Weekender 8/23/19

Weekly News Recap

• Revenue recovery software vendor Ontario Systems is acquired by an investment firm.
• Allscripts announces availability of Apple Health Records in its EHRs.
• A watchdog group publishes emails detailing the involvement of the “Mar-A-Lago crowd,” including an associate of President Trump, with the VA’s contracting with Cerner.
• EHealth Exchange announces go-live of a national, single-connection gateway service.
• A Nature article covers the responsible use of machine learning in healthcare.
• Several investment firms are reported to be in discussions to buy Emids Technologies.
• Ciitizen rates hospitals on how effectively they respond to patient requests for copies of their information.
• An OIG report finds that the VA’s overdue, over-budget scheduling project is nearly finished, just in time to be replaced by its Cerner implementation.

Best Reader Comments

[From the author of a report predicting that clinical decision support systems will replace EHRs as the primary physician interface] CDS are now mostly point solutions, but the CDS vendors are expanding their reach and are discovering something interesting: the more they expand, the more EHR data is required. At some point most of the data in an EHR is then in the CDS. We have not reached that point yet, but when that happens, it makes logical sense to invert the model, where an EHR gates most health It functionality and change it to a model where the EHR is actually subordinate to a more user friendly interface: likely one that looks a lot like a CDS … The essential notion is solid: EHRs are not user friendly, but CDS generally are. This is an unstable dynamic and we believe that someone will move to address the problem. Also, we did talk to practically every CDS vendor as well as every EHR vendor and healthcare delivery organization. The interesting thing is that the idea that CDS would take over did not come from the CDS community, but came from the healthcare delivery community. (Mike Jude)

[To the author of the report above] You make some sweeping assertions without any basis in fact. “EHRs are not user friendly, but CDS generally are” – what is this conclusion based on? You assert “CDS are often developed in response to specific pain points: new regulations, new dosing requirements, etc.” Are there any serious CDS systems certified for Meaningful Use AND in general adoption by doctors at the point of care? And on what fact base do you assert that EHR vendors don’t “incorporate human factors to ensure low impact human interactions?” (Supporting good decisions)

[Referencing an article on Apple Health Records] How will access to my EHR data help me “shop for high value health care services” and “avoid the need to repeatedly supply data for entry?” These discussions are without substantive support in any fashion that I can see. I hope my tax dollars did not pay for this. (FormerCIO)

The ACR AUC system is ridiculous for specialist physicians. I am a board certified orthopaedic surgeon who knows when I need an MRI or CT scan. At what point does the system trust me to make a decision about the care of my patients? After two MOC exams? After 20 years in practice? Am I an outlier with studies? No. So if ACR wants to do AUC, then have the radiologists do it, not me. I know what study I need and want to care for my patients. If you think you know better, then you take over the care of the patient when you deny the test. (meltoots)

Watercooler Talk Tidbits

Millennials who document every potentially enviable aspect of their lives on Instagram are hiring professional photographers to shoot both natural and C-section childbirth, with full-time birth photographers elbowing doulas out of the way to charge up to $4,000 at trendy hospitals like Cedars-Sinai and UCLA. They leave business cards in exam rooms and with providers who hand them out. OBs aren’t always thrilled with the potential additional malpractice exposure of having everything recorded in photos or video and hospital policies are often inconsistent or non-existent.

A dozen of Facebook’s low-paid content moderators – contracted from Accenture to review up to 800 pieces of disturbing user content such as child sexual abuse in a single shift – accuse Accenture of trying for force company-provided “wellbeing counselors” to disclose the details of their trauma sessions in what they say is a violation of HIPAA.

SimplyVitalHealth, which offers “blockchain-based solutions to emerging value-based healthcare programs,” returns $6 million to investors after the SEC charges it with conducting an unregistered securities offering in the form of an Initial Coin Offering.

Google DeepMind co-founder Mustafa Suleyman takes indefinite leave from the artificial intelligence company.

University Medical Center of El Paso disputes President Trump’s claim that its surgeons left the OR to see him in during his post-shootings visit there, reassuring the public that in no case would that ever happen. The president said surgeons came out of ORs in both El Paso and Dayton in a spontaneous showing of “the love for me.” 

A Miami plastic surgeon self-styled as “Dr. Slimthick” whose billboards offer Brazilian butt lifts financed at $30 per week is found to have falsified most of the credentials claimed on his website. The local paper checked his background in running a story about one of his patients, a 35-year-old woman who remains in critical condition a month after he performed her procedure. His cosmetic center is offering a silicone implants or liposuction for $3,500 if you’re in the market.

A Texas woman faces 20 years in prison after being accused after subjecting her healthy son to 323 hospital and clinic visits and 13 major surgeries in the first eight years of his life in a case of Munchausen syndrome by proxy. She had also started several online fundraisers for the boy, claiming that he was dying from a genetic disorder and later from cancer. She had placed him on a lung transplant list and enrolled him in hospice care, caught only when employees of a Dallas hospital called child protective services. 

Wolfson Children’s Hospital (FL) posts a video of 15-year-old Yanira Guzaman, who was able to stand for the first time and dance with her father at her quinceañera thanks to spina bifida treatments and a new power chair.

In Case You Missed It

• News 8/23/19
• EPtalk by Dr. Jayne 8/22/19
• HIStalk Interviews Steven Davidson, MD, Retired CMIO
• News 8/21/19
• Curbside Consult with Dr. Jayne 8/19/19
• Monday Morning Update 8/19/19

Get Involved

• Sponsor
• Report a news item or rumor (anonymous or not)
• Sign up for email updates
• Connect on LinkedIn
• Contact Mr. H

Morning Headlines 8/23/19

Crew Obtains New Docs on Mar-a-Lago Member’s VA Influence

Emails from VA officials obtained by a watchdog group provide greater insight into the influence President Trump’s “Mar-a-Lago crowd” had on the VA’s contract with Cerner.

Ontario Systems Announces Investment from New Mountain Capital

New Mountain Capital acquires revenue recovery software vendor Ontario Systems, which counts over 600 hospitals among its enterprise healthcare and government customers.

Apple Health Records Available for Allscripts Clients

Allscripts releases access to Apple Health Records to users of Sunrise, TouchWorks, and Professional EHRs.

Former military records technician accused of bilking millions of dollars from US soldiers and vets

The Justice Department arrests five people for stealing millions of dollars from soldiers and veterans by taking photos of their AHLTA EHR screens at an Army base in South Korea, then using that information to log in to DoD’s self-service system to steal bank account details.

News 8/23/19

Top News

A watchdog group obtains emails from VA officials – invoking the Freedom of Information Act – as they discussed the so-called “Mar-a-Lago crowd” of non-experts who provided advice to the VA with the implied endorsement of President Trump, with much of that involving its contracting with Cerner.

One of the emails contradicts reports that the group’s involvement was unsolicited and that then-Secretary David Shulkin, MD resented it. The VA’s acting CIO asked the group for their help as recommended by Trump associate Bruce Moskowitz, MD, a West Palm Beach internist. 

John Windom, who heads up the VA’s EHR modernization project, said a scheduled meeting was a “grin and bear it” session, while that group’s former chief medical officer termed their questions as “ridiculous” and lacking even a basic understanding of systems and interoperability.

Moskowitz emailed to insist that the trio be “on every call that the group is on to discuss the contract.”

One of the released emails contains a detailed list of questions that were posed to the VA in response to Cerner’s RFP in a conference call with the group, with the VA providing detail for such observations such as:

• Any requirement of “true interoperability” would require contractual terms with both Cerner and other primary EHR vendors such as Epic, Meditech, and Allscripts. The VA said its contract only covers Cerner, but the VA is pursuing partnerships with other health system providers “to meet Cerner’s commitment to data sharing.”
• Commenters noted Cerner’s weakness in medical imaging.
• An observer asked why the contract doesn’t require a single Cerner instance shared between the VA and DoD.
• One commenter said their experience with Cerner is that reports from outside providers are imported as CCD/CCA and labeled as “Outside Material” instead of within normal workflow.
• Another worried that a lack of definition of interoperability, observing that DoD users are “rebelling” over unsuitability for their needs.
• One comment said that Cerner has lagged in FHIR development and assigned few resources to it.
• A reviewer worried that instead of creating a next-generation system, Cerner will “just add more unmaintainable code to the existing spaghetti bowl.”

Reader Comments

From Grahame Grieve: “Re: Apple Health Records. HIStalk responded to a reader comment in saying that healthcare ‘embraces the most proprietary technology vendor in touting Apple-only patient access.’ I would like to point out that Apple has implemented the Patient API as published in the Argonaut specification, and the same interface is used by other vendors, including AllOfUs, CareEvolution, Coral Health, Ciitizen, 1UpHealth, PatientLink, and many others. While Apple may have business advantages due to their size and significance, any other vendor is able to use the same standard interface, and they are welcome to join with open FHIR community to help them do so.” Grahame is HL7 FHIR product director. A couple of folks offered other reasons that most people can access their health records only if they are among the fewer Americans that use Apple phones instead of Android: (a) Google hasn’t added that capability to Android; (b) Apple must have worked around some Epic licensing issues; and (c) health systems may be reluctant to create and maintain access to their systems for Android.

From Alias: “Re: Pulse Systems. Acquired by Amazing Charts, A Harris Healthcare Company, last Thursday. Announced to Amazing Charts employees this week.” Unverified. I ran this as a redacted rumor from another reader on Tuesday, waiting to hear back from my inquiry to a Harris Computer PR contact before naming names (they never did respond). Pulse Systems is (or was, if the rumor is true) owned by France-based Cegedim.

From For Closers: “Re: healthcare sales roles. After years (decades?) of reading HIStalk, I’ve seen several people show up more than once in the People section. Has anyone ever analyzed the number of retread healthcare sales roles? It seem a bunch of folks just flit from company to company to be VP of sales.” Good question, although hard to answer without of LinkedIn digging to (a) find experienced health IT sales VPs, and (b) count how many jobs they’ve had as sales VP (or the trendier chief revenue officer or chief growth officer titles). I’m also surprised at how often a CIO has been burned by a vendor’s oversold product, but then buddies up to the same salesperson who has moved on to another vendor. You might reasonably assume that a relationship history is not a plus when it involves lying and the resulting buyer’s remorse, but CIOs can be like doctors who let drug salespeople pull their strings – they can be manipulated to think that the salesperson is their trusted ally and personal friend.

HIStalk Announcements and Requests

Lorre asked me what we will do at HIMSS20 now that we don’t have HIStalkapalooza or an exhibit hall booth to deal with. I’m thinking we’ll just cruise around looking for news and rumors, although (a) Lorre could use an exhibitor’s pass if anyone has a spare; and (b) I guess our Smokin’ Doc standee will have to stay home since we don’t have a booth so passersby can take selfies, which is perfectly fine since his box is a pain to cart around. 

Webinars

September 5 (Thursday) 2:00 ET. “Driving 90% Patient Adoption Across Your Network: How US Dermatology Partners is Showing Us The Way.” Sponsor: Relatient. Presenters: Michele Perry, CEO, Relatient; Sara Nguyen, VP of applications and integrations, US Dermatology Partners. US Dermatology Partners is helping its physicians reclaim time they can spend with patients and is turning patient engagement strategies into business results across its 90 locations in eight states. Attendees will learn how US Dermatology Partners defined its patient engagement objectives and physician-optimized strategies. They presenters will provide advice on starting or accelerating  patient engagement goals.

September 26 (Thursday) 2 ET. “Patient Education Data: A Key Ingredient for Improving Quality and Patient Experience.” Sponsor: Healthwise. Presenters: Victoria L. Maisonneuve, MSN, RN, director of the Nursing Center for Excellence and Magnet program, Parkview Health; Marta Sylvia, MPH, senior manager of quality improvement and outcomes research, Healthwise. Healthcare data is everywhere! It’s scattered across various systems and in countless formats, making it difficult to collect and glean actionable information. Knowing where to start depends on what your organization wants to accomplish. Vicki Maisonneuve will share how her team analyzes data around the use of patient education. By combining different data sets, she can easily identify trends, gaps, and opportunities to improve quality and patient experience across Parkview Health.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.

Acquisitions, Funding, Business, and Stock

New Mountain Capital acquires revenue recovery software vendor Ontario Systems, which counts over 600 hospitals among its enterprise healthcare and government customers. NMC has also invested in healthcare companies like Ciox Health, which it acquired in 2014 back when it was known as HealthPort.

Sales

• University of Maryland St. Joseph Medical Center will offer the Babyscripts app and remote monitoring support to expectant mothers.
• Wentworth-Douglass Hospital (NH) will implement Epic in October through a software-sharing arrangement with parent company Partners HealthCare.

People

RCM and analytics vendor AGS Health names Patrice Wolfe (Medicity) CEO.

Announcements and Implementations

Allscripts releases access to Apple Health Records to users of Sunrise, TouchWorks, and Professional EHRs. Test sites include Sharp HealthCare, Erie County Medical Center, and Sarasota Memorial Health Care System.

UCHealth affiliate Ivinson Memorial Hospital (WY) will go live on Epic this weekend.

Appriss Health develops SMART on FHIR capabilities for its PMP Gateway integration software for state PDMPs.

Adventist Health’s Rideout Hospital (CA) implements Cerner. The company took over management of the multi-state health system’s revenue cycle and clinical applications IT staff last year.

Einstein Medical Center (PA) keeps its Cerner Millennium go-live on schedule by migrating data from several legacy systems using the robotic process automation and integration platform of Boston Software Systems, avoiding manual entry and creating  a consistent, low-complexity process to make appointment and registration data available for go-live.

Government and Politics

Politico reports that Genevieve Morris will run for office as a Republican in Maryland’s second congressional district. Morris spent a year as ONC’s principal deputy national coordinator and then just two months as the VA’s chief health information officer, a role she relinquished last summer after realizing that her vision for the Cerner implementation differed from that of her colleagues.

Other

The Justice Department arrests five people for stealing millions of dollars from soldiers and veterans by taking photos of their AHLTA EHR screens at at Army base in South Korea, then using that information to log in to DoD’s self-service system, which provides access to 70 military systems with a single username and password. One of those systems stores the individual’s bank account and routing numbers to which government payments are sent, allowing the conspirators to transfer money, sign up for loans, and have VA payments made directly to them. One of the group’s “money mules” was a military dependent labeled as “GH,” who the conspirators threatened for slow payments by looking up GH’s own AHLTA record to find family members they could threaten.

In an interview with Xconomy, John Halamka, MD weighs in on the hype surrounding AI in healthcare, noting that its usefulness will likely come from enhancing behind-the-scenes clinical workflows rather than the more headline-grabbing notion that AI will eventually replace physicians: “Machine learning is very good, but empathy and respect and active listening – that would not be the first use case I would pursue.”

Cancer patients in Port Arthur, TX say they will pursue legal action against the Medical Center of Southeast Texas for abruptly closing a cancer center last year, a development they contend has prevented them from accessing their medical records and continuing treatment elsewhere. The center’s majority owner, Trip Chaudhury, MD, contends the center closed due to a dispute with MCST over repairs that needed to be made, while hospital representatives say the center was closed for non-payment of rent by Chaudhury and that he was (and still is) responsible for equipment maintenance and records access.

Sponsor Updates

• Einstein Medical Center (PA) leverages software and consulting services from Boston Software Systems to migrate appointment data from its legacy systems to Cerner Millennium.
• Elsevier Clinical Solutions, Healthfinch, Healthwise, InterSystems,  and Intelligent Medical Objects will exhibit at Epic UGM August 26-29 in Verona, WI.
• Ensocare will exhibit at the ACMA Louisiana Chapter Annual Conference August 24 in Baton Rouge.
• Hayes Management Consulting names David Rajfer (Athenahealth) product manager and Lizz Fuller (Athenahealth) implementation project manager.
• Gartner includes Imat Solutions in its report on “The Current State of Clinical Data Integration Among US Healthcare Payers.”
• ConnectiveRx will exhibit at NACDS Total Store Expo August 25-27 in Boston.
• Redox announces that its customer base grew 33% over the first half of 2019.
• TransformativeMed renews its Core Workflow Suite contract with VCU Health (VA), and announces it will become a strategic development partner to fast-track mobile notifications and messaging into EHR workflows.
• As a payment facilitator, Patientco gives health systems more flexibility to address patient payment needs.
• A new report from Surescripts covers the ways in which the Surescripts Network Alliance has helped improve e-prescription accuracy by 64% over the last three years.

Blog Posts

• Recipe for a Successful EHR Implementation (EClinicalWorks)
• Top things to do during your visit to Madison (Nordic)
• 5 reasons your legacy data warehouse won’t cut it (Google Cloud)
• 22 ways to promote patient portal use and increase patient engagement (Greenway Health)
• Top things to do during your visit to Madison (Nordic)
• Why a “War Room” Could Save Your Meditech Go-Live (The HCI Group)
• Promising News from the NCQA HL7 Digital Quality Summit (Healthwise)
• Is your organization on the same page regarding clinical photographs? (Hyland)
• Data Conversions: Facilitating Success Through Planning (Impact Advisors)
• Leveraging Technology to Simplify Clinical Workflow (Imprivata)
• How Home Health agencies can prepare for the new Patient-Driven Groupings Model (Meditech)
• Healthcare IT: Can You Accurately Assess Your Healthcare Tech Needs In-House? (Fortified Health Security)
• 5 Steps to Create a Governance Model to Become an IT Genius in Healthcare (Spok)

Contacts

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

EPtalk by Dr. Jayne 8/22/19

Time is ticking for practices that haven’t completed the full transition to the new Medicare Beneficiary Identifier numbers. Claims submitted with the previous numbers will be rejected starting January 1, 2020. At this point, the new MBI is only being used for 77% of Medicare fee-for-service claims. Given the duration of the transition period, I’m surprised to hear that nearly a quarter of claims are still going out under the old numbers.

Telehealth is of interest to many young active patients, but clinicians are concerned about how well it might work for older patients for whom technology might be a challenge. A recent research letter details findings on video visits that were used with homebound geriatric patients. Physicians in New York state piloted the program from June to December 2018 as they sought to identify cost-effective ways to care for older adults. The authors labeled the program as “not yet ready for prime time” even though most patients and medical social workers involved in the study felt that when a video visit was successful, it met their needs and was preferred over long wait times for in-person visits. The difficulty apparently stems from inability to successfully complete the visits, with only a 49% completion rate. Installation of the telehealth app was performed by researchers after patients were identified from a pool of enrollees in a home-based primary care program.

Of 500 eligible patients, only 56 were enrolled. Patients were assessed to ensure they were cognitively and technologically capable of conducting a visit and that there was a family caregiver willing to participate as well. Even with those controls, there were a number of technical and equipment compatibility issues, with only 39 patients completing at least one video visit with their medical social worker. The average visit length was 18 minutes. The average patient was 85 years old and issues cited included failure to remember their Apple ID or passwords. Another issue involved two-factor authentication, where patients had to receive a code to access the app before they could enter the video conference.

There are significant shortages for home-based primary care for the frail elderly who want to remain in their homes. I’d argue that even with the challenges, if we could manage a percentage of patients via video, that might be better than the current state of affairs. Using technology that doesn’t require an Apple ID (especially since Apple is no longer the darling many people once thought it was) and relaxing the need for two-factor authentication might increase the percentage of successful visits. The authors next plan to pilot a device that connects via a patient’s home television and allows use of a TV remote, which might be a better option for the target population.

There are so many publications from CMS and other governmental entities that I occasionally miss something interesting. Apparently deep within the interoperability proposed rule is a provision that requires hospitals to inform primary care physicians about patient admissions, transfers, and discharges. Although Accountable Care Organizations want access to the data, hospitals are pushing back. One stumbling point is the need to inform physicians of these activities electronically.

Another is the requirement of this notification as a condition of Medicare participation for the hospital. It also would require hospitals to determine which physician might be the most appropriate to notify. I’ve worked with the attribution issue for several of my clients and it’s never straightforward, especially when patients might have recently changed primary care physicians or when they might be admitted for a problem that is primarily under the care of a subspecialist. Patients and patient advocates are also wading into the discussion, claiming that notifying physicians without express patient consent is a violation of privacy. The comment period on this particular proposed rule closed in May, so we’ll have to see what changes might be made.

For those of us who closely monitor Medicare spending, not only professionally but personally (hoping there will still be some money available when we get to the magic age), take a look at this piece on wasteful drug spending. One of the tricks commonly used by pharmaceutical manufacturers to extend their revenue streams is the creation of drugs that are nearly identical to existing drugs, but that are different enough to have their own patent. A recent study looked at spending on these drugs and found that Medicare could have saved nearly $17 billion from 2011-2017 by substituting 12 older drugs for the newer agents. There is little clinical evidence that these newer drugs deliver better outcomes than their older generic precursors. Researchers used the Drugs@FDA database to identify drugs that had been approved and analyzed both Medicare and patient out-of-pocket spending on the drugs. The out of pocket spending by patients could have been reduced by $1.1 billion on top of the Medicare savings.

Healthcare IT could be positioned to help educate prescribers and patients about this issue through a variety of strategies. One might be displaying relative cost at the point of prescribing. Another might be showing therapeutic equivalents as a part of clinical decision support. Payers are already trying to stem the tide by putting the higher-priced drugs on higher formulary tiers, which are easily identified in some EHRs. I wonder if the development of some of this functionality in current EHRs is being stymied by the vendors’ engagement with pharmaceutical companies, since several are selling patient data behind the scenes.

Another option would be to use clinical decision support to prompt lifestyle interventions before prescribing some of the drugs and enrolling patients in care management programs to ensure they can be successful with lifestyle change. Those are more high-touch options that are less popular in our US culture, however. It’s easier to take a pill and many patients find taking the latest and greatest drug to be desirable regardless of the cost.

Mr. H scooped me with his report on the Patient Record Scorecard, which grades hospitals on how effectively they respond to records requests from their patients. I had heard about it in a different context, when a reader clued me in to a site called MedRxiv (prounced “med archive”) which describes itself as “The Preprint Server for Health Sciences.” Essentially, the site is publishing manuscripts that are preliminary in nature and haven’t yet been through a peer review process. The site was founded by non-profit Cold Spring Harbor Laboratory, Yale University, and BMJ and operates as “a platform for researchers to share, comment, and receive feedback on their work prior to journal publication.” I hope the authors of the Scorecard can ultimately get their findings published since they seem consistent with what many of us are experiencing.

Email Dr. Jayne.

Morning Headlines 8/22/19

HHS Awards $107 Million to Support Health Center Quality Improvement

HHS awards $107 million in Quality Improvement Awards to 1,273 health centers across the country that have, among other improvements, advanced the use of health IT.

Mobile EKG maker AliveCor has cut ties with Apple amid rising tensions over wearable EKGs

AliveCor takes its Apple Watch-compatible KardiaBand off the market to focus more on expanding the capabilities of its KardiaMobile EKG products.

Fitbit wins contract with Singapore to supply trackers to potentially hundreds of thousands of citizens

Fitbit edges out Apple in a contract win that will see the wearables company provide devices to Singaporeans who enroll in the country’s Live Healthy SG program.

VA scheduling tool enhancement ‘almost complete,’ just in time to be replaced

A report from the Department of Veterans Affairs Inspector General finds that enhancements to the VA’s scheduling software are four years overdue, over budget, and soon to be replaced by capabilities within the department’s new Cerner EHR.

HIStalk Interviews Steven Davidson, MD, Retired CMIO

Steve Davidson, MD, MBA is retired as an emergency physician and CMIO of Maimonides Medical Center in Brooklyn, NY and provides consulting services as EMedConcepts.

Tell me about yourself.

I was born in Philadelphia. My dad was an internist-gastroenterologist, doing endoscopies back in the era of rigid scopes. My grandfathers were home carpenters, so I grew up with the idea that you could use your brain and you could use your hands. I went to medical school because I had ambitions to be an academic. I discovered emergency medicine as a new field. I was impressed by David Wagner, who was one of the grandfathers of the field. He was a pediatric surgeon who worked in the ER so he could pay his kids’ tuition.

Since it was a new field and there were fewer people clambering around on the ladder, I thought I might get to the top quicker. I never really made it to the top, but did OK. As one of the earliest trainees, I got involved in academic emergency medicine and was a tenured full professor. I went to Wharton, got an MBA, and managed to land a really nifty job in Brooklyn, working for a guy who was doing a turnaround on a hospital there, Maimonides Medical Center. 

He let me take the ER as an independent business unit. I ran the medical side and the business side of the ER. Everybody who worked in the ER worked for me, including nursing. If there were more than five people in a job title, they worked for me. I did that for 15 years, managed to piss off a few people, and got kicked upstairs to the CMIO gig. I discovered that my impatience and short attention span, which was an asset in the ER, was a contributor to a crash landing in the executive suite.

I went back to taking care of patients for a few years, sold my place in Brooklyn at the top of the market, and came back to Philly, where I had real connections beyond professional friends. I’ve spent the last 16 months renovating an old stone pile, a 100-year-old house, and working on Steve — going to the gym, eating right. I’ve gone to hear lots of live music. That’s enough.

Now that you’re somewhat of an outside observer of healthcare, what do you see?

If you’ve seen one ER, you’ve seen one ER. They are all different. I brought to that my experience with W. Edwards Deming and the idea of improvement processes, things like that.

Culture is an overwhelming force that is hard to overcome, and healthcare’s culture has been incredibly physician-centric. The nursing force was always there, but has gotten much stronger with the real administrative control that has gotten much, much stronger. It’s hard to see how, other than in small-scale improvement efforts, overall system improvement is going to happen without major legislative and financial flow change.

Your work in the ED was the ultimate episodic practice. Is it a marketing challenge to convince patients / consumers why they should value continuity of care when they are reasonably happy with the status quo other than price?

Middle-class folks who can afford the drop-in to the urgent care centers are eager to scratch that itch right away. In my experience in caring for the people who were not regularly doctored – for example, the folks who were on medical assistance in Brooklyn and had to make do with hospital clinics — would get very dejected when the internal medicine resident who had clinic once a week graduated after three years and was no longer their doctor.

I can’t tell you how many people I saw over my 15 years in the ER who would show up after not having been in the ER very much in the previous several years. They had been assigned to a new doc and clinic and they didn’t like that doc. Those people craved the continuity of care. My middle-class friends on Facebook, to all appearances, are glad for the networks of urgent care centers.

How should we apply social determinants of health to improve public health?

Many ERs, including where I used to work, have identified lists of frequent flyers. This goes back to the work of a guy at Cooper in Camden that was written up in the New Yorker, it might be 10 years ago now. He identified people who needed a new refrigerator, a new bed, or their roof repaired. Social determinants of health.

What’s happening in a place like Maimonides Medical Center is that the patients who were constantly in the emergency department, they are trying to get at the contributors to these visits. They get social work and community organizations engaged. At Maimonides – I’m not hawking what they’re doing as anything special because I know other places are doing it, I’m just telling you about the place where I know a little something — put together this community health network. They have integrated behavioral health with primary care for this patient population, for the broader group of patients with any serious behavioral health issues. It’s apparently having some impact on the frequency of utilization of the emergency department by individuals identified within this population.

As someone who ran medical services for a big-city fire department, how well have we integrated 911 services, pre-hospital care, and related technology into hospital practices?

There was a time when EMS developed as a medical service. If you go way back, ambulances were a secondary function of hearses. If you move a little bit past that, Frank Pantridge created heart ambulances in Belfast, Northern Ireland to save “hearts too good to die” with a defibrillator. Trauma surgeon David Boyd recognized that trauma care in Vietnam was better than it was for a motor vehicle crash victims.

Pre-hospital care developed as a medical service. Over the years, fire departments increasingly engaged it, initially for their own purposes to provide services to their own people who got injured at scenes. Over the years, as the number of structure fires began diminishing — both because older structures had burned out and because of better fire prevention practices — fire chiefs needed to maintain a reason for a handle on the public purse. Since they already had ambulance services for their own folks, they increasingly moved into EMS. Ultimately, what we’ve decided as a country by and large is that EMS pre-hospital care mostly resides in paid fire departments, at least in the urban and inner suburban areas.

Even as that was happening, Joe Ryan in Pinellas, Florida and others like him identified that a large number of people were calling for care. They were worried well or had something small and self-limiting that could be dealt with on the scene. In Brooklyn’s Orthodox Jewish community, you have Hatzolah, an all-male volunteer ambulance service that raises funds, does not bill, and hence has no requirement to transport. Without transport in EMS, nobody pays. You get paid for the transport, not for the care. Hatzolah is an example of doing this right within the community — responding to people’s needs, offering help at their bedside or in their home or workplace, and not necessarily transporting.

Emergency medical dispatch, created by Jeff Clawson, MD, is a discipline that has developed data-driven protocols to give telephone advice prior to arrival and to help select the requirements for urgency of response. The fire departments are overwhelmed and budgets everywhere are under such stress that they are interested in interventions that avoid transport and divert callers / patients into other means of care. That’s probably a good thing if it’s being done correctly. Joe Ryan, who now is in Reno, got money from CMS several years ago to look at an expanded role for paramedics to offer care in the community. I don’t know whether he was able to move forward with that based on issues with the local ambulance providers.

Doctors and nurses, by and large, have a charitable and helping impulse. With the public safety mindset — firefighters among them, who are rightly celebrated for running into the danger when everybody else is running away — there remains some question in my mind as to how suited the fire department is to be doing this work. But clearly fire chief leadership across the country has taken up this role throughout and is doing the best they can with it.

Jim Page was a fire chief, founder of the Journal of Emergency Medical Services, and a big booster of EMS on the fire side in California. Mr. Page has been dead for a decade or so, but there was a point at which he quite publicly said that doctors in EMS were bossy nuisances. To some degree, that’s part of the environment I worked in and why I decided to move on from the EMS leadership roles I’d had.

We first exchanged emails about the extent of misdiagnosis and how machine learning and artificial intelligence might have a role. As a doctor, how much value would you receive from technology helping you arrive at a diagnosis?

In the dim, dark past, I was a clinician working with John Clark, a surgeon. He was able to show that a junior resident using his software solution, running on an old Mac, was more accurate in diagnosing appendicitis than the most experienced surgeons by themselves. There was a period of time where John’s software was used on the orbiting space station. That was before we did a lot of bedside ultrasound and CT scanning of the abdomen. I’m telling you this story just to preface my response that in medicine, certainly emergency medicine, we are learning about our cognitive errors in reaching decisions for patients, including diagnostic decisions.

The heuristic is that you know what you know, and if you don’t think of something, it doesn’t end up on your differential diagnosis. If it’s not something you see very often, you may not think of it. Systematic ways of prompting consideration of reasonable possibilities — and who the hell knows what “reasonable” is? —  can be of value.

I just saw a paper pointing to the three areas of most diagnostic error harm – vascular events, infections, and cancer. These are big categories, even in the emergency department. Patients have cancer that hasn’t yet been diagnosed or they’ve had previously diagnosed and treated cancers and present with a new set of symptoms. It’s easy to think in terms of the statistical probabilities rather than considering the possibility of other cancer stuff.

What advice would you offer to someone looking forward to retiring and not having to go to work every day?

I’m no great fan of Arthur Brooks, who just announced that he’s retiring as executive director of the American Enterprise Institute, but he had a spectacular essay in the Atlantic called “Your Professional Decline Is Coming (Much) Sooner Than You Think.” It basically says that you are already past the peak of your career. You just don’t know it.

He writes very broadly in terms of how you might think of the rest of your life. I have found it thought-provoking and well worth the read. For me, I am a reader. I am a curious person. I’m a big-time lover of acoustic music – bluegrass, old-timey Irish music, and all the mash-ups of that.

You must be more than your career. I’m extraordinarily fortunate that my folks introduced me to music while I was young. They didn’t give me a hard time when they found me reading the Encyclopedia Britannica under the bedclothes by flashlight in the middle of the night.

People are where it’s at. The residency that I was part of at Hahnemann Hospital is gone and the hospital is closing down. Before that, Medical College of Pennsylvania, where I spent 20 years. That’s gone, absorbed into Drexel. Places disappear, places change.

I’ll just close with one last thing. A man very close to me — we’ve been friends since we were 18 — had a terrible fall last week. He was horribly injured and is in an ICU of a big trauma center. I got to his bedside about 20 hours after he got to the hospital, but I got help by reaching out to the broader emergency medicine community. I was connected to the doctor who first cared for him when he hit the ER. That doctor was two degrees of separation from me, and I was connected to that doctor within about two to three hours of calling out for help to my network.

It’s people, it’s people, it’s people. Whatever you do in retirement, stay connected to people.

Morning Headlines 8/21/19

Veterans Health Administration, AdventHealth, OCHIN, & InterCommunity CCO Pioneer New eHealth Exchange Health Information Network Infrastructure

EHealth Exchange announces go-live of a national, single-connection, InterSystems-powered gateway service whose charter members include the VA, AdventHealth, InterCommunity CCO, and OCHIN.

Health2047 Spins Out Zing Health to Improve Health Outcomes for Underserved Populations

AMA-backed Health2047 launches Zing Health to offer community-focused and analytics-driven Medicare Advantage plans that take into account social determinants of health.

Hospital website hijacked by ‘pirates’

The URL of Sonoma Valley Hospital (CA) is “maliciously acquired,” forcing the hospital to change its prized three-letter domain name of “svh.com” to “sonomavalleyhospital.org.”

New Tampa General Hospital center uses human and artificial intelligence to improve patient care

Tampa General Hospital (FL) joins the “Mission Control” club with the launch of CareComm, an 8,000 square-foot center the hospital will use to coordinate patient care using AI and predictive analytics.

Healthcare Embracing New Era of Compliance and Analytics

Healthcare analytics company Protenus raises $17 million in a Series C funding round led by LTP.

News 8/21/19

Top News

Nature magazine has run some good healthcare related articles lately (they are always called to my attention via tweets from Eric Topol). A new perspective piece covers the responsible use of machine learning in healthcare, containing many points that are likely new to the healthcare-inexperienced technologists who might be searching for any protruding nail for their proudly-created hammer:

• Choose the right problem, not just one for which a convenient ML training database exists. You can predict in-hospital mortality from a wealth of data, but does it tell clinicians something they don’t already know? Will the right people be involved in considering the actions that will be taken in response?
• Make sure the data elements are appropriate. ICD-10 codes entered after the patient’s encounter won’t be available when they are needed. They may also be driven by billing requirements rather than clinical ones.
• Account for inconsistent data collection practices across departments and health systems.
• Make sure that training data represents all populations.
• Watch for potential bias, such as creating an algorithm of whether a patient should have surgery based on those patients who actually did, who are probably more affluent than those who didn’t. Or in cases of a system that can infer information that the patient declined to provide, such as smoking or HIV status, which may cross ethical boundaries.
• Avoid “label leakage” in model testing, such as randomly assigning X-rays between training and testing sets without recognizing that patients have multiple images, which would then overweight the model’s accuracy.
• Break out the model’s testing results into the specific areas where it either excels or fails. Potential users need to know what a particular model works well in adults but not pediatrics, for example.
• Use clinically relevant evaluation metrics that look at the positive predictive value and sensitivity. A model whose high false-positive rate predicts a situation that requires high-cost, limited-value drug therapy isn’t going to be useful.
• Publish results with restraint, sharing code, data sets, and documentation so that other researchers can make their own assessments of usefulness.
• Test the system on real-life patients in silent mode only, where clinicians review the predictions without acting on them. Then move on to randomized controlled trials while recognizing that randomization at the patient or physician level is difficult and could endanger patients.

Reader Comments

From Mo Exposure CEO: “Re: links. Thanks for linking to our company’s news item. The response from HIStalk readers was amazing.” Thanks for deciding to sponsor the site as a result, especially since I don’t run fluff news pieces, meaning your announcement had to earn its way into my news post. Items I mention sometimes get a lot of clicks. Even webinar announcements sometimes get a couple of thousand clicks, and announcing a new sponsor always draws several hundred. Sponsor support comes from having loyal, influential readers, so my only job and outcomes measure is to make it worth their while to return.

From She Lives on Love Street: “Re: [RCM business line omitted.] Word on the street is that it’s been sold to [acquirer name omitted].” I’ve emailed the rumored acquirer’s PR contract but haven’t heard back. I’m running the redacted version to remind myself to follow up.

From Core Cutter: “Re: Apple. This CNBC article suggests internal trouble with its health offerings.” Reporter Chrissy Farr sometimes writes good health IT-related stories, but this isn’t one of them. I suspect her editors are pushing her too hard into drumming up questionably researched, speculation-based stories that hold minimal news value, as in her never-ending quest to take guesses at “what Amazon is doing in healthcare” because naming those big names draws eyeballs, but leave their owners with little useful information. This one tries to extrapolate Apple’s health-related departures into “differing visions for the future” that aren’t backed up by the stated facts. My take:

• She interviewed “eight people familiar with the situation,” none of whom are the people whose departures she noted, and those people she spoke to are simply speculating on why those people left.
• The five folks listed as having departed held wildly unrelated Apple “health” jobs, ranging from marketing to wellness clinic executives. It’s not like a mass exodus, either in numbers or in area of focus.
• The denominator of health-related jobs at Apple isn’t given, so we only know that it’s five positions out of hundreds.
• The story reports from the unnamed sources a difference of opinion among health-related employees about Apple’s direction, but those weren’t tied directly to the departures and those former employees didn’t say that’s why they were moving on.
• The clickbaity, present-tense headline implies a sudden uptick in internal tension, but does little to back that up with facts.
• We don’t have anything to suggest that Apple is disappointed in its health-related results or that it would like to change direction.
• Health and health IT have always had high turnover, some of it based on unreasonable expectations or finding out that big companies just want to make money instead of making people healthier, but in Apple’s case there’s also the possibility of parlaying an Apple credential into an even better job.
• Even if the story is right in claiming internal tension, so what? You’ll know if Apple makes major product or organizational changes. Speculating beforehand may be entertaining doesn’t really add value, except for the sites trying to sound insightful.

HIStalk Announcements and Requests

I Google-discovered Zenni in helping a friend get eyeglasses and it’s pretty cool. You key in the vision numbers from your eye doctor’s prescription (they don’t want the actual prescription), use a ruler to measure the distance between your pupils, and then head off through a long list of frames to choose your glasses. It takes a couple of weeks to received them in the mail from China and then you’re set unless you need to bend them a bit like your optician does for a perfect fit (not necessary in his case). The biggest draw beyond convenience is price – a pair of snazzy progressive glasses cost him less than $50 (they look exactly like his $300+ pair from Costco), single-vision sports glasses with polarized lenses were $60, and no-nonsense single-vision sunglasses were $15 (!!). At these prices, you could stash a pair of prescription sunglasses in every car, get some glasses set for computer monitor distance, and get backup normal glasses for next to nothing.  What you end up with is pretty much exactly what the optician would sell you for five times the price after two trips to the store. You still need an eye exam every year or two, but what happens afterward is Zenni’s strong suit. You could do a life-changing but inexpensive good deed by treating someone who can’t afford glasses to a pair of Zennis.

Color me skeptical: a new Frost & Sullivan white paper (which you can download only if you provide work details) predicts that clinical decision support systems “are poised to become the user interface of choice for clinical interaction with health IT,” replacing the EHR. My take is exactly opposite – clinical decision support systems will feed their information and recommendations through the EHR, disappearing in the background but providing no less of a service in recognizing that clinicians rightfully want everything placed into their EHR workflow and design. Nobody in their right mind would suggest that CDSS systems contain everything a clinician needs to see, or to visualize how those systems would interact with the user when several are in use (one for radiology image appropriateness, one for antibiotic stewardship, etc.) I think F&S is way off base here, and had I cared enough to download the report, I bet I would find some CDSS vendor involvement. The HIMSS rag gave it a dramatic headline, a pointless stock art photo, and a non-critical acceptance of what the report’s author said, assuming they paraphrased it accurately. This is one of those reports that predicts huge growth in some market segment, knowing that a more realistic report wouldn’t exactly fly off the shelf.

Webinars

September 5 (Thursday) 2:00 ET. “Driving 90% Patient Adoption Across Your Network: How US Dermatology Partners is Showing Us The Way.” Sponsor: Relatient. Presenters: Michele Perry, CEO, Relatient; Sara Nguyen, VP of applications and integrations, US Dermatology Partners. US Dermatology Partners is helping its physicians reclaim time they can spend with patients and is turning patient engagement strategies into business results across its 90 locations in eight states. Attendees will learn how US Dermatology Partners defined its patient engagement objectives and physician-optimized strategies. They presenters will provide advice on starting or accelerating  patient engagement goals.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.

Acquisitions, Funding, Business, and Stock

The newly hired, cost-cutting CEO of India’s second-largest hospital chain will slash its expenses by 20% in trying to recover from the misappropriation of company funds by its previous owners. Publicly traded Fortis Healthcare will reduce doctor pay, replace people with software, close underperforming hospitals, sell non-essential assets, and ensure that nurses perform only those tasks that lower-paid employees can’t do.

EHealth Exchange announces go-live of a national, single-connection, InterSystems-powered gateway service whose charter members include the VA, AdventHealth, InterCommunity CCO, and OCHIN.

Sales

• Vanderbilt Health chooses Sectra for PACS and VNA in diagnostic radiology and cardiology.
• Medical records retrieval vendor Womba chooses Allscripts Veradigm EChart Courier to aggregate provider patient records to its attorney clients.

People

Spok hires Matt Mesnik, MD (Vigilant Diagnostics) as chief medical officer.

Josh Hoders, MBA (DrFirst) joins Forward Health Group as sales VP.

FDA hires Vid Desai (Vyaire Medical) as CTO.

Announcements and Implementations

A KLAS review of drug diversion monitoring technology finds that Omnicell Analytics is the most widely adopted solution, but many customers fail to achieve their expected outcomes because they decline to pay the extra cost of EHR integration.Medacist RxAuditor has a lot of customers, but outdated technology and workflows cause most of them to use only its simplest dispensing reports in then chasing down problems via manual workflows. Kit Check’s Bluesight for Controlled Substances holds promise based on early adopter reports.

Other

The URL of Sonoma Valley Hospital (CA) is “maliciously acquired,” forcing the hospital to change its prized three-letter domain name of “svh.com” to “sonomavalleyhospital.org.” The hospital’s URL registration was good through late 2021, but someone updated it using credentials from an unknown source to take control, which an expert contacted by the local paper says is nearly impossible to reverse. I checked the Whois for the URL and it’s now running on China-based servers with “registrar lock” turned on. I thought it was straightforward to contact the web registrar or ICANN with proof of ownership to get the transfer reversed, but regardless, hospitals should:

• Use complex passwords for their domain service’s website.
• Change the registration address if it points to the same domain since otherwise you’ll lose the ability to be contacted if someone grabs that URL.
• Turn on the “registrar lock” option of your domain service so it can’t be transferred.

A fired VA hospital chief pathologist is charged with three counts of involuntary manslaughter after a review of his needle biopsy cases showed a misdiagnosis rate of 10%, 10 times the expected rate. The VA says he was responsible for at least 15 deaths and an unknown number of incorrect diagnoses. Colleagues had complained of his erratic behavior for years, but the VA let him continue working while he underwent drug and alcohol rehab, finally firing him in 2018 after a DUI arrest.

Kaiser Health News covers the plight of several “no-stoplight” rural towns that believed Miami entrepreneur Jorge Perez, who promised to save their tiny local hospitals but instead used them in a massive insurance fraud scheme that took advantage of higher lab billing rates for rural hospitals. A 14-bed hospital cranked out bills for $120 million in just six months, of which $80 million went to the hospital’s new owner and little to the hospital, as employees reported running out food, cleaning supplies, and IV fluids, with patients in one of them displaced because their hospital beds were repossessed while they were still occupying them. When insurers eventually stopped paying, 12 of the hospitals filed bankruptcy and eight closed. Perez paid $3.5 million to settle the the DoJ’s false claims charges and says he’ll now focus on his software businesses.

Sponsor Updates

• Hackensack Meridian Health Jersey Shore University Medical Center reduces stroke-related readmissions by 50% after implementing Vocera Care Inform to provide personalized audio discharge instructions and educational materials.
• Healthfinch announces several new customers of its Epic-integrated Charlie Practice Automation Platform and its exhibit at Epic’s UGM next week.
• Aprima will host its 2019 User Conference August 23-25 in Grapevine, TX.
• Artifact Health publishes a new case study describing how its mobile physician query tool helps Western Maryland Health System accurately code episodes of care in a quality-based reimbursement program.
• Burwood Group is raising money for the Boys & Girls Club of Greater San Diego.
• Wolters Kluwer Health releases six new Audio Digest Topical Collections for CME.
• CoverMyMeds and Culbert Healthcare Solutions will exhibit at Epic’s UGM August 26-29 in Verona, WI.

Blog Posts

• Healthcare ERP System Selection (Optimum Healthcare IT)
• Receive a well-rounded educational experience at Evo19 (AdvancedMD)
• 5 years ago, Mayo Clinic made 3 huge bets. Are they paying off? (Advisory Board)
• How Are IT Risks Different For A Company That Handles Protected Health Information? (Fortified Health Security)
• How do you build, deploy and maintain an imaging data management strategy? #The Imaging Data Management Strategy Series (Agfa Healthcare)
• More Than Medicine: Southcoast Health Raises the Bar with Avaya (Avaya)
• Collective Medical Stands by ACEP’s Efforts to Make EDs Safer (Collective Medical)
• Updates from Our 2018 CoverMyQuest Winners: Part 2 (CoverMyMeds)

Contacts

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

Morning Headlines 8/20/19

US healthcare BPO may be valued at $225 million: PE firms in race to acquire emids Technologies

Several investment firms, including Everstone Capital and ChrysCapital Advisors, are in talks to buy Nashville-based health IT vendor Emids Technologies for between $200 million and $225 million.

athenahealth Appoints Simon Mouyal as Chief Marketing Officer

Simon Mouyal (Medidata Solutions) joins Athenahealth as chief marketing officer.

Two Chairs raises $21M to continue to build out its mental health clinics

Mental healthcare company Two Chairs will use a $21 million Series B funding round to expand its clinic footprint in California, and improve and expand upon its patient/provider matching technology.

Curbside Consult with Dr. Jayne 8/19/19

I wrote back in 2017 about the All of Us research program, sponsored by the National Institutes of Health. Originally they were trying to build a cohort of 1 million patients to help them look at genomic, clinical, and lifestyle data over a 10-year period. The New England Journal of Medicine recently published an update on the program’s progress.

Following the original beta program that I wrote about, All of Us opened for general enrollment in May 2018. Elements of the program include health questionnaires, EHR data, physical measurements, and the collection of biospecimens.

As of last month, more than 175,000 participants had contributed biospecimens, with more than 80% of those participants being from “groups that have been historically underrepresented in biomedical research. That’s a pretty big deal, since it’s difficult to recruit research subjects from certain subsets of our population. They’ve also collected EHR data on more than 112,000 participants from 34 recruitment sites. Should the researchers meet their goals, the robust nature of the data would allow researchers to explore factors related to individual lifestyle differences, socioeconomic factors, environment, and biology in order to better understand how we can prevent, diagnose, and treat diseases.

Having historically underrepresented patients join the program is great since those populations often have inadequate access to healthcare. Although some conditions can be linked to race and ethnicity, they’re only pieces of the puzzle. Other factors influencing health include age, sex, gender identity, sexual orientation, disability status, access to healthcare resources, income, educational level, ZIP code, and more. Researchers are prioritizing those underrepresented populations for physical measurements and biospecimen collection.

Unlike other data-gathering programs, All of Us doesn’t focus on any particular set of diseases like cardiovascular conditions or cancers. It seeks to create a broad data set that can be used for a variety of investigations, including outcomes research. Although they’re currently only enrolling adults with the ability to participate in an informed consent process, they’re looking at protocols for enrolling minors as well as adults who might be cognitively impaired. The materials are only available in English and Spanish, so it’s not a true cross section of the population, but the program is moving in the right direction.

The program has launched a web-based data browser where you can search concepts for some of the conditions and statuses being tracked. Although patients can only see their biometrics and survey responses, the researchers are working to build protocols to share genetic, laboratory, and EHR data back to participants. Priority will be given for actionable genetic information and pharmacogenetic results, delivered to those patients who have elected to receive that information.

Since the database is intended to be longitudinal, it will be interesting to see how many patients continue to participate over time. Since its inception, Congress has allocated $1.02 billion to the program, including funding for genome sequencing and setup of genetic counseling resources for participants receiving actionable results. The 21st Century Cures Act authorized funding through 2026 in the amount of $1.14 billion.

Another element that they’re still trying to work out is the incorporation of wearables data. Patients can share data gathered from Fitbit devices and investigators are looking at collection of data from other sources. Given the number and diversity of devices out there, they would need to support quite a few platforms to be able to get a good sampling. My extended family’s affinity for devices ranges from Garmin to Fitbit to Apple. Even with concerns about the validity of data from wearables, it’s interesting to note that simply having a wearable health tracker of any kind says something about a patient’s socioeconomic status and awareness of health issues.

One of the challenges noted by the authors is the incomplete nature of some of the EHR data, along with variability in that data. They are working to harmonize the data that they bring in from EHRs at recruiting institutions and are discussing ways to incorporate data from patients receiving care in rural settings. Health Information Exchanges might be another data source for those patients.

A quick tour through the online data browser illustrates some of the challenges of managing the data. The concept of diabetes can be rendered as the presence of disease, as a factor leading to adjustment of other lab values, and as a status identifier. There are also issues with EHR data in that it’s not always going to be complete enough to have the statistical power that you might find with data collected as part of a prospective trial. Still, it’s better than some of the current options, and I’m eager to see how things develop.

The biggest challenge they’ll have to face, however, is recruiting the more than 800,000 patients they still need to create their target population. It’s likely that in the early days of the program enthusiasm and awareness were high, resulting in the enrollments they already have. They’re going to have to stay on pace at the recruiting centers they already have up and running or dramatically expand the number of locations that can assist in the recruiting process.

Another option is to expand what they call direct volunteers, which are patients who come to the program from outside the designated recruiting centers. Reaching those folks who might be in rural areas or who just don’t come into care and are therefore less likely to be recruited requires different kinds of efforts. I haven’t personally heard anything about the program except from healthcare IT sources, and I’m constantly in and out of medical centers across the country. I’ve seen more signage about Ebola virus than I’ve seen about the program.

Given the size and breadth of our reader base, I’m hoping someone has first-hand experience with All of Us, either as a researcher or as part of one of the recruiting institutions. What has your experience been? How enthusiastic is the team? What can the rest of the healthcare community to do help you meet that million patient goal? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 8/19/19

Starboard Value shrinks stake in Cerner

Activist investor Starboard Value, which scared Cerner into giving it board seats in a “cooperation agreement” in April 2019, has sold CERN shares as the price moves up.

Cape Cod Healthcare to build $180M patient tower on Hyannis Harbor

Cape Cod Healthcare will build a $180 million patient tower in Hyannis and will implement Epic.

The Patient Record Scorecard: What is it and Why we did it.

Consumer health data platform vendor Ciitizen rates hospitals on how well they respond to patient requests for copies of their own information.

Monday Morning Update 8/19/19

Top News

Consumer health data platform vendor Ciitizen rates hospitals on how well they respond to patient requests for copies of their own information.

It’s an interesting idea that isn’t well fleshed out in this initial effort due to a tiny, possibly non-representative sample size and reliance on self-reported hospital policies that were collected via a survey.

This limited information, along with anecdotal stories (such as my own), don’t paint a true picture. I would rather see the federal government (via HHS / CMS / ONC) provide a mandatory records request portal that requires the hospital to log its eventual actions (with timestamps) and allows patients to add comments or complaints. That bypasses the problem in trying to educate masses of consumers about the legal obligations of providers and how to file a complaint when they aren’t met.

Otherwise, hospitals seem happy with their contrived system of paper forms, in-person HIM department visits, faxed copies, and high fees since they don’t really want to share the data of patients anyway due to competitive and malpractice concerns.

Reader Comments

From ApplestoApples: “Re: JAMA article on Apple Health Records. It’s Apple-only and the highlighted use of FHIR is irrelevant. The next report should cover providers that offer a published mechanism for any vendor who wants to be a member, given the article’s prediction of an eventual ‘ecosystem’ (that number would be zero right now). Even better, how about limiting it to those providers who make the full EHR record of the patient available as HIPAA requires? Until the right to access records is not just the law and the subject of toothless Office for Civil Rights letters, HHS infographics and YouTube videos but also enforced, FHIR doesn’t matter. But definitely cool that JAMA gave us some pretty underwhelming Apple Health adoption data.” Agreed on all counts. The industry whines about proprietary solutions, then embraces the most proprietary technology vendor in touting Apple-only patient access to a tiny subset of their own Epic-only records (IOS represents less than half the US mobile device market). The article reports that only 0.7% of the patient portal users of the studied health systems have used Apple Health Records. It did not attempt to quantify any outcomes that resulted or the extent of ongoing patient use and for what purposes. I agree that health systems, including the Apple-partnering ones, make it difficult for patients to obtain electronic or paper copies of their complete medical records and HHS does nothing to make them comply with federal regulations.

HIStalk Announcements and Requests

Most poll respondents found at least some forms of technology useful in their most recent provider visit, with the patient portal topping the list and the virtual visit bottoming it. I get the sense that few of us place a lot of value on the IT aspects of our provider encounters, while my previous poll results suggest that even fewer of us – even among my healthcare IT-centric readership who obsess over “Most Wired” type self-stroking awards — choose providers based on the technologies they use or even care one way or another.

New poll to your right or here: How proud are you of the largest healthcare system near you in terms of patient outcomes, community benefit, and financial practices? Click the Comments link after voting to explain.

Webinars

September 5 (Thursday) 2:00 ET. “Driving 90% Patient Adoption Across Your Network: How US Dermatology Partners is Showing Us The Way.” Sponsor: Relatient. Presenters: Michele Perry, CEO, Relatient; Sara Nguyen, VP of applications and integrations, US Dermatology Partners. US Dermatology Partners is helping its physicians reclaim time they can spend with patients and is turning patient engagement strategies into business results across its 90 locations in eight states. Attendees will learn how US Dermatology Partners defined its patient engagement objectives and physician-optimized strategies. They presenters will provide advice on starting or accelerating  patient engagement goals.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.

Acquisitions, Funding, Business, and Stock

Activist investor Starboard Value, which scared Cerner into giving it board seats in a “cooperation agreement” in April 2019, has sold CERN shares as the price moves up.

Sales

• Nebraska Health Information Initiative chooses InterSystems HealthShare for provider data-sharing.

Announcements and Implementations

Cape Cod Healthcare will build a $180 million patient tower in Hyannis and will implement Epic. Its most recent tax filings show a profit of $48 million on revenue of $871 million, with the CEO earning $1.6 million and the CIO $367K. I believe Cape Cod Hospital was an original Meditech site going back to the late 1960s, then switched to Siemens / Cerner Soarian in 2010.

Other

Sources report that informatics pioneer Donald Lindberg, MD has passed away. He was a pathologist, former director of of the National Library of Medicine, and the first president of AMIA, having focused on informatics since 1960. He was 85.

The New York Times profiles the thousands of outsourced workers who sit in cubicles India all day marking up medical images to train AI systems. It observes that the systems they are training may eventually reduce human employment, but in the mean time have created jobs that range from decent to exploitative. One woman’s entire workday was spent listening to recordings of people coughing to help train a diagnostic system. 

A commercial construction magazine previews “smart hospitals” that include such technology such as heart attack alerts that are triggered by patient alarms that then call the care team members, detect their locations, and then override elevator settings to get them to the patient’s room quickly. Engineering firms are also looking at ways to incorporate smart speakers.

A Nature op-ed piece says that the AI algorithms touted in research articles aren’t really usable by providers because: (a) they don’t change the incentives that led to optimizing processes for the current state; and (b) individual providers don’t have the technology and expertise to train the algorithms for local conditions and to test for bias. The authors draw a comparison with EHR “data liberation,” which sounds great but doesn’t happen because entrenched players are rewarded by the status quo. It concludes,

Health systems are faced with a choice: to significantly downgrade the enthusiasm regarding the potential of AI in everyday clinical practice, or to resolve issues of data ownership and trust and invest in the data infrastructure to realize it … the opportunity exists to both transform population health and realize the potential of AI, if governments are willing to foster a productive resolution to issues of ownership of healthcare data through a process that necessarily transcends election cycles and overcomes or co-opts the vested interests that maintain the status quo—a tall order. Without this however, opportunities for AI in healthcare will remain just that—opportunities.

An NHS hospital in Scotland apologizes to 400 patients whose discharge letter incorrectly indicated that they have cancer, an error the hospital blames on a computer system switchover.

Vermont State Rep. Ben Jickling resigns his seat (and his golf course day job) in accepting a job offer from Epic. The 24-year-old doesn’t appear to fit the usual Epic profile since he didn’t graduate from the small liberal arts college he attended.

Non-programmers won’t get this: a security researcher who bought a vanity license plate of “NULL” in trying to avoid getting traffic tickets by confusing California’s DMV system gets the opposite result – he has racked up $12,000 in tickets that were intended for other drivers whose tag number was accidentally omitted by the citing officer. The state’s ticketing subcontractor will cancel his individual tickets only if he can’t prove he wasn’t involved, potentially preventing him from renewing his registration. A Wired journalist named Christopher Null says he could have told the man that using the word “null” in any form is asking for problems because poorly tested programming often mishandles it.

A woman who boiled eggs in the microwave as instructed by YouTube videos is rushed to a hospital burn unit when the eggs explode upon removal, causing skin and eye damage that doctors worry could be permanent.

Sponsor Updates

• Waystar donates over 100 used laptops to families in the Louisville area to help support tech education in underserved neighborhoods.
• NextGate will exhibit at the 2019 SHIEC Conference August 18-21 in National Harbor, MD.
• Netsmart will exhibit at the Florida Behavioral Health Conference August 21-23 in Orlando.
• Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the 6th Annual OBGYN Conference for Nurses and Physicians August 22-23 in Chattanooga, TN.
• Diameter Health will exhibit at the SHIEC conference August 18-21 at National Harbor, MD.
• Relatient expands its offerings in the Greenway Marketplace to include patient self-scheduling, patient intake, online payments, visit surveys, and two-way messaging.
• Nordic posts a podcast titled “How to drive efficiencies between your ERP and EHR in OR and beyond.”
• Surescripts will exhibit at the 2019 Aprima User Conference August 23-25 in Grapevine, TX.
• TriNetX will exhibit at the International Conference on Pharmacoepidemiology & Therapeutic Risk Management August 24-28 in Philadelphia.

Blog Posts

• The Secrets of Great Telehealth Quality (MDLive)
• How to improve discharge procedures for homeless patients (Meditech)
• Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians (Health Catalyst)
• 5 Things to Look Forward to at MHUG 2019 (Mobile Heartbeat)
• 2020 Medicare Proposed Changes for PTA and OTA Billing, Modifiers, and Reimbursements (MWTherapy)
• An Eye in the Sky for Social Determinants of Health, Part 1 of 3 (Omni-HealthData)
• The Growing Importance of RCM (EClinicalWorks)
• 3 ways to use social determinants of health data for better care management (Experian Health)
• What is Patient Empowerment & How Does It Impact Health Outcomes? (PatientBond)
• Piedmont’s VP of Experience on Personalized Patient Care (Patientco)
• Did EHRs Light the Physician Burnout Fuse? (PatientKeeper)
• Healthcare IT: Facing the Staffing Crisis through an Alternative Approach (Fortified Health Security)
• Top Considerations for a Meditech Implementation (Santa Rosa Consulting)
• When Paperwork Comes Before Patients: Missing Key Information Complicates Specialty Prescribing (Surescripts)
• The 2020 Proposed Rule: Bite-Sized Edition (WebPT)

Contacts

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

Morning Headlines 8/16/19

Nurx Secures $52 Million to Expand Access to Sensitive Health Needs

Contraceptive and at-home STI testing telemedicine company Nurx raises $52 million in a Series C round led by Kleiner Perkins Digital Growth Fund and Union Square Ventures.

Accenture Federal Services Wins U.S. Navy Bureau of Medicine and Surgery Contract to Help Transform Healthcare Delivery for Sailors, Marines and their Families

Navy Medicine awards Accenture a $79 million contract for program and project management support for EHR optimization and health informatics, virtual health, and AI initiatives.

Computer blunder forces Queensland hospitals back to paper records

A handful of Queensland Health hospitals in Australia revert to paper for several hours after a routine overnight update to the state’s beleaguered IEMR system goes awry, making the medical records of male patients inaccessible.

News 8/16/19

Top News

Navy Medicine awards Accenture a five-year, $79 million contract for program and project management support for EHR optimization and health informatics, virtual health, and AI initiatives.

Webinars

September 5 (Thursday) 2:00 ET. “Driving 90% Patient Adoption Across Your Network: How US Dermatology Partners is Showing Us The Way.” Sponsor: Relatient. Presenters: Michele Perry, CEO, Relatient; Sara Nguyen, VP of applications and integrations, US Dermatology Partners. US Dermatology Partners is helping its physicians reclaim time they can spend with patients and is turning patient engagement strategies into business results across its 90 locations in eight states. Attendees will learn how US Dermatology Partners defined its patient engagement objectives and physician-optimized strategies. They presenters will provide advice on starting or accelerating  patient engagement goals.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.

Acquisitions, Funding, Business, and Stock

Ambrosia founder Jesse Karmazin says the anti-aging blood transfusion business has shut down for good. The company, which pitched transfusions of “young” blood to older people for $8,000 a liter, shut down for a few months earlier this year after receiving a warning letter from the FDA. Karmazin managed to get operations back up and running in two states, and now says he has started a new company called Ivy Plasma, which will offer transfusions from people of all ages.

Sales

• Providence Health & Services (OR) will implement the Loopback Rx Platform from Loopback Analytics at its Credena Health pharmacy.
• Quorom Health (TN) will implement Medhost’s clinical and financial software at 25 hospitals over the next 20 months.
• HIEs OneHealthPort (WA) and Healthcare Access San Antonio select health data integration software from Diameter Health.

Announcements and Implementations

St. Claire HealthCare implements emergency department information exchange software from Collective Medical through a partnership with the Kentucky Hospital Association first announced last December.

Florida’s E-FORCSE PDMP uses technology from Appriss Health and Express Scripts to connect to the Military Health System PDMP, which now shares data and analytics with 39 state-based PDMPs.

The People-Centered Research Foundation will use data de-identification services from Datavant to securely link patient data across its National Patient-Centered Clinical Research Network. Organized with funding from the Patient-Centered Outcomes Research Institute, the network comprises 70 provider and payer organizations that share data for research purposes. Datavant added de-identification capabilities to its health data management services when it acquired Universal Patient Key last year alongside a $40 million funding round.

A new KLAS report covers payer care management, a term it uses to encompasses utilization management, disease management, case management, care coordination, and member engagement. ZeOmega and Cognizant are most often considered in new decisions, but VirtualHealth and AssureCare are making inroads as newer market entrants. Medecision is the vendor most often mentioned as potentially being replaced, while Casenet leads in overall satisfaction but is trending down due to missed expectations. 

Privacy and Security

Intraprise Health develops BluePrint Protect security software to help enterprises with third-party risk management.

Other

A handful of Queensland Health hospitals in Australia revert to paper for several hours after a routine overnight update to the state’s beleaguered IEMR system goes awry, making the medical records of male patients inaccessible. Hospital staff attributed the glitch to a later-than-normal start time.

Developers of the Anura app claim its machine learning technology can accurately assess a user’s heart rate, stress level, body mass index, blood pressure, and risk for heart disease and attack from a 30-second selfie using transdermal optical imaging. Research published last week in an American Heart Association journal found that the app could measure blood pressure accurately 96% of the time.

Sponsor Updates

• Elsevier Clinical Solutions will exhibit at NACDS TSE 2019 August 24-26 in Boston.
• EClinicalWorks will exhibit at the East Hawaii IPA Annual Healthcare Symposium August 16-18 in Waimea.
• Ellkay, Imat Solutions, and InterSystems will exhibit at the 2019 SHIEC Conference August 18-21 in National Harbor, MD.
• Ensocare will exhibit at the ACMA Florida Chapter Annual Conference August 22-23 in Championsgate, FL.
• Hayes Management Consulting names Craig Surette (Athenahealth) senior solutions engineer and William Heuschneider (Athenahealth) client success manager.
• HCTec Marketing and Sales Operations VP Rob Borella joins the Tennessee HIMSS board.
• Imprivata makes Identity Governance available to customers working with Microsoft Azure Active Directory.
• Nordic releases a new podcast, “How to drive efficiencies between your ERP and EHR in OR and beyond.”

Blog Posts

• Dawn of the Age of Population Health (EClinicalWorks)
• Can You Find and Secure the Sensitive Information in Your Organization’s Network Infrastructure? (Fortified Health Security)
• The expanding role of the EHR in the opioid battle (Greenway Health)
• Why an EHR Alone Isn’t Going to Make Population Health Possible (The HCI Group)
• Why Social Media in Healthcare is Important (Optimum Healthcare IT)
• After the Fever Pitch, Prevent the “Helpless” Desk (HCTec)
• Is Remote Staffing Right for your Prescription Renewal Center? (Healthfinch)
• The Value of Using the Right Health Education Videos (Healthwise)
• 3 considerations for multifactor authentication in healthcare (Imprivata)
• The Interoperability Directive: What the Proposed ONC and CMS Regulations Mean – Part 3 (InterSystems)
• Keynote Spotlight: Former CEO of Cleveland Clinic Shares How to Expand the Boundaries of Healthcare (Kyruus)

Contacts

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

EPtalk by Dr. Jayne 8/15/19

EHR vendors, get ready to make some updates: The US Preventive Services Task Force (USPSTF) plans to recommend screening all adults for illicit drug use, including inappropriate use of prescription drugs. The draft recommendation statement is open for public comment through September 9. As an EHR client, we expect these kinds of recommendations to play out in our EHR as soon as they’re published, but for many vendors it’s a long road between when a recommendation is issued or a guideline is updated and when it actually is in the hands of the majority of their clients. I’d be interested to hear from vendors how they approach these types of updates and how quickly they can get them to the point of care.

Speaking of recommendations and regulations that never become reality, here comes yet another delay for implementation of the Appropriate Use Criteria for advanced diagnostic imaging that was initially passed in 2014. NPR reports that the delay will continue, with 2020 as a “testing” year where Medicare will not block inappropriate scans. CMS won’t make a decision until 2022 or 2023 on whether (and when) penalties will begin. The reality is that Medicare and other payers continue to pay for unneeded diagnostic exams. These exams are often ordered because patients demand them, even though they show low clinical utility. Physicians increasingly worrying about being “dinged” on patient satisfaction scores that go along with it, often under duress. Advanced imaging services are a profit center for many medical institutions and physicians chafed at the idea that they’d have to log additional keystrokes in the EHR to document compliance with the criteria.

A friend of mine who used to work in corporate IT has recently moved into the world of healthcare IT. I’ve been enjoying his reactions as he learns about all the crazy stuff that we have to deal with, including managing claims, handling capitation payments, and more. He recently visited a practice that was processing data using stacks of papers to trigger the workflow and track who was doing the work. I’m thinking about prescribing him some muscle relaxers to counteract the ill effects of all the head shaking he’s probably doing. It’s always amusing, but sad in many ways, to watch someone experience the dirty underbelly of healthcare. It’s a mix of shock, disbelief, and outrage. Those are the same emotions I’m feeling while I read “Code Blue: Inside America’s Medical Industrial Complex” by Mike Magee. I had started it prior to my international medical adventures and resumed the read after hearing from my fellow volunteers. Hearing from them about how healthcare is delivered with lower cost and higher quality in their countries just makes my blood pressure rise. I sold any stock in EHR vendors long ago, but will be divesting some remaining pharma investments shortly. Shareholders are part of the problem, not the solution.

Corporate profiteering is everywhere, and I experienced it in another conversation today. One of my residency colleagues went to work last year for a group that does Direct Primary Care as an employee benefit. She’s been enjoying the work, especially the part where she has an hour for new patient visits and 30 minutes for regular visits, and feels like she actually has time to partner with her patients to improve their health. She wanted me to know that her company is expanding to my area and to see if I was interested in a referral to their recruiter. Since that’s a major aspect of primary care that I miss in my current clinical practice, I said I was game.

She proceeded to tell me a little more about the company, including that they were recently purchased by a PE firm and that there has been the addition of a good number of VPs that don’t seem to do anything but have titles in sales, marketing, and operations. That’s part of why and how they’re expanding; the PE money is an infusion but also increases the need to create some revenue from the system. Although their profit is largely driven by the difference between what the employers pay and the services the patients use, she agrees it’s only a matter of time before the nature of the practice changes. For providers in the trenches, though, it’s a difficult balance between practice paradigms that have good elements but some features that are unsettling. Her final thought was that it’s still better than the HMO she used to work for, so I guess there’s that.

I’ve always wanted to visit Spain, and I wish I was still doing a reasonable volume of lab work so I would have justification to attend the upcoming LOINC Conference outside of Barcelona. Both the Laboratory and Clinical LOINC Committees will be at the same meeting for the first time, and the conference fee is low compared to other organizations. For those of you heading to the sun-drenched Mediterranean, enjoy!

The next couple of months are full of meetings and functions. ONC is hosting an interoperability forum  August 21-22 that has a good-looking agenda, but there are too many parallel tracks – I wouldn’t be able to pick just one to attend. There’s also a symposium on September 6 around patient matching for prescription drug monitoring programs. This also starts the User Group meeting season, beginning with the Aprima User Conference from August 22-25 in the Dallas area. I hear that’s a fun one, but have never been able to make it work with my schedule.

New Hampshire becomes the latest state to expand telehealth services, with Governor Chris Sununu signing a bill expanding the scope of services covered under Medicaid. Previous regulations limited telehealth services to specialists, but the new law mandates coverage for virtual primary care, remote patient monitoring, and substance abuse disorder treatment as long as the patient has already established care face-to-face. The definition for “originating sites” for those face-to-face services has been expanded from medical offices to include “the patient’s home or another nonmedical environment such as a school-based health center, a university-based health center, or the patient’s workplace.” It’s not as expansive as providers might like, but it definitely helps the state move forward. The law also creates definitions around asynchronous telehealth for non-urgent issues, which will help provide services when video visits might not be realistic.

I skim a lot of journals and publications, but have to admit I wasn’t aware of the Renal & Urology News before a reader sent me this snippet: A recent study looked at referral patterns at Wake Forest School of Medicine and found that patients with rare genetic conditions might be more likely to refer themselves to an academic medical center based on information they find on the Internet. The authors noted that primary care physicians might not be aware of certain rare conditions, so “If patients suspect a rare disorder that is undiagnosed by their physicians, actively pursuing self-diagnosis using the Internet can be successful.” Dr. Google, take note.

Email Dr. Jayne.

Morning Headlines 8/15/19

Grays Harbor Community Hospital Provides Notice of Recent Ransomware Attack

Grays Harbor Community Hospital and Harbor Medical Group in Washington confirm that a ransomware attack caused their downtime in June.

The founder of a startup that charged $8,000 to fill your veins with young blood says he’s shuttering the company and starting a new one

Controversial blood transfusion startup Ambrosia shuts down for good after receiving an FDA warning that prompted it to close its operations in all but three states earlier this year.

Ancestry’s CEO signals a major healthcare play is on the horizon

Genealogy and consumer DNA testing company Ancestry is actively building out its health team as it prepares to move into precision medicine.

Morning Headlines 8/14/19

Mercy’s Tech Arm Launches a Nationwide Real-World Evidence Network to Pool Clinical Data for Advanced Analysis

Mercy Technology Services launches a real-world evidence database in which de-identified data from a consortium of health systems will be sold to drug and medical device manufacturers.

Microsoft welcomes new Chief Medical Officer Dr. David Rhew

David Rhew, MD (Samsung Electronics) joins Microsoft as chief medical officer/VP of healthcare.

Q-State Biosciences and 2bPrecise Announce Partnership

Allscripts backs a partnership that will combine the precision medicine data tools of 2bPrecise (in which Allscripts is the primary investor) with those of genetic sequencing vendor Q-State Biosciences.