global market — in Australia, the Middle East, and the United States – and that gives us a broad perspective on healthcare. We have an international advisory board with medical doctors and IT superstars and technologists from around the world and that group is transforming our product. That’s where we have the leading edge. We feel we’re on the crest of the wave in this market.
How important is it to extend the engagement beyond just the patient’s room to post-discharge follow-up on mobile devices?
Patients have to take a knack for all of their treatment and care. They have to expect better outcomes. For them to be truly prepared for that, hospitals and providers need to communicate with their patients before they come into the hospital, once they’re in the hospital, and also when they’re at home.
We have built our own patient portal, but we also have an open architecture, so we integrate into existing patient portals. We’re not re-creating the wheel. We’re now also going to the assisted living market, and eventually by the end of this year, we’ll be in the home market and integrating with products that will give information back into the hospital about the patient’s condition.
What problems are hospitals asking you to solve using your technology?
The financial reality is that revenue is not going up, so cost must go down. There will be a continued shift to care in an outpatient setting and even in the home. The big problem for hospitals is that the average margin in the United States at the moment is about 2.5 percent. If the hospital performs poorly looking after a patient, they’re going to be hit even harder on that very small margin. There will be more care outside of the hospital environment and that would be obviously facilitated then by patient portals, where it’s going to make it easier for patients and clinicians to connect.
You’re doing some work with UCSF. What success metrics would a hospital or a health system track?
Number one is the whole patient experience and how patients view the product. It’s a fantastic hospital to work with. We’re across their three hospitals, which is a children’s hospital, a cancer hospital, and a women’s hospital.
The metrics that they would be using is that the patient is much more engaged. They understand what the treatment is. They understand what their discharge dates are. They understand what their goals for the day are. They have a pathway to understand what they need to do to make them better and to get out of the hospital. Then by educating that patient through that continuum of care and continuing that education while the patient is out, it should reduce readmissions, which is a huge problem for American hospitals.
Are you getting product suggestions back from UCSF that will be rolled into future versions of the product?
Yes. One of the things that I’m very, very strong on is that it’s very much a partnership approach. When a hospital takes our system, they have the ability to join our advisory board. Dr. Seth Bokser is on our advisory board from UCSF. He has the ability to shape the product in consultation with the staff and other hospital leaders. There will be many exciting developments coming from UCSF in the future. We’re just delighted to be part of that experience.
I was impressed that you provide accessibility options, which health systems seem to pay little attention to even though they see special needs patients who need technical accommodation. Based on your experience with accessibility tools such as sip-and-puff, what should vendors be offering in their consumer-facing products?
I don’t think it should be a problem for any person, in whatever form of disability, to have an interactive approach within the hospital. We’ve leaped in with a couple of different companies.
You asked specifically about sip-and-puff, which enables a patient who can’t use their hands to navigate using sip-and-puff hardware. They can watch entertainment, they can watch their favorite movies, and they can be part of that whole media experience with the hospital. We’re also looking at eye tracking for navigating our system using the latest eye-tracking technology. A person will focus on a point and then that point will then open up whatever they’re looking at. They could be looking at an icon for a movie. We’re also looking at speech recognition and screen readers, which enable patients with limited sight to read on-screen information. It’s just making everybody a part of that multimedia experience within the hospital.
The hospital experience can be grim where you’re stuck in a bed with limited TV options and a nurse call button. Are patients surprised that they can carry on their lives with communications, entertainment, and Internet connectivity?
Surprised and delighted would be the words. I was at the opening of UCSF and I spent the week within the hospital, just going around asking people what they thought. We have messaging in our system where the patients or the family members can post a message. When the clinicians come into the room, the message is clearly visible for the clinician to see. The very first message we got was from a little boy who was seven years of age who said, "When can I go home?" I met him two days afterwards, and he said, "I want to stay here because it’s just fantastic. I’ve got a 65-inch TV, I’ve got a tablet, and I’m having a blast." I thought that was just fantastic.
Do you have any final thoughts?
We’re delighted to be involved in this business. We’re delighted to be part of something that I think is going to be fantastic for patient engagement and patient experience. Technology will play an important role in this. It will have to be from companies that have open platforms that are easily integratable. I think that’s going to be the top priority for hospitals for the next three years.
Outside it was 19 degrees and snow continued to fall as it had for the last few days. Inside the two-story brick building in downtown Asbury Park, NJ, a group of operators huddled around a set of whiteboards and large flat-screen TVs doubling as computer monitors that are connected to a variety of computer hardware.
One of the screens provided satellite images of a convention center. Another screen detailed the locations of all the hotels being used by attendees of a healthcare conference. Yet another screen highlighted the booth locations of the key exhibitors, with cross-references to their key clients, employees, and partners with their LinkedIn, Facebook, and Twitter account names and pages.
The operators had been developing cyber-attack plans for one of the largest healthcare information technology conferences in the world. The Alpha teams would focus on infiltrating the conference itself, while Bravo team members would exploit opportunities at hotels, restaurants, and the popular vendor-sponsored parties. The current debate was centered around if team members should register to attend the conference or simply swipe the passes of attendees and blend in with the crowd.
The last team, Command One, would provide command and control. It had already secured several adjoining suites at a hotel across from the convention center. The suite would provide real-time, 24×7 communications to the team members as well as manage the botnet and provide the initial command and control capabilities for the RAT software the field teams would be deploying.
The RATs being deployed by the field team were custom developed using a derivative of Stuxnet. This assured that the RATs would work across operating systems and devices. It also assured that the RAT would lie dormant for the most part except in some special cases.
One of those special cases was that if the RAT determined it was on a laptop, it would turn on the computer’s microphone and camera to record confidential conversations between vendors and clients as well as between vendor teams about their clients. The hope was to garner details that could later be used to exploit employees or other details that could lead to further compromises. RATs deployed to machines running a server operating system or Linux variant would replicate, eventually being introduced to a corporate network and then become active establishing themselves inside the corporate infrastructure of vendors and attendees.
Aside from the RATs, the Bravo teams had already visited area hotels and catalogued the wireless networks and their providers, deploying SDR and other toys to about 40 hotels. The goal was to eventually compromise the wireless networks using man-in-the-middle attacks and other techniques. In situations where they could not bypass the hotel’s wireless infrastructure, the team planned to compromise targets of opportunity being used in lobbies and public areas.
The team was now in its final planning stages. “Do we have the dummy business cards?”
The team had created a fictitious company, complete with a website, Delaware LLC, and 800 phone number complete with employee directory and voicemail. The team also had false employee IDs issued by the fictitious company. This allowed the team to play the role of a vendor attending the conference.
A subset of the team had spent the past two weeks becoming familiar with their cover of representing a new hospital system being created in the Midwest. The team included a fake CMIO, CIO, and VP of operations. The team developed LinkedIn accounts with complete work and educational histories as well as a fake website for the new healthcare system, with architectural renderings of their new 650-bed acute care facility and their upcoming regional clinical care centers.
At this point, you are probably wondering if what you are reading is an expose of a crack hacking team or simply a fictional piece of work. It is actually a little of both.
One of the things my team often does is to run simulated attacks on a variety of targets. We basically map out the entire attack and do all the prep work, short of launching the attacks. In this scenario, we decided to attack a healthcare conference.
The simulation was actually carried out over a period of three days. Everything you read is real. All the techniques, tools, and practices are the actual methods we would use to carry out a large scale cyber-attack against a healthcare conference. Our goal in doing this was to help develop suggestions for those attending any healthcare conference in hopes of making the lives of people like us much more difficult.
The above doesn’t include everything we would do or how we would do it, but what I did divulge is not all that sophisticated or uncommon. There is nothing in the story that isn’t already known or possibly already being undertaken by cyber-criminals, cyber-terrorists, or cyber-spies. Although we would never carry out this type of activity, there are those who would and probably will. Hopefully you will heed our counsel and employ the suggestions below, thereby keeping you and your organization a little safer.
Share the wealth. One of the most important things you can do is educate others on the possible threats that exist when attending conferences of any size. An easy way to do that is forward this article to your teams. Like GI Joe once said, “Knowing is half the battle,” and that is especially true in the world of cyber-security. Most people don’t realize the sheer audacity that attackers employ. Hopefully the above story illustrates a little bit of that audacity.
Encryption matters. All of your devices should use local file encryption, especially if you are going to be shipping them where they are out of your control. This also applies to any device that you are taking with you on the road — laptop, tablets, etc. All communication should be encrypted, even if you are using a closed network, but especially if you are connecting to the Internet.
Stay In control. Do not leave your laptops or other computing devices in your hotel. If you are going to leave them behind, lock them in a safe and make sure the device is encrypted.
Remove history. Delete your web browser history every day and also delete all previous wireless access points from your computing device history. For example, if your iPad is setup to automatically connect to your home wireless network, delete that before you go to a conference. Why? Because I can use the MAC address of your home network to find your home address. Don’t believe me? Email me your MAC address and we can bet a cafe mocha.
Just say no to thumb drives and DVDs. If anyone — partner in crime, spouse, child, parent, boss, vendor, speaker (including George Bush) — offers to give you a thumb drive or DVD for any reason, just say no. Ask them to e-mail you the item, or better, print it out. If they e-mail it, do a virus scan and make sure it is from someone you met before the show. Otherwise, FedEx works great to mail you documents quickly. Thumb drives and DVDs can harbor malware. Even if you know the person, you don’t know where they got the thumb drive or how they made the DVD. Save yourself a lot of pain and just say no.
Lock down machines. Vendors should lock their server rooms and demo equipment. You shouldn’t hire third-party security — you should be your own security during off hours. I know this sucks and is a burden, but it’s your technology. If the answer to this is that you wipe your equipment, good for you, but I am not after your equipment — I am after your data and network. Wipe away — chances are someone on your team will connect to your demo network.
No demo networks. Don’t connect to demo networks. You don’t know what is on them no matter what your IT team tells you.
Limit Wi-Fi. If you must use Wi-Fi, limit it to your hotel (it’s not the safest, but it’s better than a coffee shop or airport) and use a secure connection over a VPN. A better alternative, though not cheap, is your own personal hotspot over a secure connection.
Wipe machines. After every conference, you should do a DoD-level format of all hardware used at the conference. This includes a visual inspection of the internals, if possible, to assure that nothing was added by your third-party, $10 per hour security resource.
Lock down demo machines. Tape over webcams, disable USB drives, and put tape over the ports. Disable unused ports and other services. Hire someone to attack your demo environment.
Establish a conference VPN. Set up a VPN just for the conference and require two-factor authentication using something like Google Authentication to connect back to your corporate resources. After the conference, disable the VPN system and never use it again.
Establish BIOS passwords.
Create a bootable DVD. A great option for vendors is to use a bootable DVD with your demo clients on them. Please don’t tell me that you use virtual machines and somehow that makes you safer. If you believe that, you have a lot to learn about cyber-security.
Awareness. If something doesn’t feel, smell, or seem right, it probably isn’t. Conferences are highly social venues. It is important that you don’t forget that most of what happens to you is because you let it happen. This applies in the real and cyber worlds and is critical in both to maintain your personal security.
Email invites and marketing. Vendors love to send you all kinds of invites, updates, tidbits, and other neat stuff via e-mail during a conference. I would suggest you unsubscribe or just delete mass e-mailing from any vendor. A better option is to inform your rep that you will only accept e-mails from them directly and would appreciate minimizing things you have to click on. Think this is overboard? Consider that Anthem was compromised with a single click in an e-mail message.
Blips matter. Ever say, “That was strange,” or “What just happened?” and then things go back to normal? Often this is just an anomaly, but it could also be an indication that your computer device is under attack. Think about what you were doing right before the blip — surfing the web, opening an e-mail, connecting to a network, clicking a link, downloading something. Put things in context, and if you get nervous for any reason, say something to your IT team.
Hopefully if nothing else this article will get you to think and ask questions of your teams and how well you are prepared to attend a conference. Conference operators do all they can to provide a safe and secure environment. But in this day and age, there is only so much they can do. The real burden of security — physical and cyber — is on the shoulders of individuals. This is how it should be because security works best when it is a personal responsibility.
Take time to talk with your teams (exhibitor or attendee) about security best practices. The pre-meeting is a great time to brief your teams on security practices or invite someone to speak to them. You should also have a cyber-security response plan for the conference that includes who to speak to, what to do if there is a threat, and how to report information to the conference coordinators so that multiple incidents can be correlated and viewed through a broader lens.
The reality is that life has changed.
The simulation outlined in the opening of this article was simply that — a planning simulation for a real-world attack. The emphasis is on real-world attack planning. The only thing that kept us from carrying out that simulation is that we fight for good, but there are plenty of others out there who don’t — we call them the bad guys.
I mentioned in Monday’s Curbside Consult that I took some time off from my day job this week to immerse myself in the routine at my new moonlighting gig. I also used some of the time yesterday to finish my tax return. As I went to put my documentation in the file cabinet, I realized that the drawer was full and I should probably spend some time dealing with some non-hospital document retention.
At work, we’re rabid about document retention. We keep everything exactly as long as required by laws or regulations, and then it’s off to the physical or virtual shredder. There’s a certain liability in keeping things longer than you need to, and as a risk-averse organization, we don’t want to shoulder any more liability than required. I definitely had files at home that were well past the need for retention, so I started culling through them. The amount of document detritus that can accumulate over a physician’s career is pretty impressive.
In addition to the usual household paperwork such as tax documentation, financial paperwork, mortgage paperwork, and important receipts, physicians have a host of other documents to manage. If you’re lucky enough to work for the same employer for most of your career it might not be too bad, but for those of us that have worked for several groups, the paper carnage can be impressive.
I’m not even talking about patient records or office-related information – just the personal ones. There are medical liability insurance documents, payer credentialing documents, hospital privilege documents, employment contracts, CME documentation, licenses, and DEA and state narcotics documents. There are college and medical transcripts, records of licensing exams, diplomas (and their certified translations if you went to a Latin-loving med school like I did), board certification documents, and now maintenance of certification documentation.
The pile was impressive. For conventional financial documents, there are retention standards. Some of the professional documents need to be kept for even longer, especially if they relate to liability insurance. I’m not going to rely on a former employer to prove that I had liability coverage if a claim occurs at the end of the statute of limitations. With the prevalence of identity theft, I’m not going to get rid of some of my original documents that relate to licensing or board certification. I was, however, able to weed out quite a bit of documentation and reduce the pile. Now that it’s more organized I should scan it all, but that’s a project for another day.
After I made it through the “official” file drawers, I turned to some of the documents I had kept for more personal reasons. It was a reverse chronological tour through what it takes to become a doctor. I started with student loan payoff documents and worked my way back through the application to defer payment during residency and the heart-stopping promissory notes I originally signed as a 22-year-old. I distinctly remember the day I signed the first one – if nothing motivates you to not wash out of medical school, it’s the possibility that you could have upwards of $200K in debt with no way to repay it.
The tour down memory lane also included rejection letters from a handful of medical schools and acceptance letters from others, as well as my original Association of American Medical Colleges application packet. Back in the days of the typewriter, I had filled it out by hand first and then typed it up. Both copies were there and it was funny to think about doing business without the now-familiar fillable PDF or online form. Reading the essay made me smile – it was a good reminder of youthful optimism, untarnished by E&M coding regulations, fear of litigation, or Meaningful Use.
One might ask why I still had all that. Although I do probably tend to be overly sentimental, I think it is more due to the realities of rushing from college to medical school to residency to solo practice without a break. The boxes just moved from one tiny student apartment to another and then to a house. With the crazy hours we work, as long as you have space to keep it, there’s little motivation to spend your free time sorting it all out. It got me thinking about the volume of electronic documents I might have, where space is not a limitation.
For good or bad, my hospital has a fairly liberal retention policy for email. A CMIO buddy of mine works at a hospital where all emails delete after three months and they have limited archive space allotted, so he’s constantly having to either save emails to other file formats or risk deletion. I try not to keep email too long but there’s never time to sit down and clean it out. I realized I hadn’t purged my archive folder in what looked like about two years. I spent a couple of hours deleting tens of thousands of emails. In that history were both the mundane and the heroic. I looked back fondly on standing up the region’s first HIE, but with the bittersweet sense that it is now defunct.
Those electronic missives tell the story of hundreds of thousands of hours of work. Not only by the IT teams, but also by the clinicians and other end users that did the work alongside us, whether enthusiastically or reluctantly. I know the emails needed to go and it was somewhat cathartic to watch those massive chunks of data disappear from my folders. On the other hand, it made me miss the simpler days when our main goal was to do the right thing by our patients rather than checking boxes and counting measures.
I enjoyed being reminded of colleagues who have moved on to bigger and better things as well as some pretty crazy stories. The hail storm that struck during one of our EHR design sessions, totaling cars. The analyst who ran our first EHR upgrade and slept at the office all night in a folding lawn chair while the rest of us went to our vendor’s user group meeting (bad plan, by the way). The vendor rep who got food poisoning during a site visit and still called in to our meetings while lying on the hotel bathroom floor (that’s dedication). Team-building tricycle races, cosmic bowling, and mini golf. And the software developer who put up with my newbie questions and helped me bring a feature live that no one else seemed to care about but that made a huge difference for our users.
Those are not exactly the stories you memorialize in a scrapbook but I’m grateful for the memories and to everyone who has helped me along the way. We may not always have Paris, but we’ll have the EHR.
In just 24 hours, Stanford University enrolled 11,000 people in a cardiovascular study through Apple’s recently unveiled medical research API ResearchKit, a feat it says would have taken 50 medical centers a full year to accomplish.
In Michigan, 11 people have been charged with ID theft and fraud after a Blue Cross and Blue Shield employee stole the personal information of 5,000 customers and then shared the information with a team of criminals that fraudulently purchase $742,000 worth of merchandise from Sam’s Club.
Stanford University reports that 11,000 people signed up for one of its cardiovascular studies using Apple’s ResearchKit in the first 24 hours of the app’s availability on the iPhone. The university says it usually takes a year and 50 medical centers to hit the 10,000-enrollee mark. However, the best metric won’t be known for some time and may never be announced – how many of those 11,000 casual applicants will be actually be accepted into the study and participate? My suspicion is that the majority of responses are from people screwing around with their new Apple toy who don’t realize what’s involved, so it’s going to take quite a bit of work for Stanford to get down to usable subjects. Someone make a note to ask Stanford in a month how large their cohort is and what percentage of the Apple self-submitters were accepted.
I was thinking about the “research” part of ResearchKit. Traditional medical studies involve carefully assembling a cohort of people who meet narrowly defined study criteria, with the intention of proving a specific hypothesis in a specific population. On the other hand, research using patient-generated data may uncover relationships that nobody thought of or that may prove useful in managing an individual patient’s condition even in the absence of a generalized population study. Direct care lives at the interesting intersection of big, decisive research studies and anecdotal “it just works” clinician practice based on experience. A given patient’s endless supply of non-inpatient electronic data, along with similar data generated by people like themselves, could improve that patient’s life more decisively than any study, provided that physicians are willing to practice based on data snapshots rather than studies that take many years to complete. Another positive is that studies are often funded by drug companies or special interests that have a vested interest in manipulating data in particular way or in killing a study that might hurt product sales.
From Clinic Director: “Re: Meaningful Use audits. We are now at 96 audit requests of our 139 Epic-using physicians and have passed all. CMS says providers are chosen randomly, but is 70 percent of our providers really random? I needed help, so I asked our congressional office, which referred me to the auditor. ONC referred me to the CMS EHR Info line, which referred me to the auditor. The auditor referred me to the CMS Info Line. It feels as though I’ve entered the Twilight Zone.”
HIStalk Announcements and Requests
Several CMIOs expressed interest in a HIMSS get-together. I booked a table for Tuesday, April 14 at either noon or 1 p.m. right in McCormick Place and I’ll buy lunch for up to 20 attendees via the Bistro HIMSS program. CMIOs or physicians working in a CMIO-type role regardless of title can sign up here. It’s a convenient location near the exhibit hall where you can actually sit to eat (unlike most other convention center locations), the food should be decent (salads, lemon-sage chicken with polenta cakes, and dessert with healthy options), and Lorre will be on hand to say hello and introduce everybody since it was her idea.
Speaking of events, some readers are confused by the two I’m having at the HIMSS conference. Event #1: HIStalkapalooza is the big event on Monday evening – it’s open to those whom I will invite from the list of folks who previously submitted the online form indicating their desire to attend. Event #2: the sponsor-only networking event is Sunday evening and is open only to sponsors of HIStalk, HIStalk Practice, and HIStalk Connect. We’ve reached out several times to our sponsor contacts (not all of whom are efficient in passing the word along to the suits upstairs who might want to come), so Lorre will still entertain invitation requests for that event (and new sponsorship inquiries from companies anxious to talk business with their peers in a social setting). I suppose we now have Event #3: the CMIO lunch above. I just know I’m writing a lot of checks. Anyway, just to be clear, walk-ups will be politely turned away from all three events since I’m working with a fixed attendee count.
You can wear one of the four “Secret Crush” sashes like the above at HIStalkapalooza if you email me explaining why you have a crush on Dr. Jayne, Jenn, Lorre, or me. People like being sashed and I couldn’t come up with anything more original than the “Secret Crush” ones I’ve done before. I don’t expect many responses, so your odds of winning are good. Of course you need to have signed up for HIStalkapalooza and plan to attend to be sashed since I’m not mailing it for someone to wear around the house.
I’m going to stop mentioning press releases that list a hospital or health system without including its location (both city and state) because I’m annoyed at lame PR people who expect me to do their jobs in deciphering an over-edited company announcement into something factual. Surely it’s not hard to understand that “St. Mary’s Hospital” could be anywhere, as could a hospital whose location is stated only as “Missouri” (if the location is named at all). I’m also annoyed at ‘’announcements” that are too vaguely worded to tell whether a hospital has bought a new system, is beginning its implementation, or is continuing a previous installation (the latter two of which aren’t really news). Attention PR people, especially the lesser competent ones: I’ll consider running your announcement if it’s newsworthy, but being newsworthy means that you provide the five Ws: who did it, what they did, when did they did it, where it happened, and why it happened. Anybody want to see me call out exceptions?
This week on HIStalk Practice: Mental health professionals weigh the pros and cons of moving to EHRs. HealthSpot and Pacify secure new funding. LaHIE launches a patient portal. Kareo acquires DoctorBase. PatientPoint partners with Telemundo for point-of-care content. St. Peters Health Partners Medical Associates and Northwestern Memorial Physicians Group implement new population health management tools. Jim Denny digs deep into physician ICD-10 readiness.
Apple introduces ResearchKit, an open-source API designed to help medical researchers collect data from iPhone and iPad users. The Department of Homeland Security launches an accelerator program targeting wearable technology startups building applications for first responders. TechStars welcomes its second class of digital health startups to its Kansas City campus for a 12-week program. SocialWellth raises $7.5 million to expand its digital health app formulary service platform.
March 31 (Tuesday) 1:00 ET. “Best Practices for Increasing Patient Collections.” Sponsored by MedData. Presenter: Jason Bird, director of client operations, MedData. Healthcare is perhaps the last major industry where the consumer does not generally have access to what they owe and how they can pay for their services. Collecting from patients is estimated to cost up to four times more than collecting from payers and patient pay responsibility is projected to climb to 50 percent of the healthcare dollar by the end of the decade. Learn how creating a consumer-focused culture, one that emphasizes patient satisfaction over collections, can streamline your revenue cycle process and directly impact your bottom line.
Here is the video of Thursday’s webinar by West Corporation titled “Turn Your Contact Center into a Patient-Centered Access Center.”
Acquisitions, Funding, Business, and Stock
Government contractor Maximus acquires Acentia for $300 million in cash from private equity owner Snow Phipps Group, with Maximus lustily eyeing Acentia’s contracts with HHS, FDA, NIH, CDC, CMS, and the Military Health System.
Austria-based blood sugar tracking app vendor mySugr raises $4.8 million in funding. Its FDA-approved product synchronizes data from medical devices, even using the smartphone’s camera to import readings from the displays of non-connected glucometers (that part works only in Austria).
DaVita selects Cureatr for secure messaging and patient care transition event notification.
Citizens Memorial Healthcare (MO) chooses Summit Healthcare Web Services Adapter to send public health and immunization information to the state’s HIE, with plans to expand its use to meet Meaningful Use Stage 3 requirements.
Trinity Health (ND) chooses managed cybersecurity services from Leidos Health.
Dana Alexander (Caradigm) joins Divurgent as VP of clinical transformation.
William Bria, MD (The HCI Group) joins CHIME as EVP of medical informatics and patient safety.
Announcements and Implementations
Craneware will offer its customers analytics software from Aridhia Informatics. I’m baffled that someone thought this would be a good product name: “Aridhia Analytixagility.” It looks like the result of my snoozing off at the keyboard after working too late.
Cerner will use Validic’s digital health platform to incorporate data created by home medical devices and wearables into Cerner’s HealtheLife patient portal.
Online doctor visit service HealthTap launches RateRx, which lets its member doctors rate the effectiveness of individual drugs and treatments.
Mediware releases MediLinks Outpatient for pulmonary rehab.
Todd Fisher, who founded consulting and software engineering firm Intraprise Solutions in 1997 and was CEO of MobileMD when it was sold to Siemens in 2011, launches Intraprise Healthcare.
Government and Politics
The family of a VA patient who died of low blood oxygen levels sues the hospital after its former nurse admits turning off the patient’s alarms.
SAMHSA (HHS’s Substance Abuse and Mental Health Services Administration) launches Suicide Safe, an app that provides guidance for PCPs and behavioral health providers who are faced with potentially suicidal patients.
Privacy and Security
The US attorney indicts 11 Detroit-area residents after a former Blue Cross Blue Shield of Michigan employee provides 5,000 subscriber screen shots to accomplices who used their information to obtain phony credit cards to buy $742,000 worth of merchandise from Sam’s Club. The BCBS CEO announces new steps (the key here being that these practices weren’t already in place) that include limiting employee access to Social Security numbers, enforcing employee password changes, and installing secure printers that require employees to scan their badges before their document prints. The US Attorney makes the point that while technology makes it easier to commit identity fraud, it also makes it easier to capture those who do so. Interestingly, BCBS of Michigan brags on its site that it wasn’t part of Anthem’s breach while not featuring its own breach prominently.
A small survey-based study of children’s hospitals finds that inpatient EHRs don’t support peds very well, adding speculation that vendor and customer fixation on Meaningful Use is delaying rollout of needed pediatric functionality. It’s somewhat of a subjective study, the survey results are old (going back to September 2011), and dumping responsibility for customer-needed features on ONC rather than the vendors selling EHRs (and thus the customers who drive their development agendas in chasing MU money) seems biased. Correlation also seems skimpy since some hospitals seem to be doing fine, presumably using the same EHR although the study didn’t ask the important question of “which product are you using and how long have you used it?” In addition, some hospitals said they weren’t interested in implementing the features that were missing, such as weight-adjusted blood pressure percentiles or immunization contraindication warnings. It would also have been helpful to know whether those that reported missing features have worse outcomes since simply having the feature available doesn’t necessarily improve care. I was going to to check the supplementary material to see how the survey was worded, but the link is dead. Quite a few publications and tweets summarized this report as thought it’s decisive and insightful, while I would say the only thing newsworthy about it (and thus why I’m mentioning it) is that it really isn’t and those writers and tweeters need to spend more time analyzing the study itself rather than dreaming up attention-seeking headlines.
Here’s a pretty funny commercial from Cox Business, tweeted out by Eric Topol, MD as an unintended reference to his new book, “The Patient Will See You Now.” He adds, “Suck it, doctor’s office.”
Ireland rolls out a national patient identifier, with the CIO of its health services saying it offers “patient safety and ensuring that the right information is associated with the right individual at the point of care. The IHI will also help in managing our health services more efficiently and ensure that health information can be shared safely, seamlessly across different healthcare organizations associated with patient care. ” The government points to effectiveness studies from Canada and the UK showing that a national ID reduces errors, improves EHR data, increases efficiency, and protects privacy.
The bond rating agency of 445-bed Memorial Hospital of Gulfport (MS) notes the hospital’s “sharp decline in liquidity in 2014” due to a Cerner EHR conversion that inflated its accounts receivable by $25 million and jumped A/R days to 100.
NBC News fires Chief Medical Editor Nancy Snyderman, MD over fallout from her previously admitted violation of voluntary 21-day Ebola quarantine when she and her crew, fresh back from Liberia, picked up takeout food. She also appeared to be impaired during a February 22 live broadcast. She will be taking a faculty position at an unnamed medical school.
Cerner’s Neal Patterson and his wife Jeanne (who has cancer) are featured in a KQED series on EHR interoperability. Jeanne says she has given up on having 20 health systems share her records with each other, so she instead carries around a bag of printouts and DVDs. Neal says, “The paradox is that I am one of the few people that should be able to fix this. I’m frustrated that we’re not moving faster.” He adds that the US is one of few countries that don’t have a national patient identifier and streamlined consent processes and that he’s putting his money where his mouth is in funding CommonWell. Epic responded to the reporter’s question of why they haven’t joined CommonWell in saying that its clients can already exchange information and Care Everywhere is “much more mature” than CommonWell. Neal says that if the industry commits to interoperability and the government creates “compelling guidelines,” the interoperability problem can be solved within 10 years.
I ran across some email exchanges between an ambulatory EHR vendor (one I’ve never heard of) and one of its practice clients. The practice, which is replacing the vendor’s system, gave its new vendor access to the old vendor’s system so they could convert patient data. The old vendor says giving them access violated its copyright and is thus a breach of contract. The old vendor is suing the practice and says it will drop the lawsuit for $25,000, adding that lack of immediate response doubles the settlement fee to $50,000. My reactions: (a) practices never seem to pay adequate attention to the contracts they sign, happily agreeing to terms that any lawyer would advise against; (b) practices also seem to choose their systems and vendors with questionable amounts of research; and (c) the old vendor has every right to hold the practice accountable for the contract it signed but shouldn’t have, although the “pay fast or we double it” part is scummy for sure. I suppose vendors are like significant others – you don’t really know what they’re capable of until you try to move on without them.
Forbes should know better than to let a private wealth advisor try to explain “How Telemedicine Can Kill You.” The lack of insight is stunning given the article’s two “potentially devastating problems”: (a) possible computer glitches that “can alter medical records” along with implantable devices “that can go haywire”; and (b) hackers. The fact that neither of these theoretical “problems” have anything specifically to do with telemedicine was missed by whoever crafted the click-baiting headline. I couldn’t decide whether to be angry at the article’s failure to deliver or to laugh at some of its unintentionally hilarious conclusions, such as “being able to control if a person lives or dies can readily lead to exhortation and murder-for-hire” (I’m assuming the author meant “extortion.”) Just last week the same editorially ubiquitous author wrote an equally lame telemedicine piece consisting entirely of quotes from a telemedicine company CEO, who not surprisingly didn’t mention killing any of his patients.
Quantros produces a video to support National Patient Safety Awareness Week, which is this week.
BIDMC CIO John Halamka, MD says that “outsourcing your mess to someone else to host is not cloud computing,” suggesting that CIOs instead focus on “Outcomes as a Service” where vendors are paid for managing people, processes, and technology.
Navicure completes ICD-10 testing with eight Medicare jurisdictions, to be followed by testing with all 16 jurisdictions in April.
Nordic leads off its “HIT Breakdown” podcast series with an episode on population health and adds a new video in its series on Epic conversion planning.
Hayes Management Consulting offers “Overcoming Resistance to Change: It’s All About the Buy-In.”
LifeImage will exhibit at the American College of Surgeons Committee on Trauma Annual Meeting March 13 in Chicago.
HCS will exhibit at the National Association of Psychiatric Health Systems Annual Meeting March 16-18 in Washington, DC.
Healthfinch posts “Apps that optimize your EHR workflow are essential for care redesign.”
IHS posts a blog on “Making the Hard Decisions” when going through the HIT selection process.
Healthgrades gets a nod in a Forbes piece on a need for bipartisan action on healthcare transparency.
VMware posts “Creating the Perfect Clinical Desktop with Horizon View.”
Galen Healthcare Solutions posts the second installment of its series og on shifting to value-based payment models.
HealthMEDX will exhibit at the LeadingAge PEAK Summit March 16-18 in Washington, D.C.
Healthwise commemorates Patient Safety Awareness Week with “Why Safety is Personal When it Comes to Medical Care.”
Logicworks will present at the National HIPAA Summit March 16-18 in Washington, D.C.
Holon Solutions will exhibit at the NW Regional Critical Access Hospital Conference March 17-19 in Spokane, WA.
Ingenious Med posts the fourteenth installment of its blog series by President and CEO Hart Williford.
InterSystems outlines the factors creating excitement around patient engagement.
Lifepoint Informatics will host its annual users conference March 18-19 in Orlando.
Influence Health will exhibit at TIPAAA (the IPA Association of America) March 19-21 in San Antonio, TX.
CMS introduces a new ACO program that it is calling the Next Generation ACO Model, that will allow providers to assume a higher level of risk than either the Pioneer ACO or Shared Savings Program, and will generate a larger financial return for providers that successful manage those risks.
FDA efforts to create a medical device ID numbering system have received political pushback from CMS administrator Marilyn Tavenner, who says that adding a medical device ID number on claims forms would require significant work from her department and would result in significant unanticipated costs.
Antelope Valley Hospital (CA) is challenging claims made by a local nurses union after the group claimed that unplanned EHR downtime forced the hospital to close its ED. The hospital acknowledged redirecting some patients to other hospitals during the downtime, but reports that it still treated 900 ED patients during the event.
Telehealth: Ready for Prime Time By Jonathan Leviss, MD
Telephone rings. “Hello?” answers Sonia, age 73 with heart failure and living at home.
“Hello, Sonia. It’s Linda, your telehealth nurse. I received an alert that you gained two pounds a day for the last three days.” Further assessment reveals that over the last few days Sonia has eaten more salt than usual and has leg edema. Linda prescribes furosemide under protocol, educates Sonia about her diet, establishes a plan of care, and sends a report to Sonia’s cardiologist.
Why is Sonia’s tale becoming more common? Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and other models of value-based care and bundled payments require reducing readmissions, addressing problems before they require more expensive interventions, and reducing high cost utilization. Telehealth is now a proven solution for all three.
Telehealth means robust, real-time, patient management solutions including remote patient monitoring of blood pressure and glucose; self-reported symptoms and medication compliance; live video visits with clinicians and health coaches; alerts for risks of clinical compromise; the ability to organize actionable information into dashboards or into a provider’s EHR; and the power of analytics to predictably detect problems earlier and develop new treatment approaches.
These real-time tools connect patients to the right care in the right place at the right time, and most commonly, that connection occurs in the patient’s own home. Not only does this save provider, payer, and patient resources, it’s most convenient for the patient and often most effective.
The effectiveness of telehealth is no longer a matter of speculation. There is a growing body of rigorous research published in peer-reviewed journals that validates these benefits, including the following findings from AMC Health programs. This sampling of peer-reviewed studies demonstrates the significant value that evidence-based telehealth programs provide across care settings, disease states and patient populations.
Medical Care, January 2012. Geisinger Health Plan reduced all-cause 30-day hospital readmissions for high-risk patients by 20 percent by adding interactive voice response calls to their care management outreach.
Journal of Managed Care Medicine, November 2012. New York City Health & Hospitals Corporation combined personalized case management and real-time patient management solutions to enable Medicaid patients with poorly controlled Type 2 diabetes reduce HbA1c levels by a mean of 1.8 points.
Journal of The American Medical Association , July 2013. When Health Partners of Minnesota added telehealth and pharmacist management to their usual care for hypertension, 71.2 percent of the patients participating in the program had their blood pressure well-controlled after 12 months versus 52.8 percent of the control group.
Population Health Management, December 2014. Geisinger Health Plan significantly reduced hospital readmissions and cost of care for patients with heart failure. For every $1 spent to implement this program, GHP saved about $3.30, which translated to 11 percent per patient per month between 2008 and 2012.
As the healthcare market continues its transition to value-based care, this compelling evidence combined with exciting new technologies that expand how patients can engage in care virtually is fueling demand for customized telehealth programs ranging from full turnkey programs to the ability to seamlessly augment existing care management resources. To facilitate the adoption of telehealth, legislative and regulatory barriers are also being addressed:
The Tele-Med Act of 2013 (H.R. 3077), introduced to the House in September 2013, amends title XVIII of the Social Security Act to permit certain Medicare providers licensed in a state to deliver telemedicine services to Medicare beneficiaries in a different state.
The companion Telehealth Modernization Act of 2013 (H.R. 3750), introduced to the House in December 2013, calls for states to authorize health care professionals to deliver healthcare to individuals through telehealth.
The ACO Improvement Act (H.R. 5558) introduced on September 22, 2014, would permit ACOs to use remote patient monitoring and store-and-forward technology that delivers images to remote providers. The bill also strives to improve care coordination by improving the process through which data are shared between ACOs and the Medicare administration.
Not having visibility into a patient’s condition in real time when the patient is at home and outside of a clinical setting is like a chef overseeing a kitchen, but not being able to view the prep line. In the era of accountable care and pay for performance, the primary objective for patients with chronic conditions is to keep them healthy with fewer high-cost visits to the hospital or other clinical settings. Therefore, gaining at-home visibility is critical.
By incorporating proven telehealth services as part of a well-designed care plan, the entire care team can work with a patient to manage a chronic condition between clinician visits, altering treatments or creating early interventions to keep a patient healthier and reduce the spiraling cost of care.
As healthcare reform continues to drive providers to share risk and deliver greater value, understanding what is happening with their patients with chronic conditions outside the clinical setting is no longer a nice-to-have. It’s a must have. It’s time for telehealth to go mainstream.
Jonathan Leviss, MD is SVP/medical director of AMC Health; staff physician at Thundermist Health Center; and assistant clinical professor of health services, policy, and practice at Brown University School of Public Health.
The Pursuit of Health Optimization By Jeff Margolis
For over 30 years I have been burdened with Crohn’s disease, a serious and currently incurable illness. It may seem ironic that I am on a crusade to enable all the “mostly healthy” people to achieve their highest possible health status at the lowest possible cost. After all, a number of excellent physicians, nurses, hospital staff, and technicians of all varieties performed skillfully in the US “sickcare” system with surgical and medical interventions that kept me alive.
These expensive interventions, which were largely paid for by my health insurance plan, would have otherwise financially disrupted me and my family. Let me be clear in saying that I am not ungrateful for the currently inefficient sickcare system nor do I have anything less than admiration for the efforts and capabilities of the medical professionals who comprise it. And yes, I am in a small minority that fully understands the critical role of our health insurance plans in weaving together the incredibly complex fabric of access and economics for our population.
I would be unequivocally grateful for a highly efficient and holistic “healthcare” system, whereby a cultural norm of admiration and rewards for each of us being skilled healthcare consumers would co-exist in a complementary way alongside our skilled medical professionals. After all, most of us in the population are healthy most of the time. In other words, except for the sickest of us who cannot care for ourselves at all at points in time, we have the opportunity to make choices and take actions every day that affect our health status and costs.
Our society has developed the cultural norm of seeking professional medical assistance when we become sick. How do you argue that such behavior is not rational? We start that behavior when we are young, throughout adulthood, and into our last days.
Let’s play this out in contrast a bit. When we are young and hungry, we typically rely on an adult to cook for us and feed us. Likewise, when we are children most of us (unfortunately not all) receive unconditional love whether or not our actions are deserving. Somehow, as we get older, we take responsibility for feeding ourselves when we’re hungry and we learn that loving relationships require effort to maintain. We generally learn to navigate abundant consumer options in order to get nourishment – ranging from five-star restaurants to growing our own food. We also pursue multiple pathways to personal relationships.
So, who decided that we should not be responsible, either individually or as a population, for the status of our health? And when was it decided that the way in which our actions impact our controllable health factors and costs was not our responsibility?
We have a challenge to solve in the affordability of healthcare and a huge opportunity to have a healthier population. Let’s begin by embracing the incredible array of consumer-facing resources that each of us healthcare consumers can wield — whether on our own or in coordination with our doctors and health plans. These resources, propelled by the digital age, include education and content about health benefits and care; methods of connecting to other consumers with common issues; wearable and carry-able devices that give us anytime access to capture and share health-related data; programs that increase our levels of fitness, nutritional, and physical well-being; programs that help us manage our known health challenges; methods that understand our motivations and lower our likelihood of developing depression or malaise; and capabilities to incentivize and reward us to do the right things.
The challenge is (and has been) that these types of consumer-facing resources are 1) fragmented into thousands of partial solutions; 2) constantly being innovated and updated in the marketplace; 3) disconnected from the way the current sickcare system operates; and 4) not contextually attached to any meaningful intrinsic or economic benefits for the healthcare consumer.
Stated another way, the well-intended ecosystem of things that a consumer can do to achieve their highest health status at the lowest possible cost exist in a state of confusion and chaos for the healthcare consumer. Further, the consumer is not incented or rewarded (i.e., paid for performance) to be skillful in matters of our health, as contrasted to the medical professionals to whom we turn.
The promise of health optimization platforms are both practical and staggering in its enormity. Think of it this way: If we place such a platform and its capabilities alongside the existing sickcare system (which remains essential for the aspect of our health that we cannot control as consumers), then we get a new kind mathematical equation in the US healthcare system. One where the sum of the parts becomes less than the whole – with that whole being the current three trillion dollar cost of US healthcare spend.
Jeff Margolis is chairman and CEO of Welltok of Denver, CO.
The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.
Why IT Governance is Impotent
Every CIO I speak with struggles with IT governance. Despite everything written, numerous conference sessions, and creative processes, IT governance is a quagmire.
I wrestle with the “why.” I write extensively about it, give sessions, and publish creative models, but have not yet hit the mark. The literature is full of theory and process flows, but none seem to pass the test of time and stress. IT Governance remains a struggle for the majority of organizations across industries.
This riddle won’t be answered with new models. Innovation and creative models will inevitably fail unless we address three key factors. If accounted for, these influences will help ensure It Governance success: culture, leadership, and identified outcomes.
It does not matter who sits on the IT Governance committee or what model you use. When I switched organizations a few years ago, I transferred in what was a reasonable model. But what works in the North may not work in the South. It is a mistake to believe that models are portable, yet that is our focus. We keep thinking the answer is in the model.
You can leverage any model to achieve effective governance. Let’s stop copying other organizations models and start homing in on and adopting the principles that run through the few working models out there. Build these values in your IT Governance fabric and you will find success.
CIOs forsake our IT Governance leadership responsibility. Consensus is the enemy of collaboration. In an effort to appease key stakeholders, we no longer walk in our authority and thus the entire process has become deluded, rendering us impotent.
If you are not making people mad, you are not leading well. Stirring up contention is not the point. But when you lead with authority, not everyone will like your decisions. If our goal is to not upset the apple cart, our produce will eventually spoil and nobody will be happy.
So make the tough calls. That’s what you are paid to do. Don’t give it away and shortchange your organization. You, not a committee, are responsible for IT.
When will you know IT governance is successful?
The answer to this question will drive your model and principles. Collaborate with organizational leaders to establish desired outcomes.
If a focus is leveraging IT resources to do more strategic initiatives, then adjust your model accordingly. Set targets and then measure and report on them. Use these to prioritize requests. What percentage of your resources should be spent on strategic versus tactical? Know this answer and lead accordingly. Make adjustments to hit the outcome.
An outcome might be financial, related to establishing and defending budgets. I always have clinicians and executives as co-chairs in my models. Practically, I gain three times the influence, as they are surrogate CIOs when it comes time to acquire or defend resources. Adoption and usability are no longer on my shoulders, but rather the responsibility of all stakeholders. I retain authority by sharing it. Yet I remain accountable.
Strategic alignment is a valuable outcome. Ensure that everything you do is aligned with organizational objectives. You can build this into your process. Establishing alignment as a measurable outcome is one of the most effective ways to ensure the continued allocation of scarce resources. Moreover, you are demonstrating that your focus is not IT, but the greater good of helping your organization fulfill its mission and vision.
Focus less on the model and more on culture, leadership, and desired outcomes and the odds for effective IT governance increase exponentially.
Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.
The GAO audits the Patient-Centered Outcomes Research Institute, concluding that the organization’s $271 million on PCORnet research network will struggle to support researchers because EHR vendors do not subscribe to an industry standard data model and therefore the organization will need to hire additional staff to support data migration and mapping.
Epic CEO Judy Faulkner tells Modern Healthcare that she will create a charitable foundation that will fund not-for-profit organizations working in and out of healthcare. “Nearly every share of stock that I own will be put in there,” she says.
A GAO audit of the PPACA-mandated Patient-Centered Outcomes Research Institute (PCORI) predicts that its PCORnet research data network will struggle because EHRs have no common data model, which will require hiring resources to process the submitted information manually. GAO also questions whether the organization’s funding will be ongoing and sufficient, but notes that PCORI plans to sell data to drug companies. (Does any healthcare organization’s business model not involve selling data to drug companies?) PCORI also notes that it doesn’t always have or need claims data. It also acknowledges that its information will rarely be complete because of lack of a national patient identifier. PCORnet has spent $106 million so far of an expected total cost of $271 million through FY2019.
From Justin Graham: “Re: infectious disease informatics docs. There are a handful of us ID/IT types. Harris Stuttman at Memorial Long Beach, Gifford Leoung at Dignity, and David Classen in Utah and a few others immediately spring to mind. I’m sure there are more since the ID procedure of choice is the chart biopsy.” I shouldn’t have ignored that tiny warning in the back of my head as I was interviewing Ogechika Alozie and mentioned that he was probably the only informatics person I know with an ID background. I’ll hide behind my carefully placed “probably” in claiming good intentions while admitting poor off-the-cuff execution. Justin and I also talked about CMIO networking at the HIMSS conference and I volunteered to coordinate something for those CMIOs who are interested – let me know if that describes you (maybe Dr. Jayne will hang out with her peers).
From Solilliquist: “Re: NantHealth rumor. They aren’t making Allscripts their sales organization. Just a few salespeople were let go and in fact new sales leadership is coming on board.” Unverified, but the source is sound.
From Watcher of the Skies: “Re: eClinicalWorks. They have installed an inpatient system in 10+ hospitals in India. They are looking at hospitals in Europe and may someway bring the product to the US.” Unverified.
From Nurse Tina: “Re: Antelope Valley Hospital EHR failure. The nurse union is asking the LA County Department of Public Health to investigate.” The California Nurses Association wants to know why the hospital didn’t have a backup plan for its unexplained system failure, which the nurses say caused a variety of clinical problems. The financially struggling hospital raised eyebrows a couple of years ago when it admitted marketing its OB services to pregnant women in China, who in return for paying their bills, earned their newborns instant US citizenship.
Cerner’s Implementation of OpenNotes
I mentioned my interest in talking to an EHR vendor about their support of OpenNotes. Cerner connected me with Brian Carter, senior director and general manager of member engagement.
Brian says Cerner’s HealtheLife patient portal has given patients access to provider documents for at least five years, so it wasn’t challenging to expose yet another document in the form of provider notes. Cerner created a facility-wide configuration setting of whether the client wants to expose the notes. A second level of granularity is provided by allowing each client the option to allow their providers to designate a specific note as “private,” but interestingly only one client has chosen that option – none of the rest of its customers allow doctors to hide individual patient notes.
I asked Brian if clients are monitoring whether patients are reading their notes. He says clients use a lot of patient engagement reports, such as showing how long it takes each provider to respond to electronic patient inquiries, and seeing how patients are interacting with the notes about them will probably become a popular measure.
Brian says that no customer has complained that a patient saw something awkward or misleading. Any issues of that type lead to having a conversation with the patient that was probably important to have for other reasons. He mentioned an HIE-like example where a confused ED patient remembered that he had access to his records at another hospital via OpenNotes and he helped staff read up on his condition, avoiding an expensive battery of lab tests that was about to be ordered (I joked that it was like a patient-carried HIE, where the providers can’t access each other’s records except through individual patients, which isn’t a bad model).
I asked about planned support for OurNotes, where patients can annotate or add their own thoughts to the chart. Brian says patients could use that to correct their meds list or report a new allergy. I asked if that is wise since the hospital would be on the hook legally to actively monitor and react to those messages that could be coming in around the clock. Brian says the option will be offered only if the patient has a scheduled appointment within an upcoming window of time, which would then allow the provider to review all of their generated notes at once and reconcile their official EHR information during the visit.
I asked if Cerner plans to support patient-entered forms to make visits more efficient. The company is developing a custom form generator to create documents that patients can complete in advance, conserving their face-to-face provider time for more important interaction. Brian gave an example of a neurology practice that has a 90-question form that the patient can complete at home, which not only saves time, it also populates discrete Millennium data fields that can trigger alerts or document workflow.
March 12 (Thursday) 1:00 ET. “Turn Your Contact Center Into A Patient-Centered Access Center.” Sponsored by West Healthcare Practice. Presenter: Brian Cooper, SVP, West Interactive. A patient-centered access center can extend population health management efforts and scale up care coordination programs with the right approach, technology, and performance metrics. Implementing a patient-centered access center is a journey and this program will provide the roadmap.
Acquisitions, Funding, Business, and Stock
Evidence-based imaging analysis vendor HealthMyne raises $4.5 million in a Series A funding round led by two Madison-area venture firms.
Kareo acquires patient engagement and marketing technology vendor DoctorBase.
Doctor house call vendor Pager raises $10.4 million from existing investors despite what would seem to be significant scaling barriers.
In Scotland, Craneware announces six-month financial results: revenue up 2 2 percent, adjusted EPS $0.165 vs. $0.143.
Epic CEO Judy Faulkner tells Modern Healthcare’s Joe Conn that she has created a private foundation that will receive all of her billions’ worth of Epic shares upon her death or any time at her discretion, guaranteeing that the company will never go public. She explains,
“One, I didn’t want the money, personally, or for my family. What would you want with all that money? It doesn’t seem right and I can’t tell you why. (We’re) putting it into a trust that can be used for the benefit of healthcare organizations, other exempt organizations and our communities. We can use it to (help) other charitable organizations that have contributed to our success. Because that’s where it came from.”
St. Peters Health Partners (NY) chooses Phytel for population health management.
Cornerstone Healthcare Group (TX) chooses MModal for documentation services and technology.
Greenville Health System (SC) will implement performance management tools from Practical Data Solutions as part of its Epic implementation.
New York’s Healthix RHIO names Todd Rogow (HealthInfoNet) as SVP/CIO.
Announcements and Implementations
Northwestern Memorial Physicians Group (IL) goes live with Forward Health Group’s PopulationManager.
For-profit consulting firm Ethisphere has been criticized in the past for charging companies to apply for its “World’s Most Ethical Company” award and charging winners again to use the resulting logo. If you’re still interested, the healthcare-related 2015 winners are Novation, Premier, Baptist Health South Florida, Cleveland Clinic, HCA, North Shore-LIJ, University Hospitals, and three Blue Cross companies. HCA also made the ethical list for the sixth year in a row despite having paid $2 billion in a 2002 settlement for Medicare fraud and another $20 million in 2005 for share dumping by several HCA executives right before the company announced poor earnings.
Zynx Health releases Consensus Builder, a web-based addition to its Knowledge Analyzer that allows clinicians to discuss and approve clinical content being developed.
Cleveland Clinic will partner with lab testing high flyer Theranos to explore the possibility of reducing testing costs and turnaround time.
Two academic medical centers in the Netherlands halt their implementation of the former Siemens Soarian, saying they are uncertain about the product’s direction under its new owner Cerner. A reader from there suggests that Cerner wasn’t showing much enthusiasm for the project at Erasmus University Medical Center Rotterdam and University Medical Center Groningen, adding that the small country has only eight academic medical centers and they are each going their own way instead of working together. Siemens announced the $55 million deal a year ago.
Allscripts will embed Elsevier’s CPM Framework nurse treatment plans product in its Sunrise EHR, clearly hoping (given the fawning press release wording) to bolster its DoD EHR bid chances. The announcement is interesting since Sunrise developer Eclipsys (acquired by Allscripts in 2010) originally owned CPM Resource Center and sold it to Elsevier in 2007 for $25 million. Eclipsys originally bought the well-traveled CPMRC in 2004 for $5 million.
Chesapeake Regional Medical Center (VA) will implement Epic using services from Bon Secours Health System subsidiary Good Health Connections, replacing McKesson Horizon.
CoverMyMeds publishes the Electronic Prior Authorization (ePA) Scorecard. Facts from it:
ePA volume is increasing 20 percent per year.
40 percent of prior authorizations are abandoned because of the workload involved.
70 percent of patients with prescriptions requiring paper-based prior authorization don’t receive the meds originally prescribed.
54 percent of EHR vendors have committed to supporting ePA, but only Allscripts, DrFirst, Epic, NextGen, NewCrop, and Practice Fusion have it available now.
67 percent of payors and 70 percent of pharmacists have committed to supporting ePA and most of them are live.
Telehealth solutions vendor Ostar Healthcare technology announces its cell-enabled, vendor-neutral gateway that integrates payer and provider systems with remote monitoring devices such as scales and glucometers.
Mark Neuenschwander has been around pharmacy-related IT for a long time, having brought out early comparative reports on automated dispensing machines and then on bedside barcoding. His new focus is on technology-assisted sterile compounding systems, those IT systems used in pharmacy IV rooms to make sure custom bags are correctly prepared (robotic systems, barcode scanning, imaging, volumetric and gravimetric analysis, etc.) His new report is available to hospitals for $349 and to everyone else for $499. I will say that when I was once asked to approve the purchase of one his reports for the IT department I was skeptical about the value, but once I saw it I (and used it) I declared it to be one of the most cost-effective information sources I had seen and I used it to plan our medication automation strategy. I’m mentioning it here since I know his work and some readers will be interested in it.
Government and Politics
Oregon finally legislatively kills its Cover Oregon health insurance exchange, having not enrolled a single citizen for its $248 million cost and generating lawsuits between the state and its developer Oracle.
The cost of the Vermont Health Connect health insurance exchange could reach $200 million and the backlog of coverage change requests stands at more than 11,000.
FDA issues draft guidance (in the form of Q&A) for using electronic informed consent in clinical studies. It addresses such issues as how subject questions are handled, how to make sure subjects understand the information, and subjects are notified of changes during the study, and whether electronic signatures can be used.
Bizarre: FDA recently developed a smart plan to stamp implantable medical devices with barcodes to allow tracking and recording them for clinical purposes. IT-inept CMS bureaucrats (the folks who brought you Healthcare.gov) are trying to kill the project, saying it’s too much trouble for them to add the ID number to claims forms, or as recently departed CMS Administrator Marilyn Tavenner explained in a February 23 complaint to two senators, “including UDIs on claims would entail significant technological challenges, costs, and risks” (to her agency, not to patients, just to be clear.) HHS Secretary Sylvia Burwell is on record as favoring including device IDs on claim forms.
Apple announces its smartwatch and its long-awaited price — $350 to $17,000, depending on style (surely only rich fools would pay $17,000 for a first-generation electronic device that will be obsolete in a year). The ship date for the Apple Watch is April 24. As expected, it requires an iPhone for connectivity and does little that the phone can’t do perfectly well on its own, with the most obvious minor benefit being that people who stare at their phones all day instead of the world around them might appear slightly less self-fixated in staring instead at their wrists. Its most important feature is that fanboys will love it and toy with it conspicuously to make the rest of us feel that our lives are barren without it. The reviews have one point in common: nobody can figure out why it exists other than because Apple says it’s cool. The best reason to stick a new, expensive input device between you and your iPhone would have been the health tracking capabilities that Apple had to leave out.
Apple also announces ResearchKit, an open source iOS software framework that allows people to connect with medical research studies via their iPhones. Developers can create testing apps that analyze voice patterns, handwriting, and gait that can then connect possible research subjects to programs and allow subjects to submit forms from their iPhones. Apps have already been developed for asthma (Mount Sinai), breast cancer symptoms (Dana-Farber), cardiovascular health (Stanford), blood glucose (Mass General), and Parkinson’s disease (University of Rochester). Sound good except that self-selected research participants don’t necessarily form a representative cohort, limiting the ability to draw inferences from their experience. There’s also the question of positively identifying candidates and their suitability based on something they type onto an iPhone screen.
A fitness app developer says wearables (a term he deems “insufferable”) are making people less healthy as they focus entirely on hitting their easy 10,000 walking steps instead of doing actual strenuous activity. I’ve said that many times – an exercise program that doesn’t involve cardio and weights isn’t really an exercise program and instead is just plain old “activity,” which at least is better than sitting on the couch or at a desk.
Personal ECG app vendor AliveCor earns FDA approval for providing a “normal ECG” message to users or to let them know their data is unreadable and to try again.
Influential 10-year-old technology blog Gigaom shuts down due to going broke.
A HIMSS Europe report that brashly declares that health IT reduces inpatient mortality, which it “proved” by simply matching up EMR Adoption Model scores vs. weighted mortality (note the not-very-many data points wandering around all over the place). It “confirms” its conclusion by asking IT people in hospitals that spend more money on IT if those systems improved outcomes, which of course resulted in a lot of “yes” answers. Skip all the verbiage to the end, where you’ll find, “Organizations with a higher EMRAM score tended to have a low mortality rate.” That’s an Evel Knievel-sized jump away from proving that if A correlates to B, then A must have caused B. Maybe higher-spending hospitals had more cash to invest in hiring better people, or were located in an area with a milder flu season, or were more enlightened about processes and outcomes which resulted in their buying technology rather than vice versa. We also don’t know how those hospitals performed before they implemented technology, which might be the most useful of the omitted information. HIMSS has a multitude of vested interests here: selling its EMRAM, pitching the wares sold by its Diamond members, and selling memberships and publications. They failed to prove anything decisively.
PatientSafe Solutions publishes “Unsecured Texting – The Monster Underneath the Bed.”
Direct Consulting Associates is profiled in a regional business publication after being named a NEO Success Award winner recognizing top-performing companies in Northeast Ohio.
Surgical Information Systems releases a quality extract for surgery-related eMeasures.
Novation will offer its members Versus RTLS workflow solutions.
First Databank posts “Sharing Lessons Learned in NDC Data Collection and Publishing with UDI Initiative Stakeholders.”
CoverMyMeds will exhibit at the sPCMA 2015 Business Forum March 16-17 in Orlando.
Clockwise.MD is named a semifinalist in the HIMSS HX360 Innovation Challenge.
CareTech will exhibit at the ACHE Congress on Healthcare Leadership March 17-19 in Troy, MI.
Bottomline Technologies will exhibit at Microsoft Convergence 2015 March 16-19 in Atlanta.
Clinical Architecture posts “The Road to Precision Medicine.”
CitiusTech offers “Making Clinical Data Actionable for Payers.”
Culbert Healthcare Solutions highlights “Issues to Consider When Sunsetting a Legacy Practice Management System.”
Apple unveils Research Kit, an open source API designed to connect medical researchers with research study participants to improve communication and streamline data capture. Five projects are already live on the framework, including a breast cancer research project from Dana Farber, a diabetes project from Massachusetts General Hospital, and a Parkinson’s disease diagnostic tool from the University of Rochester.
CHIME and AMDIS announce a new partnership under which CHIME will provide operational, administrative, and staff support to AMIDS and AMDIS will act as the primary physician informatics advisor to CHIME. A similar arrangement was announced between the organizations in June.
I mentioned last week that I’ve been gearing up to start a new urgent care position. Unless you have been on the provider side of things, it may be difficult to understand all the moving pieces that go with a physician starting a new job.
It’s not just about adding them to the EHR and making sure they have logins. There are countless steps before you can even consider that. In addition to passing the normal steps in the hiring process (interview, reference checks, background check, drug test, pre-employment physical, etc.) there are applications for medical liability insurance and credentialing applications for all the different insurance payers. We also have to update our licenses and DEA registrations, not to mention state narcotics board certificates, hospital privileges, and more.
Since I’ve done a fair amount of locum tenens work, I was lucky to have all the required documentation already organized and scanned. The practice’s onboarding coordinator was excited about that, as was the medical liability carrier. Rumor has it that my onboarding process was one of the most streamlined they’ve had. I suppose that’s the benefit of having been on the employer side – I’ve seen what happens when a new physician stalls in filling out the paperwork and I didn’t want to be “that doctor.” It can literally take months to get everything ready to go if there’s a lot of back and forth with the documentation.
Based on the initial progress, they were convinced things would come together quickly and scheduled me for some shifts. They use staff management software that not only proactively asks me for my schedule requests, but also makes sure recipients acknowledge their receipt of the final schedules.
I started my EHR training last week while waiting for the above dominoes to fall into place. The online training was engaging, but I didn’t get very far due to the length of the modules and competing priorities on my schedule. Luckily I had completed the EHR overview, so I crossed my fingers and headed to my first day of work.
With as long as EHRs have been around, practices expect new physicians to be able to hit the ground running. Even if physicians haven’t had an EHR in the office, most of us have used electronic records in the hospital to at least some degree. Even if we’re not writing our notes on a computer, we may be doing CPOE or reviewing nursing documentation.
The practice arranged for one of their in-house trainers to stay with me during my shift. I was fortunate that she is not only a trainer, but also one of the most skilled medical assistants in the practice. She was able to teach me about office workflow and how the staff handles various situations in addition to making sure I wasn’t missing key EHR documentation.
I was honest and told her that I hadn’t completed all the training. Apparently getting through any at all was a big plus compared to other physicians she had trained. She said that most physicians don’t bother to do the self-directed learning until they work their first shift and realize they’re unprepared.
I guess that’s one way to figure out whether an EHR is truly intuitive or not, but I’m glad I didn’t take any chances. The EHR wasn’t as smooth as it had looked during the training, which was no surprise because trainers by design are skilled at making things look easy.
Most systems perform differently in the heat of battle than they do in the rarified air of the training room. This wasn’t the first time I’ve been trained on the job in an ER or urgent care – most of the time when you are a fill-in physician, that’s how things happen. Physicians who are paid hourly aren’t willing to donate their time for training and employers aren’t likely to want to pay for training time.
This system wasn’t any different from others I had used in that the first four or five patient notes were acutely painful as I tried to develop muscle memory and a feel for the different variations in the layout for the different patient complaints. Although there was another physician in the office, he was there only to back me up if I got too far behind. The organization prides itself on short wait times and immediate care and he was there to maintain standards while I got my feet wet.
By the end of the shift, I was feeling pretty good, but I’m nowhere close to the productivity I know I’ll have after two or three days in the office. Since I’ve spent the last year documenting most of my work using a paper-based template system, I was happy to be back in the EHR world. I’ll take some extra clicking any day in exchange for allergy and interaction checking, medication refill history, and clinical decision support. The e-prescribing system acted a little quirky, but I’m guessing it’s due to the fact that I’m enrolled on multiple vendor systems. Hopefully a couple of phone calls will sort that out.
At the busiest part of the day, I had 8-10 incomplete charts with a full count of patients in the exam rooms. Things slowly got easier, but I still had a pile of half-finished charts when we accepted our last patient for the night. While she received some IV medication, I was able to complete the rest of my documentation so that I could walk out the door right behind the patient. That’s always a good feeling and I know the staff appreciated the effort so they could get home as well.
Although the practice allows me to complete my charts from home, I’ve never liked that approach. I had to do that during my first EHR implementation and it was too easy to forget patient details and miss documentation. Processing refill requests and reviewing lab results is one thing, but trying to do visit note hours after the fact has never worked for me. I’m taking the immersion approach and working three shifts this week, so hopefully by the weekend I’ll be where I need to be to feel like I’m pulling my weight. It’s a heck of a way to spend a week of vacation, that’s for sure.
How long does it take your new physicians to get up to speed? Email me.
All I Needed to Know to Disrupt Healthcare I Learned from “Seinfeld” (and “SNL"): Part III – Serenity Now By Bruce Brandes
Competition. A foundational element that drives greater success in a capitalistic society. And yet, examination of the array of perceptions and reactions regarding one’s competitors in business is both fascinating and revealing.
As we get to know an entrepreneur and assess a prospective investment, an important insight is their response to the multidimensional question, “How do you view your competition?”
How an entrepreneur expresses awareness, insights, differentiation, and honesty in recognition of competition can illuminate market opportunity, commercial viability, and personal credibility. Do you deny, dismiss, disparage, or do you choose to recognize and embrace others in your space? How does that answer vary when discussing competition internally or externally? Does the stress of competition drive your organization to catalyze improvement or to react with paralyzing stress?
What lessons can be learned from the competitive battle between George Costanza and his nemesis, Lloyd Braun? Serenity now.
In our early days at Eclipsys in the late 1990s, the market was peaking with good, old-fashioned street fights to win new business from a hospital. An expansive bevy of vendors were lined up for marathon beauty pageants. Even Miss Rhode Island had a chance to compete. I was oriented with a friendly disdain for Cerner, our chief competitor of the day (hindsight obviously shows who got the last laugh).
Each vendor’s sales reps were diligently trained to know as much about what the other company could not do as they did about what their own company could do. Accuracy and validity of this information was inherently suspect. Some vendors became adept at lying better than others could tell the truth. I sometimes wonder if this was how the Soviets learned about Americans during the Cold War.
Whether with a prospective customer, recruiting a new hire, or in seeking capital from an investor, there are several potential reactions when questioned about your competition and important implications for you in how your answer may be interpreted.
Reaction 1: Denial
Apart from the Soup Nazi’s crab bisque, how many products or services today are so uniquely innovative that they are beyond compare? Yet some entrepreneurs communicate they are such game-changers that they face no competition.
Upon further questioning, they may reluctantly concede that “doing nothing” is a prospect’s only alternative. While potentially valid on rare occasions for true breakthroughs, this is almost always wrong. The arrogance of holding this belief (and the manner in which this position is often communicated) generally discredits the individual and their organization. In most procurement processes in healthcare over the last quarter century, “doing nothing” has won more competitions than anyone.
Reaction 2: Disparagement
Sometimes more intentional and overt than others, the speculation and innuendo concerning another company often elevates that other vendor’s status as a leader and reflects more poorly on you 100 percent of the time.
When Seinfeld dentist Tim Whatley announced that he had become Jewish, Jerry disparaged Whatley to a priest claiming that he only converted to Judiasm for the jokes. "This offends you as a Jewish person?” inquired the priest. No,” replied Jerry. “It offends me as a comedian.” Jerry is subsequently outcast, labeled as an “anti-dentite.”
Reaction 3: Logo Bingo
Virtually every pitch deck will have one of two versions of this slide, both of which can be effective but dangerously predictable.
The first version shows a checkbox-a-palooza with a limited number of vendor logos on one axis and a capabilities list on the other. I have never seen this slide that did not have the presenting company with the most check marks possible, which immediately raises the question what other capabilities are not on the list that should be. The second version depicts four quadrants which universally position the presenting company in the farthest upper-right corner with no competitive logos even close to the neighborhood.
Reaction 4: Just Dance
Put your best foot forward and honestly assess if this is the best mutual fit. Be realistic about how you compare with your competition and gracefully admit that you are not always the best choice. The decision may or may not be close, as Chris Farley and Patrick Swayze remind us in this classic skit from Saturday Night Live.
In a free and transparent marketplace, given fair access to decision-makers and equal opportunity to compete, the innovators delivering a superior solution with a compelling value proposition should have better than a puncher’s chance to succeed. Even better than Little Jerry Seinfeld in a cockfight. How you perceive, understand, and communicate your place in a competitive landscape is a critical factor that may dictate your market success. Here’s to hoping you don’t end up living in a van down by the river.
Bruce Brandes is managing director at Martin Ventures, serves on the board of advisors at AirStrip and Valence Health, and is entrepreneur in residence at the University of Florida’s Warrington College of Business.
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