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Weekender 7/26/19

July 26, 2019 Weekender 14 Comments

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Weekly News Recap

  • Shares of Health Catalyst, Livongo, and Phreesia begin trading with significant first-day price jumps.
  • Cerner announces plans to create a “monetized distribution model” of selling patient data to drug companies and insurers.
  • Tenet announces that it will spin off its Conifer revenue cycle management and population health business into a publicly traded company and that Conifer CEO Stephen Mooney has resigned.
  • Cerner’s Q2 earnings meet Wall Street expectations as revenue fell short.
  • Essence, parent company of Lumeris, faces CMS review for using Lumeris software to identify patients who could be billed as “enhanced encounters.”
  • AHIMA and CHIME urge the Senate to pass a House bill that would allow HHS to participate in the rollout of a national patient identifier.
  • Amazon threatens to sue Surescripts over the potential loss of access to patient prescription data for its PillPack mail order pharmacy subsidiary.
  • Tennessee creates a committee to study state EHR use for efficiency and potential fraud.

Best Reader Comments

Cerner CommunityWorks is a multi-tenant domain for critical access hospitals and community hospitals under 200 beds. I believe that Cerner is now moving this type of model to larger medium-sized hospitals but will have less per domain (CommWx can have 20+ per domain) whereas this model for say a 300-500 bed hospital may have only 3-4 customers in a domain. Also, its not technically already configured. Similar to Epic, its call the Model Experiencer where about 80% of the domain is standard / stock content and then each customer has the ability to customize about 20% of it (some rules, reports, documentation format, etc.) Implementation for CommWx is currently scheduled at 10-12 months. However, it still essentially sits on standard architecture. Now if Cerner would really commit to either AWS/Azure or true cloud, then I think that would be move the needle. (Associate CIO)

Rural broadband (broadband in general) needs to be treated as a public utility. This country should handle this the way we handled electricity in the rural South in the 1950s, take it on a a public works project, and wire everyone up. It has become a fundamental tool in communication and commerce, there is no reason (other than paying some C-level executives millions in salary and stock) why we as a country should not ensure that all of our citizens can participate in civic life. (HIT Girl)

There is no such thing as an “Epic API” whereby third-party developers can craft solutions that developers can go market to Epic clients and generate some form of income along the way. In the Epic space you have two options – share your solution with Epic as a submission for the community sharing site (whereby you explicitly grant Epic rights to ALL of your IP embedded in that solution, even if it is never added to the community site) or craft some sort of app for submission to the App Orchard whereby your application / solution is sending transactions into Epic via some very narrowly defined messages (think HL7 here). There are absolutely, hands down, 100% zero options for what (uninformed and snobby) folks may traditionally consider an API for an application whereby complementary, third-party apps can in some fashion manage or change the behavior of the parent application in the Epic space.  (Code Jockey)

In all of the time and locations I’ve done pre-implementation build, I’ve never encountered an Epic resource that fully understood the impact of the build decisions that they were leading their clients to implement. No Epic resources know / realize / are trained on the downstream impacts of their area of build or the upstream build areas that will impact their area of responsibility. Those lessons are learned and that knowledge developed only after go live, as the site implementation matures and are long after Epic has left the site. (Code Jockey)

Do you really think that Epic doesn’t share best practices with organizations during implementation? The Foundation System is more or less a best practice soup. Every organization believes they are different and special so there is no reason to believe that Providence would have any more success convincing implementing customers to change their workflows and adopt best practices. Despite staff turnover, no customer organization has more experience implementing Epic’s software than Epic itself. (But we’re special)

Outsourcing some of the business office and IT makes sense. Yes, I know that it mentions [at John Muir Health] about 500+ people badge flipping, but being someone that has worked on deals like this previously, many of those people don’t make it long term. They are re-evaluated and many are given early departure packages, keeping the cream of the crop and then backfilling virtually with people that living in lower cost of living areas. Usually look at a 30% or more reduction in staff. These resources that are kept also get leveraged across other clients as well, so that needs to be kept in mind too. Sharing resources isn’t the worst thing, its just that you need to be tight with cost, SLA’s (service levels), and customer satisfaction. Plus, by outsourcing, the burden is now on the vendor to produce, they are now the throat to choke. I have seen this model be successful but I have also seen in flop and the hospital takes things back over. Again, its a case by case basis. (Associate CIO)


Watercooler Talk Tidbits

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Readers funded the DonorsChoose teacher grant request of Ms. R in Florida, who requested three Chromebooks for her high school class. She reports, “Having computers accessible in a science classroom is a real game changer. The students are digital natives, and being able to translate what they are learning into a language they are familiar with using is awesome! They are able to collaborate, engage in digital simulations, conduct research , create presentations, and more! These are useful to every level I teach. From my freshman physical science students, in my Pre AICE chemistry class, to my Chem 2 honors and AP chemistry class. It is applicable in each one. I also teach theater and then I can use them for the students to do CAD design without having to sign up to go to a computer lab or wait for a computer cart to be available. Thank you!”

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Nanowear launches a study of using its sensor-powered underwear that is connected to a closed-loop machine learning system for early detection of heart failure. It monitors cardiac output, heart rate, respiratory rate, thoracic impedance, activity, and posture.

AHA and other hospital groups ask CMS to change its HCAHPS patient survey, suggesting that it reduce the number of questions from the current 27, create a digital version to improve response rates, expand it to cover transitions in care rather than just discharges, and allow patients to enter comments.

Guild members hold a garage sale to help cover the $1 million in uncompensated care provided by Seattle Children’s Hospital, whose most recent tax filings show a profit of $165 million on revenue of $1.5 billion. The hospital is running a $1 billion donation campaign.

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Malls that are desperate to fill vacant storefronts are leasing space to medical clinics, hoping against reality that someone who comes in for a flu shot or eye exam will do a bit of shopping and that clinic employees will hit Sbarro or Cinnabon for lunch.

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Police arrest a Charleston, SC pulmonologist for voyeurism after an 18-year-old tenant of one of his beach rental properties caught the doctor peering through a hole in the bathroom wall from an adjacent unfinished room. The boy and his father chased the fleeing doctor down the beach, who told them he was just the pest control guy. Investigating officers found bathroom peep holes in both of the doctor’s rental houses. He previously lost but regained his medical license after three complaints that he exposed himself to drive-through restaurant employees.


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Currently there are "14 comments" on this Article:

  1. CodeJockey is wildly misinformed or intentionally misinforming others. Why post such stuff when it’s obviously incorrect.

    From CJ: I’ve never encountered an Epic resource that fully understood the impact of the build decisions that they were leading their clients to implement.

    Really, not even one?

    and more from CJ: there are absolutely, hands down, 100% zero options for what (uninformed and snobby) folks may traditionally consider an API for an application whereby complementary, third-party apps can in some fashion manage or change the behavior of the parent application in the Epic space.

    Really, just zero. Hands down zero?

    Mr H, we can find better than that, can’t we?

    • (Mr HIS – please delete the uncompleted entry)

      Always interesting when the kids show up…..

      Do some (freshmen 100 level basic research) – see: Amazon: “Drifting to Failure”

      Epic (and other EHR solutions) clearly meet the definitions of a ‘highly complex system”: stuff like (a) no single human being can understand 100% of the system (b) all actors in the development/configuration of the system by definition only are capable of working (understanding) the system on a regional basis (c) regional actors can only be aware of a limited number of direct impacts their actions have on related (think: next door) regions they will have an impact on as they make decisions and (d) they can not possibly be aware of or understand the impacts of their configuration decisions on regions far removed from their immediate neighbors.

      If you’ve failed to provide your employer with some appropriate level of discovery and come to the conclusion that someone Epic has presented to you has a 100% clear level of all of the complexities of their solutions then you may want to rush over to LinkedIn and update your profile.

      And, show us one (as in 1 = 0 + 1) example of an Epic interface or external option for fundamentally CHANGING the behavior of Epic apps within the Epic environment.

      You can pass data in, you can query data from (via a number of options), but I am not aware of ANY options for an external system to change (read:override) the configuration settings that an Epic client has set within Epic.

      If you really want to bring value to your employer/customer in healthcare IT do some due diligence in risk mitigation for highly complex systems.

      Nothing I’ve said in this forum is intended to reflect poorly on any Epic resources (implementation or TS staff members or developers) – on the contrary the (hands down) most valuable ones are those that ‘get’ the complexity and realize the limitations of their knowledge and understanding. Without question some of the most talented folks I’ve encountered have been Epic staff members that were consumed with the well-being of their customers.

      If you are a person who has some level of authority in a healthcare location/system that has or is implementing one of the leading EHR options I would suggest: risk mitigation, highly complex systems, unexpected outcome discovery and correction, cross training, matrix-ed teams and work groups, root cause analysis, auditing and related – do your homework. You will go live with whatever they have created, you’ll spend the balance of your career in these areas (i.e. making them work).

      Does anyone really think that a full-boat, 35+ apps, 30 + inpatient campus implementation of an EHR is any less complex than (for example): the construction of a 747, or a 737 MAX, or laws from Congress, or a Cruise Ship or the launch of a Space Shuttle or the Southwest flight you just caught on your way to your next consulting gig?

      “Gentle Reader” – before you cast comments derisively on my notes your might want to do just a weee bit more research/education.

      • Epic customers can and do write any form of custom code and even design their own APIs. They also have the freedom to allow external vendors to do this. Code Jockey couldn’t be more wrong.

        • Sigh…. Code Corrections – the origin of this conversation was a statement by someone that Epic clients were creating their own solutions with Epic that they could then take to market to other Epic client sites.

          Yes, EVERY Epic client contract grants the client a license to 100% of the source code to Epic AND the right to modify/add to/extend the Epic code base as they see fit. In my years I’ve seen some very innovative and powerful extensions to Epic by clients (including creating their ‘own’ APIs for hooking into Epic).

          That said – NO Epic customer is allowed to take any such solutions to market – for profit or income. Per Epic’s contract you must submit the code to Epic – they may offer it for free to other Epic clients or they may not. You also must grant Epic an unrestricted right to absorb your IP (as expressed in your code) and they are then free to use it however they chose.

          ANY external vendor that has access to Epic at a client site (including as a ‘developer’) is required to execute an agreement with Epic before the client site may grant you access. In that agreement you agree that anything you do is a work for hire, is the sole property of the client, and may not be sold to any other client in any fashion. YOUR Epic client may opt to take your (contracted) solution to market – but only through Epic as described above.

          • Come on Code Junkie…

            Would any software company on the planet let you take their code, do a minor modification and SELL IT TO ANYONE THEY WANTED TO?

            Epic allows each site to create local innovations based on its code for their own benefit, but is well within its rights to control commercial distribution of such works.

            You’re a fool to vilify Epic for this. If you worked in this domain for real and used your “Code Jockey” status to create anything of value, you’d likely impose even stricter rules.

            Don’t complain about Epic for something you’d likely even be more strict about yourself.

            You seem like a bitter failure in the coding world. Create some magic and figure out how you’d like to manage it. It’s complicated but what Epic is doing is generous compared to all the major software companies on the planet. Yet you complain…. Do you have a chip upon your shoulder?

          • From my experience 7 years as an Epic employee and then 4+ years integrating 3rd party clinical content/software into EHRs – CodeJunkie’s comments seems spot on.

            Of all the EHRs I’ve worked with directly as 3rd party add-on, Epic is by far the most restrictive contractually in this domain than Cerner/Athenahealth/Allscripts/meditech.

            And pretty much anyone else I’ve worked w/ similar background shares same perspective.

            So, it’s discouraging to see the occasional comments (a few in this thread) that wish to discredit the direct experience of those working in the trenches.


            P.S. Epic is still my fav overall and the vendor I trust the most to make meaningful improvements in this area

          • Mr. H – this is a response to ‘Really’ but I’m not sure how to respond to his post. Also, this is a note for both you and your legions of readers.

            I started reading and following this site – daily – over 13 years ago when I first engaged in healthcare IT. I cannot measure the value that the articles you’ve posted over those years have returned to me in my career (and personal life). Dr. Jayne is a treasure. Your interviews with movers and shakers bring great insights into things that otherwise would not be available to your readers. The collection of stories and links almost daily leads to information that enhances the work that I do and the value that I try to deliver to my clients/employers. And, how many of us readers can actually understand that killer series on ‘Machine Learning’? To my awareness there is nowhere else to get this mix of info.

            I don’t understand your policy for allowing/not allowing comments and posts to be published, but I’ll take the opportunity to encourage you to consider drawing the line when the comments offered are not professional, not substantive and delve into (silly) personal and/or derogatory attacks.

            “You’re a fool”, “You seem like a bitter failure”, “Do you have a chip on your shoulder”. Compared to the (extremely) high bar that your contributors submissions meet I’d like to suggest that when comments dip to this level you just ignore them.

            I don’t know who this person is (and frankly don’t want to know), but I DO KNOW that HIS Talk is a forum where healthcare IT professionals share information at a very high level of professionalism and your willingness to allow us to post in an anonymous fashion lets us share details that otherwise would most likely not enter into the broader conversation.

            Healthcare IT is not Spacely Sprockets or widgets or whatever – pretty much every single thing we do has the potential to have impact on real human beings. In my mind – it’s serious work, almost like a ‘calling’ if you will, and there really isn’t a lot of room for this sort of silliness.

            I’ll reiterate my core point in this chain: Epic, via contractual agreements with their customers, does not allow anyone to develop and take to market any sort of solution that ties into Epic short of their (very) narrowly defined pathways. Apple and others do this, and to the point ‘Really’ made – any number of software firms do. I’ve offered no criticism of this, suggested in any fashion that it’s ‘bad’ or whatever – all I’ve tried to do is share with the HIS Talk community the reality of the terms that Epic requires their clients to agree to.

            Do these terms protect Epic’s IP – without question. Do these terms mean that valuable related solutions are never presented to the market – yes. Do these terms mean that Epic clients are forced to solve the same problems over and over again without being able to leverage the learning and experience of other Epic clients that came before them – yes.

            An example – I had the good fortune to complete an engagement with an Epic client that had some world class cache and windows developers in their stack. They created a form (a help ticket request), in Epic, that end users can click on that captures details of their session (including a screenshot of what they where looking at in the moment), a number of details about their Epic session and generate a ticket in ServiceNow that (a) included all of these details and (b) slipped them right into their IT help desk management system. Cool stuff that was of great value to the organization and significantly enhanced the experience of the end users because the help desk staff had a ton of Epic specific info to work with BEFORE they ever responded to the end user.

            All of this, in the Epic universe, cannot be taken to market (for profit) to other Epic customers. Each customer (if they have ServiceNow) would have to (a) obtain the required talent and (b) commit to the development of a similar solution. I’m not casting a judgement on whether this is a “good” or “bad” thing. All I’m suggesting is that this is the way it works in the Epic world.

            I value, tremendously, the information that HIS Talk brings to me every single day. I’ll encourage you to ask your users, and to the extent that you are comfortable with, limit the publication of comments and articles that meet some bar that is appropriate to the seriousness of the impact of the work that all of us in HealthCare IT are involved in every hour of every day in our work.

            Please do continue to do the work that you do, please (Dr Jayne) continue to share as you do. To the rest of the reader community – let’s all take the opportunity presented to us here to elevate our work and knowledge and leave the twitter kind of participation somewhere else.

    • Have to agree with Code Jockey. I’ve been in the trenches of implementations since 1990 (TDS lightpens,anyone?!). My latest has been Epic – I became an expert in a handful of large vendors over my career. I’m am not bashing Epic, there are some things they do wonderfully, and other things they fail at miserably. Just like every other vendor I’ve worked with.

      But, their implementation staff is green, inexperienced and taught to walk the Epic Foundation line. They in no way have experience in a hospital, or in any sort of maintenance of the systems they implement. The PMs are similar, but with a few more years experience and good with a project plan. Since I’ve been doing this for decades, I do have experience 🙂 So it became my job to listen to their solutions, and fight them on those that would require an army to maintain. I have the belief if you build things correctly and with thought, even if it takes longer initially, in the end life is easier for all involved. Since hospital IT management defers to Epic on most application decisions, I not only had to plead my case to Epic, but then to my own leadership that Epic had no idea what they were doing. It was exhausting.

      On the other hand – if I had to hire staff, I would hire any Epic employee in a heartbeat. They are hard workers, bright and great presenters, I have nothing bad to say about any I have encountered. It’s their lack of true experience that bothers me.

  2. One of the reasons IT and hospital administration favor systems like Epic and Cerner is that they want to standardize across the health system. They don’t want an app to be able to come in and override their configuration. They want everyone in their system to be on the same software and they want one throat to choke for getting software to do what they want. This is especially true for the particulars of this period of time in healthcare in which ensuring quality while reducing cost is on everyone’s mind. We aren’t designing aircraft or cruise ships or other innovative developments. We need good execution of the good ideas already out there at an attainable price.

  3. Code Jockey – thanks a tonne for persisting and for your rational and informed responses to a lot of name calling and misinformation being spread by likely Epic insiders.

    Your comments and the last response with specific example of help desk form is absolutely spot on and many ‘small guys and gals’ who have been stomped upon by Epic’s monopolistic market power applaud you.

    • Code Jockey’s example of an IT form that ties into Epic’s system is wrong though – you are allowed to do that and you are welcome to sell it to other Epic customers. They even have a stable API that gives you info about the user, their session, the patient they are interacting with, etc.. However, they aren’t going to maintain a function that allows you to take a screenshot of the application and they aren’t going to let you sell something to other companies that relies on a screenshot API that they want to be able to change at any point. They likely built that screenshot API for their support people and let customers know about it. Most enterprise software companies like SAP or Salesforce don’t have documented screenshot APIs that you can rely on in prod. Apple and Microsoft do because they sell operating systems, not industry specific crud apps. This is all pretty basic software company stuff and Code Jockey (and you) appear disingenuous when you state or support incorrect information.

      • I’d also point out that Epic insiders are probably right to be touchy about this topic as they get flack publicly and likely in their contract process for interoperability. However, it seems that they do fine with regards to interoperability based on most of the metrics I’ve seen (info actually exchanged, number of customers participating, enthusiasm/knowledge of participants, HL7 support, KLAS ratings, etc.) I’ve been an Epic user and in my experience they are at least as good as the other major or non-legacy vendors. The reputation seems to mostly be due to others slinging mud/ muddying the waters.

        • Finally, CodeJockey has a incentive to play up issues with developing custom solutions for Epic’s platform as improvements Epic makes in this area would benefit him or her financially as a consultant to Epic’s customers.

          • Gotta love it when the kids show up…..

            After a number of years of almost constant travel and well over 700+ flights (as in 700+ times up and then back down), I’ve hung up my traveling shoes and, while I’ve settled into a FTE role at a local health care system – they don’t have Epic and nothing I’m doing is Epic related.

            If anyone wants to comment on this subject further and question the accuracy of my notes I’d like to request that they affirm that they have at one time or another signed a consultant agreement with Epic and have actually seen and read the specific wording included in that agreement (and of course, have contractually agreed to meet the terms of the agreement).

            If you don’t have that DIRECT experience then any comments/suggestions/criticism here are ill informed (at best) and clearly not accurate. Epic hasn’t changed the wording of the required agreement since I first started working for their customers over 13 years ago.

            And, for those of you that may be joining in here as Epic fans – God Bless Judy Faulkner and everything she has created and maintained at Epic. I’ve made a great living for a long time because (a) they have a hell of a product and (b) their restrictive policies force Epic customers to hire folks that have advanced skill sets related to Epic.

            The fact that the work that I’ve done / am doing is in healthcare and in some portion has advanced care and outcomes for humans and healthcare providers is just the icing on the cake!







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Reader Comments

  • Math: Dittoing on how awesome Zenni is, I've been using them for a couple of years. Most people don't realize how much of an ...
  • Code Jockey: Gotta love it when the kids show up..... After a number of years of almost constant travel and well over 700+ flights...
  • Kermit: My family's been happily using Zenni for years. Never a problem with the quality of their products. My last order was fo...
  • Cosmos: During an inpatient stay at a Boston area teaching hospital, my wife was approached by a research assistant about enroll...
  • AlphaCodeJockey: Finally, CodeJockey has a incentive to play up issues with developing custom solutions for Epic's platform as improvemen...
  • DeltaCodeJockey: I'd also point out that Epic insiders are probably right to be touchy about this topic as they get flack publicly and li...
  • Gamma Code Jockey: Code Jockey's example of an IT form that ties into Epic's system is wrong though - you are allowed to do that and you ar...
  • Bravo Code Jockey: Code Jockey - thanks a tonne for persisting and for your rational and informed responses to a lot of name calling and mi...
  • Bill O'Toole: Confirming first hand that Cape Cod Hospital was MEDITECH's first customer. My father, the Chief of Pathology, saw the i...
  • FormerCIO: Re JAMA article. How will access to my EHR data help me 'shop for high value health care services' and 'avoid the need t...

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