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Monday Morning Update 11/4/19

November 3, 2019 News 13 Comments

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CMS delays a requirement that Medicare-accepting hospitals share their secretly negotiated insurance rates in machine-readable format and online.

CMS Administrator Seema Verma said Friday that the government now wants to make insurers disclose their contracted prices as well. She says the revised plan that includes both hospitals and insurers will be rolled out by the end of the year.

Lawsuits that question the the government’s authority to compel private companies to disclose competitive trade secrets are inevitable.

Hospitals would be fined $300 per day for failing to comply with the disclosure requirement, which would cost a multi-billion dollar health system just $109,500 per year to keep its prices secret.

Verma also credits President Trump for lowering health insurance premium prices on Healthcare.gov via his Executive Orders as open enrollment begins.


Reader Comments

From Built to Spill: ”Re: patient name on labels. We changed our system to use the patient’s preferred name on wristbands and labels. The impact was positive, but now fewer characters print and the names are being truncated. Name length issues are a challenge, and this is an unexpected adverse outcome of trying to do a positive thing.” Label formatting is more maddening than a layperson would appreciate. You have limited space and the nature of most text fields is that, unless you use a fixed-width font, you can neither predict nor highlight truncation (names with I’s and E’s may not truncate, but those with M’s and W’s might). I’ve pored over reams of test data as formatted onto a Crystal Reports label or report, dragging the text box a tiny bit wider or narrower in shooting for the best outcome with critical drug and lab test names. You could do something to trigger an adjacent ellipsis to warn the user that the name has been shortened or perhaps check length and then override the default label font to a smaller one, but that leaves the problem unsolved. I vaguely remember that I once programmed a label to combine all its fields into a single big text box with programmatically-added spacing and line breaks in trying to squeeze it all in without truncating (since the odds of all data elements being oversized was small), but I seem to recall that the result didn’t line up nicely and clinicians accustomed to glancing at predictably formatted information were justifiably less than ecstatic.

From Dogged Determination: “Re: Ed Marx. Hope it’s not true that he has left Cleveland Clinic.” Ed didn’t respond to my inquiry, but I see that he has updated his LinkedIn over the weekend to indicate that he left the Clinic last month after 2 1/2 years as CIO and is now an independent consultant.

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From Sunny Jim: “Re: our industry. It never fails to not deliver! I took this in a health system-sponsored, grocery store-based convenient clinic during daytime hours. I told the receptionist it was down, but she just shrugged her shoulders like it happens all the time. We just can’t get away from the clipboard!” I’m amused that the kiosk’s splash screen helpfully explains that it is “Epic’s Self Service Check In Kiosk” and then someone has helpfully taped on a torn scrap of printed paper in an act of customization that announces “KIOSK.” This self-aware message reminds me of no-hunting signs that needlessly say “POSTED” or the legendary title and theme song of the late-1980s Showtime series “It’s Garry Shandling’s Show,” where the song’s opening lyrics were, “This is the theme to Garry’s show.”


HIStalk Announcements and Requests

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About two-thirds of poll respondents who attended HIMSS19 will be at HIMSS20, while a few folks who didn’t go last year will be in Orlando in March. HIMSS is trying to invoke the bandwagon effect of touting increased C-suite and physician registration compared to HIMSS19, but A-Rod’s keynote aside, I would still put my money on a modest attendance decline.

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New poll to your right or here, since people always say the biggest benefit of the HIMSS conference is the networking opportunities: how much of your conference networking benefits your employer versus you personally? Is it more than just socializing, catching up with old friends, having fun, and connecting for a possible job change?

Speaking of HIMSS, I still have a twinge of both regret and relief that I didn’t buy a tiny booth this year so Lorre could say hi to readers in the one time each year she sees them in person, but it involved a lot of money for minimal ROI.  The map of available booths suggests that 250 of the available 449 10×10 booths (the size I bought in previous years) are unassigned. The exhibit hall floor plan shows 1,126 booths taken, about two-thirds of the number available. It also shows just over 100 first-time exhibitors, although the usual churn (along with consolidation) will likely more than offset that number with non-returning HIMSS19 vendors. Total booth square footage leaders, at least by eyeballing, are Epic (12,064), Allscripts (10,800), IBM (10,110), and Cerner (9,074). HIMSS charges a base rate of $39 per square foot, which puts Epic’s basic rent for the three days at $500K, which must be a fraction of what the company will spend for freight, signage, travel and salary costs, and various forms of conference advertising and sponsorship.

I had some big site upgrades performed over the weekend, just in case you noticed something weird (and if you’re still seeing it, let me know since maybe I missed something, although I still have a couple of punch list items). I moved to PHP 7 (specifically 7.3), a faster and more secure version of the server-side scripting language that has been around since 2015. Newer versions are used by only a small percentage of sites since they breaks a lot of old code that someone has to analyze and fix, which to which I can personally attest. 

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Welcome to new HIStalk Platinum Sponsor Bright.md. The Portland, OR-based, physician-founded company offers SmartExam, an AI-powered, asynchronous virtual care platform that increases provider capacity by a factor of 10 and reduces care costs by up to 90%. Patients with hundreds of conditions can be treated in under two minutes and in just three clicks without the provider touching the EHR. The patient interface doesn’t require appointments, video visits, or a broadband connection. SmartExam serves as the virtual front door for health systems, the first step in a ladder of care that moves the patient along their care journey for more complex issues. It can be brought live in 10 weeks or less, delivering a quick win for physician satisfaction and patient delight. The company just delivered significant improvements that include care escalation to a 911 call when triggered by patient question responses, AI-powered interpretation of patient responses to eliminate dropdowns, configurable formularies, and an all-inclusive design approach that is also ADA compliant and does not require patients to choose a gender. Thanks to Bright.md for supporting HIStalk.

Listening: new from Tacocat, Seattle-based punkish, smart-assy pop rockers (whose name is a palindrome, I just noticed) who sound like high school best girlfriends who decided to form a band. Pitchfork summarized an earlier album as, “It feels like taking a joyride with four bonafide party experts egging you on as you drunk-text an ex.” On a more somber side is “Ghosteen,” a new double release from the always-poetic Nick Cave & the Bad Seeds, Cave’s first album written after the 2015 death of his 15-year old son. Nick Cave is a genius and master of art forms that include performing, writing, film scoring, acting, and screenwriting and the Bad Seeds are underrated in being more than just backing musicians. Their live performances are intense, although unfortunately next year’s tour contains no US dates so far.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

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Google will acquire Fitbit for $2.1 billion in cash, saying it will bring together the best hardware, software, and AI to build wearables. CNBC notes that Google’s hardware aspirations have mostly failed with Nest, Google Glass, its light-selling Pixel smartphone, and its purchase of IP from smart watch maker Fossil having failed to make much of a dent. Its acquisition of Motorola lasted just three years as it sold the company to Lenovo for less than 25% of the price it paid. Fitbit sales were in big trouble, so perhaps the company was right to recast itself as a healthcare and data collection company in catching Google’s eye in what started as a collaboration in April 2018. Let’s see if Google takes a Facebook-like route in linking up wearables data to the wealth of information it holds, using it for purposes we as users might not like, at least those of us who aren’t in Europe where GDPR offers at least some consumer privacy protection. 

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Cleveland’s Global Center for Health Innovation loses its biggest tenant, BioEnterprise, which was also promoting the taxpayer-funded facility that had previously parted ways with its then-largest tenant HIMSS. The developer is trying to figure out how to use the building, with one option being to convert it to meeting space to expand the attached Huntington Convention Center. Taxpayers paid $465 million to build the Center and the convention center.

The Kansas City paper questions whether residents of the declining neighborhoods of south Kansas City are benefiting from the $1.6 billion incentive package that was given to Cerner to build a $4.3 billion campus there on the site of an abandoned mall. They complain that even though 3,000 Cerner employees work on the campus, the only other new development is a single gas station and most employees go straight from the Interstate to the gated Cerner campus and then leave the area after work. The school district loses $2.7 million in annual revenue because of the tax breaks. Local politicians and Cerner had predicted a rejuvenation of the area through new development, but the Walmart remains closed and a neighborhood survey found that the only retail need being met is liquor stores.


People

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Cerner announces in SEC filings the departure of COO Mike Nill and Chief Strategy Officer Joanne Burns in the first quarter of next year. That leaves four executives who were on board when Neal Patterson died in July 2017 – Chief Client Officer John Peterzalek, CFO Marc Naughton, EVP Jeff Townsend, and EVP Donald Trigg. I also noticed that John Glaser has been removed from the executive page even though his individual page as SVP of population health remains, while his LinkedIn shows him as executive senior advisor.

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Denis Zerr (Catholic Health Initiatives) joins Radiology Partners as CIO.


Announcements and Implementations

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The local paper covers the go-live of Kern Medical (CA) on its $30 million Cerner system, showing pride that the hospital, “which had a well-documented history of financial dysfunction,” now has a modern system that is on par with those of competing local hospitals of Dignity Health and Adventist Health.


Government and Politics

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The administrator of Guam Memorial Hospital tells legislators that support for its Optimum system (formerly Keane, then NTT Data, now Cantata Health) will end December 31 but it doesn’t have the money to even start the search for a replacement that could cost $50 million.

CMS is working on Healthcare.gov errors that users experienced on Friday’s first day of open enrollment.


Privacy and Security

The Brooklyn Hospital (NY) says it discovered ransomware in its systems in July 2019 and found that in September 2019 some of its patient data cannot be recovered. Among the lost information is patient name (!!) and cardiac and dental images. The hospital says that recovery efforts are continuing.


Other

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A Newsweek opinion piece by “House of God” author Samuel Shem (aka psychiatrist Joseph Bergman, MD, DPhil) says that “the EMR is essentially a cash register” that was “developed by technocrats as part of the mandate of the Obama administration in 2008” (which is obviously way wrong, but let’s call it creative license). Shem describes a war being waged on both sides of the screen – the hospital’s billing team trying to maximize payment while the insurer’s team tries to minimize it. Shem thinks EHRs should be redesigned to ignore billing requirements like the VA’s VistA (again, good idea, but apropos only in a fictional world, and the VA is dumping VistA for one of those cash registers besides). He closes strong: when someone falls in a theater, does anyone call, “Is there an insurance executive in the house?” Meanwhile, I’ve pre-ordered Shem’s latest book, a “House of God” follow-up that comes out November 12 titled “Man’s 4th Best Hospital.”

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A New York Times essay by UCSF internist, assistant professor, author, and podcaster Emily Silverman, MD says the hospital’s new Epic system amplifies the insecurities of its physician users. She notes:

  • Her first Epic log-in presented a warning that she had “deficiencies,” which she says made her feel like a middle school student whose name was called out in assembly. In contrast, her friends who work at Facebook says the company talks a lot about “voice” in trying to make users feel cared for, with birthday reminders and display of photo memories.
  • Epic has “unintelligible medical notes, filled with ragged vines of superfluous, robot-generated text” and interruptive, mid-documentation demands to choose a patient’s diagnosis from a drop-down list while she is trying to figure out what’s happening with the patient.
  • Entering the chart of a deceased patient, which is often when the physician finds out their patient has died, provides an empathy-free “Deceased Patient Warning” pop-up.
  • She concludes, “A more humane version of Epic would take a different tone. In the absence of a true emergency, its colors and symbols would be neutral, even tranquil. Deceased-patient warnings would recognize the emotional impact of a life lost. Deficiencies and delinquencies would become incomplete tasks, and pop-ups would float into view as small islands of empathy, like the system’s periodic emails. (“Thank you for all of your hard work.”) But until then, the voice of the program itself — urgent, intimidating, and tinged with allegation — will continue to contribute to the profession’s growing sense of despair.”

Cerner SVP John Gresham says the company’s integration with Uber for patient transportation is just one way that Cerner will address social determinants of health, which could include new services such as appointment and prescription reminders that include transportation options, alternatives to ambulance transport that goes beyond Uber’s capability, and prescription delivery.

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Boston Children’s Hospital celebrates the 25th anniversary of its Computational Health Informatics Program (CHIP), which in addition to providing education, created the first personal health record, developed the SMART interoperability protocol, developed HealthMap for visualizing global disease outbreaks, demonstrated the power of analytics and genomics, and spun out several startups. A September 26 symposium reviewed CHIP’s history, then offered panel discussions on what healthcare will look like 25 years from now, including the role hospitals will serve, who will make clinical decisions, how therapies will be developed, and what R&D should be performed now to prepare for the future.

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UCSF hospitalists say moral distress is a root cause of physician burnout and that hospitals should prioritize ethics and the “inherently unethical” healthcare system should be reformed to prioritize patients over shareholder profits. They also urge education in ethics and for doctors to be encourage to advocate for issues that affect their patients, such as gun control and universal health coverage. They cite these specific problems:

  • Pressure to reduce costs in some areas while increasing them in others through profitable prescribing or referrals.
  • Being forced to provide futile or harmful treatments because the patient hasn’t completed an advance directive or family members can’t agree on end-of-life care.
  • Trying to deliver consistently good care despite economic disparities caused by high costs, high insurance deductibles, and a “gutted social safety net.”

Sponsor Updates

  • Health Catalyst and Nordic will exhibit at the CHIME19 Fall CIO Forum November 3-6 in Phoenix.
  • Mobile Heartbeat will host MHUG 2019 November 6-8 in Phoenix.
  • Waystar will exhibit at the Health Management Academy CFO Forum November 6-10 in Laguna Beach, FL.
  • Netsmart will exhibit at the MHCA Fall Conference November 5-7 in Atlanta.
  • Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the HIMSS South Carolina Annual Fall Conference November 1 in Columbia.
  • Experian Health and StayWell will exhibit at the Healthcare Internet Conference November 4-6 in Orlando.
  • PerfectServe will exhibit at the Society of Hospital Medicine Leadership Academy November 4-7 in Nashville.
  • Surescripts will exhibit at the PointClickCare Summit November 3-6 in Dallas.
  • Vocera will exhibit at the Florida Organization of Nurse Executives Fall Conference November 7-8 in Orlando.

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Currently there are "13 comments" on this Article:

  1. Whenever I read one of these op-eds (that have become an entire genre in themselves) penned by physicians identifying the EMR as The Thing That Is Ruining Medicine, it always makes me wonder if they are intentionally over-simplifying the problem or if they are genuinely unaware how a system like Epic gets purchased and implemented.

    “Why is this enterprise software that serves as a source of truth for medical, legal, and financial information in a heavily regulated industry different than a consumer-facing social network [which would probably benefit from additional oversight]? Whyyyy?” has got to be the dumbest question out there, and yet the physicians authoring these screeds seem to be willfully ignorant of the difference.

    Would Epic benefit from having a better UI and more clinicians actively involved in software and workflow design? Absolutely. But the idea that “deficiences” is something that Epic dreamed up and foisted upon their users? Come on – Epic configuration is heavily controlled by your own organization. You want Epic to be nicer to you? Talk to administrative and operational leadership at your organization. I’m sure they could ask IT to write an alert to pop up once a week to say “Great job!!” – which everyone would then complain about being distracting and “adding clicks”.

    • Also, Facebook design is meant to maximize engagement so that they can deliver the most ads. Do you want to maximize engagement with your EHR or do you want to make eye contact with the patient?

      • Everything about this OpEd by this physician is what is wrong with this country at this point. How in the world do people get through their day-to-day lives if every word that crosses their screen is “offensive” to them? It’s absurd. There are plenty of things wrong with EMR’s in today’s world, but guess what — colors and “word choices” are not one of them. Not everything is about offending you, it’s simply just a word that by definition means something whether it hurts your feelings or not. Get over yourself.

        • Maybe if she completed her required documentation on her patients in a timely manner she wouldn’t feel scolded when the EMR pops up her deficiency messages.

  2. What AnonZ said! 😉 There’s a great group of Epic CMIOs across the country that are in communications now to draft a response that hopefully can add a bit of balance along with the process of purchase, implementation and ongoing maintenance that goes into large tech projects like an EHR. I’ve found it very helpful to share a ‘physician-friendly’ organization chart that outlines who does what. This empowers the frontline users to target their feedback appropriately and build trust that ‘we aren’t trying to hide things’.

    One example that we started at a previous organization is to make sure there is a hyperlink (or text in the alert) that shows with each BPA (pop-up alert) which links to the ‘decision-making body’ that approved it. Typically, it has a colleague on the committee that they know and can email directly or ask them about it. This provides accountability to the “Alert Committee” as well as the operational leaders that may have come up with the ‘software solution to a peopleware problem’. This small proof of concept also decreased IT tickets by frustrated users. Many would just state ‘that alert sucks’ or ‘get rid of the alert’ etc. Local IT or IS departments have no authority (they have the ability) to do this without clinical and operational ‘approval’. Very few of my colleagues know this fact. They will blast IT (‘the messenger’) for a clinical and operational leadership decision. #ThisIsSPARTA 😉 .

    Overall, I definitely agree with the author that there need to be improvements. I feel that continued machine learning, slicker UI/UX with emotionally intelligent messaging would improve the EHR UI/UX (user interface and user experience). A colleague once told me “Hey Dave…you know what would streamline my user experience the most? A more streamlined healthcare system in the US!” I had to laugh and definitely agree with him! #my2cents

  3. Regarding Ethics in Conflict: A slippery slope. While I’ll acknowledge the potential for stress-inducing circumstances as a physician (and I’ll extend to other healthcare professionals, not just physicians), I think that some of the examples cited by the authors 1) come with the territory, or 2) overstep their bounds.

    Part of the job: Providing (what you believe is) futile care because advanced directives are not in place, or not in line with what you would do or halting treatment – again, because it is not what you would do, to me feels a little bit like a lawyer only wanting to represent (who he or she believes is) innocent clients (rather than provide legal services to any client regardless of guilt or innocence). Patients have rights and choices. As healthcare professionals, you have to respect that and acknowledge those rights. I would also offer, real moral conflict is the respiratory therapist and nurse who are ordered to actually “pull the plug” and end a life.

    Not part of the job: Politics. Period. The physician-patient relationship should not be muddied with opinion on social or economical issues or policies. Certainly help patients understand anything and everything that influences their health and well-being, but hold your politics for off hours. Everyone else in the working world (except, apparently celebrities and sports figures) are required to do so.

    Lastly, the authors rail against profit-seeking entities. Very slippery slope. No margin, no mission. Physicians can certainly fulfill their sense of moral mission and alignment in volunteer work, free clinics or other worthy ventures. Those skills are needed everywhere.

  4. “Epic has “unintelligible medical notes”
    Nope, Epic has no such thing. I don’t think it’s achieved sentience yet (thankfully). Talk to your co-workers who wrote the notes.

    “urgent, intimidating, and tinged with allegation”
    She’s looking for comfort and empathy from a computer system??

    And this coming from an “internist, assistant professor, author, MD.” Either very disingenuous, or completely lacking comprehension about reality. Not really enticing me to read that op-ed.

  5. In addition to all the accurate takes from everyone already concerning Dr. Silverman’s Op-Ed. I was particularly flabbergasted by her assertion that often physicians are notified of a deceased patient only when opening the patient’s chart. Is that…accurate? I’m not a doctor but that doesn’t seem like an efficient workflow for medical care. The reason Epic even has that warning in the first place is because it assumes you are opening the chart in question in error. If this is the desired notification method i feel like the problem lies not with the EMR.

    A couple other questions, she said the system is “new,” Hasn’t UCSF been on Epic for years (decades?) Is this a new rollout or upgrade shes referring to? Is she new to the hospital? Kinda curious what that’s going on there.

    Also, I don’t consider myself an old fogey but “pop-ups would float into view as small islands of empathy” Seriously? In a NYT piece? Millenials these days am i right?

  6. “pop-ups would float into view as small islands of empathy, like the system’s periodic emails. (“Thank you for all of your hard work.”)”

    To quote Don Draper: “That’s what the money is for!”

  7. Doctor’s NYT essay complains of Epic’s on-screen wording

    I enjoyed all the comments here much more than the NYT essay.

    If that sort of thing was so demoralizing to my physician then I would have to say: #NotMyDoctor







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