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Startup CEOs and Investors: Brian Weiss, Carebox

Startup CEOs and investors with strong writing and teaching skills are welcome to post their ongoing stories and lessons learned. Contact me if interested.

Delivering Opening Lines
By Brian Weiss


My name is Brian Weiss and I’m the founder of a healthcare IT startup.

I’ve got these really great ideas about how to make everyone healthier, solve healthcare data interoperability, enable payment reform, advance clinical research, leverage big data to fix the US healthcare systems, make the world a better place, and create a billion-dollar company. Oh, and did I mention it all runs in the cloud?

You’re not really buying that, are you? I don’t blame you. It’s not a very good opening line.

Opening Lines

I’ve spent much of the last few months delivering opening lines – to (potential) investors, team members, strategic partners, pilot customers, editors of healthcare IT publications with proper-capitalization fetishes …

It’s not like I’ve never delivered an opening line before I became a startup founder. In everything we all do, there’s always a first line, a first slide, an opening paragraph, a first impression, a useless abstract class at the top of the object model hierarchy (what, I’m the only former software engineer in the room?)

I’ve had to pitch ideas, sell things, present solutions, and introduce myself many hundreds of times. No, I haven’t ever written a column in a publication like HIStalk (is there even such a thing?) But I’ve delivered really bad opening lines countless times! I’m even experienced enough to know it’s not the end of the world. At various times in my past, I’ve somehow managed to get hired, promoted, selected in an RFP, invited back to a conference, and even married, despite being opening-line-challenged.

So why am I having such a hard time writing this column’s opening?

Matchmaker, Matchmaker, Make Me A Match …

Today, I’m attending a “Matchmaking Session” in New York as part of the ONC Market R&D Pilot Challenge. To help encourage innovation around some of its strategic priorities, ONC is sponsoring a contest that will select six winning pilot projects. Each pilot proposal has to be presented jointly by an innovator (an early-stage healthcare technology company) and a host (an established healthcare organization operating in a clinical environment). To help match up hosts and innovators, there are three of these matchmaking events taking place over the next few weeks.

If “matchmaking session” sounds like something from “Fiddler on the Roof,” you’re on the right track. The format here is speed dating for startups, commonly used at events that bring together startups and investors. I will have 13 minutes to woo my date(s).

They also sent me a colorful one-page tip sheet to help me prepare. It seems they think I will do a better job if I make an effort to have a clue in advance about the company I will be meeting with, make my presentation engaging, explain what I do, and say something about my team and business model. And, they suggested that I practice in advance.

I’m being a tad cynical about their tip sheet. I suppose it’s pretty good advice… for presentation beginners.

My Kindergarten Artwork

My memory from when I was five years old is probably flawed, but I think this is close to being a direct quote from my kindergarten teacher to my parents about my artwork: “Brian is trying hard and we don’t want to discourage him. The important thing is to keep at it.”

A couple of weeks ago, I was in a meeting with a senior executive at an important partner of ours. It was a preparation meeting in advance of a larger meeting she had coordinated in which I would be presenting my startup to other leaders at her company.

I showed her what I had prepared. In a very polite and cheerful way (curiously reminiscent of the disposition of my aforementioned kindergarten teacher), she told me (in not so many words) that what I had prepared for the meeting clearly showed I was trying hard and she didn’t want to discourage me, but the important thing was …

… to just say very concisely what the problem was we were trying to solve, what our solution was, why it was good for her company, why we could do a good job, and “then just show them the demo.”

I dusted off my ego, did my best to do exactly what she suggested, and I thought it went pretty well.

I’ve coached others with similar advice countless times. Why did I need to be told that now?

Introductory Presentations

Last week I had a call with the CMO of a very large healthcare organization, which I can barely allow myself to dream might one day be a partner of ours. The call lasted less than 15 minutes.

Just as I was concluding my build up to Slide 1, he said he was already on Slide 8 and asked me a couple of short questions. Then he told me it all looked pretty clear, sounded interesting, he would do some checking internally, and get back if they were interested in hearing more. He got back to me the next day about setting up a follow-up meeting to go into more detail. We’ll see where it goes.

I’ve done 10s of similar calls before that one. They run 30-60 minutes and my results generally weren’t as good. I now have a much better presentation than I had before and the obvious advice I got a few weeks ago was clearly something I needed to hear.

What’s Different/Special About That?

My column will only be worth reading if I have unique and valuable perspectives to share with you that emanate from the fact that I’m a healthcare IT startup CEO, not just some guy who has to get better at introductory presentations and opening lines.

Can I do that? I’m not really sure – and this might be a very short-lived column.

For now, I just want to share with you why (I think I’ve figures it out) I am now having experiences like the ones above that sound like something out of “my first days a junior salesman” – when I am quite certain I knew how to do an effective introductory presentation many, many years ago.

Starting Up Means Starting Over

Each step in our career generally lets us build on the previous ones. When I was EVP/SVP/pick-your-favorite-letterVP of products, my title, the company and organization I represented, the many people working for me, a ton of support infrastructure — all came through the front door with me.

But it’s even more than that.

Once you get your degree, you don’t have to pass your mid-term exams anymore. But could you if you had to? On the way to the where you are today in your career, you probably paid your dues on many rungs of the ladder. But could you go back and do a good job at each level again, now?

When you are given a new challenge today, is it really all that new? Or is it a natural evolution of what you do today that lets you relatively easily carry over your skills, expertise, experience, and credentials?

I’m no longer the exec who gives good advice to others about how to structure their presentations. I am the junior salesman getting better at making a pitch. I’m the guy at the ONC matchmaking event who needs the tip sheet. I’m the guy working on the template, the web site, the demo, the story. Everything I do starts with a blank piece of paper. I’m the guy who now needs the feedback that people who do that kind of stuff get.

The fact that I could do a good job presenting as a corporate exec doesn’t mean I can do a good job presenting in this context. The fact that I could give advice to others about the kinds of presentations I am now making doesn’t mean I don’t need to hear that advice myself from others, now.

Whatever I think I’ve learned or accomplished in my career to this point only matters if I can translate it into something concrete that helps me better do the stuff I need to do now. That’s always a true statement for all of us, but it takes on a whole new meaning when you have to do something that isn’t a natural evolution of what you did yesterday.

What Is This?

Two weeks ago, Mr. H put out a call for a "startup CEO or a venture capitalist who wants to share their keen insight and sharp writing skills with the world."His intent, I believe, is that this column provide interesting and different insights and perspectives for the many HIStalk readers who are employees in established companies and interested in getting an insider view of the world of healthcare startups.

I told him I qualified as, “A startup CEO who wants to share” and we could see about the rest.

The column I’m planning to write (exact frequency to be determined) will draw from both agendas – the healthcare IT topics we’re focusing on and the ups and downs of the stages in the growth (I hope) of a startup – with a special emphasis on where the two meet.

I’m a beginner column writer. I hope to not completely disappoint relative to Mr. H’s objectives. If you’re able to suggest topics, approaches, improvements, etc. that can help me do that – I’d be most grateful. You can write to me directly.

Brian Weiss is founder of Carebox.

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January 7, 2015 Startup CEOs and Investors 3 Comments

Morning Headlines 1/7/15

January 6, 2015 Headlines 5 Comments

Top 10 issues for physicians to watch in 2015

The American Medical Association says that it will spend 2015 fighting to remove “barriers to providing high-quality care” by lobbying for relaxed Meaningful Use rules, improved EHR usability, and improved interoperability.

Epic Systems draws on literature greats for its next expansion

Epic unveils the designs for five new buildings it will construct on its increasingly cramped Verona, WI campus, adding 500,000 square feet and 1,600 offices. The new building designs were inspired by children’s literature classics, like “Charlie and the Chocolate Factory” and “The Wizard of Oz..”

Allina Health and Health Catalyst Sign $100 Million Agreement Creating Model for System-wide Outcomes Improvement

Allina Health (MN) signs a 10-year,  $100 million deal with Health Catalyst to accelerate outcomes improvement across the organizations 12 hospitals and 90 clinics.

A Restraining Order Can Be Just A Videoconference Away

Domestic abuse patients being treated in the ED at St. Joseph’s Regional Medical Center (NJ) will have a new videoconferencing platform that will connect them with a local judge who will hear their case and issue a restraining order while they are still in the hospital.

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January 6, 2015 Headlines 5 Comments

News 1/7/15

January 6, 2015 News 2 Comments

Top News


The American Medical Association says EHRs, ICD-10, prior authorization, and Medicare fraud detection programs are “barriers to providing high-quality care” that it will oppose in 2015. AMA will continue its push to make the Meaningful Use program more flexible, improve EHR usability, and expand EHR interoperability. It will also “urge regulators to ease this physician burden” of the October 1 implementation of ICD-10, study the physician workload impact of prior authorization, and push CMS to overhaul its RAC-centered “bounty hunter” fraud and abuse programs.

Reader Comments


From Hallway: “Re: smartphone wayfinding apps. I passed along information on Jibestream that you mentioned in June 2014. I agree that this type of application will offer competitive advantage, not only with patients and visitors, but for new hires, for patient transportation, and for ancillary staff that need to deliver services at the bedside, maybe even eventually to route robots delivering supplies (I can just picture R2D2s roaming the halls).”


From Title Contender: “Re: smartphone wayfinding apps. Check out Logic Junction, whose solution works on both web and mobile with a single database that can be updated in real time.” The company lists Cleveland Clinic, LA County, Sarasota Memorial, and the VA as clients. The online demo is pretty cool and doesn’t require registration to run. If I were the company, I would white label the product and let hospitals sell ads or promote their own services to make it cost neutral.

HIStalk Announcements and Requests


I’ve ordered Eric Topol’s “The Patient Will See You Now” and Steven Brill’s “America’s Bitter Pill,” so I’ll have book reports soon.

The latest in my long line of pet grammar peeves: starting sentences with “there.” The next-to-latest: sites that post articles with a question as the headline, indicating that the author isn’t confident enough to actually answer the question (meaning: the article is a complete waste of time). I’m curmudgeonly even in restaurants whose menus gets overly cute by offering “veggies” and “mashers.”


January 13 (Tuesday) 1:00 ET. “The Bug Stops Here: How Our Hospital Used its EHR and RTLS Systems to Contain a Deadly New Virus.” Sponsored by Versus Technology. Presenter: John Olmstead, RN, MBA, FACHE, director of surgical and emergency services, The Community Hospital, Munster, Indiana. Community Hospital was the first US hospital to treat a patient with MERS (Middle East Respiratory Syndrome). It used clinical data from its EHR and staff contact information from a real-time locating system to provide on-site CDC staff with the information they needed to contain the virus and to study how it spreads. Employees who were identified as being exposed were quickly tested, avoiding a hospital shutdown.

Acquisitions, Funding, Business, and Stock


Allina Health (MN) will take an equity position in Health Catalyst as part of a 10-year agreement in which the Allina will outsource its 60-employee analytics and quality improvement teams to Health Catalyst and will contribute its clinical expertise, while Health Catalyst earns a portion of its payment when Allina hits specific quality improvement targets as overseen by a governing committee. The organizations value the agreement at $100 million. I interviewed newly promoted Allina President and CEO Penny Wheeler, MD this week about the agreement and other topics.


Lexmark acquires Toronto-based medical imaging technology vendor Claron Technology for $37 million in cash. Lexmark will position the company’s medical imaging viewing platform and zero-footprint viewer within its Perceptive Software business, which offers a vendor-neutral archive and medical content management.


Staffing services company General Employment Enterprises acquires Jacksonville, FL-based medical scribe contractor Scribe Solutions.


Baltimore-based hospital hiring software vendor Pegged Software, which claims to have reduced employee turnover in its customers by an average of 45 percent, raises $9.2 million to increase its sales and marketing efforts.


Guided episode management software vendor Wellbe raises $2.42 million.


Honeywell renames its HomMed remote patient monitoring business to Honeywell Life Care Solutions.


The non-profit MedicAlert Foundation will reduce headcount and cut its budget “to better focus on its core mission of protecting and saving lives by serving as the global information link between members and emergency responders during medical emergencies and other times of need.” Beyond a variety of bracelet-type medical IDs, the organization offers an online health record linked to the medical ID number for an annual membership fee that starts at $19.99.



Saint Luke’s Health System (MO) chooses Phynd to create a single provider profile of its 15,000 referring and credentialed physicians.

Children’s Hospital of San Antonio (TX) selects Ingenious Med’s patient encounter platform.


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HIMSS adds four new board members who will serve three-year terms: Michael Nusbaum (MH Nusbaum & Associates); James Peake, MD (SVP, CGI Federal); Christopher Ross (CIO, Mayo Clinic); and Ferdinand Velasco, MD (CHIO, Texas Health Resources).  


CHIME names University of Michigan Hospitals and Health Centers CIO Sue Schade as its 2014 John E. Gall, Jr. CIO of the Year.


Rick Adam is named president and COO of analytics vendor Stanson Health. He has work for a variety of health IT vendors over the years, including Baxter, NEON, and Recondo Technology. The company’s board chair is Scott Weingarten, MD now with Cedars-Sinai after co-founding Zynx Health.


Halfpenny Technologies hires Carl Smith (Airclic) as CFO.


David Silberstein (Teradata) joins Leidos Health as service line director for analytics.


The former HHS acting director of cybersecurity is sentenced to 25 years in federal prison for distribution of child pornography, including participating in discussions with another member of a private website that the two get together to fulfill their mutual fantasies of raping and murdering children. The FBI says Timothy DeFoggi used the technology expertise he gained in working for HHS to evade detection, ultimately unsuccessfully.

Announcements and Implementations


Epic announces plans for Campus Five, a five-building expansion that will add 500,000 square feet of space, 1,600 offices, and 1,500 parking spaces, all with a children’s literature theme. The company says it needs the space because 45 percent of its employees are sharing offices. Epic’s Wizards Academy campus is already under construction and will open in about a year.

Connance adds a Claims Optimization platform to its predictive analytics solution.

The HCI Group creates a freely viewable e-book, “The Definitive EHR Go-Live Guide.”

Government and Politics


Steven Brill, who wrote a lengthy Time magazine cover story two years ago called “Bitter Pill: Why Medical Bills Are Killing Us,” says in a new book that the Affordable Care Act won’t help control healthcare costs because Democrats struck too many industry-friendly deals to get it passed. He adds in a Washington Post interview that organizations like Cleveland Clinic should be allowed to sell their own insurance under tight regulation, such as limits on hospital profitability and CEO salaries. He thinks insurance companies are the victims of providers who overcharge, leaving those insurance companies to run a low-margin business by abusing their customers. He says about ACA-driven value-based payments:

Sure, I think there’s more focus, for example, on hospital readmission for Medicare patients, which is costly, but in the sum total of things, it’s kind of a drop in the bucket. There are little things like that, but there aren’t any big things, there’s nothing to control the price of drugs, there’s no tort reform, there’s nothing to control the profits of allegedly nonprofit hospitals. There’s nothing to deal with the profits and the secret contracts that device-makers negotiate with hospitals that buy their products.

It’s not just the lobbying influence. You combine that money with the emotional pull and fear that people have when they think about healthcare. People care more about their health than they do about healthcare policy. And then you add to that the multi-channel political power of the healthcare industry in every congressional district, because in about every congressional district, the largest employer is the local hospital. And the local hospital is again seen as a charity. You combine that kind of local power with the lobbying power, with the fear and emotion that’s attached to healthcare, and that makes for a toxic political stew.

How is that going to change? I think the only way it’s going to change relates to what the thinking was in Massachusetts when Romneycare passed. They’re very candid about this — we’ll give everybody coverage and then when people see how much it costs, there’ll be this huge political wave to say we have to reform this or we’re going bankrupt.


NPR’s “All Things Considered” covers the consumer medical devices being displayed this week at the International Consumer Electronics Show in a piece titled “Self-Tracking Gadgets That Play Doctor Abound at CES.” It mentions CellScope (a phone-powered ear camera that sends images to doctors for diagnosis) and Neurotrack (quiz-based Alzheimer’s diagnosis). The article wanders confusingly into thinking that phone apps have something to do with cyberattacks and telemedicine, so the only interesting aspect is that NPR wrote up the article in the first place.


An interesting use of telemedicine: St. Joseph’s Regional Medical Center (NJ) connects ED victims of domestic violence with county court officers, allowing them to take out restraining orders within 45 minutes directly from the hospital. The program is being expanded to make an iPad-equipped judge available around the clock to handle night and weekend cases, which are the majority.


Physicians responding to a Sermo poll name wearables-based remote patient monitoring and telemedicine as the top two expected trends of 2015.


Surgeon and writer Atul Gawande, MD, MPH weighs in on technology in an interview with Bob Wachter, MD:

Information is our most valuable resource, yet we treat it like a byproduct. The systems we have – Epic and our other systems – are not particularly useful right now in helping us execute on these objectives. We’re having to build systems around those systems … the issues have less to do with systems than with governance … the residents feel they’re caught up in this world where everything they need to know is on the computer screen. That’s creating angst in their day-to-day life. You go up to the floor of the medical service in my hospital, and there are no doctors there. They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work. That means that many of the informal interactions that used to occur between the docs and the nurses, or the docs and the patients and their families, have withered away.

A veteran sues the Atlanta VA hospital that was treating him for PTSD, claiming that the single dose of antidepressant he was prescribed created a weeks-long erection that made him the laughingstock of doctors and nurses and resulted in improper treatment that left him disfigured. “One had mentioned that I should line up all the women. I haven’t had that many people who had seen it in my whole life until I went to that hospital.” His attorney (Mr. Johnson, strangely enough) cites another patient who took the same drug with the same result, to whom a jury awarded $10 million.


Weird News Andy drives us into the new year with a story he titles, “Making a turn for the better.” Surgeons remove a turn signal lever from a 1963 Thunderbird from the arm of a man who had been in a car accident 51 years ago, unaware until now that he had a seven-inch piece of metal embedded there.

Sponsor Updates

  • Phynd publishes a blog post titled “Direct Addresses Are Yet Another Reasons Hospitals Need to Move to a Single Provider Profile (SPP) Model.”
  • ADP AdvancedMD will integrate its EHR with physician practice reporting from Iron Bridge Integration, giving customers access to pre-built connections to 57 registries in 48 states to help meet Meaningful use Stage 2 requirements.
  • Chadron Community Hospital (NE) successfully attests to Meaningful Use Stage 2 using NTT DATA’s Optimum product suite. I interviewed CIO/COO Anna Turman several months ago and it’s still among my favorites.
  • Netsmart publishes several new white papers: “In Transition: How Electronic Data Sharing Enables Improved Outcomes and Reduced Costs,” “5 Things to Consider When Selecting Your New (Next) EHR,” and “Transforming the EHR into a Knowledge Platform to Ensure Improved Health and Healthcare.”
  • Medhost describes the use by Larkin Community Hospital (FL) of its YourCareLink integration service to automate public health reporting for Meaningful Use Stage 2.
  • Amerinet will offer the interoperability and population health management solutions of Sandlot Solutions to its members.
  • A market research survey finds that VMware’s AirWatch enterprise mobility management solution is the #1 choice of decision-makers, handily beating out MobileIron.
  • Four Army National Guard locations will use AtHoc’s network-centric crisis communications system, which allows base officials to quickly send deployment orders and emergency notifications via text, phone, and desktop.
  • Besler Consulting offers a review of the FY2015 Hospital Outpatient Prospective Payment System.
  • A CareSync blog post reviews CMS’s chronic care management reimbursement program and how doctors can use the company’s CareSync CCM product.
  • Clinovations posts an article titled “Patient Access: What Does Failure Cost?”
  • CommVault announces the schedule of its “Hockey Helping Kids” fundraiser.
  • DataMotion publishes an article, “Want to ensure secure and compliant data exchange? Integrate security!”
  • Divurgent will participate in the HIMSS East Tennessee Summit on January 22, 2015 in Knoxville and the HFMA Florida Mid-Winter Conference January 26 in Miami.


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

More news: HIStalk Practice, HIStalk Connect.

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January 6, 2015 News 2 Comments

HIStalk Interviews Penny Wheeler, MD, President and CEO, Allina Health

January 6, 2015 Interviews 5 Comments

Penny Wheeler, MD is president and CEO of Allina Health of  Minneapolis, MN.


You’re a brand new health system CEO, unusual in that you’re female, you’re a practicing physician, and you’re not afraid to get your hands dirty digging into IT and data issues. What are the challenges Allina is facing and how does IT fit into those?

The challenges aren’t atypical to other healthcare organizations. Our biggest challenge is that what we want to accomplish for our mission isn’t necessarily the way that our incentives are lined up right now. Our financial success doesn’t always equal the success for our patients.

For example, right now we’re having, unfortunately for the community, a bad flu season. A lot of people are getting sick. That’s meaning good things for us financially. That’s not the way it should be. We want to help drive an incentive system that rewards us for good health for the community. That’s our biggest challenge. 

The challenge to get to that is the second biggest challenge … to transform into a whole different business model. What we have to do to reduce costs and have the right information to do that.

The third thing would be to have the infrastructure set up to be able to do that successfully, which is why this information and turning data and information and consolidating that and organizing that in a way that actually can move towards better better outcomes is so important.


Regarding the announcement that just came out (Allina Health and Health Catalyst Sign $100 Million Agreement Creating Model for System-wide Outcomes Improvement), most people would see Health Catalyst as an IT tools and services vendor. What gave you the confidence to let them get so involved in quality projects going beyond the technology?

We have a history with Health Catalyst. We were their first customer out of the chute when they were a two-man shop, then known as Health Quality Catalyst. At that point, I was leading the quality agenda for the organization. I saw that we had insufficient information to know what outcomes we were getting at what price for the patients we served. 

We had to integrate dozens of databases to be able to show what that looked like, to show our outcomes. The electronic medical record was not enough. It was one source input, but it wasn’t nearly enough for us to do what we needed to do to get all the — you can call it big data, you can call it whatever you want — integrated in a way that it allowed us to focus our resources correctly for patients.

We engaged the two founders of the Health Quality Catalyst, now Health Catalyst, Steve Barlow and Tom Burton. We were their first customer because we realized we wanted a way to set up a data in an integrated way akin to what Intermountain Health had done, and they came from Intermountain Health.


There’s the question of whether organizations don’t have enough data or whether they don’t have the willingness to act on the data that may already have available to them. How do you quantify an organization as to whether they’re ready to be data driven?

I’d say it’s neither of those two things. We have tons of data, but our previous data was just dumped, like a dumping ground, into what was a data warehouse. There was no way to get it out in any meaningful ways nor have it be actionable on the back side.

I would say that it’s actually the integration of the data in a way that’s usable and meaningful for the people who know the work the best. That is the biggest challenge for folks. Everybody and their mother might say they have a data warehouse and they do. We had one before, too. It was a big dumping ground and we couldn’t get anything meaningful out of it.

Now we have a data warehouse that actually integrates over 27 different databases and shows us an outcome of what our variation is in the way that we’re caring for people. What outcomes at what cost. It puts an overlay on it that gives us a dashboard so that people can make some use out of the numbers.

For example, through all these databases, we were able to develop using hundreds of factors a predictive model that told us who was at greatest risk for readmission. Now we have a predictive model that predicts with about 80 percent effectiveness who’s likely to be at greatest risk. They’re flagged right when they’re in the hospital. We know we can put care management resources right to those people because they’re flagged as being high risk for readmission.

It’s those kinds of things that we can do. Our caregivers can use that information directly.


Other than readmissions, what impactful results have you seen from the use of data analytics?

A lot of its success has been cultural. We’ve been able to engage physicians much better in better care improvement activities because they know that we have measures of performance that are meaningful and accurate. A huge part of this has been cultural and engagement of physicians and caregivers because they’re the ones who really can improve care process, which is where most of the wasted cost is now is … on care processes. A lot of it’s been on the engagement because they know it.

I’ll give you an example that shows you about an initiative and shows you about that engagement. We had an early initiative about reducing, like many organizations have, early inductions of labor. We had integrated all the data that shows us where they were happening, by what physicians, at what gestation, for what reasons. We could get it in moments where other health care organizations were taking months and months to get that information. We could get it in moments.

Then I was at a conference table where somebody said to another doctor, "Well, that can’t be right. That can’t be what my induction of labor is." The other person looked at them and says, "Nope, I’ve looked at the data. I trust the data and it is right." We were able to, in that case, reduce our elective inductions of labors from 14 percent — which it should be next to zero — to about 1 percent. We have maintained that for the last two and a half years. That results in about 250 fewer women having Cesarean sections per year and many fewer babies being in the intensive care unit.

That’s an example of where we’ve been able to engage the physicians. They believe the data. We’ve been able to drive towards an outcome that has meaning in terms of better health for the individuals at a lower cost.


For a health system that doesn’t have a physician CEO, what would you recommend as a structure to take that information and convince physicians to act on it?

We try not to invent what has already worked well other places. The structure we’ve used is looking at our clinical service lines across the organization for specialty care and also our primary care base. Then having content expert groups around a particular care conditions of the patients focus on what they wanted to measure and what data and information they needed to make sure that the care was the best.

For example, in the oncology clinical service line, we have a breast program committee. That breast program committee decided the 31 things that they wanted to measure around quality. That breast program committee includes doctors, but it also includes administrators and nurses and radiation folks and all kinds of multidisciplinary physicians from oncologists to surgeons to radiation oncology people and general medicine. I think focusing around a condition of the patients was important and getting the multidisciplinary team together to do that and to find what was important.

One other thing I’ll add is in the best of our groups, adding some patients to it also has helped. The patients — I’m just thinking about that breast program committee — said, "You’re measuring how long it takes me to get a diagnostic mammogram done. That doesn’t matter to me. What matters to me is when you find a problem, how long it takes me to get in for the next test, because that’s when I don’t sleep at night."

That’s where we’ve been able to connect that dot with the patients in our best forms. We don’t have that everywhere, but that’s been best. That changes the conversation and makes it assured that it’s patient focused because, as I said when you were talking to me about challenges right now, right now one of our biggest challenges in healthcare is that the waste that we’re trying to reduce in healthcare is somebody’s revenue these days. That’s where it gets very difficult.


The agreement with Health Catalyst must have been complicated to negotiate since Health Catalyst is taking financial risk along with Allina, but then Allina gets partial ownership of Health Catalyst. Is the agreement that you’ve signed going to be difficult to manage and measure?

We spent a lot of time on that part. I think it’s a great partnership because Health Catalyst has incredible tools, but most people like them just hand you the software tools and they say, "OK, now here do." Through this partnership, we can have these incredible tools, but then we have the arm that shows us how to implement those and how to engage caregivers around implementing them in the right way for the right reasons for the right patient. We think it’s a good marriage that marries the knowing and the doing in a big, important way, so that’s huge.

We spent a lot of time, to your point, about what do we each look at as measures of success. We spent just painstaking time saying, “What looks like success in this? What key process indicators do we have? What do we have to make sure is maintained in this agreement to make sure it’s successful?” I think we’ve done that enough up front so that it won’t be very difficult to administer now that we’ve defined it on the front end of these negotiations. We’ve aligned our interests in a very profound way.


There’s a lot of discussion about the need for patient empowerment, getting patients involved in their care and having some control over their care episodes. Are there any projects that you’re working on that address that?

That’s a really great question. That’s where we’ll have to evolve to. Right now we’re evolving in ways that we can have trusted outcomes information and an implementation arm in terms of management to move those outcomes in a better way.

But you’re absolutely right. The holy grail is, how can we make patients the principle agents in their own health so that we move even further upstream instead of just reacting to how we can better care for those who are ill? How can we better support them to be well? I don’t think we’re all the way there yet, but we’re talking about tools and ways in which to do that better.


How do you draw the line between the healthcare system and social services delivery, where the health system has responsibility for managing populations but can only go so far into the community? What are the challenges or opportunities?

That’s another really great insight and question. There will surely be partnerships and walls broken down in ways that we never envisioned them to be broken down. I certainly don’t think that we as a healthcare organization can do things like fixing the cracks in the sidewalk. We need partnerships with social services agencies. But a lot of what we do will become more an more analogous to social work services and partnerships with those social service organizations than we do today.

I’ll give you an example. We did actually merge with a organization called the Courage Center for people with disabilities. We had all the acute care services for those people who had had a recent stroke and needed physical rehabilitation. We had some sports and PT clinics. But we didn’t have the in-betweens of having post-acute care for those patients, transitional care. What the Courage Center brought us was vocational training, activity-based training, and sports and activity programs where they were able to see how they could drive, where they could do some of those community-based programs. That’s the full continuum.

In this case, we did it through a merger. In other cases, we’ll have to do it through partnerships. But you’re absolutely right to ask that question because the continuum is becoming much broader than we ever thought of in the past.

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January 6, 2015 Interviews 5 Comments

Morning Headlines 1/6/15

January 5, 2015 Headlines No Comments

Lexmark International to Buy Medical Imaging Company Claron

Lexmark acquires Claron Technology, a web-based medical image sharing platform, for $37 million. The company will be integrated into Lexmark’s content management software division.

U-M Hospitals’ Sue Schade named CIO of the Year

Sue Schade, CIO of University of Michigan Hospitals and Health Centers in Ann Arbor, is named CIO of the year by CHIME and HIMSS.

A Look Back at 2014

John Halamka, MD and CIO of Beth Israel Deaconess Medical Center, blogs about the major events that shaped 2014, both in health IT and on his small farm outside Boston, of which he quips “ I shovel manure because it is so different from my varied day jobs, although some debate that point.”

The remaining uninsured: Closing ACA gaps

While the Affordable Care Act has significantly reduced the uninsured rate in the US, 14 to 18 percent of the general public are still uninsured, despite the fact that most of the remaining uninsured qualify for one or more assistance programs.

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January 5, 2015 Headlines No Comments

Curbside Consult with Dr. Jayne 1/5/15

January 5, 2015 Dr. Jayne No Comments


For many, the end of the year means time off and relaxation. The end of 2014 brought extra stress for our medical group as our Meaningful Use coordinator took an unexpected medical leave three days before the end of our reporting period. 

After having previous employees leave us in the lurch, we’ve learned to assume that someone could win the lottery and not come into work the next day. We’ve tried hard to make sure that all of our key roles have a backup person designated to step in. We also have strong policies and procedures regarding documentation to ensure that if we have to replace someone, the potential negatives are minimized. This was a good test of our system. So far, things seem to be working well with just some minor glitches. 

Our leadership group had already approved the plans for creating the attestation documentation for Eligible Providers. Those parts of it that could be done in advance were already largely complete. Fortunately, our vendor provided extremely detailed Meaningful Use training with almost ridiculously specific instructions for how to prepare documentation in case of an audit. Although we made fun of it at the time, we’re very grateful for it now because it has allowed us to quickly determine what documentation we have and what we still need for each physician.

Although some people instinctively react to the billions of dollars spent on Meaningful Use and even more specifically to the $44K per Eligible Provider figure as some kind of a windfall for physicians, it doesn’t even begin to cover the amount of money needed to actually install, maintain, and optimize the software needed to qualify. It doesn’t pay for the lost productivity while we check boxes that don’t assist us clinically, either. For our group of several hundred providers, it also requires multiple full-time staff members to train, report, retrain, track, analyze, and educate so that we don’t miss our goals. 

We’ve definitely been hurt by the fact that Meaningful Use is all or none. Last year, we had a couple of providers who were really close, but failed on one or two measures, which results in an unsuccessful attestation. We redoubled our efforts around those providers and it looks like they’re going to be successful this year.

Still, my office is now full of hundreds of individual physician binders, ready to receive the rest of the attestation documentation as it becomes available. I wound up as the lucky repository for it since my office is a converted conference room and I’m in it only rarely. I didn’t think much of it initially, but now that I sit here looking at all the work in progress, I think about how many hundreds of hours of staff and physician time have been taken up trying to chase the MU money and avoid future penalties. I can’t help but think that it hasn’t been worth it.

As employed physicians, most of my colleagues don’t have a choice whether to participate or not. As we continue to acquire practices, it has become more complicated. Some may have attested previously under another employment agreement or as individuals and may not have the data we need. Others are unsure whether they’ve attested or not. 

For those who have been employed at the same place since 2011 when this all started, though, it has been a little less complex. Still, those "complicated" binders take up an entire folding table in my office. At least as independent physicians they received the MU payments directly. However, as employees, the payments are shared between the physicians and the organization.

Our group is one of the only employed groups in the area that actually shares the incentive payments between the employer and the physician. Our competitors absorb the payments as a cost of doing business. It’s all part of the complexity of physician compensation and reimbursement. 

Some health systems "charge" employed physicians for EHR costs and maintenance, while others don’t. Some distribute payments based on overall group performance (so providers might get compensated for MU payments although they would be filtered into the general fund first). Still others have arcane and specific accounting systems that charge or reward physicians on a line item basis. As employees, they could determine whether MU payments were a boost or a bust, but they still wouldn’t be able to do much about it.

The one entity for which MU was definitely not a boost (at least not at my organization) was the environment. We’re printing reams of paper for our attestation documentation binders (aka audit defense). Although we have soft copies as well, providers will be required to maintain the documentation at their primary practice locations and we will also keep a copy at the home office. The amount of paper moving into my office on a daily basis as more reports are delivered and more screenshots are prepared is truly staggering. At least someone had the foresight to buy printer paper that was already binder drilled so we don’t wind up with repetitive motion injuries from the three-hole punch.

I don’t think any of us expected to be in this position a decade ago, where we would be using twice the paper we eliminated with EHR just to keep up with government mandates. Although we’ve streamlined care through interoperability and data sharing (at least in my surrounding community), we’ve created more bureaucracy than we’ve eliminated.

Still, it’s a new year and I remain hopeful. Hopeful that MU Stage 3 will not bring more onerous requirements and that our vendors will have some breathing room to return to coding features we actually want and need rather than what government entities think we want and need. I’m hopeful that patients will continue to take advantage of all the patient engagement opportunities and that those who are not yet doing so begin to manage their health and have preventive services performed as appropriate. I’m less hopeful that physician and staff burnout will decrease, but I’m trying to remain optimistic and instead just hope that it won’t increase.

What are your hopes for the New Year?  Email me.

Email Dr. Jayne.

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January 5, 2015 Dr. Jayne No Comments

Readers Write: Death to the Dinosaurs! DRGs and the Legacy of What it Means Under the Affordable Healthcare Act

January 5, 2015 Readers Write No Comments

Death to the Dinosaurs! DRGs and the Legacy of What it Means Under the Affordable Healthcare Act
By Matthew B. Smith


You could really also call this piece “History Repeats Itself.”

For those of you who recall the reimbursement transformation of the healthcare industry from a cost-plus formula (no institution in the field lost money under this approach) to the DRG Era (October 1983), life is about to repeat itself.

Payment caps were placed on 466 diagnostic and therapeutic procedures based upon the type and place where a procedure was performed. The Old Guard of Dinosaur Hospital Administrators couldn’t adapt and the nearly 6,000 U.S. hospitals at the time underwent a financial operation that affected their health.

Prior to the enactment of the federal regulations, less than 1 percent of all inpatient facilities (which funneled about 80 percent of all healthcare dollars) were in financial straits. Within seven years, well more than half were suffering asset declines and nearly 20 percent were facing cash flow dilemmas that threatened their very existence as going concerns. New York State had more than half its hospitals in financial difficulty.

A new breed of administrator — drawn from outside the industry, by and large, and with MBAs, not the soon-to-be outdated MHA — had to find their way into the industry (along with substantially larger salaries and performance structures) to reformulate how these institutions play the game.

Now the Affordable Healthcare Act (AHCA) portends yet another drastic (read: draconian) change to our beloved industry. The current crop of dinosaurs will need to be replaced yet again.

The AHCA will drive reimbursement towards direct links with patient outcomes and be a distinct report card on the deliverers of care. Penalties for not achieving population catchment healthcare levels (too many readmissions; too many specific conditions with below average status; higher costs per unit of service relative to the patient’s achievement level; mistakes in medication administration; higher than normal nosocomial infection rates) will cause the bottom 3 –5 percent of providers to lose payments and have it redirected to the top 3-5 percent. This is a “taking from Peter to pay Paul”* concept so that net/net healthcare payments are flat.

The ability to achieve this and measure it so that it can be implemented (along with the other AHCA factors that are mandated) will give rise to a new healthcare administrator extremely well versed in IT and data accumulation and farming the data. The accent on secured and incontrovertible healthcare information adhering to the concepts of confidentiality, integrity and authenticity (CIA) to make an institution’s case will demand new management with a decided proficiency in not only amassing, but organizing and clinically and financially proving that the provider organization has successfully delivered care.

Failure to be a top performer or even a middling-level participant will have excruciating financial impact as it did when DRGs came into effect. These new breed leaders will look at industry and non-industry solutions to accumulate and manage the massive amount of data that the HITECH Act is encouraging. The New Breed will master it as other industries have shown they can, but the healthcare field will, once again, be strewn with the fossils of dinosaurs among providers and vendors who didn’t listen to the changing reimbursement and care outcome winds that are blowing.

*For those of you not familiar with the origins of this phrase, it arose when the Church of England separated from the Roman Catholic Church and the English King (Henry) levied taxes on the Cathedral of St. Peter (Catholic) in London to pay for the construction of the Church of St. Paul (which Henry headed as the Church of England) also in London.

Matthew B. Smith is president and CEO of SecLingua of Shelton, CT.

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January 5, 2015 Readers Write No Comments

Readers Write: Leveraging Technology to Create Payer-Provider Collaboration

January 5, 2015 Readers Write No Comments

Leveraging Technology to Create Payer-Provider Collaboration
By Andrew Underhill


Although providers and payers play a critical role in elevating US healthcare, these two entities have not traditionally worked collaboratively, especially when it comes to sharing information. Up to this point, the two groups have shied away from exchanging data, with providers holding on to patient clinical information and payers protecting patient financial information. However, the walls are slowly but surely coming down as more providers and payers begin to partner in delivering accountable care.

There are both operational and patient care benefits to smoother provider-payer information exchange. For example, when providers are given access to claims data, they are able to garner a more longitudinal perspective of the patient’s health and treatment to date. This enables more informed care decisions and also reduces the likelihood of duplicative or unnecessary tests. It also limits the reliance on patient memory and perspective, ensuring care decisions are based on facts rather than educated guesses.

On the payer side, having access to clinical data allows the organization to adjudicate claims more effectively, improving efficiency and ensuring the most appropriate care for members. Clinical data also helps payers proactively manage their members’ care rather than responding to issues after the fact.

Despite the advantages, there are some significant roadblocks to payer-provider information exchange. Although some would suggest technology shortfalls have been the primary hurdle, it is the business barriers that present the greater obstacle. Providers in particular have been hesitant to share data with payers because it includes competitive and pricing information they would prefer to keep internal. Moreover, some physicians are concerned that making this kind of data available to payers may open the physician up to criticism on how he or she treated the patient.

To reap the benefits of information exchange while still acknowledging provider and payer qualms, organizations should take a well-considered approach to any data sharing arrangements. Following are a few tips to ensure these agreements meet all parties’ goals.

  • Appoint an advocate. To truly realize provider-payer data exchange, organizations must have an advocate who will push the idea forward and raise awareness of the strategic, financial and patient care benefits.
  • Develop a strategic roadmap. The advocate should work closely with organization leadership to identify the business drivers for data exchange and craft a strategic plan to lay the cultural and operational groundwork. Basically, this plan should be a roadmap that underscores the importance of provider-payer information sharing and defines how to achieve success.
  • Establish trading partner agreements. Before actually exchanging information, providers and payers must set up trading partner agreements that define the types of data to be shared, the appropriate data-sharing standards, and how the data will be used. This should be a customized agreement that reflects the unique needs and characteristics of the institutions involved. By setting the parameters upfront, both parties can be confident any data exchange will meet their needs and not violate internal strategic goals.
  • Define an exchange framework. Once organizations have a forward path, they can search out solutions to enable seamless information sharing. Providers and payers may want to consider using health information exchanges—such as those provided by the state or a local entity—to securely share data. A commercial product that facilitates payer-provider information exchange can also be a good option.

Greater transparency will ultimately drive better healthcare, and a key to transparency is robust data exchange between providers and payers. Organizations that embrace this idea now can be on the forefront of collaborative care, improving the patient experience and driving better health outcomes.

Andrew Underhill is a chief technologist at Systems Made Simple of Syracuse, NY.

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January 5, 2015 Readers Write No Comments

Morning Headlines 1/5/15

January 4, 2015 Headlines No Comments

Analytics-based U.S. tech firm Inovalon files for IPO

Inovalon Holdings, a data analytics vendor focused on healthcare, files a $500 million IPO.

Blue Cross starts health system payouts for value-based contracts

In Michigan, Blue Cross Blue Shield pays out $25 million to five hospitals that signed value-based reimbursement contracts in 2011 and 2012.

Wilmington doctor waits for NC Tracks payment

Physicians in North Carolina file a law suit against the state’s Department of Health and Human Services over billing issues that they claim led to doctors being paid lower Medicaid rates for services provided to Medicare patients. The payment problem stems from a custom software system developed by CSC at a cost of $484 million. The state DHHS has filed to dismiss the suit and refuses to acknowledge that there is a problem.

Adviser Guides Obama Into the Google Age

The New York Times profiles Megan Smith, the new White House chief technology officer, and her transition from a Google executive to a federal employee, where she now carries a BlackBerry and supports information systems that still partially rely on floppy disks.

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January 4, 2015 Headlines No Comments

Monday Morning Update 1/5/15

January 3, 2015 News 11 Comments

Top News


Healthcare analytics vendor Inovalon Holdings (known until a 2012 name change as MedAssurant) files for a $500 million IPO. The CEO and board chair is cardiologist Keith Dunleavy, MD. The company’s technology is used by NextGen, Greenway, Allscripts, and Walgreens.  

Reader Comments


From KimJongDeux: “Re: Athenahealth. Interesting that Jonathan was the much celebrated, drunk, foul-mouthed (and most un-funny) host of HIStalkapalooza for a few years and the article above seems to indicate the bloom is off the rose. Guess he’s not on the program this year? We seem to have a company run by force of personality. The quote, ‘Those naysayers don’t understand the company’s business model’ is the same cry as we hear from self-styled ‘artists’ when their works are panned and from CEOs who either get no push back from their yes-men staffs or who weeds out or banishes anyone who disagrees. The fact that their corporate meeting involves officially sanctioned heavy drinking games tells me all I need to know. And the fact that the CEO openly supports it as a good thing is troublesome. I agree that if the force of personality ever left, the company would fold like a house of cards. Being brash, loud, and verbally overpowering others can keep the airplane aloft only so long.” The company has a new logo and website, I’ve noticed, moving away from the squint-inducing yellow and green color scheme to a more serious-looking purple and green.


From PM_from_Haities: “Re: Epic’s going public. It would have very little effect. The capital structure of a company (i.e. going from private to public) impacts who owns Epic, but it’s leadership would likely be unchanged. Given Judy has plenty of cash, it would make very little sense for her to add that kind of public scrutiny unless it helped in gaining government contracts. Epic would continue to deliver on its promises and continue to grow. If anything, Epic might get BETTER by being publicly traded as they would typically have a stronger marketing department.”

HIStalk Announcements and Requests


One-fourth of respondents to my poll expressed a positive impression of HIMSS, with 38 percent each having neutral or negative feelings. New poll to your right or here, triggered by last week’s Fortune article: which set of quotes best describes Athenahealth, the positive ones by CEO Jonathan Bush or the negative ones from a skeptical hedge fund manager? Vote and then click the “Comments” link in the poll box to explain yourself.

Attendees of our webinars have asked about the possibility of receiving continuing education hours. I looked into this years ago and concluded that the only way to accomplish that would be to connect with a university already set up to award CEUs to physicians, nurses, and pharmacists. I’m open to suggestions.


I registered for the HIMSS conference this weekend since the early full registration rate of $745 is good through January 27. My impressions:

  • The online registration is slow because it tries to upsell you on extra-cost events, but it’s efficient otherwise.
  • The registration policies document says that HIMSS doesn’t share attendee email addresses and to report any email received from an exhibitors. I assume that means that, as usual, registrants will receive a barrage of promotional snail mail (some of it invariably arriving after the conference has concluded).
  • The registration policy references a “use of photographic images” clause in the same document, but the only related item involves “recording any educational session content,” so apparently the widely ignored ban against taking exhibit hall photos has been eliminated.


Divurgent, Elsevier, Falcon Consulting, Sunquest, and Thrasys have signed on as sponsors of HIStalkapalooza, which will be held Monday of the HIMSS conference week at the House of Blues Chicago. It’s an expensive event to put on — the facility, food, bar, and band add up to more than $175 per attendee — and the number and level of sponsors dictates the number of people I can invite (and thus the number I can’t invite) without going deep into the red. We still have a couple of weeks to add new sponsors – let me know if your company is interested in standing out among all the conference noise that week.

Last Week’s Most Interesting News

  • An report looking at six ONC-funded state HIEs finds that large health systems can be either supporters or competitors, HIEs are beginning to embrace Direct despite its poor EHR integration, and the HIEs are still searching for use cases that the market wants.
  • A Wall Street Journal report finds that a significant portion of Medicare fraud is perpetrated by the 45,000 newly registered providers each month that CMS says it doesn’t have the resources to review.
  • CSC pays $190 million to settle an SEC fraud case that includes its UK NPfIT contracts.
  • A Fortune profile contrasts Athenahealth’s high-flying public image with the skepticism of investment advisers and managers who say the company’s tiny market share and flattening performance suggests otherwise.


January 13 (Tuesday) 1:00 ET. “The Bug Stops Here: How Our Hospital Used its EHR and RTLS Systems to Contain a Deadly New Virus.” Sponsored by Versus Technology. Presenter: John Olmstead, RN, MBA, FACHE, director of surgical and emergency services, The Community Hospital, Munster, Indiana. Community Hospital was the first US hospital to treat a patient with MERS (Middle East Respiratory Syndrome). It used clinical data from its EHR and staff contact information from a real-time locating system to provide on-site CDC staff with the information they needed to contain the virus and to study how it spreads. Employees who were identified as being exposed were quickly tested, avoiding a hospital shutdown.



OB/GYN EHR vendor DigiChart promotes Rodney Hamilton, MD to president and CEO.

Announcements and Implementations


Terrebonne General Medical Center (LA) goes live in its admissions area on RightPatient facial recognition software from Atlanta-based M2SYS Technology.

Government and Politics


The New York Times profiles US CTO Megan Smith, with insiders concluding that while she has a big vision and the president’s ear, she’s also in a position that comes with unclear mandates, minimal budget, and responsibility for outdated technology platforms. The article points out that the newly created United States Digital Service reports to the Office of Management and Budget instead of her office.


A class action lawsuit filed by doctors against North Carolina’s Department of Health and Human Services over software that incorrectly paid practices Medicaid rates for services provided to Medicare patients lingers on a year later. A family practice doctor says the state owes him $100,000, adding that in his pleas to DHHS, “There was a complete lack of courtesy. Those people have no humanity.” The NCTracks system was developed by CSC at a cost of $484 million, with a significant portion copied from a similar system CSC built for New York City. The US Justice Department sued CSC and New York City in October for Medicaid fraud, claiming that the $1 billion New York system didn’t correctly bill Medicaid secondarily to private insurance. Neither system was related to CSC’s $190 million settlement with the SEC last week over accounting and fraud claims involving the company’s work on the UK’s failed NPfIT project.

Oregon’s proposed 2015-2017 budget includes $3 million for a prison system EHR, which is expected to go live in early 2016.  

Privacy and Security

The US Postal Service announces that a previously reported breach of its systems that exposed the Social Security numbers of 800,000 employees also included medical information on 485,000 current and former employees as well as retirees who had filed for worker’s compensation. The most interesting aspect to me is the huge number of injury claims filed with USPS.


I mentioned last week that John Olmstead, who runs the ED and surgery departments of The Community Hospital (IN), says in an upcoming Versus webinar that he would like to see a GPS-wayfinding type technology so that hospital visitors could navigate around campus using their smartphones. Readers sent information on two companies that offer such technology:

Connexient offers a smartphone app that provides turn-by-turn navigation to visitors at Robert Wood Johnson University Hospital and will bring six more hospitals live on it in the next few months.


Madison, WI startup Solomo Technology is using similar technology to help conference attendees locate session rooms. It offers APIs so that developers can integrate its location and content services into their own apps.


An excellent analysis of the fitness tracker market makes great points:

  • Courts are beginning to accept fitness tracker data in cases ranging from vehicular accidents to worker’s compensation, with resulting privacy concerns.
  • Wearable device manufactures use glossy marketing to position themselves as health and wellness brands instead of step counters. “You will never find a review for Jawbone or Fitbit that says ‘works as advertised’ because no one knows what they’re advertising.”
  • Trackers have penetrated only 3 percent of the market and the washout rate is high.
  • The Scanadu medical tricorder-type device holds great promise, as does senior monitoring app Lively.
  • Companies that have bought a single brand of fitness tracker for employees haven’t seen broadly successful results because people are motivated differently.
  • Users don’t want more data, they want to have devices tell them what to do and to simplify their technology interactions rather than to add new ones.



This headline from the Rome, GA newspaper succinctly describes a lot of what’s wrong with the US economy. Taxpayer-funded organizations that don’t pay taxes themselves shouldn’t be the only hope of employment growth. At least government hiring didn’t top the list.


The Madison newspaper profiles Nordic Consulting co-founder Mark Bakken’s transition from entrepreneur to venture capitalist. He’s putting together a $10-$20 million venture fund that will invest $300,000 to $500,000 in Madison-area companies whose technologies work with Epic. He has raised $4 million so far (including $1 million of his own money) and says several Epic-using health systems have expressed interest in investing. The article mentions that he has personally invested in eight startups (Catalyze, Forward Health Group, Wellbe, Moxe Health, 100health, Quietyme, Healthfinch, and HealthMyne) and four of those have hit $1 million in annual revenue. Bakken, who stepped down from the CEO role at Nordic last month but remains board chair, says he “won the lottery with Nordic,” which had $81 million in revenue in 2013.


A fundraising project for the children of The Johns Hopkins Hospital senior software engineer and bike shop owner Tom Palermo that included a 1,000-participant New Year’s Day ride has raised $60,000 so far, well beyond its original goal of $10,000. Palermo, 41, was killed last weekend when he was run over while bicycling by an Episcopalian bishop with a previous drunk driving arrest who fled the scene. She has been placed on administrative leave pending possible criminal charges following her admission that she hit Palermo, who leaves behind his wife, six-year-old daughter, and four-year-old son. The bishop had previously received probation for her 2010 DUI arrest (before she was hired by the diocese) in which she was driving a car with a tire shredded to the rim, told police she had drunk alcohol and smoked marijuana, and recorded a 0.27 on a blood alcohol breath test.

Five Michigan health systems receive $25 million in value-based payouts from Blue Cross Blue Shield of Michigan, which says the hospitals and physicians are communicating better because of EHRs and HIEs. The systems will also receive $500,000 each over three years to improve their IT systems and care coordination. The chief medical officer of Henry Ford Physician Network says he gets immediate notification if his patient is is seen by any provider in the network or at an area hospital that uses Epic, but otherwise he won’t know about it until he sees the patient next, so he’s looking forward to using the money to improve HIE connectivity and to improve data capture from physician practices.


Lenox Hill Hospital (NY), embarrassed by international press coverage of a British couple unfortunate enough to have their premature baby delivered in the US at a cost of $200,000 instead of free in England, hints that it will simply write off the bill, sticking less-publicized patients with the burden of its profitability. It really annoys me that when media outlets publicize a ridiculous hospital bill involving a feel-good patient, the hospital nobly agrees to cancel the bill as though it doesn’t really need the money. The rest of us who get equally absurd hospital bills are turned over to collections for every dime. Somehow the public never sees through this PR scam to realize that we’re all paying for it. The same hospital annoyed patients and families three years ago by restricting visitor access so that Beyonce and Jay-Z could have their baby in the manner to which they have become accustomed, with the star couple adding their own private security force to guard the VIP suite (the hospital denies rumors that the couple spent $1.3 million to upgrade their room). The CEO of North Shore-LIJ Health System, which owns the hospital, was paid $4.3 million in 2013.


The Sioux City paper describes the interoperability situation between UnityPoint Health – St. Luke’s and Mercy Medical Center, running Epic and Cerner, respectively, and still faxing scanned chart images back and forth. The hospitals are bringing up Iowa Health Information Network with hopes of electronically exchanging at least summary records.

Tennessee doctors are diagnosing and treating people with flu by telephone or telemedicine, telling them not to come to the office for fear they’ll spread the virus to other waiting patients.


A ProPublica investigative article exposes the billing practices of the for-profit debt collection agency run by non-profit health system Mosaic Life Care (MO), which has filed 11,000 lawsuits in five years to collect money from uninsured hospital patients and to garnish their usually low wages. The part of the story that always drives me crazy: uninsured patients are sued for the full (phony) list prices hospitals make up in order to give 90 percent discounts to insurance companies, so people are losing their homes to pay for $12 Tylenols and the ever-accruing interest charges and attorney fees. It seems reasonable that hospitals be required to charge cash-paying patients their lowest prevailing contracted prices.

A JAMA opinion piece written by informatics people from Christus Health points out the rising numbers of medical scribes, the number of companies (22) offering their services, and the creation of a scribe aptitude test and a vendor-led member association. It says that overuse of scribes to make up for EHR inefficiency can lead to compliance and clinical issues, concluding:

The answer to today’s inadequate EHRs is not scribe support. Instead, physicians should demand improved products, should educate vendors to ensure that they understand how physicians think clinically, and should clarify what is needed for an intuitive, quick, and navigable user interface. If such usual market forces are vibrant, and physicians engaged robustly, EHRs will evolve rapidly. Yet even after a decade of use, some EHRs and CPOE may not compete with the speed of a paper checklist, and may never.

The New York Times notes that a doctor whose office was raided by federal agents for writing oxycodone prescriptions for $200 in cash was caught only because neighbors complained about the traffic outside his unmarked office that was guarded by an armed bouncer. The doctor made $2.6 million in cash over two years writing narcotics prescriptions to patients who then turned the drugs over to “crew chiefs” to sell on the street. The practice created false medical records that included MRI reports and urinalysis results.


Dr. Oz makes a lot of headlines, most of them negative. His ABC TV show, “NY Med,” takes heat when a female viewer watches her husband die in an episode filmed at New York-Presbyterian Hospital without the family’s permission. Producers blurred the man’s face in the video, but the woman recognized him and heard his last words as the cameras rolled. Her son has filed complaints with the hospital, the state’s Department of Health, and HHS’s Office for Civil Rights. The hospital and ABC claim the patient isn’t identifiable, ABC says news is protected by the First Amendment, and the hospital says the man’s privacy rights ended when he died and blames the family instead for calling attention to his identity by complaining.


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

More news: HIStalk Practice, HIStalk Connect.

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January 3, 2015 News 11 Comments

CIO Unplugged 12/31/14

December 31, 2014 Ed Marx 2 Comments

The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

Forever Young

The song ‘Forever Young,” originally recorded by Alphaville, has been covered by numerous artists, most notably Jay-Z. As with many popular lyrics, the meaning differs for each listener. For sure, it’s a reference to the Cold War, during which it was written. But for me, it’s my 2015 anthem.

To live every day with my heart in the moment and only one eye on the horizon.

I’ve missed many heart moments. At age 14, I wanted to be 16 and then I wanted to be 18 and then 21. My first time swimming across San Francisco Bay, all I wanted to do was get out of the frigid waters. I hated it. When I was in college, I wanted to graduate and didn’t give a hoot about absorbing what I was learning. My freshman year, I fell in love, but romanticized the future and focused on getting married instead of developing a solid relationship foundation. When my babies were born, I groaned for the day they’d be potty trained. I missed critical bonding moments between “boring” infancy and tee ball age.

Essentially, I stunted my emotional evolution. Distracted with the stuff of earth, I was so absorbed in what I might gain in the future that I missed the present.

As are some of you, I’m a visionary by design. Without a vision, we go nowhere fast or drive backwards through life’s maze. But if we’re uber focused on vision, we shortchange relationships and forgo eternally valuable opportunities. Both ends of this spectrum are danger zones. When we lean too far toward vision, we lose two critical elements to a fulfilling life. Pain and Joy. And you can’t have one without the other.

“Forever Young” opened my eyes to being in the moment—emotionally.

I want to avoid pain, and relationships are painful. Work is painful. Can’t I just skip all the hard stuff and jump straight to the Promise Land? Why suffer? Let’s introduce new technologies and not deal with required culture and workflow changes. Keep pushing and everyone will eventually accept it as designed. So what if we rub one another the wrong way or talk behind a person’s back? Let’s just pretend that no one ever gets hurt and move on in our grand masquerade. Life is good!

Not really. Really living means we have to touch pain.

Years ago, I suffered rope burns on a challenge course. The skin on my hands was ripped off, exposing flesh. My ER friends could have simply put on salve, a bandage, fed me some drugs, and patted my back as I walked out. But then I’d return in worse condition. Instead, I screamed as they flushed my hand with saline, rubbing Betadine through my wounds and under the remaining skin. Today, you can’t see the trauma because they were willing to touch my wound.

A new year is prime time to change your game. Touch your wounds; touch the pain of those you love. Stop running and put on your big boy pants. I’d prefer putting on an Elizabethan collar (that lampshade thing dogs wear) to keep me from seeing or touching any wounds. Forgive and forget. Pretend nothing happened. Ignore pain. Get over it! I’ll be OK.

No! Pain unresolved only leaves open scars. You’ll feel counterfeit relief for a spell, but emotional scar tissue builds up. Continue to ignore and you’ll never reach your full potential. Every time you run from pain, you deaden part of your soul and become a false you. I am learning to embrace pain. In the moment. “Forever Young.”

Unspeakable joy. Only after you endure pain can you experience true joy. If you skip through the hard stuff, you cheat yourself. Total counterfeit. Superficial. And that’s boring!

The second time swimming the Bay, I stopped in the middle and beheld the San Fran skyline and the Golden Gate Bridge. Not only did I enjoy the moment, I then swam faster than my first time. Climbing some of the world’s tallest peaks, I marvel at the beauty of God’s creation and enjoy the moment. It makes the summit pure joy. I don’t reach the peak without the pain. The same goes for enduring emotional pain. Your soul reaches a new high.

Work conflicts. Not on my fun list. But I won’t run any more, meaning I won’t run away. I’ll run toward it, hoping to put some humanity back into the corporate world—culture shock! Some of my best working relationships will only be born out of pain if I don’t repeat past mistakes.

For example, a while back, an executive director was stuck in his ways and our personalities clashed. We never saw i2i. Did I go through the pain of deeper conversations or opening my heart to him, despite how he might stab me? No. I took the lazy way out. Smiled and nodded then walked out of meetings, rolling my eyes inside. But had we resolved, we could have become a dynamic duo rather than each other’s arch nemesis. We could have changed the future of our hospital. Working through the pain could have led to professional and personal joy.

I’m embracing the pain of my personal relationships. It’s messy! And it hurts deeply with every touch. I have plenty of open scars, and I’ve caused even more. But I have a new vision for healthy relationships, and the only way to achieve joy is to touch the pain. If I don’t change the game, I’ll become so callous I’ll no longer feel.

I am tired of missing moments. Of being shallow. No more counterfeit. Instead, “Forever Young.” I wanna be “Forever Young.”


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.

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December 31, 2014 Ed Marx 2 Comments

Morning Headlines 12/31/14

December 31, 2014 Headlines 1 Comment

CSC pays $190M to settle accounting fraud case with SEC

CSC will pay $190 million to settle fraud charges brought by the SEC.

The State HIE Program Four Years Later

ONC publishes a report on the state-level rollout of health information exchanges, the strategies and solutions they’re offering, and the problems they’re working through.

It’s ‘stupidity’ to install health IT without re-engineering workflow

Outgoing Geisinger Health System CEO Dr. Glenn Steele discusses reimbursement reform, health IT, and care management in a Modern Healthcare interview.

Is Athenahealth CEO Jonathan Bush in a bubble?

Fortune profiles Jonathan Bush, CEO of athenahealth, and his More Disruption Please program. He explains, “The plan is we’re going to create and curate the health care Internet.”

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December 31, 2014 Headlines 1 Comment

News 12/31/14

December 30, 2014 News 12 Comments

Top News


CSC will pay $190 million and will restate previous years’ financial statements to settle a variety of SEC fraud charges that includes its participation in the UK’s NPfIT program. That’s a minor amount compared to the $2.75 billion the company already wrote off for its work on the failed NPfIT project. CSC will change its 2011 balance sheet to reflect a $1.16 billion impairment charge.

Reader Comments


From Brandom: “Re: Barnes Jewish Christian. Rumor is it they will be installing Epic.” Unverified, but I ran a reader’s rumor saying the same thing on December 5. Often the earliest confirmation is a health system’s posting of a ton of open Epic positions, but BJC doesn’t have any of those on its recruitment site.

HIStalk Announcements and Requests

I have to disclose a brilliant idea I heard in listening to the rehearsal of the Versus webinar I mention below, which I honestly think is the most interesting webinar I’ve ever watched. John Olmstead of Community Munster captivated me all the way through on the hospital’s use of ED technology, but he really grabbed me at the end when he suggested technology tools he needs. His holy grail is a way-finding, GPS-type app that patients and visitors can use on their own devices to locate themselves precisely on a hospital floor plan, then receive directions to get them to a desired location. Example: I’m in room 4401 with my mom and I want to go to the cafeteria, then to the financial counselor, then to the gift shop, and then back to 4401, so give me turn-by-turn directions like I get with my car GPS. His take is interesting: patients will become so attached to hospitals that offer this app that they won’t consider going elsewhere, where they’ll go back to stumbling around lost or trying to follow decades-old red vs. green lines on the floor that lead to confusing elevators. Hospitals are always a poorly conceived patchwork of added-on construction that went up quickly as funding allowed, so visitors spend a lot of time wandering and wasting the time of employees who have to assist them. Turning that universally embarrassing situation into a competitive advantage is brilliant.

What’s really bugging me lately (it always has, but even more so now): companies that make portions of their name incorrectly upper or lower case, defying all of the civilized rules of spelling just because someone in marketing who’s never run a business has decided that being flagrantly incorrect is a desperate way to distinguish a company from its competitors. I’ve always refused to recognize all-caps vendor names like Meditech, Medseek, and Medhost, but I’ve also decided that I’m also no longer letting Athenahealth slide with the oh-so-cute small “a” at the beginning of the company’s name. Names in America start with a capitalized letter and then have all lower case letters following, so now I have to decide what to do with the many cutesy company names that stick capitalized letters midstream (even providers like Partners HealthCare mistakenly think that’s cool). I’ll even concede that HIStalk should really be Histalk if that will convince other companies to value conformity to accepted rules over marketing nonsense.


January 13 (Tuesday) 1:00 ET. “The Bug Stops Here: How Our Hospital Used its EHR and RTLS Systems to Contain a Deadly New Virus.” Sponsored by Versus Technology. Presenter: John Olmstead, RN, MBA, FACHE, director of surgical and emergency services, The Community Hospital, Munster, Indiana. Community Hospital was the first US hospital to treat a patient with MERS (Middle East Respiratory Syndrome). It used clinical data from its EHR and staff contact information from a real-time locating system to provide on-site CDC staff with the information they needed to contain the virus and to study how it spreads. Employees who were identified as being exposed were quickly tested, avoiding a hospital shutdown.

Acquisitions, Funding, Business, and Stock


Fortune describes Athenahealth’s “More Disruption Please” conference as “the Animal House of corporate gatherings,” with the company’s 387-acre Maine resort hosting drinking games and an after-party cabin for investors and corporate hangers-on led by CEO Jonathan Bush, described as a “hyperactive, no-filter goofball of a chief executive.” The article contrasts the party atmosphere to skeptical investors who believe that Athenahealth shares are massively overvalued, especially since the company just announced that revenue growth has slowed as it continues to lose money. Bush says those naysayers don’t understand the company’s business model and will miss the building of a Salesforce-like technology company that will “create and curate the healthcare Internet.” Hedge fund manager and ATHN short-seller David Einhorn isn’t buying it (literally), saying, “They’re a niche provider way out on the periphery with a tiny market share. I don’t see how they’re going to become a backbone of anything.” My take is that Athenahealth would have been an obscure, offshore-powered medical paper pusher without the cult of Bush’s personality; investors had better hope he sticks around and keeps his mojo since that’s the only way shares can continue to trade independently of tepid company performance as a self-proclaimed Internet high flyer. The money gods would lose interest quickly if recommending or owning ATHN stock no longer paid the dues for being a member of JB’s frenetic fraternity.


Athenahealth shares (in blue above) did OK in the past year, falling a bit short of the Nasdaq’s 15.6 percent gain but 25 percent off their March 2014 highs. The company is valued at $5.6 billion on annual revenue of $711 million and a negative operating margin. Jonathan Bush hold shares worth $46 million.


The Forbes article on Athenahealth mentions that the company’s $1.1 million investment in Castlight Health was worth $75 million at the end of Q1, allowing Athenahealth to buy a private plane it calls “the Castlight jet.” At least Athenahealth ended up with something more high flying than CSLT shares — above is the CSLT price chart since its March IPO (blue, down 71 percent) vs. the Dow (up 12 percent).


Cincinnati-based revenue cycle management firm The Consult Inc. (TCI) will acquire RCM software and services vendor Physician Management Information Services of Denver.


Specialty EMR vendor Modernizing Medicine acquires Aesyntix Health, which offers dermatology practice RCM, inventory management, and group purchasing services.  



The federal government awards Accenture a five-year, $563 million contract to continue the work it started on after CGI Federal was fired.

Medical practice performance management company GloStream chooses DrFirst’s EPCS Gold 2.0 controlled drug e-prescribing system to comply with New York’s I-STOP mandatory e-prescribing requirement.



Tom Palermo, a 41-year-old senior software engineer at The Johns Hopkins Hospital (MD), was killed in a bicycling accident Saturday. Memorial Mass will be celebrated Saturday in Towson, MD.

Announcements and Implementations


Lafayette General Medical Center (LA) donates a telemedicine station to a local elementary school, allowing ill students to be evaluated by a physician without leaving school.

Government and Politics


An ONC-commissioned report studying HIEs in six states finds that they commonly offer care summary exchange, lab results reporting and exchange, public health reporting, and ADT messaging, but otherwise their technologies and strategies vary. Lessons learned include setting attainable short-term goals to maintain stakeholder interest, recognizing that big health systems can be either supporters or competitors of grant-funded HIEs, and data standards are often voluntary but need to be standardized to achieve real interoperability. Five of the six states plan to charge subscription fees but haven’t set rates (the sixth HIE already shut down). The study found that Direct is still a confounder, with HIEs originally seeing it as a competing model but are now looking at Direct as an easier workaround to problems they found with query-based services, but Direct is still poorly integrated with EHRS (usually requiring providers to log in to a separate portal) since it wasn’t required of vendors until Meaningful Use Stage 2 and they’ve been slow to incorporate it. Wyoming’s HIE gets a special mention for shutting down immediately once its federal grant money ran out. The issue of sustainability is nicely summarized by this statement: “In the short term, grantees are trying to identify use cases that align with the market” (i.e., we built it and they didn’t come before the government money ran out, so it’s like being the owner of a tattoo shop when the local military base closes).



Iltifat Husain, MD names his best medical apps for 2014:

  • ASCVD Risk Estimator (#1)
  • JAMA Network Medical Image Challenge
  • Medscape MedPulse
  • UMEM Pearls
  • Multiple Sclerosis @Point of Care
  • PreopEval14
  • Pediatric Quick Reference
  • Eye Emergency Manual
  • Blood Donor by American Red Cross
  • CDC Vaccine Schedules
  • Family Practice Notebook
  • Change Talk: Childhood Obesity and Motivational Interviewing

A German hacker replicates a politician’s biometric thumbprint using only a press conference photo and off-the-shelf software. The politician, ironically, was speaking at a hacker’s convention. The hacker, who’s apparently not a fan of biometric security, says he assumes that politicians will start wearing gloves when speaking in public.


Siemens has been caught countless times over at least 100 years for bribing people to earn government bids, so this is hardly news: Israel’s securities regulator arrests six electric company employees for accepting $20 million in Siemens bribes related to a power station turbine bid.



Geisinger Health System CEO Glenn Steele, Jr., MD, PhD, who is retiring next year, comments on physician complaints about health IT in a Modern Healthcare interview:

Here’s my Jonathan Gruber statement: This is an issue of stupidity. If people believe that you can put IT in, continue working the same way you did before IT, and not get inefficiency, we are talking double-digit IQs here. What everybody’s learned over the last 15 to 20 years is if you put IT in, whether it’s hospital-based or ambulatory, you have to look at the entire workflow and use the IT implementation as an excuse for re-engineering your workflow from beginning to end. If you don’t do that, it’s going to create havoc. You’ve got to look at your patient-care processes from beginning to end and say, “How are we going to do it differently? How is this going to make it better?”

On the benefits of health IT, we couldn’t do point-of-service care innovation without having near real-time data fed back to us. You’ve got to have data both from the insurer side and the provider side to predict which patients or cohorts of patients are most likely to need the highest-intensity vigilance. If you don’t have feedback in a timely fashion, it’s not going to work.


The president and CEO of Campbell Soup Company says she’s a fan of the quantified self movement, in which people will “[take] charge of their well-being through the use of data and digital sensors, wearable health bands, and smartphone apps that can track and quantify everything from their heart rate, blood pressure, and sleep quality to steps walked and calories consumed. The word ‘quantify’ is what’s really important because people will use the personal data and feedback from these devices to make healthier lifestyle choices and adjust the way they eat, exercise, work and rest.”

I’m not interested enough to look up the details, but somehow Cerner and Allscripts are both involved in a patent dispute with RLIS, which apparently took a stab at the EMR market in the late 1990s but then folded. I mentioned a reader’s report of the lawsuit in mid-2012, so apparently it’s still churning its way through the court system.


CDC declares the 2014-15 flu season as an epidemic, with 22 states reporting significant influenza-like activity vs. 13 last week. Flu vaccine doesn’t seem to be working well against this year’s strain.

This is sad: a hospital Santa of 30 years hangs up her red and white suit, saying the drug test, background check, fingerprinting, and HIPAA requirements make it too much trouble to give young inpatients their December dose of Christmas cheer. At least a new Santa is happy to take over the suit, which the former Santa donated.

Only in America, home of too many lawyers trying to drum up work and too many righteously indignant people convinced that everything that happens to them is an egregious injustice wrought by deep-pockets defendants: the family of  a woman killed when a driver allegedly high on nitrous oxide rear-ends her as she slows for a traffic light sues: (a) the driver, which makes sense; (b) Toyota, because the family claimed the victim’s car was defective; (c) the driver’s sister, a doctor the family claimed helped the woman get drugs; (d) the towing company who released the driver’s car to her; and (e) a local ambulance company, who the family says caused the crash by responding to an accident with flashing lights on, causing cars to pull over right before the crash.


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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.



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December 30, 2014 News 12 Comments

Morning Headlines 12/30/14

December 29, 2014 Headlines 1 Comment

Accenture wins $563M contract to continue with

Accenture signs a $563 million five-year contract extension with HHS to manage and continue developing

ICD-10 Testing Results and DMEPOS Competitive Bidding Registration Reminder

CMS reports that during its November ICD-10 open testing period more than 500 providers, suppliers, billing companies, and clearinghouses submitted test claims, resulting in a 76 percent claim acceptance rate. The test checked that claims had a valid diagnosis code, ICD-10 companion qualifier code, national provider identifier, and date of service, and returned an automated acceptance notification when all criteria were met.

Startup Health Insights Annual Report 2014: The Year Digital Health Broke Out

Startup Health reports that $6.5 billion in startup funding flowed into the digital health sector during 2014, a 125 percent increase over 2013.

The National Patient-Centered Clinical Research Network: Clinical Data Research Networks (CDRN)—Phase II

PCORI will award $87 million to establish 13 clinical data research networks and $26 million to establish 22 patient-powered research networks as part of the second phase of its PCORnet project.

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December 29, 2014 Headlines 1 Comment

Curbside Consult with Dr. Jayne 12/29/14

December 29, 2014 Dr. Jayne 4 Comments

Whenever something happens with our EHR that physicians don’t immediately like, there is bound to be grumbling. Sometimes it doesn’t even have anything truly to do with the EHR, such as a change in requirements for Patient-Centered Medical Home recognition or with Joint Commission accreditation.

Physicians and clinical staff would have had to comply in the paper world, but they don’t see it that way. They seem to perceive such mandates as uniquely burdensome and EHR related despite our attempts to educate.

We’re going through one of those periods now. Our accountable care team has decided that we need to collect certain information in a specific way that doesn’t fit very well with some of our workflows. That’s the problem in an organization like ours – each hospital has its own CMIO, but we don’t have one over-arching person who can cut through the noise and make decisions that fully take into account the limitations of our various systems and vendors. The accountable care team has good intentions, but I doubt half of them have even seen the workflow of some of our clinical systems.

On the ambulatory side, we’re trying to make it as smooth as possible, even using some programming sleight of hand to get the data into the right format without clinicians having to enter it twice. The problem of non-clinicians dictating data that clinical staff must document certainly isn’t new. It goes back to the creation of ICD codes and E&M coding requirements. Anyone who has ever had to formally diagnose a patient with “Bone and Mineral Disease, NOS” rather than osteopenia simply to get it billed will know what I’m talking about.

In some ways, Meaningful Use has helped with this, allowing us to use SNOMED codes to capture that level of clinical granularity. We do still have to translate them into billing codes, however, resulting in parallel diagnosis lists in the chart. That can have issues as well.

When we first started using SNOMED, we found out there were issues with some of our mappings to ICD-9. As long as the data flowed from SNOMED to ICD, we were fine. But if clinicians tried to pull diagnoses off the billing list and convert them to SNOMED, detail was frequently lost.

Physicians immediately jumped on this as a patient safety issue. The financial team jumped on it because the loss of specificity could lead to decreased reimbursement. Those two forces combined made it easy to get access to resources to fix the problem quickly. One of our most vocal EHR haters used it as a reason to again call for discontinuing use of the EHR because of its many safety flaws.

We hear that chorus all the time. Although there are many valid points about EHR design and patient safety, there are also numerous points where EHR makes our work safer as well as more efficient.

I was thinking about this last night as I worked in the ER. There is a great deal of attention to EHR-related patient safety and people are always crying out for regulation. How much attention is there to financially-driven patient safety risks?

One of the patients I treated was a prime example of what happens as more and more of our decisions are financially driven. The patient was a young woman who came in because she couldn’t reach the on-call nurse covering her case. That’s the first point of failure – that physicians are no longer taking their own call because it’s more cost effective (and burnout reducing) to have a nurse cover your call.

Unfortunately, she has four different specialists involved in her care and didn’t actually have a problem that we could address in the ER. Her condition is complex and still partially undiagnosed. Her visit was more about coming to us as the place of last resort. She thought that if we tried to call her specialists, we’d have some magical ability to get her some answers.

If she had come into the medical system when I was a student, she would have been admitted to the hospital until the full workup was complete and we had a plan of care. Each of her specialists would have seen her daily and seen each other in the halls and at the nursing station. However, it’s cheaper to care for people as outpatients, so money was saved by sending her home. Unfortunately, her care was fragmented by this decision – the second point of failure.

During the course of her care, she developed a serious infection that required weeks of intravenous antibiotics. Her insurance company has a policy that patients under Medicare age be “trained” to administer their own infusions at home to save on the cost of the home health nurse. There is no regulation in my state about this practice, which gives payers the ability to make these determinations.

Apparently the patient either didn’t understand or didn’t receive the information that the antibiotic packets had to be kept refrigerated. When she went to the infectious disease physician’s office each week to have her IV line and dressing checked, it didn’t come up there, either. This resulted in the patient infusing 21 days of non-effective medication, which likely contributed to the recurrence of her infection, which was why she was in the ER — she was worried about whether it was extending.

Failure point number three is assuming that just because it’s statistically likely to be OK to allow a patient to administer their own IV antibiotics, that doesn’t make a clinical treatment plan applicable to all patients.

For each person demanding regulation of EHRs, where is the demand for regulation of situations like this? She did determine five days ago (after talking to the on-call nurse about her IV line) that the medication had to be refrigerated and a new supply was sent out, but the infection isn’t looking any better, which was why she was trying to reach her physician in the first place.

In talking to her, I struggled to figure out the best person to call. The infectious disease specialist was out of the country. His primary nurse had gone into labor and was being covered by a nurse who initially told the patient to call the surgeon and then didn’t return subsequent pages. The surgeon was also out of the country, but the patient didn’t think he was the right person to call since he wasn’t involved in the antibiotics. The primary care physician hadn’t seen her in six months. The other specialist involved is a plastic surgeon, who wouldn’t be of much assistance in this situation.

Failure point number four is lack of ownership of this patient and her complex situation, again in part due to cost-cutting maneuvers. Physicians just aren’t likely to spend hours playing phone tag with various specialists when that time isn’t reimbursed and payments are being cut.

I had the charge nurse put out a couple of pages to different specialists involved in her care, figuring there was an equal chance that whoever called back wouldn’t know anything about her, so might as well cast a broad net. In the mean time, I went back in and looked at the patient’s medication that she had brought with her. Sure enough, nowhere on the labeling did it indicate that it was to be refrigerated. It was from a compounding pharmacy contracted by an infusion company contracted by the insurance company. Many cooks in the kitchen always make for a questionable dish.

Ultimately one of the infectious disease nurses called back and we made a plan for the patient. Since she was clinically stable, fever-free, and had no new symptoms, she was stable to go home and the nurse would see her first thing the next morning. I reassured the patient and explained that our goal in the ER is to take care of any critical issues and make sure that patients are stable and that follow-up has been arranged. I chose my words carefully. Usually I say something about making sure any life-threatening conditions have been addressed. In this situation, there are still multiple factors that may threaten her health (and ultimately her life), but they were completely beyond my scope.

I’ve been thinking about her all day today and wondering how things turned out this morning. That’s the problem with putting a family physician in the ER. I always wonder about the follow up since continuity of care is one of the reasons I wanted to be a physician in the first place.

I’ve also been thinking about the ways that the system failed this patient. I can’t help but draw a parallel to all of the people out there who think that more technology is going to solve all the problems and that regulating the technology is the answer. Dealing with technology is just the tip of the iceberg in healthcare. This case is a prime example of everything out there that also needs to be addressed.

To the people who demand broad regulation of health information technology by the FDA as the solution to patient safety problems, I’ll get on board with that at about the same time the FDA gets oversight of compounding pharmacies, home infusion agencies, and payer executives squeezing the maximum profit out of the system. Based on the 50 patients I saw yesterday, they’re a much greater threat to patient safety than my EHR.

Email Dr. Jayne.

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December 29, 2014 Dr. Jayne 4 Comments

Readers Write: The Eve of War

December 29, 2014 Readers Write 3 Comments

The Eve of War
By John Gomez

Steve Lewis arrived at his office at 7:03 a.m., draining the last remains of his grande mocha as he finished chewing on his blueberry scone. These were his last few minutes of peace before the day started. He did all he could to savor them as his laptop booted. He began the login to his corporate network.




There on the screen in front of him was an image a red skeleton and the words “Hacked by #GOP.”

Steve pressed Escape, F1, ALT-TAB, CTRL-ALT-DELETE. Nothing. The skeleton just starred back at him. Power off. No luck — the skeleton remained. He closed the laptop and opened it. The skeleton was still there.

The sudden ringing of the phone made Steve jump. He noticed that every line on his phone was lit up with inbound calls. He randomly choose one and answered, “Sony Pictures network support, Steve speaking …”

Steve would handle hundreds of calls that morning, as would his colleagues. Everyone reported that their computer bore the image of a skeleton. Within minutes, word had spread across the corporation of the computer attack.

Managers scrambled to calm employees and asked them to remain, though many decided to take immediate time off as they didn’t feel safe. If you were to have asked Steve’s colleagues that morning, not one of them would have said, “I feel safe and secure.” 

In the coming days, Sony Pictures executives would make a gutsy choice and agree to the demands of the company’s attackers. Meanwhile, several hundred miles away, members of the Department of Defense Cyber Command were spending their time analyzing cybermunitions and strategies to provide the President of the United States with options in the event he ordered cyberattack on North Korea.

As the dawn of 2015 appears on the horizon, the United States is poised to engage in the first cyberwar in the history of mankind. If there is any irony to all of this, it would be that it all reads very much like a Tom Clancy script. Unfortunately, all of the events and the situation we find ourselves in as the year comes to an end are all too real.

The attacks on Sony Pictures by North Korea are interesting. Studying what happened is critical to protecting our own infrastructure and systems. The key takeaways are that although the attacks were not sophisticated or highly technical, the strategy by those who executed the attack was advanced.

We now know that Sony was being probed and scanned for months, with the sole purpose being to gather massive amounts of intelligence that could be used to formulate escalating attack strategies. We also know that as a result of this intelligence gathering, the attackers were able to carefully and selectively control the attacks and the resulting damage.

We should also keep in mind that since the attacks themselves were not highly advanced, it does show that the use of proactive security hardening measures could have helped Sony minimize or defend against the attacks.

What do we do now? We as an industry and nation have never had to prepare for a cyberwar. The battle is now all of ours. The actions we take in the coming days and weeks will be critical to how we navigate and survive whatever may occur on the cyberfront.

The top three targets for cyberterrorism and warfare are finance, utilities, and healthcare. Attacking any of those areas creates extreme consequence to the citizens. Of the three, the most damaging would be healthcare. The worst case would be affecting patient outcomes in some form or manner. In my eyes, this could be done.

My prescription is as follows.

Top-Down Education

Educate the C-suite and board of directors to provide clarity in terms of what occurred and the reality of the attack types and strategy. Clarify the resources and support needed to harden systems.

Little Things Matter

The technically simple attacks on Sony were effective because Sony didn’t do the little things: using old technology like Windows XP; not enforcing security policies or policies, and giving in to the screaming user or privileged executive while compromising the overall welfare of the organization.

Holistic Approach

Fight as a team. Cyberattacks aren’t about singling out one system. They involve finding a vulnerability anywhere and exploiting that for all it’s worth. If someone can exploit security cameras to gather compromising information that leads to greater exploits, they win. Think of the entire organization, physical and digital, as a single entity and then consider the possible risks and threats. What if someone shut down the proximity readers? What if they disabled the elevators? What if biometric devices or medical devices running Linux were infected with malware?

Monthly War Games

This is a fun way to build a security-minded culture. Once a month, gather the security team (which should represent the physical and digital world) and start proposing attacks and how the organization would respond or defend. Invite someone from outside.

Fire The Professionals

Organizations rely on those who help them feel good by saying all the right things – clean-cut consultants with cool pedigrees and fancy offices. Those might be the right people to review financials, but for security, look for crazy, go-for-broke, “been there, done that” people. The ones who make you a little scared when you meet them that maybe they bugged your office while you stepped out for a minute. When it comes to testing systems and infrastructure, be liberal with the rules of engagement and highly selective in who to engage. Get someone who makes everybody uncomfortable but who can also provide guidance.

Admit You Need Help

For most people, cybersecurity is not something they do day and night. Even a dedicated team won’t see everything outsiders see because they are exposed only to a single organization. Consider getting help from people who do this every second of the day, regardless of if the help entails remote monitoring, managed services, surprise attacks on a subscription basis, or delivering quarterly educational workshops. The SEAL teams of cybersecurity exist.

Education Matters

Cybersecurity education is as critical as that for infection control and privacy. It could be that last line of defense before becoming the next Sony, Target, Kmart, Staples, or Sands Casino. Also consider providing ongoing education for the in-house technologists.

Integrate Business Associates

Don’t let business associates do whatever they want. Set standards and insist that they be followed. Minimize shared data with them, enforce strong passwords, require surprise security assessments, and get the board and C-suite to understand that they are the weakest link.

The Technology Vendor Exposure

Hardware or software doesn’t matter — most vendors do not design or engineer secure systems. Not because they don’t want to, but they overlook things when trying to get hundreds of features to market and dealing with client issues and priorities. Not to mention many of today’s HIT systems were designed and developed decades ago, well before the words “buffer overflow”, “SQL injection,” or “cyberwarfare” were known. Push vendors hard to demonstrate how they are designing and developing highly secure systems that keep customers and patients safe and secure.

Security Service Level Agreement:

Do this is nothing else – it will make sure the other stuff gets done. Set a clear and aggressive Security Service Level Agreement (SSLA). This should be a critical success factor that holds the CIO, CISO, COO, and CEO accountable. Defining what is part of the SSLA should be a joint venture between the C-suite and the board, but it should clearly dictate the level of security to be maintained and how it will be measured.

These aren’t earth-shattering suggestions. However, had someone from Sony read this last year, they would have said, “We already do this,” yet Sony may very well end up being a case study for cybersecurity (and depending what happens in the coming days, a key part of our history lessons for centuries to come).

The bottom line is that HIT is an insecure industry that has not done enough to pull forward and become the standard of cybersecurity that everyone outside the industry expects (and thinks we are already doing).

Now is the time to set a standard, fight back, and take things to a new level. Sony provides an opportunity to educate the board, create a partnership with the CEO, reexamine trusted partnerships, and push vendors to step up their game. Let’s hope that Sony is more than enough to be a call to action for our industry.

John Gomez is CEO of Sensato of Asbury Park, NJ.

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December 29, 2014 Readers Write 3 Comments

Readers Write: EHR Vendors: Barriers to Interoperability

December 29, 2014 Readers Write 2 Comments

EHR Vendors: Barriers to Interoperability
By King Coal

As patients and taxpayers, I encourage everyone to contact your Congressional members about this topic. Mention that the barriers to EHR interoperability are not just technical — they are contractual as well.

EHR vendors that enjoy the benefit of our tax dollars under the HITECH Act are preventing interoperability — and innovation around the edges of their EHR products by third-party developers — by placing limitations and threats in their contracts with clients. The vendors who are engaged in this antitrust behavior can point to their technology and say, "See? We can share data. We follow data sharing technical standards. Quit criticizing us."

But when you look at these vendors’ contracts, the license fees associated with interoperability are cost prohibitive. In addition, the interoperability clauses are surrounded by onerous contractual obstacles that are veiled to protect the vendors’ intellectual property, but are actually ensuring the vendors’ continued monopoly and preventing innovation around their products.

This behavior on the part of some EHR vendors is strikingly ironic given the enormous success of open source, easily accessible APIs that benefit interoperability. The more open products are from a software architecture perspective, the more value that accretes to a product’s intellectual property. Open, transparent APIs create a larger dependence and ecosystem around products, not less.

Several years ago, I sponsored a meeting with senior executives from three large EHR vendors, lobbying them to open their APIs and migrate their software engineering architecture from tightly coupled, difficult to modify and upgrade, message-oriented architectures to loosely coupled, flexible, services-oriented architectures with open, published APIs so that my development teams could write innovative products around the edges of these EHR products. 

I will never forget the response from one of those EHR vendor’s senior executives: “We see ourselves as more than a database vendor.” Meaning, of course, “Our closed APIs are a market advantage.” 

Bill Gates and Microsoft used to think the same thing about Windows, Office, and Internet Explorer. You can see how that worked out for them when you compare what’s happened with the openness of Android, iOS, the browser market, and office suite products. is the supreme example of business success based upon an open API and open culture.

A colleague described his thoughts in an email:

Current interoperability standards selected by the ONC and required by MU-S2 do not contain an adequate amount of data/data types to support the quality measurement requirements of the same MU-S2 program. This gap in data is what enables the EHR suppliers to continue the veil of interoperability while still protecting their proprietary intellectual property, serving the interests of the owners of these companies with little regard to what may be best for care, providers, patients, or consumers.

Several EHR vendors are banning together around a new magic bullet technical standard called HL7-FHIR based on JASON technology. While this new standard is great from a technical perspective (XML, REST, etc.), in its current form based largely on existing HL7 v2, v3 and CDA concepts, it does not improve the accessibility of proprietary EHR data types and those data types are needed for quality and cost performance improvement in healthcare. While FHIR could be expanded to include this type of data, it appears the first efforts are focused on reinventing the technology for currently defined interoperability data types.

I’m not sure what if anything Congress can do at this point to fix the ills of Meaningful Use Stage 1, which rewarded existing vendors with billions of dollars in tax money to maintain those vendors’ closed and proprietary APIs. Decertification by ONC will become a bureaucratic mess, but I appreciate the symbolic stance taken by Congress around decertification nonetheless.

One thing that must happen—and maybe our legal courts are the only option for this—the contractual threats and barriers in EHR vendor contracts that stand in the way of interoperability and innovation must be removed.

Interoperability and innovation in healthcare IT are suffering, both technically and contractually, by old-fashioned, old-school thinking on the part of EHR vendors. As a consequence, our healthcare system and patient care are suffering, too. ​

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December 29, 2014 Readers Write 2 Comments

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