Why Can’t I Be Both Patient and Customer? By Peter Longo
I love the clinicians at my local health system. However, I hate the bills from my local health system.
When the clinic staff helped last month with my knee, they were the best — rock stars. When I got their confusing bill, they were the worst. Is there any other industry where you love the service, but 30 days later, they go out of their way to take away all of your happy thoughts?
Yes, I did something stupid again. Over the holidays, I took some time off to go skiing with the family. Time with the family was not stupid; skiing in the trees was stupid. (note to self; you are not in your 20s any more and need to take it easy). The ensuing tumble, spin, twist, and crash resulted in an injured knee.
I entered the local university health system in search of a cure. In total amazement, I walked into the office and the entire staff greeted me. Just like in the Gap, the entire front staff looked up and said “hello” loudly.
Over the next month, the medical group and hospital went out of their way to make me feel at home … until the bill came. Or should I say “bills” (plural). They should have stamped on the envelopes, “Screw you” in an effort to be more honest.
Most of the bills appeared to be for my knee, based on the dates of service. But for the record, they decided to add some of my wife’s medical charges into the mix on one statement.
Having spent 25 years working in the healthcare tech world plus having two graduate degrees, it still did not give me the skills to make any sense of the bills. I decided to call them at 4:50 one afternoon. The very nice recording said, “The billing office closes at 4 p.m. Monday through Friday.” Seriously? What about people who work and don’t have time to call until after work, or on the weekend? The Gap has greeters, but they are open nights and weekends. Seems my health system copied the Gap only on the greeters.
A few days later, I was able to talk to someone. I started the call by saying, “I want to pay all that I owe, so please provide a summary and explain the charges so I can pay you.” Surprisingly, they did not understand half the statements. They indicated they could not access the “other system that has more information,” so they would need to call me back.
A few days later, someone from the billing office called. Together we figured out where there were some discrepancies and determined the correct amount owed. She indicated she would clean everything up and send me a new statement. Thirty days later, I got the statement and paid right away. As I was writing that check, I had already forgotten about how they “cured” me, as it seemed so long ago.
The cost for the billing staff involved in my bill was probably more that what I owed, so I did feel bad for them. That sympathetic feeling only lasted a short time. Last night I got a call at the house. My 15-year-old handed the phone to me. I owe $25 and they sent it off to their collection agency.
Is it too much to ask that my health system treat me both as a patient and as a customer?
Peter Longo is SVP/chief revenue officer of Sirono of Berkeley, CA.
Three Reasons EHRs Need to Treat Biosimilars Differently from Generics By Tony Schueth
Biosimilars are being introduced in the United States and are expected to quickly become more mainstream in the near future. In response, stakeholders are beginning to work on how to make them safe and useful within the parameters of today’s healthcare system.
The reason is that biosimilars, like biologics, are made from living organisms, which makes them very different from today’s conventional drugs. These differences will create challenges and opportunities in how they are integrated in electronic health records (EHRs) and user workflows as well as how patient safety may be improved.
Normally, there is a lot of lead time before EHR vendors must address such issues. Things are different with biosimilars. Here are some reasons.
There are powerful drivers
Several drivers will stimulate demand for EHRs to address biosimilars sooner rather than later. This is because of central role EHRs play in value-based care coordination and patient safety.
New biologics will be bursting on the healthcare scene. Although biosimilars have recently been approved for use in the US, they have been in use extensively in Europe and Asia for many years. More than 80 biosimilars are in development worldwide, and the global biosimilars market is expected to reach $3.7 billion. This will stimulate rapid adoption by payers and physicians in the US, which, in turn, will create the need for EHRs to capture and share a variety of information about biologics and biosimilars. It is easy to envision the availability of four biosimilars for 10 reference products in 2020, given projected market expansions.
Next, uptake in the US is expected to take off because biosimilars are lower-cost alternatives that will be used to treat the growing number of patients with such chronic diseases as arthritis, diabetes, and cancer. Rand has estimated savings from using biosimilars at $44.2 billion over 10 years. Money talks and payers will create demand for EHRs to fold biosimilars and biologics into EHR functionalities and workflows.
Payers and regulators also will demand enhanced tracking of biologics and biosimilars because they are key pieces of the move toward value-based reimbursement and are a focus of public and private payers. Identifying, tracking, and reporting adverse events that might be associated with biologics and biosimilars are expected to become key metrics for assessing care quality and pay-for-performance incentives.
Biosimilars are not generics
It would be a mistake to think of biosimilars as being synonymous with generics, which have been around for years and use mature substitution methodology. The reason begins with the fact that biologics and biosimilars are medications that are made from living organisms. Unlike generics, which have simple chemical structures, biosimilars are complex, “large molecule” drugs that are not necessarily identical to their reference products, thus the term “biosimilar,” not “bioequivalent.” In addition, biosimilars made by different manufacturers will differ from the reference product and from each other, making each biosimilar a unique therapeutic option for patients.
Furthermore, biologics and biosimilars have varying locations where they are administered, most commonly infused in physician offices, hospitals, or special ambulatory centers, or by patients at home. Given that administration location and type can vary, such information — along with the particulars of the drug that was administered — must get back to the physician and incorporated into the patient’s EHR record.
Getting this information into the patient’s record in the EHR also is important for improving patient safety. That is because it will help in identifying and distinguishing the source of the adverse drug events and patient outcomes from a biosimilar, its reference biologic, and other biosimilars.
Substitution laws are expanding and evolving
Developers of EHR systems will need to keep abreast of evolving state laws concerning substitution. In fact, many states already are considering substitution legislation or have enacted it. According to the National Conference of State Legislatures, as of early January 2016, bills or resolutions related to biologics and/or biosimilars were filed in 31 states. Keeping pace with these new laws is likely to be a challenge to ensure that EHRs are compliant, especially since requirements are apt to vary considerably from state to state. Given the rapid changes in the regulatory landscape, latency of updates to EHR systems is a problem that needs to be addressed.
Not only that, the drug that is dispensed may be very different than what was prescribed. As a result, it is important for physicians to know whether a substitution has been made and capture information about the drug that was administered in the patient’s EHR record. Because of the differences from conventional medications, different, more granular information such as lot number, will also be required. This is important for treatment and follow-up care as well as in cases where an adverse drug event or patient outcome occurs later on.
All in all, EHRs will face a brave new world when it comes to adapting to biologics and biosimilars.
Kaiser Permanente has launched a new research tool that will allow its 675,000 members to submit their genetic, environmental, and general health data to a database that will be used by researchers to study how genetic and environmental factors affect health.
A woman is suing Tampa General Hospital (FL) after a nurse inadvertently disclosed her HIV status in front of family members. The nurse was coordinating with transplant team personnel over a Vocera speakerphone.
CMS announces a five-year, 5,000-practice test of Comprehensive Primary Care Plus (CPC+), a new medical home model that moves payments further away from fee-for-service. Eligible practices can apply to participate in one of two tracks, both of which require use of a certified EHR.
Track 1 practices will be paid $15 per month per Medicare patient plus performance-based incentives in return for providing 24/7 patient access and supporting quality improvement activities. Track 2 practices will be paid $28 per Medicare patient plus performance-based incentives and must also follow up after ED or inpatient discharge, connect patients to community resources, and have their EHR vendor sign an agreement that “reiterates their willingness to work together with CPC+ practice participants to develop the required health IT capabilities.”
CPC+ will begin in January 2017.
From Bob: “Re: Meditab. Any news? Emails are bouncing and phone numbers are disconnected.” I’ve barely heard of the ambulatory EHR vendor, so I don’t have a lot of interest or knowledge about whether they are defunct or not. I tried to contact sales and got into an endless PBX loop.
From Lance Carbuncle: “Re: Vocera. Lawsuits are flying after an infringement on the privacy (and dignity) of a patient. A mother whose baby passed away was subjected to an open communication between the transplant team and the nurse wearing her Vocera badge. Then the worst part was the care team disclosed that the mother has HIV to the family over a ‘speakerphone’ Vocera badge.” Unverified. A patient sues Tampa General Hospital (FL) for disclosing HIV test results without authorization, claiming that a nurse spoke to the transplant team on speakerphone. The hospital has announced its intention to replace Vocera with Voalte.
From Portobello: “Re: Arkansas Children’s Hospital. Is walking away from its Meditech 6.1 implementation for Epic. I am wondering if the hospital is being acquired by a larger health system and it just hasn’t been announced yet or if the ambulatory product was so poorly implemented that it pushed them away.” Sources tell me the hospital is not happy with Meditech’s new ambulatory system, to the point they had to halt its rollout. Ambulatory has been the Achilles heel of Meditech and lack of a competitive offering is further marginalizing company as the choice of small hospitals that would rather have Epic or Cerner but can’t afford them. It’s a shame because we really could use more inpatient EHR competition. Meditech’s executives and directors average 65 and 77 years of age, respectively, and while I admire that the company has rigidly stuck to its knitting for 50 years, sometimes it feels like the rich, Boston-society guys in charge are no longer fully engaged enough to successfully run a technology company in the face of better competition than they had in 1990. It would have been interesting if Athenahealth had bought Meditech in its effort to penetrate the inpatient market, but that would have probably been a $1 billion acquisition loaded with legacy baggage and a customer base of small hospitals that are being bought out by larger health systems who want everybody running the same system.
From Diametric: “Re: Bill Childs. He published this document in April 1968 when he was at Lockheed. I’ve always kept this document to remind me what’s important. While the technology has changed, I think this can still serve as a supplemental guide for rational development. I have interacted with perhaps 200 vendors over the years and found those that held close to this philosophy made the best partners.” I set up the document for downloading here. It’s a remarkable manifesto written nearly 50 years ago that spells out the still-valid requirements for hospital clinical systems. Bill started at Lockheed doing missile programming, then in 1968 moved over to the company’s new project of building a hospital information system. He later joined Technicon Data Systems. Not only was he a healthcare IT technology pioneer, he then started what became Healthcare Informatics magazine and ran that from 1980 to 1995 before getting back into the vendor world. Somehow he hasn’t yet won the HIStalk Lifetime Achievement Award despite being amply qualified. Thanks for sending over the document – it made my day.
HIStalk Announcements and Requests
I uncharacteristically funded a non-STEM DonorsChoose project from Ms. A from Texas, whose grant request asked for two trumpets for her music classes that are creating the area’s first school band. She reports, “While many of our scholars have very little material possessions, I truly believe we are providing them with something that cannot be purchased with money. We are offering them something that goes beyond what they can buy, which is confidence, creativity, and self-expression.”
None scheduled soon. Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.
Acquisitions, Funding, Business, and Stock
GE Ventures and Mayo Clinic create Vitruvian Networks, which will offer software and manufacturing capabilities to support personalized medicine in the treatment of cancer, specifically those blood diseases that can be treated by reengineering the patient’s own blood cells.
Diabetes management software vendor Livongo Health, founded by former Allscripts CEO Glen Tullman, raises $44.5 million in a Series C round, increasing its total to $77.5 million.
North Memorial Health Care (MN) goes live on the VitraView enterprise image viewer from Vital Images.
Tift Regional Health System (GA) chooses Cerner’s clinical and financial systems.
University of Kansas Hospital (KS) will replace Cisco phones and Vocera voice badges with Voalte’s clinical communication and alert notification system.
The State of Vermont will offer PatientPing to all state providers to give them real-time alerts when their patient is being seen by another provider.
Susan Pouzar (Versus Technology) joins H.I. S. Professionals as SVP of sales and marketing.
NIH hires Eric Dishman (Intel) as director of its Precision Medicine Initiative Cohort Program.
Adrienne Edens (Sutter Health) joins CHIME as VP of education services.
Forward Health Group hires Subbu Ravi (Amphion Medical Solutions) as COO.
Streamline Health Solutions names Shaun Priest (Influence Health) as SVP/chief growth officer.
GetWellNetwork hires Scott Filion (Digital Health Innovations) to the newly created role of president.
Announcements and Implementations
Kaiser Permanente launches Research Bank, where volunteer KP members will contribute their genetic information as well as behavioral and environmental factors to allow researchers to study their effect on health.
Presbyterian Homes of Georgia (GA) goes live with the HCS Interactant EHR.
Logicalis will offer its healthcare clients single sign-on and biometric ID solutions from HealthCast Solutions to support e-prescribing.
Boston Children’s Hospital (MA) launches cloud-based parent education for Alexa-powered devices such as Amazon Echo. KidsMD will be packaged as an Alexa “skill” that can be enabled by saying phrases such as, “Alexa, ask KidsMD about fever.”
A former Michigan house majority whip who is also a physician is charged with healthcare fraud for providing nerve blocks for patients he hadn’t examined, then billing for his services although nurse practitioners staffed his clinics. Paul DeWeese is accused of storing his signature electronically in the EHR and then giving employees his login credentials to falsely indicate that he had met the insurance company’s requirement of reviewing the clinical documentation before being paid. He lost his medical license last summer for writing narcotics prescriptions for patients he hadn’t examined.
Former University of Missouri Chancellor R. Bowen Loftin, forced out of his job and into a newly created position with the joint MU-Cerner project called Tiger Institute for Health Innovation, never took the promised job after Cerner complained that the university didn’t consult them before announcing it.
PatientKeeper will exhibit at the 2016 International MUSE Conference in Orlando, May 31-June 3.
AirStrip will exhibit at the Regional CEO Forum April 13-15 in Chicago.
Frost & Sullivan recognizes Bernoulli with the 2016 North American Frost & Sullivan Award for Product Leadership.
PatientPay will plant a tree through The Nature Conservancy for every patient payment the company receives on Earth Day, April 22.
Besler Consulting is named a finalist in several B2B Marketer Awards categories.
CapsuleTech will exhibit at the 2016 American Nursing Informatics Association Conference April 21-23 in San Francisco.
CoverMyMeds will exhibit at the North Carolina HIMSS Annual Conference April 20-21 in Raleigh.
Direct Consulting Associates will exhibit at the Health IT Summit April 19-20 in Cleveland.
EClinicalWorks joins the National Patient Safety Foundation’s Patient Safety Coalition.
Although the majority of my consulting work revolves around healthcare IT, I’ve done a fair number of practice management and operations engagements along the way. Many of the opportunities have bubbled up as a result of a practice or medical group trying to implement EHR.
Going through the process tends to highlight overall inefficiencies, role confusion, lack of management, financial issues, and more. Over the last six months, I’ve seen the requests for those types of services increase, which is part of why I joined forces with another consultant. We’ve written a number of engagements that don’t really have any information technology components.
As we’ve been exploring the different kinds of services we can offer and the needs of our potential customers, we’re seeing more organizations that are at a crossroads. It seems that quite a few primary care organizations are having what amounts to an identity crisis. Should they press ahead towards value-based care? Should they transform their systems and prepare to accept full-risk contracts? Or should they retreat towards their roots with personalized (and sometimes concierge) care? Two emails this week from the American Academy of Family Physicians highlighted this looming crisis.
On one hand, the AAFP has launched what is describes as a “full-court press” to ensure that family physicians are ready for payment reform. Calling it a “ground-breaking, knock-your-socks off change that opens to the door to a whole new era of Medicare physician payment,” the AAFP is positioning itself to help physicians “reap the benefits of a new payment system that, unlike fee-for-service, values the training, skill level… and time that goes into taking care of patients in a family medicine setting.”
In order to prepare for the transition, they’re encouraging physicians to participate in the Physician Quality Reporting System (PQRS). They also recommend that practices review their Quality Resource and Use Reports (QRURs) which will show physicians where they stand as far as future payments for the MIPS track. Most of the primary care physicians I know have never heard of a QRUR and would be put off by the process one needs to go through to obtain theirs.
AAFP also recommends that practices embark on clinical practice improvement activities around access to services, patient engagement, care coordination, and more. Smaller practices (and some larger organizations) are often ill-equipped to try to make these changes on their own. Their articles are pushing physicians towards the new models with comments that the process won’t go away or be delayed, and that “this train has left the station.” There’s going to be a huge market for services around helping physicians make the transition and I’m sure the AAFP teams will be gearing up with offerings of their own.
On the other hand, AAFP is hedging its bets by also marketing services towards physicians who are choosing to opt out of payment reform entirely. They’ll be hosting a Direct Primary Care Summit in July. The meeting is targeted towards not only physicians who have already converted to direct primary care, but for those who are thinking about it or trying to figure out how to manage the transition. They’ll be educating physicians on the legal aspects of operating a direct care practice as well as how to address business development around the new model. The conference promotion materials cite the “momentum” and “growing excitement” saying Direct Primary Care is “no longer a trend” and is being supported by positive legislation across the country.
I certainly don’t fault AAFP for playing both angles. Primary care is at a crossroads. The National Residency Matching Program “Match Day” was last month. This year’s match saw only 1,481 graduates from United States medical schools choosing family medicine. There were some other interesting statistics coming out of the Match:
Family medicine offered 11.7 percent of all positions in the Match.
The fill rate in family medicine for US seniors has decreased from 1996 (72.6 percent) to 2005 (40.7 percent) with a slight increase this year (45.4 percent).
The fill rate in family medicine for US seniors has been below 50 percent since 2001.
Aggregate primary care positions (family med, general internal med, general pediatrics, and internal med/peds) filled with US seniors at a rate of 50.7 percent.
Only 12 percent of US seniors participating in the Match selected primary care residencies.
Looking at non-US seniors who matched into family medicine, the numbers are climbing overall. Although I’m happy to see qualified international graduates matching into primary care specialties, I think the fact that US grads continue to choose other pursuits is very telling. Primary care salaries are among the lowest in the physician ranks and primary care physicians report some of the highest burnout levels compared to their peers.
The loss of autonomy brought by shifting healthcare policy over the last decade has hit primary care physicians disproportionately compared to specialists in many markets. Although payment reform may extend that loss of autonomy more fairly across the board, if feels like we’re moving towards the lowest common denominator rather than trying to elevate everyone.
Lots of people are looking at the decline of primary care. A recent JAMA article looks as the expanded use of the term “primary care provider” as having negative consequences for the future of primary care. It asserts that although increased use of the term provider “reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician,” it has also had negative impacts. Patients may not be reaching the appropriate member of the primary care team if they can’t distinguish between different types of primary care providers. A mismatch in care delivery can lead to both over- and under-performance as well as challenges to patient safety and the delivery of cost-effective care.
The article specifically cites the rise of Direct Primary Care as being from “the resultant uncertainty and insecurity about who is going to handle their medical problem.” It also mentions that not differentiating between providers may put some individuals into “situations beyond their level of training and competence.”
I’ve seen this with one of our practice’s competitors, whose push for their nurse practitioners and physician assistants to practice independently is causing them to seek employment elsewhere. Healthcare IT is cited as a potential bridge for providers in those situations, who may be able to use protocols and clinical decision support mechanisms to “help mitigate some of the front-line diagnostic and management challenges for team members facing situations beyond their level of expertise.” I leverage technology often in practice, but it’s not a substitute for experience.
The authors also mention that the provider designation ”risks de-professionalizing” physicians, NPs, PAs, and nurses “who value their specific professional identities.” My favorite part of the article says it all:
Using the “provider” designation in primary care also suggests that primary care is simple care that can be commoditized and delivered piecemeal in a variety of settings by less well-trained personnel operating interchangeably at low cost. As such, use of the term may promote low levels of compensation and diminishes respect for the field, compromising its fundamental mission. Although low-cost approaches to some very basic elements of primary care, such as immunizations and treatment of upper respiratory infections, make enormous sense, they do not apply to the resources, skill, and training needed to deliver the full spectrum of comprehensive primary care in personalized, coordinated fashion, especially to an aging population with multiple comorbidities. “Provider” belies the complexity and amount of effort required. Note that the designation of “provider” has not been applied to such fields as surgery or cardiology, even though these too entail multidisciplinary, team-based care structures.
It goes on to recommend that we “cease referring to and treating primary care clinicians (as well as all other physicians and health care practitioners) as “providers” and address and relate to them as the highly trained professionals they are. If only things were that simple, that we could change some terminology and things would improve. Healthcare seems to just keep riding tide after tide and grabbing after the next shiny object that they think will solve the problems. We hoped for the last decade that technology would solve all our problems, that if we just added automation to the practice of medicine that we’d solve problems. Unfortunately, automation was often poorly applied and shifted the work to physicians.
Now we think that if we make the data more accessible, we can fix the problem. It feels like we’re pinning our hopes on interoperability, but we’re not doing what we need to make better use of the data, whether by physicians and other care providers or by patients themselves. Professional and educational organizations are weighing in, but are somewhat hampered by the lack of details on how new care models will unfold.
“Providers” are tired of waiting and continue to leave practice or pursue alternatives such as Direct Primary Care or to opt out of Meaningful Use or Medicare/Medicaid. The giants of our industry are increasingly reactive rather than being proactive or innovative. Eventually, something will have to give, and I fear it will be the people on the front lines.
Do you think emerging payment models will fix the healthcare crisis? Email me.
Jim Litterer is president and CEO of Vital Images, A Toshiba Medical Systems Group Company, of Minnetonka, MN.
Tell me about yourself and the company.
Vital Images is a company that’s been around for about 25 years. It was founded by Vincent Argiro. For the first 20 years of existence, it focused on advanced visualization and clinical applications. We’ve been broadening the focus of the organization over the past several years because we realized that advanced visualization and 3D imaging capabilities are a great way to communicate to downstream care teams.
We’ve been broadening our solution offerings and have created three divisions within Vital. One is focused on enterprise imaging, our Personalized Viewing Solutions.
In the second, Enterprise Informatics, we deliver a unique interoperability solution where information can be connected across disparate structured content systems to provide the right information to the right person at the right time within the care cycle.
Our third division focuses on image practice management software and an analytics platform. We are able help IDNs visualize the imaging operations across all locations in real time, in conjunction with the ability to drill down to patient-level quality benchmarking. That data is then used to make informed decisions on operations management and capital investments in lockstep with accountable care imperatives within the organization.
Describe what visualization tools do and how they are used.
Visualization tools can range from diagnostic decision-making tools to enterprise viewers to assist the care team. Even patient communication, which is crucial as organizations strive to attain patient engagement.
The personalized viewing platform delivers the ability to adapt to simple examples of clinical review, or drill down to diagnostic view, then further advanced visualization. In essence, the platform adapts to the role of the clinician and disease state of the patient.
Our advanced visualization solution creates quantitative data that can then be stored as discrete data that can be leveraged in broader sets of applications.
From the diagnostic imaging side, we provide patient-centric viewers to imaging specialists — such as radiologists and cardiologists – who use that to make the diagnosis.
Finally, we have viewers beyond diagnosis that help care teams treat patients ongoing. Clinicians use our zero-footprint viewer, VitreaView, to understand the diagnosis and make treatment planning decisions.
What will the next generation of VNAs and enterprise viewers look like?
It’s heading to a place where hospitals are looking for enterprise systems that connect not just imaging information, but discrete data as well. We’ve all heard of PACS 3.0. These solutions are migrating to where you’re accessing locations of information, and then you use viewers and interfaces to create care dashboards for the clinical specialists to more effectively treat patients by being presented with the right information at the right time.
We reviewed the VNA and enterprise viewer market, Based on direct feedback of our customers, we launched second-generation products. For instance, VNA On Demand allows the CIO to incrementally build a VNA based on their architecture.
What is the expectation that images will be shareable in an interoperable world?
Images, multimedia, and other structured content are critical to decision-making and treatment planning. As a support line within a hospital, imaging practices are going through a large amount of change due to the effects of the Affordable Care Act. Hospitals need solutions that help align imaging activities with bundled payment models. Imaging is a key technology to driving cost-effective diagnosis, but in order to get the full value from imaging practices, the information needs to be completely integrated in with the health record.
In the past, it was assumed that you’d have to aggregate information to a central location to use it. We’re creating solutions that can access imaging data and imaging content in their native sources, which allows physicians to access that data through the health record in a patient-centric context.
What are the most pressing issues in medical imaging?
Imaging data is exploding and accounts for the majority of the storage claimed within a health system. This large set of data is also one of the most underutilized in terms of population management and risk stratification.
The largest task at hand is to take that image content that is being successfully used within a radiology department and then extend it across the healthcare enterprise. Imaging investments are large and there is much more we can do to leverage the information for improved patient care outcomes and improved efficiencies to align with the Affordable Care Act payment models.
Who consumes the actual images rather than the interpreted description of what the images are believed to show?
Text-based reports have been the primary focus of delivering imaging results to the treating physicians. We have found that if you provide treating physicians with a zero-footprint, three-dimensional viewer and quantitative results displayed on image itself, this information is used just as much as the text-based report. The old adage, “A picture is worth a thousand words” couldn’t be truer in medical imaging.
As an example, once you’re able to provide simple volumetric viewing tools along with the text information, it’s a much easier way for a surgeon to plan a complex procedure or learn the best way to operate on a specific disease to save OR time, not to mention educating the patient on the procedure.
We’re seeing applications for this imaging data as health systems investigate 3D printing applications. 3D printing is a hot topic and is starting to build momentum in the market today, primarily for treatment planning and for patient education. We are just starting to scratch the surface with this technology. It will be something to pay attention to.
What has been the impact of having the surgeon be able to walk through a representation of the procedure as a practice run before doing it for real?
We’re on the edge of 3D printing becoming a much more broadly used application. We have about 5,000 installations of our advanced digitalization tools around the world. We’re seeing a lot of interest from radiology practices that are looking to offer 3D printing as a value-add to their practice for downstream physicians. We’re certainly seeing it in big hospitals and large academic sites. Many of them have invested in 3D printers to handle this type of workflow.
You released an imaging analytics solution specifically for ACOs. How are their needs different?
We are using Vitality IQ to enable IDNs to visualize the all activities that are happening within their imaging department. Operationally, this solution provides real-time access to frontline management to understand where bottlenecks and idle time are occurring. Strategically, the solution provides aggregated information from EMR, PACS, HIS/RIS, and financial systems to make larger informed decisions on future equipment investments or how to better market to referring physicians based on trending information.
Where do you see the company in five years?
We will be a healthcare informatics company that provides an enterprise service bus for structured data that help HIEs and IDNs integrate in the imaging information through our viewers. We’ll continue to be focused on viewing or imaging-based applications, but we know that these solutions must tie in much beyond a specific department. We’re going to continue to evolve our solutions to help our customers solve the challenges they have within imaging and in the utilization of that information.
Dell Security Works publishes its annual Underground Hackers Markets report, which lists the typical cost of various black hat services, including hacking email and social media accounts, running DDoS attacks, and stealing bank account information.
Artificial Intelligence company Sentient Technologies sets its sights on healthcare with AI nurse, a system that forecasts changes in a patient’s condition, predicting sepsis and other critical conditions.
Dell’s security business finds that the going rate for hiring a hacker to penetrate Gmail, Hotmail, or Yahoo email accounts is $129, while breaching a corporate email account runs $500. They will hack into a Facebook or Twitter account for $129, provide a complete US identity (driver’s license, Social Security Card, and utility bill) for $90, or provide a Visa or MasterCard for $7. They’ll even turn over a US bank account with a $1,000 balance for just $40.
The enterprise price list is even more sobering – hackers will launch a denial-of-service attack for as little as $5 or will install a remote access Trojan for $5 to $10. Security sites have noted that hackers are selling Ransomware as a Service for $50 plus a 10 percent commission on the ransom money paid, allowing non-technical criminals to easily and immediately launch their own extortion business.
From Twidiots: “Re: [publication name omitted]. Stole your story about the DoD’s EHR project name without giving credit. I’m going to email them.” It’s common for sites to miss subtle but significant news items until they read about them on HIStalk, but it’s obvious this time because I ran the Tuesday evening announcement in my Thursday night news and suddenly everybody’s running it first thing Friday, pretending they found the days-old announcement themselves. That’s OK, but it’s still lazy to reword the DoD’s announcement without linking to it and to cite the published quotes as “US Department of Defense officials said” like some general called them up with a scoop. I guess they get lots of readers, just like those clueless “9 things you need to know” sites that rarely contain anything you might actually need to know. I think HIStalk readers are smarter than that, so there’s no need to email the publication.
From Vince Ciotti: “Re: Leapfrog’s tests that showed CPOE systems missed 39 percent of harmful drug orders and 13 percent of potentially fatal ones. That means they flag 61 percent and 87 percent, respectively – great progress since paper charts caught none of them!” Leapfrog took a measured approach in describing its findings as it does every year during Medication Safety Awareness Week, noting that CPOE warnings are doing a pretty good job. It’s nice that we’ve moved from questioning whether such warnings work at all to urging that it work 100 percent of the time.
From boyfrommer: “Re: Decision Resources Group. CEO Jim Lang quit and will be replaced with Jon Sandler of IndUS Group, the private equity arm of the group that purchased (and overpaid for) DRG in 2012. Jon has no operating experience and neither does his COO, who also comes from IndUS.” I’ve never heard of the company, which appears to provide medically related research reports.
From The PACS Designer: “Re: ICD-10-PCS. It’s an exciting time for healthcare as the ICD-10-PCS Procedure Codes will be updated with 3,651 additions by CMS to further enhance it starting October 1. Here’s a sample: 0273356 Dilate 4+ Cor Art, Bifurc, w 2 Drug-elut, Perc (abbreviated version) or Dilation of Coronary Artery, Four or More Arteries, Bifurcation, with Two Drug-eluting Intraluminal Devices, Percutaneous Approach.”
HIStalk Announcements and Requests
Poll respondents would fell safest having their medical information in the hands of Apple and an EHR vendor, placing the least trust with Microsoft and an HIE. My suspicion is that the spate of health system breaches of many kinds has cause people in general (and healthcare IT people in particular) to lose faith that their information will remain confidential. New poll to your right or here: have you had a virtual visit in the past 12 months?
Ms. Chestnut from Indiana says her fourth graders are becoming better world citizens by studying the library of nearly 100 books we provided in funding her DonorsChoose grant request.
Also checking in is Mrs. P from Virginia, who says she has “been laminating like a mad woman and our new printer is SO FAST” in describing some of the supplies that we provided, from which her elementary school students are creating their own math and reading games that they play independently.
Listening: The Raconteurs, the possibly defunct Detroit-Nashville supergroup foursome that includes Jack White, formerly of The White Stripes. It’s catchy, has big horns, and pushes into acid rock/Led Zeppelin in its experimentation. That sent me back (as happens frequently) to one the greatest (and most intelligent) live rock and roll bands in the world, Sweden’s Howlin’ Pelle Almqvist and The Hives.
Last Week’s Most Interesting News
The Department of Defense gives its Cerner project the name MHS Genesis.
MedStar Health (MD) disputes reports that its ransomware attack was made possible by unpatched server software.
HHS asks for suggestions for interoperability measures that it should incorporate into MACRA objectives.
Massachusetts General Hospital (MA) and two hospitals of NYC Health + Hospitals go live on Epic.
At least two more hospitals are taken offline by ransomware attacks, this time in California and Indiana.
One of the best (and most timely) webinars we’ve done was last week’s “Ransomware in Healthcare: Tactics, Techniques, and Response” by Sensato CEO John Gomez. We had a big, engaged crowd that asked John so many questions that we didn’t have time to address them all in our scheduled one hour. It’s worth watching — we asked John to put this together purely as a public service, so there’s zero pitch or commercial influence involved.
None scheduled soon. Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.
Acquisitions, Funding, Business, and Stock
Medical equipment and workflow vendor Midmark Corporation will acquire RTLS vendor Versus Technology to enhance its clinical workflow offerings.
Asset, facilities, and real estate management software vendor Accruent acquires Mainspring Healthcare Solutions, which offers equipment maintenance and asset management systems.
Oncology EHR vendor Flatiron Health announces strategic partnerships with its drug company customers Celgene and Amgen, both of which participated in the company’s $175 million funding round in January 2016.
St. Peter’s Health Partners (NY) promotes interim VP/CIO Chuck Fennell to the permanent position.
Announcements and Implementations
IBM and drug company Pfizer will collaborate to remotely monitoring sensor data from people with Parkinson’s disease to look for new diagnostic and treatment insights.
Privacy and Security
Einstein Healthcare Network (PA) notifies 3,000 people who filled out a web form requesting information that their entries were exposed when the form’s underlying database was inadvertently opened up to the Internet.
Target says in a securities filing that it has spent $300 million cleaning up the mess from its 2013 data breach, of which it expects only $90 million to be covered by cyberinsurance.
Adobe urges computer users to upgrade to the latest level of Flash released last week after finding flaws that allow delivery of ransomware. Steve Jobs was right when he said in 2010, “Symantec recently highlighted Flash for having one of the worst security records in 2009. We also know first hand that Flash is the number one reason Macs crash. We have been working with Adobe to fix these problems, but they have persisted for several years now. We don’t want to reduce the reliability and security of our iPhones, iPods, and iPads by adding Flash.”
Want to make it obvious you don’t really know healthcare IT? Refer to inpatient drug “orders” as “prescriptions.”
Wired profiles artificial intelligence technology vendor Sentient Technologies, which has raised $143 million in funding since 2008 to create financial applications. The company is developing an “AI nurse” that can predict patient condition changes. The co-founder describes how such a system can teach humans:
One of the good things about evolutionary AI is that — if you know how to read it — you can actually see the rule sets. In the case of traders or of AI nurses (on which we are working, too), they are fairly complex beings. A trader may have up to 128 rules, each with up to 64 conditions. Same thing for an AI nurse. So, they are pretty complex systems and the interplay among these rules is not always linear. But if you spend some time on it, you can still understand what this thing is doing, because it’s declaratory — it says what it is doing, in other words. So we can certainly take this and learn from this what works and what doesn’t work when it comes to solving a certain problem. AI can teach people to make better decisions.
Authors from Kaiser Permanente describe what the organization has learned from having many of its patients use its patient portal over several years.
Seventy percent of KP’s eligible adult patients, 5.2 million people, have registered to use its Epic MyChart-powered portal called My Health Manager.
KP providers and patients exchanged 23 million secure emails in 2015, representing one-third of all PCP encounters in the first half of 2015.
Use of secure email was associated with a 2 to 6.5 percent improvement in HEDIS measures and a 90 percent approval rate by users with chronic conditions.
My Health Manager users are 2.6 times more likely to remain KP members.
KP is studying the disparities introduced by e-health technologies after its studies found that a disproportionate number of users are white, older, and better educated.
Weird News Andy says he’s a sucker for stories like this. Wichita, KS police arrest a 36-year-old man for child abuse after the two-year-old son of his 21-year-old girlfriend is brought to the ED not breathing due to a two-inch dead octopus blocking his throat. The boyfriend claims the child swallowed the octopus while the mother was at work. Police say it wasn’t a pet – it was intended for sushi. The child is OK.
DrFirstwill exhibitat the 2016 International MUSE Conference May 31 – June 3 in Orlando, FL.
T-System will exhibit at the UCAOA National Urgent Care Convention April 17-20 in Orlando.
TierPoint will host a seminar on Emerging Threats & Strategies for Defense April 13 in Liberty Lake, WA.
TransUnion CMO Julie Springer is inducted into Direct Marketing’s 2016 Marketing Hall of Femme.
Valence Health will exhibit at the First Illinois HFMA Spring Symposium April 11-12 in Chicago.
Visage Imaging will exhibit at the 2016 Spring Radiology & Imaging Conference April 13-15 in Atlanta.
VitalWare will exhibit at the 2016 Vizient Supplier Summit April 11-13 in Las Vegas.
Huron Consulting Group will exhibit at the 2016 AAPL Annual Meeting and Spring Institute April 11-17 in Washington, DC.
West Corp. will exhibit at the World Health Care Congress April 10-13 in Washington, DC.
A physician at Massachusetts General Hospital (MA) argues that EHRs fail to capture a meaningful patient story, arguing that EHRs mask “how one symptom relates to another, the emotional context in which the symptoms or events occurred, or the thought process of the physician trying to pull together individual strands of data into a coherent narrative.”
The Department of Defense christens its Cerner-centered EHR project as MHS Genesis. The functional project champion explains, “We want people to know MHS Genesis is a safe, secure, accessible record for patients and healthcare professionals that is easily transferred to external providers, including major medical systems and Department of Veterans Affairs hospitals and clinics. When our beneficiaries see this logo or hear the name, they’ll know their records will be seamlessly and efficiently shared with their chosen care provider.”
I might quibble that the DoD’s new logo incorrectly contains all capital letters in spelling GENESIS and looks like something a Photoshop newbie might design, but at least it uses the correct Greek mythology symbol of the wingless Staff of Asclepius – which denotes healing and medicine –rather than the oft-mistaken winged Staff of Caduceus, which is symbol of commerce. Still, I can understand how the latter is more appropriate than the former in our convoluted healthcare system, where the lines at the financial trough are often serpentine.
From ZenMaster: “Re: Sandlot Solutions. Website down. Phone not working. Clients frantic. A cautionary tale for all the start up Population Health Analytics companies out there. HIE / Healthcare Data Aggregation / Population Analytics is hard. Proceed with caution.”
From A Vendor That Also Finds Email Tracking Slimy: “Re: vendors being informed when you open their spam email and then contacting you directly. Most of these programs function by embedding a one-pixel image into emails and tracking when that image is loaded. Disable the automatic download of images in your mailbox settings or contact your organization’s IT team about blocking or filtering items that are created using similar methods like Tout, Sidekick, Yesware, Streak, etc.” Promos for the Yesware tracker shows why aggressive companies keep using it for “prescriptive analytics” to pester prospects – unfortunately, it works, just like other sales techniques that range from cold calling to outright lying.
HIStalk Announcements and Requests
We funded the DonorsChoose grant request of Ms. S in Texas, who asked for five animation studio kits for her elementary school class to produce STEM-related movies.
Also checking in is Mrs. S from Connecticut, whose middle schoolers are using the Chromebooks we provided to publish and discuss their writing, with some of the most active participants being those students who don’t otherwise engage.
Speaking of Chromebooks, I decided to round out my little technology arsenal of everything I use to research and write HIStalk (a $300 Toshiba laptop and a $200 iPad Mini) with a Chromebook. The Asus C201 has an 11.6-inch monitor (perfect for traveling), 4 GB of memory, a 16 GB solid state drive, a very nice Chiclet keyboard (I’m not a fan of on-screen and tiny Bluetooth keyboards), and a battery life of around 10-12 hours. It weighs about 2 pounds and is 0.7 inches thick. It powers on and off almost instantly and took almost no time to set up, automatically updating itself as needed in the background with no third-party antivirus needed. The learning curve is pretty much zero – the only workaround I had to look up was how to regain Delete-key function since that key is omitted from most Chromebooks for space reasons. Best of all, it was only $200 complete with a nice padded sleeve and a wireless mouse with nano receiver. Chromebooks use the Chrome OS operating system instead of Windows or Linux, so they won’t run most desktop apps, but the Chrome browser is very fast (as are Google Docs and Gmail), Dropbox works fine, and thankfully my most valuable program LastPass works great on it for automatically logging me in password-protected sites I’ve saved, like Amazon. I even installed the Chrome OS version of Teamviewer in case I need to remote back into the laptop to do something. It’s not for everyone – for example, folks who rely on desktop versions of Office – but you might be surprised at how much of your work is online once you think about it and this is an inexpensive, lightweight, headache-free alternative to Windows or Apple laptops.
This week on HIStalk Practice: KAI Innovations acquires Trimara Corp. Family physician Kim Howerton, MD stumps for direct primary care in Tennessee. DuPage Medical Group expands relationship with PinpointCare. Cable and home security business Connect Your Home gets into the telemedicine business. Culbert Healthcare Solutions VP Johanna Epstein offers advice on improving patient access (and ROI to boot). Kaiser Permanente Northwest puts medical record access at patient fingertips. Tribeca Pediatrics founder details the drastic steps he took to revitalize his failing practice. Biotricity CEO Waqaas Al-Siddiqoffers his take on what’s holding physicians back from making the wearables leap.
April 8 (Friday) 1:00 ET. “Ransomware in Healthcare: Tactics, Techniques, and Response.” Sponsored by HIStalk. Presenter: John Gomez, CEO, Sensato. Ransomware continues to be an effective attack against healthcare infrastructure, with the clear ability to disrupt operations and impact patient care. This webinar will provide an inside look at how attackers use ransomware; why it so effective; and recommendations for mitigation.
Andover, MA-based National Decision Support Company opens a research and development headquarters in Madison, WI.
Population health management systems vendor Lightbeam Health Solutions acquires Browsersoft, which offers an HIE solution built with open source tools.
Digital check-in vendor CrossChx raises its second $15 million round in two years, increasing its total to $35 million.
Tampa General Hospital (FL) will implement the Voalte Platform for caregiver communication.
Universal Health Services will replace the former Siemens Invision revenue cycle solution with Cerner’s revenue cycle solution, integrating with UHS’s existing Millennium products. For-profit hospital management company UHS operates 25 hospitals.
The Department of Defense awards a five-year, $139 million contract to McKesson’s RelayHealth for patient engagement and messaging solutions. I assume that’s an extension or expansion since the military was already using RelayHealth.
Ernest Health (NM) will expand its use of NTT Data’s Optimum Clinicals suite in four facilities. The organization uses Optimum RCM in its 25 locations.
Queensland, Australia’s Metro North chooses the referrals management system of Orion Health.
Influence Health names Michael Nolte (MedAssets) as CEO. He replaces Peter Kuhn, who remains as president, chief customer officer, and board member.
Announcements and Implementations
Franciscan Alliance (IN) uses InterSystems HealthShare to create a vital signs viewer for legacy data that can be accessed from inside Epic by its 140-physician group.
India-based doctor finding and appointment scheduling app vendor Practo begins answering medical questions from India, the Philippines, and Singapore at no charge via Twitter using the @AskPracto account.
Government and Politics
National Coordinator Karen DeSalvo, MD, MPH says of information blocking in a Wall Street Journal interview, “We don’t have all the authority we need to really be able to dig into the blocking effort. We have put forward a proposal to Congress asking for more opportunities to address the issue.” She says that it’s a big step that the major inpatient EHR vendors have pledged to not participate in information blocking vs. a year ago when “people said blocking is a unicorn and not happening.” She adds consumers are interested in third-party apps that can extract data from elsewhere to create their own longitudinal health record and says that person-centric medical records will shift “very deliberately away from the electronic health record as being the source or center of the health IT universe.”
HHS asks for ideas about how to measure interoperability within MACRA objectives, with responses due June 3. The most interesting part of the information published in the Federal Register is that ONC is considering analyzing the audit logs of EHR users to determine how often they exchange information.
AMIA says proposed HHS changes that would give drug and alcohol abuse patients more control over their medical records aren’t adequate and fail to address electronic information exchange. AMIA wants HHS to revisit the idea of giving patients granular sharing control over their entire medical record, saying that managing substance abuse data differently is “a dated concept and flawed approach.” Doug Fridsma, MD, PhD, AMIA president and CEO, said in a statement, “Clearly, the trend in healthcare is to make patients first-order participants in their care. This means giving them complete access to their own medical records, and it should mean giving them complete control over who sees their medical information.”
Privacy and Security
MedStar Health (MD) disputes earlier Associate Press reports indicating that an unpatched JBoss server allowed hackers to take its systems down with ransomware. MedStar says Symantec, which it hired to investigate the attack, has ruled out unapplied 2007 and 2010 JBoss patches as the problem. The AP stands by its earlier report and adds that experts say that the Samsam ransomware that infected MedStar can be prevented by keeping updates current.
Google’s Verily Life Sciences biotechnology company comes under fire for awarding a research contract to a company its own CEO owns and for failing to tell its Baseline health study volunteers that it is planning to sell their data to drug companies for a profit.
Metropolitan Jewish Health System (NY) announces that an employee of one of its participating agencies responded to a phishing email in January 2016, with the unidentified hacker gaining access to the email account that contained PHI.
Leapfrog Group finds that CPOE systems still miss a significant number of drug ordering errors, failing to warn the prescriber of potentially harmful orders 39 percent of the time and also missing 13 percent of potentially fatal orders. Leapfrog collects voluntary CPOE test results from hospitals that use its testing tool.
The AMA publicly supports AllTrials, a global campaign that calls for every past and present clinical trial to be registered with their methods and summary results reported. The campaign says it’s not fair to study participants to hide study results that are inconclusive or unfavorable to the sponsoring organization, such as a drug company buying a study that finds one of its products ineffective. Commendably, the AMA’s involvement came from a proposal from its Medical Student Section.
The COO of BCBS of North Carolina, promoted from CIO four years ago, resigns abruptly after the botched rollout of a billing and enrollment system last November during Healthcare.gov’s open enrollment period. The company is scrambling to rewrite the system in time the next open enrollment that starts November 1. It found an unspecified “fatal problem” in its software before last year’s open enrollment began, but continued anyway thinking it could fix problems as they arose, causing 147,000 customer calls on November 1 alone and 500,000 in the first week. The company imposed emergency measures in January 2016 after projecting that it will lose $400 million in North Carolina Healthcare.gov business, turning off the ability for consumers to apply online since they had no way to determine whether the applicant was actually eligible to purchase insurance.
The always-hustling Newt Gingrich pens an editorial criticizing his home state of Georgia for proposing to outlaw people doing their own eyeglass exams at home via a company’s app. USA Today got the assurance of Newt’s people that he had no financial interest in any related firms before running his op-ed piece, only to find out afterward that he’s running a $100 million tech fund with a private equity firm.
I missed a great April Fool’s prank by MedData, who announced the April 1 hiring of Hayden Siddhartha "Sidd" Finch as chief experience officer, slyly referencing a 1985 George Plimpton April’s Fool fake story in Sports Illustrated involving a Tibetan pitcher with a 168 mph fastball. The brilliant Plimpton even led off the 1985 story with a clever clue in spelling out “Happy April Fool’s Day” with the first letters of each word in the opening sentence, but still duped a significant number of people who should have known better (including a Senator, reporters, and Mets fans looking for hope).
An article questions whether it’s OK for sexting-comfortable teens to send genitalia photos to their doctors for diagnosis, wondering whether those images should be sent securely or whether the doctor receiving them might even be charged with possessing child pornography.
A woman who recorded her hernia operation with a hidden recorder captures OR staff making fun of her belly button and calling her “Precious” from the movie about an overweight teen. Harris Health System (TX) declined to comment citing HIPAA, but told the woman they had reminded OR staff to watch their comments and that was enough. She says she was racially profiled and is considering suing.
A primary care physician at Massachusetts General Hospital (MA) says the lack of patient narrative in EHRs dehumanizes patients and hampers the diagnostic abilities of physicians, noting that the story of Cinderella, if entered into the hospital’s newly implemented Epic system, would be a problem list consisting of “Poverty, Soot Inhalation, Overwork, and Lost Slipper.” She describes Epic (and thus EHRs in general) as:
Epic features lists of diagnoses and template-generated descriptions of symptoms and physical examination findings. But it provides little sense of how one event led to the next, how one symptom relates to another, the emotional context in which the symptoms or events occurred, or the thought process of the physician trying to pull together individual strands of data into a coherent narrative. Epic is not well-suited to communicating a patient’s complex experience or a physician’s interpretation of that experience as it evolves over time, which is to say: Epic is not built to tell a story.
A Boston Globe article ponders why the medical schools of Harvard and nine of its prestigious peers like Yale, Johns Hopkins, and Columbia don’t have a department of family medicine. Harvard blames lack of costly participation by its affiliate hospitals to support a residency. However, a Harvard medical student says doctors specializing in internal medicine and pediatrics often bolt for more lucrative subspecialties while most family medicine practitioners remain in primary care, adding that Harvard Med thinks, “You’re less competitive or you’re less rigorous if you’re interested in primary care.” Ironically, Harvard launched one of the first family practice residencies in 1965, but the federal government ended its funding 10 years later due to poor quality. The chair of the recently created family medicine program at Icahn School of Medicine says bluntly, “It’s bizarre to me that you have these institutions that don’t really feel that there’s a requirement to introduce their students to the second-largest specialty in the United States.”
The department of physical and occupational therapy at Massachusetts General Hospital (MA) create a video just before its April 2 go-live with Epic.
CloudWave joins the Microsoft Cloud Solution Provider program.
Experian Health will exhibit at the SE Managed Care Conference April 7-8 in Charleston, SC.
PeriGen publishes its annual review of labor and delivery malpractice awards.
Red Hat announces the winners of its 2015 North American Partner Award Winners.
The SSI Group will exhibit at the Texas Ambulatory Surgery Center Society 2016 Annual Conference April 7-8 in San Antonio.
Streamline Health will exhibit at the 2016 HASC Annual Meeting April 13-15 in Dana Point, CA.
Surescripts announces its 2015 White Coat of Quality Award winners for excellence in e-prescribing quality.
Iatric Systems will exhibit at the Hospital & Healthcare IT Reverse Expo April 13-15 in Atlanta.
RTLS technology from Versus earns Cisco Compatible Extensions certification.
A record number of attendees gather at InstaMed’s annual user conference.
InterSystems will host its annual Global Summit April 10-12 in Phoenix.
Intelligent Medical Objects will exhibit at HealthCon2016 April 10-13 in Lake Buena Vista, FL.
Netsmart will exhibit at the Texas Public Health Association Conference April 11 in Galveston.
Obix Perinatal Data System will exhibit at the SSMHealth Annual Perinatal Nursing Conference April 14 in Fenton, MO.
In a previous post, I mentioned Epic vital signs alerts with values that were way out of range. Several readers commented, with one saying this couldn’t possibly be a client value and another wondering what other customer-built “garbage” might be in their system. The original reader who shared the alert sent me a screenshot of the Epic foundation build, showing the Epic-released values that are delivered read-only. Although you can modify it on age-based overrides, the the maximum pulse of 500 is out of the box.
Even worse, I noted that the pulse values all have trailing zeroes. I’ve spent more than a decade arguing with EHR vendor staffers about the concepts of precision and significant digits, and the fact that trailing zeroes don’t belong in fields like these. Since a pulse measurement obtained via traditional clinical skills can’t technically be precise to two decimal places, it shouldn’t be reported as such. Weird News Andy chimed in as well, suggesting that perhaps it was an alert for hummingbirds.
It’s National Public Health Week. Events in our area focused on tobacco, obesity, and diabetes. One of our offices had planned to host a blood drive, but it was canceled by the blood bank due to an “equipment malfunction.” I’m not sure what might be malfunctioning that would prevent us from using disposable collection gear, but we weren’t able to find another agency that had availability. Hopefully we’ll be able to make up for it next month.
Several of my consultant friends have a betting pool running on when CMS will release the MIPS/MACRA proposed rule. It looks like it has gone to the White House Office of Management and Budget, which might mean we could see it sooner than some of us thought. I’m banking on Memorial Day weekend since CMS has made a habit out of releasing it just before long weekends. By law, it has to be released within 90 days, but I think there may have been one recent proposed rule that came out past the 90-day mark. I’m too tired to Google it though, and it doesn’t really matter, so props to those of you who know for sure. I’m seeing a deluge of information from professional societies asking their members if they’re ready for MACRA, which is funny because many of the front line physicians I talk to don’t even have an idea what it is.
I mentioned it before, but the White House petition supporting a voluntary patient identifier doesn’t seem to be getting much traction. Only 6,000 people have signed it since it went live on March 20. It needs nearly 94,000 more signature prior to April 19 in order to receive a response from the White House. Although the Executive Branch can’t actually solve the problem, getting enough signatures on the petition would make a statement. If you’re supportive, please consider signing to have your voice heard.
The AMIA iHealth conference is right around the corner. I’ll unfortunately be attending another conference at the same time, but am interested to hear from readers that may attend. It’s approved for 12 hours of ABPM LLSA credit, so if you’re board certified in Clinical Informatics and haven’t started earning your hours, it would make a nice start. I’m nearly done with my continuing education for the year, which is a good feeling. The only thing I have left is a module for my primary board certification, and I’m waiting until summer when a new MOC paradigm goes into effect for us.
I often have physicians throwing articles at me with ratings and rankings of the “best EHRs.” Such pieces generally drive me crazy, because once you dig into the number of participants and truly dissect the data, it is often poor. In one recent study, the physicians polled couldn’t even correctly identify their vendor and instead claimed they were using systems from vendors such as “CPOE” and multiple acronyms developed by hospitals to brand or market their systems. The prize for the best article of the week goes to GomerBlog, however. Thanks for the laugh because I sorely needed it this week.
Fast Company discusses barriers to expanding patient access to their medical information after an informal internet survey finds that 77 percent of patients are very interested in having access to the information.
The Future of Mobility and Cloud in Healthcare By Joe Petro
For some time now, we’ve been hearing concerns voiced by physicians about how complicated their lives have become due to the mountainous documentation requirements. Among the most difficult is capturing the details a patient shares during a consultation and trying to fit that information into the structured template found in today’s EHRs.
How can we expect a patient’s story to be impactful when all its context and richness is lost to making sure we click and check the right boxes? This is a byproduct of all the initiatives coming out of the federal government. The EHRs are left with no choice but to force the structured capture of clinical documentation.
At the same time that we see these changing requirements, we’re also seeing a change in the technology used by physicians. Physicians are becoming increasingly more mobile and technologies can improve the physician experience and allow them to capture the patient story across the multitude of devices they currently use throughout the day. Executed properly, this ultimately offers physicians a way to streamline this documentation burden as certain technologies, such as speech recognition and language understanding, let them capture the required documentation in a more natural way.
In parallel, we are seeing an emergence of a cottage industry of mHealth app vendors looking to bring innovative technologies to the healthcare workflow. We have reached a tipping point where technical tools make it easier to leverage a large number of advanced capabilities. This makes it easier for the entire industry to create solutions and applications that are immediately impactful. This is a unique time and place in our technological evolution in the healthcare space.
Cloud is an example of a set of technologies that makes things easier and has the potential to deliver high impact. The cloud makes it possible for technologies to meet physicians wherever they are, on any device, at any time. For example, physicians can enter data into their mobile devices/apps any time, anywhere, and on the go. The cloud will be there to broadcast this information far and wide to EHRs or other apps and tools in a more meaningful way no matter where it originated. Thanks to cloud enablement, mHealth apps and other innovations become more useful to the physicians who want to be mobile.
Mobile and cloud innovations are impacting patients as well. Mobile applications and wearable devices are allowing patients to manage their own health, capture their own health data, and turn this data into actionable insights. Our lives and our health are on the brink of being substantially instrumented. We are now tracking sleep and eating patterns and mobile devices are starting to capture valuable information from blood pressure to heart rate to weight and more.
This technology can help patients comply with the treatment plans that physicians prescribe by allowing them to report progress or other important details in real time. The cloud is connecting patients to their own personal health experience, enabling them with the tools they need to better look after and manage their own health. It also connects patients to their healthcare providers and institutions before they actually need to receive care, potentially keeping them out the hospital in the first place. This evolution is taking place today.
We’re transitioning to a phase where we can truly call this “healthcare” instead of “sick care,” a phase where we are shifting to managing our health proactively instead of just managing a sickness after it has already happened. With all this data available via the cloud, EHRs and all health-oriented applications will evolve, making it easier for physicians to leverage the technology to increase productivity and improve quality of care. The value that the EHRs are promising to deliver will be delivered partly through this mechanism.
As we continue down this path, we move towards a setting that seems as if it’s almost from a futuristic movie where everything in healthcare is mobile, connected, and intelligent. We’re going to see patients surrounded by enabling technology in such a way that intelligent services in the cloud will help their mobile devices keep track of important information that can then be used during visits with their physicians or, more importantly, prior to visits.
Physicians will be primed for the visit with everything they need on a device, reducing the time patients spend having to tell the same thing to three different people upon entering a health system. Present-day documentation requirement problems will eventually fade into the background as technology advances and interacting with these systems become more human-like and natural. Physicians will be able to focus fully on what got them into medicine in the first place: caring for their patients.
Joe Petro is senior vice president of healthcare research and development of Nuance of Burlington, MA.
Now that tax season is in full swing and the eventual rebate is around the corner, it is an ideal time to think about another kind of rebate. This one stems from the changes in healthcare policy with the Affordable Care Act (ACA) with the increasing push of the triple aim of improved patient experience, improving the health of populations, and reducing the per capita cost of healthcare.
With the individual markets becoming the fastest-growing part of the payer sector and increasingly competitive, payers are searching for any potential leverage to obtain, retain, and grow their membership base. There is more discussion on the importance of net promoter score (NPS), whereby payers can utilize their existing members to act as promoters.
By utilizing new innovations and alternative service modalities, insurance companies are able to hit all three parts of the triple aim. Almost on a daily basis we are hearing about innovations that have greater than 90 percent user satisfaction rates and significantly having positive impact on population health at potentially a fraction of the cost.
Health plans are required to have an 80 percent or 85 percent medical loss ratio (MLR), meaning that they spend this amount of the premiums they collect on medical expenses. The rest can be used for administrative, profit, and marketing. Any difference in this percentage must be refunded to the members, according to law. Great idea, but does this actually work?
Looking back to 2014, there are plentiful insurers offering rebates to their members in a wide variety of markets from individual, small group, and large group. Take, for instance, Celtic Insurance Company in Arkansas, which had $6,774,488 in rebates to its individual market. Or how about California Physicians Service ,with an astounding $21,819,095 for its small group market. In the large group market, Cigna Health and Life Insurance Company of DC sent back $5,608,359.
One would think this is an opportunity to fully engage and grow membership. Data from the Kaiser Family Foundation shows that many insurance companies are not meeting the medical loss ratio standards. This signals a missed opportunity.
To calculate the MLR is quite simple.
Let’s take, for instance, a population of 3 million Americans using a service that traditionally costs $1,751 per person per year. If there was an alternative service modality that is clinically equivalent for $30, this would create a savings of $1,721 and a percentage difference of 98 percent. If the premiums and other elements remain the same, this could be extrapolated out to provide bountiful rebates to the members.
Next time you are thinking about innovative strategies to increase the NPS of your members while increasing membership, think about your taxes. Your members will thank you, tell their friends, and increase your membership.
All Claim Attachments are Not Created Equal By Kent McAllister
According to the 2014 CAQH Index, responding health plans representing 103 million enrollees returned data on claim attachments. There was approximately one claim attachment for every 24 claims during 2013 from those same responses.
Interestingly, the vast majority of claim attachments were submitted manually via paper delivery or fax. CAQH counted approximately 46 million claim attachments processed among the plans reporting, which can be extrapolated to roughly 110 million claim attachments industry-wide.
CAQH also estimates another 10 million prior authorization attachments. This statistic suggests a total of 120 million attachments annually across healthcare.
There’s a clarification, however, that must be made when dealing with attachments. Electronic attachments, in and of themselves, are not always the same despite industry rhetoric claiming that there is little difference between the healthcare sectors.
When dealing with the substance of attachments, there are two major distinct segments that providers must accommodate. These two segments are vaguely similar at the highest level, but distinctly different at the business process level for a few reasons. These two segments align with respective accountable payer organizations:
Health and dental plans: commercial health plans and federal and state fiscal agents and administrators,
Workers compensation (WorkComp): property and casualty insurance carriers and third-party-administrators.
The majority of the 120 million attachments are processed by health plans. Dental plans also manage an essentially equivalent business process for handling attachments, often through the same technical channels and human resources with similar skills.
Workers compensation claims, on the other hand, while voluminous, have a notably different set of business processes because of a number of distinctions in both the property and casualty insurance business and in the nature of “claims” in WorkComp parlance.
A WorkComp claim is generally related to an individual injured on the job. That claim may have a life of many months, or, in some cases, years. Resulting from that claim are typically many bills (or e-bills) that usually have an attachment. The e-bill submission process is more similar to property and casualty processes — such as auto physical damage — than to traditional health and dental plan processes.
An interesting contributor to this distinction is that property and casualty insurers are not considered “covered entities” under the 1996 HIPAA legislation. This is important, and any industry observers not recognizing this are failing to accommodate a major consideration.
Just as not all claim attachments are equal, neither are all vendors. For example, some companies that are heavily involved in the P&C space don’t work with the medical side, while others focus almost exclusively on medical. Vendors usually serve one of the two often-unrelated markets.
Providers must be aware of the differences. P&C electronic attachments, even though they may sound as if they’re in the healthcare setting, just don’t carry the same weight as electronic claims actually exchanged to support patient claims generated within a health system. Likewise, those vendors that work almost entirely in healthcare have little claim, if any, to the P&C market.
In a market filled with healthcare claims-related vendors, healthcare organizations must be able to place their trust in partners that understand the complete landscape of the healthcare space. They should also know that even though WorkComp may appear on the surface to be medical, it requires an entirely different scope of work than their counterparts working in the space. In this burgeoning sector of healthcare administration, messages are often painted too broadly with too wide a brush and healthcare leaders should be wary when entering into conversations that broach the subject of electronic attachments.
For the improvement of all parties involved, vendors should recognize and articulate the differences between health and dental attachment processes and WorkComp attachment processes in their public messages. The industry will be better served if vendors accept a mandate to clarify market confusion and to paint clearer lines as to their roles in electronic attachments.
Kent McAllister is chief development officer of MEA|NEA|TWSG of Dunwoody, GA.
I’ve been CEO of PatientKeeper for almost 14 years. Our company is focused on automating physicians, primarily in an inpatient setting. We offer an overlay solution that allows doctors to automate their entire days, regardless of the back-end system that they are working on in their hospital.
Given the data entry that’s expected of physicians, is it possible to make usability better?
Certainly usability has come to the forefront as we have gotten past the adoption question and people are using it. But now the question is, can people use it in a way that saves them time? Clicks and keystrokes are the enemy of saving time. Lack of intuitiveness is as well. If you have to puzzle over a screen and figure out what is being asked of me, or how do I find that order that I’m looking for, those things all kill productivity.
Clearly we think it’s possible to create systems that save physicians time, but it requires a very thoughtful set of work. Not only on software design, but also on, what are we going to ask the physician to do?
Obviously in our current healthcare environment, there are a lot different people in different organizations that have very legitimate things they would like physicians to do. Unfortunately, without some sort of filter or prioritization of them, you end up with all of them being thrust on the doctors. That just kills their productivity.
How do you go beyond the technical definition of usability to design software that physicians will at least tolerate and maybe even enjoy using?
In healthcare, that is a particularly challenging question. If you go back to the days of Hewlett-Packard, they were engineers building software or systems for engineers. They had this next-bench idea, where literally they would be building a tool for an engineer at the next workbench at Hewlett-Packard. They had this great environment for design.
In the healthcare world, that’s just not practical. You can’t just go sit in a hospital and have doctors write software while they are taking care of patients. That would be a bad thing for lots of reasons.
We think the best approach is get as close to that as you can, though, which is to have full contact with practicing providers to get feedback on what the real world is in healthcare delivery. Not a theoretical world, a theorized world, or a world they way we would like it to be. The actual world of all the crazy data patterns and situations that occur.
Then, get experienced designers who have usability training who understand how to build good software. If you don’t expose them to the chaotic and complicated world that physicians face every day, they just can’t build software that works for them. It’s really hard. It’s a difficult challenge to get access to that environment and then also to digest it in a way that makes sense.
The handful of significant inpatient EHR vendors are running decades-old code. Are they challenged to meet customer demands without rebuilding their products from the ground up?
Cerner Millennium — which I think is the most modern of the systems — was released before the millennium, in 1997. They certainly all have some legacy aspects to them in terms of technology. They weren’t built yesterday. You couldn’t have built them yesterday, because it takes a long time to build these systems. They’re big and complicated and they have many, many elements to them.
But I do think that some of the vendors — with the move towards interoperability and some of the standards that are being proposed, the FHIR concept if not the standard — pressure is starting to get applied that will allow these systems to become more open and allow innovation to occur that hasn’t before. Even a system as old as Meditech Magic can be made very open. It’s not a technological limitation, it’s a philosophical limitation. The push towards interoperability is helping to get the philosophy aligned more where we would like the technology to go.
When we talked three years ago, you said that healthcare is the only area left where it’s OK to have a monolithic, closed system that doesn’t support interoperability or an ecosystem. Where do you see that going?
Certainly in the last three years it has improved a lot. The FHIR standard has come out. At HIMSS, we saw Cerner demonstrating applications running against Millennium and moving across and running those same applications against Epic or even PatientKeeper, since we support it as well.
That’s a big change. That’s awesome. But it’s not yet sufficient. Even if you make the software interoperable, the data underneath in many hospitals isn’t yet. It’s not LOINC encoded and all that stuff like it would be if you started from scratch. But they did their implementations 30 years ago as well.
There’s still a lot of work to do as an industry. It’s a little bit chicken-and-egg. The more we open stuff, the more people can innovate and invent and other vendors can create cool applications that motivate people to want to exercise interoperability. That says, we’ll make more interoperability. It becomes a virtuous cycle. Without that pull, it’s just theoretical, “Hey, you should be interoperable and make some new APIs available” and no one really uses them. That isn’t going to drive it.
I think we’re starting to see that cycle start a little bit. You see a variety of organizations — like xG health, for example — taking some products that Geisinger has written for in-house and trying to bring them out to the market. It’s starting. It will be really cool to see that happens over the next three or four years.
How will that impact your business? PatientKeeper has been connected to these systems for more than a decade and new entrants will then have the bar lowered to do the same.
We had to spend a tremendous amount of money building all these integrations, but we would just as soon not have to build them. We built them so that we could build the software that we expose to physicians and that they use.
We embrace it. We’ve implemented the FHIR standards on both ends of our application. Somebody can run FHIR on top of us. We can run using FHIR on top of something that is FHIR enabled.
We think openness is philosophically the way to go. That means if someone finds a better application than we have, well then, shame on us. Our job is to have the best applications, and if we don’t, then someone should buy one that is different from ours and have it work with ours that they do think are best.
That’s the way innovation works. That’s the way it works in the tech world. That creates a great ecosystem, an ecosystem that has all ships rising because it puts competitive pressure on everybody. I’m a huge fan, philosophically. I think it can do nothing but good things for us and for other vendors like us.
You just added imaging appropriate use criteria to your product. Are you seeing more interest in having point-of-care systems offer guidance, reminders, or other features that keep providers on the best practices track?
Hopefully it’s the tip of the iceberg. I believe the reason that we as a country spent $40-plus billion getting doctors onto electronic systems isn’t so that we can just get rid of paper, although that was nice. It’s so that we can take this next step of improving healthcare and making the computer an essential tool for physicians.
The analogy I like to use is if you go to most doctors today and say, "Would you write this order on paper instead of putting it into the computer?" Depending on what kind of computer they have, they might gladly say, "Yes, please give me that paper. I can’t wait to write it on paper." If we do our job right as informaticists and as healthcare IT providers, the answer to that should be, “No. I would never write it on paper, because that’s dangerous. I get so much good information and so much help from the computer to do my job that I would never consider practicing without the computer.”
We’re not there yet. PatientKeeper isn’t there. I don’t think anyone is there. But that is the ultimate test. Imaging criteria is one small step. As we start to deploy more advanced techniques, with all the big data analytics techniques, we’ll have computers that know everything about that patient that is all codified.
The computers aren’t really helping the doctors that much. In some cases, the computer asks the doctor questions the computer knows about. Did you give aspirin to this patient? Well, yes, because I put the aspirin order in the system — why are you asking me? It’s even worse.
The next four, five, six years is going to be that renaissance, helping the physicians with what they do in a way that works for them. Interoperability is such a key to that because it’s going to require the entrepreneurial horsepower of an industry. It’s not going to be one company that solves that problem.
We’re seeing early steps in using little data, where instead of waiting years for big clinical studies to be completed, doctors are getting immediate data analysis from their own systems, such as, “If I have 10 patients in my database who are somewhat like this one, how many of them benefited from this treatment option I’m considering?” Is that concept ripe for development?
I am so excited about that concept. If you think about clinical trials the way they have existed to date, we have a molecule or we have a procedure or a hypothesis. We go out and recruit people, we do all kinds of stuff, and we see whether it works or not.
But every day, there are millions of clinical trials being done. Patients are seeing providers. Things are happening. Outcomes are happening. If we can learn from all of that, even in the smaller cohort, that here are patients like you and and let’s observe how they work. Here are different protocols.
Our parent company HCA has been doing clinical research essentially by just observing different practice patterns across their hospitals. They have done groundbreaking research around sepsis prevention and what things worked and what things didn’t work around preventing infection. Just by observing that there are three or four different ways people do this in terms of washing hands, prophylactic antibiotics, et cetera. They figured out which ones work better without a clinical trial — just by observing the data they have.
That is the future. It might even change the clinical trials industry. At some point you still have to come up with new molecules, but when you start getting into these practices and procedures and off-label use, there is a lot we can learn.
I haven’t heard much about the HCA acquisition since it was first announced. What has changed since?
Certainly the goal of the acquisition was to have exactly what you just described happen, which is business as usual for PatientKeeper from a customer perspective and from an organization perspective. I’m pleased to report that we have achieved that goal. We’re a year and a half in to the acquisition. I’ve talked to some of our customers and they didn’t even know we were acquired. That’s awesome.
The big thing that has changed, which our customers will start to notice over time, is that we’ve made some very big investments in our R&D organization and our hosting center operations. We now have a world-class hosting operation. We had a pretty good one before, but we have a much better one now.
That’s really the big change that we have made. We’ve accelerated R&D efforts and accelerated a variety of projects that we had on the back burner. We’re in the pipeline that we’ve now pulled forward. We haven’t gotten those out to the market yet, so if you are a customer of ours, you haven’t seen the benefits of that. But in the next six to 12 months, you’ll start to see those things hitting the release cycle.
Otherwise, it is just business as usual for us. We’re deploying our advanced clinical software throughout the HCA hospitals and having a great time continuing to go against our original vision.
Do you have any final thoughts?
We’re at the beginning of a new era in healthcare IT. Up until now, it’s been, get rid of paper, get stuff automated. We’ve mostly done that. I wouldn’t say we’re complete, but that phase is coming to an end, where you’re taking processes that have never been automated and automating them.
Now it really is about that next generation. If you think of the evolution of the Internet, we now have concepts like Facebook and EBay that were not possible on paper. They are new concepts. What we’re going to find is a whole new set of innovation in healthcare IT around concepts that were not possible until everybody is electronic. As a company, we’re excited to participate in that. We’re excited to see the ecosystem and the healthcare IT industry itself blossom as that occurs.
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