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Morning Headlines 11/20/18

November 19, 2018 Headlines No Comments

The health care venture from Amazon, Berkshire and JP Morgan just hired its first female exec, and she comes from a big insurance company

The ABJ health initiative hires Dana Safran (BCBS of Massachusetts) as head of measurement, leading analysts to surmise the still-unnamed joint venture will focus heavily on health data analytics.

Update on our Smart Lens program with Alcon

Citing insufficient consistency in measurements, Verily shuts down its four-year smart contact lens project with the eye-care division of Novartis, which sought to help diabetics manage their disease through tear-based glucose measurement.

Information on Medicare Telehealth

CMS reports that telemedicine utilization by Medicare beneficiaries increased 50 percent between 2014 and 2016, with members in rural areas making up the bulk of visits for mostly mental health and chronic conditions.

Readers Write: Our Experience with Epic’s App Orchard

November 19, 2018 Readers Write No Comments

Our Experience with Epic’s App Orchard
By Chinmay Singh

Chinmay Singh, MBA, MSE is co-founder and CEO of SimplifiMed of San Francisco, CA.


SimplifiMed went live last month on App Orchard after several months of work. I believe other startups can benefit from our experience as they pursue integration with Epic.

We integrated with many other EHRs before Epic, including Athenahealth, Centricity, and Drchrono. As I review my experience, there may be a whiff of unavoidable comparison.

1. Epic is the most customer-focused EHR vendor

This became clear to me in my first call with Epic’s App Orchard team. I could vividly imagine a customer in the center of anything App Orchard team discussed — workflow, security, or marketing message. For this reason, I would recommend that startups first integrate with other EHRs, learn from that, and then approach Epic.

2. The App Orchard team knows the customer

Your contact at App Orchard is unlikely to be a mere project manager. He or she will be an active participant and will gently prod and challenge you on your workflows and the selection of APIs. If you don’t have an active Epic customer, this is one of the best resources you have to compensate for the lack of information. Use it.

3. Epic listens to App Orchard members

We all have heard about a certain recalcitrant Midwest company. I was surprised at how receptive the App Orchard team was to my suggestions on the program, pricing, and terms. They listened to my concerns and responded to them in a timely fashion, and I assume that the new program terms were partially influenced by the feedback I provided to them. Reach out to them with your feedback.

4. App Orchard documentation is lacking

The API documentation is very basic, and in some cases, unusable. For example, there is no explanation of the different versions of the same APIs. Or that two different APIs appear to be doing the same thing (they are not) without a good explanation. The advice in #1 and #2 above partially compensates for this. If Epic team needs some inspiration, they should look at Athenahealth’s developer suite. Not only does Athenahealth have more robust documentation, all of their APIs can be tried in the sandbox.

5. No Hyperspace

This is the biggest issue with App Orchard. Without access to Hyperspace, it is difficult to test the product. Moreover, Epic periodically resets the back end, forcing you to re-create your test cases. This is a huge time sink. As we are experiencing now, prospects want to see a demo of SimplifiMed working with Epic. But without access to an Epic instance, we are unable to do so. I would love to hear from other App Orchard partners on how they are overcoming this problem.

Curbside Consult with Dr. Jayne 11/19/18

November 19, 2018 Dr. Jayne No Comments


Thanksgiving is upon us, a quintessential US holiday. A friend sent me some seasonally appropriate ICD codes, including the W61.43 category “Pecked by Turkey” and W60 “Contact with Sharp Leaves.” There’s also Z63.1 “Problems in Relationship with In-Laws” for those of you with challenging holiday kinship arrangements.

All kidding aside, in some areas, Thanksgiving marks the beginning of increased healthcare utilization, which stresses the system in a variety of ways. People who have reached their deductibles for the year may be trying to schedule elective procedures at the same time providers and staff are trying to take time off with their families. There tends to be a bit of overeating in the US, which can lead to an increase in gallbladder disease, gout attacks, and elevated blood sugars. Family and personal stress levels increase. Just when things start to settle down, influenza and other viral illnesses will begin to peak.

Just in time for the holiday magic, the United States Preventive Services Task Force released a final recommendation statement regarding screening for unhealthy alcohol use in adolescents and adults. Adults 18 and over should be screened in the primary care setting and in addition to screening and practices should also be providing brief behavioral health counseling interventions to reduce unhealthy alcohol use. However, current information is insufficient to recommend screening in adolescents aged 12 to 17. EHR vendors, get ready to update your clinical guidelines packages.

To further dampen our holiday spirits, the Department of Health and Human Services has released its new Physical Activity Guidelines for Adults that emphasize the fact that roughly 80 percent of US adults and adolescents are not sufficiently active. HHS recommends that adults complete at least 150-300 minutes of moderate intensity activity each week, or 75-150 minutes of vigorous intensity activity each week. We should also be doing muscle-strengthening activities twice weekly. There are other specific recommendations for older adults and pregnant / postpartum women. The bottom line is “sit less, move more,” and even if you’re already moving, you’re probably not moving enough.

As we move toward the end of the calendar year, the healthcare IT space is in the doldrums, with vendors marking time until HIMSS, when they’ll try to make a big splash (among the dozens of other vendors trying to do the same thing) with various product releases and enhancements. The user group season is winding down with hospitals and health systems having exhausted their travel budgets for the year. Even those facilities that have cash to spend might be waiting until the beginning of the calendar year to start dispersing it unless they’ve aligned their fiscal years to the federal calendar and their year started in October. Nothing big usually happens between now and HIMSS unless it’s scandalous or completely revolutionary and unexpected.

It’s a good time to reflect on the year that has been and to think about what we might like to accomplish in the year ahead. I’m encouraging my team to think about their priorities, both professional and personal. Are there new skills that they’d like to learn, or a different area of the healthcare IT world in which they’d like to be more knowledgeable? Are they satisfied with their work-life balance and travel schedule, or do they want opportunities to slow down (or speed up?)

I work with several people who have recently become relatively empty nesters and they’re interested in potentially picking up extra work opportunities to fund things like retirement catch-up savings or creating college savings accounts for grandchildren. I had incorrectly assumed they were interested in slowing down, and without a structured conversation about priorities, I might have missed out on extra capacity with some outstanding resources. Another member of my team will be leaving at the beginning of summer, having decided to purse a public health masters’ program. Sometimes these goals align across personal and professional domains and sometimes they’re at cross purposes, but I appreciate the opportunity to try to help people meet their goals.

I have several good friends who have had it pretty rough this year with layoffs, family illness, natural disasters, and other unexpected surprises. I’m continually impressed by their resilience and their ability to look at the world through a glass-half-full lens (even if it is occasionally tinted with a hint of desperation). It helps put things in perspective and reminds me of how important it is to support the people around you from an emotional standpoint. It has taught me that time is short and success can be fleeting. I’ve made it a point to schedule quarterly meetings with friends and colleagues I had previously lost touch with, even if it’s to meet to walk a couple of miles at the park during a child’s soccer practice rather than sip wine as we might have liked to do in the past. If we don’t make those relationships a priority, it’s too easy to lose touch.

I’d like to challenge our readers to make a list of things they’d like to do in the coming year that will bring them either closer to friends and family or to help them explore a part of themselves that they’ve allowed to be put by the wayside. Maybe it’s a larger commitment such as a new hobby, or maybe it’s something as small as taking yourself to a local museum. I’d love to hear from readers about what they find satisfying and what they’d like to accomplish in the coming year. In the meantime, I’m going to try to find my pre-Thanksgiving bliss with some pastry therapy. Caramel apple pecan pie, in case you’re curious.


Email Dr. Jayne.

Morning Headlines 11/19/18

November 18, 2018 Headlines 1 Comment

The 25 most valuable US startups that failed this year

Business Insider lists “The 25 Most Valuable US Startups that Failed This Year,” including four health technology companies that raised a combined $1.1 billion.

The Chopraj Group Launches Imperativ, Inc., Delivering Unique Artificial Intelligence For Healthcare

Industry long-timer and neurosurgeon Gopal Chopra, MBBS, MBA launches healthcare AI company Imperativ.

CommonWell Health Alliance Announces General Availability of Carequality Connection

CommonWell announces GA of its connection to Carequality two years after the organizations announced a connectivity agreement.

Monday Morning Update 11/19/18

November 18, 2018 News 3 Comments

Top News


Business Insider lists “The 25 Most Valuable US Startups that Failed This Year,” including these health technology companies and the amounts they raised:

  • Paieon (medical imaging, $34 million)
  • Candescent Health (radiology software, $94 million)
  • Medical Simulation (training, $55 million)
  • Theranos (lab testing, $910 million)

Reader Comments


From HCInvestor: “Re: Seeking Alpha article on Cerner. Quality of reporting to guide investors is very poor outside of the industry. It’s as if the author hasn’t looked at Cerner’s financial statements or leadership challenges.” I would question quite a few of the statements by the UAE-based research analyst, some of which are so wooden and uninformed that it’s like a computer generated them from financial reports or web pages:

  • I’m not so sure that healthcare IT has “a massive potential to grow,” at least as compared to the boom years of Meaningful Use. CERN shares have been stuck in an up-and-down trading range since early 2015 after years of nearly straight-line growth, and over the past five years, CERN shares are unchanged vs. the Nasdaq’s 82 percent rise. 
  • I don’t understand why Medicare Advantage gives Cerner a competitive edge.
  • The comparison to McKesson makes no sense since the company is mostly out of health IT other than its stake in Change Healthcare
  • The author mentions the DoD contract (in which Cerner is a subcontractor) but fails to mention the larger VA contract (in which Cerner is the prime contractor and thus will pocket a ton more taxpayer cash). The conclusion is cartoonishly oversimplified: “This contract will help build the company’s credibility further, which would pave the way for Cerner to acquire new business.”
  • Cerner, he says, has a “management with a proven track record of delivering growth” even though Chairman and CEO Brent Shafer has been on the job less than a year (and in his first CEO job) and President Zane Burke resigned earlier this month and his position was eliminated.
  • Here’s a bizarre statement: “A single malfunction of their systems would be enough to wipe Cerner off the healthcare IT industry forever,” with the author apparently unaware that such malfunctions happen with every vendor and Cerner in particular was associated (albeit in a poorly researched study) with increased patient mortality at a children’s hospital, which despite headlines had no discernible impact on the company’s growth.
  • The author claims that despite his proclaimed Cerner “moat” and barrier to entry due to long development cycles, the entry of large-scale competitors could drive down profit margins. Which is it?


From Bam Margarita: “Re: innovator awards. Pay for play?” Healthcare Informatics flags as breaking news its invitation to vendors to apply for its Innovator Awards winner for a $1,999 submission fee, after which I assume advertising persuasion is then exerted to the “winners” to publicize their “accomplishment.” The magazine’s pitch page humbly accepts its own nomination to facilitate “meaningful conversations” between providers and vendors (in other words, sell ads). I don’t fault anything they do – it seems like quite a few health IT publications and websites have hit hard times and are scrambling to pivot into conferences or running sponsored “news,” which I suspect has created the now-common journalism death spiral as readers find even less motivation to return. Healthcare Informatics was just sold, with the new owner seeming to be most interest in its conferences.

From Cold Gin: “Re: updates. I would like to see you tweet out more frequent HIStalk updates as news develops.” People get crazy stressed out from constantly staring at their glowing screens for political, stock market, and sports updates even as they become oblivious to the real life that is unfolding around them. Sites that provide that information are thrilled that users think such manic behavior is not only normal, but necessary, because the frantic eyeballs earn them advertising dollars even though the nail-biting vigil has zero impact on the outcome. Bottom line: only rarely are health IT events so newsworthy that I would break into your day to relay them. Meanwhile, my thrice-weekly news schedule is nearly perfect for getting the signal without much of the noise.

From Kenyan Jambo: “Re: Allscripts Avenel EHR. What happens at HIMSS19 when a product launched with great fanfare at HIMSS18 hasn’t been heard of since?” In a perfect world, the hope for short memories will be dashed, after which embarrassment ensues. Developing a new product and giving it a high-profile launch is perfectly fine, but the months of radio silence that followed suggests that the public celebration and vendor executive high-fiving was premature.

From Agent Orange: “Re: speech recognition. What’s an easy way to dictate documents without cost or system overhead?” Open a Google Docs document, click Tools / Voice Typing (or Ctrl-Shift-S), click the microphone icon and answer any microphone permission messages, and then simply speak away. Accuracy is good even with only a webcam microphone, system impact is minimal, and cost is zero. Just copy and paste your completed text into whatever app you want. You can also dictate directly into Word, which I often forget about since I basically never use Word.

HIStalk Announcements and Requests


Poll respondents say EHR vendors and the government are the dirty old dastards who made EHRs unfriendly.

  • Dean Sittig thinks that while everyone is complicit, EHR vendors didn’t do a great job of operationalizing requirements or constraints.
  • Evan Steele says vendors are forced to make guns-or-butter decisions in either cramming in RFP-sweetening functionality (some of it via the government’s prescriptive requirements) vs. addressing usability.
  • EHR Girl wishes physicians had not taken a hands-off approach when vendors were trying to computerize the medical record in the early 2000s and that the federal government hadn’t trotted out the HITECH carrot without first assessing the state of the EHR market that stood to benefit hugely.
  • Frank Poggio says clinicians are most responsible because all of the vendors have them on staff, also adding that the chestnut that EHRs were built as a by-product of billing isn’t true since Cerner and Epic didn’t even have billing systems until long after they had rolled out clinical systems.
  • Ross Martin takes the long view in blaming World War II, after which the US ended up with employer-based health insurance that begat third-party payers, then Meaningful Use which increased adoption of systems that weren’t focused on patients and users.
  • Industry Stalwart blames insurance companies (of which he or she includes CMS), but also notes that doctors could have opted out of HITECH and accepting insurance, but otherwise have to obey the wishes of outsiders who send them checks.
  • Cosmos works for a vendor that spends half its nursing development team’s time addressing regulatory requirements and the other half dealing with patient safety events and customer escalations, with usability always taking the back seat. He or she also ponders whether the government’s regulation of healthcare threatens competition in favor of what they see as patient safety benefits.


New poll to your right or here, as requested by a reader but modified a bit by me: What was your reaction to Black Book’s survey naming Allscripts the #1 integrated EHR/PM? (my post on Black Book’s methodology provides more information). I’m sure the reader who asked for this poll would also like to hear your thoughts, which you can provide after voting by clicking the poll’s “comments” link.

UPDATE: poll cheating has the #1 option (Allscripts as the best EHR/PM makes sense) as the biggest vote-getter. This is pretty obvious:

  • Voting was far heavier than normal, with several votes per minute making it clear that scripting was being used to stuff the ballot box.
  • 170 of the 274 votes that were cast shortly after I wrote this post (more than 60 percent of the total) came from someone hiding their identity and location via the Tor browser. Every one of those votes chose the #1 option.
  • A bunch of votes came from foreign IP addresses, and every single one of those also chose the #1 option.
  • Just about all of the legitimate-looking votes said it’s fishy that Allscripts did so well in the Black Book survey, while none of the suspicious ones did so.

It’s fun and ironic than most of the genuine respondents are skeptical of Black Book’s poll results (most of them wondering whether Allscripts influenced the outcome), and now someone is trying to support that Black Book poll result by cheating on my poll. I think we can assume that all online polls or surveys that aren’t locked down to a validated identity are likely to be gamed by someone who benefits from a particular result.


UPDATE 2: I turned off poll voting since the bot-driven cheating is continuing. The results excluding those votes are above. Infer what you will that the “Allscripts being ranked #1 makes sense” option gets 67 percent of the vote when you include the obviously fake voters, but just 9 percent with those omitted. Your “false flag” conspiracy theories are welcome.


LinkedIn profile padders and social media aficionados beware: a lot of people roll their eyes when you anoint yourself with non-quantifiable honorifics whose purpose seems to be to deflect from a lack of accomplishment. Poll respondents are OK with innovator, keynote speaker, and entrepreneur since they are can at least be reviewed against career accomplishments. Demo Chic says she’s tired of social media influencers and ambassadors who have nothing better to do while the rest of us are trying to get work done. Being Real says if you really are an influencer or thought leader, you wouldn’t need to broadcast it. Title Smitle believes that the idea of social media ambassadors is a “load of BS” consisting of un-unsightful tweets and “a preponderance of selfies.”

Listening: the new EP from the upcoming 10th album of Papa Roach, which reminds me only slightly of their angrier, earlier nu metal with more of a 21 Pilots sort of intimate, melodic rhyming. I like it. I’m also marveling at live Skillet, drawn in fascination to one of rock’s best and most joyously dynamic drummers in Jen Ledger.  And while I loathe holiday-themed albums (I always picture uninspired, drugged-out rockers who are bound by record company contracts to stumble unconvincingly through ancient, lame Christmas songs in a June LA recording session) Sia’s “Everday [sic] is Christmas” is stellar, barely recognizable as Christmas music because it’s all new songs that you could play year around. She is brilliant.

Jenn has to miss HIMSS19 due to fun family events, so that leaves Lorre to cover our booth solo for three long days with no chance to scurry quickly away for intake and output. Let her know if you would like to stand in for a few minutes or an hour, posing with visitors anxious to take a picture with The Smokin’ Doc or representing me without doing something scandalous (or if it is scandalous, at least making sure it’s fun, yet not legally actionable). I’m also up for hearing about things we might do in our tiny booth that would be fun since we don’t have anything to sell or do except say hello to puzzled passersby.


December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock


I missed this item previously. VC-backed, Philadelphia-based health cloud vendor CloudMine files for Chapter 7 bankruptcy after defaulting on a $1.8 million bank loan and laying off its 11 remaining employees. The company had raised $16.5 million, most recently in an undersubscribed Series A round in early 2017.  Companies that built applications using CloudMine’s platform were warned that it would be shut down with data deleted per HIPAA requirements.


Industry long-timer and neurosurgeon Gopal Chopra, MBBS, MBA launches healthcare AI company Imperativ.


  • Australia’s Perth Children’s Hospital selects Vocera Collaboration Suite.
  • Signature Healthcare (MA) chooses Santa Rosa Consulting to lead its upgrade to Meditech Expanse and implementation at its multi-specialty physician group.


  • Franklin County Medical Center (ID) replaced Evident with Athenahealth in October 2018.
  • Pana Community Hospital (IL) will switch from Allscripts to Cerner in 2019.
  • San Juan Regional Medical Center (NM) will implement Workday for financial management software in July 2019, replacing Meditech.

These provider-reported updates are supplied by Definitive Healthcare, which offers a free trial of its powerful intelligence on hospitals, physicians, and healthcare providers.


image image

DocuTAP hires Ron Curtis (Cardlytics) as SVP of product and Kerri Tietgen (KT Consulting) as EVP of people and culture.

Announcements and Implementations

Research network provider TriNetX adds ambulatory care, medical claims, and pharmacy claims from 190 million patients to its network. It also adds propensity score matching to address potential cohort bias.

Catholic Health Initiatives and Dignity Health name their merger-created organization CommonSpirit Health, with the press release brimming with the usual marketing mumbo-jumbo explaining the “positive resonance” that the made-up word (called “one powerful word” despite the fact it’s two words with a trendily omitted space) will create in unifying every single person who is involved in the sprawling endeavor. There’s something unsettling about a ministry preaching the prosperity gospel in “serving the common good” while simultaneously bragging about annual revenue of $28 billion.


Ciox Health announces HealthSource Vault, a member-centric data repository that creates a longitudinal patient record from medical records, health assessments, clinical data feeds, and other information sources using OCR and NLP extraction.

CommonWell announces GA of its connection to Carequality two years after the organizations announced a connectivity agreement in December 2016.

Privacy and Security


Japan’s newly appointed minister of cybersecurity admits to Parliament that he has never actually used a computer because “I order my employees or secretaries to do it.” He’s also in charge of the 2020 Tokyo Olympics.


The former CTO of Cleveland Clinic spinoff Interactive Visual Health Records, which offered a system that presented a physician-friendly view of Epic data (the company appears to be defunct), pleads guilty to defrauding the Clinic of $2.7 million by skimming payments made to a foreign company. He agreed to being deported following sentencing. The former CEO of Cleveland Clinic Innovations, who prosecutors said was involved in the scheme, was sentenced to federal prison for fraud last year.

Two China-based Google AI researchers return to Stanford University’s medical school to work on healthcare projects.

HIMSS Media says that providing expert news and analysis isn’t really important since “decision-based content” is what drives vendor sales leads and thus pays the bills. The guy who runs the HIMSS media lab explains that “we provide deeper insight for HIT vendors seeking sales prospects” and that he “specializes in the neuroscience of HIT buyers.” In other words, it’s all about ads posing as news and collecting reader information for advertisers, which is in itself hardly news to anyone. Healthcare really pushes the boundaries of “non-profit.”

Daily Mail provides some gruesome photos and videos to show the sad results of fame-hungry teens taking the “Fire Challenge” that involves pouring flammable liquid on themselves and then igniting it while recording on video. It’s not technology’s crowning achievement that kids who are the age of those who died on Normandy’s beaches are now seeking their place in history by eating Tide Pods.


Local TV covers how AnMed Health Medical Center (SC) honors veterans who die in the hospital. The hospital announces their passing (with the family’s permission) along with their name and rank, their body is covered with the American flag and escorted to a hearse by available doctors and nurses, and employees line up with hands over hearts to honor the deceased.

Sponsor Updates


  • PatientSafe Solutions employees in San Diego relocate to larger office space.
  • Meditech releases a new video, “How the Meditech mobile app transformed home care for Kalispell Regional.”
  • PatientPing moves to expanded office space in Boston.
  • PreparedHealth wins several awards at the inaugural Matter Accenture Digital Health & Life Sciences Pitch Competition.
  • Philips Wellcentive publishes a new white paper, “Embracing Disruption.”
  • Access releases version 8.17 of its Passport web-based electronic forms hospital solution.
  • ZappRx founder and CEO Zoe Barry joins the Life Sciences Cares Board of Advisors.

Blog Posts



Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.


Weekender 11/16/18

November 16, 2018 Weekender 1 Comment


Weekly News Recap

  • The VA tells a House EHR subcommittee that it will need to spend an extra $350 million on top of its $16 billion Cerner budget to hire “subject matter experts to grade the implementation efforts of Cerner”
  • HHS OCR issues an RFI to solicit the public’s views on whether HIPAA rules prevent or discourage providers, payers, and patients from sharing information for care coordination and case management
  • App vendor Driver, whose technology matches cancer patients with clinical trials, runs out of cash and shuts down just two months after its high-profile launch
  • Veritas Capital and Elliott Management subsidiary Evergreen Coast Capital announced their deal to acquire Athenahealth for $5.7 billion
  • Allscripts rebrands its Payer & Life Sciences Division to Veradigm, offering clinical workflow, research, and analytics software and services to providers, payers, and health IT and life sciences companies
  • Alphabet will move its London-based DeepMind healthcare AI subsidiary under the newly formed Google Health, which will be led by former Geisinger CEO David Feinberg

Best Reader Comments

From my own personal experiences being around and using Allscripts products again NONE of their products are remotely close to being seamlessly, fully integrated … With a dwindling client base, very little new sales in US or abroad it is hard to believe anything about this survey and the process used. (DrJay)

The fear for us as a vendor is that when clients are blindly encouraged to take any external survey, there is then a mechanism for that client to overly complain (not recommend) and our total company satisfaction scores actually drop, not rise. Trust me when I confirm, vendors are not relied on for client participation! Obviously the reaction here is about Allscripts because they promoted this single, narrow focused award so much. Cerner, Epic GE, Athena, Meditech etc. all broadly receive many more Black Book awards every year but publicize them far less, or at least the reactions are tamer. (Longtime HIT Marketer)

Biggest winners [in Athenahealth’s sale to Veritas Capital] — eCW, Greenway, and small vendors willing to go after the long tail. Epic, Cerner, and Meditech in the IDN market. Biggest losers — Athena customers, Athena employees, Athena shareholders who don’t sell in the next six months, and Jonathan Bush’s legacy. (Pickin up the pieces)

I’m sure it’s heartwarming to Athenahealth customers that Immelt’s lead-in was “maximize shareholder value.” (sam lawrence)

Blockchain and bitcoin fever is over. Great! No more explaining what this is to executives and others who are worried we are missing the Blockchain Train! (CaveNerd)

Watercooler Talk Tidbits

SNAGHTML8d122b8 image

Readers funded the DonorsChoose teacher grant request of Ms. S in Ohio, who asked for a long list of “Rube Goldberg machines” for her fourth-grade gifted and talented class. She reports, “Students were given materials to create their own Goldberg. We started with the marble run and the Angry Birds LEGO set. Students had to explain why certain things would work. Then they were given different supplies and had to put the marble in the cup. My students loved the hands on aspect of this project and they learned a great deal. Thank you for your generous donation to our classroom!”

US exceptionalism of the negative kind is evidenced by schools offering “Stop the Bleed” training so that students can try to save their classmates who have been taken down by a mass shooter. It’s depressing to think of sixth graders screaming “medic” while pinned down by hostile fire like you see in a Vietnam war movie.


The ED of England’s Northwick Park Hospital pilots using smartphone-dispatched patient transporters (they call them “porters” there), replacing a two-page paper form (!!)

Mayo Clinic will rename its medical school after turnaround consulting firm founder Jay Alix., who has donated $200 million to make the school’s tuition more affordable and to allow it to build technology-focused programs that include artificial intelligence.


A Salt Lake City newspaper columnist draws heat for gleefully recounting the “night when I beat the system” by skipping out on an ED bill after being examined for an eye problem. She complains that she doesn’t make enough money to afford health insurance but makes too much to earn government subsidies, then describes how she realized that the ED’s computer downtime left them with nothing more than her name, so she and a friend “crouched and ran toward the exit” and hopped a cab home to avoid paying. She then concludes that it’s cheaper to pay out of pocket (she cluelessly assumes the ED bill was probably around $50, puzzling given that she graduated from the London School of Economics) and that “someone should do something about that.” Readers chimed in with fun comments, such as the fact that the real cost of an ED visit makes her a felon, that “cutesy-poo” writing doesn’t hide the fact that she’s a thief, and that she probably wouldn’t behave similarly at a restaurant.

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A woman who had just delivered a baby girl by C-section at Camp Fire-engulfed Adventist Health Feather River is immediately evacuated, after which the ambulance in which she is crammed in with other patients and several hospital clinicians catches fire. The hospital workers, including Tammy Ferguson, RN, who took the photos above, got everybody out and moved the patients to a nearby home, then grabbed garden hoses and shovels to successfully save the house and themselves.

In Case You Missed It

Get Involved



Morning Headlines 11/16/18

November 15, 2018 Headlines No Comments

Lawmakers balk at $350M addition to VA’s health record deal

John Windom, director of the VA’s EHR modernization efforts, says during a congressional hearing that an additional $350 million in personnel costs will be part of the Cerner project’s already $16 billion budget.

Surescripts Prescription Price Transparency Tool Realizes Massive Provider Adoption, Achieves Breakthrough In Healthcare Market

Surescripts announces that its Real-Time Prescription Benefit tool has increased prescriber count 40-fold, and has been used 30 million times within EHRs to look up patient-specific drug price and alternative information.

HIPAA Privacy: Request for Information on Changes to Support, and Remove Barriers to, Coordinated Care

HHS OCR issues an RFI to solicit the public’s views on whether HIPAA rules prevent or discourage providers, payers, and patients from sharing information for care coordination and case management.

News 11/16/18

November 15, 2018 News 2 Comments

Top News


Pointed fingers fly at a House Veterans’ Affairs EHR subcommittee meeting, with most aiming towards VA program director John Windom once he let it be known an additional $350 million in personnel costs would be part of the Cerner project’s already $16 billion budget.

Windom attributed the hiring costs (part of the “fuzzy math” some committee members have complained about) to EHRM office downsizing and the need to have “highly qualified subject matter experts to grade the implementation efforts of Cerner. Those people cost money.”

Other items of interest from the oversight meeting:

  • Computers – most of them at least five years old – will be replaced six months ahead of the Cerner implementation at most VA facilities.
  • The DoD and VA will use the same web address to access the online system.
  • The agencies will share a patient identity management system.
  • Progress checks should be made every 90 days over the life of the 10-year project, a recommendation in line with Cerner President of Government Services Travis Dalton’s promise that the VA project won’t suffer from a lack of frequent engagement with implementation sites – a problem that has plagued initial DoD sites in the Pacific Northwest.
  • Leadership over the joint DoD-VA project is still in doubt. VA Secretary Robert Wilkie has said he will take the lead, while Windom told the committee that acting Deputy VA Secretary Jim Byrne is in charge.

Reader Comments


From Ginsu Sharpener: “Re: CommonWell. Launching a search for a technology vendor.” The company will issue an RFP in December 2018 for “interoperability infrastructure and services.” I assume these are the services that RelayHealth has provided since CommonWell’s founding in 2013. They’ will explain more in the RFP Bidder Call on Friday, November 16 at 4:00 p.m ET.

From Watcher: “Re: ONC proposed rule from Tuesday. #3 supports a safe harbor for care coordination, which would significantly benefit social determinant and social care workflows.” HHS OCR issues an RFI to solicit the public’s views on whether HIPAA rules prevent or discourage providers, payors, and patients from sharing information for care coordination and case management. One item specifically addresses creating a safe harbor for good-faith PHI disclosure for coordinating or managing care. The change is being considered under HHS’s “Regulatory Sprint to Coordinated Care,” which hopes to remove regulatory barriers that impede coordinated, value-based care. 

From Hanzi: “Re: Centra Health. Blames its Cerner implementation for its loss.” The health systems nine-month report says Cerner went live on September 1, increasing staffing costs while reducing clinic volumes. It spent $65 million on Phase I. Year-over-year operating income dropped from a $18.8 million to –$2.7 million.

From Curved Air: “Re: 3M. We were notified that one of their administrator accounts was compromised. We’re in the midst of our investigation. I figured it’s the same issue as the anonymous report you posted early.” That is correct. Two C-level readers say they received a communication from the company, but haven’t seen public reports otherwise.

HIStalk Announcements and Requests


I’ll report the results of this poll over the weekend, so it’s last call to vote (exit polls suggest a possible upset in that “disruptor” is even more loathed as a self-assigned adjective than “thought leader.”)


December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock


In the UK, RenalytixAI raises $29 million in an IPO that will be used to fund the launch of AI-enabled applications for the early detection of kidney disease and transplant management. The company was spun out of Mount Sinai Health System’s New York-based commercialization arm, and will use de-identified data from the health system’s Epic EHR in its product development.


Allscripts rebrands its Payer & Life Sciences Division to the far more confusing moniker of Veradigm, offering clinical workflow, research, and analytics software and services to providers, payers, and health IT and life sciences companies.



Loyale Healthcare names Timothy Sykes (Regroup) as VP of sales.

image image

Health Catalyst appoints Jason Jones (Kaiser Permanente) chief data scientist and Elia Stupka (Dana-Farber Cancer Institute) chief analytics officer / SVP of life science.


  • Dartmouth-Hitchcock Health (NH) will use technology from Philips to develop a tele-ICU program at Dartmouth-Hitchcock Medical Center and Cheshire Medical Center.

Announcements and Implementations


Casenet announces GA of its TruCare 7.0 population health management software, including chronic care guidelines from MCG Health.

Wake Forest Baptist Health (NC) implements tele-ICU services from Advanced ICU Care at three hospitals.

LogicStream Health releases a drug shortage app to help hospital pharmacies identify and manage drug shortages, noting that manual process require up to 10 hours to evaluate each shortage as organizations experience 3-4 per week, basically a full-time pharmacy department position. 


A new KLAS report on healthcare management consulting finds that health systems are seeking help with value-based care transformation (top choices: Premier, Optum / Advisory Board, McKinsey); financial improvement (Huron, Deloitte, Navigant); strategy (McKinsey, The Chartis Group, Deloitte); and consumer experience (Press Ganey, Huron, Optum / Advisory Board). The high-mindshare, cross-industry firms are Deloitte, McKinsey, and Huron, although KLAS notes that McKinsey and Huron are also the two lowest-performing firms.  


Surescripts announces that its Real-Time Prescription Benefit tool, launched last year, has increased prescriber count 40-fold and has been used 30 million times within EHRs to look up patient-specific drug price and alternative information. CVS Health says prescribers switch non-formulary prescriptions 75 percent of the time and higher-cost meds 40 percent of the time, saving patients an average of $130 per prescription.



A New York Times analysis of hospital mergers in 25 markets reveals what most of us already know from Econ 101 – less competition has resulted in higher prices, despite hospital PR efforts touting the contrary. Admission prices have gone up between 11 and 54 percent in the years following mergers in the analyzed areas; they tick up even further once acquired physician groups are taken into account. The cost of replacing or integrating the health IT systems of acquired organizations isn’t mentioned as part of the price increases, but I’m willing to bet it has a strong downstream effect on patient pocketbooks.

The New York Times also looks at the incredible wealth made by the family-related owners of Wall Street-backed private hospital chains in China that control 8,000 facilities, 80 percent of the private hospital total. The hospitals, overseen mostly by overwhelmed local governments, have been caught fabricating patient testimonials, claiming 100 percent cure rates, falsifying doctor credentials, and using outdated or dangerous treatment protocols. The original founder made his money selling a homemade remedy for scabies door to door, overcoming his lack of medical background in recognizing that the country’s medical system was a mess. His company grew quickly as the government realized public hospitals could not handle a rapidly growing population.


AI celebrity Andrew Ng launches a Coursera program aimed at non-technical business leaders called “AI For Everyone.” The three-week course requires 2-3 hours of work per week and opens in early 2019. 

Sponsor Updates

  • EClinicalWorks will exhibit at the Annual Pain Care for Primary Care event November 16-17 in Bayside, San Diego.
  • Healthfinch launches the first of a four-part e-book series, “Introduction to Prescription Refills Requests.”
  • IDC MarketScape names Lightbeam Health Solutions a leader in its US Population Health 2018 Vendor Assessment.
  • Visage Imaging will preview its new Visage 7 technology with AI capabilities at RSNA November 25-29 in Chicago.
  • Surescripts reports a fortyfold increase in adoption of its Real-Time Prescription Benefit tool since it launched last year.
  • Meditech publishes a new case study, “Union Hospital’s Journey To Stage 7.”
  • Nordic releases a new podcast, “Expert advice on preparing your MSSP submission.”

Blog Posts



Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.


Black Book’s Vendor Report Methodology

November 15, 2018 News 5 Comments


Readers asked how Black Book performs its survey-driven health IT vendor reports, apparently surprised that Allscripts finished in the #1 spot for integrated EHR/PM/RCM vendors.

Doug Brown is president and CEO of Black Book Market Research, LLC. He has a long background in hospital administration and a master’s degree in hospital and healthcare administration. He provided quite a bit of information and the full detail behind this particular report, responding nearly instantly to my email. He says the company received a dozen calls in one day about this report, which is just one of 140 it publishes each year.

My questions and Doug’s answers (paraphrased for conciseness by me except when in quotes) are below.

How do you choose the people you survey?

The company sends survey invitations – usually during the big conference season – to those who have volunteered. That includes 90,000 past participants; 330,000 website signups; contact lists obtained from membership groups, journal subscribers, conference attendees; and for private physician practices, contact information from third-party lists. Participants are required to provide a verified company email address for validation.

Are vendors involved, either in providing a client list or publicizing the survey?

Never, Doug says, and he invites anyone to ask any highly-ranked vendors if they’ve ever been in contact with Black Book. Black Book discourages vendor and public relations company involvement and doesn’t communicate with them as surveys are underway (and doesn’t ask them for client lists). He also adds that plenty of vendors publicize their #1 rankings without even buying the detailed report, which he says is just fine.

Black Book can’t restrict vendors from suggesting that their clients complete surveys, but it discourages the practice.

Do you have a sample questionnaire?

The company provided its standard list of 18 KPIs for software or services, which have remain unchanged since they were developed in 2010 with help from academics with relevant software and services experience. It may explain a given item differently based on the audience, such as an infection control nurse vs. a business office manager.

In the 18 principles under “support and customer care,” it is stated that “External analysts, press/media and other clients reference this vendor as a services leader and top vendor correctly.” Does that mean customers provide a response, or that this element isn’t provided by customers?

“The content under the 18 key performance indicators is meant to only be a guide and are modified occasionally to suggest ways that that KPI can be interpreted. For instance, if the analysts or other clients are highly satisfied in terms of support and customer care, so may you. They are suggestive ways to consider the KPI theme – such as reliability or trust. Our goal was to find aspects of the client experience that a prospective buyer could not find in vendor RFP responses or get from tainted vendor-provided client reference calls. We aim to find the user level experience from a wide response pool perceptions, -not the input of a couple dozen financial decision makers or CIOs on advisory boards.”

Was additional information used for the report on integrated ambulatory systems?

“After we are in the audit stages, we often go back to the survey respondents with some additional questions on trends and strategies to give the vendor results some additional color. You will find that in the report before the vendor rankings (much is in the press release) and feel free to share that info.”


The survey responses are reviewed immediately by both internal and external auditors for completeness, accuracy, and respondent validity. Responses from at least 10 unique clients are required to be named in the top 10. Sample sizes that fall below required limits are asterisked.

Overall vendor rank is based on the mean score of the 18 criteria. Each company’s rank in each of the 18 criteria is provided as well.

Some categories had interesting responses of the “wonder what they were thinking here?” types. You’ll have to obtain the full report for details, but I’m flabbergasted that four companies that finished well in the “viability and competent financial management and leadership” category either replaced top executives or sold themselves recently; the top finisher in data security was the only company to have gone offline due to a ransomware attack; and Epic failed to crack the top 10 in surprising categories, finishing behind some questionable players.

However, these are the responses of customers, so their impressions and willingness to remain customers is what counts most.


Here’s a sample category result. I removed the vendor information since that’s in the report that Black Book sells (and that they sent me).

Note that this particular survey really didn’t address EHR functionality, just the practice management capability of EHR-integrated systems. Also, it does not appear that vendors selling multiple product lines (Allscripts would top this category, as well) have their individual products broken out, so mixing Practice Fusion with TouchWorks may not yield a sound product-specific result.

Another potentially weak point is one that KLAS struggles with – can a given respondent answer all the questions accurately, such as IT people scoring training or a nurse opining on security?

I’m interested in your opinions.


EPtalk by Dr. Jayne 11/15/18

November 15, 2018 Dr. Jayne No Comments


I’m always on the lookout for interesting startups and young vendors and have been following Diasyst for a while. Looks like they’re hitting their stride as Piedmont Healthcare plans to implement their solution in both diabetes specialty and primary care clinics along with independent Piedmont-affiliated practices and the residency programs at Piedmont Columbus Regional.

Diasyst uses a patient-facing app to gather blood glucose readings and other information, then analyzes the data against best practices and current clinical guidelines. Clinicians can use an intuitive dashboard to make adjustments to patient treatment regimens and communicate those treatment plans directly to the patients, who can review them and indicate acceptance.

I had a chance to see a demo a while ago. The screens are intuitive and the data is backed by research collaboration with institutions like Emory University, Georgia Tech, Grady Memorial Hospital, and the Atlanta VA Medical Center. It’s a great way for physicians to leverage other members of the care team in managing diabetes. I also like that they’re not just engaging with physicians – they’re looking to work with employer-based clinics and payers as well.


Although Mr. H and Jenn have weighed in on the Athenahealth acquisition, I haven’t had a chance to put in my two cents. I agree with the sentiment that it seems like the end of an era, especially since the company has been highly visible in its campaigns for disruption, although at times it feels like they were leading what surely had to be a bubble.

It’s definitely causing some anxiety for clients. I had drinks with my favorite OB this week and they just switched to Athenahealth after some disastrous interactions with a previous vendor. They were hoping for stability, but now feel uncertain about what the changes might mean. Athenahealth has been doing a nice job transitioning from the “more disruption please” era to continue looking at important factors, such as physician burnout.

They just released some new data from their research that showed that physicians feel well supported when they have effective communication and strong communication. Isolation is a predictor of burnout and is exacerbated by administrative burdens, time pressure, and limited referral options.

As industry watchers, we miss Jonathan Bush and his antics (wrestling at MGMA and HIStalkapalooza at the New Orleans Rock’n’Bowl are two of my favorite memories), but seeing what happens next will surely hold our interest.

Back to the story of the demise of my OB colleague’s relationship with her EHR vendor. They had been in negotiations for some time around some serious customer service and financial issues. The discussions stalled and the vendor issued an ultimatum that sounded like it was going to block access to their charts, leading to the decision to make a hasty switch. They’re still sorting through some data migration issues, but are at least up and running.

I’ve seen the emails and notices from the vendor and the best way I can describe them is a cross between a high-pressure timeshare pitch and a blackmail letter, with a side note of pleading. Several emails conflicted each other and different company reps threatened different termination dates and processes while begging them to stay. I was embarrassed for our industry as I read them. We can do better, folks.


Speaking of doing better, NextGen Healthcare hosted its annual User Group Meeting in Nashville this week with the theme “Better Never Stops.” A reader shared this photo of CEO Rusty Frantz on the dance floor.


I always joke that some year I’d like to hit the EHR vendor user group circuit, attending all the major get-togethers as part of a road trip to end all road trips. The budget for that adventure is beyond my reach, but I was more than happy to attend a regional summit hosted by Slalom in St. Louis along with partners AWS, Salesforce, and Tableau. For those of you who haven’t had the pleasure of visiting that Midwest city, you’re missing out on a delightful intersection of barbecue, hot chicken, and Italian food (including something called a toasted ravioli, which is a wonder by itself). Crashing with a med school colleague definitely left more room in the budget for culinary delights, along with the fact that the registration fee for the meeting was a requested donation to the United Way.

It was a different kind of conference, focused on the goal of “reimagining healthcare for the local community” with afternoon breakout sessions where participants worked together to design solutions to problems like price transparency, managing complex care, and battling healthcare inequality. I enjoyed the hands-on approach and hearing directly from people in the trenches rather than being a passive listener. A white-board artist captured comments from a panel discussion as well as from keynote speaker Allison Massari, who spoke about an intense personal trauma and the value of compassion and connection as part of healthcare. My favorite quote was from a speaker who asked, “Is there a way to not essentially make the patient a victim in their own care?” Those are powerful words.

The Slalom team did an excellent job pulling everything together and facilitating the breakouts. I may have to start checking out more regional conferences, especially those in cities where I can find a sofa to sleep on.


At the conference, I also got to prep for HIMSS with some shoe watching. The AWS rep had snazzy trainers and company socks. One of the panelists had some seriously kicky boots, but I couldn’t figure out how to get a picture of them without being too obvious. I’ll have to practice my covert shoe capture skills before February rolls around.


One of my intrepid readers noticed that I didn’t make my usual mention of Veterans Day in Monday’s Curbside Consult. It wasn’t an intentional slight, but rather an issue with my writing timeline ahead of some other commitments, including celebrating a family milestone with my favorite veterans. Many of my physician co-workers trained in the military and their wealth of experience is an ongoing reflection of the years they dedicated to protecting our nation.

The one hundredth anniversary of the armistice ending WWI was an historic event, but also shows that history continues to repeat itself because the “war to end all wars” has been followed by conflict after conflict. I’m angry when I see people lacking respect for our veterans, but I am heartened by images such as this one of Cub Scouts presenting a wreath at the Tomb of the Unknowns in Arlington National Cemetery. For those who don’t recognize the yellow neckerchief, it means these girls are second graders. Thank you to our youngest generation and let’s hope they Never Forget. (Photo credit: National Capital Area Council, BSA)


Email Dr. Jayne.

Reader Question: Forward Primary Care Clinics

November 15, 2018 News 2 Comments


A reader asked me to look into a Twitter war that broke out yesterday among doctors and an investor in direct primary care practice Forward, described by Quartz nearly two years ago as, “a slick, seamless, Uber-like experience, a bit like a luxury health spa on the starship Enterprise.” The company was founded by Adrian Aoun, a 34-year-old investor and former Google special projects director.

Aoun describes Forward — which operates gadget-heavy, millennial-focused concierge medicine clinics in three cities (San Francisco, Los Angeles, and New York) — as  “a doctor’s office that looks and feels more like an Apple Store … you’ve got this kind of cool thing where you’ve got the doctor’s office that kind of learns over time.” Members pay $1,800 per year (not covered by insurance) for unlimited access to doctors and lab tests.


The original tweet involved a Wall Street media site’s interview with Aroun (which was mostly him pitching the company in response to frothy questions). Some healthcare folks questioned on Twitter whether the company is really doing anything innovative or important, which obviously ticked off a remarkably hostile and defensive Keith Rabois (who disclosed only late in the conversation in response to a direct question that he is Forward’s lead investor).










About Keith Rabois

Keith Rabois is a billionaire Silicon Valley investor who put early-stage money into PayPal, LinkedIn, Square, and Yelp. He is one of the so-called “PayPal Mafia” that also includes Peter Thiel, Elon Musk, and Reid Hoffman. His educational background is a JD from Harvard Law School. He’s a partner in Khosla Ventures.

Rabois claimed in 2015 that computers would replace doctors and lawyers.

As is the case with some other members of the PayPal Mafia, his personal history suggests brash brilliance, but with some character issues (1, 2).

About Forward

Forward is a direct primary care practice (“A full-stack company: doctors, designers, and engineers work together to build their own software and hardware, including our own electronic health records system” that “prevents us from being held back by legacy systems.” The company emphasizes its tech-heavy “custom-built exam room,” a body scanner, and a care management system.

The company has offices in San Francisco, Los Angeles, and New York. It has 12 young doctors on staff, with either two or three offering services at each location.

image image

Founder Adrian Aroun describes the company as offering:

  • A “comforting and smart” environment
  • Doctors guided by data and real-time tools
  • 24×7 access to advice and information
  • Doctors who spend time listening instead of performing administrative tasks and note-taking.
  • “All my data in one place, fed into AI.”
  • “Beautiful software and hardware, the likes of  which we’ve come to know and love from companies like Tesla.”


Forward charges an all-inclusive membership fee of $1,800 per year (misleadingly described on its site as a $149 monthly charge, members have complained), which includes unlimited visits and lab tests. Yelp reviewers are usually positive early in their tenure as customers (although some of them claim that Forward had negative reviews taken down), although one noted, “None of the bells and whistles that were touted around AI, mobile app, and hardware provided any real value-add as a customer.”

The company’s job openings are mostly for “brand ambassador” and “membership sales advisor” positions. It is hiring for remote care coordinators (first responders) for $17 per hour with no medical benefits. It’s also looking for several remote medical scribes and 12 primary care physicians.


Forward’s Challenges

  • Hiring and retaining doctors. Are they unnecessary, as Rabois has said, or are they empowered to work in non-traditional, satisfying ways?
  • Scaling beyond a modest three-city, six-office operation.
  • Convincing health millennials to keep their memberships after the initial customer service thrill, realizing that most of them probably require no ongoing services and could just as easily see an insurance-covered PCP for their infrequent medical needs (and they still need insurance for non-routine medical needs anyway). Customer acquisition cost and retention rate are key.
  • Steering away more expensive members, such as the elderly, those with chronic diseases, and those who might take advantage of an all-you-can-eat membership.
  • Proving the value of its practices in outcomes beyond wowing customers with Star Trek gadgets, sparkling water, comfy chairs instead of exam tables, and Lulemon shorts instead of paper gowns.
  • Complying with a myriad of state-specific medical practice laws.
  • Competing with other investor-backed, ambitious chains such as One Health and Carbon Health as well as creative local concierge practices.
  • Trying to disrupt an industry that is not only complicated for outsiders to understand, but full of big players that are resistant to disruption.

Your thoughts and personal experience with Forward are welcome.


Morning Headlines 11/15/18

November 14, 2018 Headlines No Comments

Mount Sinai Technology Spinout RenalytixAI Completes Initial Public Offering, Raising $29 Million to Combat Kidney Disease

RenalytixAI raises $29 million in an IPO that will be used to fund the launch of AI-enabled applications for the early detection of kidney disease and transplant management.

Dartmouth-Hitchcock Health teams with Philips on Tele-ICU program

Dartmouth-Hitchcock Health (NH) will use technology from Philips to develop a tele-ICU program, initially focusing on medical, surgical, and neurology ICUs.

Introducing Veradigm™ Providing Next Generation Healthcare Solutions for Today’s Healthcare Challenges

Allscripts rebrands its Payer & Life Sciences Division to Veradigm, offering clinical workflow, research, and analytics software and services to providers, payers, and health IT and life sciences companies.

A Machine Learning Primer for Clinicians–Part 5

Alexander Scarlat, MD is a physician and data scientist, board-certified in anesthesiology with a degree in computer sciences. He has a keen interest in machine learning applications in healthcare. He welcomes feedback on this series at


Previous articles:

  1. An Introduction to Machine Learning
  2. Supervised Learning
  3. Unsupervised Learning
  4. How to Properly Feed Data to a ML Model

How Does a Machine Actually Learn?

Most ML models will have the following components:

  • Weights – units that contain the model parameters and are modified with each new learning experience. a.k.a train epoch.
  • Metric – a measure (accuracy, mean square error) of the distance between the model prediction and the true value of that epoch.
  • Loss or Cost Function – used to update the weights with each train epoch according to the calculated metric.
  • Optimizer – algorithm overseeing the loss function so the model will find the global minimum in a reasonable time frame, basically preventing the model from wondering all over the loss function hyperspace.

The learning process or model training is done in epochs. With each epoch, the model is exposed to a batch of samples. 

Each epoch has two steps:

  1. Forward propagation of the input. The input features undergo math calculations with all the model weights and the model predicts an output.
  2. Back propagation of the errors. The model prediction is compared to the real output. This metric is used by the loss function and its master – the optimizer algorithm – to update all the weights according to the last epoch performance.


Consider a model, in this case a neural network (NN) that tries to predict LOS using two features: age and BMI. We have a table with 100 samples / instances / rows and three columns: age, BMI, and LOS.

  • Task: using age and BMI, predict the LOS.
  • Input: age and BMI,
  • Output: LOS.
  • Performance: mean square error (MSE),  the squared difference between predicted and true value of LOS.


Forward Propagation of the Input

Input is being fed one batch at a time. In our example, let’s assume the batch size is equal to one sample (instance).

In the above case, one instance enters the model at the two left red dots: one for age and one for BMI (I stands for Input). The model weights are initialized as very small, random numbers near zero.

All the input features of one instance interact simultaneously through a complex mathematical transformation with all the model parameters (weights are denoted with H from hidden). These interactions are then summarized as the model LOS prediction at the rightmost green dot – output.

Note the numbers on the diagram above and the color of the lines as weights are being modified according to the last train epoch performance. Blue = positive feedback vs. black = negative feedback.

The predicted value of LOS will be far off initially as the weights have been randomly initialized, but the model improves iteratively as it is exposed to more experiences. The difference between the predicted and true value is calculated as the model metric.

Back Propagation of the Error

The model optimizer updates all the weights simultaneously, according to the last metric and loss function results. The weights are slightly modified with each sample the model sees – the cost function is providing the necessary feedback from the metric that measures the distance between the recent prediction vs. the true LOS value. The optimizer basically searches for the global minimum of the loss function

This process is now repeated with the next instance (sample or batch) and so on. The model learns with each and every experience until it is trained on the whole dataset.

The cost function below shows how the model approaches the minimum with each iteration / epoch.


From “Coding with Data” by Tamas Szilagyi.

Once the training has ended, the model has a set of weights that have been exposed to 100 samples of age and BMI. These weights have been iteratively modified during the forward propagation of the input and the back propagation of errors. Now, when faced with a new, never before seen instance of age and BMI, the model can predict the LOS based on previous experiences.

Unsupervised Learning

Just because there is no output (labels) in unsupervised learning doesn’t mean the model is not constrained by a loss / cost function. In the clustering algorithm from the article on Unsupervised Learning , for example, its cost function was the distance between each point and its cluster centroid, and the model optimizer tried to minimize this function with each iteration.

Loss / Cost Function vs. Features

We can chart the loss function (Z) vs. the input features: age (X) and BMI (Y) and follow the model as it performs a gradient descent on a nice, convex cost function that has only one (global) minimum:


Sometimes two features can present a more complex landscape of a loss function, one with many local minima, saddles and the one, much sought after, global minimum:


From “Intro to optimization in deep learning” – PaperSpace Blog.

Here is a comparison of several ML model optimizers, competing to escape a saddle point on a loss function, in order to get to the optimizers’ nirvana – the global minimum. Some optimizers are using a technique called momentum, which simulates a ball accumulating physical momentum as it goes down hill.  Getting stuck on a saddle in hyperspace is not a good thing for a model / optimizer, as the poor red Stochastic Gradient Descent (SGD) optimizer may be able to tell, if it will ever escape.


From “Behavior of adaptive learning rate algorithms at a saddle point – NVIDIA blog.

Just to give you an idea of how complex a loss / cost function landscape can be, below is the loss function of VGG-56 – a known image analysis model trained on a set of several million images. This specific model loss function has as X – Y axes the two main principal components of all the features of an image. Z axis is the cost function.

The interesting landscape below is where VGG-56 has to navigate and find the global minimum – not just any minimum, but the lowest of them. Not a trivial task.


From “Intro to optimization in deep learning” – PaperSpace Blog.

Compressing many dimensions an image usually has, into only two (X-Y) – while minimizing the loss of variance – is usually a job performed by principal component analysis (PCA),  a type of insupervised ML algorithm. That’s another aspect of ML – models that can help us visualize stuff which was unimaginable only a couple of years ago, such as the 3D map of the cost function of an image analysis algorithm.

Next Article

Artificial Neural Networks Exposed

Morning Headlines 11/14/18

November 13, 2018 Headlines No Comments

‘We ran out of money’: High-profile startup seeking to connect patients with clinical trials shuts down

Driver, whose technology matches cancer patients with clinical trials, runs out of cash and shuts down just two months after its high-profile launch.

The new Google Health unit is absorbing health business from DeepMind, Alphabet’s AI research group

Alphabet will move its London-based DeepMind healthcare AI subsidiary under the newly formed Google Health, which will be led by former Geisinger CEO David Feinberg.

LeanTaaS Secures $15 Million in Series C Investment to Accelerate Growth of Its Healthcare Operations Platform

Smart scheduling and throughput technology vendor LeanTaaS raises $15 million in a Series C funding round, increasing its total to $39 million.

News 11/14/18

November 13, 2018 News 9 Comments

Top News


Driver, whose technology matches cancer patients with clinical trials, runs out of cash and shuts down just two months after its high-profile launch.

The company had 85 employees and 30 cancer centers participating, but its revenue model was to charge patients $3,000 upfront plus a monthly fee to be matched with studies (lesson learned – never base your revenue projections on what healthcare consumers are willing or able to pay unless your product involves recreational drugs, vanity surgery, or sex).

The company says it will try to help its few paying customers transition smoothly, but cautions that it doesn’t have the money to issue refunds.

Reader Comments


From Randy: “Re: the $20 million donation to Seattle Children’s from former Microsoft CEO Steve Ballmer. I generally agree with the sentiment about big donations to hospitals instead of public health, but the Ballmer gift is to the Odessa Brown Children’s Clinic, which serves the historically underserved, African-American neighborhood in Seattle. They will use it to locate a second facility near the light rail station so that the families of patients who are displaced by Seattle housing prices can still access the clinic’s services.” I saw that and it’s indeed a good cause, although Seattle Children’s makes enough profit that they should have been able to do the right thing without waiting for Ballmer’s donation. Still, I recognize that hospitals – including whose that have employed me – never seemed to be able to get anything done without borrowing more money (probably because they were always erecting or buying new buildings), so perhaps the donation avoided that.

From BH: “Re: breach. [vendor name omitted] contacted one of our partner hospitals to inform them that an employee of the company had their credentials compromised, and that those compromised credentials may have accessed their servers. Not sure yet what products or product lines were affected, but the company that received this notice is a hospital that uses multiple products. I have not yet seen any public statement about this activity or any breach notifications” Unverified, so I’ve left the company name off for now. Forward the email to me, please. 

HIStalk Announcements and Requests


Thoughts on the acquisition of Athenahealth by Veritas Capital:

  • We’ve now seen health IT’s own example of the damage that can be wrought by a vulture fund that will do anything to make money by running roughshod over whatever company is unfortunate enough to find itself in its crosshairs.
  • The activist investor and minority shareholder, Elliott Management, is a bone-picker, not a long-term investor (this is the company that bought heavily discounted Argentina sovereign debt, then seized one of its navy ships for non-payment). They will pressure the new Athenahealth to cut costs, sell parts piecemeal, and then run another IPO with a new story. That will likely not resonate with Veritas, which has a more measured approach (and healthcare experience) in increasing value by improving operations and strategy. It will be interesting to see how those two owners co-exist.
  • We’ve also seen yet another downside of going public, where you can’t control who buys your shares or what public demands significant shareholders will make.
  • Perhaps the most ironic pairing since Jimi Hendrix opened concerts for the Monkees is combining Athenahealth with the health IT assets of the former GE Healthcare. Integrating those portfolios with the Cotiviti payments processing and analytics business to create something worth more than the sum of their parts will be challenging, especially in establishing a brand identity (quick – what does Emdeon sell?)
  • Athenahealth Chairman Jeff Immelt obviously brought little to the table in his short tenure as a quick Jonathan Bush replacement, spending his days trying to convince potential buyers and likely engineering the pairing of Athenahealth with the assets of GE Healthcare (after being fired by the wildly underperforming GE and previously overseeing the hot mess that was GE Healthcare IT in his executive tour that also included plastics and appliances).
  • It’s likely that the acquisition marks the end of the nascent Athenahealth inpatient EHR business and thus its hopes to become an enterprise player that can compete with Epic, Cerner, and Meditech.
  • Athenahealth struggled with contracting ambulatory EHR demand and some of its competitors have been acquired for presumably unimpressive sums, highlighting big problems with the ambulatory EHR/PM market in the absence of Meaningful Use stimulus and the strong trend toward health systems acquiring practices and replacing their EHR/PM systems with the hospital standard.
  • GE Healthcare’s 2014 workforce management technology acquisition API Healthcare will see new life as a separate company once again. Veritas Capital acquired the well-regarded business in July 2018.
  • Athenahealth’s claims of being a healthcare disruptor — which earned airplay mostly because of its charismatic and investor-entrancing former CEO Jonathan Bush — weren’t always believable  since the company had a lot of India-based workers pushing paper and was an easily swatted fly of Bush’s favorite target Epic, but whatever innovation the company has accomplished or promised is probably not going to happen under private equity ownership and a CEO with no healthcare experience.
  • Jonathan Bush made Athenahealth more interesting than the company deserved.


HIMSS19 starts in 90 days, so I threw down a few thoughts.


None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock


Smart scheduling and throughput technology vendor LeanTaaS raises $15 million in a Series C funding round, increasing its total to $39 million.


Several health IT startup CEOs form HealthTech4Medicaid, which will advocate for Medicaid’s use of technology (with special emphasis on the ones its members sell). I’ve heard of only a handful of the 40+ companies whose CEOs are involved.

Business Insider fawns over a former exec of Facebook and Google whose company is working on continuous, wearable imaging devices that it hopes to sell in drugstores in competing with MRIs. It’s an interesting idea with a lot of potential pitfalls along the way (such as the FDA’s approval), but the real problem is that investors, startups, and consumers obsess over new diagnostic tools that can create false positives (requiring clinician time and possibly causing harm as the patient gets roped into the healthcare widget factory). We have many problems with US healthcare, but misdiagnosis and under-diagnosis aren’t anywhere near the biggest ones other than to investors looking to make mint.

The best reporter in the business, CNBC’s Chrissy Farr, reports that Alphabet will move its London-based DeepMind healthcare AI subsidiary under the newly formed Google Health, which will be led by former Geisinger CEO David Feinberg. The Google Health name is apparently being recycled from the company’s failed personal health record, which was rolled out in 2008 and shut down in 2011 when the company finally realized the obvious – nobody (including Google executives, no doubt) will bother entering their information into a PHR.


image image image

Veritas Capital-owned Virence Health, soon to be merged with Athenahealth under the latter’s name, hires Karl Salnoske (Laureate International Universities) as SVP of engineering and cloud operations; Sal Mahbouba (Ratava Partners) as SVP of professional services and support; and R.J. Timmons (Tenet Healthcare) as SVP and general counsel.

Announcements and Implementations

A Black Book survey of 3,000 hospital-owned or employed practices finds that 40 percent are budgeting to replace their practice management systems in favor of hospital-integrated systems, with 89 percent of hospital executives saying non-integrated EHR/PM systems impede their ability to participate in alternative payment methods. Hospitals say moving to an integrated PM system increases scheduling satisfaction, increases collections, and reduces time and resources required. Allscripts, GE Healthcare, and Cerner topped the integrated ambulatory systems review, while NextGen, Aprima, and Azalea Health took the bottom spots. The results might seem screwy, but as reader Longtime HIT Marketer reminds us, Black Book is not evaluating products or deep-diving with a handful of handpicked customers, but instead is simply reporting the perception of a statistically valid number of users. As he or she adds, “If Allscripts clients believe their products are integrated, then they are integrated.”


A Dimensional Insight survey of 85 health IT executives finds that few have high levels of trust regarding the financial, clinical, and operational data their organization makes available via self-service tools. The company recommends keeping subject matter experts involved in collecting, transforming and presenting data; automating complex data manipulation logic; and getting frontline data consumers involved.


Microsoft announces the open source FHIR Server for Azure. And please, enough with the witless “fire” puns since it’s a convenient but illogical way to sound it out (the accurate way will elicit more gasps than giggles).


Analysis finds that half of the $52 billion in quarterly profits of publicly traded healthcare corporations came from just 10 companies, nine of which sell drugs. Drug companies pocketed nearly two-thirds of the profit on just 23 percent of the revenue. The new tax law that reduced corporate tax rates helped, as AbbVie paid just $14 million (0.5 percent) of its $2.76 billion in profit in taxes, while Pfizer’s tax rate was just 1.6 percent.


St. Charles Health System (OR) removes patient gender from wristbands at the urging of psychologists who say it causes harm to transgender patients while providing no benefits. Epic reviewed how it stores gender or name to determine how the information is used – to address the patient, to communicate with insurers, or for clinical purposes – although it says only one-third of customers use its expanded gender identity categories. It’s a fine line to walk when such patient characteristics as age, race, ethnicity, weight, religion, and genomic characteristics are required to make good clinical decisions, yet aren’t appropriate to use elsewhere, with the saving grace being that electronic systems can show the information only to those who need it. 


I get the newsletter of innovation and investment advisor CB Insights, which also produces conferences. CEO Anand Sanwal offers these ideas that are pretty much the opposite of health IT conferences:

  • No sponsors on stage, ever – it’s disrespectful to attendees to have speakers who “do a sales pitch, often dressed up as mediocre thought leadership.”
  • All sessions are moderated by impartial, real journalists.
  • No panel discussions since 99 percent of them are terrible
  • “Thought leaders” ruin events – 47 percent of poll respondents say someone loses all credibility if they refer to themselves as a thought leader.
  • Sanwal says that only four of the 100 conferences at which he has spoken in the past four years were content-first and thus good for business, while the rest had negative value. He has learned that writing content has better ROI since the audience is larger and the shelf life is longer.


The CB Insights rant led me to create my own poll. Which terms turn you off in a LinkedIn profile, Twitter profile, or speaker bio? (note: the self-flattering choices all came from the LinkedIn profiles of health IT folks whose list of accomplishments and tenure per employer are, to be kind, a bit short). I’m the only LinkedIn profile self-reporting as “blowhard” of the many who repeatedly earn the title. Has ‘health IT’s poet laureate” been claimed?


Weird News Andy pivots from his entertainingly odd stories to laud the nurses of Adventist Health Feather River Hospital (CA), who hastily evacuated patients as the Camp Fire reached the hospital’s parking lot, then had to make their way back to the hospital when their own escape routes were blocked. The hospital employees set up triage in the fire-surrounded parking lot for locals who were unable to evacuate, then were ordered by firefighters to leave when the hospital roof caught fire, by which time roads were less congested because everybody had already fled for safety. 

Sponsor Updates


  • FDB employees volunteer at the Midwest Food Bank to support those in need.
  • Bluetree will exhibit at the RCM Leaders Forum November 14-16 in Dallas.
  • Collective Medical integrates its care collaboration network with California’s CURES 2.0 prescription drug monitoring program database.
  • CarePort Health will exhibit at the ACMA Western Pennsylvania event November 17.
  • EClinicalWorks publishers customer success stories from Gastro Health and Big Sur Health Center.
  • Carevive Systems will exhibit at the 2018 Palliative and Supportive Care in Oncology Symposium November 16 in San Diego.
  • Impact Advisors is named to Consulting Magazine’s “Fastest Growing Firms” for the second straight year.
  • Diameter Health will exhibit at the NCQA HL7 Digital Quality Summit November 14-16 in Washington, DC.
  • A Riverside Medical Center (IL) study finds that use of Glytec’s EGlycemic Management System reduced hypoglycemia in critical care patients by 73 percent and was associated with patients transferring out 0.25 days faster.
  • Meditech integrates DrFirst’s MyBenefitCheck prescription pricing solution with its Expanse EHR.
  • Mental and behavioral screening technology vendor AssessURhealth is named Tampa Bay Tech’s “Emerging Technology Company of the Year” for 2018.

Blog Posts



Mr. H, Lorre, Jenn, Dr. Jayne.
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Looking Ahead to HIMSS19

November 13, 2018 News No Comments


We’re 90 days out from the start of HIMSS19. Notes:

  • Register by December 3 to obtain the early bird discount ($825 for members, $1,055 for non-members).
  • Book a hotel ASAP if you haven’t already. Rooms are available at several close-in hotels at reasonable rates. Or, do as I always do and rent a house or condo through Airbnb or VRBO and then just take Uber or Lyft to the convention center. Do not reply to the shady non-HIMSS emails offering rooms – they’re a scam since HIMSS controls basically every hotel room you’re likely to want.
  • Note the odd dates – the opening reception is Monday evening (February 11),  the opening keynote is Tuesday morning, and the conference ends after a partial day on Friday (that’s going to be a slow conference day for sure).
  • The exhibit hall will be open Tuesday morning and will close Thursday evening.

The online educational agenda is incomplete, with many sessions containing only a placeholder without presenter names (seems a bit late to still be working on that, but it’s not going to change anyone’s plans either way). All keynote speakers announced so far work in for-profit companies – Atul Gawande, MD (of the ABC consortium that hasn’t named itself yet), Susan DeVore (Premier), and Mick Ebeling (Not Impossible Labs). Many of the educational sessions have vendor presenters, quite different from the HIMSS conferences a few years back where the commercial side of health IT was kept separate from the education sessions.

The theme of the conference is the rather dopey “Champions of Health Unite,” perhaps a stretch given that most of the attendees are vendors or IT-related people whose scope and influence in “health” is tiny (we contribute slightly to the work of providers, whose services in turn contribute about 20 percent of a person’s overall health). HIMSS, as usual, proclaims itself an equal partner as we advance information and technology “to meet our biggest challenges head-on and truly transform health,” which you would think would have been accomplished by now since they claim impending “transformation” every year and the US healthcare system is a bigger mess than it’s ever been.



What we’ll be doing there:

  • Our tiny 10×10  booth is #4085. The location is OK (especially since we’re not selling anything) and several of our neighbors are HIStalk sponsors, which is often fun. We’re near the restrooms, of course, since that’s always the case except that one year we were nearly co-located with the Thai food kiosk.
  • Many small booths remain available. I wouldn’t wait long to get on board, though, since latecomers aren’t listed in the printed guide. I’m always skeptical about companies that aren’t organized enough to sign up given a full year’s notice, especially if they’re pitching project management services.
  • Exhibiting isn’t cheap. Non-member booth space costs $45 to $47 per square foot plus $725 for a corner. HIMSS provides five exhibitor or client badges for each 100 square feet purchased, which makes it a better deal for us even though we only use a couple of those badges.
  • The 10th and final HIStalkapalooza was in 2017, so there’s no need to email me asking for tickets (I still get those requests regularly). You can watch the video of the 10th and final one at HIMSS17 in Orlando if you’re feeling nostalgic.

The biggest individual booths in square feet are:

  • IBM (15,300, total space 15,810 – that cost them well over $600,000 at the corporate member rate of $39 per square foot plus extra for corners – maybe Watson made the call)
  • Allscripts (10,800, total space 11,100)
  • Epic (9,900, total space 13,500)
  • Cerner (8,400, total space 12,300)
  • GE Healthcare (7,000, total space 7,400 – I’m not sure what they’ll be pitching since they’ve sold off their health IT business)

Exhibitors get priority choice for booth space given their HIMSS Exhibitor Priority Points, earned by spending a lot on HIMSS stuff (including participating in other HIMSS-owned conferences and throwing down major advertising dollars to its HIMSS Media PR factory).

You might want to review these reader-provided tips if you’re a first-time attendee.


We’re be doing our usual HIStalk stuff at HIMSS19:

  • Having interesting characters and pseudo-celebrities hang out in our little booth. Let us know if you want to participate – my definition of celebrity-hood leans toward the offbeat.
  • Talking up HIStalk sponsors a bit beforehand to let folks know what they’re doing there. We will be too busy after January 1 to get new sponsors on board until after the conference since it’s just 41 days between New Year’s Day and the conference’s start.
  • Giving away stuff in our booth, which ranges from the slightly cool but obviously cheap (when I have to pay for it) or nicer, vendor-supplied swag that is higher quality but potentially less cool.
  • Cruising the exhibit hall to write up what we see — the buzz, giveaways, demos, and booth people behaving badly (see my exhibitor tips to avoid being called out, and for God’s sake don’t dress non-clinicians in scrubs).
  • Covering the 5 percent of vendor announcements (most of them unwisely pushed out Monday amidst the mayhem) that contain something even mildly interesting.
  • Maybe having some kind of DonorsChoose fundraising event if I can figure something out.
  • Posting the HISsies results. Which reminds me that I need to get the voting underway soon given the early conference date.

Morning Headlines 11/13/18

November 12, 2018 Headlines 3 Comments

Veritas Capital Will Acquire Athenahealth for $5.7 Billion

Veritas Capital and Elliott Management subsidiary Evergreen Coast Capital will acquire Athenahealth for $5.7 billion.

FHIR Server for Azure: An open source project for cloud-based health solutions

Microsoft Healthcare releases an open-source project on GitHub to help developers build FHIR-based services and apps in the cloud.

Manatt Adds Prominent Venture Capitalist and Entrepreneur

Healthcare venture fund expert Lisa Lisa Suennen will join Manatt Phelps & Phillips as head of its digital and technology businesses (including its healthcare consulting arm), and the firm’s venture capital fund.

Rapid Escalation of Practice Acquisitions Drives Hospital Systems to Merge Hosts of Physician Technology Platforms by 2021, Black Book Survey

Forty percent of hospital-based respondents plan to replace acquired physician practice EHR and PM systems, with Allscripts being the most recommended integrated solution.

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